The purpose of this guideline is to provide guidance about nasopharyngeal airways (NPAs) at Great Ormond Street Hospital.
The NPA is a flexible endotracheal tube that is designed to open a channel between the nostril and the nasopharynx – it can either be used in an emergency or for long-term use (European Resuscitation Council Guidelines for Resuscitation, 2010). The purpose of a NPA is to bypass upper airway obstruction at the level of the nose, nasopharynx or base of the tongue.
A correctly placed NPA will sit just above the epiglottis, having separated the soft palate from the posterior wall of the oropharynx. This knowledge is vital if the NPA is to be sized correctly in patients: if the airway is too short it will fail to separate the soft palate from the pharynx and if too long it can pass into the larynx and aggravate cough and gag reflexes (Roberts, Whalley and Bleetman, 2005).
The NPA primarily acts as a 'splint' which maintains patency of the airway, or keeps the tongue from falling back on the posterior pharyngeal wall and occluding the airway, therefore preventing airway obstruction, hypoxia and asphyxia (Dinwiddie, 1997).
NPAs are generally well tolerated by conscious children and are used in the management of children with congenital maxillofacial abnormalities, syndromic craniosynotosis, mid-facial hypoplasia or to support the upper airway post trauma or surgery (Tweedie, 2007).
Note: While the term 'child' is used throughout this guideline, all procedures are also applicable to young people.
Indications for a NPA
Indications for a NPA itself and the length required to relieve the obstruction must be determined on an individual basis for each child.
Pierre Robin Sequence
The child with Pierre Robin Sequence (PRS) is characterised by an unusually small mandible (micrognathia), posterior displacement or retraction of the tongue (glossoptosis), and upper airway obstruction. Incomplete closure of the roof of the mouth (cleft palate) is present in the majority of patients, and is commonly U-shaped.
In PRS, airway obstruction is mostly due to glossoptosis, whereby the tongue occludes the airway, resulting in difficulty breathing. Upper airway obstruction results in a failure of airflow into the lungs, despite adequate inspiratory effort. Increasing respiratory effort can worsen the obstruction, as increased intrathoracic pressure collapses the soft tissue structures inwards. PRS is seen in other syndromes including Stickler, Treacher Collins, and Velo-cardiofacial syndromes. The airway obstruction may be intermittent, and may also take time to develop, with some infants not presenting for days to weeks after birth, most commonly with failure to thrive due to on-going increased work of breathing.
Children with Craniofacial syndromes (eg Apert, Crouzon, Pfeiffer) may have a NPA for the treatment of obstructive sleep apnoea. The NPA may be used for months or years and often allows avoidance of a tracheostomy. These children have anatomical mid-facial hypoplasia which includes narrowed nasal passages, underdeveloped and setback mid-facial skeletal structures, malocclusion of the upper and lower jaws. Position of the tongue can occlude the airway. Children may present with symptoms of upper airway obstruction, feeding difficulties and failure to thrive.
Post-craniofacial mid-facial advancement surgery
This surgery is carried out to advance the facial skeleton and involves multiple facial fractures and post-operative oedema (Hayward et al 2004). The NPA is sutured in place and supports the airway and acts as a barrier between the nasal mucosa and dura of skull base – which may prevent nasal bacteria infiltrating the dura.
Do not attempt to reinsert the NPA in this group of children as the nasal cavity is vascular and aggressive attempts to insert a NPA can cause profound bleeding and trauma to the surgical site which will further compromise the airway. Contact the Craniofacial medical team for advice.
Children with obstructive sleep apnoea are at risk of respiratory compromise following an adenotonsillectomy, due to post-operative oedema (Tweedie, 2007).
The young age of the patient and severe sleep-related upper airway obstruction significantly increases this risk of airway obstruction. The NPA in this group of children is:
- usually for one to two nights post-operatively
- usually avoids a paediatric intensive care unit (PICU) admission
- consideration for sickle cell patients (to avoid hypoxia)
- consideration for patients with a narrow mid-face
- consideration in cerebral palsy/neurologically compromised patients.
Removal of the NPA must be discussed with the Ear Nose Throat Team (ENT).
In an emergency consider removing the NPA if a seal is not achieved with artificial respiratory support (ie Bag Valve Mask (BVM)). If the NPA is patent and supporting respiratory support, then leave in situ.
Do not attempt to reinsert the NPA in this group of children as the nasal cavity is vascular and aggressive attempts to insert an NPA can cause profound bleeding and trauma to the surgical site which will further compromise the airway. Contact the ENT medical team for advice.
Post cleft lip and palate repair
Occasionally a baby undergoing a unilateral or bilateral lip repair with anterior palate repair (vomerine flap) may require a NPA.
Often babies with Pierre Robin Sequence (who may or may not have had NPA pre-op) will have a NPA post-operatively, due to closure of palate and post-operative oedema potentially causing airway obstruction.
Babies with isolated cleft palate (eg whose repair was tight (+/-) lateral releasing incisions), may have post-operative swelling requiring an NPA.
The NPA is usually left in situ for one to two nights post-operatively. However, some children may have an existing NPA in situ. This will be left in situ and managed long term by the respiratory team.
Only remove the NPA on instructions of cleft team. If the NPA is removed unexpectedly, practitioners should seek advice from the cleft team as re-passing NPA can cause potential damage to cleft repair.
In an emergency consider removing the NPA if a seal is not achieved with artificial respiratory support (ie BVM). If the NPA is patent and supporting then leave in situ.
Airway obstruction is a common occurrence in paediatric resuscitation. It may be the primary cause of the cardio-respiratory arrest (eg choking) or a consequence of the underlying disease process (eg hypoxia), which leads to loss of consciousness. In unconscious children the tongue can fall backwards and occlude the airway. Regardless of the cause airway obstruction must be rapidly recognised and managed to prevent secondary hypoxic damage to vital organs (European Resuscitation Council Guidelines for Resuscitation, 2010).
In a conscious child, airway obstruction may be demonstrated by difficulty in breathing and/or increased respiratory effort. In either conscious or unconscious children there may be additional respiratory noises if the obstruction is partial, whereas respiration will be silent if there is complete obstruction.
Sizing of the NPA
The size and length of the NPA is determined by:
- obtaining the child’s crown to heel length as there is a positive correlation between this and the length of the NPA (see Appendix 1)
- referring to the lateral neck X-ray if appropriate
- clinical assessment.
The correct diameter of tube must also be determined. If the airway is too narrow it will not be an effective airway – if it is too wide, it may cause the skin to breakdown due to pressure points. This is dependent on the age of the child or infant. However, the length rather than the diameter is more pertinent in most cases.
Craniofacial and ENT
The NPA is tailor-made, depending on the indication, anatomy, size and age of the child. This is usually performed in theatre under direct vision.
The NPA is inserted under direct vision in theatre at the time of the palate repair. Those that have existing nasopharyngeal airways are inserted under the respiratory teams who use the crown to heel measurement chart as a guide.
Measure the required length for the nasopharyngeal tube by measuring the tube from tip of the child’s nose to the tragus of their ear (European Resuscitation Council Guidelines for Resuscitation, 2010). The appropriate tube width/size can be estimated by matching its diameter against the opening of the child’s nostril; when inserted, it should not cause blanching of the nostril on insertion.
Insertion of a NPA
Ensure that the child or young person and family are informed of the following to obtain consent and to maximise the effectiveness of the procedure (Rationale 1):
- the reason for the NPA
- what it will involve
- the likely duration of the airway placement
- the potential difficulties of using an airway
- the likely impact on the child and family.
If necessary, contact a play specialist or psychologist to work with the child.
Preparation of equipment and environment
The child’s bed area must be made accessible to ensure safe and unrestricted access to emergency equipment (Rationale 2 & 3).
Resuscitation and suction equipment
All equipment must be present and in working order. The child must be supervised at all times (Rationale 4).
The accompanying carer must be able to:
- recognise signs of airway obstruction
- Suction the NPA.
The child with an NPA should have an emergency NPA equipment box by the bedside containing (Rationale 2 & 3):
- a spare NPA of the same size Internal Diameter (ID) and length in case the NPA needs to be changed (Rationale 5)
- a NPA (one size smaller by 0.5mm ID) (Rationale 6)
- a water-based lubricant (Rationale 7)
- round-ended scissors to cut tape and or suture
- roll of leukoplast tape to secure flange to face (Caution: for children with a latex allergy, an alternative medical adhesive tape must be sourced which is strong and durable enough to secure the NPA) (Rationale 8)
- Personal Protective Equipment (PPE) to be worn (Rational 9).
- suction catheters – correct size (refer to suctioning section)
- hydrocolloid dressing (Rationale 10)
- saline solution for cleaning
- clean receiver with sterile bottled water to flush suction tubing
- 2ml syringe and ampoule 0.9% sodium chloride for irrigation
- clinical waste bag as per hospital policy.
Equipment to make an NPA
There are standard sized ivory NPA’s available (from theatres) that do not require customisation – these are used for short term airway management (eg post-operation craniofacial patients, resuscitation (Rationale 11)).
Below are instructions to make a NPA. The following equipment needs to be gathered:
- Portex™ endotracheal (ET) tube of the appropriate size
- Portex™ tracheal tube holder (0.5mm smaller than ET tube size)
- Nylon non-absorbable suture to secure the ET tube to the tube holder
- Round ended scissors.
Making a NPA
- Cut endotracheal tube to measured length (Rationale 12)
- Shorten the length of the tracheal tube holder and insert over the ET tube (Rationale 13)
- Suture the ET tube and tracheal tube holder together (Rationale 14)
Accompanying photos for making an NPA are included in Appendix 2.
Placement of NPA
The right sided nostril is almost always used for NPAs (Rationale 15)
Inserting the NPA
- Decontaminate hands (see Hand Hygiene guideline)
- Put on PPE (see GOSH Standard and Isolation Precautions Policy)
- Ensure the child is swaddled (if appropriate) (Rationale 17)
- Ensure the child’s nostrils are clear from secretions (Rationale 18)
- Ensure oxygen and suction are available at the bedside (Rationale 19)
- Lubricate and insert NPA gently into the nostril. Insert the tip of the tube into the right hand nostril and then gently thread the tube along the floor of the nasal passage perpendicular to the face until the flange is at the tip of the nose (Rationale 16)
- If you are unable to insert the NPA, consider:
- summoning more experienced help (eg ENT or respiratory team, craniofacial or tracheostomy Clinical Nurse Specialist (CNS), Clinical Site Practitioner)
- using a smaller size NPA
- 'steroid-based' nasal drops to assist with insertion (as prescribed)
- insertion in theatre under direct vision and general anaesthetic.
Once inserted, secure the NPA by passing the leukoplast tape through the loops of the tracheal tube holder and then onto the hydrocolloid dressing on the cheeks (Rationale 8).
Clear away equipment according to the GOSH Waste Management Policy.
Decontaminate hands (see Hand Hygiene guideline)
Whilst passing the NPA, observe for any undue respiratory distress. If present, stop and treat accordingly and summon assistance as appropriate (Rationale 20).
- Child’s general behaviour/colour
- Oxygen saturations
- Respiratory rate and effort
- Heart rate
- Children’s Early Warning Score (CEWS) scoring.
The insertion of a NPA must be recorded in the child’s health care records, including the length and the diameter of the NPA and the size of the tube holder. Practitioners should refer to the Emergency algorithm (Appendix 4) and ensure that the suction length has been recorded, to ensure that suctioning doesn’t occur distal to the tube tip which may cause trauma.
Immediately after insertion
- excessive bleeding from the nostril – contact medical team if bleeding persists
- patency with suctioning
- improvement of respiratory symptoms, monitored through regular observations and CEWS scoring
- record observations in the child’s health care record.
- Blanching of nares leading to pressure injury or skin breakdown around the nostril rim (Rationale 21)
- If milk or food comes up the NPA before, during and after feeds (Rationale 22)
- For craniofacial and respiratory patients with longer term NPAs, the length may have to be adjusted (discuss with team).
In the short term, especially with ENT or cleft patients, a donut spacer may be used at the nostril rim which can immediately shorten the length, until the NPA is removed the following morning after surgery (Rationale 23) (Appendix 3).
If the NPA is not inserted under direct vision (using a flexible endoscopy scope) a lateral neck X-ray may be considered to verify tube tip position. This could be used in conjunction with clinical monitoring of vital signs and/or improvement of respiratory symptoms or function.
When the child moves away from their bed space, their emergency box and portable suction apparatus must accompany the child.
For children with a long term NPA who will be discharged with a NPA, early communication between the hospital and community health professionals must occur. Frequency of NPA changes will be discussed on an individual basis and would be included in the discharge plan (Rationale 24).
Care of the long term NPA airway
Nursing actions during the few days following insertion of the NPA centres on:
- maintaining the correct positioning and patency of the NPA
- skin integrity
- parental teaching to support safe discharge.
Care of the skin
- Clean the nostrils as required to prevent excoriation.
- Change leukoplast tape daily or as required. The strong adhesive backing ensures a secure bond onto the tube holder and duoderm. Caution: for children with a latex allergy, an alternative medical adhesive tape must be sourced which is strong and durable enough to secure the NPA.
- Observe pressure areas for redness or breakdown especially around the nostrils – document and contact relevant team if concerned.
- Use hydrocolloid dressing to protect cheeks.
The importance of precise suctioning cannot be underestimated in paediatric NPA care. If the suction length is too short, the child is at risk of tube blockage, yet if the suction length is too long it may lead to trauma to the distal soft tissue.
Practitioners must be competent in respiratory assessment, indications for suctioning and suction technique as this will minimise complications and maximise treatment.
Suctioning is associated with potential complications, and is only recommended when there are clear indications that the patency or ventilation of the children is compromised (American Association for Respiratory Care, 2010: Argent, 2009: Davies et al, 2015: Glass and Grap, 1995: Raymond, 1995: Scobie et al, 2001: Spence et al, 2003)
Potential complications include:
- formation of distal granulation tissue or ulceration
- cardiovascular changes
- bacterial infection
- intracranial changes.
The GOSH clinical guideline on Airway Suction is a useful resource.
The procedure should be explained to the child and the parent or carer (Rationale 1) and the following equipment prepared:
- suction catheters of the correct size
- suction unit with variable vacuum control
- sterile bottled water (in clean container)
- orange waste bag for disposal of waste in line with waste management policy
- apply standard precautions and wear PPE (apron, mask, gloves) (see GOSH Standard and Isolation Precautions Policy)
- decontaminate hands.
The following measures help to reduce the complications from suctioning, but maximise effect.
Suction catheters must meet the following criteria (American Association for Respiratory Care, 2010: Ackerman and Gugerty, 1990: American Thoracic Society, 2000: Argent, 2009: Davies et al, 2015: Glass and Grap, 1995, Scobie et al, 2001: Spence et al, 2003, Raymond, 1995):
- A suction catheter that is double the internal diameter of the NPA (eg a NPA ET size 4.0: use a suction catheter sized 8.0 (Rationale 25)).
- Have one distal and two lateral ports with rounded ends (Rationale 26).
- Have a lateral port that is smaller than the distal ports, so that mucosal adhesion and biopsy do not occur.
- Have an integrated valve for vacuum control (Rationale 27).
- Have numbered graduations for accurate insertion lengths (Rationale 28).
Technique for suctioning:
- Do not rotate the catheter on withdrawal (Rationale 29).
- Suctioning should not be carried out on a routine basis but only when needed – except if the airway is less than 7 days old.
- Suctioning should be quick but effective enough to remove secretions and minimise complications especially atelectasis, hypoxia and cardiovascular changes.
- Practitioners must know the length of the NPA. The suction catheter should remain within the tube and not to go further. The distal and lateral holes of the catheter can just go beyond the end of the NPA but are still protected by the tip of the tube (Rational 28).
- Practitioners should only touch the proximal end of the catheter to minimise contamination (Rationale 30).
- Repeat the procedure only as necessary.
- Record in the child’s health care records if the secretions are bloody, purulent, foul smelling or unusually thick. Take samples for analysis as required.
Instillation of saline
- Instillation of saline drops is a contentious area and there is little evidence to support this practice so should not be used routinely (Rationale 31) (Ackerman and Gugerty, 1990: Neil, 2001).
The child may require extra humidity and this can be delivered via a nebuliser or by a continuous humidity system.
Secretions may become thick and tenacious, making their expulsion difficult. The NPA bypasses the natural route for humidification – which may lead to occlusion of the tube (American Thoracic Society, 2000). Humidification of the NPA must be done artificially, see below:
Saline nebulisers / Water humidification
Water humidifiers are particularly useful when there is a higher requirement for humidification, for example, when the child requires a high minute volume during an acute respiratory illness or post anaesthesia (Raymond, 1995). This could be administered via a face mask.
It is also important that a child with a NPA remains systemically hydrated and practitioners should consider increasing the child’s intake during times of illness such as vomiting, diarrhoea, pyrexia etc.
Practitioners must consider alternative methods of hydrating the child particularly in the post-operative period.
NPA emergency algorithm
Oxygen, suction and resuscitation equipment must be kept by the child’s bedside. The emergency algorithm must be placed at the child’s bedside (Appendix 4).
Liaison must take place with the child’s local hospital and/or community team after insertion and an equipment list faxed to them (Appendix 5).
A child with a NPA may be discharged home whenever their condition is stable and when the parents or carers have been trained to care for the NPA independently (Appendix 6).
The child should have appropriate follow-up according to their medical need.
A copy of the training booklet may be sent to the community team, depending on their local policy.
Rationale 1: To gain cooperation and understanding
Rationale 2: Correct emergency equipment must be readily available to facilitate an immediate response and possible resuscitation.
Rationale 3: A dedicated area with the correct equipment, stored in an emergency NPA equipment box, must be readily available to facilitate an immediate response, and possible resuscitation.
Rationale 4: A NPA is an artificial airway requiring constant care to keep airway patent.
Rationale 5: In case of blockage, displacement or accidental removal a spare NPA of the same size can be re-passed immediately.
Rationale 6: In case you are unable to re-pass usual size, due to oedema
Rationale 7: To facilitate insertion
Rationale 8: Leukoplast is the preferred method of securing, as it’s been found to have good adhesive qualities if placed correctly over the hydrocolloid dressing.
Rationale 9: In line with the local infection prevention and control policy
Rationale 10: provides a barrier between the skin and adhesive tape to prevent excoriation.
Rationale 11: For short term use such as resuscitation, immediate post-operative care there are standard sized ivory NPA’s available (ready made) that do not require customisation. For some children these will be too long and therefore not suitable. Children requiring a specific length NPA will require a custom made tube.
Rationale 12: Once the desired length is known, the ET tube is cut to size – this is usually through the nostrils sitting just above the epiglottis.
Rationale 13: The tube holder must be cut short to ensure that it doesn’t increase the diameter of the ET tube, causing a pressure injury to the nares, but not too short that you can’t suture the two tubes together.
Rationale 14: Sutures should be circumferential to secure the tube holder to the ET tube. Avoid the sutures occluding the opening, thus preventing the suction catheter from being inserted into the NPA. Sutures must be neat and secured.
Rationale 15: This is because of the natural curve of the ET tube and the flange bevel will open into the pharynx. If the standard ET tube is put in on the left nostril the bevel will sit against the pharyngeal wall and is likely to become occluded.
Rationale 16: Anatomically the placement of the NPA should follow the natural downward curve of the nasal cavity. Forcing the NPA is not recommended as this can cause trauma, pain, oedema and incorrect placement.
Rationale 17: Although well tolerated the insertion of the tube can be uncomfortable, therefore to ensure the safe and timely placement of the tube, swaddling may be required.
Rationale 18: Nostrils must be cleaned and any obstruction removed to allow for an easier insertion.
Removed 19: Inserting the NPA can be distressing; having oxygen and suction readily available will support the child during this time and allow immediate suctioning of the NPA.
Rationale 20: Insertion may be distressing for the child therefore there may be a change in the child’s vital signs/CEW scoring. Careful monitoring, give supportive measures, such as oxygen, suctioning, summon additional help as required.
Rationale 21: This may as a result of the ET tube holder being too wide for the child’s nostril. Blanching is an early sign of vascular compromise and must be reported to the medical team immediately.
Rationale 22: this may indicate that the NPA is too long, and interfering with the child’s ability to swallow, leading to food/milk coming back up the NPA. If this occurs, keep the child nil by mouth (NBM) and refer to team who inserted NPA.
Rationale 23: ‘A doughnut spacer’ (Appendix 3) is a temporary solution to immediately shorten the length of the NPA without the need to remove the existing one. This is especially useful when the NPA is only required in the short term. For children requiring long term NPA’s the tube must changed in liaison with Medical and CNS Team.
Rationale 24: Early engagement with local hospital and community support is essential, so that discharge planning/ obtaining the necessary equipment/training staff can be started as soon as possible.
Rationale 25: Suction catheter only occupies half the diameter of the tracheostomy tube allowing the child to continue breathing during the procedure.
Rationale 26: This allows secretions to be collected distally and from the sides of the tube. Catheters with more than three lateral holes weaken the catheter.
Rationale 27: Suction should be applied only on withdrawal. Catheters should not be kinked prior to insertion, in an effort to control the vacuum. In infants and children while there is little evidence to support the optimal negative pressure to be applied, the lowest pressure that will effectively clear secretions should always be used.
Rationale 28: Passing the distal and lateral holes just out of the end of the NPA allows retrieval of secretions coughed up, keeping the tube tip clear. By just going beyond the NPA tip this still protects the catheter preventing the end from adhering to the vulnerable nasopharyngeal mucosa. Practitioners must know the length of the tube.
Rationale 29: Both the distal and lateral holes on the new design of catheter allows for circumferential suctioning.
Rationale 30: Catheters should be discarded prior to use if the distal end is contaminated. Catheters can be re-used during the same episode of suctioning if the distal end is clear from secretions.
Rationale 31: Saline down the NPA may support the retrieval of secretions. This should be done on an individualised basis and only by experienced practitioners.
Rationale 32: The advantage of using water droplets in the respiratory tract is not well documented or understood and some argue that excessive saturation of the lower airways may cause atelectasis and impair the function of distal cilia. For this reason nebulisers should be used as an addition too and not replace a primary method of humidification.
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American Association for Respiratory Care (2010) Clinical Guidelines Endotracheal Suctioning of mechanically Ventilated Patients with artificial Airways, Respir care. 55 (6) 758-764
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Hayward R, Jones B, Dunaway D and Evans R. (eds) (2004) The Clinical Management of Craniosynostosis. London: MacKeith Press
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Raymond SJ. (1995) Normal saline instillation before suctioning: helpful or harmful? A review of the literature. Am J Crit Care. 4 (4): 267-71.
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Scobie M., Copnell, B., Taylor, A., Kinney, S., Shann, F. (2001) Effect of reusing suction catheters on the occurrence of pneumonia in children. Heart and Lung. 30(3) 225-33.
Spence K, Gillies D, Waterworth L. (2003) Deep versus shallow suction of endotracheal tubes in ventilated neonates and young infants. Cochrane Database Syst Rev (3): CD003309.
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Appendix 2: Making of the NPA (photograph) (294.61 KB)
Appendix 3: Use and placement of the donut (photograph) (395.93 KB)
Appendix 4: Emergency Algorithm (454.66 KB)
Appendix 5: Discharge Equipment List (22.3 KB)
Appendix 6: NPA Training record (carer) (581.83 KB)