Dietrich Easter

Nasopharyngeal Airway (NPA) vs. Oropharyngeal Airway (OPA): Airway Adjuncts 

Nasopharyngeal airways (NPAs) and oropharyngeal airways (OPAs) are basic components of a first aid kit. 

The NPA passes through the nose and extends to the back of the throat, creating a clear passage for air to enter the lungs. The OPA is inserted through the mouth. Like the NPA, the OPA works to hold the tongue off the back of the throat, allowing air to pass freely into the trachea. 

Unfortunately, many paramedics, EMTs, and civilian first responders misunderstand the NPA and the OPA. 

These tools appear simple, but if airway-adjuncts are misused, people can get hurt. 


What's the Difference Between the OPA and the NPA? 

The NPA and OPA are two different rescue tools designed to do similar things. However, there are times when one is a more appropriate choice than the other.


Here are several differences between the OPA and NPA: 

  • NPAs are inserted into the nose
  • OPAs are placed in the mouth
  • NPAs avoid stimulating a gag reflex 
  • OPAs will stimulate the gag reflex and could induce vomiting 
  • NPAs can cause nose bleeding, and they are relatively contraindicated in possible skull fracture patients (there is debate whether this is truly a concern)
  • OPAs act as a bite block, giving a passage for suctioning secretions
  • NPAs need to be lubricated 
  • OPAs can cause trauma to teeth or soft tissue in the mouth if improperly placed

Alright, now that you have a few ideas about these two airways, let's look at each in more depth. 


What's an NPA? 

A Nasopharyngeal airway or NPA is used to help people who are breathing inadequately. 

NPAs are small hollow tubes made of silicone material. The NPA is sometimes known as a "nose hose." The NPA has a bevel (the end inserted into the nose) and a flange (that rests against the nare and prevents the NPA from getting lost in the nose). 

NPAs come in many sizes, from infant to adult. They also come in many different brands and several variations. 


Here are two types of NPA: 

  • Pre-Lubricated NPAs: These NPA's come pre-lubricated in their package, allowing for rapid deployment. They also have a different bevel placement, making them simple to place in both nostrils. 
  • Standard NPAs: You'll need to lubricate these NPA's before insertion. 

Let's discuss when to use an NPA. 


When Should I Use an NPA? 

Consider an NPA anytime you encounter a patient with respiratory failure or apnea (not breathing at all). However, just because someone isn't breathing well doesn't mean they can handle an NPA. 


Here are some patients who may need an NPA: 

  • Patients in respiratory failure who need bag-valve-mask ventilation, but their gag reflex is intact.
  • Patient's who have clenched their jaw, leaving NPA as your only option. 


Here are a few conditions that may require an NPA:

  • Seizure patients 
  • Respiratory failure second to COPD 
  • Overdose 
  • Trauma patients with intact facial structure 


Now, let's list several times you should avoid the NPA: 

  • Awake patient's who cannot tolerate insertion
  • Possibility for nose bleeds 
  • Facial and specifically nasal trauma 

Note: Always follow your local protocol for guidance on when to use airway adjuncts. 


How To Use an NPA?

Always handle an NPA with respect. If you cause a nose bleed, this can make a bad situation worse. 

Steps to using an NPA: 

  1. Safety: Gloves, eye protection, facial protection. 
  2. Size the NPA: Measure the NPA from the earlobe to the nostril. You want to get the size as perfect as possible. 
  3. Prepare the NPA: Using NPA lubrication is important to prevent trauma to the nose. 
  4. Insertion: It's recommended to start with the right nare. Most recommend placing the bevel of the NPA towards the septum (middle) of the nose. 
  5. Slowly advance: Angle the NPA toward the base of the nose. Imagine the nose is a pig nose, and the NPA needs to go straight back.
  6. Evaluate and make changes: If the patient is awake, ask them how they feel. If you're ventilating the patient with a BVM, did the breathing become easier? Is the chest rising and falling? If something isn't working, change for a different size, or ask for another rescuer’s opinion. 


Here's a video on how to place an NPA


What is an OPA? 

An oropharyngeal airway, or OPA, is inserted into a person's mouth to help them breathe. OPAs work by holding the tongue off the back of the throat. 

OPAs are often made of polypropylene (PP), a semi-pliable plastic material. This material isn't so rigid that it could snap in the patient's mouth, but it’s sturdy enough to do its job. 

OPAs come in many sizes - infant, child, and adult. OPAs are a pretty simple design, and they don't have a ton of variation. 


Here are the two main types of OPA: 

  • Standard open OPA: This OPA has open sides and holes down the inner spine of the OPA, allowing for air to pass easily and allowing for easy suctioning of secretions in the airway. 
  • Standard tubular OPA: These OPAs are almost like NPAs in that they have a tubed design without an open side. 

Let's discuss the best times to use an OPA. 


When Should I Use an OPA? 

Use OPA's for a patient who is breathing inadequately. OPA's will stimulate a gag reflex, so you must determine the patients' state of consciousness before placement. 

If you become hasty or irreverent with the OPA, you could end up with a patient's lunch erupting, exposing you and potentially entering their lungs (aspiration). 


Here are some times to use an OPA: 

  • Drug overdose 
  • Respiratory arrest 
  • Drowning patients 
  • When a patient is unable to breathe on their own. 


Here are several times to avoid an OPA: 

  • Seizures: You don't want to put anything in a patient's mouth during a seizure. If the patient needs rescue breathing after the seizure, then an OPA could be considered. 
  • Intact gag reflex: How do you check for an intact gag reflex? First, you can lightly touch a patient's eyelash; if their blink reflex is still in place, then they likely have their gag reflex. Another way to determine a gag reflex is to watch if a patient can still swallow. If you observe them swallowing back secretions, that means they are providing some protection from secretions, and their gag reflex is likely intact. 

Let's talk about how to use an OPA. 


How To Use an OPA? 

Using an OPA is a simple task. However, it seems that simple tasks can make us careless. Unfortunately, there have been plenty of times where someone harmed a patient because of an inappropriate OPA insertion. 

Before we talk about how to insert an OPA, let's go over several things to remember: 

  • Gag-reflex: Be sure to determine the patient's gag-reflex; if they have an intact gag reflex, the OPA could induce vomiting. 
  • Size: Think of the OPA as the key to the lungs; only the proper size will work.
  • Dentures: OPAs can be placed with and without dentures - just beware you don't cause an obstruction. If the dentures become dislodged, remove them.


Here are the steps to using an OPA: 

  1. Safety: Always wear PPE. Blood and vomit are no fun. 
  2. Sizing: Size the OPA from the corner of the mouth to the angle of the jaw. Also, don't be afraid to exchanges sizes if something isn't working after placement.
  3. Insert: Unlike the NPA, OPAs don't usually require lubrication. To insert the OPA, you can bring it toward the mouth sideways, spinning it down into place while you advance it into the mouth. Using a tongue depressor while inserting the OPA is also effective. 
  4. Evaluate: Is the OPA working? Is bag-valve-mask ventilation working? Is their oxygen saturation improving? Are they gagging? Emergency care isn't static - always be ready to make a change. 


Here's a video on how to insert an OPA

Note: When using an OPA, always think about controlling the tongue because that's the OPA's job. If you jam the OPA into place, you can cause harm. Always ensure the OPA controls the tongue. 


Common Questions about NPAs and OPAs

Below, we answer some common NPA and OPA questions. 


Do You Place an NPA During a Seizure? 

Yes, you can place an NPA during status epilepticus. However, the best way to protect an airway during a seizure is to stop the seizure. Call 911 if you're a civilian. Paramedics have medications to treat a dangerous seizure. 


Which Nostril Do You Use for the NPA? 

Traditionally, you try the right nostril first, as this is typically the larger nare. However, you can use either. And, you can place two NPAs if needed.


Can You Use an NPA and an OPA at the Same Time? 

Yes, you can use an NPA and OPA at the same time. However, only perform extra procedures because you believe it's in the patient's best interest. 


Final Words 

The NPA and OPA are effective tools for establishing a patent airway. If used effectively, the NPA and OPA can help save lives. 

Treat every emergency medical tool with respect, especially the simple ones like the NPA and OPA. These tools are simple to use, but they're also simple to misuse.