Contraindications to nasopharyngeal airway insertion

A NASOPHARYNGEAL AIRWAY (NPA), commonly called a nasal trumpet, is a short uncuffed tube that's inserted nasally along the floor of the nasopharynx past the base of the tongue to maintain a patent airway. Once inserted, the NPA prevents the patient's tongue from occluding the airway. It also provides access for nasotracheal suctioning with minimal discomfort or trauma to the patient's nasopharyngeal tissue. This article explores indications and contraindications for this basic airway adjunct. A closer look at an NPA The single-use disposable NPA is made of sterile, latex-free, medical-grade polyvinyl chloride (PVC) that's soft and flexible. Medical-grade PVC, a nontoxic material free from lead, is molded to form medical devices that meet strict FDA requirements. NPAs have a soft beveled tip that minimizes tissue trauma during insertion. The other end of the NPA is flared to prevent complete retraction of the tube into the nasopharyngeal cavity once it's been inserted.1 (See Sizing up an NPA.) Unlike an oropharyngeal airway (OPA), which is used only in unconscious patients, an NPA may be used for patients who are semiconscious (with intact cough and gag reflexes) or unconscious. Other indications include: prolonged seizure activity2 need for frequent nasotracheal suctioning airway obstructed by the tongue.3,4 If insertion of an OPA isn't possible due to, for example, trismus (lockjaw) or wiring of the jaws, an NPA may be used. The NPA will prevent the tongue from falling back into the posterior pharynx, obstructing airflow, and causing anoxic brain injury.5 As the patient's level of consciousness declines and cough and gag reflexes diminish, an OPA may provide more therapeutic benefit than an NPA until an advanced airway can be placed. Understanding contraindications Contraindications to placing an NPA include the following. Traumatic brain injury (TBI) or central facial fractures, which generally result from blunt force trauma to the head or face, can cause a structural collapse of the bones that separate the brain from the nasopharyngeal area. Placing an NPA in patients with these fractures could further damage the structural integrity of the bone and surrounding tissue or result in direct penetration of the NPA into the brain. Facial fractures or TBI can also tear the brain's dura, resulting in cerebral spinal fluid (CSF) rhinorrhea. Inserting an NPA could contaminate the sterile CSF and cause a potentially life-threatening infection, such as meningitis.6,7 Assessment findings suggesting basilar skull or cribriform fractures include Battle sign (the presence of ecchymosis over the mastoid bone), raccoon's eyes (periorbital ecchymosis), CSF otorrhea, or CSF rhinorrhea. The posterior base of the nasal cavity is the roof of the mouth or cribriform plate. This thin bone joins the posterior roof of the mouth to the ethmoid sinus and protects the anterior fossa of the brain. Placing an NPA is contraindicated if the patient might have a cribriform fracture because the device could penetrate the brain's anterior fossa.5,6,8 Anticoagulant therapy, such as with aspirin, warfarin, heparin, or enoxaparin, is a contraindication to NPA placement because this predisposes the patient to epistaxis.5,6 Coagulopathic disorders can be genetic, the result of disease, or an adverse reaction to medication and may be a contraindication to NPA insertion. Examples include: end-stage liver failure disseminated intravascular coagulation heparin-induced thrombocytopenia hemophilia A or B Factor II, V, VII, X, or XII deficiency idiopathic thrombocytopenic purpura von Willebrand disease.5 If the nasal mucosa were inadvertently damaged during insertion of the NPA, a patient could experience profound hemorrhage. Consult with other members of the healthcare team before inserting an NPA.5,6 Transsphenoidal surgery is performed by making an incision inside the superior upper lip and above the hard palate. Part of the sella floor is removed after the sphenoid sinus floor is dissected, and the dura is incised for certain surgical procedures. These include procedures used to control CSF rhinorrhea or to remove the pituitary, pituitary adenomas, or craniopharyngioma tumors that extend into the sphenoid sinus. It's also used to perform a complete hypophysectomy to help control bone pain in patients with metastatic cancer.9,10 Additional contraindications. An NPA is generally contraindicated in new postoperative rhinoplasty or septoplasty patients because it can cause tissue trauma or damage the newly altered structural integrity of the surgical site. The nasal passages may also be occluded with surgical packing.11 Better safe than sorry As patient advocates, we must consult with multidisciplinary healthcare team members such as healthcare providers, other nurses, and respiratory therapists when the potential risks of inserting an NPA might outweigh the benefits. Sizing up an NPAFigure: Sizing up an NPA