Nasopharyngeal Airway
A flexible tube inserted through the nostril and into the pharynx to maintain airway patency in unconscious or semi-conscious patients, generally tolerated by patients with intact gag reflex.
In the Field
The nasopharyngeal airway, or NPA, is one of the most underused tools in tactical medicine. It is small, simple to insert, and tolerated even by patients who are still partially responsive. Most operators have one in their IFAK without ever practicing how to use it, which is a missed opportunity. An NPA on a casualty with altered mental status or trauma to the face can be the difference between maintained airway and progressive airway compromise during evacuation. Knowing the term and the indication is the first step. Practicing the placement is what makes the skill real.
Common Mistake
Inserting an NPA by following the angle of the nares and not inserting it at 90 degree angle to the face.
Technical Detail
The Nasopharyngeal Airway (NPA), also called a nasal trumpet, is a flexible plastic or rubber tube inserted through a nostril and advanced into the pharynx (the throat behind the nose). The NPA establishes and maintains an open airway in patients who are unconscious or have decreased level of consciousness but still have an intact gag reflex.
How it works. In a patient with depressed level of consciousness, the muscles of the upper airway relax. The tongue can fall backward against the posterior pharynx, partially or fully obstructing the airway. The NPA bypasses this obstruction by providing an open conduit from the nostril through the pharynx, allowing air to move past the relaxed tongue.
The NPA is well-tolerated by patients with intact gag reflex because it does not contact the back of the tongue or the posterior pharynx in a way that triggers the gag reflex. This contrasts with the oropharyngeal airway (OPA), which sits at the back of the tongue and is poorly tolerated in patients with intact gag reflex.
Indications. The NPA is appropriate for:
Patients with decreased level of consciousness and inadequate airway protection but intact gag reflex.
Patients with maxillofacial trauma where oral airway access is compromised by blood, broken teeth, or anatomic distortion.
Patients with seizures or trismus (jaw clenching) that prevents oral access.
As an adjunct during bag-mask ventilation to improve airway patency.
Patients on the threshold between alert and unconscious, where airway support is needed but the patient cannot tolerate an OPA.
Contraindications. The NPA is generally avoided in:
Patients with suspected basilar skull fracture. The NPA can theoretically pass through a fracture into the cranial vault. The classical signs of basilar skull fracture (raccoon eyes, Battle sign, CSF leak from nose or ear) raise concern, though the actual incidence of intracranial NPA placement is rare.
Patients with significant nasal trauma, deformity, or obstruction that prevents safe insertion.
Patients with bleeding disorders or on anticoagulants, where the procedure may produce significant nasal bleeding.
Sizing. NPA sizing is critical for proper function:
Length. The proper length is from the tip of the patient's nose to the angle of the jaw or earlobe. Too short and the airway is not bypassed; too long and the tube extends past the appropriate position and may stimulate gag reflex or cause injury.
Diameter. The NPA should fit comfortably in the nostril without forced insertion. A diameter that is too large causes pain and bleeding; too small reduces airflow.
Standard adult NPAs are typically size 28 to 32 French (approximately 7 to 8 mm internal diameter). Smaller sizes are used for women and smaller adults.
Insertion technique. Standard insertion technique:
Select the appropriate size NPA.
Lubricate the tube with water-soluble lubricant.
Insert into the nostril (typically the right, due to anatomic preference) with the bevel facing the septum.
Advance gently, perpendicular to the face, until the flange seats against the nostril.
If resistance is encountered, do not force. Try the other nostril or use a different size.
Confirm placement by feeling for air movement through the tube and listening for breath sounds.
Insertion should be performed in less than 30 seconds.
Field use. The NPA is one of the most accessible airway adjuncts in tactical medicine:
Standard contents of IFAKs and aid bags.
Multiple sizes carried in advanced kits.
Compact, lightweight, and inexpensive.
Tolerable by patients with intact gag reflex, expanding the patient population in whom airway adjuncts can be used.
Self-aid feasible in some scenarios, where a casualty can place their own NPA.
Provider scope. NPA placement is taught at multiple levels:
Stop the Bleed and basic civilian first responder courses (basic awareness).
EMT level (formal placement skill).
TCCC ASM and CLS levels (military foundation).
TECC for first responders.
Higher provider levels build NPA placement into a broader airway management skill set.
In the MARCH context. The NPA is one of the interventions in the A (Airway) component of the MARCH algorithm. It addresses airway compromise in conscious or semi-conscious patients without requiring the more advanced skills (supraglottic airway, surgical airway) that are limited to provider levels. See the MARCH Algorithm and Surgical Airway entries.
Procurement implications. NPA inclusion is reflected in:
Standard IFAK contents (typically one NPA per IFAK).
Aid bag contents (multiple sizes for different patient populations).
Lubricant supplies for proper insertion.
Training in NPA selection, sizing, and insertion technique.
How it works. In a patient with depressed level of consciousness, the muscles of the upper airway relax. The tongue can fall backward against the posterior pharynx, partially or fully obstructing the airway. The NPA bypasses this obstruction by providing an open conduit from the nostril through the pharynx, allowing air to move past the relaxed tongue.
The NPA is well-tolerated by patients with intact gag reflex because it does not contact the back of the tongue or the posterior pharynx in a way that triggers the gag reflex. This contrasts with the oropharyngeal airway (OPA), which sits at the back of the tongue and is poorly tolerated in patients with intact gag reflex.
Indications. The NPA is appropriate for:
Patients with decreased level of consciousness and inadequate airway protection but intact gag reflex.
Patients with maxillofacial trauma where oral airway access is compromised by blood, broken teeth, or anatomic distortion.
Patients with seizures or trismus (jaw clenching) that prevents oral access.
As an adjunct during bag-mask ventilation to improve airway patency.
Patients on the threshold between alert and unconscious, where airway support is needed but the patient cannot tolerate an OPA.
Contraindications. The NPA is generally avoided in:
Patients with suspected basilar skull fracture. The NPA can theoretically pass through a fracture into the cranial vault. The classical signs of basilar skull fracture (raccoon eyes, Battle sign, CSF leak from nose or ear) raise concern, though the actual incidence of intracranial NPA placement is rare.
Patients with significant nasal trauma, deformity, or obstruction that prevents safe insertion.
Patients with bleeding disorders or on anticoagulants, where the procedure may produce significant nasal bleeding.
Sizing. NPA sizing is critical for proper function:
Length. The proper length is from the tip of the patient's nose to the angle of the jaw or earlobe. Too short and the airway is not bypassed; too long and the tube extends past the appropriate position and may stimulate gag reflex or cause injury.
Diameter. The NPA should fit comfortably in the nostril without forced insertion. A diameter that is too large causes pain and bleeding; too small reduces airflow.
Standard adult NPAs are typically size 28 to 32 French (approximately 7 to 8 mm internal diameter). Smaller sizes are used for women and smaller adults.
Insertion technique. Standard insertion technique:
Select the appropriate size NPA.
Lubricate the tube with water-soluble lubricant.
Insert into the nostril (typically the right, due to anatomic preference) with the bevel facing the septum.
Advance gently, perpendicular to the face, until the flange seats against the nostril.
If resistance is encountered, do not force. Try the other nostril or use a different size.
Confirm placement by feeling for air movement through the tube and listening for breath sounds.
Insertion should be performed in less than 30 seconds.
Field use. The NPA is one of the most accessible airway adjuncts in tactical medicine:
Standard contents of IFAKs and aid bags.
Multiple sizes carried in advanced kits.
Compact, lightweight, and inexpensive.
Tolerable by patients with intact gag reflex, expanding the patient population in whom airway adjuncts can be used.
Self-aid feasible in some scenarios, where a casualty can place their own NPA.
Provider scope. NPA placement is taught at multiple levels:
Stop the Bleed and basic civilian first responder courses (basic awareness).
EMT level (formal placement skill).
TCCC ASM and CLS levels (military foundation).
TECC for first responders.
Higher provider levels build NPA placement into a broader airway management skill set.
In the MARCH context. The NPA is one of the interventions in the A (Airway) component of the MARCH algorithm. It addresses airway compromise in conscious or semi-conscious patients without requiring the more advanced skills (supraglottic airway, surgical airway) that are limited to provider levels. See the MARCH Algorithm and Surgical Airway entries.
Procurement implications. NPA inclusion is reflected in:
Standard IFAK contents (typically one NPA per IFAK).
Aid bag contents (multiple sizes for different patient populations).
Lubricant supplies for proper insertion.
Training in NPA selection, sizing, and insertion technique.