Code 3 Workshop

Paramedic Education
Home/All lessons/Airway & Breathing/OPA & NPA: Airway Adjuncts That Work
Lesson

OPA & NPA: Airway Adjuncts That Work

10 min Airway & Breathing

Objective: Pick and size an OPA or NPA so the BVM actually ventilates — and know when the adjunct is the wrong tool.

Why This Is Hard

Adjuncts look like beginner skills. They fail as often as BVM seals: wrong size, gagging an intact patient, an NPA shoved into a suspected basilar-skull fracture, or an OPA that sits on the tongue and worsens obstruction. The adjunct is a bridge for bagging, not a trophy airway.

AHA 2025 adult BLS teaching still treats bag-mask ventilation as a two-person skill when a second rescuer is available — one opens and seals, one squeezes. The OPA or NPA makes that seal useful. It does not replace it.

On this truck
  • You bag in a tight cab, often with one extra set of hands if you are lucky. Size the adjunct, then go back to position and a two-person seal.
  • An NPA is not “safe in every trauma face.” Severe midface trauma and cribriform-plate concern still belong to your protocol language — not a reflex nasal trumpet.
  • If they gag, the OPA comes out. Vomiting in the truck is worse than a proud adjunct.
Say out loud
  • Gag present? OPA is the wrong tool
  • Size first — corner-of-mouth to angle of jaw (OPA); nostril to earlobe/tragus (NPA)
  • Position (ear-to-sternal-notch) before you blame the adjunct
  • Two-person seal when you have hands

OPA (Oropharyngeal Airway)

  • When it fits: unresponsive, no gag, you need a path for BVM or spontaneous effort that is still obstructed by the tongue.
  • Size: flange at the corner of the mouth to the angle of the mandible (or tragus). Too short parks on the tongue; too long can push the epiglottis down.
  • Seat: follow your training (invert-and-rotate in many adult methods, or tongue-blade insertion). Stop if they gag — pull it and switch plans.
  • Not for: a talking, coughing, or intact-gag patient. Forcing an OPA causes vomit and a worse airway.

NPA (Nasopharyngeal Airway)

  • When it fits: clenched jaw, light gag, or you need a nasal path for oxygen/BVM while they still have some tone. Often better tolerated than an OPA.
  • Size: nostril to the earlobe or tragus; diameter should pass without brutal force. Lubricate.
  • Bevel and direction: follow the floor of the nose. If one side will not pass, try the other — do not punch through resistance.
  • Caution: suspected midface trauma or basilar-skull fracture (raccoon eyes, Battle sign, CSF leak teaching clues) — many protocols prefer oral routes. The cribriform-plate injury literature is mostly nasotracheal tubes, not NPAs, but do not force past resistance. Do not treat “possible head injury” as a free pass to skip every NPA when the mouth is wrecked and they need oxygen now.

Street Rules (Education)

  • Open, suction, position — then adjunct. A closed airway with a pretty OPA is still closed.
  • Reassess after every move. Adjuncts displace when you package.
  • If SpO2 will not climb, run DOPE-S before you keep bagging the same leak.

Field Pitfalls

  • OPA in a patient who still gags.
  • One-size-fits-none: grabbing the first tube in the pouch.
  • Calling the airway “secured” because an adjunct is in — it is not an ETT or SGA.

Practice

60-second drill

Partner names three patients: snoring unresponsive with no gag; clenched jaw after a seizure, still breathing; facial smash with CSF from one nare. For each, say OPA, NPA, or neither — plus one sizing landmark.

Related: Effective BVM Ventilation, Supraglottic Airways.

Sources & Further Study

Named guidelines for further study. They are not clinical orders and do not replace your protocol or medical direction.

Education only. Apply learning within your protocols and medical direction. This is not clinical care guidance.

Check Your Understanding

Street decisions from this lesson only. After you check, the key is highlighted. Education practice — not a certification exam.

1. An oropharyngeal airway is the wrong first adjunct when:
2. A common adult OPA sizing landmark is:
3. Nasopharyngeal airways are often better tolerated than OPAs, but a teaching caution is:
4. An OPA or NPA in place means:
← Preoxygenation & Apneic Oxygenation Foreign-Body Airway Obstruction →