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Lesson

OPA & NPA Adjuncts

10 min Airway & Breathing Skip to quiz

Objective: Size an oropharyngeal airway (OPA) or a nasopharyngeal airway (NPA) so the bag moves air. Take the OPA out if they gag. Do not force an NPA past resistance in a crushed face.

Why this matters

An airway adjunct fails as often as a bad bag seal. The usual reasons are that the airway is the wrong length, you place an oropharyngeal airway (OPA) in a patient who still gags, you force a nasopharyngeal airway (NPA) into a crushed face, or the OPA sits on the tongue and makes the blockage worse. The adjunct helps the bag move air. It is not a secured airway.

When a second person is there, this is a two-person skill. One person opens the airway and seals the mask. The other squeezes the bag. A two-handed jaw-thrust seal beats a one-handed E-C clamp. The adjunct makes that seal useful. It does not replace it. You often do this in a tight ambulance cab, with only one extra set of hands.

Verbalize
  • If they gag, the OPA comes out. Vomiting in the ambulance is worse than taking the adjunct out.
  • I size an OPA from the corner of the mouth to the angle of the jaw only. I do not use the tragus for an OPA.
  • I size an NPA from the nostril to the earlobe or the tragus.
  • I line the ear up with the sternal notch before I blame the adjunct.

Clinical sequence

  1. Check for a gag first. If they gag, cough, or talk, do not place an OPA.
  2. Measure before you insert. An OPA goes from the corner of the mouth to the angle of the jaw. An NPA goes from the nostril to the earlobe or the tragus. Use lubricant on the NPA, and do not force a size that will not pass.
  3. Open the airway, suction, and line the ear up with the sternal notch. Then place the adjunct. An OPA in a closed airway does not open it.
  4. Bag with two people when you have them. One lifts the jaw into the mask. The other squeezes. Check the adjunct again after every move, because it shifts when you package the patient.

OPA (Oropharyngeal Airway)

Several sizes of curved oropharyngeal airways with colored flanges. Oropharyngeal airways
A nasopharyngeal airway in its wrapper. The tip has a beveled opening. Nasopharyngeal airway
These are the devices. OPA length is the corner of the mouth to the angle of the jaw. NPA length is the nostril to the tragus, or the nostril to the earlobe. Do not size an OPA from the ear. The NPA bevel opening faces the septum, and the pointed end stays lateral. On the photo, that opening is the hole at the tip. Advance the airway along the floor of the nose, not upward. A correct tip sits in the pharynx, above the epiglottis. Too short, and an OPA sits on the tongue. Too long, and the tip can push the epiglottis down. Protocol decides which adjunct, if any. Oropharyngeal airways by Intersurgical, Wikimedia Commons, CC BY-SA 3.0. Nasopharyngeal airway by Struppig taucher, Wikimedia Commons, CC BY 4.0. Cropped and contrast adjusted. The adapted oropharyngeal photo stays under CC BY-SA 3.0.
  • When it fits. The patient is unresponsive, has no gag, and you need a path for the bag, or the tongue is still blocking their own breaths.
  • If the length is wrong, the adjunct blocks the airway. Too short, and the OPA sits on the tongue. Too long, and it can push the epiglottis down.
  • Place it the way you were trained. Many adult methods turn it as it goes in, or use a tongue blade. Stop if they gag. Take it out and change the plan.
  • Do not force it in a patient who is talking, coughing, or still has a gag. That causes vomit and a worse airway.

NPA (Nasopharyngeal Airway)

  • When it fits. The jaw is clenched, the gag is light, or you need a nasal path while they still have some muscle tone. Patients often tolerate an NPA better than an OPA.
  • Direction. Aim posteriorly along the floor of the nose, not upward. The bevel opening faces the nasal septum, and the pointed end stays lateral. If one side will not pass, try the other side. Do not force it through resistance.
  • Caution. Suspect midface trauma or a basilar skull fracture if you see raccoon eyes, Battle sign (bruising behind the ear), or cerebrospinal fluid leaking from the nose or ear. Many protocols prefer an oral route. Reports of injury through the cribriform plate are mostly about nasotracheal tubes, not NPAs, but do not force past resistance. Do not skip every NPA just because there might be a head injury, if the mouth is destroyed and they need oxygen now.

Teaching points

  • An NPA is not safe in every injured face. Severe midface trauma still follows your protocol. Do not place a nasal airway out of habit.
  • If the sat will not rise, run DOPE-S before you keep bagging the same leak. That check is displacement, obstruction, pneumothorax, equipment, and seal.
  • An adjunct in place is not an endotracheal tube and it is not a supraglottic airway. Do not call the airway secured.

Common errors

  • Placing an OPA in a patient who still gags.
  • Grabbing the first airway in the pouch without measuring.
  • Calling the airway secured because an adjunct is in.

Practice

One-minute check

Your partner names three patients: snoring and unresponsive with no gag; a clenched jaw after a seizure, still breathing; a crushed face with clear fluid from one nostril. For each, say OPA, NPA, or neither, and name 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

Questions drawn only from this lesson. 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 NPA is sized from:
5. An OPA or NPA in place means:
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