# 194 "Though she be but little, she is fierce"
Wm. Shakespeare. "Midsummer Night's Dream"
The humble, yet greatly capable, nasopharyngeal airway, in modified form, with a 15 mm endotracheal tube connector tightly inserted in the outer end, and an additional 'Murphy Eye' cut into the distal convexity, solves many problems. Though it does not put an inflated cuff past the vocal cords into the trachea, an endotracheal tube in the pharynx will work, until it is possible to place it intratracheally.
- The 15-mm connector prevents aspiration and connects directly to a breathing circuit. The 'eye' prevents obstruction if the bevel abuts tissue. Length placed is adjusted by listening for, or, feeling best airflow or inspection by scope (~10 mm from glottis, in adults).
- Insertion is possible even in trismus or during convulsions. Facial disproportion or irregularities are bypassed; lips and other nostril are held closed by hand.
- Overcomes palatal and base of tongue obstruction in the airway delivering flow adjacent to the glottis. The combined internal diameter of two NPAs is greater than an endotracheal tube (using a mask or double connector). High flow or CPAP is effective in preoxygenation, apneic oxygenation, and distends the pharyngeal diameter. A maximally open airway lessens pressures and gastric insufflation.
- Well-lubricated NPAs carefully inserted along the natural curves are generally atraumatic; vasoconstrictors can minimize epistaxis potential. This curve can be a conduit for flexible bronchoscopic intubation or a difficult nasogastric tube placement. The NPA can be slit on its curve to make removal easy with the delivered item in situ.
- An ETT, used as an NPA, can have its cuff inflated to further displace the base of tongue. Remember to deflate the cuff before advancing or removing the tube.
- Oxygenation and ventilation can continue during intubation or flexible laryngoscopy via the other nostril. One can also pass the scope through the NPA, during such, with a bronchoscopy swivel adaptor to the circuit.
- The attached breathing circuit 'stays where needed' during unassisted, or minimal staff , CPR. Heavy circuits may need support.
- Airways and lubricant are easily pocket-carried within a plastic bag.
- Although most literature is recent, NPAs have been used, anecdotally, since long before the mid-1970s.
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