# OPA plus two NPA's?



## zzyzx (Feb 1, 2012)

I was watching Dr. Weingarten's excellent podcast the other day, and one of contributors to his podcast was advocating using an OPA and dual NPA's whenever you bag a patient. 

Hasn't it been shown that using two NPA is no more effective than one NPA? I seem to remember an old study showing this was so. 

What about using an OPA and one NPA---never seen anyone do this.


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## emtpche (Feb 1, 2012)

Not sure but that's a lot of time on your hands if your bagging your patient and able to stick that all in.  Might want to figure out why you are bagging the pt and fix those prior to plugging all three openings, just my two cents.


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## the_negro_puppy (Feb 1, 2012)

If i need to use an OPA, my next move is a more advanced airway, not thetriplication my basic airway.


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## technocardy (Feb 1, 2012)

the_negro_puppy said:


> If i need to use an OPA, my next move is a more advanced airway, not thetriplication my basic airway.



Assuming you have access to a more advanced airway.


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## NomadicMedic (Feb 1, 2012)

I've wedged a couple of NPAs in a PT that needed bagged. Certainly better than having to RSI a diabetic.


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## Medic Tim (Feb 1, 2012)

If for whatever reason I can't or don't want to drop a tube I will double stack the NPAs or go OPA with a. NPA.


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## NomadicMedic (Feb 1, 2012)

Medic Tim said:


> If for whatever reason I can't or don't want to drop a tube I will double stack the NPAs or go OPA with a. NPA.



Agreed. I enjoy intubating as much as every other medic, but I'm not married to it. If a good old BLS airway will do the job, why not keep it simple?


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## Lozenger19 (Feb 2, 2012)

I've treated a patient who needed OPA and NPA at the same time. We were able to control his airway and he was stable the whole time.


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## Brandon O (Feb 2, 2012)

For anyone unfamiliar, this is the podcast zzyzx referred to: http://emcrit.org/podcasts/bvm-ventilation/ one of the best (and most EMS-relevant) available over there, IMO.

The issue you mention is a matter of ongoing interest for me, as it does contradict some teachings and I've been unable to find any literature supporting it. (Dr. Weingart also said he knew of nothing published.) However, it's definitely widespread and seems effective.

In my baseless opinion, the issue seems to be that in real life, sick patients typically have so little tone in the soft tissues of the airway that rather than the airway "splinting" open the pharynx as we were taught, everything collapses around the it, leaving only the actual internal lumen of the plastic as your patent space. So, more airways means more space means less resistance, a good thing when bagging is already so tough sometimes.

Everyone should seriously take a few minutes to catch that podcast; he may break you from using the "EC" technique forever.


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## mycrofft (Feb 2, 2012)

OK, those are the mostly positive side of the equation.
How about the risks/negative side?

1. Uses time that could be spent otherwise (for better, or not? See above).

2. What about "common" trauma introducing the device? Or, your pt has nasal polyp's or a deviated septum? Could nasopharyngeal bleeding and/or swelling complicate later attempts to introduce an intratracheal device?

3. Vagal stimulation? 

I can see that a pt by pt decision might be best, but what would the criteria be?


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## NomadicMedic (Feb 2, 2012)

mycrofft said:


> I can see that a pt by pt decision might be best, but what would the criteria be?



I view it this way, if I need to assist the PTs respirations, but I feel I'll be able to soon correct the condition, ie: naran or D50, I'll use a BLS airway to prevent an intubation, and subsequent extubation... and to assist with keeping that airway patent. 

Obviously, some patients just need to be intubated... Others can be managed without a tube. It is truly decided on a case by case basis.


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## Brandon O (Feb 3, 2012)

mycrofft said:


> OK, those are the mostly positive side of the equation.
> How about the risks/negative side?
> 
> 1. Uses time that could be spent otherwise (for better, or not? See above).
> ...



Well, I would suggest: anyone getting the BVM should at least be a candidate for a basic airway. If there's any difficulty at all with the one, consider another. Rinse and repeat as needed.

I tend to find the adverse effects of these little guys a little underwhelming, but as in all things a gimlet eye is advised.


I also want to call attention to the point made in the podcast that there is real benefit to simply using an airway/grip that leaves the mouth open, rather than squeezing it shut and relying on nasal flow... I know we were mostly taught that you don't need the mouth open to bag, but that may not be 100% true.


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## jwk (Feb 13, 2012)

Brandon Oto said:


> For anyone unfamiliar, this is the podcast zzyzx referred to: http://emcrit.org/podcasts/bvm-ventilation/ one of the best (and most EMS-relevant) available over there, IMO.
> 
> The issue you mention is a matter of ongoing interest for me, as it does contradict some teachings and I've been unable to find any literature supporting it. (Dr. Weingart also said he knew of nothing published.) However, it's definitely widespread and seems effective.
> 
> ...



If you have a problem bagging a patient, you need better BVM technique or you need to move to a more definitive airway.  Patients don't "need" an OPA and an NPA.  An appropriately sized airway, one or the other, should be enough.  Messing around trying to bag someone with a marginal airway is pointless.  Some patients are just tremendously difficult to manage with a mask airway - I have all the toys in the OR with me and there are still patients I can't bag well, particularly those who are edentulous or bearded.  If you have to have an airway, give them one!


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## Veneficus (Feb 13, 2012)

jwk said:


> I have all the toys in the OR with me and there are still patients I can't bag well, particularly those who are edentulous or *bearded*.  If you have to have an airway, give them one!



have you tried a razor or a scalpel? 

Sorry, rough day, couldn't resist.


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## jwk (Feb 13, 2012)

Veneficus said:


> have you tried a razor or a scalpel?
> 
> Sorry, rough day, couldn't resist.



LOL - funny you mention that.  When I first started doing anesthesia more than 30 years ago, an anesthesiologist I worked with refused to put anyone to sleep that had a beard, no exceptions.

And even now (and I'm only talking elective OR situations) if you REALLY think the airway is going to be a problem, it's perfectly reasonable to ask the patient to shave their beard.  They may not do it, but you can ask.  Something about "if I can't breathe for you, you might die" makes the decision somewhat easier.


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## Brandon O (Feb 13, 2012)

jwk said:


> If you have a problem bagging a patient, you need better BVM technique or you need to move to a more definitive airway.  Patients don't "need" an OPA and an NPA.  An appropriately sized airway, one or the other, should be enough.  Messing around trying to bag someone with a marginal airway is pointless.  Some patients are just tremendously difficult to manage with a mask airway - I have all the toys in the OR with me and there are still patients I can't bag well, particularly those who are edentulous or bearded.  If you have to have an airway, give them one!



Fair enough. But with respect, I think it bears remembering that at the BLS level, there are really no better airways available. We have no rescue device, and our take on "Can't intubate/Can't ventilate" is "can't do anything else either." I am a big believer in having multiple lines and multiple options for virtually every problem, and the challenge faced by BLS providers is that for something as crucial as airway management, there are essentially only a couple lines. If you can't manage the patient with positioning and perhaps suction, there is just the BVM, with or without the "basic" airway devices. If that's not working, well, keep trying, because there's no plan B except driving faster toward ALS or definitive care. That's why I'm very interested in every boost or improvement we can give to the BVM concept; even if something's rarely needed or appropriate, having it in your toolbox can make a big difference between something and nothing.


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## Fish (Feb 13, 2012)

Can't ya'll BLS providers drop in a King or Combitube? Hell even some services in San DIego allow their Basics to drop Combitubes and San DIego is the Most bassackwards conservative County as far as Emergency Medicene is concerned.


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## Brandon O (Feb 13, 2012)

Yes, sometimes. But the only common denominator across the different states and regions is the squishy bag and the little plastic things.


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## Handsome Robb (Feb 13, 2012)

It does amaze me that BIADs haven't been added to the scope for BLS providers in many places. 

I'm all for more education before expanding the scope of practice but they are one thing that I do think makes sense at the BLS level. When it comes down to it insertion and securing them are easy. There are a few more contraindications to consider but honestly they aren't much more complicated than an OPA.


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## bstone (Feb 13, 2012)

NPAs=plural of NPA
NPA's="NPA is" -or- denoting ownership by the NPA

/petpeeve


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## Handsome Robb (Feb 13, 2012)

bstone said:


> NPAs=plural of NPA
> NPA's="NPA is" -or- denoting ownership by the NPA
> 
> /petpeeve



Is it just me or does nearly every single one of your posts recently have the same structure and/or topic? That being you *****ing about apostrophes and the usage of them.

Get over it, please. It brings nothing to the conversation.


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## bstone (Feb 13, 2012)

NVRob said:


> Is it just me or does nearly every single one of your posts recently have the same structure and/or topic? That being you *****ing about apostrophes and the usage of them.
> 
> Get over it, please. It brings nothing to the conversation.



Have a lovely evening.


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