# NPA Bevel In-or-Out



## Aprz (Dec 28, 2012)

I am reading Manual of Emergency Airway Management 3rd Edition (thanks Linuss). It talked about Kiesselbach's plexus (Little's area) and the nasal turbinates (concha), and it answered one question I've always wondered.


_"Why does it matter which direction the bevel faces when inserting the NPA?"_​

This was an interesting conundrum to me because I thought that the goal of the NPA was to form a tunnel-like spot behind the tongue to allow air to go in and out. Behind the tongue, you shouldn't have to worry about the nasal septum (I thought). Plus if it did stop at the nasal septum, which wouldn't make sense, having the bevel face the septum would occlude that nare.

If I understood correctly (I think the book worded this weirdly), if the bevel is facing towards the septum, the tip of the bevel can more likely lacerate the kiesselbach's plexus, which is a very vascular spot in the nose and the origin of most nosebleeds (epistaxis). If the bevel is facing away, it can more likely lacerate the nasal turbinates.

For the reason above, the author recommended that NPAs (and nasatracheal tubes for intubation) be inserted with the bevel facing away from the septum.

In regards to NPAs, some people recommend just facing the bevel edge inferiorly (towards the patient's chest) and not worry about it.

So my question is, which way do you face the bevel?


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## martor (Dec 29, 2012)

It was explained to me that it needs to face septum. It was meant to avoid the collection of nasal mucus and such. I had to use the NPA a few times. Twice it was in such a stressful situation that I didn't even look at the nose. I just shoved it in. Patient was fine, no bleeding. if you choose the proper size, it doesn't matter.


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## PaddyWagon (Dec 29, 2012)

In basic class we're taught bevel towards the septum on the way in to avoid spearing the delicate bits, then once past rotate around so it curves the proper way (only if you went in the upside-down nostril).  The NPA skills test mirrors this.


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## DesertMedic66 (Dec 29, 2012)

I was always taught both in skills and by the book to insert the bevel facing the septum to avoid damaging the turbinates. This is the same way that I teach it to the new EMT students and also the way we insert the NPAs into willing students. 

This is however the first time I have heard of not facing the bevel towards the septum. 

From what I'm gathering from your post if you insert it bevel facing septum you can lacerate the Kiesselbach's plexus but if you insert it facing away from the septum you can lacerate/damage the Turbinates? Sounds like you run the possibility of getting a nosebleed either way.


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## Veneficus (Dec 29, 2012)

Doesn't matter.


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## Aprz (Dec 29, 2012)

firefite said:


> Sounds like you run the possibility of getting a nosebleed either way.


The author of the book was suggesting that the kiesselbach's plexus is more likely to be lacerated if the bevel is facing towards the septum than the turbinates being lacerated if the bevel was facing away from the septum therefore it makes sense for the bevel to face away based on the origin of most epistaxis and how vascular it is.

You also run the risk of epistaxis (regardless of which way the bevel is facing) because the NPA or nasotracheal tube can puncture the mucosal membrane inferior to the adenoids where the eustachian tube enters the nasopharynx.


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## Sandog (Dec 29, 2012)

It would seem to me that with the bevel facing towards the septum the NPA would more easily conform to the shape of the nasal cavity.

If the bevel were facing opposite the septum, then the tip may tend to fold towards itself slightly kinda like a door, thus increasing friction to air flow.  :unsure:

In your poll, answer 2 and 3 sound like the same thing? Away from the septum is towards the mouth/chest. Or am I missing something?


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## Aprz (Dec 29, 2012)

Sandog said:


> It would seem to me that with the bevel facing towards the septum the NPA would more easily conform to the shape of the nasal cavity.
> 
> If the bevel were facing opposite the septum, then the tip may tend to fold towards itself slightly kinda like a door, thus increasing friction to air flow.  :unsure:


It also recommended to rotate it 180 degrees.


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## the_negro_puppy (Dec 29, 2012)

I was always taught bevel facing spetum.

The whole point of the bevel is so that you can twist it around easily to aid insertion if need be


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## Clare (Dec 29, 2012)

the_negro_puppy said:


> \The whole point of the bevel is so that you can twist it around easily to aid insertion if need be



This.  I was taught to "just insert it" by aiming for the back of the head and slowly and gently rocking it from side to side if need be.

Bevel facing septum makes sense to me, kinda like how we start a drip with bevel of cannula facing upward, however I was never formally taught this regarding the NPA


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## RemoteMedicineIreland (Dec 29, 2012)

It doesn't matter. As long as you aim towards the outer ear lobe you will miss the turbinates. 

Just because everyone teaches the wrong way doesn't make it right.


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## EpiEMS (Dec 29, 2012)

On practical exams, "bevel facing, yessir nosir, O2 and LSBs for everyone."
Real life, it doesn't matter.


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