# Securing a Nasopharyngeal Airway (NPA)



## ThadeusJ (Jun 30, 2017)

I was once taught (by a sage wise man...or was it a woman?) that upon placement of a NPA, one should secure it using a safety pin and a piece of tape to the bridge of the nose.  I was asked about this and after a 30 minute search on Dr. Google, I was able to find a single reference in a Respiratory Therapy exam review textbook and one "study" published in 2008 (not able to access the actual document, only the abstract).

Two questions: 
1) is this standard practice in your service, and
2) is the action of securing the NPA device part of your policies and procedures?


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## NPO (Jun 30, 2017)

ThadeusJ said:


> I was once taught (by a sage wise man...or was it a woman?) that upon placement of a NPA, one should secure it using a safety pin and a piece of tape to the bridge of the nose.  I was asked about this and after a 30 minute search on Dr. Google, I was able to find a single reference in a Respiratory Therapy exam review textbook and one "study" published in 2008 (not able to access the actual document, only the abstract).
> 
> Two questions:
> 1) is this standard practice in your service, and
> 2) is the action of securing the NPA device part of your policies and procedures?


I secure mine with the NRB over the face. If the patient coughs it may come out about an inch, but that's it. 

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## ThadeusJ (Jun 30, 2017)

Actually the questions stem from two separate incidents I have heard about where the NPA was _*pushed down*_ into the airway and was deemed "lost" only to be discovered some time later when the patient was undergoing intubation (whoops).


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## NPO (Jun 30, 2017)

ThadeusJ said:


> Actually the questions stem from two separate incidents I have heard about where the NPA was _*pushed down*_ into the airway and was deemed "lost" only to be discovered some time later when the patient was undergoing intubation (whoops).


Well in that case, you're pushing way too hard. It should just glide in and there is a flange to prevent that. 

But, I did see some med students lose an OPA in a oropharynx during a (failed) intubation attempt and they couldn't figure out why his sats were not improving with a BVM until the attending pulled it out of the back of the guys throat...

So I guess anything is possible.

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## Carlos Danger (Jun 30, 2017)

I have heard of securing an NPA that way, but have never done it or seen it or heard of it being a standard anywhere. 

There are various urban legends about NPA's being sucked into the nasopharynx and then aspirated, and I'm highly skeptical of them. Of course I can't say that it has _never_ happened, but I'm pretty confident that it's an unlikely enough event to fit easily into the "not really a concern" category. 

I would imagine that the risk of causing a problem messing with a safety pin near the eyes and airway is greater than the risk of simply keeping an eye on your NPA.


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## DrParasite (Jun 30, 2017)

http://www.oxfordmedicaleducation.com/clinical-skills/procedures/nasopharyngeal-airway/

https://clinicalgate.com/emergency-airway-management-2/ references the safety pin, when using an ET tube as an improvised NPA

here is a picture of an NPA 









if the patient snorts the NPA in, then they have overcame the flange completely, and either you chose the wrong size NPA, or the manufacturer designed it poorly, and you should no longer be using it.  Or you are pushing it down waaaaaaay further than you should be

In any case, I have never seen the safety pin used, nor will I be putting one on any NPA in the near future.


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## NomadicMedic (Jun 30, 2017)

I've also placed a LOT of NPAs, and even though it's anecdotal, never had one end up anywhere other than where it was supposed to be.


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## luke_31 (Jun 30, 2017)

NomadicMedic said:


> I've also placed a LOT of NPAs, and even though it's anecdotal, never had one end up anywhere other than where it was supposed to be.


Agree, same here never had one go where it didn't belong.


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## DesertMedic66 (Jun 30, 2017)

I didn’t even know securing them was a thing. I’ve used a decent amount and have never had any issues


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## VFlutter (Jun 30, 2017)

I have had NPAs slide back out slightly when a lot of lube is used. Most of the time they aren't left in long enough to be an issue but the times I want to keep them in for frequent NT suctioning I will secure them similar to how I secure NG tubes. Split tape half way up, place on bridge of nose, and twist 1/2 pieces around back up.


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## StCEMT (Jun 30, 2017)

I've had issues with them coming out a bit, but never going too deep. NPA's have typically been a very temporary thing for me, they usually get pulled after a while.


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## GMCmedic (Jun 30, 2017)

Ive never secured one and I cant remember the last time I used one. 

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## ResQchick (Jul 1, 2017)

I think I placed one about 19 years ago.  None since then.  

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## NomadicMedic (Jul 1, 2017)

ResQchick said:


> I think I placed one about 19 years ago.  None since then.
> 
> Sent from my SM-G935V using Tapatalk



I'm guessing you no longer work in the field?


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## ResQchick (Jul 1, 2017)

NomadicMedic said:


> I'm guessing you no longer work in the field?


I'm still in the field, and quite active. We just don't get patients requiring an npa as opposed to an opa. 

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## E tank (Jul 1, 2017)

What indications for an NPA v. OPA do folks use? I'll say that I use them as a "reminder" to breathe in patients at risk for or diagnosed with obstructive sleep apnea that are just on the edge with narcotic and I don't want to give narcan to.

 An OPA would be too much and nothing wouldn't be enough...Of note, I'd never put one in a patient taking blood thinners or without neosynepherine (or equivalent)  nasal spray if I had it.


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## NomadicMedic (Jul 1, 2017)

ResQchick said:


> I'm still in the field, and quite active. We just don't get patients requiring an npa as opposed to an opa.



Interesting. The only time I *ever* use an OPA is during an arrest. And even then, not for long, as I usually place an SGA. Anyone else that needs any type of airway management gets one (or 2) NPAs.


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## NomadicMedic (Jul 1, 2017)

E tank said:


> What indications for an NPA v. OPA do folks use? I'll say that I use them as a "reminder" to breathe in patients at risk for or diagnosed with obstructive sleep apnea that are just on the edge with narcotic and I don't want to give narcan to.
> 
> An OPA would be too much and nothing wouldn't be enough...Of note, I'd never put one in a patient taking blood thinners or without neosynepherine (or equivalent)  nasal spray if I had it.




OPAs go in dead people. Seems like just about everyone else has a semblance of a gag... an NPA is much easier. Anyone I have to bag, that's not a GCS of 3 or 4, ODs, stroke, DKA... all would get an NPA. 

The guy I had today, GI bleed, GCS of 4, in the house was bagged with 2 NPAs, then quickly intubated.


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## ResQchick (Jul 1, 2017)

NomadicMedic said:


> Interesting. The only time I *ever* use an OPA is during an arrest. And even then, not for long, as I usually place an SGA. Anyone else that needs any type of airway management gets one (or 2) NPAs.


From what I've noticed from many people in my County-npa's aren't used as often as many other places.  I believe our npa pack expired before it was used.  (We replaced it, but it sits, lonely and ignored.  Lol)
In an arrest, an opa is only used until als arrives to intubate.  

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## ResQchick (Jul 1, 2017)

Oh, I might add that I'm 5 minutes from 2 hospitals, and our level 1 trauma Center is 15 minutes. 

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## VentMonkey (Jul 1, 2017)

ResQchick said:


> Oh, I might add that I'm 5 minutes from 2 hospitals, and our level 1 trauma Center is 15 minutes.


Regardless, how is this relevant to proper airway management techniques?


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## ResQchick (Jul 1, 2017)

VentMonkey said:


> Regardless, how is this relevant to proper airway management techniques?


Sorry? I haven't had a patient needing airway management that needed an npa.
Is there an issue with that? 

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## VentMonkey (Jul 1, 2017)

ResQchick said:


> I'm still in the field, and quite active. We just don't get patients requiring an npa as opposed to an opa.





ResQchick said:


> Sorry? I haven't had a patient needing airway management that needed an npa.
> Is there an issue with that?


I'll just leave this here then:


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## ResQchick (Jul 1, 2017)

VentMonkey said:


> I'll just leave this here then:
> View attachment 3883


? 
OK then.  

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## SandpitMedic (Jul 1, 2017)

The NPA is my go to. If I think they may not be able to control their own airway they get one.

The true test of unconsciousness. 

At least once a week I drop an NPA. 


Perhaps in 19 years you've just never recognized the patient needed one. It takes 30 seconds from recognizing a potential for airway compromise to insertion, so being 5 minutes from an ER is irrelevant.

Or perhaps you're really just not getting any true emergencies, in which case you'd be the whitest cloud I've ever heard of.


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## SandpitMedic (Jul 1, 2017)

Put another way, if they didn't wake up screaming and rip it out... they needed it.


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## NomadicMedic (Jul 1, 2017)

SandpitMedic said:


> Perhaps in 19 years you've just never recognized the patient needed one. It takes 30 seconds from recognizing a potential for airway compromise to insertion, so being 5 minutes from an ER is irrelevant.
> 
> Or perhaps you're really just not getting any true emergencies, in which case you'd be the whitest cloud I've ever heard of.



This was my thought. Probably one NPA a week for me.


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## DesertMedic66 (Jul 1, 2017)

I don’t get to place very many NPAs. I think for the 2 years I have been a medic I have placed maybe 4. I haven’t really had any patients who would have benefited from it. Either my patients will tolerate an OPA or they are with it enough to not tolerate an NPA.


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## VentMonkey (Jul 1, 2017)

@ResQchick your posts elude to a serious misunderstanding of basic airway management.

Am I off base? I don't know, I'm only going off of a string off posts. One of which makes mention of being 5 minutes from a receiving, and that doesn't seem to quite grasp how relevant an NPA can be in the face of many lethargic, and/ or semi-conscious patients.

I'm shy 4 years of your experience, but have experienced differently nonetheless. I can be anywhere from 5 minutes away from a receiving to an hour away, and yet still can't fathom how learning the ongoing concepts that entail airway management front to back, top to bottom, basic to advanced would not yield a more engaging response.


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## ResQchick (Jul 1, 2017)

VentMonkey said:


> @ResQchick your posts elude to a serious misunderstanding of basic airway management.
> 
> Am I off base? I don't know, I'm only going off of a string off posts. One of which makes mention of being 5 minutes from a receiving, and that doesn't seem to quite grasp how relevant an NPA can be in the face of many lethargic, and/ or semi-conscious patients.
> 
> I'm shy 4 years of your experience, but have experienced differently nonetheless. I can be anywhere from 5 minutes away from a receiving to an hour away, and yet still can't fathom how learning the ongoing concepts that entail airway management front to back, top to bottom, basic to advanced would not yield a more engaging response.


Then I'm guessing I am in a whole department of sadly lacking personnel. According to you. 
I sincerely hope that when I finish my cc course I understand airway management and am able to tube someone.
I winery how my patients have all survived without my sticking a rubber tube up their noses. Lol.  
My colleagues and myself might need further training. 
But seriously, I've had no semi conscious patients that needed one.  Am I a white cloud? Not really. We just haven't found a huge need for that type of airway management I suppose.  I'm going to have to poll the 3 departments I ride with. 


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## Qulevrius (Jul 1, 2017)

VentMonkey said:


> I'll just leave this here then:
> View attachment 3883



The woman heard me cracking up, came to ask what's up. After seeing the pic, her initial reaction (she's a nurse) was: 'Isn't it easier to just intubate ?', followed by 'Yeah, it's the same with chest compressions. You only stop if the pt fights back...'


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## VFlutter (Jul 1, 2017)

ResQchick said:


> I sincerely hope that when I finish my cc course I understand airway management and am able to tube someone.
> I winery how my patients have all survived without my sticking a rubber tube up their noses. Lol.



I think this sums up the point. Airway management is not just the ability to intubate someone. And a CC course is not going to make you an airway expert, nor a expert at critical care for that matter. Don't try to downplay the importance of NPAs just because all your patients "survived without them"!!


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## NomadicMedic (Jul 1, 2017)

ResQchick said:


> Then I'm guessing I am in a whole department of sadly lacking personnel. According to you.
> I sincerely hope that when I finish my cc course I understand airway management and am able to tube someone.
> I winery how my patients have all survived without my sticking a rubber tube up their noses. Lol.
> My colleagues and myself might need further training.
> ...




You've never had to bag a semi conscious patient? You've never bagged a stroke or an OD?


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## ResQchick (Jul 1, 2017)

NomadicMedic said:


> You've never had to bag a semi conscious patient? You've never bagged a stroke or an OD?


I have bagged in both those situations. Many times.  Without an npa. But most times if a person was satting low,  an nrb with high flow worked well.  I understand your need for one, I also understand that I've had no obvious need or I would have used one. 


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## VentMonkey (Jul 1, 2017)

ResQchick said:


> I have bagged in both those situations. Many times. Without an npa.


Please tell us you used an OPA then?


ResQchick said:


> most times if a person was satting low,  an nrb with high flow worked well.


Again, you have much to learn. And if all three of your departments feel the same as you, then so do they.


ResQchick said:


> I understand your need for one.


No, clearly you do not. Good luck on your "CC" (cardiac tech?) course.


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## ResQchick (Jul 1, 2017)

VentMonkey said:


> Please tell us you used an OPA then?
> 
> Again, you have much to learn. And if all three of your departments feel the same as you, then so do they.
> 
> No, clearly you do not. Good luck on your "CC" (cardiac tech?) course.



I'll let our medics know that you think they also need more training. Most of them also work in the city, so I'm certain they'll hop on your advice. 
I think I'm doing just fine. But if I ever move to wherever you're from, I'll be certain to brush up.


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## SandpitMedic (Jul 1, 2017)

ResQchick said:


> I have bagged in both those situations. Many times.  Without an npa. But most times if a person was satting low,  an nrb with high flow worked well.  I understand your need for one, I also understand that I've had no obvious need or I would have used one.
> 
> 
> Sent from my SM-G935V using Tapatalk


As the man said, you are certainly lacking in the department of basic airway management.

I apologize for the dogpile, and am not intending to insult your abilities. 

Perhaps you can use this for a learning tool as the forum title indicates. 

A study was done a few years ago that indicated the single most misunderstood and under utilized intervention in airway management was the head-tilt-chin-lift. This was at all provider levels from basics to medics. 

I can see that had the study continued, the use of NPAs (adjuncts in general) would be a close second place.


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## SandpitMedic (Jul 1, 2017)

An NPA is a simple BLS measure to ensure the airway is open. It is very very easy to apply, and once it's there you can continue your assessment and other treatments.

If the patient tolerates it, then clearly it is of benefit to the patient. Seeing as how you won't realize their airway is occluded until you notice changes in their presentation or vitals, in which case you are behind a very simple and preventable eightball, so to speak. Especially considering what we know now about the detriments of even a single event of hypoxia in some patients.


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## StCEMT (Jul 1, 2017)

With the prevalence of opiate overdoses, I don't see how they wouldn't be used on a somewhat regular basis. Hell, I prefer them with things I can immediately fix just because I hate dealing with vomit. Not a fan of messing with gag reflexes....


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## NomadicMedic (Jul 1, 2017)

ResQchick said:


> I'll let our medics know that you think they also need more training. Most of them also work in the city, so I'm certain they'll hop on your advice.
> I think I'm doing just fine. But if I ever move to wherever you're from, I'll be certain to brush up.



Probably a good idea. Prehospital medicine has advanced quite a bit since you started in the field. Might not be a bad idea to pick up a book every now and again. 

FWIW, your hypoxic patients would probably also appreciate you brushing up on airway management.


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## VentMonkey (Jul 1, 2017)

ResQchick said:


> I'll let our medics know that you think they also need more training.


Please do, it will benefit the patient population you all serve, and not appease your egos.


ResQchick said:


> Most of them also work in the city, so I'm certain they'll hop on your advice.


I haven't a clue what this even means. Either way, people such as yourself are a prime example why prehospital providers do not deserve the right, or privilege to continue to intubate people outside of a hospital setting.

I've fed you a 12-course meals worth, I'm done here.


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## Qulevrius (Jul 1, 2017)

This is my 1st time ever seeing Monkeh going ape...


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## DesertMedic66 (Jul 1, 2017)

StCEMT said:


> With the prevalence of opiate overdoses, I don't see how they wouldn't be used on a somewhat regular basis. Hell, I prefer them with things I can immediately fix just because I hate dealing with vomit. Not a fan of messing with gag reflexes....


Opiate ODs are pretty rare in my my neck of the woods. I don’t remember the last time I have even heard of a crew having one let alone one of my own.


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## VentMonkey (Jul 2, 2017)

Qulevrius said:


> This is my 1st time ever seeing Monkey  going ape...


"Just when I think I'm out..."

Long story short, we're talking one of the subjects I enjoy and pride myself on most: airway management. 

When you can't comprehend the basics, what makes you worthy of advanced management, and all of their responsibilities?


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## Qulevrius (Jul 2, 2017)

VentMonkey said:


> "Just when I think I'm out..."
> 
> Long story short, we're talking one of the subjects I enjoy and pride myself on most: airway management.
> 
> When you can't comprehend the basics, what makes you worthy of advanced management, and all of their responsibilities?



I know exactly where you're coming from. I feel the same way about pathogens, and when people start spewing nonsense, it hurts. Physically.


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## DrParasite (Jul 2, 2017)

ResQchick said:


> I'll let our medics know that you think they also need more training. Most of them also work in the city, so I'm certain they'll hop on your advice.


Based on the fact that your in cc class, and most of your medics works in the city, I'm guessing your an NYS EMT living on long island?  

You should let them know, they will probably tell you that NPAs have their roles, and if you aren't dropping one, you are doing your patient a disservice.  


ResQchick said:


> I think I'm doing just fine. But if I ever move to wherever you're from, I'll be certain to brush up.


Well, as long as you think your doing fine, I guess that pretty much shows how open minded you are to the current standards of prehospital medicine...

BTW, I know many people who work EMS in the city, and they think they are the best at everything, an opinion that is shared by nobody else.........


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## StCEMT (Jul 2, 2017)

Haven't even had it come up with Coachella and all that mess?


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## DesertMedic66 (Jul 2, 2017)

StCEMT said:


> Haven't even had it come up with Coachella and all that mess?


That is really the only time that I ever need to use NPAs.


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## E tank (Jul 3, 2017)

I have to say that, IME,  if an NPA will work for a patient, so will a head tilt/ jaw lift/thrust. It provides a more "hands free" situation and doesn't mean the difference between having an airway or not. I can't personally say that about an OPA. If a patient really needs one to maintain his airway or to make mask ventilation possible, nothing else will do. There are those situations where either or might work, but there are definitely those times when only an OPA will work. 

So folks not ever having used one or used them extremely rarely doesn't surprise me at all. They're more of a finesse type of device, IME.


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## ThadeusJ (Jul 4, 2017)

I used OPA's far more than NPA's and almost (almost) was at the point where I thought that NPA's were just another piece of equipment that was cluttering up the airway bag...until I had a patient with trismus that needed suctioning...thought to myself, "Huh, now _where_ did I put that NPA thingy?"

For context, one of the anecdotes did occur on a patient where I worked and another occurred to a colleague in a service far, far away, so I consider the occurrences verified.  Also, the one that happened closer to home had the very confused patient fire it back into the airway themselves when left unattended.

Thanks everyone for their feedback.


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## Carlos Danger (Jul 4, 2017)

Basic adjuncts were never emphasized during my initial paramedic training or any of my continuing education, so unfortunately I just never got in the habit of using them. I used OPA's occasionally (probably not nearly as often as I should have), but I honestly don't know if I ever placed a NPA in the field. It seems that nowadays since we have so much easier access to information, many paramedics are more aware of and accepting of the idea of _managing the airway _rather than just intubating everyone as soon as possible, and so are generally more comfortable (or at least familiar) with a wider range of techniques, including the use of basic adjuncts. 

So, I wouldn't agree that never having used a NPA in the field necessarily indicates a lack of experience, or poor judgement. But I would say that the "we've always done it this way, so I know we are right" attitude that we are all to familiar with is apparently alive and well.


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## GMCmedic (Jul 4, 2017)

I think Ive  been turned off of NPAs. When I was a new EMT, I thought it was super cool when my Medic partners asked me to stick an NPA in a drunk guys nose. Now that I have more time and experience I realize that was just them being a ****. 

I probably should get in the habit of using them during RSI, mainly when I have a firefighter bagging. With passive oxygenation, I really ever think about them. 

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## NomadicMedic (Jul 4, 2017)

Anyone who's altered enough that I'd even think about airway management gets an NPA right off the bat. ODs and strokes especially. 
I may move further down the airway pathway or I might pull it. 

I think not using an NPA (or an OPA if tolerated) in a case where you're providing airway management is lazy.


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## VentMonkey (Jul 4, 2017)

NomadicMedic said:


> I think not using an NPA (or an OPA if tolerated) in a case where you're providing airway management is lazy.


And in some providers cases, it shows lack of fundamentals. I'm not saying everyone semi-comatose has gotten one, and I like that the _even more_ advanced-than-paramedic providers on this forum make mention of head-tilt chin lifts.This shows...(drumroll please)...fundamentals. 

If you can't comprehend every airway technique from start to finish then by all means stay away from said patients airway, you are not entitled to that privilege. "I get to (got the) tube" is old, foolish, dangerous, and has no place in clinical practice; prehospital, or otherwise.


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## SandpitMedic (Jul 4, 2017)

I don't even know why this is a debate. It's on the damn NREMT psychomotor exam checklist under airway. (Not the infallible end-all-be-all, I know). It's there for a reason. Maybe if instructors wouldn't let candidates "verbalize" everything...

For crying out loud, it's not the only way to skin a cat, but some of you guys are acting like it's some alien device or just taking up space in the airway roll?  Placing an NPA was a punitive move, you assumed, so now you never use them?

**** man, no wonder taking away intubation is on the table... we can't even get a group of like minded EMS professionals, who are in a group that gives enough ****s to be on an online education forum, to agree that the use of a NPA is probably a good idea in basic airway management.

I realize I might not be making many friends in this thread, but this is a BLS technique and in most cases works better than an OPA (no puke , allows for passive O2/preoxygenation, doesn't get in the way of intubation, etc.)
Sheesh, you should be using two to allow passive oxygenation prior to and during intubation on unconscious or sedated airway patients.

I would encourage anyone doubting the validity or constructive use of the NPA to use one this week if they get any patient that might tolerate it. Just... try the damn thing.


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