# Left Nare NPA Insertion



## dmc2007 (Sep 7, 2009)

In class we were taught that inserting the NPA on the left side is not preferred, but if it does need to be done, the bevel should be cut so that it faces the septum as it would when inserted via the right Nare.  Upon reviewing my textbook tonight however, it said to insert the NPA upside down into the left nare so that the bevel faces the septum and to advance it until you meet resistance, than rotate it 180 degrees as you would an OPA.  This latter method doesn't seem quite right to me.  Thoughts?


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## Dominion (Sep 7, 2009)

dmc2007 said:


> In class we were taught that inserting the NPA on the left side is not preferred, but if it does need to be done, the bevel should be cut so that it faces the septum as it would when inserted via the right Nare.  Upon reviewing my textbook tonight however, it said to insert the NPA upside down into the left nare so that the bevel faces the septum and to advance it until you meet resistance, than rotate it 180 degrees as you would an OPA.  This latter method doesn't seem quite right to me.  Thoughts?



I was always taught the rotate method of insertion.  As well that's how you should know it if you go to boards and the proctor asks you how you'd insert it on the left.


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## Lifeguards For Life (Sep 7, 2009)

we were not taught to cut a npa... I was taught the rotation method if using the left nare.


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## Pudge40 (Sep 7, 2009)

I was told the cuting way.


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## Dominion (Sep 7, 2009)

When I took my EMT boards, we had everyone from my class there and a few from others.  In our airway station we made the insertion of the NPA and the proctor asked us "If your patient for whatever reason could not tolerate insertion in the right nare, show me how you would insert the NPA in the left nare".

Everyone in my class said I would insert bevel facing the nare and rotate when resistance is met.  Two from the other classes said they would cut the NPA to form a new bezel and they failed.  

Not saying this is going to happen everywhere but it can happen.  These boards were also 3 years ago so it may have changed some.  However when we mentioned NPA in paramedic class we also went over the bevel and the rotation method was brought up again.


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## audreyj (Sep 7, 2009)

We were taught the right or the largest, the reason we were given for using the right was that the it is often the largest but you can definitely use the left.  Insertion was no different than the right.  Measure the bevel to the pinky finger nail, measure length from the nostril to the tip of the earlobe, then lube it up, insert with bevel to the septum.  

Also we were told never to cut it.


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## VentMedic (Sep 7, 2009)

You can use either nare with the correct measurement and insertion method.  In the hospital we will rotate from nare to nare every 8 - 12 hours or just leave it out for 4 hours if possible when the opposite nare will not cooperate. 

Do not cut the NPA as that can lead to damage to the soft tissues in the nare.  It is also altering medical equipment which can be costly for you if something happens to the patient.


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## Akulahawk (Sep 7, 2009)

VentMedic said:


> You can use either nare with the correct measurement and insertion method.  In the hospital we will rotate from nare to nare every 8 - 12 hours or just leave it out for 4 hours if possible when the opposite nare will not cooperate.
> 
> Do not cut the NPA as that can lead to damage to the soft tissues in the nare.  *It is also altering medical equipment which can be costly for you if something happens to the patient.*


Even if you do cut the NPA in such a manner as to preclude damage to soft tissues within the nasopharynx, should something happen, you're going to be "on the hook" for altering that medical device that you (in all likelihood) have no certification, training, or licensure for altering that equipment. If I'm going to alter something, you can be certain that I know how to and (more importantly) I can show that I have specific training and education as to how and why to do that alteration.


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## dmc2007 (Sep 7, 2009)

VentMedic said:


> It is also altering medical equipment which can be costly for you if something happens to the patient.



I never even thought of it that way.  Thanks for brining that up.

So if I understand it correctly the orientation of the bevel only matters as it is being inserted?  Once the bevel reaches the pharynx its orientation doesn't matter?


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## TransportJockey (Sep 7, 2009)

It can also depend on which nare is larger to begin with, and, from what I'm told, which side dominant they are. I know when I put an NPA in myself for medic class (our instructors had us do it to ourselves so we know that NPAs themselves are not as benign as a lot of EMTs look at them) I had to use the left nare, as my right nare wouldn't take it. I'm also left handed and left side dominant. 
I used to rotation method, which is the way it's taught here


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## ResTech (Sep 8, 2009)

Bevel towards the septum and insert.... if resistance go to the next. If one is obviously larger than use that one. I love NPA's! so underused by EMT's.


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## Brandon O (Sep 8, 2009)

You know, NPAs often seem to be considered "secondary" to OPAs (in the sense that if you can use the latter instead, you do), but is there really any downside? I guess with only a single NPA inserted you've maybe got a narrower airway than with an OPA?


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## WolfmanHarris (Sep 8, 2009)

Brandon Oto said:


> I guess with only a single NPA inserted you've maybe got a narrower airway than with an OPA?



This is a really weird misconception that seems to be surprisingly common. Despite the hole in the center of most OPA's and NPA's these adjuncts are not a route for ventilation like the lumen of a King LT, Combitube or ETT. The role of these adjuncts is to help keep the tongue from interfering with the airway. Air can still flow around these devices through either the mouth or nose as well as through any hole that may be part of the design.


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## MasterIntubator (Sep 8, 2009)

Unfortunately, the NPA is poorly taught... and underused.  Just as with many proceedures in the EMT curriculum, talk all about it... very little of showing 'how to do it' in real life.
Many things I have learned over the years that class has not taught, allow me to regurgitate the info:  Out of the many hundreds I have placed over my career, I prefer the NPA over the OPA by a long shot. In many folks, it will cure the "snoring" while they lay there unconscious. 
I happen to use it for more diagnostic reasons, and the benefit is a more quiet and easier respiratory drive, and a great guide for suctioning with a french suction cath.
I don't like fingers near the mouth much, and rotating an airway blindly can cause more damage than good.  A tongue depressor with the OPA is a godsend.

The trick to a good NPA insertion ( I does not matter which nare you choose ), just size it correctly for the pt. 
Lube the outside with some Kentucky jelly....
Enter the nare of your choice literally going UP the nose about 1/2 - 1 inch. 
Now.... this is where you need to pay attention to technique....
Keep the distal end medially ( towards the septum ), and increase the angle of the nose hose so it is about 90 degrees to the face ( you are aiming directly to the back of the head ).  Use your other finger to push the tip of the nose upwards ( piggyface ).
Gently introduce the tube right in. If you want, you could rotate the tube back and forth no more than 15 degrees either way... its really not necessary to do more than that.

Just push it in as far as it will go, have not made a person gag yet.

Using this technique, you decrease your chances of meeting any resistance, and any damage to the inside nasal structures. ( you don't want a bloody nose.... bad stuff, and it looks awful.  Which has happened twice to me... mainly because I used to big of a NPA ).

There is nothing wrong with trying one, then downsizing if needed.

Hope this helps... and if the pt resists you, they probably don't need it.... and now you have a great diagnostic AVPU report for the ED as well. 

Good luck... and be safe


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## Brandon O (Sep 8, 2009)

WolfmanHarris said:


> This is a really weird misconception that seems to be surprisingly common. Despite the hole in the center of most OPA's and NPA's these adjuncts are not a route for ventilation like the lumen of a King LT, Combitube or ETT. The role of these adjuncts is to help keep the tongue from interfering with the airway. Air can still flow around these devices through either the mouth or nose as well as through any hole that may be part of the design.



That's an outstanding point -- so good I don't have much else to say. I think people definitely understand OPAs to be mainly about keeping the tongue back, but it's far less obvious for the NPA, so the latter gets treated more like a magic wand if people haven't really thought about it. Thanks for pointing that out.


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## Akulahawk (Sep 8, 2009)

Something else to consider is that if someone "takes" an OPA, either they've suppressed their gag reflex, or they're down far enough that they're going to need a tube anyway. With an NPA, you typically won't see a gag reflex and they're tolerated much better by conscious/semi-conscious patients... Either way, insert device in a snoring patient and they stop snoring... that's useful info!


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## JonTullos (Sep 12, 2009)

I was taught to insert with the bevel toward the septum and to insert until resistance is met.  Rotation wasn't mentioned except with the OPA.


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## Ridryder911 (Sep 12, 2009)

JonTullos said:


> I was taught to insert with the bevel toward the septum and to insert until resistance is met.  Rotation wasn't mentioned except with the OPA.



The rotation is not needed for the NPA as the only reason rotation is needed for the OPA is to hold the tongue down and prevent it from pushing backwards. 

Alike the other method of inserting a OPA is the tongue blade method which one holds the tongue down while inserting. Inserting the NPA following the natural curvature of the nasal passage grove to rest properly configuration to the post hypopharynx. 

Yes, the right nare is preferred because of the slant is made but that does not meant it cannot be used in either one or both. 

Personally, I have placed two NP trumpets & a OPA in and had a decent airway for those cases where intubation was to be excluded. 
R/r 911


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## VentMedic (Sep 12, 2009)

Ridryder911 said:


> Personally, I have placed two NP trumpets & a OPA in and had a decent airway for those cases where intubation was to be excluded.
> R/r 911


 
I don't advise placing two  NPAs unless the nares are very large and I don't mean just a big nose.  Instead of one nice big "milk shake" size straw, you could end up with two tiny cocktail straws.  

If this patient still needs both trumpet and  an OPA upon arrival to the hospital, he/she will be intubated.  Unless someone is constantly maintaining the airway, the OPA is a sure way to achieve aspiration if left unattended.  But, if this is what it takes to ventilate the patient until you get to the hospital, then you must do what you must.


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## Brandon O (Sep 12, 2009)

What would be the advantage to both OPA and NPA? Is the tongue going to sneak around one?


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## VentMedic (Sep 12, 2009)

Brandon Oto said:


> What would be the advantage to both OPA and NPA? Is the tongue going to sneak around one?


 
This all depends on the size of the nares and how much the tongue is obstucting. If you still can not effectively ventilate through the NPA due to a very small size inserted, the OPA would hopefully be an option. One may start with an NPA to suffice in a patient with a present gag but as they become more unconscious, the OPA might be your better option. The NPA is also an excellent way to clear some secretions from the back of the throat and lungs with a suction catheter.  One could have the OPA to maintain an airway for use with the BVM and the NPA for secretion removal.


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