What is the Adjustable Flange Nasopharyngeal Airway and when is it used?
The Adjustable Flange Nasopharyngeal Airway (NPA) by Sunmed is a single-use, sterile airway adjunct made from Neoprene® that maintains a patent airway in unconscious or obtunded trauma casualties. It is the first-line pre-hospital airway tool recommended under TCCC guidelines for casualties with airway obstruction, altered mental status, or reduced protective reflexes who are not in complete respiratory failure. Unlike an oropharyngeal airway, the NPA is tolerated by patients with intact gag reflexes, making it more versatile in semi-conscious casualties.
What sizes are available, and how do I select the right size NPA?
The Adjustable Flange NPA is available in 22 Fr (~7.3 mm), 24 Fr (~8.0 mm), 26 Fr (~8.7 mm), and 28 Fr (~9.3 mm) sizes. Size selection is based on the nares-to-tragus method — measure from the tip of the nostril to the tragus of the ear to approximate the correct length — or by matching the NPA diameter to the patient's nostril diameter. As a general guide: 22–24 Fr fits smaller adults and average females, 26 Fr fits average adult males, and 28 Fr fits large-build adult males. When uncertain, select the largest size that inserts without resistance.
What does the adjustable flange feature provide that standard NPAs do not?
The adjustable flange allows the provider to set the precise insertion depth, preventing both under-insertion (which fails to bypass the obstruction) and over-insertion (which can stimulate gagging or laryngeal contact in lighter patients). Once positioned correctly, the flange can be slid along the tube and locked, securing the NPA at the optimal depth for that individual casualty. This is particularly useful during prolonged field care when the device must remain in place during patient movement or evacuation without requiring continuous manual adjustment.
What are the absolute contraindications for NPA insertion?
The primary absolute contraindications are suspected basilar skull fracture — indicated by Battle's sign (bruising behind the ear), raccoon eyes, or CSF leaking from the nose or ears — and significant midface trauma with disruption of the nasopharynx, which creates risk of intracranial placement. Known nasal or facial fractures in the insertion path are also absolute contraindications. Relative contraindications requiring additional caution include suspected epiglottitis, large nasal polyps, recent nasal surgery, and coagulopathy due to elevated epistaxis risk.
How do I correctly insert the Adjustable Flange NPA?
Apply water-soluble lubricant generously to the NPA tip and body. Inspect both nostrils for patency and select the more patent side — the right nostril is generally preferred. Position the bevel facing the nasal septum and insert the NPA at a perpendicular angle to the face, directed posteriorly along the nasal floor (not upward toward the skull). Advance with gentle rotating motion; if firm resistance is encountered, try the other nostril. Stop when the flange reaches the nares, adjust the flange depth as needed, and confirm airway patency by looking, listening, and feeling for air movement. Per current TCCC guidance, place the unconscious casualty in the recovery position after insertion.
