Inserting an Oropharyngeal Airway

Skill 14-8

Inserting an Oropharyngeal Airway

Skill Variation: Inserting a Nasopharyngeal Airway

An oropharyngeal airway is a semicircular tube of plastic inserted into the back of the pharynx through the mouth in an unconscious patient who is breathing spontaneously (Hinkle et al., 2022). The oropharyngeal airway can help protect the airway of an unconscious patient by preventing the tongue from falling back against the posterior pharynx and blocking it. Once the patient regains consciousness, the oropharyngeal airway is removed. Tape is not used to hold the airway in place because the patient should be able to expel the airway once they become alert. The nurse can insert this device at the bedside with little to no trauma to the unconscious patient. Oropharyngeal airways may also be used to aid in ventilation during a code situation and to facilitate suctioning an unconscious or semiconscious patient. Alternatively, airway support may be provided with a nasopharyngeal airway (refer to the accompanying Skill Variation).

Delegation Considerations

The insertion of an oropharyngeal airway is not delegated to assistive personnel (AP). Depending on the state's nurse practice act and the organization's policies and procedures, the insertion of an oropharyngeal airway may be delegated to licensed practical/vocational nurses (LPN/LVNs). The decision to delegate must be based on careful analysis of the patient's needs and circumstances as well as the qualifications of the person to whom the task is being delegated. Refer to the Delegation Guidelines in Appendix A.

Equipment

Oropharyngeal airway of appropriate size
Disposable gloves
Suction equipment
Goggles and mask or face shield (optional)
Flashlight (optional)
Additional PPE, as indicated

Assessment

Assess the patient's level of consciousness and ability to protect the airway. Assess amount and consistency of oral secretions. Auscultate lung sounds. If the tongue is occluding the airway, lung sounds may be diminished. Assess for loose teeth or recent oral surgery, which may contraindicate the use of an oropharyngeal airway.

Actual or Potential Health Problems and Needs

Many actual or potential health problems or issues may require the use of this skill as part of related interventions. An appropriate health problem or issue may include:

Aspiration risk
Ineffective airway clearance
Injury risk

Outcome Identification and Planning

The expected outcome to achieve is that the patient will maintain a patent airway and exhibit oxygen saturation within acceptable parameters. Another outcome that may be appropriate is that the patient remains free from aspiration and injury.

Implementation

Action	Rationale
1. Gather equipment.	Assembling equipment provides for an organized approach to the task.
2. Perform hand hygiene and put on PPE, if indicated.	Hand hygiene and PPE prevent the spread of microorganisms. PPE is required based on transmission precautions.
3. Identify the patient.	Identifying the patient ensures the right patient receives the intervention and helps prevent errors.
4. Assemble equipment on the overbed table or other surface within reach.	Arranging items nearby is convenient, saves time, and avoids unnecessary stretching and twisting of muscles on the part of the nurse.
5. Close the curtains around the bed and close the door to the room, if possible.	This ensures the patient's privacy.
6. Explain to the patient what you are going to do and why, even if the patient does not appear to be alert.	Explanation alleviates fears. Even if a patient appears unconscious, the nurse should explain what is happening.
7. Put on disposable gloves; put on goggles and a mask or face shield, as indicated.	Gloves and other PPE prevent contact with contaminants and body fluids.
8. Measure the oropharyngeal airway for the correct size (Figure 1). Measure the oropharyngeal airway by holding the airway on the side of the patient's face. The airway should reach from the opening of the mouth to the back angle of the jaw, and the tip of the airway should reach no farther than the pinna of the ear (Hess et al., 2021).	The correct size ensures correct insertion and fit, allowing for conformation of the airway to the curvature of the palate.
9. Adjust the bed to a comfortable working level (VHACEOSH, 2016). Check the patient's mouth for any loose teeth, dentures, or other foreign material. Remove dentures or material, if present.	Having the bed at the proper height prevents back and muscle strain. Checking for these materials prevents aspiration or swallowing of objects. During insertion, the airway may push any foreign objects in the mouth to the back of the throat.
10. Position the patient in the semi-Fowler position.	This position facilitates airway insertion and helps prevent the tongue from moving back against the posterior pharynx.
11. Suction the patient, if necessary.	This removes excess secretions and helps maintain a patent airway.
12. Open the patient's mouth by using your thumb and index finger to gently pry the teeth apart. Insert the airway with the curved tip pointing up toward the roof of the mouth (Figure 2).	This is done to advance the tip of the airway past the tongue, toward the back of the throat.
13. Slide the airway across the tongue to the back of the mouth. Rotate the airway 180 degrees as it passes the uvula (Figure 3). The tip should point down, and the curvature should follow the contour of the roof of the mouth. Use a flashlight to confirm the position of the airway with the curve fitting over the tongue.	This is done to shift the tongue anteriorly, thereby allowing the patient to breathe through and around the airway.
14. Ensure accurate placement and adequate ventilation by auscultating breath sounds (Figure 4).	If the airway is placed correctly, lung sounds should be audible and equal in all lobes.
15. Position the patient on their side when the airway is in place.	This position helps keep the tongue out of the posterior pharynx area and helps to prevent aspiration if the unconscious patient should vomit.
16. Remove gloves and additional PPE, if used. Perform hand hygiene.	Proper removal of PPE reduces the risk for infection transmission and contamination of other items. Hand hygiene prevents the spread of microorganisms.
17. Remove the airway for a brief period every 4 hours, or according to facility policy. Suction the oropharynx prior to removal of the airway. Assess the mouth; provide mouth care and clean the airway according to facility policy before reinserting it.	Tissue irritation and ulceration can result from prolonged use of an airway. Mouth care provides moisture to mucous membranes and helps maintain tissue integrity.

Evaluation

The expected outcomes have been met when the patient has exhibited a patent airway with oxygen saturation within acceptable parameters and has remained free from injury and aspiration.

Documentation

Guidelines

Document the suctioning of the airway, characteristics of any secretions, placement of the airway, airway size, removal/cleaning and oral care, assessment before and after the intervention, and oxygen saturation level.

Sample Documentation

Developing Clinical Reasoning and Clinical Judgment

Unexpected Situations and Associated Interventions

Patient awakens: Remove the oral airway once the patient is awake because it may be uncomfortable and cause vomiting. Conscious patients can usually protect their airway.
Patient's tongue is sliding back into the posterior pharynx, causing respiratory difficulties: Put on disposable gloves and remove the airway. Make sure the airway is the appropriate size for the patient.
Patient vomits as oropharyngeal airway is inserted: Quickly position the patient onto their side to prevent aspiration. Remove the oral airway. Suction the mouth and oropharynx as indicated.

Special Considerations

General Considerations

Wearing gloves, remove the airway briefly every 4 hours to provide oral hygiene. Assess the mouth and tongue for tissue irritation, tooth damage, bleeding, and ulceration. Ensure that the lips and tongue are not between the teeth and the airway to prevent injury.
When reinserting the oropharyngeal airway, attempt to insert it on the other side of the patient's mouth. This helps to prevent irritation to the tongue and mouth.
Suction secretions, as needed, by manipulating around and through the oropharyngeal airway.

Inserting a Nasopharyngeal Airway

Nasopharyngeal airways (nasal trumpets) are curved, uncuffed, soft, plastic tubes inserted into the back of the pharynx through the nose in patients who are breathing spontaneously. The nasal trumpet provides a route from the nares to the pharynx to help maintain a patent airway. These airways may be indicated if the patient's teeth are clenched, the patient's tongue is enlarged, or the patient needs frequent nasopharyngeal suctioning. This airway may be left in place, without much discomfort, in the patient who is alert and conscious.

The appropriate-size range for a nasal trumpet for adolescents to adults is 24 to 36 Fr. Additional assessments include assessing for the presence of nasal conditions, such as a deviated septum or recent nasal or oral surgery; traumatic brain injury; central facial fractures; basilar skull or cribriform fractures; and increased risk for bleeding, such as from anticoagulant therapy, which would contraindicate the use of a nasopharyngeal airway.

Perform hand hygiene and put on PPE, if indicated.
Identify the patient.
Assemble equipment on the overbed table or other surface within reach.
Close the curtains around the bed and close the door to the room, if possible.
Explain to the patient what you are going to do and why, even if the patient does not appear to be alert.
Put on disposable gloves. If the patient is coughing or has copious secretions, also wear a mask and goggles.
Measure the nasopharyngeal airway for the correct size (Figure A). Measure the nasopharyngeal airway length by holding the airway on the side of the patient's face. The airway should reach from the tip of the nose to the earlobe. The airway with the largest outer diameter that fits the patient's nostril should be used (Morton & Fontaine, 2018).
Adjust the bed to a comfortable working level (VHACEOSH, 2016).If the patient is awake and alert, position them in semi-Fowler position. If the patient is not conscious or alert, position them in a side-lying position.
Suction the patient, if necessary.
Lubricate the nasopharyngeal airway generously with the water-soluble lubricant, covering the airway from the tip to the guard rim (Figure B).
Gently insert the airway into the naris (Figure C), the narrow end first, pointing it down and toward the back of the throat, until the rim is touching the naris (Figure D).If resistance is met, stop and try the other naris.
Check placement by closing the patient's mouth and placing your fingers in front of the tube opening to check for air movement. Assess the pharynx to visualize the tip of the airway behind the uvula. Assess the nose for blanching or skin stretching.
Remove gloves and perform hand hygiene. Place the bed in the lowest position. Remove additional PPE, if used. Perform hand hygiene.
Remove the airway, clean it in warm soapy water, and place in the other naris at least every 8 hours, or according to facility policy. Assess for evidence of alterations in skin integrity. If the patient coughs or gags on insertion, the nasal trumpet may be too long. Assess the pharynx. You should be able to visualize the tip of the airway behind the uvula.

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Skill 14-8