Nasopharyngeal Airway Complications

Precision and skill is required for Advanced airway management, especially in vulnerable patients. When performed correctly, initiating nasopharyngeal airways is very safe—and much safer than the alternative of doing nothing. Many first responders are reluctant to initiate a nasopharyngeal airway, citing fears of complications. But this route can enable intubation in patients with an intact gag reflex. Proper training can promote greater confidence, so don’t let fear deter you from practicing this life-saving technique. Forewarned is forearmed, so let’s look at some potential complications



1. Aspiration

The risk of regurgitation may be higher with a nasopharyngeal airway. This raises the risk of aspiration, which is a risk of all artificial airways. A nasopharyngeal airway may also trigger a nosebleed, further elevating the risk of aspiration, but careful monitoring of the patient can reduce this risk. If a patient begins actively vomiting or is bleeding from the airway, aggressive removal of potential contaminants can prevent aspiration or reduce the volume of aspirated fluid. Suction-assisted laryngoscopy and airway decontamination (SALAD) using the DuCanto CatheterⓇ is highly effective. 

When intubation activates the gag reflex, intracranial pressure may increase, potentially complicating or causing other injuries. And so first responders should be mindful that regurgitation and aspiration may indicate other injuries. 

New: Free Emergency Aspirator Purchasing Guide for Hospitals

2. Airway Trauma 

Airway trauma is the most common complication of a nasopharyngeal airway. In most cases, the injuries are minor, causing small bruises or wounds. However, an open wound increases the risk of developing an infection, especially if the patient bleeds, vomits, or aspirates. Long-term use of a nasopharyngeal airway may cause ulcers, particularly if you use a tube that is too rigid or too large. Selecting the right tube and ensuring that you can see the airway prior to intubation greatly reduces the risk of serious injuries. 


3. Sinusitis and Nasal Structure Damage 

A nasopharyngeal airway may trigger sinusitis, especially in patients with a history of sinus disease. Very rarely, improper insertion can cause significant damage to nasal or sinus structures. This may increase the risk of chronic sinusitis. For example, a deviated septum makes it easier for bacterial biofilms to form inside the nose and sinuses, increasing the risk of chronic sinus disease. First responders must intubate slowly, choosing appropriately sized tubing to mitigate the risk. Always wear gloves, and never reuse tubing, because doing so can introduce bacteria into the sinuses. 


4. Cribriform Insertion

Cribriform insertion is perhaps the most catastrophic complication of a nasopharyngeal airway, but it is also the least likely. Improper technique can cause the tube to enter the cribriform plate, causing soft tissue or skull damage, and potentially even penetrating the brain. Avoiding nasopharyngeal airways in patients with basal skull fractures, visible head injuries, or suspected spinal cord injuries virtually eliminates this risk. 


Strategies for Safe Insertion and Maintenance 

First responders should proceed with caution in patients with a history of airway injuries, and should ask about a history of bleeding disorders. Carefully monitor the patient during the entire procedure, even if it initially seems that the airway placement occurred with no complications. 


Suctioning before the placement of a nasopharyngeal airway decreases the risk of complications. However, when performed incorrectly, suctioning may be incomplete, or even cause serious tissue damage that leaves a patient vulnerable to infection and other airway complications.


The right suctioning equipment improves patient outcomes and reduces first responder stress. Portable emergency suction allows you to tend to a patient immediately, without waiting for help or undertaking the risk of moving them. Yet many portable suction machines deliver inconsistent, unreliable suction. For help selecting the right machine for your agency, download our free guide, The Ultimate Guide to Purchasing a Portable Emergency Suction Device.


Editor's Note: This blog was originally published in July 2020. It has been re-published with additional up to date content.