(See also Airway Establishment and Control, How To Do Head Tilt–Chin Lift and Jaw-Thrust Maneuvers, and How To Insert a Nasopharyngeal Airway.)
Pharyngeal airways (both oropharyngeal and nasopharyngeal) are a component of preliminary upper airway management for patients with apnea or severe ventilatory failure, which also includes
The goal of all of these methods is to relieve upper airway obstruction caused by a relaxed tongue lying on the posterior pharyngeal wall.
Indications
Contraindications
Complications
Equipment
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Gloves, mask, and gown
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Towels, sheets, or commercial devices as needed for placing neck and head into sniffing position
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Various sizes of oropharyngeal airways
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Suctioning apparatus and Yankauer catheter; Magill forceps (if needed to remove easily accessible foreign bodies), to clear the pharynx as needed
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Nasogastric tube, to relieve gastric insufflation as needed
Additional Considerations
Positioning
The sniffing position—only in the absence of cervical spine injury:
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Position the patient supine on the stretcher.
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Align the upper airway for optimal air passage by placing the patient into a proper sniffing position. Proper sniffing position aligns the external auditory canal with the sternal notch. To achieve the sniffing position, folded towels or other materials may need to be placed under the head, neck, or shoulders, so that the neck is flexed on the body and the head is extended on the neck. In obese patients, many folded towels or a commercial ramp device may be needed to sufficiently elevate the shoulders and neck. In children, padding is usually needed behind the shoulders to accommodate the enlarged occiput.
If cervical spine injury is a possibility:
Head and neck positioning to open the airway: Sniffing position
Relevant Anatomy
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Aligning the external auditory canal with the sternal notch may help open the upper airway and establishes the best position to view the airway if endotracheal intubation becomes necessary.
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The degree of head elevation that best aligns the ear and sternal notch varies (eg, none in children with large occiputs, a large degree in obese patients).
Step-by-Step Description of Procedure
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As necessary, clear the oropharynx of obstructing secretions, vomitus, or foreign material.
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Determine the appropriate size of the oropharyngeal airway. Hold the airway beside the patient’s cheek with the flange at the corner of the mouth. The tip of an appropriately sized airway should just reach the angle of the mandibular ramus.
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Next, begin inserting the airway into the mouth with the tip pointed to the roof of the mouth (ie, concave up).
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To avoid cutting the lips, be careful not to pinch the lips between the teeth and the airway as you insert the airway.
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Rotate the airway 180 degrees as you advance it into the posterior oropharynx. This technique prevents the airway from pushing the tongue backwards during insertion and further obstructing the airway.
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When fully inserted, the flange of the device should rest at the patient’s lips.
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Alternatively, use a tongue blade to depress the tongue as you insert the airway with the tip pointed to the floor of the mouth (ie, concave down). Use of the tongue blade prevents the airway from pushing the tongue backward during insertion.
