The nasopharyngeal airway (NPA) is the adjunct candidates tend to know least well, because the oropharyngeal airway gets most of the teaching time. That is a mistake for the FREC paper, because the NPA is the answer to a very specific question: what do you do when the patient needs airway support but an oral airway will not go in or will not be tolerated?
If you can answer that, and you know the one contraindication that examiners love, most of the marks are already yours. This post follows a Geeky Medics demonstration and reframes it for the Qualsafe multiple choice format.
What the tube actually does
The NPA is a soft, curved tube with a flange at one end and a bevelled tip at the other. Sat correctly, the flange rests against the nostril, the tube runs along the floor of the nasal cavity, curves gently down, and the bevelled tip sits at the back of the oropharynx.
“The first part of the tube going along the floor of the nasal cavity and then gently curving around so the tip is sitting in the back of the oropharynx.”
It works for the same reason a Guedel does: it holds a channel open past the soft tissues of the tongue and palate that collapse backwards in a patient with reduced consciousness. The difference is the route. Coming in through the nose, it avoids the oral cavity entirely, and that is what makes it useful in patients who cannot or will not accept something in their mouth.
Indications: the grey zone patient
The clearest way to hold the indications in your head is that the NPA is for the patient who is not fully unconscious. The video calls this the grey zone, and it is a useful phrase.
- Reduced but not absent consciousness. Someone emerging from anaesthesia, or obtunded by alcohol or other drugs, will often gag or vomit on an oropharyngeal airway. The NPA is much better tolerated.
- Clenched jaw. During a seizure, or with trismus from any cause, you may simply be unable to open the mouth. The nasal route bypasses the problem.
- Maxillofacial injury. Where facial trauma has distorted or obscured the oral airway, the NPA offers an alternative route.
Notice what these share. In every case, the oral route is either unavailable or unwise. That is the exam logic. When a question describes a patient who is groaning, semi-responsive, biting down, or bleeding heavily from the mouth, the examiner is steering you towards the nose.
For the contrast with the oral adjunct, the earlier post on oropharyngeal airway insertion sets out why the Guedel belongs to the unconscious patient only.
The contraindication everyone is tested on
Base of skull fracture is a relative contraindication to inserting an NPA. The concern is a small but potentially fatal complication: the tube passing through a fractured skull base and into the cranial vault.
“This risk must be balanced against the need to protect the patient’s airway.”
Two things matter here for the exam. First, the word is relative, not absolute. The tube is not automatically forbidden, and an obstructed airway will kill far more reliably than the rare intracranial misplacement. Second, you need to recognise the signs that should make you suspect a skull base injury in the first place. A head injury mechanism with blood or clear fluid from the nose or ears, bruising behind the ears, or bruising around both eyes should all make you pause and think before reaching for the nasal route.
Whether you proceed in that situation is a judgement made by the clinician responsible, within their scope and protocol. As a candidate, you need to know the risk exists and why.
Sizing: there is no clever rule
This is where the NPA differs from the Guedel, and it catches people out. There is no reliable landmark measurement for the NPA.
“There’s no reliable way of sizing the right tube for the right patient but it’s a matter of looking at the patient’s nostril and seeing which size you’re likely to get in.”
The practical approach is:
- Look at the nostril and estimate which tube will pass without stretching the skin of the nostril.
- Most adults are suited to a size 6 or 7.
- If the patient coughs or gags after insertion, the tube is too long. Remove it and replace it with a smaller size.
Older teaching about matching the tube to the little finger or measuring against the tragus has fallen out of favour because neither correlates well with the internal anatomy. If a question offers you a landmark rule for the NPA, be suspicious. The current Resuscitation Council UK position mirrors the video: choose by nostril, default to 6 or 7 in an adult, and adjust if it is clearly wrong.
| Feature | Oropharyngeal airway | Nasopharyngeal airway |
|---|---|---|
| Route | Mouth | Nose |
| Conscious level | Unconscious with no gag reflex | Reduced consciousness, better tolerated |
| Sizing | Incisors to angle of jaw | Look at nostril, size 6 or 7 for most adults |
| Clenched jaw | Cannot insert | Bypasses the problem |
| Key caution | Provokes gagging and vomiting if gag present | Relative contraindication in base of skull fracture |
Insertion, step by step
The demonstration is on a manikin, and the sequence is straightforward. This is a description for revision purposes, not a substitute for a supervised practical.
- Position yourself so you can see the nostrils clearly, and lubricate the outside of the tube.
- Inspect both nostrils by gently lifting the tip of the nose with your non-dominant hand. Look for a deviated septum or large inferior turbinates that would block the way. Convention is to try the right nostril first, but pick the larger, clearer one.
- Insert the tip downwards, following the floor of the nasal cavity, not upwards towards the bridge of the nose. This is the most common error.
- Twist gently as you advance, letting the tube find its own path rather than forcing it.
- Stop when the flange sits at the nostril.
- Reassess. Check the airway is now patent and the patient is ventilating.
“Once the nasopharyngeal airway is in it’s important clearly to reassess the patient and make sure they have a patent airway.”
That last point deserves emphasis. The adjunct is not the end of the airway step. You may still need a head tilt or jaw thrust alongside it, and the patient may need supplemental oxygen. An airway device that has been placed and then ignored is a device that has not been assessed. This is why the ABCDE approach, which the medical emergencies post walks through, insists on reassessment after every intervention.
Monitoring is part of that reassessment. If oxygen saturation is being measured, the earlier post on pulse oximetry explains what the number does and does not tell you about ventilation.
Removal
Because the NPA is so well tolerated, a recovering patient may be sat up and talking with it still in place. Many will pull it out themselves. If they cannot, or would prefer you to do it, removal is simply a matter of gently pulling on the flange.
How this is examined
The FREC paper is multiple choice, so it cannot ask you to demonstrate insertion. What it can do is describe a patient and ask you to choose the right adjunct, or describe a head injury and ask what changes your thinking. Expect:
- A scenario pairing: semi-conscious patient with a gag reflex versus deeply unconscious patient. One takes an NPA, the other a Guedel.
- A seizure or trismus stem where the mouth cannot be opened.
- A head injury stem with blood from the ear or bruising behind it, testing whether you recall base of skull fracture as a caution.
- A sizing question, where the correct answer is the nostril-based estimate and the distractors are landmark rules borrowed from the oral airway.
- A post-insertion question, where the right answer is to reassess, not to move on.
Read the conscious level in the stem before anything else. It is the single detail that separates the two adjuncts.
Where this sits in your revision
Airway adjuncts are core content for both the Level 3 Award and the Level 4 Certificate, and they sit inside the wider ABCDE assessment that runs through the whole syllabus. Nothing here replaces your practical training, your assessor’s feedback or your scope of practice. The purpose is to make the multiple choice paper feel familiar.
FREC 3 & 4 Exam Revision covers airway management alongside the rest of the Qualsafe syllabus, with 585 questions across 8 topics and 80 of them free to try. The app is an independent revision tool that mirrors the multiple choice question paper format. It is not accredited or endorsed by Qualsafe Awards.
- Airway management
- ABCDE
- FREC
Frequently asked
When is a nasopharyngeal airway preferred over an oropharyngeal airway?
When the patient is not fully unconscious and would gag on an oral airway, when the jaw is clenched during a seizure or by trismus so the mouth cannot be opened, or when maxillofacial injury obscures the oral route. The NPA is better tolerated because it bypasses the tongue and the gag reflex is less provoked.
Is a base of skull fracture an absolute contraindication to an NPA?
It is described as a relative contraindication. There is a small but potentially life-threatening risk of the tube passing into the cranial vault, and that risk has to be weighed against the need to keep the airway open. Follow your training and local protocol.
How do you size a nasopharyngeal airway?
There is no reliable anatomical rule. Look at the nostril and choose a tube that will pass without stretching the skin of the nostril. Most adults take a size 6 or 7. If the patient gags or coughs once it is in, the tube is too long and should be swapped for a smaller one.
Which nostril do you use for an NPA?
Look first and pick the larger, clearer nostril. Convention is to try the right nostril first, but a deviated septum or enlarged turbinates may make the left the better choice.
Does an NPA mean you can stop the head tilt or jaw thrust?
No. An adjunct supports the airway, it does not replace simple manoeuvres. Reassess after insertion, keep using airway opening manoeuvres if needed, and give oxygen where indicated.
