Nasopharyngeal Tubes use???

[rickp]

Another question,
I have a couple of j tubes in my bag but I'm noticing that more and more people are carrying nasopharyngeal tubes. So again, are the tubes more effective or are they being used because J tubes can be a bit tricky to insert?

R.

[gimpface]

I assume that by "J-tube" you're referring to OPAs. With an unresponsive person, I like to drop an OPA first, because this tells me if the patient has a gag reflex. If not, they need to be intubated. If they are unresponsive but do have a gag reflex, I'll drop an NPA and start thinking about RSI or nasal intubation. Or I'll use an NPA if I'm in a shitty mood and some jerk is faking a seizure. I notice that most first responders in my area are a bit squeamish about OPAs, I guess they feel that NPAs are easier to place. I don't see much difference, personally.

[rickp]

Yes OPA is what I meant. You got some good points.

What are they squeamish about???

I guess I need to pick up some NPA's

[gimpface]

I'm not really sure. I've seen firefighters who have placed dozens of NPAs balk at putting in OPAs... I just asked my partner his opinion, he thinks they're afraid of being bitten. In a zombie apocalypse, this seems perfectly reasonable.

[rickp]

LOL!! yeah I guess they have a legitimate concern then!! LOL

R.

[DannusMaximus]

I would think a nasal would be less effective than an oral, simply because the size of the tube is smaller. Physiologically this might not be an issue, just a thought. We use nasal, oral, and combitubes on our department. I usually base which I use on the level of consciousness of the patient and the anticipated arrival time of the transport ambulance. If I can see or hear the ambulance coming shortly after we arrive on scene, I'll usually hold off on the combitube, because a dedicated endotracheal tube is kind of the gold standard for airways, and a standard oral will do fine for the few minutes it takes for the paramedic to prep to intubate the patient. If we're going to be minus an ambulance for much longer than that (pretty common) I'll generally use a combitube.

Paras used to pretty routinely remove the combitubes we dropped, so fire kind of got away from using them - - they're sort of expensive to use for 2 minutes than throw on the floor. Recently, though, it seems like the transport service is leaving the combitube in place if we've got one in, so I'm using them more.

Both nasal airways and oral airways (and combitubes, really) are quick and easy to use with a little practice. Proper size selection and lubrication is the key for nasals, size is key for the orals.

[gimpface]

I would think a nasal would be less effective than an oral, simply because the size of the tube is smaller. Physiologically this might not be an issue, just a thought. We use nasal, oral, and combitubes on our department. I usually base which I use on the level of consciousness of the patient and the anticipated arrival time of the transport ambulance. If I can see or hear the ambulance coming shortly after we arrive on scene, I'll usually hold off on the combitube, because a dedicated endotracheal tube is kind of the gold standard for airways, and a standard oral will do fine for the few minutes it takes for the paramedic to prep to intubate the patient. If we're going to be minus an ambulance for much longer than that (pretty common) I'll generally use a combitube.

I love combitubes, and as far as I'm concerned, there is no legitimate reason to remove a patent combitube in favor of an ET tube, if for no other reason than because of the risk of varices- if you've ever seen a combitube pulled out of a guy you didn't know had them, the bleeding is unbelievable... makes getting a tube in to replace the combi a nightmare. On another note, if the combitube is working right (ventilating through lumen #1), you don't have to pull it to intubate them- you can deflate the large cuff, leave the small one in place (in the esophagus) and blindly jam an ET tube into the airway- there's only one place it can go.

[Tel0004]

Here is a great article on NPA's and OPA's.

viewtopic.php?f=43&t=27798&p=583110&hilit=essentials+opa#p583110

Just don't use NPA's when there is facial trauma (due to risk of poking into the brain, or when they are bleeding through the nose (as the blood would clog it up.

[Prepared American]

I like j-tubes but if i can drop a j-tube and they tolerate it I will usually just intubat them. I in 21 years of EMS (I have been involved in about every facet of ems, ambulance, fire service, flight, tactical, military, etc.) I can probably count the number of NPA's I have placed on both hands, where as j-tubes (OPA's) and ETT"s are in the 100's if not 1000's range. I have also performed a few crich's but that really isn't appropriate for most people on this forum.

My opinion, sure Cary an NPa or two but don't dismiss your OPA's because in most cases they are better and more suitable.

[ehunter72]

Keep in mind that NPa's and OPa's are at the firstresponder/ EMT-b level (while some states allow B's to combi tube.

I think that is why EMT-P's and above use them far far less.

For the level of training they are used in they are a good tool.
I dont like orals so much been biten a time or two.lol although the get the faker to gag trick is good,
Also I think it is much harder to guesstimate the propper size of an Opa than it is to guess at an Npa, it either fits in the hole or it dont, just a thought.


Most of the time I have use a NPa is simply to not have to babysit the airway while I had someone else bag/breath.
If I was stopping a bleed , traction or something like that....

I do carry Opa's and Npa's in my carry bag, I do not have combi's or Et's....

[claren]

Also I think it is much harder to guesstimate the propper size of an Opa than it is to guess at a Opa, it either fits in the hole or it dont, just a thought.

Your post doesn't make it clear which one you are referring to, OPA or NPA. Either way, for an OPA the "corner of the mouth to the head of the mandible" method works well for me.

[ehunter72]

YEs i see that..

I meant the Orals are harder for the untrained (not that they should be useing them lol), than a Nasal, I was half joking with the if it don't fit in the hole......
I use the same metheod as you for an OPA

[Berserker]

I'm not really sure. I've seen firefighters who have placed dozens of NPAs balk at putting in OPAs... I just asked my partner his opinion, he thinks they're afraid of being bitten. In a zombie apocalypse, this seems perfectly reasonable.

Why would you be putting either in a Zombie? They need no airway.

[croaker260]

I assume that by "J-tube" you're referring to OPAs. With an unresponsive person, I like to drop an OPA first, because this tells me if the patient has a gag reflex. If not, they need to be intubated. If they are unresponsive but do have a gag reflex .

I personally steer my interns/students far away from this practice. There are other ways to determine need for intubation, without running the chance of causing vomiting, and thus risking aspiration in an unconscious patient. Remember: Vomiting -> Aspiration -> Aspiration Pneumonia/ARDS -> Death.

Things I look at (although to be sure, if they have a gag, I can RSI them if needed.)

- Lash reflex

- Ability to swallow/cough on command of spontaneously to control secretions.

- Respiratory effort/work of breathing and predicted fatigue.


WHile I LOVE the NPA, it is often not taught correctly/completely. Now some words of caution on an NPA:

1- Its a DELICATE TWO FINGER TECHNIQUE.

2- LUBE!!!!

3- carry neosynepherine (sp). Empty 1/2 of the bottle in each nare prior to placement. See comments #4 below.

4- If you "force" it, you WILL cause bleeding. The bleeding WILL cause an airway problem if you dont already have one, and if they are on blood thinners, ASA, or if it is just not your day this WILL be a HUGE airway problem, and you have caused more problems than you have solved. .

As a side note, if you dont have RSI available, but you can place an ETT, you damm-sure-better be familiar with nasal ETT.

[croaker260]

Keep in mind that NPa's and OPa's are at the firstresponder/ EMT-b level (while some states allow B's to combi tube.

I think that is why EMT-P's and above use them far far less.

.

This is a misconception. Speaking locally as a 16 year medic/21 year EMS-er.... I do use both NPA's and OPA's, especially to salvage a difficult airway that one of my options is not good for. Usually it is not done simply because I am transitioning to an ET within 1-2 minutes. Even then, if I notice it I will often encourage the FF to use one. That's "IF" I notice it. A lot goes on within the first few minutes of a critical patient and sometimes you have got to trust that your co-responders are doing their job right or you will never get to doing yours.

The biggest risk of not placing an OPA properly is that you will shove the tongue back, occluding the airway (that is why you place them inverted at first, then rotate them), or that you will use one too small and lose it in the hypo-pharynx, occluding the airway as well. I have seen this happen on several occasions when it was placed and then not noticed throught the BVM Mask.
Too large and you also will occlude the airway/cause some swelling.

[croaker260]

I would think a nasal would be less effective than an oral, simply because the size of the tube is smaller. Physiologically this might not be an issue, just a thought.

This is true, but not always an issue. One of the difficult airway courses I have taken reccommends using two NPAs and an OPA (if tolorated) in a patient whom prolonged BVM use is a reality and for what ever reeason another alternative airway (ETT, Combi, King, LMA, etc etc) isnt an option.

Paras used to pretty routinely remove the combitubes we dropped, so fire kind of got away from using them - - they're sort of expensive to use for 2 minutes than throw on the floor. Recently, though, it seems like the transport service is leaving the combitube in place if we've got one in, so I'm using them more.

We had this same problem 10 years ago when one of our local first response agencies started using combi tubes. Then we had the same problem when we would bring in combis to the ER with ER docs yanking them out.

Its just a matter of training, communication, and education. In our case training of all parties solved the problem. We tend now to leave it in unless their is a reason not to. Very seldom is this the case.

Both nasal airways and oral airways (and combitubes, really) are quick and easy to use with a little practice. Proper size selection and lubrication is the key for nasals, size is key for the orals.

Agreed, though I would say most agencies tend to overlook this key tool(s) in their ongoign training, "assuming" everyone knows how to use it and will when it is needed.

If you cant tell, I teach a lot and this is a soap box for me. Sorry for the rant.

[PotatoMuncher]

Used one when a Pesh Merga soldier took a bullet to his upper jaw. Dude had all sorts of bits in there: Teeth, flesh, blood, tongue, etc. He started to choke on some of it, and when I saw air bubbles emerging from the back of his mouth, I decided to drop a pretty long NPA down there. It worked as a make-shift intubation until I could get my King LT out. Might not be a super amount of air getting down there, but it's better than nothing.

Other than that, I kept it for the exact reasons that gimpface stated. That and for new E1's and E2's to try out when they got bored.

[Medic Mentor]

Used one when a Pesh Merga soldier took a bullet to his upper jaw. Dude had all sorts of bits in there: Teeth, flesh, blood, tongue, etc. He started to choke on some of it, and when I saw air bubbles emerging from the back of his mouth, I decided to drop a pretty long NPA down there. It worked as a make-shift intubation until I could get my King LT out. Might not be a super amount of air getting down there, but it's better than nothing.

Other than that, I kept it for the exact reasons that gimpface stated. That and for new E1's and E2's to try out when they got bored.

Right on P-muncher. I was in Northern Iraq, used a few NPA's. THe bottom line is that they are easy to use if you train the rescuer, pretty much placed them if I gave Mo-fine or was dealing with MCI.

Teaching TCCC I always have folks place a real one in their buddy. And I go first by grabbing the least confident student and have them place it in me.

[doitnstyle1]

two instances where I used NPA's

1. Maxillo-facial trauma rendering the use of OPA ineffective

2. Massive brain injury that caused severe maxillary clenching not allowing me to insert an OPA.

[Medic Mentor]

2. Massive brain injury that caused severe maxillary clenching not allowing me to insert an OPA.

YESSSSS Very good call. Good to get in until more advanced airway or meds are given!!

Resp

MM