Oropharyngeal Airway

Oropharyngeal airways are plastic, rubber, or metallic devices designed to lie be-
tween the base of the tongue and the posterior pharyngeal wall (Figure 31-12).

From: Sedation (Fifth Edition), 2010

Related terms:

Resuscitation, Nasopharyngeal Airway, Continuous Positive Airway Pressure, Intu-

bation, Ventilation, Epinephrine, Mandible

View all Topics

Armamentarium, Drugs, and Tech-

niques
In Sedation (Sixth Edition), 2018

Oropharyngeal and Nasopharyngeal Airways

Oropharyngeal (Fig. 31.9) and nasopharyngeal airways (Fig. 31.10) are used to assist
in maintaining a patent airway at any point during anesthetic procedure. Oropharyn-
geal airways are plastic, rubber, or metallic devices designed to lie between the base
of the tongue and the posterior pharyngeal wall (Fig. 31.11). The NPA (also known
as a nasal trumpet) is a thin, flexible rubber tube designed to be inserted through the
nares and to rest between the base of the tongue and posterior pharynx (Fig. 31.12).
The purpose of both of these devices is to displace the tongue from the pharynx and
thereby permit the patient to exchange air either around or through the airway. The
NPA is better tolerated than an oropharyngeal airway by the conscious or sedated
patient, thereby minimizing the occurrence of gagging and vomiting.
Figure 31.9. Oropharyngeal airways are available in a variety of sizes.

(Courtesy Sedation Resource, One Oak, TX.)

Figure 31.10. Nasopharyngeal airways.

(From McSwain N: The basic EMT: comprehensive prehospital care, ed 2, St Louis, 2003,
Mosby.)

Figure 31.11. The oropharyngeal airway is designed to lift the tongue off the posterior
wall of the pharynx.
(From McSwain N: The basic EMT: comprehensive prehospital care, ed 2, St Louis, 2003,
Mosby.)

Figure 31.12. The nasopharyngeal airway is designed to rest between the base of the
tongue and pharyngeal wall, thus permitting air to pass between the lungs and the
nose.

(From McSwain N: The basic EMT: comprehensive prehospital care, ed 2, St Louis, 2003,
Mosby.)

> Read full chapter

Airway Management
Robert S. Holzman, in Smith's Anesthesia for Infants and Children (Eighth Edition),
2011

Airway Adjuncts
Oropharyngeal airway devices should be available in the full range of sizes at
each anesthetizing location. The required airway size can be estimated by a careful
external examination of the child and by measuring the distance from the teeth to
the base of the tongue. An oropharyngeal airway device that is too small can displace
the base of the patient's tongue inferiorly toward the pharynx, thereby increasing
the degree of obstruction, which may worsen with the application of CPAP in an
effort to improve the airway obstruction. An airway that is too large may reach the
laryngeal inlet and result in trauma or laryngeal hyperactivity and laryngospasm. It is
common practice by some clinicians to insert an oropharyngeal airway device upside
down, or convex to the natural curvature of the tongue and then to rotate the airway
180 degrees. However, this maneuver may abrade the hard palate and it is therefore
not recommended. A less traumatic technique for the insertion of an oropharyngeal
airway device is to use a tongue depressor to displace the tongue to the floor of the
mouth and to insert the device concave to the tongue's surface.

Oropharyngeal airway devices are often used as “bite blocks” after a patient's trachea
has been intubated, in order to prevent the clenching of the teeth on the endo-
tracheal tube. This maneuver may, however, be hazardous in children between 5
and 10 years of age with loose deciduous teeth. Oropharyngeal airway devices are
responsible for up to 55% of anesthesia-related dental complications (Clokie et al.,
1989). Furthermore, when an oropharyngeal airway device is used as a bite block
during long cases, it may cause necrosis of the tongue, uvular edema, or lip damage
(Moore and Rauscher, 1977; Shulman, 1981). A gauze pad that has been rolled up
and placed between the patient's upper and lower molar teeth is a better method
of preventing the teeth from clenching on an endotracheal tube and minimizing
dental trauma. Caution must be exercised, however, that the roll not slip and place
undue pressure on the lateral aspect of the tongue (paraglossal sulcus), where the
hypoglossal nerve runs.

Nasopharyngeal airway devices are generally constructed from red rubber or

polyvinyl chloride and are available in various sizes. A nasal airway should be lubricat-
ed and gently inserted transnasally. Nasopharyngeal airway devices may traumatize
the turbinates or adenoids of young children. Moreover, care must be exercised
when using a nasopharyngeal airway device in children who have a bleeding diathe-
sis or a congenital abnormality of the midface such as choanal atresia or frontonasal
dysplasia. The proper length for the nasopharyngeal airway may be estimated by
measuring the distance between the patient's auditory meatus and the tip of the
nose. The insertion of a nasopharyngeal airway device that is too long may cause
laryngospasm. Furthermore, if the airway is too short, the upper airway obstruction
may not be relieved.

The LMA is used successfully for routine pediatric anesthetics and even for adeno-
tonsillectomies (Webster et al., 1993; Williams and Bailey, 1993). LMAs are currently
manufactured in several sizes, for patients ranging from neonates to large adults.
With minimal inflation of the mask's cushion and thorough lubrication of the non-
laryngeal surface, an LMA should be seated at the laryngeal inlet and cause minimal
discomfort to the patient postoperatively. Following its blind passage through the
oral cavity, the proper seating of an LMA is generally heralded by a slight rise of
the device when the mask's cushion is inflated with air. Care should be taken to use
the minimal effective inflation pressure for the cuff, typically up to 60 cm H2O. The
routine use of a manometer is advocated. In some patients, the cushion of the LMA
overrides the proximal portion of the esophagus, thereby exposing the patient to the
risk of the aspiration of gastric contents, with the LMA serving as a conduit to the
lungs (Nanji and Maltby, 1992). Nevertheless, although ideal positioning of an LMA
appears to be achieved in only 50% of cases, the vast majority of patients fare very
well (Rowbottom et al., 1991; Goudsouzian et al., 1992; Mizushima et al., 1992).

Although it was originally thought that pediatric-sized LMAs might not function
adequately because of differences in airway anatomy, this fear proved to be unfound-
ed. The #1 LMA, a miniature version of the adult LMA, was designed to fit infants
who weigh less than 6.5 kg. It has worked satisfactorily even in premature infants
as small as 1 kg, in newborn resuscitation, and in airway maintenance for infants
with upper-airway congenital anomalies (e.g., Pierre-Robin, Goldenhar's, Treach-
er-Collins, and Schwartz-Jampel syndromes). In difficult intubating conditions,
it has been used throughout the whole procedure or as a conduit for endotracheal
intubation. The endotracheal tube can often be easily directed through an LMA
without fiberoptic laryngoscopy.

Flexible LMAs in sizes 2, 2.5, and 3 are also available for pediatric use. The cuff i
s similar to a standard LMA, but the airway tube is wire-reinforced, longer, and
more flexible, allowing it to be positioned away from the surgical field. Although the
flexibility of the tube is advantageous for positioning, it is more difficult to insert, it
may dislodge more easily, and biting can occlude it. Moreover, the flexibility of this
LMA does not allow the rotation technique for insertion. Adenoidectomy or even
tonsillectomy can be performed with the flexible LMA, because the cuff prevents
soiling of the glottis and the trachea by blood and secretions from the surgical site.
If tracheal intubation is planned via LMA, a standard LMA is a more logical choice
in children, because it is shorter and has a larger diameter; in adolescents or adults,
the intubating LMA (Fastrach) can be used.

The more cephalad and anterior position of the larynx of a child as compared with
an adult has prompted the use of an alternate insertion technique in children. In this
case, the LMA is inserted with its cushion placed against the hard palate. The device
is then rotated through 180 degrees until the cushion is seated at the laryngeal inlet
(McNicol, 1991). This method for the insertion of an LMA appears to be especially
useful in preschool and young school-age children.

> Read full chapter

Airway Management
Ann E. Thompson, Rosanne Salonia, in Pediatric Critical Care (Fourth Edition), 2011

Oropharyngeal Airways
Oropharyngeal airways displace the base of the tongue from the posterior pharyn-
geal wall and break contact between the tongue and palate (see Figure 119-2). Size
selection is important. An excessively long airway may encroach upon the larynx
and cause laryngospasm. An airway that is too short may actually push the tongue
posteriorly and exacerbate obstruction. If the airway is held at the side of the face
with the flange just anterior to the incisors, the tip should be at or near the angle
of the mandible. The airway should be positioned following the curve of the tongue
while the tongue is held down and forward with a tongue depressor. Inserting the
airway with its concave side facing the palate and then rotating it may traumatize
the oral mucosa or damage teeth. Oral airways are poorly tolerated in any patient
with a functional gag reflex and may induce vomiting. As a consequence, they are of
little more than temporary value in the critically ill child. They may support a patent
airway for bag-valve-mask ventilation in preparation for intubation.

> Read full chapter

Pediatric Equipment
Patrick A. Ross, ... Charles J. Coté, in A Practice of Anesthesia for Infants and Children
(Sixth Edition), 2019

Oropharyngeal Airways
Oropharyngeal airways are hard, non-latex plastic that are preformed in different
sizes from 40 mm (infant) to 100 mm (large adult). Care should be taken to choose
an airway that is the correct size for the child because an airway that is too small
displaces the posterior portion of the tongue or epiglottis into the glottic opening,
causing upper airway obstruction. Alternatively, if the airway is too large, the airway
device may cause damage to laryngeal structures, causing swelling and potential
postoperative obstruction (see Fig. 14.13). An oral airway should always be placed
midline, without rotating it as it is inserted as is commonly done in adults, since
at every age, children have some loose teeth and others that are ready to fall out.
Rotating the hard airway may dislodge one or more teeth, leading to a possible
pulmonary aspiration. Misplaced oral airways that obstruct venous and/or lymphatic
drainage of the tongue can precipitate acute macroglossia.38 Additional causes of
acute macroglossia include retained throat packs,39 surgical positioning,40 and the
presence of TEE probes.

> Read full chapter

Nonintubation Management of the Air-
way
Eric C. Matten, ... Jefferey S. Vender, in Benumof and Hagberg's Airway Manage-
ment, 2013

1 Oropharyngeal Airways
An oropharyngeal airway (OPA) is the most commonly used device to provide a
patent upper airway. OPAs are manufactured in a wide variety of sizes from neonatal
to large adult, and they are typically made of plastic or rubber (Fig. 15-7). They
should be wide enough to make contact with two or three teeth on each of the
mandible and maxilla, and they should be slightly compressible so that the pressure
exerted by a clenched jaw is distributed over all of the teeth while the lumen remains
patent. OPAs are frequently designed with a flange at the buccal (proximal) end to
prevent swallowing or over insertion. They also feature a distal semicircular section
to follow the curvature of the mouth, tongue, and posterior pharynx so that the
tongue is displaced anteriorly (concave side against the tongue). An air channel is
often provided to facilitate oropharyngeal suctioning.

Figure 15-7. Oropharyngeal airways. A, Guedel Airways in sizes from neonatal to

large adult. B, The Ovassapian Airway has a large anterior flange to control the
tongue. The airway is open posteriorly (including no posterior flange) so that an
endotracheal tube can be inserted with a flexible fiberoptic scope and the assembly
later separated.
The most commonly used OPA in adults is the Guedel Airway (see Fig. 15-7). It has a
plastic elliptical tube with a central lumen reinforced by a harder inner plastic tube at
the level of the teeth and by plastic ridges along the pharyngeal section. Because the
airway is completely enclosed (other than the proximal and distal ends), redundant
oral and pharyngeal mucosae cannot occlude or narrow the lumen from the side.
Its oval cross section allows the four central incisors to make contact with it during
masseter spasm.

The Ovassapian Airway has a large anterior flange to control the tongue and a large
opening at the level of the teeth (open posteriorly) to allow a flexible fiberoptic
bronchoscope and ETT to be passed through it and later disengaged from the airway
(see Fig. 15-7). Consequently, it is often employed during fiberoptic intubations to
aid in maintaining upper airway patency.

Use of an OPA seems deceptively simple, but the device must be used correctly.
The patient's pharyngeal and laryngeal reflexes should be depressed before insertion
to avoid worsening obstruction due to airway reactivity. The mouth is opened, and
a tongue blade is placed at the base of the tongue and drawn upward, lifting the
tongue off of the posterior pharyngeal wall (Fig. 15-8A). The airway is then placed so
that the OPA is just off the posterior wall of the oropharynx, with 1 to 2 cm protruding
above the incisors (see Fig. 15-8B). If the flange is at the teeth when the tip is just at
the base of the tongue, the airway is too small, and a larger size should be inserted.
A jaw thrust is then performed as described previously to lift the tongue off of the
pharyngeal wall while the thumbs tap down the airway the last 1 to 2 cm so that the
curve of the OPA lies behind the base of the tongue (see Fig. 15-8C). The mandible
is then allowed to reduce back into the temporomandibular joint, and the mouth
is inspected to ensure that neither the tongue nor the lips are caught between the
teeth and the OPA.
Figure 15-8. Techniques for insertion of an oropharyngeal airway: standard tech-
nique (A–C) and alternative technique (D) without a tongue blade. A, The tongue
blade is placed deep into the mouth and depresses the tongue at its posterior half.
The tongue is then pulled forward in an attempt to pull it off the back wall of the
pharynx. B, The airway is then inserted with the concave side toward the tongue until
the tube is just off the posterior wall of the oropharynx with 1 to 2 cm protruding
above the incisors. The tongue blade is then removed. C, A jaw thrust is performed
while the thumb taps the airway into place. After the jaw is allowed to relax, the lips
are inspected to ensure they are not caught between the teeth and airway. D, In an
alternative technique, the airway is placed in a reverse manner (convex side toward
tongue) and then spun 180 degrees into place so that the lower section of the airway
rotates between the tongue and posterior pharyngeal wall.

An alternative method of placement is to insert the airway backward (convex side

toward the tongue) until the tip is close to the pharyngeal wall of the oropharynx. It
is then rotated 180 degrees so that the tip rotates and sweeps under the tongue from
the side (see Fig. 15-8D). This method is not as reliable as the tongue blade–assisted
technique described earlier, and it has the added risk of causing dental trauma in
patients with poor dentition.
If the upper airway is not patent after the placement of an OPA, the following
situations must be considered. With an OPA that is too small, the pronounced curve
may impinge on the base of the tongue, or the tongue may obstruct the native airway
distal to the OPA. If a larger OPA still results in obstruction, the curve might have
brought the distal end into the vallecula or the OPA might have pushed the epiglottis
into the glottic opening or posterior wall of the laryngopharynx. In the lightly
anesthetized or awake patient, this stimulation causes coughing or laryngospasm.
The best treatment for this problem is to withdraw the OPA 1 to 2 cm. A topical
anesthetic spray or a water-soluble local anesthetic lubricant reduces the chance of
laryngeal activity, but it should be used judiciously or avoided in patients thought to
be at increased risk for aspiration.

Two major complications can occur with the use of OPAs: iatrogenic trauma and
airway hyperreactivity. Minor trauma, including pinching of the lips and tongue, is
common. Ulceration and necrosis of oropharyngeal structures from pressure and
long-term contact (days) have been reported.16 These problems necessitate inter-
mittent surveillance during extended use. Dental injury can result from twisting of
the airway, involuntary clenching of the jaw, or direct axial pressure. Dental damage
is most common in patients with periodontal disease, dental caries, pronounced
degrees of dental proclination, and isolated teeth.

Airway hyperactivity is a potentially lethal complication of OPA use, because oropha-

ryngeal and laryngeal reflexes can be stimulated by the placement of an artificial
airway. Coughing, retching, emesis, laryngospasm, and bronchospasm are common
reflex responses. Any OPA that touches the epiglottis or vocal cords can cause these
responses, but the problem is more common with larger OPAs. Initial management
is to partially withdraw the OPA. If an anesthetic is being administered, deepening
the plane of anesthesia (most easily accomplished with an intravenous agent) is
often effective in blunting airway hyperreactivity. In cases of laryngospasm, it may be
necessary to apply mild positive airway pressure and, in trained hands, to cautiously
administer small doses of succinylcholine to achieve resolution.

> Read full chapter

Pediatric Anesthesia Equipment and

Monitoring
Ronald S. Litman, ... Robert J. Sclabassi, in Smith's Anesthesia for Infants and
Children (Seventh Edition), 2006
▪ CUFFED OROPHARYNGEAL AIRWAY
The cuffed oropharyngeal airway (COPA) is essentially a Guedel airway manufactured
with a 15-mm anesthesia breathing circuit connector on the proximal end and an
inflatable cuff on the distal end (Fig. 9-12). It has an integrated bite block, which is
color coded for size and to help with proper positioning. The device is inserted in a
similar manner to that of an oral airway; once inserted, the cuff is inflated (with 20 to
40 mL air) to provide a low-pressure seal in the hypopharynx to facilitate spontaneous
or controlled ventilation. Once inserted, the COPA can be secured in place using
an accompanying head strap that attaches to the posts on the tooth/lip guard. The
COPA is intended as a single-use device.

FIGURE 9-12. The cuffed oropharyngeal airway (COPA) is essentially a Guedel airway
manufactured with a 15-mm anesthesia breathing circuit connector on the proximal
end and an inflatable cuff on the distal end.

The principal indication of the COPA is to aid airway management by replacing the
use of an anesthesia facemask, freeing up the hands of the anesthesia practitioner
(Robbins and Connelly, 2000; Sammartino and Ferro, 2002). It is primarily intended
for use in anesthetized patients who are breathing spontaneously, but it also can be
used with controlled ventilation in some patients.

The COPA is available in four sizes (Table 9-1). The smallest (size 8) is appropri-
ate for most school-aged children. When held adjacent to the patient's head, the
appropriately sized COPA should rest with the bite block just above the teeth and
the distal tip at the angle of the mandible. This is usually one size larger than the
corresponding appropriately sized oral airway. Before insertion, the distal end of the
device is lubricated and the cuff is tested for leaks. When sized correctly, the COPA
“locks into place” behind the base of the tongue. If the proper size has been chosen,
the colored bite block should “transition” at the teeth. Once inserted, the COPA is
fastened to the head strap, a jaw-thrust/chin-lift maneuver is performed, and the cuff i
s inflated with the proper amount of air (see Table 9-1).

TABLE 9-1. Characteristics of the cuffed oropharyngeal airway

Size Color Amount of Air Needed to Inflate

Cuff (mL)
8 Green 25
9 Yellow 30
10 Red 35
11 Light green 40

On occasion, manual airway adjustments may be required to enhance the proper

functioning of the COPA; these include increased or decreased head tilt, turning
the head to one side, supporting the shoulders, gentle chin lift, or application of
continuous positive airway pressure (CPAP) up to 10 cm H2O (Bussolin and Busoni,
2002). The COPA can be removed at any time, preferably with the cuff remaining
inflated to facilitate removal of oral secretions.

When compared with the laryngeal mask airway (LMA) in children, the use of a COPA
resulted in a greater number of subsequent airway maneuvers or a switch to another
airway method to establish ventilation (Mamaya, 2002). Its use was also associated
with less airway response with cuff inflation and decreased requirement for assisted
ventilation compared with the LMA.

> Read full chapter

Teaching Airway Management Outside

the Operating Room
Sebastian G. Russo, Stephen F. Dierdorf, in Benumof and Hagberg's Airway Man-
agement, 2013

B Pharyngeal Airways
Pharyngeal airways, including oropharyngeal and nasopharyngeal airways, are de-
signed to provide a patent passage through the mouth and hypopharynx by elevating
the tongue and epiglottis. Pharyngeal airways are simple in design but extremely
effective for alleviating upper airway obstruction. Insertion of a pharyngeal airway
and two-person ventilation can provide effective ventilation in some of the most
challenging DA cases. The use of pharyngeal airways can be easily integrated into
the instructional program for BMV. Any medical provider who may encounter upper
airway obstruction should be proficient with the use of pharyngeal airways.

> Read full chapter

The Difficult Airway in Conventional

Head and Neck Surgery
Alexander T. Hillel, ... Nasir I. Bhatti, in Benumof and Hagberg's Airway Manage-
ment, 2013

c Fiberoptic-Guided Orotracheal Intubation

Orotracheal intubation is facilitated with an oropharyngeal airway (OPA), such as
a Williams or Ovassapian OPA. Similar to nasotracheal intubation, optimal topical
anesthesia of the oral cavity and oropharynx is warranted to overcome the patient's
gag reflex. The lubricated ETT, with its connector removed, is loaded onto the
proximal end of the FFB. The tip of the scope is then introduced through the OPA
and passed behind the epiglottis into the glottic opening leading into the trachea.
When the scope is past the vocal folds, the tracheal rings should be identified
before advancing the ETT. The ETT is then eased into the trachea over the scope,
and placement is confirmed with a combination of bilateral chest auscultation and
end-tidal carbon dioxide (Etco2) measurement. After confirmation of the placement,
general anesthesia is induced.

> Read full chapter

Disaster Preparedness, Cardiopul-

monary Resuscitation, and Airway Man-
agement
Joseph H. McisaacIII, Lauren C. Berkow, in Benumof and Hagberg's Airway Man-
agement, 2013

C Passive Oxygen Insufflation

Oxygen can be delivered passively through an oropharyngeal airway, face mask,
supraglottic airway, or modified endotracheal tube (Boussignac endotracheal tube,
Vygon Corporation, Montgomeryville, PA). The Boussignac tube contains capillaries
through which oxygen is delivered by continuous insufflation, generating a constant
positive alveolar pressure. The proximal end of the tube remains open to allow
exhalation (Fig. 34-10). The changes in intrathoracic pressure that occur during chest
compressions trigger passive inhalation and active exhalation, allowing adequate gas
exchange.

Figure 34-10. The Boussignac endotracheal tube contains capillaries through which
oxygen is delivered by continuous insufflation, generating a constant positive alve-
olar pressure.

(Courtesy of Vygon, Ecouen, France.)

Passive oxygen delivery does not require the use of a rescuer to deliver ventilations,
minimizes interruptions in chest compressions, and may reduce the risk of barotrau-
ma caused by excessive ventilation. Evidence shows passive oxygen delivery to be as
effective as bag-mask ventilation or mechanical ventilation through an endotracheal
tube.40,41 Passive oxygen delivery is described as an alternative but not a replacement
for ventilation during CPR in the 2010 AHA guidelines.

> Read full chapter

Respiratory Disorders in the Newborn

Noah H. Hillman MD, Hugh Simon Lam MBBChir, MD, in Kendig's Disorders of
the Respiratory Tract in Children (Ninth Edition), 2019

Management
Nasal causes of obstruction can be relieved by an appropriately sized oropharyngeal
airway. Choanal atresia requires surgical intervention to correct the occlusion. For
 cases with pharyngeal obstruction, some may respond to prone positioning. In the
prone position, the base of the tongue can fall forwards and relieve obstruction of
the pharyngeal airway. Oropharyngeal or nasopharyngeal airways may be helpful,
but ET intubation or tracheostomy may be required in more severe cases.

In the absence of associated structural obstructive lesions, many of the common

causes of laryngeal obstruction may resolve with expectant management. For ex-
ample, laryngomalacia usually resolves by the age of 18–24 months,281 whereas
unilateral vocal cord palsy may resolve within weeks after resolution of the under-
lying cause.286 If there are no signs of severe disease, conservative management is
recommended. For those with substantial risk of life-threatening airway obstruction
(e.g., bilateral vocal cord palsy), the infant may require ET intubation or tracheosto-
my. For infants with subglottic stenosis secondary to ET intubation, preextubation
corticosteroids may be useful. Surgical intervention may be indicated in cases with
severe disease (e.g., failure to thrive) and respiratory compromise.

> Read full chapter

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