Revisiting the Nasopharyngeal Airway (NPA): The Next-Level NPA

Airway compromise continues to account for approximately 1 in 10 preventable battlefield deaths. Combat medics often provide care in no or low-light conditions, surrounded by the chaos of combat, and with the limited dexterity that accompanies bulky body armor, gloves, and heavy equipment. Far-forward medical care is also limited by available resources, which are often only what a combat medic can fit in their aid bag. Therefore, a procedure such as airway management that currently requires a high degree of skill becomes substantially more complex. The purpose of this research and development project is to significantly enhance the effectiveness of one of their most basic lifesaving airway management tools, the nasopharyngeal airway (NPA). The NPA factors prominently within Tactical Combat Casualty Care (TCCC) guidelines and within civilian acute care, however, NPAs are not universally effective in relieving airway obstruction, they are underutilized in the TCCC environment, and they are in desperate need of an innovative overhaul. The NPA, also known as the nasal trumpet (because of its flared proximal end), is designed to be inserted into the nose and into the upper airway of a patient in order to relieve breathing obstruction caused by the collapse of airway soft tissues that occurs during depressed levels of consciousness. Upper airway collapse (the airway above the vocal cords) can occur in conditions such as severe head injury, coma, stroke, severe trauma, or anesthesia. The NPA, which has remained largely unchanged since its invention in 1881, has been considered an essential part of hospital and prehospital emergency care kits since at least the 1970s. However, despite the NPA’s simplicity and its prominence within TCCC guidelines, the literature demonstrates that prehospital NPA’s appear to be underutilized within Role 1 and Role 2 levels of care. This assertion is further supported by information within TCCC Guidelines Change 17-01 which states “combat medics have been observed to perform surgical airways on a number of occasions for casualties who were unconscious from hemorrhagic shock or traumatic brain injury (TBI), but who had no direct maxillofacial injuries or documented airway problems.” This is troubling, because the failure rate for combat medic-performed cricothyroidotomy is as high as 33%. NPA’s are also not always effective in relieving airway obstruction. Based upon the known shortcomings of the existing 140-year-old NPA and contemporary knowledge gained regarding the mechanisms of upper airway collapse, we are developing a concept next-level NPA (nl-NPA) which aims to address DoD user needs by effectively opening the entire upper airway. The nl-NPA also aims to be easy to place and to minimize airway trauma during insertion.