INTRODUCTION: An elderly man with decreased mental status aspirated a 28 French Nasopharyngeal Airway (NPA) over a suction catheter and developed inspiratory stridor. This is the only documented video of NPA aspiration and its immediate management. This case highlights an uncommon complication of a commonly used device. NPA aspiration was first documented in 1985 and remains an important consideration for patient safety.
CASE PRESENTATION: An 84 year-old man with GCS 5 had a 28 French Robertazzi NPA (Rusch) lubricated with Surgilube placed. His nurse passed a 14 French Medline Suction Catheter via the NPA. Once the catheter was inserted to a depth of 13–15 cm, the nurse applied suction and turned to view the monitor. Upon turning back to view the patient, the nasal airway was missing, with the suction catheter still in place at the same depth. Vitals signs were unchanged. Inspiratory stridor developed when suction catheter was removed. The attending arrived within 5 minutes. The oropharynx was evaluated with a flashlight, tongue depressor, and then a laryngoscope with a Macintosh #3 blade. Bloody secretions were present with no gag reflex. An intubating fiberoptic scope, Video Cart, and a tongue retractor revealed a grade one view with no gag, no cough, and image 1. Video shows the NPA flange above the glottis, with inspiration causing inward bowing of the flange, slight inward migration, with concurrent inspiratory stridor. The tip of the NPA was in the trachea. Direct laryngoscopy was performed with a Macintosh blade #4 video laryngoscope providing a grade one view. The NPA was removed with forceps. The stridor resolved immediately.
DISCUSSIONS: The first documented NPA aspiration was in 1985 by Hayes et al with flange located 4cm below glottis and tip more distal, requiring rigid bronchoscopy for removal. Milam et al documented a patient in whom the NPA “disappeared” with no change in respiratory status or chest film. Autopsy revealed distal tip of NPA at carina and flange at level of larynx. Ho et al documented an NPA aspiration while the nurse advanced the suction catheter via the NPA with a “snug fit”. The NPA was retrieved with a hemostat under direct laryngoscopy after aerosolized lidocaine and intravenous midazolam. Yokoyama et al described a patient with an NPA slipping “through his nasal cavity into his trachea” during pharyngeal suctioning. Despite no radio-opaque stripe the NPA was seen in the trachea and projecting into the bronchus intermedius on chest film. A general anesthetic was given to remove the NPA with Jackson's laryngeal scope and forceps. Our case describes a similar clinical scenario of an elderly male with declining mental status, poor gag/cough reflexes, and standard placement of a common NPA. It is interesting that the pharyngeal suction catheter appears to have acted as a slide directing the NPA directly into the larynx. This is the first video documentation reported of a NPA aspiration, with collapsing flange causing stridor, and its immediate removal. Complications of aspiration of an NPA may include non-recognition of the aspiration, sub-mucosal tunneling, vomiting, airway obstruction, laryngospasm, atelectasis, infection, and airway trauma/bleeding; associated increased work of breathing, hypoxemia, and death.
CONCLUSION: In our institution, 446 of this type of NPA were utilized in 2007. Our department is investigating other reports of NPA aspiration. The aspiration of a commonly used NPA is a significant issue for patient safety with no intervention despite 23 years of literature describing this complication. These cases are an indication for re-evaluation of NPA design and use, as the original design did not intend for this device to be a conduit for suction catheters and has flawed construction for such use.
DISCLOSURE: Carlos Brun, None.