When inserting an oropharyngeal airway, the crossed-finger technique is used to:

UNCONTROLLED WHEN PRINTED

• To rapidly assist in maintaining the airway patency of an unconscious patient.

Patient Factors & Considerations

The placement of an OPA MUST NOT interrupt effective compressions in Cardiac Arrest.

• If the patient gags during the insertion of the oropharyngeal airway, remove immediately and be prepared to suction.
• Paediatrics <6 years: insertion should be performed without twisting and should follow the natural curvature of the airway to prevent damage to the oropharynx.
• Suspicion of traumatic injury: ensure spinal alignment and immobilisation of head and neck (jaw thrust method).

• All relevant infection control methods to be utilised.
• Select the most appropriate OPA size by measuring from the centre of the lips to the angle of the mandible [1].

• Place patient’s head in a neutral position.
• Ensure airway is clear; suction if necessary.
• Open the patient’s mouth using the cross finger method.
• Orientate the OPA tip to the roof of the mouth, insert it approx. 1/3 of its length,  then rotate it slowly to allow the tip to point downwards while gently pushing it into the airway[2][3].
• Progress the OPA gently into the mouth until the flange is resting on the lips[4].
• Ensure the tongue has not been inadvertently displaced into the back of the throat.

• Assess efficacy of inserted OPA by observing chest rise and fall.

• If OPA is unable to be inserted due to trismus, consider insertion of nasopharyngeal airway (NPA).

• Oropharyngeal Airway. (2014). Expert in My Pocket. http://expertinmypocket.com.au/oropharyngeal-airway/

Document Control

Head of Clinical Services

Indications

Upper airway obstruction requiring airway manoeuvres

and

Reduced left of consciousness

Contraindications (absolute in bold)

Nil

Alternatives

Nasopharyngeal airway

Laryngeal mask airway

Intubation

Informed consent

Medical emergency

Consent is not required

Potential complications

Failure to open airway

Vomiting (if gag reflex intact)

Airway obstruction (if incorrect placement causing posterior displacement of tongue)

Aspiration

Laryngospasm

Procedural hygiene

Standard precautions

PPE: non-sterile gloves, surgical mask, protective eyewear or shield

Area

Any

Staff

Procedural clinician

Equipment

Oropharyngeal airway (sized from corner of the patient’s mouth to tip of the earlobe)

Lubricant

Positioning

Neck flexion with atlanto-occipital extension (sniffing position), or

Neck in neutral position with spinal immobilisation (cervical injury suspected)

Head-tilt chin-lift or jaw thrust applied

In adults the sniffing position is achieved by elevating head approximately 10cm while tilting the head posteriorly. This achieves horizontal alignment of the sternum and external auditory meatus. Small children do not require head lift and infants will require slight elevation of the shoulders due to a relatively large occiput.

Medication

Nil

Sequence

Open the patient’s mouth with your thumb and index finger

Insert the inverted airway along the patient’s hard palate

Advance posteriorly until distal end entering hypopharynx, then rotate 180 degrees

Use a jaw thrust to aid passage if required

Advance until the flared external tip is as the oral orifice

Post-procedure care

Use definitive airway management if required

Tips

Oropharyngeal airways prevent the base of the tongue from obstructing the airway

When inserting an OPA, the clinician must avoid pushing the tongue into the posterior pharynx

Too small a device is ineffective, too large a device can press against the epiglottis obstructing the larynx

Nasopharyngeal or oropharyngeal airways should be considered with all bag-mask ventilation

Discussion

A tongue depressor can be used to move the tongue out of the way and pass the airway (instead of inverted insertion and rotation). This method may be considered with suspected oral or palate injury. It is generally not necessary.

Peer review

This guideline has been reviewed and approved by the following expert groups:

Emergency Care Institute

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References

Australian Resuscitation Council and New Zealand Resuscitation Council. ANZCOR guideline 11.6 – equipment and techniques in adult advanced life support. Melbourne: Australian Resuscitation Council and New Zealand Resuscitation Council; 2016. 16pp. Available from https://resus.org.au/guidelines/

Roberts JR, Custalow CB, Thomsen TW. Roberts and Hedges' clinical procedures in emergency medicine and acute care. 7th ed. Philadelphia, PA: Elsevier; 2019.

Dunn RJ, Borland M, O'Brien D (eds.). The emergency medicine manual. Online ed. Tennyson, SA: Venom Publishing; 2019.

Wittels KA. Basic airway management in adults. In: UpToDate. Waltham (MA): UpToDate. 2019 Sept 17. Retrieved March 2019. Available from: https://www.uptodate.com/contents/basic-airway-management-in-adults

When inserting an oropharyngeal airway in an infant or child you should?

What technique should you use to open airway?

In what maneuver is blockage of the airway by the tongue corrected by tilting the patients head back and lifting the chin?

In what maneuver is blockage of the airway by the tongue?