Cases & Commentaries

Who Nose Where the Airway Is?

Commentary By Christopher R. Lee, MD

The Case

A 70-year-old man with peripheral vascular
disease was brought to the operating room to undergo vascular
bypass surgery on his right upper extremity. Because the surgery
was expected to involve only the arm, the case was started using
local anesthesia. A certified registered nurse anesthetist (CRNA)
was present to monitor the patient and to provide intravenous
medications for anxiety, sedation, and pain control (monitored
anesthesia care [MAC]). The CRNA was supervised by an attending
anesthesiologist (a physician) but, because the surgery was a
straightforward procedure performed under local anesthesia with
MAC, the anesthesiologist was not physically present and knew very
little about the case.

During the procedure, the patient complained of
generalized discomfort and anxiety, requiring increased doses of
opiates and benzodiazepines (an anti-anxiety medication). With
these medications, the patient became sleepy but remained
arousable. To maintain a patent airway, the CRNA placed a
nasopharyngeal airway, a soft plastic tube inserted into the nose
that extends into the posterior pharynx (Figures). Normally, the tip of this tube remains
outside the nose, where it can be seen by clinicians. After this
insertion, the patient did well with normal respirations and oxygen

After 2 hours of surgery, the vascular surgeon
decided that they would need to use a vein from the patient's legs
to replace a blood vessel in his upper extremity. Because this was
expected to be a long and relatively complicated procedure, the
decision was made to switch the patient to generalized anesthesia,
which would require endotracheal intubation (placement of a plastic
tube through the mouth and down into the lungs) and mechanical
ventilation. The CRNA contacted the supervising anesthesiologist to
help convert the case to general anesthesia. Very little
information was exchanged between the two clinicians, and the
anesthesiologist intubated the patient without complication. The
CRNA managed the anesthesia, and the remainder of the surgery was
uneventful. The patient was successfully extubated and did well
after the surgery.

The following day, the patient remained stable,
and the physician team was planning on discharging him to home.
Curiously, the patient complained to the team that although he was
feeling well, when he tried to drink any liquid it would come right
out of his nose. To overcome the skepticism of the surgical team,
the patient took a gulp of his orange juice with the physicians
present, and, sure enough, most of the juice flowed out of his nose
onto his hospital gown. To the astonishment of the team, he
repeated the scenario.

The surgeons decided to make the patient NPO
(nothing by mouth) and gave him fluids intravenously. They
consulted otolaryngology (ear, nose, and throat specialists) with
concerns about a pharyngeal fistula or another anatomic
abnormality—there were no obvious abnormalities seen
extruding from the nose. The otolaryngologist discovered that the
nasopharyngeal airway, which had been placed during the initial
surgery, was still in his nose. It was not entirely clear how the
tube had become lodged within the nasal cavity (so that its
external portion was no longer extruding from the nose), but
presumably this occurred when the patient was intubated by the

The plastic tube was
removed, and the patient was discharged home later that day. He
suffered no significant consequences from the event, but he did
require an additional day in the hospital.

The Commentary

This case highlights a known hazard and
complication of airway management: airway device aspiration. A
number of different devices are employed to maintain patent airways
during surgical procedures, but among the most common is a
nasopharyngeal airway (NPA). In the course of perioperative airway
management, it is possible for the nasopharyngeal airway to be
aspirated or to become lodged in the airway (essentially becoming a
retained foreign object [RFO]). Although the incidence of airway
device aspiration is not known from any systematic study, both
published case reports (1-4)
and anecdotal evidence suggest that what happened in the presented
case is not a unique occurrence. Health care providers involved in
perioperative care and airway management should be aware of the
risk factors for, clinical presentation of, and strategies to
prevent airway device aspiration.

Specific risk factors for airway device (NPA)
aspiration are not known from the literature, but coughing and
sneezing may increase the risk because of the strong inspiratory
force generated immediately preceding the cough or sneeze. Patients
who have aspirated airway devices can have many different clinical
presentations. Although the patient in this case presented rather
comically with orange juice pouring from his nose, far more serious
complications have been reported. Unsurprisingly, foreign bodies
that completely or significantly obstruct the airway are more
rapidly symptomatic. However, with aspirated airway devices, the
presentation may be more insidious because the open lumen in the
airway device may allow air to pass with little or no obvious
immediate obstruction.(1-3)
Providers should be aware that patients who have undergone
procedures involving NPAs are at risk for immediate and delayed
airway complications. In one case, the discovery of the aspirated
NPA was delayed for weeks after the presumed event and was
discovered only after persistent cough and recurrent chest
infections triggered further evaluation. The device was lodged
within the trachea and right bronchus.(1) One death was reported in a case with an aspirated
airway, although this occurred in the context of significant
underlying respiratory failure.(4)

As these cases illustrate, intubation and
airway management are invasive procedures that carry some risk of
an RFO. Strategies to prevent complications associated with these
events include both device modifications and changes of practice to
allow for early recognition of an airway aspiration or RFO

Device Considerations

Two basic NPA designs exist—one with a
fixed flange at the distal end of the device, and the other with a
movable flange to allow for more individualized fitting (Figures). It has been suggested that the adjustable
flange may increase the risk of aspiration (2), but events have been reported with both designs.
Multiple authors have suggested device modifications that might
prevent aspiration of NPAs. Modifications include attachments to
the external portion of the NPA that would rest outside of the
patient's nose, which could make it more difficult for the device
to be pulled or pushed completely into the patient. One group
suggested the use of a safety pin (5),
while another recommended the use of an endotracheal tube
While possibly useful, the benefits of such techniques must be
weighed against the potential risk from such modifications. While
specific problems have not been reported, it is not difficult to
imagine how a safety pin could be aspirated, or a non-deformable
endotracheal tube connector might cause a pressure injury to the
nares if left in place for more than a brief period.

Practice Considerations

During airway management, the person performing
the procedure is responsible for the equipment being used on the
patient. In most circumstances, the limited number of devices in
use makes this a relatively simple task. This case highlights two
aspects that complicate the situation.

First, there was an unplanned change in airway
management as a result of the procedure becoming more complex.
Changes in airway management should trigger a reassessment of the
patient and formulation of a new airway plan. It is difficult to
ascertain when the NPA was lost into the nasopharynx of this
patient, but the location of the NPA should have been assessed
during the transition from MAC to a general anesthetic, and again
at emergence from anesthesia and extubation (removal of the
endotracheal tube).

Second, responsibility for the airway was shifted
back and forth between the CRNA and the anesthesiologist during the
case. It is well recognized that ineffective communication is the
most frequently cited category of root causes of sentinel events in
Communications during handoffs or transitions of care are of vital
importance. In 2007, The Joint Commission made the implementation
of a standardized approach to handoff communications a 2007
National Patient Safety Goal. At the time of this writing, no
specific standard of care for handoffs has been established by the
American Society of Anesthesiologists; in practice,
anesthesiologists often discuss how the airway is being managed
when they transition care. A structured handoff between the CRNA
and the anesthesiologist may have prompted an inquiry as to the
whereabouts of the airway device. In this situation, a full handoff
may not have been done since the CRNA was not actually leaving the
procedure. Nonetheless, some discussion regarding the NPA should
have occurred prior to intubation, since the anesthesiologist was
not in the operating room when it was originally placed. The
handoff to the recovery nurse in the post-anesthesia care unit was
also an opportunity to discover the missing NPA.

In this case, the providers probably were
individually trying to provide the highest quality care possible.
But the failure of "usual individual practice" to recognize the
retained NPA illustrates the need for a more systems-based
approach. As there is limited literature on systems-based solutions
to retained or aspirated airway devices, we can potentially
extrapolate from a similar but more widely studied situation: the
management of sponges and instruments during surgical

Retained surgical foreign objects have been the
focus of considerable study (8)
(and a previous AHRQ WebM&M
). Although relatively uncommon, RFOs during surgery
have significant implications for the patient, including morbidity
from the RFO, loss of patient trust, and additional costs related
to the medical and legal resolution of the case.

The traditional method of preventing RFOs in
surgery has been to perform structured counts that occur multiple
times during the procedure.(9) In
two recent large studies, the sensitivities of these counts are
only 35%-77%.(10,11)
Radiography is used in some institutions (10) to look for RFOs; however, the cost-effectiveness of
this strategy over time remains unproven. One analytic model
estimates costs of $1.1-$1.4 million per RFO event

Looking to the future, the search for a better
solution may lead to the application of technologies more commonly
used in commercial inventory control than the operating room. Use
of bar-coded sponges (13),
electronic article surveillance tags, and radiofrequency
identification (RFID) tags (14)
has been advocated to help keep track of devices used during
invasive procedures. While promising, more time and experience are
needed to determine whether these will be cost-effective solutions
for preventing RFOs.

Given that airway device retention or aspiration
is probably rarer than RFOs in surgery, it is difficult to argue
that patients without symptoms or airway obstruction should have
routine radiography after surgical procedures. But is there
anything else we can learn from the experience and literature
around RFOs to help improve the safety of airway devices? Bar
coding and other inventory-control approaches are unproven and
still require human action to work properly. Structured counts of
airway devices would likely be impractical, given the often
emergent nature of airway instrumentation.

management is a vitally important aspect of perioperative care, and
complications can have serious consequences. Handoffs during
patient care create opportunities for missed communications. When
handoffs coincide with airway management, the stakes are even
higher. To prevent retained airway devices, handoff communications
need to include a thorough accounting of invasive devices. The
development of standardized tools or checklists to facilitate
handoffs may help remind practitioners and reinforce a culture of
consistent communication.

Take-Home Points

  • Intubation and airway management are
    invasive procedures with significant associated risks.
  • Good handoff communication helps to
    prevent errors. Structured handoffs should be considered to
    minimize forgotten items and to reinforce a culture of consistency
    in handoff communications.
  • Prevention of RFOs requires personal
    vigilance as well as systems approaches, though the optimal
    approach has not been determined—and probably will vary
    depending on the specific setting. The translation of
    inventory-control devices into the operative setting may prove
    useful, although this implementation is not mature.

Christopher R. Lee,
Acting Assistant Professor, Department of Anesthesiology and Pain
University of Washington School of Medicine
Chair, Coordinated Quality Improvement Program

University of Washington Medical Center
Department of Anesthesiology


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Figure 1a. Proper placement of nasopharyngeal
airway device, a soft plastic tube inserted into the nose that
extends into the posterior pharynx. (Illustrations by Chris Gralapp.)

Figure 1b. Illustration representing
position of dislodged nasopharyngeal airway device. (Illustrations by Chris Gralapp.)

Illustrations by Chris Gralapp.