GOSH GUIDELINES

NPA
Indications for inserting an NPA
Pierre Robin Sequence (Stickler, Treacher Collins, and Velo-cardiofacial syndromes)
Apert, Crouzon, Pfeiffer, for the treatment of obstructive sleep apnoea.
Post cranio fronto-facial surgery
Post adenotonsillectomy
Post cleft lip and palate repair
Emergency airway
Sizing of the nasopharangeal airway
In respiratory children only
The size and length of NPA is determined by:

obtaining the childs crown to heel length as there is a positive correlation between this and the length of the NPA (see

Crown heel length 30cm 3.5cm, add 1.5cm for each 10cm increase in CHL.

Referring to the lateral neck X-ray if appropriate

The correct diameter of tube must also be determined. If the airway is too narrow it will not be an effective airway; if it is too wide it
may cause the skin to breakdown due to pressure points. This is dependent on the age of the child/infant. However, the length rather than
the diameter is more pertinent in most cases.
Sizing of nasopharyngeal airway in emergency care
Measure the required length for the nasopharyngeal tube by measuring the tube from tip of the childs nose to the tragus of their ear.
The appropriate tube width/size can be estimated by matching its diameter against the opening of the childs nostril; when inserted, it
should not cause blanching of the nostril on insertion.
Nasopharyngeal airway (NPA)
A correctly placed NPA will lie just above the epiglottis having separated the soft palate from the posterior wall of the oro-pharynx. This
knowledge is vital if the NPA is to be sized correctly in patients: if the airway is too short it will fail to separate the soft palate from the
pharynx and if too long it can either pass into the larynx and aggravate cough and gag reflexes.
TRACHEOSTOMY
1.

2.

Today, the main indications are:

(1) anticipated long-term cardiorespiratory compromise resulting from chronic ventilatory insufficiency or
(2) the presence of a fixed upper airway obstruction that is unlikely to resolve for a significant period of time
(3) Subglottic stenosis (31.4%),
(4) Bilateral vocal cord paralysis (22.2%),
(5) Congenital airway malformations/craniofacial syndromes, and tumors
(6) Respiratory papillomatosis
Performing a tracheostomy is difficult in pediatric patients, because a child's neck is anatomically different from an adult's
neck in the following ways:
Considerations in pediatric tracheostomy:
a. Short neck
b. Higher larynx approximately C3-C4 at rest compared to C5 in adults
c. Overlap of epiglottis over soft palate
d. Less palpable landmarks due to more subcutaneous tissues and more pliable cartilage (flat thyroid cartilage with no
prominence)
e. Cricoid overlapped by hyoid bone
f. Cricothyroid membrane more of a slit than space
g. The trachea can be easily retracted to a great extent with little pull, and care must be taken distinguish it from the
carotid vessels
h. Dome of pleura extends into the neck and is thus vulnerable to injury
i. Pliable larynx
j. Omega shaped epiglottis
k. Large arytenoids covering posterior glottis
l. Subglottis is narrowest point of airway