When inserting a nasopharyngeal airway, should the tube be rotated toward or away from the nasal septum?

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Last updated: September 28, 2026 • View editorial policy

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Nasopharyngeal Airway Insertion: Rotate Away from the Septum

When inserting a nasopharyngeal airway (NPA), the tube should be inserted with the bevel facing away from the nasal septum (laterally), with the leading edge pointing toward the septum. This technique minimizes trauma to the highly vascular Kiesselbach's plexus on the nasal septum and reduces epistaxis risk.

Anatomical Rationale

The nasal cavity has two main pathways:

  • Lower pathway: Along the nasal floor beneath the inferior turbinate (preferred route)
  • Upper pathway: Above the inferior turbinate, near the middle turbinate and cribiform plate

The lower pathway is safer as it avoids the middle turbinate and cribiform plate while minimizing contact with the vascular septum 1.

Proper Insertion Technique

Bevel orientation is critical:

  • Position the bevel tip laterally (away from the septum)
  • The leading edge of the bevel naturally points toward the septum in this configuration
  • This orientation protects the Kiesselbach's plexus, which is located on the anterior nasal septum where multiple arterial branches anastomose 2

Recent evidence from nasotracheal intubation (which follows similar nasal anatomy principles) demonstrates that reverse bevel positioning (bevel facing the septum with tip pointing away) significantly reduces epistaxis from 54.1% to 24.3% (P = 0.009) 3. While this study examined nasotracheal tubes, the anatomical principles directly apply to NPA insertion.

Additional Technical Considerations

To optimize lower pathway passage:

  • Lift the nasal tip cephalad during insertion - this increases lower pathway passage from 51.2% to 79.1% (P = 0.007) 4
  • Direct the tube along the nasal floor, parallel to the hard palate
  • Use gentle, steady pressure without forcing

Common pitfall: Tubes frequently take the upper pathway despite attempts to avoid it, particularly with certain tube designs 1. The nasal tip lifting maneuver helps counteract this tendency.

Epistaxis Prevention

When the tube passes through the lower pathway, epistaxis occurs in only 14.3% of cases versus 46.7% when passing through the upper pathway (P = 0.002) 4. The lateral bevel orientation combined with lower pathway passage provides the best protection against bleeding complications.

If epistaxis occurs: Complete the NPA insertion to protect the airway and tamponade the bleeding point 2.

References

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Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.