G Atlas, M Gaballa
G Atlas, M Gaballa. Use Of A Ligated Split Nasopharyngeal Airway During Nasal Fiberoptic Intubation.. The Internet Journal of Anesthesiology. 2021 Volume 40 Number 1.
During nasal fiberoptic intubation, a suture placed through the flange of a split nasopharyngeal airway may reduce complications associated with its inadvertent dislodgement.
split nasopharyngeal airway (sNPA)
The use of a split nasopharyngeal airway (sNPA) facilitates nasal fiberoptic intubation and may reduce bleeding occurring from trauma to the nasal mucosa by the fiberscope. However, the authors have found that the sNPA can be easily and inadvertently “pushed” into the nares by the fiberscope. This consequently makes removal of the sNPA, from around the fiberscope, difficult. Of note, aspiration into the tracheobronchial tree, of both split and intact NPAs, has been reported., 
By initially ligating the flange of the sNPA with a suture, it can be readily repositioned, retrieved, and removed without difficulty. Removal would obviously be done after the fiberscope is localized within the trachea but prior to the advancement of the tracheal tube. Figures 1 and 2 illustrate this technique. Furthermore, the use of a lubricant within the shaft of the sNPA may help prevent its inadvertent displacement and additionally facilitates intubation.