Oesophageal Atresia and Trache-Oesophageal Fistula requiring a Replogle Tube - Management of Infants with

Publication: 11/11/2014  --
Last review: 24/07/2018  
Next review: 01/07/2021  
Clinical Guideline
CURRENT 
ID: 4008 
Approved By: Trust Clinical Guidelines Group 
Copyright© Leeds Teaching Hospitals NHS Trust 2018  

 

This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Management of Infants with Oesophageal Atresia and Trache-Oesophageal Fistula requiring a Replogle Tube

Background and indications for standard operating procedure/protocol

Oesophageal atresia (OA) is a congenital abnormality where the oesophagus ends in a blind upper pouch. It can occur in isolation or there may be one or more fistulae communicating between the abnormal oesophagus and the trachea (tracheo-oesophageal fistula (TOF). Babies born with TOF/OA need to have intensive neonatal care or one nurse to one patient, prior to corrective surgery, normally within days of birth.

  • A Replogle tube is passed into position as soon as the diagnosis of trachea-oesophageal atresia is suspected / recognised. It is maintained within the pre-operative period to continuously clear secretions that put the baby at risk of aspiration. Surgical intervention is normally undertaken when the infant is stable (usually within 48hours).
  • The finding of a long-gap atresia may call for a ‘delayed primary anastomosis’ and Replogle nursing for 6-8weeks or longer, to allow the oesophagus and stomach time to grow. Variations to management plans are individually tailored to meet the specific needs of the infant. These focus on family involvement and maintaining the suck reflex for eventual oral feeding following repair.

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Repogle Tube Management

1) Preparation
2) Insertion of a Replogle tube.

  • The preferred route for passing the Replogle tube is via the nostril. NB: Access of the smaller nostril allows improved breathing via the larger nostril, however it may be more comfortable for the infant accessing the larger nostril). If in doubt alternate the nostril with required tube changes.
  • The Replogle tube will need to be passed orally if the infant is very small, (smallest replogle tube is size 8fg), or if the infant has choanal atresia.

3) On-going care.
4) On-going care with long gap oesophageal atresia

Equipment

  • Replogle tube - 10Fg - > 1500g
  • Size 8Fg Repogle < 1500g, for the very preterm infant
  • Disposable tape measure
  • Suction tubing
  • Dedicated low pressure suction pump (35-60cmH20/ 3.5-6kPa)
  • 2ml or 5ml syringe
  • Sodium chloride 0.9% for injection
  • Hydrocolloid dressing (skin protection) and fixation tape - Duoderm and Zinc oxide tape / Elastoplast
  • Monitoring equipment for saturations and heart rate
  • Resuscitation equipment including 2nd suction apparatus for nasopharyngeal suctioning, suction catheters (various sizes), stethoscope, face mask, bagging and intubation equipment.
  • Hand Mittens

 

Diagram 1. Replogle tube. (from GOS guideline)

 

(Diagrams 2 and 3, as per Bristol guideline)

 

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1. Preparation

ACTION

RATIONALE

1. When oesophageal atresia is suspected, assess the infant fully, applying all necessary intensive care monitoring by a nurse competent to care for a replogle tube (Appendix 1)

Assemble equipment listed including suctioning/ resuscitation equipment.

1. The infant with an oesophageal atresia is at high risk of aspiration.

To ensure that all equipment is available for immediate use if the infant deteriorates suddenly.

2. Clear oral secretions and nurse infant tilted head up. Keep the head of the incubator / warmer elevated at 45o.

To minimise aspiration of secretions and/ or gastric reflux through a possible associated tracheo-oesophageal fistula.

3. A Replogle tube should be passed by an experienced neonatal nurse able to assess when resistance is met (against the pouch).

The length of the average upper pouch is between 10-12cm from the lips, therefore a nasal replogle tube would be fractionally longer

3. ‘Forcing’ of the Replogle may lead to perforation of the oesophagus.

To give an approximation of the length of the replogle tube to be passed via the nostril.

4. Explain rationale of procedure to the family, including:

a) what a Replogle tube is, and why it is needed.
b) What the procedure entails, and how long it will take.
c) How long the tube is likely to stay in place.

4. To ensure that the family have an understanding of the baby’s condition and needs, and to promote parental involvement in his/her care.

5. If repogle tube not available for transfer- use a Size 10Fr NG tube

6. If unable to provide continuous suction- aspirate tube every 5-10 mins.

5. In order to be able to aspirate secretions and prevent aspiration

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2. Insertion of Repogle tube

ACTION

RATIONALE

1. Wash hands and apply gloves.

 

1. To minimise risk of cross infection.

2. Ensure 2 suction apparatus’ are available at cot-side.

2. For oropharyngeal suctioning when required, and dedicated, low pressure, apparatus for Replogle suctioning.

3. Suction nasal passages and oro-pharynx.

 

3. To clear residual secretions.

4. Lubricate tip with sterile water and gently pass the Replogle tube via the nostril

 

4. Nasal insertion better for securing/fixing the Replogle tube in place.

   

5. When resistance is felt with the blind-ending oesophagus, pull back tube very slightly, 0.25cm.

5. To ensure optimal placement for clearing secretions and preventing trauma/ adherence to oesophageal wall.

 

 

6. Connect the Replogle tube via suction tubing, to dedicated low pressure suction unit or ‘thoracic Drainage suction’ unit.

Clearly label tubing as ‘Low Suction’

 

 

 

 

6. To allow continuous Replogle suction without causing trauma.

Be able to clearly identify the low pressure suction.

7. Set suction pressure (35-60 cm H2O/ 3.5-6 kPa).

Brief increase to 7-10kPa / 70-100 cms H2O to clear thick secretions.

7. To give effective suction without causing trauma to oesophagus

To help clear thicker secretions. Do not leave at this pressure as it could lead to mucosal damage.

8. Check that secretions are draining CONTINUOUSLY along the Replogle tube and into the suction tubing.

8. Continuous drainage of secretions establishes optimal positioning of the Replogle tube.

9. Secure Replogle tube using Duoderm to skin and zinc oxide tape over tube when optimal position of the Replogle tube has been achieved.

It is essential the tube stays at the correct length at all times, and not ‘looping out’

9. To protect the infants delicate skin whilst using adherent tape to secure tube in place (to prevent accidentally displacing tube).

10. Instill 0.25 -0.5mls of Sodium chloride 0.9% into ‘side arm’ or small bore of the Replogle tube gently. Remove syringe and observe for drainage of secretions into the suction tubing.

Record irrigations on Observation chart

10. To facilitate continuous drainage of secretions. Each instillation must be followed by observations confirming efficacy of secretions removed by suction.

 

11. Anchor the suction tubing to the cot sheet if required with forceps.

11.To avoid ‘tug’ and inadvertent dislodgement of the Replogle tube.

12. Ensure there is a short length of suction tubing from the replogle tube to the suction collecting canister.

12.To reduce secretions gathering in the bend of the tubing affecting optimal suction

13.Wash hands at end of procedure

13.To minimise the risk of cross-infection

14. Record date of insertion, size and external length of tube on Daily care plan and end of bed card. (appendix 1, 2 ) Document information in care Plan. Mark tube itself at optimal position. Check position regularly.

14. To ensure the replogle tube is situated at the correct length at all times

To alert others re: replacement/length in the event of a transfer or emergency tube displacement.

15. Following first insertion, check position. Ensure secretions are draining constantly. For repeat insertions – check documented external length and insert to set position. Xrays are only indicated with problematic positions.

15.To ascertain position of Replogle tube/blind oesophageal pouch.

16. Nurse the infant in the intensive care/ high dependency setting with full HR, respiratory and O2 saturation monitoring.

17. To ensure prompt detection and intervention in the event of sudden deterioration in condition.

 

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3. Ongoing care

ACTION

RATIONALE

1. Instil 0.25 -0.5ml bolus of Sodium chloride 0.9% into the ‘side arm’ or small bore of the Replogle tube slowly. Observe for secretions draining.  Ensure that each bolus is interspersed with 0.5ml air pockets. Repeat process down ‘end  arm’ half hourly.

Repeat side arm flushes until secretions are draining easily and continuously. This may be required every 15-20minutes. Amount and frequency will be dictated by the viscosity and volume of secretions and baby’s response to irrigation.

1. To clear viscous secretions from the oesophageal pouch, ensure patency of the tube, prevent tube blocking and avoid potential tracheal aspiration between irrigations.

2. DO NOT leave the flush syringe attached to the ‘side arm’ after flushing.

2. This practice interrupts secretions removal by stopping effective suction process, increasing risk of aspiration.

3. Label the flush syringe with the date and time of opening and change at least every two hours.

3. To minimise the risk of infection.

4. Monitor suction pressures and document readings hourly. If pressure is increasing, flush Replogle tube and if still high seek assistance from an experienced nurse, who may manipulate or replace the tube.

The most common reasons for them not working are blockage or displacement, especially if infant is coughing. Replace the replogle tube.

4. An increasing pressure on the suction  pump may indicate that the Replogle tube is  becoming blocked, or is adhering to the oesophageal wall.

Risk of aspiration, recurrent chest infections.

5. Suction the oropharynx if thick or excessive secretions are present, half hourly to hourly. DO NOT irrigate the Replogle tube when there are immediate concerns about airway stability, secretions, position of the tube, or with deterioration - Use conventional oropharyngeal suctioning instead. Then fix the problem.

5. To prevent aspiration of secretions as seen with oesophageal dysmotility high atresia.

6. Observe and document colour and consistency of secretions.

6. Pouch secretions quickly become colonised with organisms

7. Do not include instilled volumes of Sodium chloride 0.9% within fluid balance.

7. Sodium chloride 0.9% instilled is
continuously aspirated and therefore not an ‘intake’.

8. Change suction tubing and bottle liner daily as per unit protocol- Leeds every 24 hours

8. To minimise the risk of infection.

9. Alternate nostril with tube replacement.

9. To reduce nostril damage from the large rigid tube.

10. The stable infant may have a dummy to suck when maintaining airway patency.

10. To offer comfort measures and encourage oral stimulation.

11. Ensure continuing support for family with regular up-dates on the infant’s condition and progress. Provide information on local and national support-groups.

11. To promote parental involvement and understanding of their infant’s specific requirements.

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4. Ongoing care with long gap atresia

ACTION

RATIONALE

1. Change Replogle tube every three to four days (more frequently if secretions are thick or excessive). Document in notes and care plan Appendix 

1. To ensure continuous and effective removal of secretions.

2. Observe and document colour and   consistency of secretions. Collect specimens of oral secretions as requested.

2. Pouch secretions quickly become colonised with organisms.

3. Check serum and urinary electrolytes regularly.

3. Sodium levels may fall due to the loss of saliva (electrolytes) during suctioning.

4. Administer oral Sodium chloride supplements as prescribed, if required.

 

4. To maintain electrolyte balance and improve weight gain.

5. Provide stimulation and play therapy. During cuddles with parents, maintain a high tilt/ upright position and continuous suction.

The stable infant requires oral stimulation, refer to speech and language team (SALT), play therapist or occupational therapist

5. To promote normal development and bonding. To prevent aspiration/reflux of secretions.

For promotion/ retention of the suck reflex.

6. The stable infant can be nursed with a pulse oximeter alone but has to be closely observed at all times.

6. To ensure prompt detection and intervention in the event of a sudden deterioration in condition.

7. Ensure continuing support for family, with regular up-dates on the baby’s condition and progress.

7. To promote parental involvement and minimise misunderstandings.

8. IF THE REPLOGLE TUBE IS NOT DRAINING:

Check the suction pump is on, connected and working.
Instil an additional 0.5ml flush of Sodium chloride 0.9% cautiously. This should be observed moving immediately along the lumen of the tube and into the suction tubing.

8. To rule out equipment failure          To ensure the Replogle tube is functioning.

9. IF THE FLUSH DOES NOT MOVE BACK IMMEDIATELY ALONG THE LUMEN:

Suction manually first then:

  1. Check that the tube is optimally positioned within the oesophageal pouch - push Replogle tube gently until resistance is felt, and withdraw 0.25cm.
  2. Inject 0.5ml air into the ‘side arm’ using a 2ml syringe.
  3. Move tube gently in nostril.
  4. If none of the above is successful, seek assistance from an experienced nurse or doctor.
  5. A brief increase of suction pressure to 10kPa/ 75mmHg may be required if secretions are very thick. However, this should not be allowed beyond a few minutes.
  6. Suction to oropharynx.
  7. Check for secretions collecting in the suction tubing itself, which is not emptying into the receptacle.

9. To ensure the Replogle tube is not displaced.

To assist in unblocking the Replogle tube.

The Replogle tube may need to be removed and replaced.

The increased pressure may result in the tube attaching to the wall of the oesophagus, preventing effective suctioning and also increasing the risk of damage to the wall of the oesophagus.
Low suction pressures may be ineffective in removing large collections of secretions from tubings.

10. Alternate nostril with tube replacement.

10. To reduce nostril damage from the large rigid tube.

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Provenance

Record: 4008
Objective:

To standardise and optimise the care and management of an infant who has a ‘Replogle’ tube - This is a double-lumen radio-opaque tube that is used to enable continuous suction and irrigation, of secretions which collects in the blind-ending oesophageal pouch of an infant with oesophageal atresia.

The baby requires constant observation and vigilance of all staff members. Specific care requirements of the infant include respiratory vigilance, continual clearance of secretions to minimise the risk of aspiration, and safeguard the airway to maintain optimal respiratory function.

Clinical condition:

Long gap Oesophageal Atresia

Target patient group: Neonatal and Paediatric
Target professional group(s): Secondary Care Doctors
Secondary Care Nurses
Adapted from:

Evidence base

References

  1. Carter, B. (1993) Manual of Paediatric Intensive Care Nursing, Chapman and Hall: London.
  2. Initial Management of an Infant with Oesophageal Atresia. SOUTHERN WEST MIDLANDS NEWBORN NETWORK.  Hereford, Worcester, Birmingham, Sandwell & Solihull. Agreed February 2009
  3. Fellows, P. Replogle tube care of oesophageal atresia. Neonatal Clinical Guideline Addenbrooke’s Hospital (2008)
  4. GOSH (2004) Care of Replogle tube
  5. http://www.ich.ucl.ac.uk/clinical_information/clinical_guidelines/cpg_guideline_00088/ Johnson, PRV (2005) Oesophageal Atresia.  Infant. 1(5): 163-167.
  6. King Edward Memorial/ Princess Margaret Hospitals, Perth Western Australia. Oesophageal atresia/ trachea-oesophageal fistula guidelines, Jan 2010
  7. Nixon, H. (1978) Surgical Conditions in Paediatrics, Butterworth & Co.: London.
  8. www.adhb.govt.nz/newborn/Guidelines/Surgery/SurgeryTOF.htm (23/03/2010)
    www.patient.co.uk
  9. Haycock GB. The influence of sodium on growth in infancy. Pediatr Nephrol.1993
  10. Skillman J, Cole A, Slator R. Sodium Supplementation in Neonates With Pierre Robin Sequence Significantly Improves Weight Gain if Urinary Sodium Is Low. Cleft Palate Craniofac J. 2012

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Approved By

Trust Clinical Guidelines Group

Document history

LHP version 1.0

Related information

Acknowledgements
With grateful thanks to members of the National Neonatal Surgical Benchmarking Group who have shared their individual hospital guidelines, particularly Sheffield, Birmingham and Guys and St.Thomas’, and to Julia Petty, Lead for the Neonatal Surgical Module at City University, for her helpful suggestions.

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