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

Publication: 11/11/2014  --
Last review: 15/03/2022  
Next review: 15/03/2025  
Clinical Guideline
CURRENT 
ID: 4008 
Approved By: Trust Clinical Guidelines Group 
Copyright© Leeds Teaching Hospitals NHS Trust 2022  

 

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

Aims

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.

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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 care by one nurse to one patient, prior to corrective surgery, normally within days of birth.

  • Congenital anomaly- 4th-8th week Embryological development
  • 1 in 3- 3500 babies (250 babies per year in UK)
  • Incomplete (blind ending of) oesophagus +/- fistula
  • 90% of OA have fistula
  • Genetic association very rare
  • Cause unknown
  • VACTRL association

Presentation:

  • Mostly picked up postnatally
  • Baby unable to swallow
  • Bubbling/frothing at mouth
  • Respiratory difficulty- choking, coughing, gagging, cyanosis
  • History of polyhydramnios
  • Rare form long gap OA- Absent stomach may be identified on antenatal scans. 

Diagnosis:

  • Unable to pass NGT
  • X-Ray findings
  • Clinical presentation

Indications for SOP:

  • 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 nursing infant with a replogle tube will be necessary 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 strategies for maintaining the suck reflex for eventual oral feeding following repair.

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Repogle Tube Management

  • Equipment
  • Replogle tube –
    • Size 10Fg – greater than 1500g,
    • Size 8Fg  - less than  1500g, for the very preterm infant
  • Suction tubing X 2
  • 1ml or 2ml Syringe
  • Sodium chloride 0.9% for injection
  • Hydrocolloid dressing (skin protection) Duoderm and fixation tape -  Zinc oxide tape / Elastoplast
  • Monitoring equipment for saturations and heart rate.
  • You need two Suction apparatus’ available
  • One of which is a dedicated low pressure suction pump
    (35-60cmH20/ 3.5-6kPa)
  • Resuscitation equipment, including 2nd suction apparatus for nasopharyngeal/oro-pharyngeal suctioning, suction catheters (various sizes including larger size ), stethoscope, face mask, bagging and intubation equipment.
  • Hand Mittens

Procedure:

Action

Rationale

1. If oesophageal atresia (OA) suspected, apply necessary ICU monitoring. Nurse in Intensive care on full monitoring.

One to one nursing care at all times

An Infant with OA is at high risk of aspiration. These Patient needs constant monitoring to prevent aspiration/choking  & attend to Replogle tube

2. Assemble all equipment.

Need equipment available in case of sudden deterioration

3. Ensure Two Suction apparatus set up

One for low pressure suction of the replogle tube and one for, normal pressure suction, oral-pharyngeal suction
The low pressure suction MUST be labelled clearly

4. Clear oral and Naso-pharyngeal Secretions with suction and nurse infant head tilted up 30-45o.

To minimise risk of aspiration through the trachea-oesophageal fistula

5. Apply lubricant or sterile water to end of replogle tube

To assist passing the replogle tube

6. Gently advance Replogle tube, through the nose, until you feel resistance, then pull back 0.25cms. Note: If you cannot pass repogle tube via the nose then pass it orally

(average length passed  10-12cms)

Do this gently so as not to cause trauma or perforation and ensure optimal placement of repogle tube for clearing secretions
NOTE: Give oro-pharyngeal suction while establishing optimum position of replogle tube

7. Explain what you are doing to parents and the rationale for this

  • Explain rationale of procedure to the family, including:
  • what a Replogle tube is, and why it is needed.
  • What the procedure entails, and how long it will take.
  • How long the tube is likely to stay in place.

To ensure parents are kept up to date

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

8. Connect Replogle tube to low pressure Suction- 3.5-6kPa (35-60 cmsH2O) (see Fig. 1 diagram below)

Can have brief increase to 7-10kPa / 70-100 cms H2O to clear thick secretions. 
Clearly label (Low Pressure Suction)

To allow continuous replogle Suction and not cause trauma.

To ensure correct suction used

9. Ensure secretions are draining CONTINUOUSLY along the replogle tube

Continuous drainage demonstrates optimum tube placement

10. Secure tube well using Duoderm on skin and then Zink oxide/Elastoplast tape

-Put Mittens on hands if available

To protect skin and reduce risk of tube getting dislodged/pulled out.

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

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

12. Document what the length of the tube inserted is at nose level

This will help if needing to replace replogle tube quickly.

13. Flush ‘side arm’ 0.25-0.5ml Sodium Chloride 0.9%- every 10-15 mins (more often if needed)

Document frequency of flushes on observation chart.

  • Can follow  flush with air to clear tube
  • NB! Do NOT leave syringe attached after instilling Sodium Chloride 0.9%
  • Needs to be opened to air for the suction to work properly.
  • To keep tube patent
  • This will affect the drainage from the replogle tube.
  • Each instillation must be followed by observations confirming efficacy of secretions removed by suction.
  • Ensure good communication about care across the team

Flush as often as needed to clear tube.

14. Following first insertion, check position. 

Ensure secretions are draining constantly.  For repeat insertions – check documented external length and insert to set position. X-rays are only indicated with problematic positions.

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. 

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

17. If you can’t get secretions draining consider changing the tube.

Have spare tube available at bed side in case of blockage and emergency equipment

18. Note- Can put sign on bedside to highlight use of replogle tube, Size of tube and length inserted

To make it easier and quicker for staff to respond quickly to a tube blocking or getting dislodged.

19. Clearly mark the low pressure suction ‘LOW’ could also add the suction pressure range to a sticker on low pressure suction

To reduce the risk of using high pressure suction inappropriately.

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On-going care of infant with a repogle tube

ACTION

RATIONALE

1.

  1. Ensure alert poster, for patient with repogle tube and details of tube, are displayed at bed side. See appendix attached
  2. Ensure baby has mittens on hands at all times- parents can also assist with ensuring in place
  3. One to one nursing essential in early days. This can be risk assessed for longer term patients with repogle tubes that are very stable.
  4. Ensure a spare repogle tube is available at the bed side and wall suction plus suction catheters at ALL times

Highlight use of repogle tube and difference to NGT
Provide east to access information about size of tube and length inserted.

To reduce risk of baby pulling out repogle tube

Aspiration and respiratory deterioration can occur very quickly with these patients so there is a need for extremely fast response to patients needs at ALL times.

To ensure timely management of blocked repogle

2. 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.

3.Repeat side arm flushes until secretions are draining easily and continuously along the repogle tube. 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.

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

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

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

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

To minimise the risk of infection.

6. 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.

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.

7. 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

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

8. If there are worsening respiratory symptoms, coughing or choking episodes- consider blocked tube or need for replacing repogle tube.

Perform oro-pharyngeal suctioning and then use measures to try and unblock the tube.
If unsuccessful then replace with new repogle tube asap.

9. Observe and document colour and consistency of secretions.

Pouch secretions quickly become colonised with organisms

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

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

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

Change Saline bottle 24 hourly. Bottle should be dated and times on opening

To minimise the risk of infection.

To reduce risk of infection.

12. Use alternate nostril with tube replacement.

To reduce nostril damage from the large rigid tube.

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

To offer comfort measures and encourage oral stimulation.

14. a. Follow SALT advice for oral stimulation and support parents understanding practice.

b. Oral mouth care with EBM as per hospital policy
      c. Avoid frequent, routine oral suctioning

To prevent oral aversion.

Promote positive oral experiences.

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

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

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On-going care with long gap Oesophageal atresia

We do not currently teach parents how to manage the repogle tube. This has been discussed by the review team. At present this is a process that needs to be risk assessed by an experienced nurse and medic, for the infant with a long term repogle tube. A training package can then be considered an put into place.

We DO NOT sham feed babies with a repogle tube. This is practice in some surgical units.

ACTION

RATIONALE

Care also as indicated in ‘on-going care’

 

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

To ensure continuous and effective removal of secretions.

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

Pouch secretions quickly become colonised with organisms.

3. Check serum and urinary electrolytes regularly.

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

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

To maintain electrolyte balance and improve weight gain.

5. Monitor growth twice weekly

Risk of poor weight gain.

6. 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

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

For promotion/ retention of the suck reflex.

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

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

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

To promote parental involvement and minimise misunderstandings.

9. 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.

To rule out equipment failure

To ensure the Replogle tube is functioning.

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

Suction manually first then:

  • Check that the tube is optimally positioned within the oesophageal pouch - push Replogle tube gently until resistance is felt, and withdraw 0.25cm.
  • Inject 0.5ml air into the ‘side arm’ using a 2ml syringe.
  • Move tube gently in nostril.
  • If none of the above is successful, seek assistance from an experienced nurse or doctor.
  • 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.
  • Suction to oropharynx.
  • 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.

11. Alternate nostril with tube replacement.

  • To reduce nostril damage from the large rigid tube.

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Provenance

Record: 4008
Objective:
Clinical condition:

Neonate requiring a Repogle tube for Oesophageal Atresia 

Target patient group: Infants less than 1 year
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. Beasley,S Oesophageal atresia and tracheo-oesophageal fistula. Paediatric Surgery- Vol 37 (11) p623-627 Nov 2019
  3. Initial Management of an Infant with Oesophageal Atresia. SOUTHERN WEST MIDLANDS NEWBORN NETWORK.  Hereford, Worcester, Birmingham, Sandwell & Solihull. Agreed February 2009 http://www.newbornnetworks.org.uk/southern/PDFs/OesAtresiaFinal.pdf   (17/03/2010)
  4. Fellows, P. Replogle tube care of oesophageal atresia. Neonatal Clinical Guideline Addenbrooke’s Hospital (2008)
  5. GOSH (2004) Care of Replogle tube 
  6. http://www.ich.ucl.ac.uk/clinical_information/clinical_guidelines/cpg_guideline_00088/Johnson, PRV (2005) Oesophageal Atresia.  Infant. 1(5): 163-167.
  7. King Edward Memorial/ Princess Margaret Hospitals, Perth Western Australia. Oesophageal atresia/ trachea-oesophageal fistula guidelines, Jan 2010
  8. Nixon, H. (1978) Surgical Conditions in Paediatrics, Butterworth & Co.: London.
  9. www.adhb.govt.nz/newborn/Guidelines/Surgery/SurgeryTOF.htm (23/03/2010) www.patient.co.uk
  10. Haycock GB. The influence of sodium on growth in infancy. Pediatr Nephrol.1993
  11. 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

Approved By

Trust Clinical Guidelines Group

Document history

LHP version 2.0

Related information

Acknowledgements
With grateful thanks to Anne Aspin, Neonatal surgical nurse consultant and  members of the National Neonatal Surgical Interest Group who have shared their individual hospital guidelines, particularly Sheffield, Birmingham and Guys and St.Thomas’, for the original development of this SOP.

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