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Nursing guidelines

Oesophageal Atresia Intermittent oesophageal pouch suction for the neonate and infant



  • Introduction 

    Intermittent oesophageal pouch suction is necessary in the management of neonates with unrepaired oesophageal atresia (OA) to avoid saliva pooling and refluxing into the lungs. This is required for all patients with an unrepaired OA who have not had a Replogle tube measured and inserted by the surgical team.

    Aim 

    To outline the principles of intermittent oesophageal pouch suction for infants with unrepaired oesophageal atresia in Newborn Intensive Care (NICU) at The Royal Children’s Hospital.

    Definition of terms 

    • Oesophageal atresia (OA): A congenital anomaly in which the oesophagus ends in a blind upper pouch. Most neonates with OA also have an abnormal connection between the trachea and oesophagus; this is called a tracheo-oesophageal fistula (TOF).
    • Long-gap oesophageal atresia: Variants of OA with a large gap (wider than ~4cm between the two ends of the oesophagus). This includes pure OA (Figure 2) and OA with a proximal TOF. An infant with OA and distal TOF may also have a large gap between the ends of the oesophagus.

    Indications 

    As the neonate continues to produce saliva, it is essential to clear the upper oesophageal pouch every 15-30 minutes (or more frequently if necessary) to prevent aspiration. This continues until surgical repair of the oesophagus is performed or a functional Replogle tube is placed. (Refer to the guideline on Replogle Tube Management)  

    Assessment

    Initial Assessment

    The length of the oesophageal pouch should be measured with a size 10Fg suction catheter by the Surgical Registrar or Oesophageal Atresia Nurse. This is done by gently passing the suction catheter into the oesophagus, via the oro-pharynx, until resistance is felt. Suction is applied at 1cm less than the measured depth of the pouch to avoid trauma to the fragile pouch wall. Once completed and documented as an order by surgical team or Oesophageal Atresia Nurse, suctioning is completed by bedside nurse.

    The infant requires: 

    • continuous cardio-respiratory and oxygen saturation monitoring 
    • assessment of cardio-respiratory status

    Ongoing Assessment 

    Ongoing assessment for any sign of respiratory distress/compromise indicating the need for immediate and more frequent suction include:

    • Apnoea 
    • Desaturation (oxygen saturation below 90%) 
    • Bradycardia 
    • Stridor 
    • Use of accessory respiratory muscles 
    • Increased respiratory rate or effort 
    • Nasal flaring 
    • Restlessness or circumoral (surrounding the mouth) cyanosis 
    • Reduced or alter breath sounds
    • Blood-stained secretions

    If any of the above signs are present, the infant should receive immediate oesophageal pouch suction.

    Signs of ongoing respiratory distress/compromise should be escalated to the neonatal registrar and surgical team to assess efficacy of current suction regime. 

    Procedure

    1. Equipment 

    • Suction Catheters 8Fg and 7Fg 
    • Standard suction set up
    • Timer 
    • Tray 
    • Sterile water
    • Measurement sign for cot (to display pouch length)

    2. Process 

    1. Perform hand hygiene and don personal protective equipment (PPE) 
    2. Ensure wall suction does not exceed 100mmHg when suction in applied
    3. Pass the suction catheter (7 or 8Fr) to the required length and apply suction
    4. Assess secretions (colour, volume, consistency) and tolerance of procedure
    5. Discard suction catheter (new catheter for each suction encounter
    6. Set timer for 15 minutes

    Time between suctioning should not exceed 30 minutes due to the risk of aspiration.

    Documentation

    Pouch and suction depth should be documented in the patient notes and displayed clearly on the sign attached to the cot in case of emergency. Any change in colour or consistency with pouch secretions should be documented and escalated to the treating team.

    Special Considerations 

    Long-gap OA

    These babies are nursed in the NICU for several weeks to months, prior to repair.  The oesophageal pouch should be remeasured by the Oesophageal Atresia Nurse or the Surgical Registrar every 2 weeks (or sooner if required), to assess growth of the upper oesophageal pouch and to recalculate required length of pouch suction.  This new suction length will then be displayed on the infant’s cot and recorded in the EMR Orders – Suction. 

    Postoperatively the surgical team will indicate revise suction depth which must be documented in the surgical notes and communicated to the team.

    Family centred care 

    It is the responsibility of the clinician caring for the infant with intermittent oesophageal pouch suction to ensure that the parents and caregivers understand the rationale for the intervention, as well as potential complications.

    Companion documents

    RCH Nursing Guideline: Replogle tube management 

    RCH Policies and Procedures: Hand Hygiene  

    RCH Policies and Procedures: Aseptic Technique  

    Links 

    Evidence Table 

    Reference  

    Source of Evidence 

    		 Key findings and considerations
    Hawley, AD & Harrison D. (2003). Suctioning Practices for the upper oesophageal pouch in infants with unrepaired oesophageal atresia in Australia and New Zealand. P105. Perinatal Society of Australia and New Zealand Annual Congress March 2003, Hobart, Australia   Descriptive qualitative study 
    • Intermittent suctioning of the upper oesophageal pouch was used in 15% of NICUs. 23% of NICUs used a combination of intermittent and Replogle suction. 
    • There are varied practices throughout Australian and New Zealand NICUs with regards to suctioning of the upper oesophageal pouch in infants with unrepaired oesophageal atresia. 
    • There is no evidence available in the literature outlining which method results in the best outcomes (short and long term) to infants and children with this condition. 
    • Further research needs to be undertaken to establish the most appropriate method for providing suction of the proximal oesophageal pouch   

      Newborn Services Clinical Guideline: Neonatal Surgery - Oesophageal Atresia with a distal Tracheo-oesophageal Fistula. (2012). Retrieved on May 2 from  
      http://www.adhb.govt.nz/newborn/guidelines/Surgery/SurgeryTOF.htm 
      		 Clinical guideline
      • Adequate drainage of the upper pouch is essential. This can be either by intermittent suction every 15 minutes or via insertion of a Replogle tube as far as it will go and placed on continuous low pressure suction. Flush with 0.9% NaCl usually Q15-30 minutes. 


      Safer Care Victoria. (2018). Neonatal eHandbook: Oesophageal atresia and tracheo-oesophageal fistula in neonates. Victorian Agency for Health Information, Safer Care Victoria, Victoria, Australia. Retrieved 3 May, 2024 from https://www.bettersafercare.vic.gov.au/resources/clinical- 
      guidance/maternity-and-newborn-clinical-network/oesophageal- 
      atresia-and-tracheo-oesophageal-fistula-in-neonates 
      		 Clinical practice guideline
      • The upper pouch must be kept clear of secretions by frequent oral suctioning to 1cm above the distal end of the oesophageal pouch - every 15 minutes or more frequently as required).
      • Time between suctioning should not exceed 30 minutes due to the risk of aspiration of saliva   
         Scoble, M. K., Copnell, B., Taylor, A., Kinney, S., & Shann, F. (2001). Effect of reusing suction catheters on the occurrence of pneumonia in children. Heart & lung, 30(3), 225-233.  RCT
        • Investigated the use of suction catheters and changing frequency in relation to development of pneumonia in ventilated patients. 
        • Using non-touch technique is applicable to OA  
         Speck, K., Rawat, N., Weiner, N. C., Tujuba, H. G., Farley, D., & Berenholtz, S. (2016). A systematic approach for developing a ventilator-associated pneumonia prevention bundle. American journal of infection control, 44(6), 652-656.   Systematic review
        • Development of a ventilator-associated pneumonia prevention bundle
        • Applicable to OA patients as aseptic technique should be maintained throughout suctioning procedures  
        Scott, JE, Hawley, A, & Brooks, J-A. (2020). Delayed diagnosis in esophageal atresia and tracheoesophageal fistula. Advances in Neonatal Care. DOI: 10.1097/ANC.0000000000000763  Case study
        • Intermittent oral suctioning was then commenced to 1 cm less than the pouch length (9.5 cm) every 10 minutes (no greater than 30-minute intervals) to prevent the pooling of secretions and to prevent aspiration. The depth of suctioning is extremely important in the preservation of pouch integrity preoperatively   
        Starship Child Health Newborn Intensive Care. (2017). Clinical Guideline: Oesophageal atresia (OA) with/without tracheo-oesophageal fistula (TOF). Starship Child Health, NZ. Retrieved on May 2, 2024  from Oesophageal atresia (OA) with/without tracheo-oesophageal fistula (TOF) (starship.org.nz)  Hospital Guideline 
        • Adequate drainage of the upper pouch is essential. This can be either by intermittent suction every 15 minutes or via insertion of a Replogle tube as far as it will go and placed on continuous low pressure suction. Flush with 0.9% NaCl usually 15-30 minutes. The baby will also need frequent oral suction   


        Please remember to read the disclaimer.


        The revision of this nursing guideline was coordinated by Brooke Smith and Julia McKeown, CNS, Butterfly and approved by the Nursing Clinical Effectiveness Committee. Updated August 2024.