Clinical Guidelines (Nursing)

Intermittent oesophageal pouch suction for the neonate - infant with unrepaired oesophageal atresia including long-gap

  • Introduction

    Aim

    Definition of terms

    Indications

    Assessment

    Procedure

    Special Considerations

    Family Centred Care

    Companion Documents 

    Links

    References

    Evidence Table


    Introduction

    Intermittent oesophageal pouch suction is used in the management of neonates and infants with unrepaired oesophageal atresia.  A suction catheter is placed into the oesophageal pouch intermittently to remove saliva. 

    Adequate drainage of the upper oesophageal pouch is essential to prevent saliva spilling over into the trachea resulting in aspiration or aspiration pneumonia.

    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: Those infants with pure OA or OA with a proximal TOF, or those with other variants of OA with a large gap where an oesophageal anastomosis is unable to be performed immediately. Neonates with long-gap OA are often managed with a delayed oesophageal repair, a growth induction procedure (e.g. Foker procedure) or oesophageal replacement surgery. 
    • Suction catheter: A single lumen tube that is placed in the upper oesophageal pouch and connected to intermittent suction to aspirate saliva and prevent aspiration.

    Indications

    Intermittent oesophageal pouch suction is indicated for all infants with unrepaired OA to prevent aspiration. Saliva accumulates in the blind upper oesophageal pouch and if not adequately cleared with suction will overflow into the infant’s trachea with resultant aspiration or aspiration pneumonia. 

    As the neonate continues to produce saliva, it is essential to clear the upper oesophageal pouch every 5-30 minutes (or more frequently if necessary) to prevent aspiration.  This continues until surgical repair of the oesophagus is performed.

    Infants with long-gap OA may be suitable for the use of a Replogle tube connected to continuous low pressure suction. (Refer to the guideline on Replogle Tube Management

    Assessment

    Assessment of suitability of neonate for intermittent suction:

    • All neonates with unrepaired OA require oesophageal pouch suction.
      • Intermittent oesophageal pouch suction should be performed routinely and as required in these infants.
    • Infants with long-gap OA may be suitable for continuous Replogle tube suction (Refer to the guideline on Replogle Tube Management). 

    Initial Assessment

    For all infants, on all occasions, the length of the oesophageal pouch should be measured with a size 10Fg suction catheter by the Surgical Registrar, NICU AUM, Oesophageal Atresia Nurse, Clinical Nurse Specialist, NICU Educator or Clinical Support Nurse,   This is done by gently passing the suction catheter into the oesophagus, via the oro-pharynx, until resistance is felt.  The suction catheter is then withdrawn 1cm and suction applied at less than 120mmHg to remove saliva from the upper oesophageal pouch.  The measurement of the oesophageal pouch length and the length for oesophageal pouch suction is recorded in the EMR Suction Orders, Progress Notes and Observation Chart. A tape measure with the suction distance marked is also attached to the infant’s cot and labeled as ‘oesophageal pouch suction’.

    The infant requires:

    • Cardio-respiratory and oxygen saturation monitoring
    • Assessment of cardio-respiratory status

    Ongoing Assessment

    The infant requires continuous:

    • Cardio-respiratory and oxygen saturation monitoring
    • Assessment of cardio-respiratory status

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

    • 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
    • Audible secretions
    • Visible secretions

    If any of the above signs are present, the infant should receive immediate oesophageal pouch suction and more frequent suction should be undertaken.

    Signs of respiratory distress/compromise should be reported to the neonatal registrar and documented on Observation Flow Sheet, and interventions performed as appropriate.

    Procedure

    1. Equipment

    • Suction Catheter 10Fg (for initial measurement of oesophageal pouch length)
    • Suction Catheters 8Fg and 7Fg
    • Suction regulator unit
    • Suction tubing (long length)
    • Suction tubing (short length)
    • Suction canister
    • Timer
    • Tray
    • Sterile water


    2. Process


    a) Connect suction regulator to suction outlet on wall.  Connect short suction tubing from suction regulator to canister and long tubing to suction catheter.

    b) The length of the oesophageal pouch and suction length should be confirmed by the Surgical Registrar, NICU AUM, Oesophageal Atresia Nurse, Clinical Nurse Specialist, NICU Educator or Clinical Support Nurse if initial oesophageal pouch suction is undertaken by the bedside nurse or NICU Registrar.


    c) Subsequent suction of the pouch is to the same length, which is 1cm above the distal end of the oesophageal pouch, to prevent trauma to the blind end of the oesophageal pouch.

    d) A size 8Fg suction catheter (size 7Fg in premature neonates) is used to intermittently suction the oesophageal pouch.  Intermittent suction is performed approximately 5-30 minutely or more frequently if necessary.

    e) This suction technique is continued for the duration of the preoperative period.  Less frequent suction may be required if the neonate is asleep or quiet.  Use timer to set appropriate time interval between suction.

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

    f) The timing of suction should be set to prevent desaturations, bradycardias, increased work of breathing and audible secretions in the oesophageal pouch from occurring.  Therefore intermittent suctioning may need to be as frequently as every 2-5 minutes.

    g) The frequency of suction should be documented in the EMR in the Progress Notes and Observation Chart.

    h) Change the suction catheter at least once per shift or more frequently if required.

    i) Change the suction canister and tubing weekly or as required. Record date of change on the suction canister. 

    j) Ensure spare suction catheters size 7Fg, 8Fg and 10Fg are at the bedside at all times.

    Special Considerations

    Long-gap OA:  These babies are nursed in the NICU for a number of weeks to months, prior to repair.  The oesophageal pouch should be remeasured by the Oesophageal Atresia Nurse, NICU AUM, Clinical Nurse Specialist, NICU Educator or Clinical Support Nurse monthly (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 on the Suction Orders and Nursing Communication Order.

    Please note: For those infants with long-gap OA, a decision may be made to use a Replogle tube to provide continuous low pressure suction to the oesophageal pouch. (Refer to the guideline on Replogle Tube Management.  (Infants with a Replogle tube in-situ may still require intermittent oesophageal pouch suctioning)

    Family centred care

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

    Companion documents

    Links

    References

    • Al-Rawi, O., & Booker, P.D.  (2007). Oesophageal atresia and trachea-oesophageal fistula. Continuing Education in Anaesthesia, Critical Care & Pain. 7(1):  15-19
    • Hawley, AD & Harrison D. ‘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.
    • Hawley, A.  2001.  Long-gap Oesophageal Atresia – A Nursing Perspective.  Journal of Child Health Care.  5 (1). Pp.19-25.
    • Hawley A, Whitelaw, J.  (2000). Congenital Abnormalities.  In:  LaTrobe University (eds).  Management of Acute Conditions in the Newborn, Part 2.  pp1-34.  LaTrobe University, Melbourne
    • Ho T & Mok, J. 2006. ‘An infant with long gap oesophageal atresia: A case report.’ Journal of Neonatal Nursing. 12: 103-109. 
      Newborn Services Clinical Guideline: Neonatal Surgery ‘Oesophageal Atresia with a distal Tracheo-oesophageal Fistula’ 2012. 
      http://www.adhb.govt.nz/newborn/guidelines/Surgery/SurgeryTOF.htm 
    • Johnson PRV, 2005. ‘Oesophageal Atresia.’ Infant. 1 (5); 163-167.
    • Telfer, H.M. and McDonnell, G.E.  (1991). Nursing Care.  In Beasley, S.W., Myers, 
    • N.A., and Auldist, A.W. (eds).  Oesophageal Atresia.  Chapman & Hall Medical, London, pp. 265-274



    Evidence table

    Intermittent oesophageal pouch suction for the neonate/infant with unrepaired oesophageal atresia (including long-gap) Evidence Table


    Please remember to read the disclaimer.


    The development of this nursing guideline was coordinated by Alisa Hawley, Care Manager & Oesophageal Atresia Nurse, NICU, and approved by the Nursing Clinical Effectiveness Committee. Updated September 2016.