Clinical Guidelines (Nursing)

Nasopharyngeal Tube NPT modified for Pierre Robin Sequence PRS

  • Introduction

    Definition of Terms

    Assessment

    Management 

    Ongoing Assessment and Monitoring 

    Other Considerations 

    Companion Documents

    Links

    Evidence Table


    Introduction

    PRS occurs in approximately 1 in 6000 babies in Victoria.  It is characterised by a cleft palate, a very small lower jaw (micrognathia) or a lower jaw that sits further back than the upper jaw (retrognathia), and airway obstruction, usually due to backward displacement of the tongue (glossoptosis), which can vary in severity.  It is important to note that not all aforementioned characteristics need to be present for diagnosis of PRS to be confirmed.  According to current best practice the most effective method for temporary relief of the upper airway obstruction due to glossoptosis is the insertion of a modified NPT.

    The aim of this guideline is to provide medical and nursing staff with a framework for the insertion and management of a modified NPT in neonates with PRS, to relieve upper airway obstruction.

    Definition of Terms

    • Modified Nasopharyngeal Tube:  An endotracheal tube (ETT), of appropriate size (see table below), is inserted to facilitate airway patency.  The modified NPT is designed to provide relief of upper airway obstruction, in a minimally invasive manner, whilst enabling oral feeding. An alternate term used in the literature is nasopharyngeal airway. A modified NPT is specific to this guideline and used in some babies with PRS who are inpatients on Butterfly at RCH. 
    • Glossoptosis:  A backward displacement or retraction of the tongue which may occlude the airway.
    • Upper Airway Obstruction: In PRS, airway obstruction is mostly due to glossoptosis, whereby the prolapsed tongue occludes the airway, resulting in difficulty breathing.  Upper airway obstruction results in a failure of airflow into the lungs, despite adequate inspiratory effort. Increasing respiratory effort can worsen the obstruction, as increased intra-thoracic pressure collapses the soft tissue structures inwards.  The airway obstruction may be intermittent, and may also take time to develop, with some infants not presenting for days to weeks after birth, most commonly with failure to thrive due to ongoing increased work of breathing.

    Assessment

    Indications for Insertion

    • Obstructive episodes noted by medical, nursing, or allied health staff.  
    • Overnight oximetry indicative of hypoxic episodes  
    • Sleep study indicative of obstructive episodes  
    • Poor feeding tolerance and insufficient weight gain  
    • Significant respiratory distress, further evidenced by hypercapnia on blood gas results  

    Measurement of NPT Size

    Selection of the size (diameter) of the ETT and length to place it at the nostril is outlined in the table below.  This table should be utilized as a guide, and a thorough respiratory assessment should be conducted during insertion to ensure that the NPT is sitting at a length that bypasses the obstructing tongue.

    Table 1: Measurement of NPT Size

    Weight of neonate (kg)

    Length of ETT (cm)

    Diameter of ETT (mm)

    < 2.5

    7.0

    3.0

    2.5 - 3.5

    7.5

    3.5

    > 3.5

    8.0

    4.0


    Management

    Modification of NPT

    Equipment

    • ETT of appropriate size  
    • Duoderm  
    • Brown Leukoplast rigid tape, size 25mm  
    • Scissors  
    • Lubricant  
    • Nasogastric tube (NGT) (if required for feeding)  
    • Clear, occlusive dressing (e.g. Tegaderm, Opsite)  


    Procedure

    1. Cut ETT 5cm longer than the length it is measured to sit at the nostril.
    2. Cut ETT into 4 strands.  Cut on either side of the blue line, and then cut on either side of the numbers.  

    image002   image004

    3. Trim off the ‘bottom’ strand of the tube, the one directly opposite the blue line.

    image006


    Insertion and Securing of NPT

    A member of the medical team should insert the initial NPT, and nurses may insert subsequent NPTs.  A lateral neck x-ray should be obtained to confirm the position of the initial NPT, which ideally should be 1cm above the epiglottis, to prevent vomiting whilst maintaining a patent airway. The NPT position should be adjusted if necessary according to the x-ray. However if respiratory distress persists, endotracheal intubation should be considered. Following successful insertion of a NPT this should be documented in EPIC as an added LDA.

    Ensure that two health practitioners (one to insert the NPT, the other to provide comfort measures to the neonate) are present for the insertion of the NPT, and that the medical registrar is aware that the procedure is occurring.  The initial NPT should only be inserted after a thorough assessment of the neonate by a member of the medical team, and discussion with the consultant. 

    Administer sucrose as per nursing clinical practice guideline (Sucrose oral for procedural pain management in infants). 

    1. There are two strands that will be taped to the face, and the thin blue strand will be trimmed and taped to the nose (see picture below).

    image008

    2. Apply Duoderm to each cheek and the nose, before insertion and taping.

    image010    image012

    3. Apply lubricant to the tip of the NPT.  Insert the tube into the nostril, and once passed through the choana, continue insertion slowly and carefully, until misting is seen in the tube, which will occur on exhalation.  Secure the tube by placing the tape directly over the straps on the cheeks and nose. Apply the tape as close to the nare as possible to prevent mobility of the tube after securing.


    4. If insertion of a NGT is required, insert this into the other nostril, and secure onto the Leukoplast tape with Tegaderm/Opsite.


    5. Ensure a lateral neck x-ray (with patient's head in neutral position) is taken after initial NPT insertion. If alteration is required, re-cut a new NPT according to the modified length required from this x-ray. Refer to x-ray below which shows a patient with an NPT in situ. The NPT is sitting just above the epiglottis and below the posterior tongue, therefore relieving the obstruction.

    NPT for PRS xray


    Timing of NPT Changes

    • In the first 10 days post insertion of the NPT, it should be changed every 2-4 days or PRN if secretions are affecting tube patency. More frequent occlusions may occur during this time from the trauma of initial insertion.  After this period it should be routinely changed every 5-7 days, with alternating nostrils utilised. If the NPT is required over long-term, size and length may need adjusting according to patient's growth.
    • Other indications to change tube:
      • Frequent occlusions 
      • Obstructive episodes 
    • When changing NPT, review the patient's weight and whether the size and length of the tube is appropriate to match recent growth
    • Tapes should only be changed as required, if security of tube or patient skin integrity is becoming compromised, or with the routine NPT change.
    • Ensure spare modified NPT of same size, and one size smaller, with tapes pre-cut are available at the bedside at all times. 
    • Further lateral neck x-rays are only required if clinically indicated. 

    Skin Integrity

    • Monitor the patient's skin integrity, inspecting the nares at least once per shift, ensuring they are pink in appearance.  If the nares are white, the tube needs to be re-taped to reduce pressure on the nostril.
    • Ensure Duoderm is always placed on the patient's cheeks to protect skin from damage caused by the tape securing the NPT. 

    Ongoing Assessment and Monitoring

    • A thorough respiratory assessment is necessary at shift commencement, and if patient's condition changes.  Respiratory assessment should always include auscultation of patient's chest with a stethoscope to assess for air entry with breathing movements. Patients with PRS may be observed to have breathing movements but not actually have adequate air entry for adequate oxygenation and ventilation. This is why auscultation with a stethoscope is a vital component of respiratory assessment for PRS patients.  
    • The presence of stridor indicates obstructed breathing, however absence of stridor does not indicate a patent airway. 
    • Continuous pulse oximetry must be applied for monitoring of infants with an NPT inserted for upper airway obstruction.  Cardio-respiratory monitoring is pertinent in the first 10 days post insertion of an NPT, but if obstructive episodes have ceased, monitoring can be ceased.  If obstructive episodes are still occurring, or the NPT is removed for a trial period continue with cardio-respiratory monitoring in addition to the continuous pulse oximetry. 
    • Continuous close observation for respiratory distress and obstructive episodes is essential, as respiratory monitoring may pick up breathing movements, but cannot measure adequate airway flow. 
    • Refer to: Nursing Assessment Nursing Clinical Guideline 


    Other considerations

    • Family Centred Care - It is the responsibility of the clinicians caring for the infant requiring a modified NPT for PRS to ensure that the parents understand the rationale for this treatment.
    • Special Considerations - An NPT is not suitable for use in all infants with PRS.  Individual assessment of the type and level of obstruction is required. 

      Medical staff must insert the modified NPT if it is used in any condition other than Pierre Robin Sequence

    Companion Documents 

    Links

    Evidence Table

    Nasopharyngeal Tube (NPT) modified for Pierre Robin Sequence (PRS) Evidence TableNPT for PRS Evidence Table

    Please remember to read the disclaimer.


    The development of this nursing guideline was coordinated by Jacquie Whitelaw, Nurse Educator, PIPER Neonatal, and approved by the Nursing Clinical Effectiveness Committee. Updated May 2016.