In this section
Note: This guideline is currently under review.
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.
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 - 3.5
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).
2. Apply Duoderm to each cheek and the nose, before insertion and taping.
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.
Nasopharyngeal Tube (NPT) modified for Pierre Robin Sequence (PRS) Evidence TableNPT for PRS Evidence Table
Please remember to read the disclaimer.
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.