Clinical Guidelines (Nursing)

Replogle tube management

  •  

    Introduction

    A Replogle tube is used in the management of neonates and infants with oesophageal atresia awaiting a delayed repair of their oesophagus. Infants with long-gap oesophageal atresia may wait up to 4 months until surgical repair of the oesophagus is undertaken.

    A Replogle tube is used to continuously drain saliva from the upper oesophageal pouch and is positioned 0.5cm above the end of the oesophageal pouch.

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

    Aim

    To outline the principles of management of infants with a Replogle tube in-situ in the Butterfly Ward (Newborn Intensive Care) at The Royal Children’s Hospital. 

    Definition of Terms

    Replogle tube: A double lumen tube, where one lumen is for drainage of saliva and the other functions as an air vent.  The Replogle tube (Figure 1) is placed in the upper oesophageal pouch and connected to continuous low pressure suction of -15 to -35 cmH20 to aspirate saliva and prevent aspiration.

    Figure 1: example of a Replogle tube

     Nursing CPG Replogle Figure 1 example of a replogle tub

    ARGYLETM Replogle Suction Catheter

    Oesophageal atresia (OA): A congenital anomaly in which the oesophagus ends in a blind upper pouch.  Most Infants with OA also have an abnormal connection between the trachea and oesophagus, which 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 (Figure 3). See pictures below:

    Figure 2

    Figure 2 Replogle

     

    Figure 3

    Nursing CPG Replogle Figure 3

    Foker Procedure: Involves growth induction of the oesophagus. The Foker process uses tension-induced growth to enable primary oesophageal reconstruction in patients with long gap OA. Sutures are placed on the upper and lower ends of the oesophagus and brought out onto the infant's chest wall.  Tension is applied to the sutures by placing short pieces of silastic tubing under the suture loops, with the tension usually increased each day over a 1-3 week period.  When enough growth in the oesophageal ends has been achieved, the baby returns to theatre for an oesophageal atresia repair (oesophageal anastomosis). The Foker procedure may also include the placement of internal sutures on the upper and lower oesophageal segments.

    Growth induction procedures: Other growth induction procedures may also be undertaken, involving internal sutures on the oesophageal ends, prior to full repair of the OA.

    Indications

    The indications for a Replogle tube are to prevent aspiration and aspiration pneumonia in patients with long gap OA.

    Assessment

    Consent must first be obtained from the infant's Surgeon and Neonatal Consultant prior to using a Replogle tube.

    A medical treatment order is required to:

    • initiate use of a Replogle tube
    • determine the size of the Replogle tube
    • record the length of Replogle tube insertion
    • determine the negative pressure set on the under-water seal drainage unit
    • discontinue treatment with a Replogle tube

    These must be documented on the EMR Orders.

    Considerations in Assessment of Suitability of Neonate for Replogle Tube:

    • Infants with OA and distal TOF who will undergo an early primary repair of OA/TOF (within first 24-48 hours) are not routinely to have a Replogle tube in-situ (as per Thoracic Surgeons’ request). They should have intermittent suction of the upper oesophageal pouch performed. (Refer to the guideline: Intermittent suction for Infants with unrepaired oesophageal atresia). A Replogle tube could be used in these infants, if consent is obtained from the Surgeon and Neonatal Consultant.
    • Size of the Replogle tube: 
      • For infants greater than 35 weeks gestation (and greater than 2.5kg) use a size 10Fg Replogle tube. A size 10Fg Replogle tube should be inserted nasally where possible; if the size 10Fg is too large for the infant’s nose, then the size 10 should be placed orally. A size 10Fg tube will provide more effective drainage than a size 8. 
      • For infants between 32 and 35 weeks gestation:
        • discuss with the infant’s surgeon if a size10Fg could be used orall
        • consider using a Replogle tube size 8Fg (this size is not as effective in draining the oesophageal pouch of saliva and may become blocked with secretions
      • For infants below 32 weeks gestation, discuss Replogle tube size with Surgeon
    • Assess amount and consistency of oesophageal pouch secretions: if very thick secretions are present, infant may be unsuitable for a Replogle tube. Refer to Surgeon, Neonatal Fellow or Consultant, Oesophageal Atresia Nurse, NICU Educator or Clinical Support Nurse, or NICU AUM for advice regarding insertion of a Replogle tube in this situation.

    • Special consideration needs to be given before insertion of a Replogle tube in infants with the following conditions. Insertion of the Replogle tube may be undertaken by the Surgical Registrar or Surgeon in these circumstances:
      • Oesophageal atresia with a proximal fistula (fistula between upper oesophageal pouch and trachea)
        • Discuss insertion length with Surgeon
        • If proximal fistula is unrepaired, flush with air instead of sodium chloride 0.9%
      • Oesophageal atresia undergoing a Foker procedure (with growth induction sutures on the upper oesophageal pouch) or other oesophageal growth induction procedure:
        • discuss insertion length with Surgeon 
        • discuss with Surgeon whether to flush Replogle tube with sodium chloride 0.9% or air 

    Measurement and Insertion Precautions and Responsibilities:

    • Discuss with the surgical team any restriction on insertion of a Replogle tube in the infant. Some infants may require the replogle tube to be placed or replaced by the surgical team.  
    • Initial measurement of and insertion of a Replogle tube should be carried out by the Oesophageal Atresia Nurse or Surgical Registrar, NICU Educator or CSN or NICU AUM.
      • The length of the oesophageal pouch should be measured with a size 10Fg Replogle tube. This is done by gently passing the Replogle tube (lubricated with water soluble lubricant) into the oesophagus, ideally via the nostril and naso-pharynx (or mouth and oro-pharynx if necessary), until resistance is felt. The Replogle tube is then withdrawn 0.5cm and secured with tape. The measured length of the Replogle tube oesophageal pouch (from nares or lips) is documented in the EMR on the Replogle Tube Care Order and LDA Assessment in Flowsheets.
    • Subsequent insertions may be undertaken by the bedside nurse with the support of a clinician who is experienced with the procedure
    • Subsequent measurement of the oesophageal pouch should be undertaken every 2-4 weeks (or sooner if indicated) by the Oesophageal Atresia Nurse, NICU Educator or CSN or NICU AUM or Neonatal Fellow, and Replogle tube length in oesophageal pouch readjusted as necessary. Documentation of the date and measurement should be in the EMR on the Replogle Tube Care Order and the LDA Assessment in Flowsheets. 

    Initial and Ongoing Assessment while Replogle tube in-situ:

    • Infants with a Replogle tube in-situ require ongoing:
      • cardio-respiratory monitoring
      • oxygen saturation monitoring
    • Ongoing assessment for signs of cardio-respiratory distress / compromise:
      • Apnoea
      • Bradycardia
      • Stridor
      • Use of accessory respiratory muscles
      • Desaturation (oxygen saturations below 90%)

    These signs indicate the need for immediate and additional oesophageal pouch suction and a problem with Replogle tube patency / suction. Provide immediate intermittent oesophageal pouch suction and ensure Replogle tube is patent and in-situ to the required length.

    • Assessment of the need for additional intermittent oesophageal pouch suction including:
      • secretions not removed with Replogle tube suction
      • cardio-respiratory distress / compromise (as above)
    • Medical staff to consider requirement for a chest x-ray if patient develops:
      • Coughing (prolonged or persistent)
      • Restlessness (prolonged or persistent)
      • Unexplained irritability or severe discomfort
      • Hoarseness or abnormal voice
    • Assessment of Replogle tube patency and effective oesophageal pouch suction and adequate clearance of saliva / secretions by ensuring Replogle continuously draining saliva, with no additional intermittent suction required
    • Signs of respiratory distress / compromise should be reported to Neonatal Registrar or Fellow and documented in the EMR on the Observations Chart in Flowsheets. 
    • Replogle Tube Care Orders must show length of Replogle tube insertion and suction pressure

    Management

    Prior to Insertion of Replogle tube:

    • Check the Replogle Tube Care Order for depth of Replogle tube insertion, suction pressure and specific requirements for each infant.
    • If the infant has had a Foker procedure or oesophageal growth induction procedure performed:
        • check that the Surgeon has consented to the use of a Replogle tube for the infant
        • Ensure the Surgeon has documented the required length for Replogle tube insertion (via mouth or nares), suction pressure and flush requirements i.e. whether the flush should be done with air instead of sodium chloride 0.9%

          Equipment

          • "Argyle" Replogle Suction Catheter size 10Fg (consider size 8Fg Replogle tube if between infant is 32-35 weeks gestation)
          • "Atrium" Oasis Dry Under Water Seal Drain (UWSD) Unit 2000ml
          • Suction regulator unit
          • Suction tubing (short length)
          • 3-way tap
          • 10 ml syringe of sodium chloride 0.9% (labelled)
          • Sterile water (bottle)
          • Brown tape and string
          • Timer
          • Water soluble lubricant

           Process for Insertion and Ongoing Management of Infant Requiring a Replogle Tube

          1. Set up suction tubing and "Atrium" UWSD unit as per "Managing Chest Drain" information booklet:
            Connect suction regulator to suction outlet on wall, attach suction tubing to "Atrium" UWSD unit. Set suction control dial on Atrium to -15cmH20. Ensure water seal is filled to 2cm line as per instructions
          2. Ensure additional suction and suction catheters are at bedside in addition to those used with the Replogle tube suction, in case intermittent suction of the oesophageal pouch is required
          3. The measured length of the oesophageal pouch and the Replogle tube length should be documented in the EMR on the Replogle Tube Care Order and LDA Assessment (flowsheets) and a sign attached to the infant'scot
          4. Nurse infant with head of bed elevated 30-45 degrees
          5. Gently insert Replogle tube to pre-determined length via mouth or nares
          6. Secure Replogle tube with string and tape as per endo-tracheal tube taping
          7. During insertion of the Replogle tube, remove the tube immediately and seek medical assistance if there is any acute respiratory distress / compromise or if there is any resistance during insertion
          8. Connect the Replogle tube to tubing on Atrium Oasis Dry Suction UWSD unit
          9. Turn on the wall suction unit to -80mmHg and ensure Atrium suction control dial is set at -15cmH20
            Suction can be increased on Atrium drain to a maximum of -35cmH20 if required following discussion with Neonatal Consultant and a written medical order on the Replogle Tube Care Order
          10. Connect 3-way tap to the vent lumen (the blue or small lumen) on the Replogle tube (see photo below).  The 3-way tap should remain open to air so that the vent lumen can function properly
            Nursing CPG Step L Replogle
          11. The vent lumen (the blue or small lumen) of the Replogle tube is flushed every 15 minutes (set the timer each 15 minutes) with 0.5ml of air or sodium chloride 0.9%  (as per Replogle Tube Order.) Check to observe whether saliva is draining back up the Replogle tube. If flushing is done with sodium chloride 0.9% ensure sodium chloide 0.9% is seen draining back up the Replogle tube. This is to prevent the Replogle tube blocking with secretions. Note: All aspects of ongoing care related to flushing (vent lumen and drainage lumen) the Replogle tube should be carried out by a Registered Nurse. This is due to the inherent risks of potential complications that require continuous assessment and prompt management.
            • Check with Surgeon if the flush should be done with air instead of sodium chloide 0.9% if the infant has had a Foker Procedure or an oesophageal growth induction procedure performed (documented in the Replogle Tube Care Order)
          12. Flush the suction / drainage lumen of the vent tube 2 - 4 hourly as required with 1-2ml sodium chloride 0.9%: First gently aspirate the suction lumen of the Replogle tube with a 10ml syringe, then flush with 1-2ml sodium chloride 0.9% and gently aspirate the 1-2ml sodium chloride 0.9% back from the pouch.
            • This is to prevent the suction lumen from blocking with secretions.
            • Check with Surgeon if the flush should be done with air instead of sodium chloride 0.9% if the infant has had a Foker or oesophageal growth induction procedure performed (documented in Replogle Tube Care Order.)
            • Photo (below) of the holes in the tip of the Replogle tube:  
              Nursing CPG Replogle Air Vent Holes
            • Photo (below) of gently aspirating the suction lumen of the Replogle tube prior to flushing::
              Nursing CPG Replogle gentley aspirating suction lumen
            • Photo (below) of flushing the suction lumen of the Replogle tube:
              Nursing CPG Replogle Suction Lumen
          13. Document on the LDA Fluid Balance Flowsheet the volume of sodium chloride 0.9% flushed and amount of drainage in Atrium UWSD unit hourly. Ensure flush volume is returned and drains appropriately into the Atrium unit, if flushed volume is not returned assess Replogle tube patency.
          14. Check level of sterile water in suction control chamber on Atrium UWSD unit hourly and top up to maintain sterile water level at 2cm
          15. Check suction pressure hourly to ensure it is set correctly as per Replogle Tube Care Order
          16. Check Replogle tube position hourly to ensure it remains in-situ at the correct distance at nares / mouth  
          17. Ensure Replogle tube remains patent, assessing tube patency every 15 minutes and as required
          18. If there is no drainage from the Replogle tube or the infant is requiring intermittent oral suction, flush Replogle tube with 1ml of air or sodium chloride 0.9% via vent lumen and check for movement of fluid through the tubing. If no movement of fluid through the Replogle tube, gently aspirate the suction lumen with a 10ml syringe and flush gently with 1-2 of sodium chloride 0.9%, gently aspirating the sodium chloride 0.9% back.
            • If the infant has had a Foker or oesophageal growth induction procedure performed, the surgeon may order flushing of the Replogle with air instead of sodium chloride 0.9% (Check Replogle Tube Care Order)
            • If still no movement of fluid through the tube, or no return of sodium chloride 0.9%, remove Replogle tube, flush, ensure it is patent and reinsert.  If Replogle tube is blocked and blockage cannot be cleared, replace Replogle tube. 
          19. Change the Replogle tube and Atrium UWSD unit weekly, or earlier if necessary.  Document changes of the Replogle tube in the LDA and label the Atrium drain with the date and time of change
          20. Alternate nostrils used for insertion of the Replogle tube
          21. Ensure a spare Replogle tube, strings and brown tape are at the bedside at all times

          Additional Information Regarding Atrium UWSD Units:

          • Continuous low pressure suction of -15 to -35 cmH20 on the Atrium drain is equal to a suction pressure of -11 to -25 mmHg
          • The suction at the wall must be set on -80mmHg for the Atrium Oasis UWSD drain to function correctly

          Family Centred Care

          It is the responsibility of the clinician caring for the infant with a Replogle tube to ensure that the parents understand the rationale for the intervention, as well as potential complications.

          Companion Documents

           Links

           Parent support groups

          References

          1. Alberti D, Boroni G, Corasaniti L & Torri F. 2011. “Esophageal atresia: pre and post-operative management.’ Journal of Maternal-Fetal and Neonatal Medicine. 24 (S(1): 4-6.
          2. ‘ArgyleTM Replogle Suction Catheters – Product information.’ 2013. Covidien.
            http://www.kendallltp.com/pageBuilder.aspx?topicID=146881&breadcrumbs=144286:0
            Accessed 16/9/13.
          3. Bairdain, S., Hamilton, T.E., Smithers, C.J., Manfredi, M., Ngo, P., & Gallagher, D., Zurakowski, D., Foker, J.E., & Jennings, R.W.  (2015). Foker process for the correction of long gap esophageal atresia: Primary treatment versus secondary treatment after prior esophageal surgery. Journal of Pediatric Surgery, 50(6): 933-937.                                              doi: 10.1016/j.jpedsurg.2015.03.01
          4. Birmingham Children’s Hospital, 2009. ‘How to insert and manage a Replogle tube in a neonate.’
          5. Braithwaite, I.  (2011). Continuous low suction pressure: an innovative solution to transporting patients with Replogle tubes.  Infant, 7(4):132-133.
          6. Children’s Hospital Boston. 2013. The patient care manual - ‘Insertion and Management of Replogle Suction Catheters.’
          7. Foker, J. E.; Kendall Krosch, T.C.; Catton, K., Munro, F.; Khan, K.M. (2009). Long-gap esophageal atresia treated by growth induction: the biological potential and early follow-up results. Seminars in Pediatric Surgery, 18(1): 23-29.
          8. Hawley, A.  2001.  Long-gap Oesophageal Atresia – A Nursing Perspective.  Journal of Child Health Care.  5 (1). Pp.19-25.
          9. 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.
          10. Holland, A.J.A, & Fitzerald, D.A.  (2010). Oesophageal atresia and trachea-oesophageal fistula: Current management strategies and complications.  Paediatric Respiratory Reviews, (11): 100-107. DOI: 10.1016/j.prrv.2010.01.00
          11. Jawaheer G & Hocking M. 2009. ‘Initial management of an infant with oesophageal atresia’ Southern West Midlands Newborn Network. 
          12. Johnson PRV. 2005. ‘Oesophageal atresia.’ Infant. 1(5): 163-167.
          13. Kolimarala, V., Jawaheer, G., & Reda, B.  (2010).  Management of the upper pouch in neonates with oesophageal atresia: National survey on use of Replogle tubes in United Kingdom (Poster).  Pediatric Research, 68, 476. Doi: 10.1203/00006450-201011001-0095
          14. Lakkundi, A, Wake C & Ormsby J. 2010 ‘Management of infant with Replogle tube in NICU. ’ Newcastle Children’s Hospital, NSW. http://www.kaleidoscope.org.au/docs/GL/Repogle_NICU.pdf’ accessed 6/9/12
          15. Leung, T.S.M., & Bayston, R., & Spitz, L.  (1985).  Bacterial colonisation of the upper pouch in neonates with oesophageal atresia.  Z Kinderchirurgie, 41: 78-80.
            Newborn Services Clinical Guideline: Neonatal Surgery ‘Oesophageal Atresia with a distal Tracheo-oesophageal Fistula’ 2016. 
            Retrieved 29 May, 2016 from http://www.adhb.govt.nz/newborn/guidelines/ Surgery/SurgeryTOF.htm  
          16. ‘NCCU Clinical Guidelines: Surgical Conditions: Oesophageal Atresia’ (2014). King Edward Memorial / Princess Margaret Hospitals Perth Western Australia. http://www.kemh.health.wa.gov.au/services/nccu/guidelines/documents/7374.pdf
            accessed 27/5/16
          17. Replogle RE. 1963. ‘Esophageal atresia. Plastic sump catheter for drainage of the proximal pouch.’ Surgery. 54: 296-297
          18. RHW (2014). Set-up and insertion of Replogle tube.
            Retrieved May 10,2016 from http://www.seslhd.health.nsw.gov.au/rhw/Newborn_Care/Guidelines/Nursing/Replogletube.pdf
          19. Spitz, L. 2007. ‘Oesophageal atresia.’ Orphanet Journal of Rare Diseases. 2: 24
          20. Southern West Midlands Maternity & Newborn Network.  (2015).  Neonatal Guidelines 2015-2017: Oesophageal Atresia.  p. 231- 233. Retrieved May 27, 2016 from: https://www.networks.nhs.uk/nhs-networks/staffordshire-shropshire-and-black-country-newborn/neonatal-guidelines/neonatal-guidelines-2015-17
            Wallis, M. 2014 ‘Clinical Guideline Replogle Tube, Care of’. Great Ormond Street Hospital, London, accessed, May 29, 2016, http://www.gosh.nhs.uk/health-professionals/clinical-guidelines/replogle-tube-care

          Evidence Table

          Refer to separate evidence table for Replogle Tube Management

           

          The development of this nursing guideline was coordinated by Alisa Hawley, Care Manager, Butterfly Ward, and approved by the Nursing Clinical Effectiveness Committee. Updated June 2016.  

          Please remember to read the disclaimer.