Replogle tube management

  • Introduction

    A Replogle tube is used in the management of neonates and infants with long-gap 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.


    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).  An infant with OA and distal TOF may also have a large gap between the ends of the oesophagus. See diagrams below:

    Figure 2: Long gap OA

     Fig 2 Replogle

    Figure 3

    Fig 3 Replogle

    Diagrams Royal Children's Hospital, Melbourne 

    Traction suture techniques: involves the placement of sutures under tension in the upper and lower ends of the oesophagus.  The infant will return to theatre after approximately 4-8 weeks for a delayed repair of the oesophageal atresia if the oesophageal ends are close enough.   


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

    Important note 

    The RN prior to caring for a neonate/infant with unrepaired OA must have successfully completed competencies on:

    1. Replogle tube management
    2. Sham feeding
    3. Intermittent oesophageal pouch suction


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

    A medical 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 in the EMR Orders.

    Considerations in Assessment of Suitability 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 managed with 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: Oesophageal atresia: Intermittent oesophageal pouch suction for the neonate and infant). 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 32 weeks gestation use a size 10Fg Replogle tube. A size 10Fg Replogle tube should be inserted nasally where possible; if the size 10Fg Replogle tube is too large for the infant’s nares, then the size 10Fg Replogle tube should be placed orally. A size 10Fg tube will provide more effective drainage than a size 8Fg Replogle tube
      • For infants below 1500gms, discuss the use of Replogle tube and appropriate size of Replogle tube with the surgeon
      • In some cases, the infant may continue to receive intermittent oesophageal pouch suction until a suitable size Replogle tube can be used with effective drainage of the oesophageal pouch
    • Assess amount and consistency of oesophageal pouch secretions: if very thick secretions are present, the infant may be unsuitable for a Replogle tube. Refer to Surgeon, Oesophageal Atresia Nurse, or NICU ANUM 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 with traction sutures in the upper oesophageal pouch:
        • 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
    • Initialmeasurement of and insertion of a Replogle tube should be carried out by the Surgical Registrar or the Oesophageal Atresia Nurse.
      • Perform hand hygiene, and ensure appropriate personal protective equipment (PPE), including eye protection, face mask, and non-sterile gloves.
      • The length of the oesophageal pouch should be measured with a size 10Fg suction catheter. This is done by gently passing the suction catheter (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 suction catheter is withdrawn and measured against a tape measure, and the length of the oesophageal pouch noted.
      • A lubricated Replogle tube is then inserted to 0.5cm above the end of the oesophageal pouch and secured with a NEOfitTM holder or secured with tape (as per endotracheal tube taping).
      • The measured length of the Replogle tube and the length of the oesophageal pouch (from nares or lips) is documented in the EMR on the Replogle Tube Care Order and LDA Assessment in Flowsheets. 
      • The length of Replogle tube insertion should also be documented on the suction card on the infant’s cot.
    • Subsequent insertions may be undertaken by the bedside nurse with the support of a clinician who is experienced with the procedure (with consent from the surgical team).
    • Subsequentmeasurement of the oesophageal pouch should be undertaken every 2-4 weeks (or sooner if indicated) by the Surgical Registrar or the Oesophageal Atresia Nurse, and Replogle tube length documented in the EMR on the Replogle Tube Care Order and LDA Assessment in Flowsheets. 

    • The required length of the Replogle tube should also be documented on the suction card on the infant’s cot.
      • 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:
    • Medical staff to consider requirement for a chest x-ray if infant develops:
    • 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 the Neonatal Registrar or Fellow and documented in the EMR on the Observation Chart in Flowsheets
    • Replogle Tube Care Orders must show length of Replogle tube insertion and suction pressure


    Prior to insertion or changing of a 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 traction sutures in-situ:
      • 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%
      • Check if the Replogle tube can be changed by nursing staff or if this needs to be changed by the surgical team.


    • "Argyle" Replogle Suction Catheter size size 10Fg & additional spare tube at patient bedside
    • "Atrium" Oasis Dry Under Water Seal Drain (UWSD) Unit 2000ml
    • Hi-flow, low vacuum suction regulator unit
    • Suction tubing (long length)
    • 3-way tap
    • 10 mL syringe 
    • 10 mL syringe of sodium chloride 0.9% (labelled)
    • NEO-fitTM endotracheal tube holder 
    • Timer
    • Water soluble lubricant
    • Suction catheters (Fg8, Fg7) for additional intermittent oesophageal pouch suction, as required
    • Additional suction regulator unit for intermittent oesophageal pouch suction, as required
    • Monitoring equipment for cardiorespiratory & SpO2 continuous monitoring
    • NeopuffTM at patient bedside

     Process for Insertion 

    1. Perform hand hygiene and ensure appropriate PPE.
    2. Collect equipment. 
    3. Ensure an additional suction regulator with suction tubing and suction catheters are present at the bedside in case intermittent oesophageal pouch suction is required.
    4. Clean work surface area.
    5. Apply eye protection and appropriate PPE.
    6. Perform hand hygiene, apply non-sterile gloves.
    7. Nurse infant with head of bed elevated 30-45 degrees.
    8. Set up suction tubing and “Atrium” UWSD unit as per “Managing Chest Drain” information booklet:
      • Ensure water seal is filled to 2cm line as per instructions 
      • Connect suction regulator to suction outlet on wall, and turn on the wall suction to -80mmHg  pressure
      • Attach suction tubing to “Atrium” UWSD unit
      • Set suction control dial on Atrium to -20cmH20
      • Suction can be increased on “Atrium” to maximum of -35cmH20 suction pressure if required, following discussion with Surgeon, Neonatal Consultant or Oesophageal Atresia Nurse with a written medical order in the Replogle Tube Care order in EMR.
    9. The measured length of the oesophageal pouch and the Replogle tube size and length should be documented in the EMR on the Replogle Tube Care Order and on a sign attached to the infant’s cot.
    10. Flush and aspirate the Replogle tube with 3mls sodium chloride 0.9% to pre-lubricate the Replogle tube prior to insertion.
    11. Gently insert the Replogle tube to predetermined length via nare or mouth.

    1. 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.
    1. Secure Replogle tube with the NEO-fitTM tube holder by wrapping snuggly around the Replogle tube (see Figure below and instructions for NEO-fitTM use). Ensure the Replogle tube is positioned securely in the channel of the NEO-fitTM tube holder and at the correct measurement on the Replogle tube. Additional hypafix may be required to secure the NEO-fitTM flanges to the infant’s face.
    1. Ensure the Replogle tube is not causing pressure on the infant’s nares or lip/gum.

    1. Perform hand hygiene at the end of the procedure.

    Replogle steps to secure

    Figure 4: Replogle tube inserted orally & secured with NEO-fitTM

    Replogle neofit

    photograph with permission

    **If at any time the NEO-fitTM is deemed to be ineffective for securing the Replogle tube or if using a Replogle tube Fg8 please revert to standard oral or nasal ETT strapping** 

    Information Regarding Atrium UWSD Units:

    • Connect the Replogle tube to tubing on Atrium Oasis Dry Suction UWSD unit.

    • Turn on the wall suction unit to-80mmHg and ensure the Atrium suction control dial is set at -20cmH2
    • Suction can be increased on the 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
    • Connect a 3-way tap to the vent lumen (the blue or small lumen) on the Replogle tube (see photo below).  Attach a 10mL luer lock syringe barrel to the 3-way tap and leave this open to air so that the vent lumen can function correctly. 

    Replogle atrium uwsd

    • Change the Replogle tube and “Atrium” UWSD unit weekly, or earlier if necessary. 
    • Continuous low pressure suction of -20 to -35 cmH20 on the Atrium drain is equal to a suction pressure of -15 to -25 mmHg
    • The suction at the wall must be set on -80mmHg for the Atrium Oasis UWSD drain to function correctly
    Photo (below) of the holes in the tip of the Replogle tube:
    Replogle holes

    Ongoing Management 

    • Alternate nostrils/nares used for insertion of the Replogle tube.
    • Ensure secretions are draining continuously along the Replolge tube.
    • The air vent lumen (blue 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).  This procedure is done to help prevent the Replogle tube blocking with secretions.
    • Check to observe whether saliva is draining back up the Replogle tube.  
    • If flushing is done with sodium chloride 0.9% ensure this is observed 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 drain lumen) the Replogle tube should be carried out by a Registered Nurse. This is due to the inherent risks and potential complications that require continuous assessment and prompt management.
    • Flush the suction / drainage lumen of the Replogle tube 2-4 hourly and as required with 1-2mL sodium chloride 0.9%. This is done by gently aspirating 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 oesophageal pouch.  This is to prevent the suction lumen from blocking with secretions.  

    Photo series (below) of gently aspirating & flushing the suction lumen of the Replogle tube:

    Replogle aspirating and flushing

    • Ensure a spare Replogle tube is at the bedside at all times.
    • Infants with a Replogle tube in-situ require ongoing:
      • cardio-respiratory monitoring
      • oxygen saturation monitoring
    • Ongoing assessment for signs of cardio-respiratory distress / compromise:
      • Apnea


    • Documentation is completed within the fluid balance and LDA flowsheets in EMR
    • On insertion, document the tube length, size and suction pressures within the LDA
    • Document site assessment, securement method and patency of vent lumen and vent lumen intervention, patency of drainage lumen, and drainage lumen interventions.
    • Observe and document the consistency and colour of oesophageal pouch secretions.  Report any concerns to neonatal medical team.  Oesophageal pouch secretions become colonised with bacteria.
    • Document the volume of normal saline flushed into the vent lumen (usually 0.5ml flush every 15 mins but record any extra volume flushed).
    • Document the volume aspirate from the drainage lumen
    • Record the amount of saliva drained in previous hour but do not include instilled volumes of sodium chloride 0.9% in fluid balance (the flushes are aspirated back and are not included as intake).
    • Document the cumulative output (drainage in Atrium UWSD) unit hourly. Ensure flush volume is returned and drains appropriately into the Atrium unit; if flush volume is not returned assess Replogle tube patency.
    • Refer to appendix A for example of documentation in EMR.

    Hourly Checks

    • Hourly checks required:
    • Check Replogle tube position hourly and prn to ensure the Replogle tube remains in-situ at the correct distance at nares / mouth 
    • Check level of sterile water in suction control chamber on Atrium UWSD unit hourly and top up to maintain sterile water level at 2cm.
    • Ensure saliva continuously draining along Replogle tube
    • Check suction pressure hourly to ensure it is set correctly as per Replogle Tube Care Order
    • Ensure Replogle tube remains patent, assessing tube patency every 15 minutes and as required.


    Signs of Replogle tube blockage:

    If fluid (sodium chloride 0.9%) runs out into the air vent syringe barrel this may indicate the Replogle tube is obstructed 

    • To trouble shoot, gently inject 2-3mL AIR to help unblock. 
    • If unsuccessful in clearing the Replogle tube, flush the suction lumen with 1- 2ml sodium chloride 0.9% with a 5mL syringe and aspirate to return  
    • If unsuccessful in restoring patency, remove Replogle tube and replace with a new Replogle tube
    • Perform intermittent oesophageal pouch suction as required until a patent Replogle tube is in-situ and draining well 

    If there is no drainage from the Replogle tube or the infant is requiring intermittent oral oesophageal pouch 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 5mL syringe
    • and gently flush the Replogle tube with 1-2mL of sodium chloride 0.9%, gently aspirating the sodium chloride 0.9% back  
    • If no movement of fluid through the Replogle tube, or no return of sodium chloride 0.9% remove and replace the Replogle tube with a new Replogle tube

    Do not flush the Replogle tube if there are immediate concerns about the infant’s deteriorating condition, position of the Replogle tube, or secretions. Perform intermittent oesophageal pouch suction until any issues with the Replogle tube position and patency have been fixed. This is to prevent aspiration with flushing a non-functioning or malpositioned Replogle tube in this situation. 

    **If the infant has had traction sutures placed in the upper oesophageal pouch the surgeon may order flushing of the Replogle with air instead of sodium chloride 0.9% (Check Replogle Tube Care Order)**

    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


     Parent support groups


    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.

    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.2015.03.010

    Braithwaite, I.  (2011). Continuous low suction pressure: an innovative solution to transporting patients with Replogle tubes.  Infant, 7(4):132-133.

    Cardinal Health (2020).  ArgyleTM Replogle Suction Catheters. 

    Retrieved June 22, 2020,

    Children’s Hospital Boston. (2013). The patient care manual - ‘Insertion and Management of Replogle Suction Catheters.’

    Hawley, A.  (2001). Long-gap Oesophageal Atresia – A Nursing Perspective.  Journal of Child Health Care.  5 (1). Pp.19-25.

    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.

    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

    Jawaheer G & Hocking M. (2009). ‘Initial management of an infant with oesophageal atresia’ Southern West Midlands Newborn Network. 

    Johnson PRV. (2005). ‘Oesophageal atresia.’ Infant. 1(5): 163-167.

    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: 10.1203/00006450-201011001-00954

    Lakkundi, A, Wake C & Ormsby J. (2010). ‘Management of infant with Replogle tube in NICU. ’ Newcastle Children’s Hospital, NSW.’ accessed 6/9/12

    Leeds Teaching Hospitals NHS Trust.  (2018).  Oesophageal atresia and trache-oesophageal fistula requiring a Replogle tube – Management of Infants with.  Leeds Teaching Hospitals NHS Trust, Leeds, UK.  Retrieved June 22, 2020 from

    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.

    Metcalfe, F.  (2019).  Yorkshire and Humber Neonatal ODN Setting up a Patient on a Replogle Tube.  The Yorkshire and Humber Neonatal Operational Delivery Network.

    Newborn Services Clinical Guideline: Neonatal Surgery ‘Oesophageal Atresia with a distal Tracheo-oesophageal Fistula’ (2016).

    Retrieved 29 May, 2016 from Surgery/SurgeryTOF.htm  

    Replogle RE. (1963). ‘Esophageal atresia. Plastic sump catheter for drainage of the proximal pouch.’ Surgery. 54: 296-297

    Royal Hospital for Women (2014). Procedure Guideline: Set-up and insertion of Replogle tube.

    Retrieved November, 2020 from

    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

    Southern West Midlands Maternity & Newborn Network.  (2015). Neonatal Guidelines 2015-2017: Oesophageal Atresia.  p. 231- 233.  Retrieved Nov 20, 2020 from:

    Spitz, L. (2007). ‘Oesophageal atresia.’ Orphanet Journal of Rare Diseases. 2: 24

      Women and Newborn Health Service Neonatal Directorate.  (2019). Clinical Practice Guideline: Oesophageal atresia/tracheoesophageal fistula.  Government of Western Australia, North Metropolitan Health Service. Retrieved April 20, 2020,

    Appendix A

    Example of Replogle tube documentation:

    Replogle EMR

    Above is a screenshot of a current patient’s Replogle tube documentation.

    The information below will explain each row, and the calculations involved.

    Replogle Tube Properties: When the Reploge tube was inserted, to what depth, size etc.

    Site Assessment: Multi select options – clean, dry, intact, bleeding, haematoma, leaking, painful, pink, red, oedematous – pick what is relevant to the site appearance.

    Securement method and status: Multi select option. We are mainly using the Neo-Fit now. Please also comment on if it is secure, have you checked the length, has it been repositioned or retaped (if applicable).

    Patency of vent lumen: Only options are Partially Blocked and Occluded, so if it is working well, leave this row blank.

    Vent Lumen Intervention: Multi-select option. You can flush with normal saline (see next comment), flush with air or aspirate it. Document whichever ones you have performed in the previous hour.

    Volume of Normal Saline Flushed into Vent Lumen (ml): This is the 0.5ml flush every 15 minutes. If you do an extra flush, or flush 1ml instead of 0.5ml, write this volume here. It’s over the hour, this is the total amount you flush in. It is usually 2ml.

    Patency of Drainage Lumen: Single option select, draining freely, partially blocked, occluded.

    Drainage Lumen Intervention: Multi-select option. You can flush with normal saline (see next comment), flush with air or aspirate it. Document whichever ones you have performed in the previous hour.

    Volume of Normal Saline Flushed into Drainage Lumen (ml): This is usually 2ml, every 1-2 hours, depending on the patient.

    Volume Aspirated from Drainage Lumen: Hopefully, this is at least the same amount that you put in. If it is more, you will need to add that additional amount to the row below (i.e. if you flush with 2 and get back 3, please add 1ml to the row Amount of Saliva Drained in the previous hour). If you flush 2ml and get back 2ml, you do not need to add anything to the next row, If you flush 2ml and only get back 1ml, you will need to minus 1ml from the next row.

    Amount of Saliva Drained in Previous Hour: You can see in the image above, that the Cumulative Output is 84 one hour, then 94 the next. The amount of saliva drained is documented at 8, and not 10. This is because we know 2ml of that is Normal Saline and we’re not interested in that. We are interested in the saliva output only. DO NOT include the normal saline volume in the saliva output total. If you have acquired extra saliva from the drainage lumen flush, add that volume here (see above)          

     ** This row is what populates to your fluid balance activity, where we review daily ins and outs. If you count the saline as output, it will give a falsely large output. Only document the saliva.**

    Cumulative Output (ml)/ Chamber Reading: The hourly reading of the Atrium. It should go up by at least 2ml each hour if the Replogle is working properly and draining the saline you are putting in. Anything above two, is saliva and counts to the overall fluid balance (see above). 

    Refer to separate evidence table for this guideline.

    Evidence Table

    Evidence table for Replogle Tube Management can be accessed here


    The development of this nursing guideline was coordinated by Alisa Hawley, Oesophageal Atresia Nurse & Lactation Consultant, Koala Ward, and approved by the Nursing Clinical Effectiveness Committee. Updated April 2021.  

    Please remember to read the disclaimer.