Replogle tube, care of

A Replogle tube is a double lumen, radio-opaque tube, which is mainly used to give continuous suction and irrigation to a blind ending pouch in the oesophagus.

The most common use of a Replogle tube is for babies with oesophageal atresia. This is a congenital condition where the oesophagus is blind ending and therefore does not connect to the stomach. The baby’s saliva therefore accumulates in the blind ending pouch and if unmanaged would spill over into the trachea causing aspiration (Hutson et al, 2008).

The Replogle tube is passed into the blind ending pouch of the upper oesophagus in the pre-operative period to provide continuous suction, allowing the secretions to be cleared. In the majority of babies this will be required for a few days prior to surgery, but if there is delay in attempting a surgical repair of the oesophagus, the Replogle tube may be required for up to six to eight weeks (Johnson, 2005).

The baby with a Replogle tube in situ requires constant observation and vigilance as having a blind ending oesophageal pouch leaves their airway vulnerable to aspiration and pneumonia. Their airway is only protected while the Replogle tube is in situ with low pressure suctioning and regular flushing of the tube to ensure patency (Hollwarth and Zaupa, 2006). The tube has two separate lumens to allow flushing and aspiration at the same time. This is different from a standard naso-gastric tube which only has one lumen.

Replogle tube diagram

Inform the family

 
Ensure the family are informed of the following:
  • that a Replogle tube will need to be passed
  • what a Replogle tube is
  • what it entails
  • the reasons for passing a Replogle tube
  • the likely duration of the procedure.
  • how long the tube will stay in situ (Rationale 1)

Preparation

  • The bed space should be prepared and the following equipment assembled before the baby is admitted (Rationale 2):
    • Replogle tube (Argyle size 10FR gauge)
    • suction tubing
    • low pressure suction pump for Replogle tube and high flow suction for oral suctioning (double outlet suction required)
    • 2ml syringe
    • 0.9 per cent sodium chloride for injection (Rationale 3)
    • white bung (Rationale 4)
    • Duoderm® & IV 3000™ dressings (Rationale 5)
  • A hand wash must be performed before the equipment is handled (Rationale 4).
  • On admission the baby should be fully assessed and monitoring and recording of the vital signs, PEWS commenced and documented.
  • The airway should be given immediate suction (Rationale 7).
  • Any necessary resuscitative measures should be taken.
  • The medical staff should be informed of the baby’s arrival (Rationale 8).
  • A Replogle tube should only be passed by, or under the supervision of, an experienced nurse or doctor (Rationale 9).

Inserting a Replogle tube

  • The preferred route for passing the Replogle tube is via the nostril (Rationale 10, Rationale 11).
  • The Replogle tube will need to be passed orally if:
  • the baby is very small
  • the baby has choanal atresia
To pass the Replogle tube:
  • Put on an apron (Rationale 4).
  • Perform a hand wash (Rationale 4).
  • Put on non-sterile gloves (Rationale 12).
  • Suction the nasal passages and the oro-pharynx (Rationale 7).
  • The Replogle tube should then be gently passed until resistance is felt against the blind ending pouch of the upper oesophagus.
  • Pull the Replogle tube back 0.5cm (Rationale 13).
  • The larger lumen of the Replogle tube is then connected to the low flow suction unit using the suction tubing.
  • Set the suction on the pump between 3.5-4 Kpa (25-30 mmHg 35-42cms water) (Replogle 1963).
  • Secretions will be observed starting to drain along the Replogle tube and into the suction tubing.
  • Secure the tube firmly once the position appears satisfactory, using Duoderm® to protect the skin and an IV 3000™ dressing (Rationale 14).
  • Instil 0.5mls of 0.9 per cent sodium chloride into the blue lumen of the Replogle tube to facilitate the continuous drainage of secretions.
  • Clear away equipment according to Waste Management Policy (Rationale 15).
  • Wash hands (Rationale 12).
  • Record the procedure in the child’s health care records (Rationale 16).
The tube should be changed every four days. It may need to be changed more frequently if the secretions are excessive or thick secretions (Rationale 17).
 
Alternating nostrils should be used wherever possible (Rationale 18).
 

Ongoing care

If the baby shows signs of deterioration, conventional naso-pharyngeal suction should be given and assistance sought (Rationale 19, Rationale 20).
If there is any doubt about the effectiveness of a Replogle tube help must be sought immediately (Rationale 21).
 
  • The baby should be nursed on an apnoea mattress and observed at all times (Rationale 6).
  • The baby should be positioned on a slight head up tilt (Rationale 22).
  • 0.5 mls of 0.9 per cent sodium chloride for injection should be instilled into the tube every 15 minutes (Rationale 23).
  • It must be recorded:
    • If the baby is on a ward - on the baby’s Replogle tube flush chart, which should be downloaded and printed on a daily basis. If the baby is on ITU - on CareVue® (Rationale 16, Rationale 24).
    • Prior to injecting the 0.9 per cent sodium chloride, the nurse must perform a hand wash and put on non-sterile gloves (Rationale 4). 
    • The ampoule of 0.9 per cent sodium chloride can be drawn up into a syringe and utilised for instillation over a 2 hour period providing the syringe is labelled with the date and time of preparation and a white bung applied between instillations. This must be changed at least two-hourly and can only be instilled by the nurse who drew it up and labelled the syringe (Rationale 16, Rationale 4).
    • The pressure of the suction pump should be monitored hourly and documented on the Replogle tube flush chart (Rationale 25).
If the Replogle tube is not draining:
  • Check that suction pump is turned on and working.
  • Instil an extra 0.5 mls of 0.9 per cent sodium chloride for injection into the narrow lumen of the tube and observe what happens. Normally the sodium chloride should be observed moving down the narrow lumen of the tube during the installation (Rationale 26)
  • If the Replogle tube is still not draining:
  • Check that the tube is positioned near the bottom of the oesophageal pouch, by pushing gently on it until resistance of the pouch is felt, then pulling back slightly (Rationale 27).
  • Move the tube gently in the nostril.
  • Briefly increase the pressure of the suction to a maximum of 7-10 pa, 50-60 mmHg, 70-84 cms of water (Rationale 28).
If none of the above are successful, remove the tube and pass a new tube.
 
If at any point the child becomes respiratory compromised, do not trouble shoot using above steps and report to the nurse in charge and medical team in line with the EWS escalation policy. 
Change the suction tubing and liner (or suction bottle) every 24 hours (Rationale 4).
 
Changes in colour and/or consistency of secretions should be noted in the baby's health care record (Rationale 29).
 
If secretions are no longer clear a sample should be obtained and sent to microbiology (Rationale 30).
To obtain the pouch secretions specimen:
  • Attach a sputum trap (obtainable from HSDU) between the Replogle tube and suction tubing (Rationale 31).
  • The larger suction catheter (provided with the trap) fits into the lumen of the Replogle tube (Rationale 32).
  • The specimen is normally obtained in a few minutes.

Skin care

The skin around the dressing should be checked at least twice a day and the condition of the skin recorded in the child’s combined mandatory risk assessment paperwork (Rationale 33, Rationale 34).
  • If excoriation is suspected, the dressing should be removed and the choice of the dressing and Replogle tube site reviewed (Rationale 35)
Provide appropriate stimulation/play therapy for the baby (Rationale 36):
  • The baby may be handled and moved out of the bed.
  • The baby may be allowed to suck a dummy (Rationale 37).
Ensure that the family are well supported and given regular updates of progress (Rationale 38, Rationale 39).

Rationale

Rationale 1: To increase understanding so facilitating shared care and family co-operation.
Rationale 2: To ensure that all equipment is working correctly and ready for immediate use.
Rationale 3: To facilitate secretions.
Rationale 4: To minimise the risk of infection and comply with standard precautions.
Rationale 5: To secure tube.
Rationale 6: To detect apnoeic attacks.
Rationale 7: To clear secretions from the nostrils and naso-pharynx.
Rationale 8: To ensure that the baby is admitted without delay.
Rationale 9: To ensure the safety of the baby.
Rationale 10: It is easier to secure.
Rationale 11: It is more comfortable for the baby.
Rationale 12: To minimise the risk of cross infection and comply with standard precautions.
Rationale 13: To reduce the risk of trauma and adherence to the oesophageal wall.
Rationale 14: To secure the Replogle tube and protect the baby's skin.
Rationale 15: To meet hospital Waste Management Policy.
Rationale 16: To provide an accurate record.
Rationale 17: The tube function diminishes when there are excessive and/or thick secretions in the lumen.
Rationale 18: To reduce the risk of damage to the nostrils.
Rationale 19: To prevent aspiration of secretions.
Rationale 20: To facilitate emergency treatment.
Rationale 21: Delay could allow secretions to overspill into the trachea causing complications and deterioration.
Rationale 22: To try to prevent aspiration of gastric contents via the lower pouch fistula (when present).
Rationale 23: To prevent tube blockage and subsequent aspiration of gastric secretions into the trachea.
Rationale 24: The flush is ‘suctioned’ out so it is not part of the child’s fluid balance.
Rationale 25: An increase in pressure could indicate that the Replogle tube is blocked or adherent to the oesophageal wall
Rationale 26: To ensure that the Replogle tube is functioning.
Rationale 27: To ensure correct placement of the Replogle tube.
Rationale 28: The tube can get attached to the oesophageal wall and the suction is no longer effective.
Rationale 29: Pouch secretions quickly become colonised with organisms (Leung et al 1986).
Rationale 30: To detect and initiate early treatment of infection.
Rationale 31: To facilitate the collection of the pouch secretions.
Rationale 32: It will give an effective seal to enable the specimen to be obtained with ease.
Rationale 33: To ensure the skin is observed regularly and any trauma or skin breakdown is detected early and appropriate measures take to minimise this.
Rationale 34: To provide an accurate record of the skin condition.
Rationale 35: To reassess the skin care, and provide an appropriate alternative.
Rationale 36: To encourage normal development.
Rationale 37: To encourage non nutritive sucking.
Rationale 38: To prevent misunderstandings.
Rationale 39: To promote parental involvement.

References

Hollwarth M.E, Zaupa P. (2006) Oesophageal Atresia in : Puri P, Hollwarth M.E. (eds) Pediatric Surgery. Springer Surgery Atlas Series. Heidelberg, Springer.

Hutson J.M, O Brian M, Woddward A.A, Beasley S.W. eds (2008) Jones’ Clinical Paediatric Surgery:Diagnosis and Management 6th edition. Oxford, Blackwell.

Johnson RVP (2005) Oesophageal Atresia. Surgery 1(5): 163-167.

Leung TSM, Bayston R, Sptiz L (1986) Bacterial colonization of the upper pouches in neonates with oesophageal atresia. Z Kinder-chirurgie 41: 78-80.

Replogle R (1963) Esophageal Atresia: plastic sump catheter for drainage of the proximal pouch. Surgery 54: 296-297.

Document control information

Lead Author(s)

Julie-Ann Milbery-Complex care clinical nurse specialist

Additional Author(s)

Mary Louise Sears - complex gastro clinical nurse specialist
Clare Rees, Surgical SNAPS consultant

Approved by

Guideline Approval Group

Reviewing and Versioning

First introduced: 
28 May 1999
Date approved: 
17 November 2017
Review schedule: 
Three years
Next review: 
17 November 2020
Document version: 
4.0
Previous version: 
3.0