"My Voice"

Order a paperback or Kindle Edition or e-book of "My Voice: A Physician's Personal Experience with Throat Cancer," the complete 282 page story of Dr. Brook's diagnosis, treatment, and recovery from throat cancer.

Order a paperback or Kindle Edition or e-book of "The Laryngectomee Guide," the 170 page practical guide for laryngectomees. To obtain a free paperback copy fill this form and mail it to J. Harrison 11390 W. Theo W. Allis, WI 53214, or fax it to 414 227 9033. The Guide can also be requested by emailing to customersupport.us@atosmedical.com

Obtain and/or view a video presentation, a slide presentation and an instructive manual how to ventilate laryngectomees and neck breathers (free). A self examination guide for detection of primary and recurrent head and neck cancer is available.

Mucus and respiratory care, humidifier, suction machine, blowing the nose and coping with cold or warm weather after laryngectomy

Mucus production is the body’s way of protecting and maintaining the health of the trachea (windpipe) and lungs. It serves to lubricate these airways and keep them moist. After a laryngectomy, the trachea opens at the stoma and laryngectomees are no longer able to cough up mucus into their mouth and then swallow it, or blowing their nose. It is still very important to cough and clear one's mucus; however, this must be done through the stoma.

Coughing up mucus through the stoma is the only means by which laryngectomees can keep their trachea and lungs clear of dust, dirt, micro - organisms (bacteria, viruses and fungi), and other contaminants that get into the airway. It is therefore important to protect the airways from inhalation of these by covering the stoma preferably by a stoma cover or Heat and Moisture Exchanger (HME) filter. Whenever an urge to cough or sneeze emerges laryngectomees must quickly remove their stoma cover or HME and use a tissue or handkerchief to cover their stoma to catch the mucus.

The best mucus consistency is clear, or almost clear, and watery. Such consistency, however, is not easy to maintain because of changes in the environment and weather. Steps can be routinely taken to maintain a healthy mucus production as shown below.

A lecture about life challenges after laryngectomy including stoma care can be viewed on YouTube.








Humidity and humidifiers

Humidity is the amount of water in the air. The amount of humidity can vary depending on the season of the year, weather and the location. Usually, humidity levels are elevated in the summer months and lower during winter. The ideal, home humidity for neck breathers should be between 40 - 50 %. Humidity that's too low or too high can cause medical problems.
·        Low humidity can cause dry skin, irritate ones nasal passages and throat, and make one’s eyes itchy.
·        High humidity can make the home feel stuffy and can cause condensation of water on walls, floors and other surfaces that enhances the growth of molds, bacteria, and dust mites. These allergens can cause respiratory problems and trigger allergy and asthma flare-ups.
The best way to test humidity levels in one's house is by using a hygrometer. The hygrometer appears like a thermometer, and measures the amount of moisture in the air. It is available at hardware and department stores. When purchasing a humidifier, it is wise to get one with a built-in hygrometer (humidistat) that can maintain humidity within the healthy range.
Humidifiers emit water vapor or steam that increase moisture levels in the air (humidity). 

There are several types of humidifiers:
  •       Central humidifiers are constructed within the home as part of the heating and air conditioning    systems and are built to humidify the entire house.
  •       Ultrasonic humidifiers generate a cool mist through ultrasonic vibration.
  •       Impeller humidifiers create a cool mist by a rotating disk.
  •       Evaporators use a fan that blows air through a wet wick, filter or belt.
  • ·     Steam vaporizers use electricity to generate steam that cools down before exciting the machine. These kind of humidifier should be avoided around children because of potential burn injury. 
  •       Nebulizer bottle is used  to turn saline  into smaller particles to be delivered to the stoma or breathing tube.

Keeping the humidifier clean
Humidifiers generally come with guidelines by the manufacturer how to keep them clean. Unplugging the humidifier before changing water or cleaning it is mandatory!
Enclosed are tips how to keep portable humidifiers free of harmful mold, fungi and bacteria.
·   
      Using only distilled or demineralized water. Tap water contains minerals that can generate deposits inside the humidifier that enhance bacterial growth. When these minerals are released into the air, they can be inhaled into the trachea and lungs and frequently appear as white dust on the furniture. Distilled or demineralized water contain a much lower amount of mineral as compared with tap water. Many manufacturers recommend the use of demineralization cartridges or filters.
·    
      Changing humidifier water frequently. Film or deposits develop inside humidifiers if their water is not changed on a regular basis. Empting the tanks, drying the inside surfaces and refilling the humidifier with clean water on a daily basis is recommended, especially when using cool mist or ultrasonic humidifiers.
·     
      Cleaning humidifiers every 3 days. Mineral deposits or film in the tank or other parts of the humidifier should be removed preferably by using a 3 % hydrogen peroxide solution. Chlorine bleach or other disinfectants are recommended by some manufacturers. The tank should be rinsed after cleaning to remove harmful chemicals that can become airborne and inhaled.
·     
      Changing humidifier filters on a regular basis. Filters in humidifiers, and in the central air conditioning and heating system, should be changed according to the manufacturer recommends - or whenever they become dirty.
·     
      Keeping the area around humidifiers dry. The humidifier should be turned down whenever the area or objects around them become damp or wet.
·    
      Proper preparation of humidifiers for storage. The humidifier should be drained and cleaned prior to storage and whenever they are taken out of storage for use. All used cartridges, cassettes or filters should be discarded.
·     
      Following instructions for central humidifiers. Humidifier built into the central heating and cooling system should be maintained according to their manufacturer’s instruction manual.
·     
      Replacing old humidifiers. With the passage of time, humidifiers can build up deposits that are difficult or impossible to remove and promote the growth of bacteria and fungi. It is best to replace them.


                                                                           
                                                                     Humidifier






Nebulizing bottle





Features of Warm and Cool Mist Humidifiers

Humidifiers help maintain a healthy humidity level in low moisture locations. Humidifiers can add moisture using either warm or cool mist technologies. Both types have their strengths and weaknessesBoth types help avoid the unwanted side effects of dry air in laryngectomees.

Cool Mist Humidifiers

Cool mist humidifiers disperse a comfortable stream of room-temperature mist throughout the environment. They are available in evaporative or ultrasonic technologies. Cool mist evaporative humidifiers use an internal wick filter to absorb water while a fan blows the air through the filter. This process causes the water to evaporate throughout the room as an ultra-fine, invisible mist. Cool mist ultrasonic humidifiers use ultrasonic vibration technology to create a micro-fine cool mist that is quietly released throughout the environment.

Because the water is not heated before it is dispersed, these humidifiers generally use less electricity.

One drawback to cool mist evaporative humidifiers, however, is noise. Since these devices use fans to blanket the room with moisture, they can be  noisier than other humidifier types. Additionally, the cool mist can cause the air to feel slightly chillier than usual.


Warm Mist Humidifiers

Warm mist humidifiers use an internal heating element that boils water before releasing it into the environment as a soothing invisible mist. They are often considered healthier since the boiling process kills waterborne bacteria and mold, which prevents them from entering the inhaled air. The absence of an internal fan makes them very quiet to operate. Warm mist humidifiers are also available in ultrasonic models.

Warm mist humidifiers work best in smaller areas and are not as well-suited for large areas as cool mist ones. Warm mist humidifiers are slightly more expensive to operate and a little more difficult to clean since mineral deposits are often left behind during the boiling process. However, many people have found them to be more comfortable for use during cold winter months.


Warm and cool capable Mist Humidifiers

Some humidifiers feature both warm and cool mist capabilities, allowing one to choose the preferred humidification method. During the winter months one may choose to run the humidifier on its warm mist setting and then change to the cool mist setting during the warmer summer months.








Mucus production and increasing air humidity


Prior to becoming a laryngectomee, the inhaled air is warmed to body temperature, humidified and cleansed of organisms and dust particles by the filtration capacity of the upper part of the respiratory system. Since these functions do not occur following laryngectomy, it is important to restore the lost functions previously provided by upper part of the respiratory system.

Followed laryngectomy the inhaled air does not get humidified and filtered by passing through the nose and mouth; accordingly, tracheal dryness, irritation and overproduction of mucus develops.  Fortunately, the trachea becomes more tolerant to dry air over time. However, when the humidity level is too low the trachea can dry out, crack, and produce some bleeding. If the bleeding is significant or does not respond to an increase in humidity, a physician should be consulted. And if the amount or color of the mucus is concerning, one should contact a physician.

Tracheal dryness, irritation and overproduction of mucus can lead to the development of mucus plugs. These plugs can cause airway obstruction that can lead to collapse of sections (atelectasis) of the lungs.

Restoring the humidification of the inhaled air reduces the overproduction of mucus to an adequate level and reduce the risk of mucus plugs. This will decrease the chances for coughing unexpectedly and plugging the HME filter. Those without an HME need to cover their stoma with a paper towel or even their hand to collect the coughed mucus. Increasing the home humidity to  40-50% relative humidity (not higher) can help in decreasing mucus production and keeping the stoma and trachea from drying out, cracking and bleeding. In addition to being painful, these cracks can also become pathways for infections.

Saline bullets are commonly used to provide quick moisture to the lower airways. These plastic bullets contain 3-10 cc sterile saline and after their tip is broken their contents is squeezed through the stoma into the trachea. The insertion of saline induces immediate coughing that facilitates the clearing of secretion. The contents of the bullets is introduced by several insertions. It is generally useful to use saline bullets as needed several times a day or as directed by one's physician.


Steps to achieve better humidification and healthier mucus production include:

·       Wearing an HME 24/7 which keeps the tracheal moisture higher and preserves the heat inside the lungs
·       Wetting the soma cover (bib) to breathe moist air (in those who wear a stoma cover). Although less effective than an HME, dampening the foam filter or stoma cover with clean plain water can also assist in increasing humidification.
·       Drinking enough fluid to keep well hydrated
·       Inserting 3-5 cc (preferably using saline "Bullets") saline into the stoma at least twice a day (see below how to prepare saline)
·       Using a humidifier in the house to achieve about 40-50% humidity and getting a hygrometer to monitor the humidity. This is important both in the summer when air conditioning is used, and in the winter when heating is used
·    Using nebulizing bottle twice daily
·       Breathing steam generated by boiling water or a hot shower 

      
A digital humidity gauge (called a hygrometer) can assist in controlling the humidity levels. Over time, as the airway adjusts, the need to always use a humidifier may decrease.






Saline "Bullets"





Preparing saline solution


Saline solution is a salt solution, which can be prepared using readily available materials.  This recipe is for a salt solution that is normal (0.9%), which means it is the same concentration or isotonic to body fluids. Because the salt composition is similar to that of the body, it causes less tissue damage than pure water. Saline solution consists of sodium chloride (table salt) in water. When using the solution to clean a wound or for squirting it into the trachea, it's important to use pure ingredients and maintain sterile conditions.

It is important to use uniodized salt, which does not have iodine added to it. Avoid using rock salt or sea salt, since they have added chemicals. Use distilled water or reverse osmosis purified water over ordinary tap water.

To prepare the saline one need to mix 1 teaspoon of salt per 2 cups (500 ml fluid ) of water.
To obtain a sterile solution, dissolve the salt in boiling water. Keep the solution sterile by placing a lid over the container so that no microorganisms get into the liquid or air space as the solution cools.
You can dispense the sterile solution into sterile containers. Sterilize containers either by boiling them. It's a good idea to label the container with the date and to discard it if the solution is not used within a few days. It's important to avoid contaminating the liquid, so ideally make just as much solution as you need at a time, allow it to cool, and discard leftover liquid. The sterile solution will remain suitable for use for several days in its sealed container, but you should expect some degree of contamination once it is opened.
The saline can be squirted into the stoma using a sterile squirting bulb.




Caring for the airway and neck in cold weather and a high altitude

Winter and high altitude can be rough for laryngectomees. The air at high altitude is thinner and colder and therefore dryer. Before a laryngectomy air is inhaled through the nose where it becomes warm and moist before entering the lungs. After a laryngectomy the air is no longer inhaled through the nose and enters the trachea directly through the stoma.  Cold air is dryer than warm air and more irritating to the trachea. This is because cold air contains less humidity and  therefore can dry the trachea and cause bleeding.The mucus can also become dry and plug the trachea.


Breathing cold air can also have an irritating effect on the airway causing the smooth muscle that surrounds the airway to contract (bronchospasm). This decreases the size of the airway and makes it hard to get the air in and out of the lungs, thus increasing shortness of breath.


Caring for the airway the steps described in the previous section as well as:

  • Coughing out or suctioning the mucus using a suction machine to clean the airway
  • Avoiding exposure to cold, dry or dusty air
  • Avoiding dust, irritants and allergens
  • When exposed to cold air, consider covering the stoma with a jacket (by zipping it all the way) or a loose scarf or bandana and breathing into the space between the jacket and the body to warm the inhaled air. Another option is to wear a thin T-shirt over the face (see picture below), that cover the nose, mouth, and stoma; like a mask. This will keep the face warm and create a space for the exhaled and inhaled air to warm up and stay humid. It also allows for air filtration and oxygen and bicarbonate exchange with the environment.
  • Preventing water from getting into the stoma when showering (see picture below)
Following a laryngectomy which involves neck dissection most individuals develop areas of numbness of area in their neck, chin and behind the ears. Consequently they cannot sense cold air and can develop frostbite at these.  It is therefore important to cover these areas with a scarf or warm garment.



                            
Warming the air by covering the stoma with a T-shirt 




Warming the inhaled air by covering the stoma with a jacket 






                                 Warming the air by covering the stoma with a bandana






Laryngectomees and hot weather

Hot weather is generally easier on a laryngectomee because of the increased air humidity. However, similar to non-laryngectomees it is important to take precautions and stay well hydrated (preferably by drinking cold drinks), avoid direct sun exposure, wear light lose cloth and cover the head, and stay indoors if the quality of air is poor.

Those at greatest risk of heat-related illnesses are people aged 65 years and older. Exposure to extreme heat has particularly adverse effects on people with chronic illnesses such as respiratory or renal diseases, cardiovascular, diabetes and obesity, and those with mental illness. Medications including blood pressure and heart medicine (beta-blockers), water pills (diuretics), antidepressants, antipsychotics and anti-convulsants (seizure medication) and antihistamines (allergy medications) may also affect how the body reacts to heat.


Laryngectomees should keep in touch with friends and family, as they may be their lifeline in case they need assistance. Wearing a heat and moisture exchanger (HME) reduces water loss through the lungs that can contribute to dehydration.








Using suction machine to clear secretions and mucus plugs

A suction machine is often used by new laryngectomee in the hospital and in the immediate period after they are discharged from hospital. During this period forceful coughing is difficult and suctioning is used to clear the mucus. However, it is important to learn to cough out mucus and clear one's secretions without a suction machine.  A deep and strong cough is more effective than a suction machine in removing respiratory secretions. However, there may be individuals that require the use of a suction machine for a longer period.

A suction machine can, however,  can be used to suction out mucus when one is unable to cough it out and/or to remove a mucus plug. A mucus plug can develop when the mucus become thick and sticky creating a plug that blocks part or, infrequently, even the whole airway.

The plug can cause a sudden and unexplained shortness of breath. A suction machine can be used in these circumstances to remove the plug.  It should therefore be readily available to treat such an emergency. Mucus plugs may also be removed by using a saline “bullet” (0.9% sterile salt water in a plastic tube) or by squirting saline solution into the stoma. The saline can loosen the plug that can be coughed out. This condition may become a medical emergency, and if the plug is not successfully removed after several attempts dialing 911 may be lifesaving.






Suction machine



Coughing blood

Blood in the mucus can originate from several sources. The most common is from a scratch just inside the stoma. The scratch can be caused by trauma while cleaning the stoma. The blood generally appears bright red. Another common cause of coughing blood in a laryngectomee is irritation of the trachea because of dryness which is common during the winter.

It is advisable to maintain a home environment with adequate humidity levels (about 40-50%) to also help minimize drying the trachea. Wearing a heat and moisture exchanger (HME) 24/7 ( See HME filter care section) and inserting sterile saline into the stoma can help. (See above in the Mucus production section)

Irradiation therapy after laryngectomy can cause local inflammation and bloodstained mucus.

Bloody sputum can also be a symptom of pneumonia, tuberculosis, lung cancer, or other lung problem.

Persistent coughing of blood should be evaluated by medical professionals. This may be urgent if it is associated with difficulties in breathing and/or pain.







Caring for a runny nose and blowing the nose

Because laryngectomees and other neck breathers no longer breathe through their nose their nasal secretions are not being dried by moving air. Consequently the secretions drip out of the nose whenever large quantities of them are produced. This is especially common when one is exposed to cold and humid air or irritating smells. Avoiding these conditions can prevent a runny nose.

Wiping the secretion is the best practical solution. Laryngectomees using a voice prosthesis may be able to blow their nose by occluding the tracheostoma and divert air through the nose.


There are several methods by which blowing the nose is possible for laryngectomees. Because the nose remains connected to the mouth swallow saliva produces sufficient suction to pull down mucus from the nose which are subsequently swallowed.

An alternative method is to sniff and blow the nose by using the air pressure generated by moving the tongue backward and forward while it touches the top of the mouth while the lips stay closed. Blowing the nose, is done one nostril at a time. This requires occluding one nostril at a time by placing a finger on its side.  


Other methods include: gently cleaning each nostril the with a voice prosthesis brush by twirling it around inside the nostril; those with voice prosthesis can occlude their stoma and forcefully exhale while the mouth is closed one nostril at a time; using a suction bulb to collect the secretion.


Keeping the nose secretion thin makes it easier to blow the nose. This can be achieved by being well hydrated and breathing humidified air or placing saline drops in the nose.






Respiratory rehabilitation

After a laryngectomy the inhaled air bypasses the upper part of the respiratory system and enters the trachea and lungs directly through the stoma. Laryngectomees therefore lose the part of
the respiratory system that used to filter, warm and humidify the air they breathe.

The change in the way breathing is done also effects the efforts needed to breathe and potential lung functions. This requires adjustment and retraining. Breathing is actually easier for laryngectomees because there is less air flow resistance when the air bypasses the nose and mouth. Because it is easier to get air into the lungs, laryngectomees no longer need to inflate and deflate their lungs as completely as they did before. It is therefore not unusual for laryngectomees to develop reduced lung capacity and breathing capabilities.

There are several measures available to laryngectomees that can preserve and increase their lung capacity:
  • The use of a HME can create resistance to air exchange. This forces the individual to fully inflate their lungs to get the needed amount of oxygen.
  • Regular exercise under medical supervision and guidance. This can get the lungs to fully inflate and improve individuals' heart and breathing rates.
  • Using diaphragmatic breathing. This method of breathing allows for greater utilization of the lung capacity. 
Another problem is the sensation of shortness of breath that some laryngectomees develop when they exercise. Normally people exhale hard when exercising. However, they propel air out against the resistance of their vocal cords, which prevents collapse of the bronchial tubes. Exhalation of air in a laryngectomee is easier and quicker as they do not have cords that modify the exhalation. Because they can no longer control their exhalation the deflation of their bronchi generating a sensation of shortness of breath. Although an HME can generate some back pressure it is not adjustable in a physiological fashion.

Laryngectomees who also suffer from chronic obstructive pulmonary disease (COPD) may find that maintaining their lung capacity is more difficult as they cannot fully inflating their lungs because of lack of pressure from nose and mouth.






Protection of laryngectomees and neck breathers from nerve gas attack

The threat of exposure to lethal nerve gas exists in several places around the world. Protection of the airways of neck breathers (including laryngetomees) is very important. A gas mask is freely provided by the Israeli Government to all neck breathers (including those with tracheostomy or laryngectomees) in the country (see picture below).

Another simple device that fulfills the essential requirements for protection of such individuals was developed in Kaplan Hospital in Israel. The device consists of a swivel conector and extension flex tubes. The filter of the gas mask is connected to the distal edge of the extension flex tubes, and the filter opening is sealed. The extension flex tube can be connected to the tracheostomy tube or to a Heat and Moisture Exchanger's (HME)  base plate. Breathing is made through the gas filter which is connected to the system. A gas mask is placed on the patient for protection of his mouth, nose and eyes. An article explaining the system and a picture of it  was published in JAMA in 1991.




The gas mask for neck breathers produced in Israel. It has 2 air filters and a drinking straw.