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Stoma care, aspiration prevention, and swimming after laryngectomy

A stoma is an opening that connects a portion of the body cavity to the outside environment. A stoma is created after a laryngectomy to generate a new opening for the trachea in the neck, thus connecting the lungs to the outside. Caring for the stoma to insure its patency and health is crucial.

General care 

If the stoma is not cleaned regularly, thick mucus may accumulate and eventually block the airway.  While stoma cleaning is frequent immediately after surgery, over time stoma care becomes easier. The risk of contamination and infection should be minimized by using only clean hands and instruments. 

It is very important  to cover the stoma at all times in order to prevent foreign material (i.e., dirt, dust, smoke, bugs)  from getting into the trachea and lungs. There are various kinds of stoma covers. The most effective ones are called Heat/Moisture Exchangers (HME) because they create a tight seal around the stoma. In addition to filtering dirt, HMEs preserve some of the moisture and heat inside the respiratory tract and prevent the person from losing them. The HME therefore assists in restoring the temperature, moisture and cleanliness of the inhaled air to the condition before the laryngectomy.

The stoma often shrinks during the first weeks or months after it is created. To prevent it from closing completely, a tracheostomy or laryngectomy tube is initially left in the stoma 24 hours a day. Over time this duration is gradually reduced. It is often left overnight until there is no more shrinking. A laryngectomy tube is a soft, silicone tube that fits into the stoma. Those with inadequate stoma (too small, too large or deformed) may benefit from surgical repair (stomaplasty).

Stoma care when using a base plate or adhesive housing: The skin around the stoma can become irritated (i.e., red, inflamed) because of repeated gluing and removal of the housing. The materials used to remove the old housing and prepare for the new one can irritate the skin. The removal of the old housing can also irritate the skin especially when it is glued.

An adhesive removal wipe containing liquid (e.g., Remove TM, Smith & Nephew, Inc. Largo Fl 33773) can assist in removing the base plate or housing. It is placed at the edge of the housing and helps the housing detach from the skin when it is lifted off. Wiping the area with Remove TM cleans the site from remnants of seal used to glue the housing. It is important to wipe off the leftover Remove TM with an alcohol wipe so that it will not irritate the skin. When a new housing is use, wiping off the Remove TM prevents it from interfering with placing glue again. 

It is generally not recommended to leave the housing on for more than 48 hours. Some individuals, however, keep the housing much longer, and replace it when it becomes loose or dirty. In some people the removal of the adhesive is more irritating than the adhesives. In the event the skin is irritated, it is better to leave the housing on only for 24 hours. If the skin is irritated, it may be advisable to give the skin a rest for a day or until the area heals and cover the stoma only with a rigid base without any glue or with a foam cover. There are special hydrocolloid adhesives that allow use on sensitive skin.

It is important to use liquid film-forming skin protecting dressing (i.e., Skin PrepTM Smith & Nephew, Inc. Largo Fl 33773) before placing the glue. 

Stoma care when using tracheostomy tube: The buildup of mucus and the rubbing of the tracheostomy tube can irritate the skin around the stoma. The skin around the stoma should be cleaned at least twice a day to prevent odor, irritation and infection. Using a hydrocolloid adhesive is often a good solution for patients with sensitive skin. 

If the area appears red, tender or smells bad, stoma cleaning should be performed more frequently. Contacting one's physician is advisable if a rash, unusual odor, and/or yellowish-green drainage appear around the stoma. This may represent a bacterial infection.

Do and don't in stoma care:

  • Keep the stoma clean:  Keep the inside of the stoma clean, moist, and glistening. Saline "bullets" can help keeping it moist.
  • Use a clean face cloth to clean the stoma. 
  • Avoid using cotton balls or paper tissues to clean the stoma: These may get sucked into your breathing tube or trachea and cause breathing problems.
  • Keep the tracheostomy tube clean; If you wear a tube follow your physicians and nurses direction for its care. 
  • Cover stoma at all times: Use a heat and moisture exchanger (HME), gauze, cotton, or crocheted covers.
  • Do not use cotton or cotton-filled gauze to clean: The fibers may get sucked into your trachea.
  • Exercise with moderation: Exercise without too much strain. The stoma cover may need to be temporarily removed during vigorous exercise.   
  • Dress comfortably: Allow for circulation of air, coughing and protection of clothing from coughing and secretions. 
  • Cover stoma when coughing or sneezing: Remove stoma cover when coughing and use thick paper tissues or handkerchiefs to pick up any coughed mucus.
  • Wear identification: Carry medical identification. It is available from the American Cancer Society, Medic Alert and or your physician. 
  • Have regular medical examinations: Have regular examinations with your primary and ear nose and throat physicians. 
  • Do not allow water to enter your stoma: Do not swim unless you use a Larchel snorkel, which helps protect your airway. Use care in bathing, shaving. Use a shower shield or a moist towel to cover your stoma.
  • Do not inhale smoke, dirt, dust or irritating fumes: Avoid inhaling smoke, dust or irritating fumes and use stoma covers to protect you from inhaling insects or objects. 


Cleaning the stoma and tubes

These are the general guidelines for keeping the airway stoma clean: 

  • The area around the stoma and inside the wall of the trachea should be regularly checked for accumulated mucus and crusts in the morning, before going to sleep, and a throughout the day. A good source of light (i.e., flashlight) and a mirror to view the stoma are essential.
  •       Saline can be used around the stoma to help loosen crusts that may accumulate.  If accumulated crusts are difficult to clear, a mixture of equal parts water and hydrogen peroxide can be used to loosen them up for easy removal.  Tweezers can be used to clean crusts once they are softened.  
  • Water based lubricants can be used if the stoma is dry, however petroleum-based products such as Vaseline should never be used around the airway.
  • Gently wash the skin around the opening with a clean face cloth and mild soap and water and wipe it dry. Keeping the stoma and the skin around it clean and free from secretions, can prevent skin irritation.
  • It is important to humidify the inhaled air. This prevent stoma crusting, eases breathing, and reduces coughing. Wearing a stoma cover (i.e., HME) helps keep your stoma clean, dust free, and retains moisture.
  • If there is mucus in the stoma it can be coughed or suctioned (using suction machine) out. Using saline bullets, saline spray, inhaling water steam (i.e., humidifier), can help in expelling the mucus by making it less viscous.
  • Mucus production may excessive during respiratory tract infection. Greater humidification using humidifiers and "slaine bullets" can loosen the secretions. Removal of dry cust can help keep the stoma patent.
  • The inside of the stoma and the voice prosthesis (TEP) can be cleaned using cotton-tipped swabs, towel, and blunt tweezers. This should be done using good lighting and a mirror. Caution is needed to prevent aspiration of the swabs or injuring the trachea in the cleaning process.

In addition to cleaning the stoma and the skin surrounding the stoma, patients also need to regularly clean the laryngectomy tube/button to prevent clogging from secretions. If the laryngectomy tube becomes clogged with secretions, it may restrict air passage to the point where the patient is unable to breathe.  In general, the tube will need to be cleaned at least twice daily immediately after surgery and less frequently over time.  The laryngectomy tube is typically cleaned with soft brushes, saline, and hydrogen peroxide.

                                                          Cotton-tipped swabs

                                                              Blunt tweezers                                

Skin irritation around the stoma

If the skin around the stoma becomes irritated and red, it is best to leave it uncovered (after cleaning it gently with  non-allergenic soap and water) by a base plate and HME and not expose it to any solvents for a while (an hour to 2 days) so that it can heal. Sometimes individuals can develop an irritation to some of the solvents used to prepare and glue an HME base plate (housing). Avoiding these solvents and finding others that do not cause irritation is helpful.

Some individuals with sensitive skin that may prone to skin irritation may benefit from a skin friendly base plate such as OptiDerm™  (Atos Medical) which is made of a hydrocolloid material.

If signs of infection such as open ulcers and redness are evident, topical antibiotics can be useful, Seeking advice from one’s physician is helpful especially if the lesion does not heal. The physician can obtain a bacterial culture of the affected area that can guide the choice of antimicrobial therapy.


Protecting the stoma from water when showering

It is important to prevent water from entering the stoma when taking a shower. A small amount of water in the trachea generally does not cause any harm and can be rapidly coughed out. However, inhalation of a large amount of water can be dangerous.

Methods to prevent water from entering the stoma are:
  • Covering the stoma with the palm and not inhaling air when water is directed at the vicinity of the stoma.
  • Wearing a bib with the plastic side out.

  • Using a commercial device that covers the stoma.

                                                     Provox (Atos Medical) ShowerAid

                                                 InHealth Stoma Shower Devices

  • Wearing one's stoma cover, the base plate or HME housing while showering may be sufficient especially if water flow is directed away from the stoma. Pausing air inhalation for a few seconds while washing the area close to the stoma is also helpful. Taking a shower at the end of the day just before removing the HME and its housing is a way to use the housing for water protection. This simple method can make taking a shower easier.

  • Some individuals can learn to take a shower without protecting their stoma using the lowest water stream. This can be done by either facing the shower head, or bending their chin to cover the stoma. Alternatively one can turn their back to the shower head and tilt their head backward allowing the water to reach the hair from behind. 

Water inhalation and aspiration pneumonia
Aspiration pneumonia is rare in laryngectomees because they can not aspirate saliva from their mouth as their lungs are not connected to the mouth. However, aspiration pneumonia can develop when bacteria get into the lungs from the stoma's area and can not be expelled out by coughing. This can occur when the mucus is not adequately coughed out usually because it is too dry. Maintaining mucus with clear consistency is imperative  (See Mucus and respiratory care section).

It is also very important  to cover the stoma at all times in order to prevent bacteria and viruses from getting into the trachea and lungs. Cleaning one's hands before touching the stoma or HME can reduce the risk of introducing bacteria and viruses to the lungs.

Laryngectomees are at risk of inhaling (aspirating) water that may not be free of bacteria.
Taking a bath is not recommended for laryngectomees because of the risk of water aspiration.  Those who take a bath should keep the water level up to their hips when seated.

Tap water contains bacteria; the number of bacteria varies, depending on the cleaning efficacy of the water treatment facilities and their source (e.g., well, lake, river etc.). Pool water contains chloride that reduces, but never sterilize the water. Sea water contains numerous bacteria; their nature and concentrations varies.

When unclean water or non-sterile saline gets into the lungs it can sometimes cause pneumonia. Developing aspiration pneumonia depends on how much water is inhaled and how much is coughed out, as well as on the individuals' immune system. 

Radiography of aspiration pneumonia

Swimming as a laryngectomee

Swimming or getting into water can be very dangerous for laryngectomees. Once the stoma is under water, water can get into the trachea and the lungs leading to drowning. This can also cause aspiration pneumonia. It may be safe to wade in shallow and calm water as long as the water level is kept at a safe distance below the stoma to enable breathing and avoid aspiration.

Some laryngectomees take short swims or get under the water for a few seconds after occluding their stoma with a finger. Some wear a baseplate and seal it with an improvised locked HME.

There may be emergency situations where a laryngectomee is forced to get into the water. In such situation it is advisable to:
  • Keep the stoma above water level
  • Avoid breathing (for a short time) when the water gets into the stoma
  • Wear a life vest that keeps the stoma above water level
  • Use a floating device that lifts the body as much as possible

It is advisable that laryngectomees avoid situations that may put them at risk of getting into water such as rafting, canoeing.

When planning a boat ride or cruise it would be wise to:
  • Have a life vest available  and floating tube (with automatic, non-manual inflation)
  • Wear your life vest when needed
  • Be aware of the evacuation routes and locations of floating devices and lifeboats
  • Practice evacuation procedures
  • Inform others and the cruise staff of your special needs 

Some life vests and floating devices require manual air inflation. Since laryngectomees are unable to do that, they may choose to carry a small air pump to inflate the devices.
Some special devices have been created to allow neck breathers to swim. The Larchel snorkel is a rubber device - a breathing tube inside an inflatable cuff is inserted into the stoma and then inflated with an air syringe, forming a seal. It is available in Europe and requires a physician’s prescription and training.

Some laryngectomees create their own devices that enable them to get into the water and swim (see picture below). The device below was created using an InHealth Shower Stoma device connected to a tube and was inserted into a glued base plate that covered the stoma .

The risks involved in swimming and diving are high. Neck breathers should consult their physicians and speech and language pathologist before attempting to swim. 

Floating tube

Preventing aspiration of tissue, paper or other objects into the stoma

One of the major causes of respiratory emergency in a neck breather is the aspiration of tissue or paper towels into their trachea. Other objects that can also be aspirated are cotton swabs and pieces of cloth. This can be very dangerous and cause asphyxiation. It usually happens after covering the stoma with a paper towel when coughing out sputum or when cleaning the stoma. Following the cough there is a very deep inspiration of air that can suck the paper back into the lungs. The way to prevent this is to use a cloth towel or a strong paper towel that does not break easily, even when moist. Thin tissues should be avoided.

Another way to prevent aspiration of paper tissues is to hold one's breath until one has completely finished wiping off the sputum and removed the paper tissue or paper towel from the stoma area.

Aspiration of other foreign material should also be prevented by covering the stoma at all times by an HME, foam cover, or stoma cover.

Aspiration of water into the stoma while taking a shower can be prevented by wearing a device that covers the stoma (see above). One can keep the HME on while showering and/or avoid breathing in when water is directed at the stoma’s site.

Taking a bath in a tub can be done safely as long as the water level does not reach the stoma. The areas above the stoma should be washed with a soapy washcloth. It is important to prevent soapy water from entering the stoma.

Covering ( hiding) the Stoma and HME

Following laryngectomy, individuals breathe through a tracheostomy site that opens through a stoma on their neck. Most place an HME or a foam filter over the stoma to filter the inhaled air and maintain warmth and humidity in the upper airway. The covered stoma site is prominent, and laryngectomees face a choice whether to cover the HME or filter with a garment, an ascot, or jewelry or to leave it uncovered.

The pros and cons of each choice are:

Breathing may be easier without an additional cover which can interfere with air flow. Leaving the area exposed allows for easier access to the stoma for purpose of cleaning and maintenance and enables a rapid removal of the HME in case one needs to cough or sneeze. The urge to cough or sneeze is often very sudden and if the HME is not taken out quickly it can become clogged with mucus.

Exposing the site provides an unspoken explanation for the weak and rusty voice of many laryngectomees and encourages others to listen to them more attentively. It also makes it easier for health care providers to recognize the laryngectomee's unique anatomy in case emergency respiratory ventilation is needed. If this condition is not rapidly recognized ventilation may be administered through the mouth or nose rather than through the stoma.

Openly displaying the covered stoma site also reveals the person’s medical history and the fact that he/she are cancer survivors who go on with their lives despite their handicap, cancer being the leading indication for a laryngectomy. Although there are many cancer survivors in the community, their identity is hidden from outward appearances.

Those who cover their stoma site with a stoma cover or cloth often do it because they do not want others to be distracted or offended by the site. They also do not want to expose anything that is disfiguring and want to be inconspicuous and appear as normal as possible. Covering the site is often more common among females who may be more concerned with their physical appearance. Some individuals feel that being a laryngectomee is only a small part of who they are as a person; and they do not want to “advertise” it.

There are advantages and repercussions to each approach and the final selection is up to the individual.

Stoma cover