Heat moisture exchanger (HME) filter care

An educational video providing information on pulmonary caring for post-operative patients who have undergone a total laryngectomy.

Heat and Moisture Exchanger (HME) filter serve as stoma covers and create a tight seal around the stoma. In addition to filtering dust and other larger airborne particles, HMEs preserve some of the moisture and heat inside the respiratory tract and prevent their loss, and adds resistance to the airflow. HME filters assist in restoring the temperature, moisture and cleanliness of the inhaled air to the same condition as before laryngectomy.

There are two types of HMEs – one that requires sealing by pressing on it with one’s finger, and the other where the sealing is activated automatically (Hands Free) whenever speaking is initiated (see below). 

The HME is not directly attached to the stoma; therefore an interface is required to keep the HME in place.  Patients may opt for either adhesive, around the stoma (peristomal) attachments, or inside the stoma (intraluminal) devices such as laryngectomy tubes and buttons.  Adhesive, peristomal attachments work best for patients with flat neck topography or large and irregular stomas.  Laryngectomy tubes and buttons are preferred for patients with deep-set stomas, irregular neck topography, and/or smaller, round stomas.

For patients who chose not to use HME filters, it remains important to keep the stoma covered to protect the airway from matter such as dust, pollen, insects, and other airborne particulates.  It is important, however to recognize that stoma covers ( i.e., laryngofoam ^TM  filter, ascot, bandana, etc.)  function only to filter and not to moisten or warm the air.  Stoma covers may also serve a cosmetic function to minimize visibility of the stoma.  Stoma covers range from small foam squares that stick to the neck above the stoma to “dickie” mock t-shirts.  Patients are often creative in using items like scarves and jewelry to “mask” the stoma as well.

The American Speech - Language - Hearing Association ( ASHA) published guidelines about use of voice prosthesis and HME and their care.

Below is a video describing breathing through a tracheostoma, with and without an HME.

HME advantages 

It is very important that laryngectoees wear an HME. In the United States the filters are available through Atos Medical and InHealth Technologies. The HME filter can be attached by using an intraluminal device inserted into the trachea or stoma, that includes laryngectomy or tracheostomy tubes, Barton Mayo ButtonTM and/or Lary Button^TM . The filter can also be inserted into a housing or a base plate attached to the skin around the stoma.

The foam media captures the warm, moistened, and humidified air upon exhalation. It is impregnated with chlorhexidine (anti-bacterial agent), sodium chloride (NaCl), calcium chloride salts (traps moisture), activated charcoal (absorbs volatile fumes), and is disposable after 24 hours of use. 

HME cassettes are designed to be removed and replaced on a daily basis. The foam media in the cassettes are treated with agents that have antimicrobial properties and help to retain moisture in the lungs. They should not be washed and reused because these agents lose their effectiveness over time or when rinsed by water or other cleaning agents.

The filter’s advantages also include: increasing the moisture within the lungs (subsequently leads to less mucus production), decreasing the viscosity of the airway secretions, decreasing risk of mucus plugs, and re-instating the normal airway resistance to the inhaled air which preserves the lung capacity.

In addition, the HME filters reduce the inhalation of bacteria, viruses, dust and pollen. Inhaling less pollen can reduce the airway irritation during high allergens season. Wearing HME may reduce the risk of getting viral and bacterial infection, especially in crowded or closed places. The number of tracheobronchitis, and pneumonia episodes as well as mortality in non-HME users is 3 times higher than in HME users. 

Laryngectomees with breathing problems such as chronic obstructive pulmonary disease (COPD), emphysema, asthma, etc., should consult their physicians before trying HME.

Provox Micron  TM, and Provox Life – Protect HME contain an electrostatic filter that is designed to filter potential respiratory pathogens, pollen and dust. These HMEs most closely resemble the normal nasal properties, as it does not only conditions, but also filters the inhaled air, and also filters the exhaled air. The electrostatic filter eliminates transfer of particulate material and airborne organisms from and to the laryngectomized patient (99% bacterial and viral filtration efficiency).

Provox Micron TM, Atos Medical

It is important to realize that simple stoma covers, such as a laryngofoam ^TM  filter, ascot, bandana, etc., do not provide the same benefits to a laryngectomee as a HME filter.

Voice prosthesis (below) and HMEs (above) produced by Atos (Provox) (left) and InHealth (Right)

Spare and replacement HME can be carried in a coin container. (see picture below)

Container used to carry spare HMEs

Cleaning mucous from the HME

It is normal for laryngectomee to cough and clear secretions throughout the day. With continued use of an HME, these secretions generally become more manageable. Many individuals notice that the amount of their secretions diminishes and become less thick. This does not occur overnight and several weeks may be required to notice this change.

When the HME is used right after laryngectomy there is not much adjustment needed, because up to the surgery the nose and throat were still functioning. However, when the laryngectomee starts using an HME not right away after the surgery, it takes time to adjust to it. This is because air resistance with the HME is higher than that with an open stoma breathing, and some patients may feel some discomfort. This can be avoided by starting with a lower resistance HME and switching after a few days up to a week to a regular resistance HME. 

More mucus is initially produced by laryngectomee after starting using an HME, when this is not done after the operation. This is because the airway of these individuals got used to produce more mucus and moisture which were lost during exhalation. These vapors are captured by the newly worn HME and the laryngectomee experiences retention of more mucus. This generally last a few days until the airway adjust to the effects of the HME.

When mucous is coughed, it will rest against the back of the HME cassette were plastic bars known as “mucous guards” are preventing the mucous from deeply penetrating the foam. When this happens, it may become difficult to breathe until the mucous is cleared. It is important, therefore, to wipe off the mucous from the HME cassette (using a soft cloth, a tissue, or a dedicated soft toothbrush) as often as necessary to ensure one is breathing comfortable and their secretions are well managed. When adequate cleaning is not possible the HME should be replaced.

HME Provox (Atos Medical)

The effect of an HME on breathing of a laryngectomee

Laryngectomy compromises the respiratory system by allowing the inhaled air to bypass the nose and upper airways which normally provide humidification, filtration and warmth. It also reduces the resistance and the effort needed for inhalation by removing air resistance and shortening the distance the air travels to their lung.  This means that laryngectomees do not have to work as hard to get air past the upper part of the system (nose, nasal passages, and throat), and their lungs do not have to inflate as much as they did before unless the person works to retain their capacity through exercise and other methods. An HME increases the resistance to inhaled air and therefore increases inhalation efforts, thus preserving previous lung capacity and function.

When needing extra air flow (i.e., running, biking) the HME can be temporarily removed and the stoma can be covered by cloth. There are less restrictive HMEs that offer less resistance to air passage and allow greater air flow (i.e., Atos Medical's XtraFlow HME, Provox Life - Go HME,  Atos Medical Provox FreeHands HME Flow, Blom-Singer's Day & Night EasyFlow HME ,  and Bloom - Singer Speak - Free Valve with Easy Flow HME). These type of HME can be used when exercising and when adapting to the breathing resistance after having been without an HME for a longer time.

There are HMEs that provide extra humidity that comes even closer to mimicking normal nasal function (i.e., Atos Medical Provox XtraMoist HME™ ,  Provox Life - Home HME,  Medical Provox FreeHands HME Moist).  These are recommended for patients who have recently undergone a total laryngectomy, and for accustomed users of HMEs. The HMEs that provide extra humidity can be replaced with those that provide extra airflow in adequately humidified environment

Placing an HME housing (including base plate)

The key to prolonging the use of an HME's housing is not only properly gluing it in place, but also removing the old adhesives and glue from the skin, cleaning the area around the stoma and applying new layers of adhesive and glue.

There are several types of HME housing:

• Regular

• Hydrocolloid that helps with sensitive skin

• Extra “sticky” that helps with seal breakdown

• More “rigid” baseplates that are helpful with Hands-Free speech

• More “flexible” baseplates that help with filling cracks/crevices that cause seal breakdown

In some individuals the shape of the neck around the stoma makes it difficult to fit a housing or a base plate. There are several types of housing; and a speech and language pathologist (SLP) can assist in selecting the best one. Finding the best HME housing may take trial and error. Over time, as the post-surgical swelling subsides and the area around the stoma reshapes itself, the type and size of the housing may change.

The buildup of mucus at the bottom of the base plate can weaken the adhesion of the base plate and eventually cause the base plate seal to break leading to air leak. The accumulation of mucus in the space behind the base plate can be minimized by placing the base plate (housing) as down as possible attaining the maximum distance between the stoma and bottom part of the seal. This allows the mucus a longer way to travel before getting to the bottom, which would then give more time to remove the mucus before it caused the base plate to fail. Because the anatomy of the stoma and the skin around it is unique for each person, finding the best location for placing the base plate can be guided by one's SLP or otolaryngologist.

Below are the suggested instructions on how to place the housing for the HME. Throughout the process it is important to wait patiently and allow the liquid film-forming skin protecting dressing (i.e., Skin Prep^TM  Smith & Nephew, Inc. Largo Fl 33773)” and silicone skin adhesive to dry before applying the next item or placing the housing. This takes time, but it is important to follow the instructions below.

Instruction how to place an HME housing:

1.     Clean the old glue with an adhesive removal wipe (e.g., Remove ^TM , Smith & Nephew, Inc. Largo Fl 33773).

2.     Wipe off the Remove ^TM  with an alcohol wipe. (if not wiped off Remove^TM  will interfere with the new adhesive).  

3.     Wipe the skin with a wet towel. 

4.     Wipe the skin with the wet towel with soap. Clean any debris, dry mucus, and dirt. Remove any hair.

5.     Wash away the soap with a wet towel and thoroughly dry.

6.     Apply Skin Prep^TM   and let it dry for 2-3 minutes.

7.     For extra adhesion apply Mastisol liquid adhesive ( Ferndle laboratories), Silicone Glue (Atos Medical)  or Skin-Tac ^TM  wipe (Torbot, Cranston, Rhode Island 20910) to the skin around the stoma nd let it dry for 3-5 minutes. Repeat application of the glue and let it dry for 3-5 minutes. The Silicon Glue provides extra adhesion which is  important for users of a hands free HME.

8.     Bend your head backward and use one hand to stretch the skin around the stoma to smooth it as much as possible. Use the other hand to attach the housing (adhesive) for the HME at the best location to allow air flow and good attachment. Attempt to place it at the center of the stoma to achieve maximum opening. Press the ring firmly to the skin making sure it is glued also to any deep creases or seams in the skin. Thoroughly massage the housing to the skin. Insert an HME into the base plate and press hard on it for a few seconds to enhance gluing the baseplate. 

9.     When using hands free HME wait for 25-30 minutes before speaking to allow the adhesive to “set”.

Some SLPs recommend warming the housing prior to placement by rubbing it in the hands, holding it under the armpit for a few minutes, or by blowing warm air on it with a hair drier. Be careful that the adhesive does not become too hot. Warming the adhesive is especially important when you use a hydrocolloid adhesive since the warmth activates the glue.

A video that demonstrates the placement of the housing that was made by Steve Staton is available.

Tips and tricks for an airtight seal around the HME housing:

• Try not to speak too loudly or with too much force
• Remove the HME from the adhesive when you begin to cough
• Always hold the adhesive in place with 2 fingers when removing the HME
• After you cough, carefully remove the mucus and do not allow the mucus to seep underneath the adhesive.

Placement of HME and its base plate (housing) on a stoma

Adhesive base plates produced by Provox (Atos Medical)

Mastisol Adhesive Liquid by Frendle laboratories

Provox Silicon Glue by Atos Medical

Re using Provox Xtrabase

When reusing Provox Xtrabase covered with Atos Tracheo-Foam, the following steps can help make the base plate reusable:

• These are the steps in making it reusable (see pictures);
• Spread a thin layer of silicone glue on the adhesive part of the base plate and let it dry for 2- 3 minutes.
• Blow warm air on the adhesive part of the base plate with a hair drier
• Place the baseplate over the stoma
• Insert an HME into the base plate and press hard on it for a few seconds to enhance gluing the baseplate.

The reused baseplate typically does not last as long as a new one. It is advisable to use a reused baseplate when you need to cover the stoma for a shorter period of time (i.e. nighttime).

Provox Xtrabase (above) and Atos Tracheo-Foam (below)

Applying silicone glue

Using and cleaning the Provox® LaryButton™ or Barton-Mayo Button™ 

Provox®LaryButton™ and  Barton-Mayo Button™ are an alternative solution to using adhesive housing for those who are using an HME (Heat/Moisture Exchange) filter,/or hands-free valve but who experienced various problems including losing the seal or allergic reactions to the glue. The buttons provide leak proof tracheostoma valve retention for near-total laryngectomy and total laryngectomy patients. 

      Provox® LaryButton™                                     Barton-Mayo Button ™

They are constructed from soft silicone material and are shaped to reduce negative side-effects such as stoma irritation and bleeding. They often do not require something to keep them in place; are reusable; and can be worn by laryngectomees regardless of their speaking method. The Provox® LaryButton™ has LaryClips to support retention of the LaryButton, especially when using an automatic speaking valve like the FreeHands HME.

LaryClips to support retention of the LaryButton

Using the Button requires that the stoma be pretty regular in shape (circular), and have regular and even surfaces on both sides of the stoma.  However, there are some alterations which a clinician can make to the Button to compensate for some irregular stoma surfaces.  It is also possible to get the Buttons custom made for the contours of an individual stoma.

The HME filters from both ATOS and InHealth fit the Buttons. 

The buttons can be used only in those whose voice prosthesis lumen is not blocked by them. The proper insertion and use of the Buttons should be taught and practiced with the assistance and guidance of SLP or one’s otolaryngologist. For insertion, they can be pulled or folded in from inside with the index finger and thumb, creating a half fold, inserting into the stoma and release. lubrication on the stomal rim is needed, and the button can be secured with one or two lary clips as needed. (see picture above)

A video presentation how to place a lary Button is available 

If the Buttons becomes clogged with secretions, it may restrict air passage to the point where the patient is unable to breathe.  In general, the Buttion will need to be cleaned at least twice daily immediately after surgery and less frequently over time.  The Button is typically cleaned with soft brushes, saline, and hydrogen peroxide.

                                        

     Video how to Insert the Provox® LaryButton™  

Using hands free HME

The hands free HME allows speaking without the need to manually press on the HME to close it off thus blocking exhalation through the stoma and directing air to the voice prosthesis. This is accomplished by placing a second valve at the level of the stoma.  The valve remains open for respiration, however upon exhalation for speech, the valve is forced closed, thus occluding the stoma.  The air then passes through the TEP for voice production.  Because of the high pressures generated to close the valve, many patients cannot sustain hands free speech for extended duration.  Thus, many patients who use hands free valves only do so in particular situations or for short duration.

Not touching the HME in order to speak offers the advantage of reducing the risk of introducing respiratory tract pathogens (i.e., bacteria, viruses) directly to the trachea.

This device frees one's hand and eases vocational and recreational possibilities. Note that when using a hands free HME more pressure is generated when air is exhaled, thus potentially leading to a break in the HME housing's seal. Reducing the exhalation pressure when speaking, speaking slower and softly (almost whispering), and taking a breath after 4-5 words can prevent a break in the seal. Supporting it with a finger before needing to speak loud can also help. It is also important to quickly remove the device before coughing.

Several hands free devices are commercially available. Atos Medical offers the Provox® FreeHands HME™ and Provox® FreeHands Flex™; InHealth Technologies markets the Adjustable Tracheostoma Valve II (ATSV II.)®, and Bloom - Singer SpeakFree Hands - Free Valve® ; (see pictures below). All devices enable automatic occlusion. The new Provox FreeHands Flex® allows both automatic and manual occlusion and a choice between a moist or high air flow HMEs.

                                                       

  

                                              Atos Med. Provox® FreeHands Flexivoice™

  

                          

                    InHealth Technologies Adjustable Tracheostoma Valve II (ATSV II.)®

The air filter (also called cassette in Provox FreeHands HME) for the hands free device has to be changed on a regular basis (every 24 hours or sooner if it becomes dirty or covered with mucus). There are two types of cassettes - ProvoxFreeHands HME Moist which provides extra moisture, and Provox FreeHands HMEFlow which allows greater air flow.
 
The HME device can be used for 6 months to a year. Proper use and cleaning can prolong its life. The hands free device requires initial adjustments to fit the laryngectomee's breathing and speaking abilities. Detailed instructions on how to use and care for the devices are provided by their manufacturers.

Provox HME Cap™ which is made of titanium is used with the Provox FreeHands HMEs. (see picture below) The Cap can be occluded manually for speech. Occluding the Cap to generate speech requires minimal pressure, making speaking easier as the trachea is not pushed backward. However, because the device's opening is located in front of the stoma caution should be employed that it is not occluded by garments or objects. 

Provox HME Cap™

I experimented with several base plates and found the Provox XtraBase (Atos) and InHealth Tracheostoma Valve housing to last the longest ( up to 48 hours). Meticulously following the instructions how to place a base plate (see above) helps in maintaining the ability to speak using a hands free HME without breaking the baseplate's seal. 

The key to speaking with a hands free HME is to learn how to speak without breaking the seal. Using diaphragmatic breathing allows for more air to be exhaled, thus reducing speaking efforts and increasing the number of words that can be articulated with each breath. This methods prevents buildup of air pressure in the trachea which can break the base plate's seal. It may take time and patience to learn how to speak in such a way, and guidance by a skilled SLP can be helpful.

Speech can be made clearer and easier by:

• Speaking slowly
• Speaking only 4-5 words between each air exhalation
• Using diaphragmatic breathing
• Over articulating the words
• Speaking by using low air pressure

Laryngectomees often try to compensate for their low volume by increasing the exhalation air pressure. This is tiring and can lead to air leak around the HME’s base plate.

Removing the foam filter from the HME when one needs to speak for a long time (i.e., lecturing, meetings) can make speaking easier. (See picture below) Because taking off the filter removes the benefits it offers, a new HME should be used as soon as the speaking task is over.

Provox HME (left) after the foam has been removed from the cassette 

It is very important to place the HME housing according to the steps outlined in the section on HME care (see "Placing an HME Housing" above) including cleaning the area around the stoma with Remove ^TM  alcohol, water and soap, placing Skin Prep ^TM  and finally glue (Skin Tag ^TM ). Following these instructions can prolong the life of the HME housing and reduce the likelihood of an air leak through the seal.

If the HNE housing (adhesive) stickiness is declining after some time, massaging it onto the skin again helps. the massage activates the glue and increases stickiness. If  needed one can apply a small amount of silicone glue on the spot where the housing has come loose. 

Air inhalation is slightly more difficult when using a free HME as compared to a regular HME. It is possible to allow for greater amounts of air intake by rotating the valve counter-clockwise in both Atos FreeHands ^TM , Atos Medical Provox® FreeHands Flexivoice™ , and InHealth HandsFree ^TM  devices. In situation where greater exchange of air is needed it may be useful to temporarily replace the hands free HME with a regular one, or to temporarily remove it .The hands free device should be used only when awake. It should be cleaned on a regular basis and when it get clogged with mucus according to the manufacturers' instructions.

Challenges using hands free HME: Patients who have difficulty achieving and/or maintaining a reliable seal may not be successful in using hands free HME. This is particularly true if the shape of the neck around the stoma is irregular because of extensive surgery, reconstruction, etc. 

Excessive “back pressure” can make using a hands free HME very difficult. Back pressure refers to the amount of pressure generated while transferring air from the lungs through the pharynx and out of the mouth. Those who develop back pressure feel as if they have to “push” somewhat to talk. The buildup of pressure is exerted against the device and the adhesive housing, which will lead to breaking of the seal. Some causes of excessive back pressure can be treated effectively. Training and guidance by SLP can help in optimizing one’s speaking ability and ensure the lowest level of back pressure possible.

For some people the stoma moves outwards when speaking hands-free, causing a decrease in voice quality. In that case, the Provox FreeHands Support can reduce the stoma movement, extend the lifespan of the baseplate by preventing breaking of the seal, and improves voice quality. (see picture below)

Despite the challenge of keeping the seal, many laryngectomee value the ability to speak in a more natural way and the freedom of using both hands. Some learn that they can keep the seal much longer when they use a voice amplifier, thus requiring less effort and generating less air pressure.

There is a video that demonstrate the placing of the a hands free valve holder that was made by Steve Staton.

Provox FreeHands Support™

Wearing the HME overnight

Some HMEs are approved for wear 24/7 ( i.e., Provox Luna ; Atos Medical, Provox Life – night Time). These HMEs are designed to be worn at nighttime by offering low breathing resistance. It has side openings designed to prevent occlusion while sleeping. It is made of hydrogel that soothes the skin during the nighttime.

Provox Luna

The advantage of wearing the HME 24/7 is that its beneficial effects are extended throughout the whole day. A hands free HME should be replaced by a regular HME cassette when sleeping.

If the seal lasts, one can keep it overnight. If it does not, it is possible to use an improvised base plate for the night period. An Atos Xtra BasePlate^TM  can be trimmed by removing the outer soft part and leaving the inner rigid part. The plate is "sticky" and thus can cover the stoma without glue, even enabling one to speak. It is also possible to use the HME inserted in a LaryTube overnight.

HME, voice prosthesis, and housing care during radiation treatment

Maintaining adequate humidity in the airways is very important during radiation treatment (RT). The mucous or phlegm coming up from the stoma is more sticky and hard to cough up during RT. The dryness tends to be worse in those who get RT during their hospitalization because of the warm atmosphere in most hospitals. Early signs of tracheal infection are the appearance of blood in the phlegm or around the stoma and discolored mucous (green, yellow or brown).

RT directed at the area around the stoma does not harm or effect the voice prosthesis. RT can cause swelling, inflammation, easy bleeding and crusting of the trachea during treatment and recovery periods. This is why it may be difficult for laryngectomies to use the voice prosthesis (TEP) during that time. It is, however, important to continue to clean the prosthesis.

Wearing an HME can allows the laryngectomee to continue to benefit from its advantages help keep the secretion are manageable. However, wearing adhesive HME housing is not recommended as the skin around the stoma usually become inflamed and is red and sore. An alternative method for housing during the treatment and recovery periods is to use a Larytube. Wear a Larybutton or a laryngectomy tube during the RT course, for at least part of the day or night can also assist in preventing the stoma from shrinking because of the exposure to radiation. 
  

Maintaining humidification can also be achieved by using a saline nebulizer frequently, and covering the stoma with a Protector/ Laryngofoam. Hospitalized patients can wear an oxygen mask that is connected to a humidifier. The SLP can guide and assist in choosing the best method for housing of the HME.

Laryngofoam

Covering ( hiding) the stoma and HME

Read at the Stoma Care section.