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Heat moisture exchanger (HME) filter care
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.
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 ButtonTM. 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 can be 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.
A new HME filter that is combined with an electrostatic filter is designed to filter potential respiratory pathogens (Provox Micron TM, Atos Medical). This HME 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 an laryngectomee as a HME filter.
The effect of an HME on breathing as 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.
When needing extra air (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., AtosMedical's XtraFlow). 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.
Placing an HME base plate (housing)
The key to prolonging the use of an HME's base plate 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.
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 ones 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 PrepTM 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 these instructions:
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 you do not do this the
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.
5. Wash away the soap with a wet towel and thoroughly dry.
6. Apply Skin PrepTM and let it dry for 2-3 minutes.
7. For extra adhesion apply silicone skin adhesive or Skin-Tac TM wipe (Torbot, Cranston, Rhode Island 20910) and let it dry for 3-4 minutes. (This is especially important for users of automatic speaking valve).
8. Attach the base plate for the HME at the best location to allow air flow and good attachment. Attempt to place it as down as possible attaining the maximum distance between the stoma and bottom part of the seal.
9. When using hands free HME wait for 5-30 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.
Placement of HME and its base plate (housing) on a stoma
Adhesive base plates produced by Provox (Atos Medical)
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 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 5-7 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.
The air filter (also called cassette in Provox FreeHands HME) in 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). However, 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.
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).
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.
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.
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 and InHealth HandsFree TM devices.
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.
Wearing the HME overnight
Some HMEs are approved for wear 24/7 ( i.e. Atos). ). The advantage of wearing the HME 24/7 is that its beneficial effects are extended throughout the whole day.
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 BasePlateTM 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.
Covering ( hiding) the 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 cones of each choice:
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 laryngectomees’ 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.