Mucus & respiratory care, humidifiers, using suction machine, blowing the nose, coping with cold & warm weather , coughing blood, popping ears, respiratory rehabilitation, protection from smoke and nerve gas inhalation in laryngectomees

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  laryngectomy, the trachea opens at the stoma and a laryngectomee is no longer able to cough up mucus and swallow it, or blow the nose. It is still very important to cough and clear one's mucus; however, this must be done through the stoma.

Immediately after surgery, the patient's tracheal secretions increases and may be difficult to clear.  While hospitalized tracheal suctioning is done by the hospital staff, and the patient and their caregivers should learn how to perform suctioning using sterile techniques prior to discharge. For the first 3-4 months many laryngectomees require tracheal suctioning as an adjunct to coughing to clear their airway. Over time mucous production slowly decreases. This is enhanced by wearing a Heat and Moisture Exchanger (HME). Also, over time, most patients are able to produce adequate coughing strength to expel secretions without the need for a suction device.  

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 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 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 saline (preferably using saline "Bullets") into the stoma at 3 to 5 times a day (see below how to prepare saline). More frequent insertions may be needed in dryer conditions (i.e., heated homes, airplanes, high altitude)
·       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 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 instructions by the manufacturer how to keep them clean. Unplugging the humidifier before changing water or cleaning it is mandatory!

Following a consistent cleaning routine is crucial to prevent bacteria, mold, and mineral buildup that can disperse into the air and impact air quality.

Enclosed are tips how to keep portable humidifiers clean:·   

             Using only distilled or demineralized water. Tap water contains minerals that can deposit inside the humidifier and 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 minerals compared with tap water. Many manufacturers recommend the use of demineralization cartridges or filters.

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      Daily cleaning: Emptying 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. Wipe down and air dry the tank after each use.

      Weekly cleaning: Unplug the humidifier and disassemble all removable parts; then pour white vinegar and water (equal parts mixture) for 15-20 minutes to loosen mineral buildup. Use a soft brush or cloth to scrub away any remaining grime or scale on all parts and rinse all components thoroughly with clean water to remove any vinegar residue. Allow all parts to fully air dry before reassembling.

     Monthly cleaning: Follow manufacturer instructions, but typically, you will want to disinfect with a 3% hydrogen peroxide or bleach solution once a month. Run the disinfecting solution through the humidifier to clean internal components, then rinse thoroughly and allow to fully dry.

     Filter Maintenance: For evaporative humidifiers, remove and rinse the filter in cold water weekly to remove mineral buildup. Replace filters every 3-6 months or as recommended by the manufacturer.  

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      Keeping the area around humidifiers dry. The humidifier should be turned down whenever the area or objects around them become damp or wet.

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      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.

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      Following instructions for central humidifiers. Humidifier built into the central heating and cooling system should be maintained according to their manufacturer’s instruction manual.

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      Replacing old humidifiers. With the passage of time, deposits can humidifiers build up in the humidifier that are difficult or impossible to remove and promote the growth of bacteria and fungi. It is best to replace them. Click to read a helpful link.

                                                                           
                                                               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 weaknesses. 

Both humidifier types help avoid the unwanted effects of dry air, which can include irritation of the laryngectomee’s upper airways that may lead to respiratory ailments. 

Cool Mist Humidifiers

Cool mist humidifiers disperse a comfortable stream of room-temperature mist. 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. The use of cool mist humidifiers avoids getting burns because of hot water accidents.

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.

Advantages

• Safe around children and pets since no heating element
• More energy efficient since no water heating
• Suitable for larger spaces due to use of fans
• Don't increase room temperature

 

Disadvantages:

• Noisier operation due to fans
• Risk of dispersing minerals/white dust if using hard tap water
• Require regular cleaning to prevent mold/bacteria growth

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 airways. 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.

Advantages:

• Quieter operation since they do not use a fan
• Provide warmth, making them suitable for cold weather
• Boiling process kills bacteria and mold, producing cleaner mist
• Don't disperse white dust from minerals like some cool mist models

 

Disadvantages:

• Higher energy consumption to boil water
• Risk of burns from hot water and steam, unsafe around children/pets
• Require frequent cleaning to prevent mineral buildup. Less ideal for warm weather/climates

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 indoors air humidity 

Cooler less humid air during the winter months, combined with an increase in the use of dry heat indoors, may lead to pulmonary changes in laryngectomees. These induces increased coughing and mucus production, thickened, blood-tinged mucus and irritated, and cracked dry skin. The cold, dry air may worsen mucociliary clearance, leading to thickening and crusting of mucus that may obstruct the airway. 

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.
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Followed laryngectomy the inhaled air does not get humidified and filtered by passing through the nose and mouth. Furthermore, tracheal humidity is lost in the exhaled air.  Accordingly, tracheal dryness, irritation and overproduction of mucus develops. The tracheal air also becomes directly exposed to the relatively cold and dry ambient air that enters the tracheostoma. This results in dehydration of mucus (altered mucus viscosity) and a reduction of ciliary activity causes impaired mucociliary clearance, and , tracheal epithelium damage ( loss of ciliated cells, goblet cell hyperplasia, and excessive)..

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.

When adequate humidification of the inhaled air is achieved with a humidifier, the HMEs that provide extra humidity can be replaced with those that provide extra airflow in adequately humidified environment. 

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 secretions. The contents of the bullets is introduced by a single or several insertions. The suction created by the empty saline container enables sometimes to remove a small amount of the secretions. It is generally useful to use saline bullets as needed several times a day or as directed by one's physician. The number of saline bullets used depends on the dryness of the sputum.

Steps to achieve better humidification and healthier mucus production  can be found above.

      

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" 

Hygrometer 

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, the salt is dissolved in boiling water. The solution can be kept sterile by placing a lid over the container so that no microorganisms get into the liquid or air space as the solution cools.

The sterile solution can be dispensed into sterile containers. The containers be sterilized by boiling them in water for one minute. 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 airways and neck in cold weather and a high altitude

Winter and high altitude can be difficult for laryngectomees. The air at high altitude is thinner  containing less oxygen, and colder and therefore drier. Before 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. This results in drying of the trachea, increased coughing, mucus production, irritation and inflammation of the airway. This may increase the risk of infection blood-tingled mucus and crusting in and around the stoma. The mucus can also become dry and plug the airways. 

Pulmonary infections (tracheobronchitis or pneumonia) are more frequent in laryngectomees in the wintertime and the accompanying tracheal crusting often requires antibiotic treatment or even hospitalization. (See below in the Tracheobroncial infections section)

Because there is less oxygen at high altitude all individuals need to breath more often and this may be harder and tiring.

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

In very cold weather the moisture in the HME can freeze making it even harder to breath. When this occurs replacing the HME can bring some relief. 

Caring for the airways in cold weather and high altitude includes:

• Avoid exposure to cold, dry or dusty air
• Avoid 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 scarf or thin T-shirt (see picture below), that cover the nose, mouth, and stoma; like a mask. This will keep the face and neck 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.
• Temporary (not prolonged) remove of the HME under a cover (see above) can be helpful allowing greater air exchange 
• Use an HME which enables greater airflow (i.e., Atos Medical Provox XtraFlow HME, AtosMedical Provox FreeHands HME Flow, Blom-Singer EasyFlow HME
• Replace a frozen HME with a new one
• Keep the airway humid by wearing an HME and inserting saline bullets
• Ensuring their indoor environment is is 40-50% humid by using humidifier   
• Cough out or suctioning the mucus using a suction machine to clean the airways

Following a laryngectomy which involves neck dissection most individuals develop areas of numbness in their neck, chin and behind the ears. Consequently they cannot sense cold air and can develop frostbite at these sites.  It is therefore important to cover these areas with a scarf or 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

Laryngectomee's challenges in and hot and humid weather

Breathing is generally easier for laryngectomees in humid weather because the inhaled humidity moistens their airways.  However, laryngectomees face several challenges during high humidity especially when it is combined with hot weather conditions:

Increased Mucus Production

High humidity can lead to increased mucus production and thickening of secretions in the trachea. This is because the air entering the trachea is already saturated with moisture, reducing the drying effect that normally helps control mucus levels. The increase in mucus production can increase the risk of lung infection.

Breathing Difficulties

The saturated air combined with increased mucus can make breathing more difficult for laryngectomees, potentially causing shortness of breath or airway obstruction from mucus plugs.

 

Discomfort and Skin Irritation

The warm, moist air can cause discomfort around the stoma site. The increased moisture can also lead to skin irritation or breakdown around the stoma and to breaks in the HME’s adhesiveness.

Heat Intolerance

Laryngectomees may experience heat intolerance during hot and humid conditions, increasing the risk of heat-related illnesses like heat exhaustion or heat stroke, especially with exertion.

To mitigate these challenges, laryngectomees should:

• Use a heat and moisture exchanger (HME) to help control humidity levels in the trachea and prevent water loss and dehydration
• Stay well-hydrated by drinking cool fluids
• Limit outdoor activities and sun exposure in hot, humid conditions
• Use a room air conditioner or dehumidifier indoors
• Suction or cough frequently to clear excess mucus
• Wear breathable clothing and consider using cooling towels
• Keep in touch with friends and family, as they may be their lifeline in case they need assistance.

 

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, cardiovascular, and renal diseases, diabetes, obesity, and mental illness. Medications including blood pressure and heart medicine (beta-blockers), water pills (diuretics), antidepressants, antipsychotics and anticonvulsants (seizure medication) and antihistamines (allergy medications) may also affect how the body reacts to heat.

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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.

Possible causes of minimal bleeding include:

• Irritation to the fragile tissue around the stoma
• Insufficient humidity to the airway
• Too frequent, deep or vigorous suctioning
• Suction pressure that is too high (Suction machine pressure for adults 100-120 mm Hg)
• Infection
• Trauma, manipulation of trach
• Foreign object in the airway
• Excessive coughing

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) inserting sterile saline into the stoma, and keeping well hydrated 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.

Popping one’s ears as a laryngectomee

The Eustachian tube supplies air to the middle ear, maintaining equal amounts of pressure on both sides of the eardrum. If there’s a difference in pressure, the eardrum may bulge inward or outward in response, causing the feeling of fullness in the ear. Popping the ears, helps move the eardrum back into place, alleviating the imbalance of pressure, and eliminating or reducing one’s discomfort.

Clogging of the Eustachian tubes can be caused by allergies, air irritants, and respiratory infections. Changes in air pressure can also close the Eustachian tube and affect fluid flow. These causes might be due to flying in an airplane or by drinking while lying down.

The Eustachian tube typically opens automatically when one swallows, blows the nose, or yawns. Because laryngectomees are unable to blow air to their nose they have greater difficulties in alleviating an imbalance of pressure in their ears.

There are several techniques a a laryngectomee can try to unclog or pop the ears:

• Swallowing: When one swallows, the muscles automatically work to open the Eustachian tube.. Chewing gum or sucking on hard candy can also help activate this response.
• Yawning: Yawning can help open the Eustachian tube. The mouth should be opened as wide as possible while yawning.
• Valsalva maneuver (modified): Pinching the nostrils closed with the fingers, while puffing the air inside the mouth with the checks closed generates pressure in the back of the nose, which may help open the Eustachian tube.
• Toynbee maneuver: Pinching the nostrils closed with the fingers while swallowing.
• Applying a warm washcloth: Holding a warm washcloth or covered heating pad against the ear can help reduce congestion and open the Eustachian tube. This method may be most effective for clogged ears due to a cold, the flu, or allergies.
• Nasal decongestants (under medical supervision): Unclogging the nasal passageways can help with clogged ears. One may want to try the Valsalva or Toynbee maneuver after using a decongestant.
• Nasal corticosteroids (under medical supervision): OTC nasal steroids may help unclog the ears by reducing the amount of inflammation in the nasal passages. This can help air move more freely through the Eustachian tube, equalizing the pressure in the ears.
• Ventilation tubes: In extreme cases, this simple surgical technique can eliminate pain and reduce pressure. Thin ventilation tubes, also known as pressure equalizing (PE) tubes, are inserted in one or both ears to drain out excess fluid.

If the tube does not open easily, it may be obstructed. This can be caused by fluid, mucus, or earwax.

Lower respiratory infections (bronchitis, tracheitis, and tracheobronchitis) in laryngectomees

Laryngectomees are directly exposed to airborne respiratory pathogens (i.e., viruses, bacteria) because the air they inhale is no longer filtered by the nasal mucosa. This makes them more susceptible to lower respiratory tract and other infections that access the body through the respiratory tract. 

Following laryngectomy the tracheal epithelium also becomes directly exposed to the relatively cold and dry ambient air entering the tracheostoma.

This can causes:

• Drying of the mucus (altered mucus viscosity)
• Reduction of ciliary activity that causes impaired mucociliary clearance
• Tracheal epithelium damage (loss of ciliated cells, goblet cell hyperplasia, and excessive mucus production and metaplasia).

Laryngectomized patients have considerable pulmonary complaints such as frequent coughing and forceful expectoration of sputum. Laryngectomees also run a higher risk of developing severe respiratory infections.

Severe pulmonary infections (tracheobronchitis or pneumonia) in laryngectomees are more frequent in wintertime and the accompanying tracheal crusting often requires antibiotic treatment or even hospitalization.

The stoma allows the inhaled air to bypasses the natural defenses (nasal hair and mucus membranes) of the upper airway that filter out dust and bacteria. The number of bronchitis, tracheobronchitis, and pneumonia episodes as well as mortality due to these infections in non-HME users was found to be 3 times higher than in HME users. Laryngectomees especially those who do not wear an HME or do not cover their stoma are therefore at a higher risk of developing lower respiratory tract infections. 

Bronchitis is an inflammation of the lining of the bronchial tubes, which carry air to and from the lungs. People who have bronchitis often cough up thickened mucus, which can be discolored. Acute bronchitis can develop from a cold or other respiratory infection.

Symptoms of bronchitis include:

• Cough
• Production of mucus (sputum), which can be clear, white, yellowish-gray or green in color- rarely, it may be streaked with blood
• Fatigue
• Shortness of breath
• Slight fever and chills
• Chest discomfort
• Mild headache or body aches.

While these symptoms usually improve in about a week, a nagging cough can linger for several weeks.

Treatment of bronchitis in laryngectomees is more challenging. Managing bronchitis in a laryngectomee requires:

• Keeping the stoma open by manually removing accumulates mucus that can dry out and clog it.
• Keeping the excessive sputum moist by breathing humidified air and inserting saline “bullets” as needed
• Coughing out or suctioning accumulated sputum
• Removing the stoma cover prior to coughing to prevent blocking it with the coughed out sputum
• Use thick paper tissues or handkerchiefs to pick up any coughed mucus. Do not use thin absorbing paper such as toilet paper or tissues, as they can be suctioned into the stoma  
• Keeping well hydrated
• Wearing an HME may be difficult during bronchitis as the excessive mucus may prevent it from adhering to the skin around the stoma.
• Elevating one’s head and chest while sleeping
• Using medication prescribed by one’s physician (such as bronchodilators, fever reducing medications, and expectorants).
• Because most cases of bronchitis are caused by viral infections, antibiotics are not effective. However, if one’s doctor suspects a bacterial infection, he or she may prescribe an antibiotic.

Tracheitis and tracheobronchitis can be caused by a virus or bacterial or a combination of both. Bacterial tracheitis can evolve as a rare complication of influenza virus infection. Tracheitis and tracheobronchitis can cause airway obstruction as dry and thick sputum can block the airway. 

Symptoms of bacterial tracheitis and tracheobronchitis include:

• Increased amount of thick mucus that may yellow, green, blood tingled, and foul smelling
• Redness, rash and/or inflamed at stoma site
• Bouts of deep barking cough, and high-pitched wheezing sound
• Elevated temperature
• Congested lung sounds
• Increased respiratory effort or change in respiratory rate
• Listlessness

Bacterial tracheitis can be a medical emergency especially in a laryngectomee and may require hospitalization. It may require intense respiratory tract care, fluid management, and antimicrobial therapy.

Treatment of tracheitis and tracheobronchitis is challenging in laryngectomees. It require special care of the stoma which includes clearing the thick sputum and the crusting around it which can compromise breathing. (See the table above in the Bronchitis Section).

Whenever antimicrobial therapy is given it should be guided by the results of the cultures of the tracheal secretion. Symptomatic treatment includes taking antipyretics, antitussive drugs, expectorants and mucolytics.

The risk of acquiring these infections can be reduced by:

• Getting vaccinated for the pneumococcal bacteria and the influenza viruses. 
• Consult your physician about getting vaccinated for Haemophilus influenzae and Neisseria meningitidis
• Washing one's hands before any stoma care
• Wearing an HME
• Maintaining adequate respiratory tract humidification
• Avoiding hypothermia and breathing cold air

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 swallowing 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: aspirating the secretion with a mucus suction bulb (see picture below), or 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.

Mucus aspiration bulb

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.

One important function of the HME is humidification.  Humidity in the trachea is important for the ciliary activity, which assists in clearance of materials out of the lungs and airway.  Ciliary activity becomes impaired when relative humidity in the trachea drops below 70%. Tracheal relative humidity is about 50% following laryngectomy compared to about 99% in nose/mouth breathers.  Use of HME increases relative humidity back to about 70% thereby protecting ciliary function for airway clearance.  Additionally, HME use minimizes and thins tracheal secretions leading to improved airway clearance.  This leads to improved cough efficiency, reduced cough frequency, improved sleep, and enriched quality of life.  Benefits extend not just to daily symptoms but also to long-term lung function.

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. This may eventually lead to collapse of portions of the base of the lower lobs of the lungs (atelectasis).

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 of a respiratory therapist. This can get the lungs to fully inflate and improve individuals' heart and breathing capacities.  One way to improve breathing capacity, is by using a modified incentive spirometer (a device that make the ball rise to the indicated range). One can mark their progress with a siding pointer.( see Picture below) The spirometer can be modified for laryngectomee use by replacing the mouthpiece with a large diameter baby bottle nipple that fits over stoma.  Another way to expand the lungs is to take 2 to 3 deep breaths, hold, and slowly let the air out..
• Using diaphragmatic breathing. This method of breathing allows for greater utilization of the lung capacity. This breathing method can be used when resting or exercising (e.g., walking, biking).

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 the exhalation, the deflation of their bronchi generates 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 their nose and mouth.

Incentive spirometer

Protecting laryngectomees and neck breathers from smoke inhalation.

Smoke inhalation can occur when one is exposed to harmful smoke from burning materials and gases. This harmful smoke may contain chemicals or poisons, such as carbon monoxide and cyanide.  Inhaling this harmful smoke, can irritate the airways, cause their swelling and blockage.

Neck breathers in the path of wildfire smoke can take certain precautionary measures to protect their lungs from smoke pollution. Since they can not filter their air in their upper airways they are more susceptible to their untoward effects. They are advised to filter air, limit outside activities or otherwise temporarily leave the impacted area.

These methods can reduce smoke exposure indoors:

• Staying indoors and windows closed and using high efficiency filters to capture fine particles from smoke in central air or room unite conditioning system.
• Avoiding adding to indoor air pollution by burn candles or use gas, propane, wood burning stoves, fireplaces, aerosol sprays, frying or broiling meat, smoking tobacco products, or vacuuming. All of these can increase air pollution indoors.
• Using a portable air cleaner to reduce indoor air pollution. Making sure it is sized for the room and that it does not make ozone, which is a harmful air pollutant. Portable air cleaners can be used along with efficient central air systems with efficient filters to maximize the reduction of indoor particles.
• Creating a “clean room” in the home. Choosing a room with no fireplace and as few windows and doors as possible, such as a bedroom, and using a portable air cleaner in the room.
• Wear an HME with greater filtering ability (e.g., Provox Micron TM).
• Using respirator mask labeled N95 or N100 and learning how to placing them to cover the stoma with the use of tap. These special masks filter out fine particles and can be found at many hardware stores and pharmacies. They are also sold over the internet. Avoiding one‐strap paper dust mask or a surgical mask as they don’t protect against fine particles.
• When air quality improves, even temporarily, airing out the home to reduce indoor air pollution. 
• Installing a smoke and bicarbonate detectors to alert on danger.

Reducing smoke exposure outdoors:

• Avoiding strenuous activities such as mowing the lawn or going for a run.
• Knowing and following changes in the air quality, and waiting until air quality is better before engaging in outdoor actives. Check your state or local air quality agency’s website or airnow.gov for air quality forecasts and current air quality conditions.
• Having enough food and medication on hand to last several days to avoid going out for suppliesAvoiding the smokiest times of day when going out.
• Reducing smoke in one’s vehicle by closing the windows and vents and running the air conditioner in recirculate mode. Slowing down when driving in smoky conditions.
• Wear an HME with greater filtering ability (e.g., Provox Micron TM). 
• Not relying on dust masks or bandanas for protection from smoke. Properly and snugly placing a N95 or 100N respirator on the stoma when going out in smoky conditions.
• Have a plan to evacuate. Know how you will get alerts and health warnings, including air quality reports and public service announcements.

N95 respirator mask

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.