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Tracheal stoma, aspiration & swimming

A stoma is an opening that connects a portion of the body cavity to the outside environment.  A tracheal stoma is created after a laryngectomy to generate a new opening for the trachea in the neck, thus connecting the lungs to the outside. When the tracheal tube is removed, it is replaced by a laryngectomy tube, which is a soft flexible silicone tube that fits just inside the stoma to help protect it.  The laryngectomy tube can also hold a Heat/Moisture Exchanger (HME), and can be fenestrated to allow the use of a voice prosthesis. Caring for the stoma to insure its patency and health is very important.


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 the Heat/Moisture Exchangers (HME) that create a tight seal around the stoma. In addition to filtering dirt, HMEs preserve some of the moisture and heat inside the respiratory tract. Therefore, an HME assists in restoring the temperature, moisture and cleanliness of the inhaled air to their condition prior to 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 (which can carry an HME) is initially left in the stoma 24/7. 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. (see picture below) A small stoma can be treated with local injection of steroids or balloon dilationThose with inadequate stoma (too small, too large or deformed) may benefit from surgical repair (stomaplasty).

The laryngectomy tube requires maintenance by cleaning it with soap, and tube brush. It is recommended to use the smaller size of tube that fits into the stoma. Insertion of the tube require several steps and should be done after being instructed by a speech and language pathologist:

  • The tube can be supported in place by tube holders or clips that should be attached before insertion.
  • Insertion of the tube can be helped by lubrication around the stoma’s rims.
  • The tube should be folded in half and prior to inserting the tip into the stoma.

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. The elderly; those who smoke, consume alcohol, had radiation and or chemotherapy, or have medical co-morbidity; and those who frequently place and remove their adhesives are at greater risk for experiencing severe skin reactions.

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 the 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 individuals, the removal of the adhesive irritates the skin. 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 can be used 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 bad 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.

Appropriate stoma care includes:

•           Keeping the inside of the stoma clean, moist, and glistening. Saline "bullets" can help keeping it moist.
•           Using a clean face cloth to clean the stoma.
•           Avoiding using cotton balls or paper tissues to clean the stoma: These may get sucked into your breathing tube or trachea and cause breathing problems.
•           Keeping the tracheostomy tube clean
•           Covering the stoma at all times by using a heat and moisture exchanger (HME), gauze, cotton, or crocheted covers.
•           Avoiding the use of cotton or cotton-filled gauze to clean: The fibers may get sucked into your trachea.
•           Exerting with moderation without too much strain.
•           Dressing comfortably allowing for circulation of air, and coughing and protection of clothing from coughing and secretions.
•           Covering the stoma when coughing or sneezing using thick paper tissues or handkerchiefs to pick up any coughed mucus.
•           Wearing medical identification such as Medic Alert informing that one is a neck breather.
•           Having regular medical examinations of the stoma by ones physician
•           Protecting the stoma from water by not swimming without a Larchel snorkel (which helps protect the airways), exercising care when bathing by using a shower shield or a towel to cover the stoma.
•           Avoiding the inhalation of smoke, dirt, dust or irritating fumes, and using a stoma cover to prevent inhalation of insects or objects.


Cleaning the stoma and tubes

Cleaning the stoma enable the air to be inhaled and exhaled without obstruction by accumulated mucus. These are the general guidelines for keeping the airways and stoma open and 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 washing 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. The suction created by the empty saline bullet enables sometimes to remove a small amount of the secretions.
  • 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. During this period, the stoma can be covered with a foam cover, a garment, or an ascot. 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 be 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 and/or systemic antibiotics can be useful.  Obtaining microbiological specimen for culture can guide the choice of antimicrobial therapy.

Those who get radiation treatment should removing the baseplate during the radiation session to reduce skin damage.                                                                                       


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 because their lungs are not connected to the mouth. However, aspiration pneumonia can develop when bacteria get into the lungs through the stoma and are 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 to prevent pneumonia(See Mucus and respiratory care section).

Covering the stoma at all times can 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. Seawater 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:
  • Keeping the stoma above water level
  • Avoiding breathing (for a short time) when the water gets into the stoma
  • Wearing a life vest that keeps the stoma above water level
  • Using 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 advisable to:
  • Have a life vest available  and floating tube (with automatic, non-manual inflation)
  • Wear your life vest when needed
  • Being aware of the evacuation routes and locations of floating devices and lifeboats
  • Practice evacuation procedures
  • Inform others and the cruise staff of one's 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.

If aspiration of paper has occurred these measures can be helpful:
  •        Staying calm and do not inhale air
  •       Attempting to remove the paper using a forceps (without pushing it deeper into the trachea)
  •       Squaring or spraying 3 – 5 cc of saline or water into the stoma and cough
  •       If these are unsuccessful call 911
  •       If available administering oxygen until help arrives 

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 inhaling 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 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 quickly removed it can get 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

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