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8/23/2004 Heat and Moisture Exchange: Laryngectomy, Issues and Answers Lynn Acton, M.S., CCC/SLP | |
| Speech-Language Pathologist Yale-New Haven Hospital New Haven, CT 06504 lynn.acton@yale.edu Introduction: Demographics & Risk Factors Approximately 9,500 Americans were diagnosed with laryngeal cancer in 2003. Laryngeal cancer occurs more frequently in men than women, with a ratio of 6:1 and squamous cell carcinoma is the most frequently occurring type (95%) of laryngeal cancer. There are approximately 55,000 laryngectomees living in the U.S. Approximately 3,800 patients with laryngeal cancer die every year. A “risk factor” is anything that increases a person’s chance of getting a disease. Risk factors related to laryngeal cancers are numerous. For example, smoking is a risk factor for laryngeal cancer, and also a risk factor for lung, mouth, bladder, and kidney cancers. The risk of developing a laryngeal cancer is 5 to 35 times greater in smokers than in non-smokers. Alcohol abuse increases the risk of laryngeal cancer by some 2 to 5 times for alcohol abusers. Combinations of tobacco use and alcohol abuse increase laryngeal cancer risk up to 100 times. Other risk factors include; heavy exposure to wood dust and paint fumes and certain chemicals used in metalworking, petroleum, plastics, and textile industries. Nutritional deficiencies, such as not eating enough foods with B vitamins, or vitamin A and retinoids may also be risk factors for laryngeal cancer. Anatomic and Physiologic Considerations: The altered anatomy of the laryngectomee patient impacts more than just their ability to communicate; it affects their entire pulmonary system. In normal patients, inhaled air passes through the nose where it is filtered, warmed to approximately 97 degrees, and humidified to approximately 98%, while passing over the mucosal lining of the nose and the nasopharynx, and traversing the respiratory anatomy of the head and neck. The nose and related air passages increase the resistance of breathing, allowing for complete expansion of the lungs. However, after removal of the larynx, patients breathe through their stoma, bypassing the nose and nasopharynx. Air passing through the stoma is not filtered, humidified or warmed. As the “unfiltererd” air passes straight into the lungs, it can serve as an irritant, increasing secretions and leading to coughing and secretion displacement through the stoma. Once a person has a total laryngectomy, they become “neck breathers.” As a result, inspired air is not filtered. Inhaled air enters the lungs at room temperature (typically 68 degrees, but highly variable), humidity is typically 42% (again, highly variable) and there is little resistance upon inhalation, making complete lung expansion difficult. The lack of filtration allows a multiplicity of particles to enter the lungs. The lungs consider these particles “foreign bodies” and produce secretions to remove them. Colder air holds less moisture and drier inhaled air also causes an increase in secretions. These factors may lead to a very serious complication post-laryngectomy, specifically mucus plugs or dried secretions occluding the airway. This complication (occlusion/blockage) can usually be avoided, with appropriate management and care. Heat and Moisture Exchangers: I recommend all laryngectomy patients wear a Heat and Moisture Exchanger (HME). An HME is like an artificial nose, warming the air temperature to 84 degrees and adding humidity, up to 65%. HMEs also filter the air and increases resistance, thereby, decreasing secretion production and allowing a more thorough and complete expansion of the lungs. When patients first wear HMEs, they report it feels “different.” They feel increased resistance when they breathe and they may initially notice an increase in secretions. However, after their body adapts to the HME, they’ll notice a significant reduction in secretions. I recommend at least a seven-day trial with HMEs. It may indeed take a full week to become adjusted to the product and to really get comfortable with any new HME product. Accordingly, many HME manufacturers give patients free sample packs for a seven day trial period. Some companies suggest trying their product for an entire month to see what the full affect will be, and this may be a good idea as each individual has their preferences. One advantage of wearing an HME is that it can improve a laryngectomee’s TEP voice if they have problems occluding a deep set, large, or irregular stoma. Also “hands free” valves can be used with HMEs, which is often a highly desirable option for appropriate patients. There are a number of manufacturers of HME products. The following is a partial list of HMEs: ATOS provides the Provox Stomafilter System (see photo below), Inhealth Technologies has the Humidifilter (see photo below), Kapitex Healthcare Ltd provides the Neo-Naze (see photo below) and Bivona Medical Technologies has the HME cartridge. ATOS, Inhealth and Bivona products are interchangeable. Therefore, if the patient prefers (for example) an ATOS housing with an InHealth humidifilter, or vice versa, they can be “mixed and matched” to best suit the patient’s preferences. Costs, CPT codes and Reimbursement Issues: HMEs are not cheap. The least expensive units are approximately $700 per year and the more expensive units are just under $3000 per year. Most patients are reimbursed through their insurance company for HME products, if and when they have durable medical equipment coverage on their individual insurance plan. Of course, each insurance company is different and most offer multiple plans with various levels of coverage. The only way to know with certainty, whether or not the HME will be a “covered product” is to contact the insurance company to review the coverage and reimbursement procedures each time one is ordered or recommended. Importantly, these products are generally considered “medically necessary” for pulmonary health. Medicare does not consider the diagnosis codes 161.9 (cancer of the larynx)/ 784.41 (total laryngectomy) sufficient for reimbursement of tracheostoma covers/filters. Often, as additional diagnosis code must be used as well: V44 (tracheostomy status), V55 (attention to tracheostomy) or 519 (complications from tracheostomy). Of course the application of these codes and services varies with each patient and their individual treatment protocol. The physician and appropriate billing and reimbursement administrative personnel should work with the patient and the insurance company/provider to maximally provide for, and manage the needs of the patient.  Inhealth Technologies-Humidifilter, ATOS-Provox Stomafilter System Permission to use images granted by InHealth Technologies, www.inhealth.com.  ATOS-Provox Stomafilter System  Kapitex Healtcare Ltd has the Trachi-Naze Preparation of the stoma: Manufacturers of each product offer general guidelines for use of their products. Of course, each patient and their situation is unique, and management and care issues should be coordinated with their physician, based on their particular needs and situation. Nonetheless, the following guidelines are offered to help demonstrate some of the issues related to stoma use and management: Inhealth Technologies recommends applying a very light coating of adhesive, and then waiting 3-4 minutes before applying the housing or base plate. ATOS recommends applying glue and waiting 5 minutes, then apply glue again and wait another 2 minutes before applying the base plate. Once the base plate is applied ATOS recommends waiting 30 minutes prior to talking, to allow the glue adequate time to set. Tissue Issues: Adhesive does not stick well to shiny red skin. You should not be able to visualize where the housing was placed. If your patient has a large red ring around their stoma they will need to leave the housing off one night to allow the skin to heal. “Skin –Prep” or “Shield Skin” provide a clear, protective barrier between skin and tape &/or adhesive. They help tape and film adhesion. “Remove” is a universal wipe which is ideal for removing glue from around the stoma. If you have used “Remove” to dispose of previous adhesives, make sure you wash off the “Remove” before you apply the new adhesive. Be sure to squeeze out excess “Skin-Prep”, “Shield Skin” or “Remove” to avoid accidental spillage into the stoma. After applying the glue and waiting the appropriate amount of time to allow for the glue to become ‘tacky’ place the housing on top of the stoma. The housing should be placed slightly lower than the stoma to aid in the removal of secretions from the stoma. Instruct the patient to keep secretions away from the adhesive to prolong the duration of the seal. This can be achieved by bending over and getting the stoma lower than the lungs when coughing. This will make it easier for the laryngectomee to cough the secretions out of the stoma. For insertion: Instruct the patient to insert the HME at 6 o’clock in the housing and push downward and backward. For removal, instruct the patient to use the index finger and thumb to remove the HME from the housing while stabilizing the housing with the index and middle finger of the other hand. If your patient is using an HME with a ‘hands free’ speaking valve there are a few things that can help with base plate adhesion. The most important thing for the patient to do while speaking with a valve, is to speak with constant, gentle air pressure. This will put the least amount of stress on the adhesive thereby increasing the time it stays secured to the neck. The opposite of this, and what should be avoided, would be if your patient started each sentence with a lot of pressure similar to a hard glottal attack. It is important to keep the prosthesis clean for many reasons. Importantly, as more air goes through the prosthesis, less air will be in the trachea, potentially breaking down the adhesive seal. Conclusions: HMEs provide many benefits to the laryngectomee patient. After a total laryngectomy, inspired air is not adequately filtered, the typical temperature goes from 97 to 68 degrees, humidity goes from 98% to 42%, and there is little resistance of breathing. This leads to increased pulmonary secretions and inadequate lung expansion. HMEs filter the air, increase air temperature to 84 degrees, and increase humidity to 65%, and provide resistance of breathing, thereby decreasing secretion production and allowing for fuller expansion of the lungs. This article has provided the SLP who works with laryngectomees information on HME functioning, how to use HMEs with their patients, and a number of companies from which HMEs can be purchased. References: ATOS Medical (Provox) 2202 N. Bartlett Ave. Milwaukee, WI 53202 Phone(800)217-0025 Fax(414)227-9033 Email: brenda.martin@atosmedical.com www.atosmedical.com Eagle Medical (Trachi-Naze) 11080 Executive Drive Boise, ID 83713 Phone(877)944-4446 Fax (208)322-0931 Email: EAGLEMED@aol.com www.eaglemedicalsupply.com Inhealth Technologies 1110 Mark Avenue Carpinteria, CA 93013-2918 Phone(800)477-5969 Fax(805)684-8594 Email: info@inhealth.com www.inhealth.com Kapitex Healthcare USA (Trachi-Naze) PO Box 936 Seguin, TX 78144 Phone(210)865-8896 Fax(830)639-4787 Email: m.finfrock@worldnet.att www.kapitex.com Lauder Enterprises PO Box 780249 (Trachi-Naze) San Antonio, TX 78278-0249 Phone(800)388-3642 Fax(210)492-1584 Email: JKLvoice@aol.com www.voicestore.com Luminaud Inc. (Trachi-Naze and Provox) 8688 Tyler Boulevard Mentor, OH 44060-4348 Phone(800)255-3408 Fax (440)255-2250 Email: info@luminaud.com www.luminaud.com Smith Medical ASD Inc. (Bivona) 10 Bowman Drive Keene, NH 03431 Phone(800)258-5361 Fax(603)352-3703 www.smiths-medical.com An early version of this article appeared in November 2003 in the Voice Points Column on Whispers on the Web, a monthly online newsletter for Web Whispers Nu -Voice Club. Permission to reprint the article was given by the coordinator of this column Dr. Kelly. | |