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 Heat and Moisture Exchanger (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 can be routinely taken to maintain a healthy mucus production as shown below.
A lecture about life challenges after laryngectomy including stoma care can be viewed on YouTube.
Humidity and humidifiers
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
Using only distilled or demineralized water. Tap water contains minerals that can generate deposits inside the humidifier that 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 mineral as compared with tap water. Many manufacturers recommend the use of demineralization cartridges or filters.
Cleaning humidifiers every 3 days. Mineral deposits or film in the tank or other parts of the humidifier should be removed preferably by using a 3 % hydrogen peroxide solution. Chlorine bleach or other disinfectants are recommended by some manufacturers. The tank should be rinsed after cleaning to remove harmful chemicals that can become airborne and inhaled.
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.
Followed laryngectomy the inhaled air does not get humidified and filtered by passing through the nose and mouth; accordingly, tracheal dryness, irritation and overproduction of mucus develops. 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.
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 secretion. The contents of the bullets is introduced by several insertions. It is generally useful to use saline bullets as needed several times a day or as directed by one's physician.
· 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 (preferably using saline "Bullets") saline into the stoma at least twice a day (see below how to prepare saline)
· 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
Breathing cold air can also have an irritating effect on the airway causing the smooth muscle that surrounds the airway to contract (bronchospasm). This decreases the size of the airway and makes it hard to get the air in and out of the lungs, thus increasing shortness of breath.
- Coughing out or suctioning the mucus using a suction machine to clean the airway
- Avoiding exposure to cold, dry or dusty air
- Avoiding dust, irritants and allergens
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 thin T-shirt over the face (see picture below), that cover the nose, mouth, and
stoma; like a mask. This will keep the face 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.
- Preventing water from getting into the stoma when showering (see picture below)
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.
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.
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) and inserting sterile saline into the stoma 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.
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.
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.
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.
- 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. This can get the lungs to fully inflate and improve individuals' heart and breathing rates.
- Using diaphragmatic breathing. This method of breathing allows for greater utilization of the lung capacity.