From the Department of Pediatrics and Medicine, Georgetown University School of Medicine, Washington, DC.
The author declares no conflicts of interest.
Reprints will not be available from the author.
Address correspondence to Itzhak Brook, MD, MSc, Department of Pediatrics and Medicine, Georgetown University School of Medicine, 4431 Albemarle St. NW, Washington, DC 20016. Address e-mail to firstname.lastname@example.org.
Accepted January 10, 2012
Published ahead of print March 26, 2012
Receiving sedation while undergoing a diagnostic procedure (i.e., colonoscopy) or general anesthesia while undergoing surgery is challenging for neck breathers including laryngectomees (an individual who had laryngectomy). As a laryngectomee, I personally realized this when I needed surgery.
Unfortunately, most medical personnel including nurses, medical technicians, surgeons, and anesthesiologists caring for laryngectomees before, during, and after surgery are not familiar with their unique anatomy, how they speak, and how to manage their airways during and after the operation. This lack of familiarity is attributable to the significant success of laryngeal conservation treatment1 that has in turn reduced the number of patients undergoing total laryngectomy.2 As a result, many health providers have less contact than ever with laryngectomees.
The goals of this article are to educate and raise awareness about the special needs of laryngectomees and other neck breathers, and explain the anatomical changes after laryngectomy, how laryngectomees speak, how to distinguish between total and partial neck breathers, and describe procedures and equipment needed to ventilate the lungs or administer air to total and partial neck breathers.
The most common indication for laryngectomy is cancer of the head and neck. Many laryngectomees also have other medical problems caused by the malignancy and its treatment that usually includes radiation, chemotherapy, and surgery. Because of the removal of their larynx, they have difficulty speaking and use various methods to communicate.
After total laryngectomy, the patient breathes through the stoma where the tracheostomy opens in the neck. There is no longer a connection between the trachea and the mouth and nose (Fig. 1).
Laryngectomees use a variety of methods of communication. These include writing, silent articulation, sign language, and 3 methods of speech: esophageal, voice prosthesis through tracheoesophageal puncture, and electronic larynx (artificial larynx device) speech.3 Each of these methods substitutes the vibration generated by the vocal cords with another source while the actual formation of words is done by the tongue and lips.
In esophageal speech, the vibrations are generated by air “belched” out from the esophagus (Fig. 2). This method does not require any instrumentation.
In tracheoesophageal speech with a voice prosthesis, pulmonary air is exhaled from the trachea into the esophagus through a small silicone prosthesis connecting the two, and the vibrations are generated by the lower pharynx (Fig. 3).4 To divert the exhaled air through the prosthesis into the esophagus, the stoma needs to be temporarily occluded. This can be done by sealing it with a finger or by pressing on a special heat and moisture exchanger (HME) worn by the laryngectomee. An HME restores the lost nasal functions. Some use a hands-free HME (automatic speaking valve) that is activated by speaking. The HME or automatic speaking valve can be attached in front of the stoma in different ways: by means of an adhesive baseplate taped to the skin in front of the stoma, or by means of a laryngectomy tube or stoma button placed inside the stoma. The tracheostomy site has a “housing” for the filter, which is glued to the skin around the stoma (Fig. 4).
Electro or Artificial Larynx Speech
The vibrations are generated by an external electric vibrator (called electro or artificial larynx) placed on the cheeks or under the chin (Fig. 5).
DIFFERENTIATING PARTIAL NECK BREATHERS FROM TOTAL NECK BREATHERS
It is important to recognize and differentiate partial neck breathers from total neck breathers (laryngectomees) because their management is different than that of total neck breathers. In total neck breathers, the trachea is not connected to the upper airways and all breathing is through the tracheostomy site. In contrast, in partial neck breathers although there is tracheostomy site, there is still a connection between the trachea and the upper airway. Even though partial neck breathers breathe mainly through their stoma, they are able to breathe air through the mouth and nose (Fig. 6). The extent of breathing through the upper airways in these individuals varies and a tracheostomy tube is present in many of them. The tube may be protruding from the stoma and is often secured by ties behind the neck (Fig. 2). Failure to recognize this condition may lead to inappropriate treatment.
VENTILATING THE LUNGS OF NECK BREATHERS
Before ventilation, it is not necessary to remove the stoma's housing unless it blocks the airway. Laryngectomy tubes or stoma buttons may be removed carefully. The voice prosthesis (also called tracheoesophageal valve) should not be removed, unless it is blocking the airway. The voice prosthesis generally does not interfere with breathing or suctioning. If the prosthesis is dislodged, it should be removed and replaced with a catheter to prevent aspiration and fistula closure. If present, the tracheal tube may need to be suctioned after insertion of 2 to 5 mL of sterile saline or removed (outer and inner) to clear any mucus plugs. The stoma should be wiped and suctioned. The next step is to listen for breathing sounds over the stoma. The chest may fail to rise because the tracheostomy tube is blocked.
If an endotracheal tube (ETT) is used, care must be taken not to advance it too deeply into a mainstem bronchus. The average distance between the skin of the stoma and carina is approximately 6 cm. Care should also be taken in inserting the tube so that it does not dislodge the voice prosthesis. This may require the use of a tube with a smaller diameter.
When intubation is required, the cuffless tracheostomy tube (if present) is usually removed before induction, to eliminate air entrainment during oxygen administration and air leaking during positive pressure ventilation; oxygen administration and ventilation are usually commenced through the neonatal mask or partially inflated laryngeal mask airway placed over the stoma. If needed, the stoma should be suctioned before induction, and then again, before introducing the ETT, to eliminate the possibility of pushing the mucus plugs/secretions/crusts deep inside the airway. The anesthesiologist should look directly into the stoma during intubation, performing it gently without causing undue trauma to the mucosa of the tract. There is usually no interference between the ETT and the tracheoesophageal valve (if present), if intubation is performed gently.
Ventilation of total neck breathers is generally similar to that performed on normal individuals with one major difference. In neck breathers, ventilation and oxygen administration are done through the stoma or using a mask (infant/toddler or adult turned through 90°). It is useless to attempt mouth-to-mouth ventilation.
Ventilation in partial neck breathers is also done through the stoma. However, even though partial neck breathers inhale and exhale mainly through their stoma, they still have a connection between their lungs and their nose and mouth. Therefore, during positive pressure ventilation via the stoma, air can escape from the mouth and/or nose in partial neck breathers thus reducing the efficacy of ventilation. Partial neck breathers should therefore also receive ventilation through their stoma, but in these individuals, the mouth should be kept closed and the nose sealed to prevent air escape.
PREPARATION FOR PROCEDURES AND SURGERY
Neck breathers describe their unique needs and anatomy before the procedure or surgery to their surgeon(s) and anesthesiologists. Using explanatory illustrations or pictures is helpful. Those with a voice prosthesis should allow the anesthesiologist to view it through their stoma so that they understand its function and do not attempt to remove it during the procedure or surgery. It is helpful to provide the anesthesiologist the video illustrating how to ventilate the lungs of a neck breather, or give him/her the link to it on YouTube.a
Undergoing a procedure with sedation or surgery under local anesthesia is very challenging because speaking with an electrolarynx or voice prosthesis is generally not possible. The stoma is covered by an oxygen mask, and the hands may be restrained. However, individuals using esophageal speech can communicate throughout the surgery if needed. A specific way of communication between the patient and the anesthesiologist must be agreed upon if the surgery will be done under sedation, especially if the planned sedation will be light. There are usually no perioperative airway problems encountered in tracheostomy patients with well-formed stomas.
My recent experience as a patient in a major medical center taught me the importance of discussing my special requirements with the staff before surgery. I had to explain my condition several times, first to surgeons, then to the anesthesiologist examining me in the presurgical visit, and lastly on the day of surgery to the anesthesia team in the operating room. I was to receive local anesthesia and light sedation during a hernia repair.
Before the surgery, I coordinated with the anesthesiologist how I would alert him that I was having pain, or needed to be suctioned. I would use rudimentary esophageal speech by verbalizing “Paa” if experiencing pain and “Suc” to request tracheal suctioning. I also requested that my surgeon ask if I have pain whenever she suspected that the procedure may cause it, and I would nod my head for “Yes” or “No.” The anesthesiologist would convey my response to her.
This presurgical planning paid off, and I had minimal discomfort or pain throughout the 2.5-hour surgery. Fortunately, my anesthesiologist was also able to read my lips, which made it easier to communicate.
I am hopeful that using these suggestions will help laryngectomees get adequate care whenever they undergo a medical procedure or surgery.
Name: Itzhak Brook, MD, MSc.
Contribution: This author prepared the manuscript.
This manuscript was handled by: Steven L. Shafer, MD.
a Brook I. Rescue Breathing of Laryngectomees and Neck Breathers. A 12-minute educational video. Atos Medical Inc., February 2011. Available at: http://www.youtube.com/watch?v=YE-n8cgl77Q. Accessed January 11, 2012. To obtain a copy of the DVD entitled “Rescue Breathing for Laryngectomees and Neck Breathers,” send a request with your address to the author at email@example.com. Video is also available at http://dribrook.blogspot.com/ along with a slide presentation about ventilating neck breathers. Accessed January 11, 2012. Cited Here...