Laryngectomy 101

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Picture of Danelle Howard
Danelle Howard
Registered Respiratory Therapist, cross-trained in the Pulmonary Lab, caring for critically ill patients one breath at a time. Professional interests: mechanical ventilation, capnography, and waveforms.

The Pre-brief

Time for trach care.  However, when you begin the process on your patient, you’re unsure what you are seeing.  It doesn’t look like a trach you have ever seen before.  That’s because the patient had laryngeal cancer and required a total laryngectomy.  The trach in place is a laryngectomy tube in the stoma.  

The larynx is a small structure of cartilage that connects the throat to the trachea, facilitates respiration, protects the lower respiratory tract, and plays a crucial role in speaking as it houses the vocal cords.  

A total laryngectomy includes the permanent removal of the larynx along with the vocal cords and associated structures.  This results in a complete restructure of the trachea.  The trachea is transected, and the open end of the trachea is sewn to the neck skin forming the stoma through which the patient breathes.  In a total laryngectomy, air can no longer pass from the lungs into the oral cavity as there is a permanent disconnection between the upper and lower airways. All breathing occurs through the stoma labeling the patient as a Total Neck Breather.

Phonation

There are a few different ways to phonate with a total laryngectomy.  

  • Electrolarynx is an external voice battery-operated voice synthesizer. 
  • Esophageal speech uses the body’s natural tissues to produce sound by swallowing small amounts of air trapped in the mouth, pushed into the upper esophagus, causing vibration. 
  • Tracheoesophageal puncture speaking valves (TEP).

TEP

Some patients will have a TEP which is a small hole made between the trachea and esophagus. A TEP prosthesis, a small circular one-way valve, is placed inside the TEP.  The one-way valve allows for air from the lungs to pass through the trachea and enter the esophagus, causing the walls of the esophagus to vibrate, producing voice. The valve also prevents gastric content from entering the airways. The patient must cover the stoma with their thumb to force exhaled air through the one way valve, thus creating speech.  If the stoma is left open, the normal route of humidification is bypassed. An HME can be attached to the stoma or a Buchannan Bib can be utilized for filtration and humidification. 

Equipment needed at the bedside

  • Soft, flexible suction catheters.
  • A humidified device such as an HME. The HME, which looks like a flat plastic button, inserts into the Lary tube, creating a tight seal.  It serves as a filter keeping out larger airborne particles and provides moisture and heat to the respiratory tract preventing less secretion production and decreasing viscosity.  The HME also reestablishes the normal airway resistance of inhaled air which preserves lung capacity.  Important to note that the HMEs must be changed every 24 hours. 
  • Soft laryngectomy tube “Lary Tube.”
  • 5.0 cuffed ETT
  • BVM with a pediatric mask

HME preferred choice 

Without the upper airway filtering and humidifying the air inhaled into the lungs, there is a decrease in humidity resulting in an increase in secretion production and increase in viscosity. A study done by Foreman et al. enrolled 48 patients undergoing total laryngectomy. Post-op, 16 patients had an HME placed on the Lary tube while the other 32 patients were placed on external humidification.  12.5% of the population wearing HME experienced mucus plugging, while 87.5% of the external humidification population experienced mucus plugging. The study concluded that the use of HME’s could reduce in-hospital complications, in particular mucus plugging. 

Bedside Care

  • Post-op, the stoma and TEP will require more frequent care due to secretion accumulation. 
  • Trach care is done once a shift. Remove the lary tube and clean with 1 part peroxide/1 part saline.
  • Clean the surrounding area removing dried secretions with tweezer size forceps. 
  • While the lary tube is out, make sure you can visualize the TEP.  If not visible, call the ENT Team.
  • Check HME every 4 hours, making sure there is no secretion build-up and discarding if saturated. 
  • Change HME every 24 hours.
  • Remove HME and suction only as needed. 

      *May vary depending on facility*

Resuscitation

If your patient goes into distress and either needs resuscitation or intubation for mechanical ventilation, manual ventilation should be done using a BVM with a pediatric mask over the stoma site. A cuffed ETT should be directly inserted into the stoma just deep enough that the balloon is nearly visible under the skin. 

The Debrief

  • Laryngectomy stomas are different from tracheostomies and require different patient care.  
  • There is a permanent disconnect between upper and lower airways labeling the patient a total neck breather. 
  •  A study concluded HME’s are more beneficial than cold aerosol in this patient population.

References

  1. Foreman, A., Santis, R. J. D., Sultanov, F., Enepekides, D. J., & Higgins, K. M. (2016, July 7). Heat and moisture exchanger use reduces in-hospital complications following total laryngectomy: a case–control study. Journal of Otolaryngology – Head & Neck Surgery. https://journalotohns.biomedcentral.com/articles/10.1186/s40463-016-0154-2. 

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