Article courtesy ATOS Medical
The Problem
The least understood consequence of becoming a laryngectomee is the gradual decrease most of us experience in lung capacity and the efficiency of our breathing process. The respiratory process where oxygen is taken in and carbon dioxide is expelled declines in larys along with the volume of air our lungs can hold in the months and years after our surgery, unless we work to keep this from happening. This hidden side-effect for laryngectomees stands in stark contrast to the consequences which are more obvious such as loss of the original voice and having to breathe through the stoma.
We notice other consequences soon after surgery such as not being able to smell much and having to deal with a flow of mucus coming from the stoma. But this loss of breathing capacity and efficiency is not as obvious, and is not even well understood by many medical professionals, particularly in the U.S., since much of the research on this issue has been done in Europe and Japan. Some medical personnel even continue to hold outmoded beliefs including, for example, that laryngectomees are actually better off since they use less energy to breathe than non-larys. Research during the last couple of decades has clearly shown this idea to be wrong.
Why it Develops
To understand why we lose lung capacity and breathing efficiency requires that we understand the changes in our anatomy which occur with the larygectomy surgery. The before and after diagrams below show that the surgery permanently separates the lungs and most of the trachea (windpipe) from the upper part of the respiratory system—the nose, mouth, and throat (pharynx). This bypassing of the nose, mouth and throat actually does make it easier for us to breathe, assuming that the stoma is of adequate size. But rather than being an advantage, this turns out to produce the problem. Because it is easier for us to breathe our lungs no longer inflate and deflate as fully as they did before the surgery. And over time, this reduces the useable capacity, or volume, of our lungs. An expression from physical fitness applies here—“Use it or lose it”.
The reason is easier to breathe and we lose lung capacity is that the upper part of the respiratory system also provided resistance to the flow of air. Our incoming air had to enter the two small nostrils and move in an upward and then curved direction past nose hairs and sticky mucus lined tissues on its way down to the lungs. The lungs had to work harder by more fully inflating to move air through that long pathway. Now it takes a shortcut in and out the stoma, there is much less resistance, and the lungs do not fully inflate. According to the experts, the critical factor occurs with exhalation (called “back pressure” or PEEP-Positive End Expiratory Pressure). It is this part of the breathing process which prevents the collapse of the alveoli, or little air sacks, in our lungs.
A related idea is referred to as dead air. Before becoming a larygectomee, in order to push the carbon dioxide out from our lungs we first had to push the dead air already in the trachea, throat, mouth and nose out ahead of lung air. When we were ready to inhale, we had to first inhale all of that dead air which did not contain much oxygen before the fresh air containing more of it reached our lungs. In order to get the oxygen we needed we had to more fully expand our lungs to make room for the dead air and the fresh oxygen-rich air. You might be able to visualise the dead air issue by imagining that you are breathing through a long tube. Then imagine how much easier it would be to breathe if the tube were much shorter.
What Can Be Done About It
There are at least three ways in which laryngectomees can lessen the deterioration of their respiratory systems: exercise, wearing a type of HME (Heat/Moisture Exchange) filter which has the resistance feature, and practicing with a modified incentive spirometer. I will emphasise the use of the incentive spirometer here, but briefly discuss the other two approaches.
Along with “use it or lose it,” another expression used in physical fitness is “no pain, no gain.” And the more times you engage in activities that cause you to have to catch your breath, the better for your lungs. Laryngectomees do engage in all kinds of strenuous physical activities. There was a recent article on a Larry from the Netherlands who competed and finished the New York City marathon this past autumn, and at least some larys participate in virtually any physical activity you can imagine.
If your idea of exercise is to get out of bed or make the journey to the refrigerator for a cold beer, you may need to begin with a modest exercise program. Walking is a good way to start a physical fitness regimen. The faster you walk the more your heart and breathing rates go up. And the more you exercise your lungs the more they retain volume and efficiency. If you have any doubts about your ability to exercise safely, get a physical check-up with your doctor before beginning. But frequent exercise obviously helps to maintain lung capacity and breathing efficiency.
HME (Heat/Moisture Exchange) filters have been referred to as “artificial noses”. They perform several functions of the nose such as filtering the air we breathe, warming it up, and retaining some of the moisture in exhaled breath within the filter until we inhale again. It turns out that before becoming a laryngectomee the ideal condition for air in our lungs was air filtered clean of impurities, at close to the body temperature of about 98 degrees Fahrenheit (36 C), and close to 100% relative humidity. HMEs cannot duplicate our pre-lary air conditioning system, but can significantly improve it.
In addition to these three functions of filtering, warming and humidifying, HMEs can also provide some resistance to incoming air and make us work a little harder to breathe and thereby retain better lung capacity and efficiency. Research has demonstrated that the sooner after the laryngectomy surgery an HME with resistance is used the more it is tolerated and likely to continue to be used. After the lung capacity has decreased it is more difficult to get laryngectomees to use the HMEs since they may make it feel like it is too difficult to get their breath. Several brands of HMEs are also available for use by hands-free TEP prosthesis speakers (ATOS Provox, InHealth and Kapitex).
HME brands which are specifically designed to emphasise resistance are the Provox finger occluded cassette which comes in two levels of resistance (regular and high flow), and the Kapitex brand which comes with three levels of resistance (night-greatest resistance; day-regular resistance; and a minimum resistance one for use when exercising). Some larys can use the Provox Trichinaze Plus HME system which can be used without an adhesive base plate. This is similar to the use of the ATOS or the In Health filters with the Barton-Mayo Button (Larry tube). Both the Barton-Mayo and Trachinaze Plus must be measured by a clinician for both diameter and length. By making you work a little harder to breathe, the HME forces your lungs to more fully deflate, and then expand.
A third approach to retaining lung capacity is the use of the incentive spirometer. The one shown in the photograph costs about $12 U.S. Choose the type with a one way valve. Hospitals often provide patients with these instruments to work with prior to discharge, particularly if the person was on oxygen while in hospital. The incentive spirometer can be modified for laryngectomee use by substituting a large diameter baby bottle nipple for the mouthpiece. Just cut the nipple part off the baby bottle nipple making the hole smaller than the diameter of the spirometer’s breathing tube. Slip it over the tube.
To use the spirometer, (1) hold it upright (2) exhale (3) place the nipple over your stoma (make a good seal) (4) inhale slowly to raise the piston in the chamber. The spirometer shown will indicate if you are inhaling at the recommended rate, or speed. Continue inhaling and try to raise the top of the piston as high as you can (5) when you cannot inhale any more, remove the mouthpiece and hold your breath for at least 10 seconds (this part of the process has been shown to cause the lungs to inflate to their maximum extent). Rest, and then repeat the process. Cough when you need to. Doing this exercise throughout the day is most beneficial. Move the indicators on the spirometer when you increase the volume, and chart your progress.
The amount of decrease in lung volume and breathing efficiency laryngectomees experience depends on the individual and his or her general activity level. But since many of us became laryngectomees as a result of smoking and are vulnerable to developing additional breathing problems, doing what can be done to retain the best and most efficient respiratory systems makes a lot of sense.
¹David Blevins is a retired college professor. He is the former editor of the “WebWhispers Journal” (now called “Whispers on the Web”)—the newsletter of the Internet-based laryngectomee support group, and the newsletter of the International Association of Laryngectomees, “The IAL News.” He lives in Virginia Beach, Virginia on the Atlantic Ocean side of the U.S., continues to be active in his local laryngectomee support group, and enjoys speaking to high school students about the dangers of smoking and to medical and speech pathology students about laryngectomee rehabilitation.