Stoma Care

 

 

 

 

hme (heat/moisture exchange)

 

Total Laryngectomee Rehabilitation and HMEs

(From WW Journal, February 2002)


For decades, the concept of "total laryngectomee rehabilitation" has been the dominant ideal and goal for laryngectomees in the U.S. and elsewhere in the world.  Additionally, there is evidence that some form of the concept has existed for as long as people have survived the surgical removal of their larynges.  It is the clear focus of organizations like the International Association of Laryngectomees and can be seen in the IAL Bylaws:

"Each member organization shall cooperate with quasi-medical agencies and organizations whether they be public, private or government, if they are able to assist in the total rehabilitation of laryngectomees."  (Article IV, Section C, Number 6.)

"To explore programs and projects designed to improve communication skills and lead to the total rehabilitation of laryngectomees."  (Article VIII, Section A, Subsection 6, Rehabilitation Committee, Part a.)

"Total laryngectomee rehabilitation" (TLR) seeks to return laryngectomees to as much of the lives they enjoyed before losing their larynges as is possible for each individual. Voice restoration has been a primary focus, but psychological, social and vocational rehabilitation have also been themes linked with the TLR concept.

Two other goals have been less prominent in the United States than in Europe, and these are the restoration of the ability to smell and improved breathing function.  While the U.S. has been a pioneer in voice restoration through the development and refinement of artificial larynges and the TEP (tracheo-esophageal puncture) prosthesis, it has lagged behind developed countries in these two areas.  And it is to respiratory rehabilitation that HME (heat/moisture exchange) filters have been designed to address.



EXCHANGING HEAT AND MOISTURE



Any good stoma cover or filter will act to some extent as an "artificial nose" - will warm and humidify incoming air by absorbing exhaled moisture, which the next incoming breath passes through before entering the stoma and then lungs. The difference in the devices that have been named and accepted by Medicare as "HMEs" is that they seal all around the stoma, so that ALL incoming air must pass through them - none can get in around the bottom or sides - and thus they are often more effective - but not necessarily so. For instance, a Buchanan Stoma Protector, tied snugly around the neck and tucked under the shirt collar, will do a very, very good job of heat-moisture exchanging - not as perfect and complete as an HME, but much, much better than nothing - and as much as a lot of people want or need, especially for the price. Even one of the foam filters under a cotton turtle neck or mock turtle neck will do a pretty good job, as will many of the other types/brands of stoma covers/filters.
 
Another thing the HMEs do is to force the lungs to work harder to breathe in and out - more like they had to when they had to bring in the air over the tissues of the nose. Again, good stoma covers/filters will do this too - but, again, not quite so completely since they don't seal around the stoma.
Dorothy Lennox

 

HMEs


Heat/Moisture Exchange (HME) filters are a type of stoma cover which help laryngectomees partially restore functions previously performed by our noses and upper airways.  They might be thought of as "artificial noses."  As the name implies, an ?exchange? of heat and moisture occurs in the HME filter as a laryngectomee inhales and exhales.  During exhalation, warmth and humidity are conveyed from the lungs and deposited into the filter.  During inhalation, the warmth and moisture are picked back up by incoming air and returned to the lungs.

HMEs are receiving more attention in the U.S. as the results of research which has been conducted in several European countries becomes more widely known, and certainly because they are now covered by Medicare.

Before the laryngectomy, the upper half of the breathing system filtered, humidified and warmed incoming air.  It also provided resistance so that the lungs fully inflated.  This helped maintain lung capacity, and facilitated an efficient exchange of gasses in the lungs (oxygen added to the blood stream and carbon dioxide removed).  Prior to the laryngectomy, by the time the inhaled air reached the lungs it was saturated with moisture and its temperature was close to the body temperature of 98 degrees Fahrenheit (37 Celsius).  Air at 100% relative humidity and 98 degrees is ideal for oxygen/carbon dioxide gas exchange.  After the laryngectomy, the incoming air was dirtier, drier and cooler.

The resistance function of the nose and upper airway might be a little more difficult to understand than dirtier, drier and cooler air and the problems those produce for laryngectomees.

Prior to the laryngectomy, the nose provided 80% of the resistance to breathing; with the mouth, larynx and trachea providing the rest.  By providing resistance the lungs had to move air a further distance, and past curved and sticky mucus covered surfaces which resisted the air flow.  This consequently made us "work" harder to breathe.  We had to breathe more deeply to move the amount of air we needed.  This helped maintain lung capacity (the volume of air our lungs could hold), and the efficiency of the gas exchange in the lungs where oxygen is added to the blood stream and carbon dioxide is removed.  The quantity of oxygen in the blood of laryngectomees is measurably reduced if they do not compensate for the loss of resistance.  And our breathing efficiency typically declines, particularly in the months immediately following the surgery.

All laryngectomees can use an HME regardless of their method of speech.  There are basically two different types of HMEs, and two major ways to attach them to the stoma.  One HME type is designed for TEP prosthesis speakers who cover their stomas (occlude) with a finger or thumb in order to speak.  This same type filter can be used by traditional esophageal speakers or those who use ALs (artificial larynges).  It consists of a housing and a filter.

A second type of HME is for TEP prosthesis speakers.  It combines the HME filter with a hands-free valve.  The hands-free valve closes when the TEP prosthesis user exhales, and air is redirected into the prosthesis without having to cover the stoma with a finger or thumb (hence the term ?hands-free?).

There are two basic ways to attach an HME or HME/hands-free valve combination.  In one, the housing is glued to the skin around the stoma, and the HME snaps into the circular hole in middle of the housing.

Some systems have reusable housings and the user applies the glue in liquid form to the housing and then lets it dry.  Other housings are pre-glued and are disposable after using them for a day or two.

In either case, the skin surface around the stoma is first cleaned in order to get good adhesion.  Many use rubbing alcohol for this purpose.  Some of those with sensitive skin also use a product such as ?Skin Prep? or ?Skin Shield? as a barrier between their skin and the housing glue.  Several suppliers have pre-glued disposable housings which use special formula glue for those with sensitive skin.

A second method for using an HME filter is to combine it with a laryngectomee tube (vent, button).  Two laryngectomee tubes/vents/buttons which are designed to accommodate an HME filter are the Lary Tube from ATOS, and the Barton-Mayo Button from Bivona and InHealth.  The Trachi-Naze Plus system combines a lary tube with a finger occluded HME. Both the ATOS Provox filter cassette HME and the InHealth Blom-Singer HME fit into these tubes.  (See "Hands-Free/Glue-Free" article in the October 2000 issue of the WWJ for more details about using the hands-free valve with the Lary Tube or the Barton-Mayo Button.

In addition to helping maintain the cleanliness, temperature, humidity and resistance to the air we breathe, HMEs have other benefits.  In addition to mucus reduction, another of the most important of these is that many laryngectomees who speak via the TEP (tracheo-esophageal puncture) prosthesis report that their voicing is improved through the use of the finger occluded HME or the hands-free valve/HME combination.  In the case of the finger occluded ones, it takes less pressure to get a good seal around the stoma to get a good and loud enough voice, and less pressure is applied to the entire area.  This often results in speech being easier to produce as well as more clear to your listener.

Heat/moisture exchange filters (MHEs) need to be tried for a period of time.  Using them continuously for at least one week is the minimum time they should be tried.  The reason is that unless you just had your laryngectomy, you have gotten used to the lack of resistance to air moving in and out of your stoma.  You may find the initial experience a little unpleasant and feel that the HME is restricting airflow.  It is, but in beneficial ways.  It takes time to get past this sensation and for you to adjust to it.

But in addition to this feeling, it also takes time for the HMEs to demonstrate some of their most important benefits such as reduced coughing and mucus production.  And these benefits are unlikely to become obvious to you for a week, or even longer.  A major mistake would be to try them for a day or less and conclude that they restrict your airflow.  Research has shown that laryngectomees are more likely to stick with the use of HMEs if they are introduced right after the laryngectomy.  The longer we go without using anything which provides resistance the more difficult it becomes to stick with them.  We have simply gotten used to less restricted airflow and the sensation of having to work harder to get air is felt by many to be uncomfortable until they have adjusted to it.

Those with breathing problems such as COPD (Chronic Obstructive Pulmonary Disease), emphysema, asthma, etc., should not try an HME without approval from your MD.  But trying them has been made easy since the three major HME producers will send you a free sample kit of their HMEs (but not the hands-free valve/HME combinations) upon request.

If you wish to try them, you might consider trying those which have the least resistance first, and then move to those with greater resistance.  This would suggest trying the Blom-Singer (or ATOS HiFlo cassette) first, and then to the ATOS Regular cassette, and finally to the Kapitex filters.  The Kapitex nighttime filter provides the greatest resistance, so it should probably be tried last after you have gotten used to the feeling of added resistance to air flow, and it should only be used during sleep.

HMEs cannot completely restore the functions of the nose and upper airway in conditioning the air we breathe to the standards we enjoyed prior to becoming laryngectomees.  They can, however, make a significant different in reducing coughing and excessive mucus production, and deliver a better quality of air to our lungs than the alternative stoma covers.  They can also make a noticeable improvement in voicing for many, and they can help maintain lung function.  While some laryngectomees will decide that they are not worth the additional hassle of using them or their cost, every laryngectomee should at least consider giving them a fair trial.

Free HME Samples

Just call these toll free numbers (or e-mail or write the companies) and request their free HME sample kits.

 

Atos

Six self-adhesive baseplates (round and oval regular, FlexiDerm and OptiDerm adhesive), ten Provox HME cassettes (five normal and five HiFlow), Two Remove adhesive remover wipes, "Life as a Laryngectomee" brochure.

800-217-0025

Fax: 414-227-9033

Email: info.us@atosmedical.com

Atos Medical, Inc.

2202 N. Bartlett Ave.

Milwaukee, WI 53202-1009

 

InHealth

One reusable humidifilter holder, seven foam filters, five TruSeal adhesive disposable housings, and a guideebook. Yo get a one yead membership in Medic Alert by requesting the kit.

800-477-5569

Fax: 805-684-8594

Email: order@inheallth.com

InHealth

1110 Mark Ave.

Carpinteria, CA  93013-2918

 

Kapitex

Five self-adhesive baseplates(two small hydrocolloid, one large hydrocolloid, one non woven adhesive, one clear), three occlusion caps, six green daytime use, and six blue night use filters.

Eagle Medical

11080 Executive Dr.

Boise,ID 83713

877-944-4446

Email: eaglemed@aol.com

Lauminaud

8688 Tyler Blvd.

Mentor, OH 44060

800-255-3408

Fax: 440-255-2250

Email: info@luminaud.com
 

 

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