The most common cause of sudden breathing difficulty in laryngectomees is airway blockage due to aspiration foreign body or a mucus plug. laryngectomees may also suffer from other medical conditions including heart, lung and vascular problems.
Communication methods used by laryngectomees
Laryngectomees use a variety of methods of communication, including writing, silent articulation, sign language and three speech methods. These methods are esophageal speech, voice prosthesis via a tracheo-esophageal puncture (TEP), and electronic larynx (artificial larynx device) speech. Each of these methods substitutes the vibration generated by the vocal cords with another source, while the actual formation of words is performed by the tongue and lips.
Many partial neck breathers breathe through a tracheostomy tube, which may be protruding from the stoma and is often strapped to the neck. Failure to recognize a partial neck breather may lead to inappropriate treatment.
1. Determine the patient's unresponsiveness
2. Activate the emergency medical services
3. Position the person by raising their shoulders
4. Expose the neck and remove anything covering the stoma such as filter or cloth that may prevent access to the airway
5. Secure the airway in the stoma and remove anything blocking the airway such as the filter or
6. Clear any mucus from the stoma.
It is not necessary to remove the stoma’s housing unless it blocks the airway. Laryngectomy tubes or stoma buttons may be carefully removed. The voice prosthesis should not be removed, unless it is blocking the airway, since it 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 2-5 cc of sterile saline or be entirely removed (both outer and inner parts) to clear any mucus plugs. The stoma should be wiped and suctioned. The next step is to listen for breathing sounds over the stoma. If the tracheostomy tube is blocked the chest may fail to rise.
A slide presentation about the emergency care of neck breather can be downloaded or obtained by contacting Dr I Brook at email@example.com
Ensuring adequate urgent care for neck breathers including laryngectomees
Neck breathers are at a high risk of receiving inadequate therapy when seeking urgent medical care because of shortness of breath. I experienced this myself on several occasions when I needed urgent care at local emergency rooms when the nurses mistakenly administered oxygen to me through my nose and not through the tracheotomy site.
Neck breathers can prevent a mishap by:
1. Wearing a bracelet that identifies them as neck breathers
2. Carrying a list describing their medical conditions, their medication, the names of their doctors and their contact information
3. Placing a sticker on the inside of their car windows identifying them as neck breathers. The card contains information about caring for them in an emergency
4. Using an electrolarynx can be helpful and allow communication even in an emergency. Those who use a TEP for speech may not be able to speak because their HME may need to be removed.
5. Placing a note on their front door identifying themselves as a neck breather
6. Informing the local 911 emergency services, EMSs and police department that they are neck breathers and may not be able to speak during an emergency
7. Ensuring that the medical personnel of their local emergency rooms can recognize and treat neck breathers
It is up to laryngectomees to be vigilant and increase the awareness of the medical personnel and EMSs in their area. This can be an ongoing task, since knowledge by health providers may vary and change over time.
A slide presentation, a video presentation, and an instructive manual that explain how to recognize, provide respiratory resuscitation, provide oxygen, ventilate and perform CPR to laryngectommes is available in this blog. The slide presentation can be downloaded and saved.
A video that explains the methods needed to administer urgent respiratory care to neck breathers can be viewed on YouTube.
To obtain a free DVD of the video e mailing a request to Dr. Brook at firstname.lastname@example.org
Neck breathers should share these presentations with their emergency care givers (Closest ED and EMS).
Undergoing a procedure with sedation or surgery under local anesthesia is challenging for a laryngectomee because speaking with an electrolarynx or voice prosthesis is generally not possible. This is because the stoma is covered by an oxygen mask and the patient's hands are typically bound. However, individuals who use esophageal speech can communicate throughout the procedure or surgery done under local anesthesia.
Cardio-Pulmonary Resuscitation (CPR) new guidelines
An official video that demonstrates the Hands-Only CPR is available.
Because laryngectomees cannot administer mouth to mouth breathing the old CPR guidelines excluded them from providing the respiratory part of CPR. Since the new guidelines do not require mouth to mouth ventilation laryngectomees can also deliver CPR. However, when possible the old CPR method using both airway ventilation and cardiac compressions should be utilized. This is because the "chest compressions only" method cannot sustain someone for a long period of time since there is no aeration of the lungs.
Laryngectomees who require CPR may also need respiratory ventilation. One of the common causes of breathing problems in laryngectomees is an airway obstruction due to a mucus plug or foreign body. Removing these may be essential. Mouth to stoma resuscitation is important and relatively easier to deliver than mouth to mouth breathing.
Laryngectomees who breathe through a Heat and Moisture Exchanger (HME) and perform CPR on a person in need of resuscitation may need to temporarily take their HME off. This allows laryngectomees to inhale more air when they deliver up to one hundred heart compressions per minute.