INTRODUCTION
People with total laryngectomy (PTL) have a permanent separation of the
trachea and oesophagus and rely on a surgically created neck
tracheostoma to breathe. This altered anatomy results in a loss of
filtering and humidification capacity of the upper airways and
consequent reduced respiratory resistance. The detrimental impact of
this on pulmonary health is well-established, with increased bronchial
secretions and reduced mucociliary clearance resulting in increased risk
of chest infections, reduced respiratory capacity and negative effects
on quality of life1,2. Additionally, the permanent
tracheostoma leaves PTL at risk of airway invasion by airborne particles
or foreign bodies. PTL are advised to use a tracheostoma cover to
protect the airway and to optimise pulmonary health.
A number of different tracheostoma covers are available: simple covers
with no humidification properties (e.g. scarves); foam-based covers or
bibs that offer some humidification3; closed-system
heat moisture exchange (HME) devices comprising a filter cassette
secured with an adhesive baseplate or laryngectomy tube (Figure 1).
Closed-system HMEs have been available on prescription in the UK since
the mid-1990s and are now considered the gold standard for
humidification for PTL. UK guidelines recommend the use of HME as soon
as possible post-surgery4 and initiation of HME use at
day one post-surgery has been reported5.
While closed system HMEs are more expensive than alternative stoma
covers3, the benefits are well recognised including
reduced coughing, shortness of breath, mucous production, plug formation
and chest infections5,6,7. There is a correlation
between duration of HME use and pulmonary benefit8.
HME use has been found to significantly enhance quality of life for
PTL9, and can offer PTL with surgical voice
restoration (SVR) improved digital occlusion for voicing and better
speech intelligibility8,9.
Despite evidence of efficacy, variable compliance rates with HME use
have been reported, from 35% to 83%10,5. Reported
reasons for resistance to HME use include excessive mucus production,
blockage of the filter and poor baseplate seal6. In
some healthcare systems the financial burden of HME use may be a
barrier3. Additional factors that could influence use
of HME include patient age, time elapsed since surgery, neck contour,
and the recommendations from different health services, clinicians and
patient communities.
With the onset of the Covid-19 pandemic in March 2020, PTL were thought
to be a high-risk group for contracting and transmitting Covid-19
infection through respiratory droplet formation and aerosolisation due
to their altered airways11,13. This paper reports on
the use of tracheostoma covers as reported by patients and/or their
clinicians during a UK-wide audit of PTL during the first UK national
lockdown period. The audit was initiated in response to queries
regarding the specific risks associated with Covid-19 for PTL. Data on
shielding, hospital admission and mortality have been reported
previously13. The objectives of the current paper are
to report on the following:
The usage of tracheostoma covers by PTL in the UK, specifically use of
a commercially available closed-system HME (termed “HME” for this
analysis) versus all alternatives (termed “non-HME” for this
analysis).
The factors that may influence HME use by PTL in the UK.
Based on literature and clinical experience, we postulate the following
factors may influence HME use in the UK: age, gender, time elapsed
since surgery, distance from the treating centre, employment status,
living circumstances and primary communication method.