Heat and Moisture Exchange: Laryngectomy, Issues and Answers

Speech-Language PathologistYale-New Haven HospitalNew Haven, CT 06504lynn.acton@yale.eduIntroduction: Demographics & Risk FactorsApproximately 9,500 Americans were diagnosed with laryngeal cancer in 2003. Laryngeal cancer occurs more frequently in men than women, with a ratio of 6:1 and squamous cell carcinoma is the most frequently occurring type (95%) of laryngeal cancer. There are approximately 55,000 laryngectomees living in the U.S. Approximately 3,800 patients with laryngeal cancer die every year. A "risk factor" is anything that increases a person's chance of getting a disease. Risk factors related to laryngeal cancers are numerous. For example, smoking is a risk factor for laryngeal cancer, and also a risk factor for lung, mouth, bladder, and kidney cancers. The risk of developing a laryngeal cancer is 5 to 35 times greater in smokers than in non-smokers. Alcohol abuse increases the risk of laryngeal cancer by some 2 to 5 times for alcohol abusers. Combinations of tobacco use and alcohol abuse increase laryngeal cancer risk up to 100 times. Other risk factors include; heavy exposure to wood dust and paint fumes and certain chemicals used in metalworking, petroleum, plastics, and textile industries. Nutritional deficiencies, such as not eating enough foods with B vitamins, or vitamin A and retinoids may also be risk factors for laryngeal cancer. Anatomic and Physiologic Considerations:The altered anatomy of the laryngectomee patient impacts more than just their ability to communicate; it affects their entire pulmonary system. In normal patients, inhaled air passes through the nose where it is filtered, warmed to approximately 97 degrees, and humidified to approximately 98%, while passing over the mucosal lining of the nose and the nasopharynx, and traversing the respiratory anatomy of the head and neck. The nose and related air passages increase the resistance of breathing, allowing for complete expansion of the lungs. However, after removal of the larynx, patients breathe through their stoma, bypassing the nose and nasopharynx. Air passing through the stoma is not filtered, humidified or warmed. As the "unfiltererd" air passes straight into the lungs, it can serve as an irritant, increasing secretions and leading to coughing and secretion displacement through the stoma.Once a person has a total laryngectomy, they become "neck breathers." As a result, inspired air is not filtered. Inhaled air enters the lungs at room temperature (typically 68 degrees, but highly variable), humidity is typically 42% (again, highly variable) and there is little resistance upon inhalation, making complete lung expansion difficult. The lack of filtration allows a multiplicity of particles to enter the lungs. The lungs consider these particles "foreign bodies" and produce secretions to remove them. Colder air holds less moisture and drier inhaled air also causes an increase in secretions. These factors may lead to a very serious complication post-laryngectomy, specifically mucus plugs or dried secretions occluding the airway. This complication (occlusion/blockage) can usually be avoided, with appropriate management and care.Heat and Moisture Exchangers:I recommend all laryngectomy patients wear a Heat and Moisture Exchanger (HME). An HME is like an artificial nose, warming the air temperature to 84 degrees and adding humidity, up to 65%. HMEs also filter the air and increases resistance, thereby, decreasing secretion production and allowing a more thorough and complete expansion of the lungs. When patients first wear HMEs, they report it feels "different." They feel increased resistance when they breathe and they may initially notice an increase in secretions. However, after their body adapts to the HME, they'll notice a significant reduction in secretions. I recommend at least a seven-day trial with HMEs. It may indeed take a full week to become adjusted to the product and to really get comfortable with any new HME product. Accordingly, many HME manufacturers give patients free sample packs for a seven day trial period. Some companies suggest trying their product for an entire month to see what the full affect will be, and this may be a good idea as each individual has their preferences. One advantage of wearing an HME is that it can improve a laryngectomee's TEP voice if they have problems occluding a deep set, large, or irregular stoma. Also "hands free" valves can be used with HMEs, which is often a highly desirable option for appropriate patients.There are a number of manufacturers of HME products. The following is a partial list of HMEs:ATOS provides the Provox Stomafilter System (see photo below), Inhealth Technologies has the Humidifilter (see photo below), Kapitex Healthcare Ltd provides the Neo-Naze (see photo below) and Bivona Medical Technologies has the HME cartridge. ATOS, Inhealth and Bivona products are interchangeable. Therefore, if the patient prefers (for example) an ATOS housing with an InHealth humidifilter, or vice versa, they can be "mixed and matched" to best suit the patient's preferences.Costs, CPT codes and Reimbursement Issues:HMEs are not cheap. The least expensive units are approximately $700 per year and the more expensive units are just under $3000 per year. Most patients are reimbursed through their insurance company for HME products, if and when they have durable medical equipment coverage on their individual insurance plan. Of course, each insurance company is different and most offer multiple plans with various levels of coverage. The only way to know with certainty, whether or not the HME will be a "covered product" is to contact the insurance company to review the coverage and reimbursement procedures each time one is ordered or recommended. Importantly, these products are generally considered "medically necessary" for pulmonary health. Medicare does not consider the diagnosis codes 161.9 (cancer of the larynx)/ 784.41 (total laryngectomy) sufficient for reimbursement of tracheostoma covers/filters. Often, as additional diagnosis code must be used as well: V44 (tracheostomy status), V55 (attention to tracheostomy) or 519 (complications from tracheostomy). Of course the application of these codes and services varies with each patient and their individual treatment protocol. The physician and appropriate billing and...