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Pulmonary Physiology & Optimization Post-Laryngectomy

Pulmonary Physiology & Optimization Post-Laryngectomy. Charley Coffey, MD FACS. Nothing to disclose. Hilgers et al,1990:.

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Pulmonary Physiology & Optimization Post-Laryngectomy

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  1. Pulmonary Physiology & OptimizationPost-Laryngectomy Charley Coffey, MD FACS

  2. Nothing to disclose

  3. Hilgers et al,1990: “Interestingly, (respiratory) symptoms were rarely noted in the patients’ hospital charts. This suggests that physicians and/or patients may consider respiratory complaints to be such a natural consequence of laryngectomy that they are not considered worthy of special note.”

  4. Overview • Fundamentals of upper airway respiratory function • Effects of laryngectomy on respiratory function • Mechanics of HME • Effects of HME

  5. Air movement, gas exchange Respiratory function At rest Expiration Inspiration

  6. Temperature & moisture equilibration:“air conditioning” Respiratory function 72° F/ C / 86° F C / 98.6° F adapted from Fink 2010

  7. HME 11 g/m3 44 g/m3 37°C 30°C 20°C 10°C 0°C

  8. Nasal cavity is key Respiratory function

  9. Particulate filtration Respiratory function Vincent 1984

  10. Reduction in particulate matter (PM) is associated with increase in life expectancy Respiratory function Pope et al. 2009

  11. Mucociliary clearance Respiratory function 1-2 cm/min Wu 2015

  12. Mucociliary clearance Respiratory function Wolff 1986

  13. Laryngectomy ... ❓

  14. TL Effects Respiratory symptoms are common post-laryngectomy n= 59 adapted from Hilgers et al. 1990

  15. TL Effects Key observations: • Patients reported more symptoms during winter months • Winter holiday in warmer climates significantly improved pulmonary symptoms...

  16. TL Effects Intrathoracic resistance increases post-laryngectomy n= 4 adapted from Harris & Jonson 1974

  17. Lung function TL Effects Airway Conductance Inspiratory Expiratory n= 10 Todisco et al. 1984

  18. Mucociliary clearance TL Effects • Progressively impaired as relative humidity drops below 90% • Effectively ceases when relative humidity drops to ~50% at 37°C Mercke 1976

  19. TL Effects Tracheal bacteria increase dramatically within one week after laryngectomy # of bacteria / swab n= 9 days months Todisco et al. 1984

  20. TL Effects • Risk of lower respiratory infections increases >50% • Loss of glottic closure • Normal cough- intrathoracic pressure increases to 150mm Hg with closed glottis • Sudden glottic opening releases air at 50-100 m/ sec • cough much less effective with loss of glottis

  21. TL Effects Natvig 1984

  22. TL Effects Warm, humid climate improves pulmonary flow post-laryngectomy n= 61 # of patients % change in pulmonary expiratory flow adapted from Natvig 1984

  23. Heat & Moisture Exchange HME 37°C 30°C 20°C 10°C 0°C

  24. Options for restoring moisture & heat HME • Move to Canary Islands • External humidification

  25. HME HME Ackerstaff et al. 1993

  26. HME mechanics HME Foam, paper, or other substrate for condensation/ evaporation Impregnated w/ hygroscopic salts (absorb moisture from air), +/- bacterostatic agent • Heat & moisture exchange capacity • Resistance- reduces dynamic airway collapse • Filtration- a bit, but only large particles Zuur et al. 2006

  27. HME mechanics HME Evans, Montgomery, & Gullane ed. 2009

  28. HME effects- temperature & humidity HME n= 11 Sheenstra et al. 2011

  29. HME effects- increases humidityof inspired air HME Absolute humidity (mg H20/ L) adapted from Zuur et al. 2008

  30. HME effects- increases temperatureof inspired air... usually HME Temperature (°C) adapted from Zuur et al. 2006 & 2008

  31. HME effects- temperature & humidity n= 11 Sheenstra et al. 2011

  32. HME effects HME • Reduces respiratory water loss Open stoma x24 hr HME x24 hr Toremalm 1960

  33. HME HME n= 16 HME resistance may* improve tissue oxygen saturation Open stoma Partial pressure (kPa) Open stoma HME Oxygen (pO2) Carbon dioxide (pCO2) adapted from McRae et al. 1995 *findings not replicated by Zuur et al. 2007

  34. HME effects- filtration? HME n= 30 # of patients # of pathogens per pt Open stoma Bib HME adapted from Kramp et al. 2009

  35. HME effects- Symptoms HME n= 30 ⬇ Expectoration ⬇ Coughing Open stoma HME x2 wks HME x6 wks HME x12 wks Parilla et al. 2015

  36. HME effects- Symptoms HME • Also significant improvements in: • Shortness of breath • Sleep • Fatigue • Speech • Psychological stress Jones et al. 2003 Parilla et al. 2015

  37. HME effects HME n= 44 Parilla et al. 2015

  38. HME effects HME n= 44 adapted from Ackerstaff et al. 2003

  39. Summary HME • Laryngectomy results in substantial changes in respiratory dynamics • The consequences of these changes may have profound effects on quality of life • Efforts to replicate the function of the upper respiratory tract may yield major benefits for laryngectomees • Restoration of heat & moisture exchange has the greatest effect; primarily via preservation of mucociliary clearance

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