Exercise Testing in Laryngectomized Patients | 215 9 Introduction A total laryngectomy (TL) is performed as primary treatment for advanced stages of laryngeal and hypopharyngeal carcinomas or as a salvage treatment. As TL separates the upper and lower respiratory tracts, air no longer passes through the upper airways. Instead, air is inhaled through a stoma in the neck, where it immediately enters the lower airways 1,2. The upper airway heats, humidifies and filters inhaled air. After a laryngectomy, these functions are lost. As a result, patients experience increased pulmonary symptoms, such as involuntary coughing, mucus retention, and a need for forced expectoration to clear the airways3,4. Additionally, patients have a higher risk of infection and inflammation of the airways 5,6. These airway problems significantly influence sleep, social contacts and quality of life7. Stoma cloth covers (bibs) and Heat and Moisture Exchangers (HMEs) have been developed to restore some of these lost functions. Bibs are worn in front of the stoma. They can provide a good level of heating and moisturizing of the inhaled air when worn correctly, and are reusable and inexpensive8. On the downside, bibs give difficulty in occluding the stoma to speak, have a high breathing resistance and are usually not preferred by patients. Therefore, HMEs are the preferred devices in most developed countries9. HMEs are placed in an adhesive baseplate which is placed over the patient’s stoma or in a canula. The device passively retains the heat and moisture from expired air, which is then transferred to the inhaled air of the next breath10–12. HMEs improve the tracheal climate, resulting in less involuntary coughing and less sputum production11. Long-term use of HMEs has shown to prevent and even restore the loss of tracheal ciliated cells and improve quality of life12. The size of the HME as well as the internal pore sizes and salt concentration determine the performance and resistance of an HME13,14. HMEs worn in front of a stoma have limited space and size. As a consequence, there is always a compromise between efficacy/performance of and HME and its resistance. HME resistance has been reported as a limiting factor for compliance (continuous use of HME) and might cause discomfort during physical activity, when ventilation demand increases11. Such discomfort contributes to lower levels of HME compliance and may cause patients to avoid physical activity or exercise. This, in turn, can lead to poorer overall health and fitness as well as a lower quality of life15. There are multiple HMEs available, with different levels of resistance and humidification, aiming to serve specific purposes such as higher filtration of (polluted) air or enhancing suitability for physical activities. In general, it is accepted that better HME’s (with higher resistance), and high compliance (wearing them 24/7) have a positive effect
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