Rescue Breathing For Laryngectomees - WebWhispers
Rescue BreathingFor LaryngectomeesAnd Other Neck Breathers InHealth Technologies
Prepared by the Medical Affairs CommitteeInternational Association of Laryngectomees.Publication layout by Len Librizzi2005
ContentsAcknowledgment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3Purpose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4Total Neck Breather . . . . . . . . . . . . . . . . . . . . . . . . . . . 5Partial Neck Breather . . . . . . . . . . . . . . . . . . . . . . . . . 7Emergency Identification Cards and Jewelry . . . . . 9Determining Person’s Condition andPreparing for Rescue Breathing . . . . . . . . . . . . 10Mouth-to-Stoma Rescue Breathing . . . . . . . . . . . . . 12Alternatives to Mouth-to-StomaRescue Breathing . . . . . . . . . . . . . . . . . . . . . . . . . 14Rescue Breathing Performed by aNeck Breather . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15Summary of Rescue Breathing Procedures . . . . . . 16Emergency Medical Services . . . . . . . . . . . . . . . . . . 17Definition of Terms . . . . . . . . . . . . . . . . . . . . . . . . . . 18International Association of Laryngectomees . . . . 20
AcknowledgmentThe principle guidelines for rescue breathing usedin this booklet were found in the Emergency CardiacCare Committee and Subcommittees, American HeartAssociation, “Guidelines for cardiopulmonary resuscitation and emergency cardiac care, II: Adult basiclife support; III: Adult advanced cardiac life support.”JAMA. 1992; 268:2184-2290.Technical review was provided by the American RedCross.
IntroductionRespiratory arrest can result from a number of causes, including drowning, stroke, foreign-body airway obstruction, smoke inhalation,drug overdose, electrocution, suffocation, injuries,heart attack, lightning strike, and coma. When respiratory arrest occurs, the heart and lungs can continue to provide oxygen to the blood for several minutes. In such cases, blood with oxygen will continue to circulate through the brain as well as other vital organs,and usually a pulse can be detected. When a pulse ispresent, cardiac arrest may be prevented and many livescan be saved if a good airway is established and rescuebreathing is delivered whenever breathing has stoppedor becomes inadequate.When someone stops breathing, the first thing arescuer thinks of is blowing air into the individual’smouth. Mouth-to-mouth rescue breathing is a quickand effective way to provide oxygen to the person.But, this technique will not work if the person isa total or partial neck breather. These individualsbreathe through an opening in their neck, and notthrough their mouth or nose. The only way theywill get oxygen is if it is given to them through the neckopening and not through the mouth or nose. A neckbreather may die if the rescuer is not knowledgeableabout the difference in breathing mechanisms.
PurposeThe emphasis of this booklet is on rescue breathing for laryngectomees (those who havehad their voice box removed), and other neck breathers. The purpose is to help the reader identify a neckbreather, and to describe the procedures used in rescuebreathing for total and partial neck breathers.This booklet is not meant to be all inclusive.It will not provide all of the information you needto know about rescue breathing. It does not includemethods of resuscitation after the heart stops beating (cardiac arrest). Cardiopulmonary resuscitation (CPR)courses are available through many sources, including the American Red Cross and American HeartAssociation. The reader is encouraged not only to takeCPR training, but to take along this booklet to ensurethat the class learns the adaptations of rescue breathingfor neck breathers.See page 18 for definitions of terms used in thisbooklet.
Total Neck BreatherIn the majority of cases, the total neck breather isa laryngectomee; that is, an individual whose larynx(voice box) has been removed because of cancer. It isestimated that there are about 50,000 laryngectomeesliving in the United States. A laryngectomee breathesONLY through a permanent opening in the neck,called a stoma (Figure 1). A metal, plastic, or siliconelaryngectomy tube may be worn in the stoma (Figure2), although not usually. No air passes through thenose or mouth.Nasal aFigure 1Total removal of the larynx results in loss of voice.The laryngectomee may have trouble speaking. Somelaryngectomees speak by shunting air from the lungsthrough a surgically created tunnel between the tracheaand esophagus (tracheoesophageal speech). A tube-likevoice prosthesis keeps the tunnel open and preventschoking and aspiration (Figure 3). The front (tracheal)
LaryngectomytubeLaryngectomytubeFigure 2Tracheaend of the voice prosthesis may or may not be attachedto the neck by a strap. The front of the prosthesis willbe visible inside the stoma (Figure 3).In addition to the voice prosthesis, the tracheo esophageal speaker may be wearing a valve over theNeck strapAdhesivetapeVoice prosthesisVoice prosthesisStomaEsophagusFigure 3Tracheastoma (Figure 4). The tracheostoma valve sits in ahousing that is attached with an adhesive to the skinaround the stoma. This valve assists the laryngectomeein speaking.A laryngectomee can also have an air filter deviceover the tracheostoma valve, or the filter may be alone
TracheostomavalveTracheostomavalve housingFigure 4in the housing. The filter looks like a circle of foamrubber.Partial Neck BreatherThere are individuals who breathe througha stoma although a connection between the lungs,nose, and mouth still exists (Figure 5). The extentof breathing they can do through the mouth ornose ranges from none to a normal flow. A metal, plastic, or silicone traNasal cavitycheostomy tube almostalways is present in thePalatestoma of a partial neckbreather.TonguePharynxVocal cordsEsophagusTracheostomy tubeTracheaFigure 5
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Figure 6bEmergency Identification CardsAnd JewelryLaryngectomees may have a brightly colored emergency card on their person and on thecar window (Figure 6a), and they may wear a special bracelet or necklace (Figure 6b). All of theseitems identify the person as a total neck breather and provide vital medical information which is helpfulin an emergency. It is important to note, however, thatin many areas, emergency medical personnel are notauthorized to go through purses and wallets, so unlessthe card, bracelet, or necklace is clearly visible, thisvaluable information will be missed.
Determining the Person’s Conditionand Preparing for Rescue Breathing1. Determine unresponsiveness:Determine whether the person is unconscious bytapping or gently shaking him/her and shouting, “Areyou OK?”2. Activate emergency medical services:As soon as it has been determined that the person isunresponsive, call 911 or a local emergency telephonenumber.3. Position the person:Place the individual on his or her back on a firm, flatsurface with the arms against the sides of the body. Therescuer should be at the individual’s side. If there is nohead or neck trauma, the rescuer should tilt the headback and lift the chin (Figure 9).4. Expose the neck:Bare the entire neck down to the sternum (breastbone). Remove anything covering the stoma thatprevents access to the airway. Typical stoma coverings include a shirt and tie, cloth or foam stoma cover,necklace, scarf, or metal screen. If the person has atracheostoma valve or filter, remove it from the housing, but leave the housing attached to the skin aroundthe stoma unless it interferes with the rescue breathingprocedures. If the housing has to be removed, it mustbe done carefully because the neck strap to the voiceprosthesis also may be attached to the skin under thehousing, and excessive pulling on the neck strap coulddislodge the prosthesis. Once the housing is removed,the neck strap to the voice prosthesis can be left loose10
while rescue breathing proceeds.Do not remove any tube or voice prosthesis frominside the stoma except the inner tube shown inFigure 8.If the prosthesis becomes dislodged, it shouldbe replaced as soon as possible with an all-purpose catheter of a compatible diameter to prevent aspiration of esophageal contents, and to maintainthe opening between the trachea and the esophagusso that a voice prosthesis can be inserted at a latertime. The catheter size can range from 14 Fr. to20 Fr.5. Determine breathlessness:The rescuer should place his or her ear over theperson’s stoma, then 1) look for the chest to rise andfall, 2) listen for air escaping during exhalation, and 3)feel the flow of air. If the chest does not move and noair is exhaled, the person is breathless. This evaluationprocedure should take only 3 to 5 seconds.6. Examine the stoma and the laryngectomy tubeor tracheostomy tube which may be in the stoma:If there are secretions, a blockage, or obstruction inthe opening, wipe it away. If a suction apparatus withsoft tubing is handy, insert the tube 3 to 5 inches intothe neck opening and suction for a few seconds.11
Figure 7Mouth-to-Stoma Rescue BreathingRescue breathing requires that the rescuer inflatethe person’s lungs adequately with each breath. It isuseless to try mouth-to-mouth breathing in any individual who breathes through an opening in the neck.Direct your attention to getting air/oxygen through theopening or tube in the neck, and not the individual’smouth.Mouth-to-stoma ventilation is performed by therescuer taking a deep breath and making an airtightseal with his or her lips around the person’s stomaor laryngectomy/tracheostomy tube (Figure 7). Therescuer initially gives two slow, full breaths, about2 seconds per breath. This is followed by a pulse check,preferably at one of the two carotid arteries locatedslightly to either side of the midline of the neck. Surgeryand radiation treatments may have hardened the tissues, making it difficult to detect a pulse in the neckarea of a laryngectomee. If this is the case, try an alternate location such as the wrist. If a pulse is present, butthe person is still not breathing, give one breath every5 seconds. Adequate ventilation is indicated by observing the chest rise and fall, and hearing and feeling air12
escape from the person during exhalation.If the chest fails to rise, the person may havea blocked laryngectomy/tracheostomy tube.If air is not passing through the laryngectomy/tracheostomy tube, remove the inner tube (Figure8), and resume rescue breathing. The inner tubeis the lining of the laryngectomy/tracheostomytube and it is a common location for heoutertubeby releasing it from aLockTop oflock on the neck plate innerof the tube (Figure 8), tubeor rotating the inner tubecounterclockwise. EachNeck platestyle of laryngectomy/Innertracheostomy tube has itstubeOuter tube withown locking mechanism.inner tube liningIf you hear or feelFigure 8air escaping from themouth and nose, the person is a partial neck breather.To ventilate a partial neck breather, the individual’smouth and nose usually must be sealed by the rescuer’shand or by a tightly fitting face mask to prevent leakageof air when the rescuer blows into the tracheostomytube (Figure 9). If the tracheos tomy tube has a cuff andit has been or can be inflated, it is not necessary to coverthe mouth and nose as the cuff will prevent the leakageof air to the mouth and nose (Figure 10).13
TubeCuffFigure 9Figure 10Alternatives to Mouth-to-StomaRescue BreathingMany rescuers prefer to use a barrier device duringmouth-to-stoma breathing. An infant or toddler maskis the size most likely to seal around a neck stoma orlaryngectomy/tracheostomy tube neck plate. For mouthto-mask ventilation, there are one-way valve mouth pieceswhich can be coupled to the mask, thereby allowinga rescuer to ventilate the person while avoiding directcontact with exhaled air or discharge from the stoma.One such device is pictured in Figure 11. The rescuermust use one hand to hold down themask while breathing into theValveone-way valve.mouthAnother alternative is to usepieceMaska bag-valve-mask unit, whichFigure 11consists of a self-inflating bagand a one-way breathing valve attached to an infant ortoddler mask (Figure 12). The mask is held firmly overthe stoma as the rescuer squeezes the bag to ventilatethe person. It should be noted, however, that in adults,bag-valve units may provide less ventilatory volume than14
mouth-to-stoma or mouth-to-mask ventilation. Also, asingle rescuer may have difficulty providing a leakproofseal to the stoma and squeezing the bag ade quately.Effective ventilation isValvemore likely when two rescuers use these devices;one to hold the maskand one to squeeze theBagMaskbag. Training is neededFigure 12to become proficient inthe use of the bag-valve-mask unit and an untrained rescuer should use the mouth-to-stoma or mouth-to-maskmethod of ventilation.Rescue Breathing Performed by aNeck BreatherThe bag-valve-mask method of rescue breathingcan be used by a laryngectomee or other neck breatherbecause the rescuer does not have to use his or her ownbreath supply. The neck breather can perform rescuebreathing through the stoma of another neck breatherby using the method just described, or on a normalbreathing child or adult by placing the appropriatesize mask over the mouth and nose of the individualand ventilating by using the bag-valve attached to themask.Rescue breathing methods for infants and childrenare not the same as for adults. Information on thesemethods should be obtained by attending a first aid orCPR course.15
Summary of Rescue BreathingProceduresDetermine unresponsivenessCall 911Expose neck, removing only what is necessaryto get air/oxygen into neck openingIf not breathing, give two slow full breathsCheck pulseIf pulseIf no pulseDeliver one breath every 5 secondsChest risesBegin CPRChest does not riseContinue rescue breathing(one breath every 5 seconds)Check nose and mouthAir escapingNo air escapingCheck and clear blockagein neck openingClose offnose and mouthChest risesContinue rescue breathing(one breath every 5 seconds)16
Emergency Medical ServicesLaryngectomees and other neck breathers shouldnotify their local police and fire departments of theirmedical condition, especially of the fact that they are neckbreathers. In addition, laryngectomees should informemergency medical services personnel that in the eventof an emergency, they may not be able to speak.The use of the 911 telephone system has simplifiedand expedited emergency assistance. A more recentdevelopment is the implementation of “enhanced 911” inmany communities. This option automatically providesdispatchers with the caller’s address, telephone number, and pertinent medical information such as the factthat an occupant is a neck breather or may be unable tospeak. Obtaining 911 service should be a top priority forall commu nities, and enhanced 911 is preferable.17
Definitions of Terms as Used in ThisBookletBag-Valve-Mask: Self-inflating bag and a one-waybreathing valve attached to a mask that is placedover the mouth or stoma for rescue breathing.Catheter: Long, flexible tube, available in a varietyof sizes.Esophagus: “Food tube” extending from the pharynxto the stomach.Laryngectomee: Person whose larynx (“voice box”)has been removed.Laryngectomy: Surgical procedure for removing thelarynx.Laryngectomy tube: A tube worn in the trachea of alaryngectomee to keep open the airway.Larynx: The upper part of the trachea; also known asthe “voice box” because it contains the vocal cords.Neck plate: Wide band of metal or plastic that surroundsthe outside opening in a laryngectomy tube or tracheostomy tube. It fits against the neck to hold thetube in place.Sternum: Breast bone.Stoma: In a laryngectomee, it is an opening in the neckto which the trachea is attached. In a partial neckbreather, it is an opening in the neck leading to thetrachea.18
Trachea: “Breathing tube” extending from the pharynxto the lungs in a person who is not a laryngectomee;and from the stoma to the lungs in a laryngectomee.Tracheoesophageal speech: Produced by shuntingexhaled air from the lungs through a voice prosthesisand into the esophagus where sound for speech isgenerated.Tracheostoma valve: A valve worn over the stomaof a tracheoesophageal speaker. The valve allowsnormal breathing, but closes for speech to redirectexhaled air into the esophagus.Tracheostoma valve housing: A silicone disc thatis affixed to the skin around the stoma. The tracheostoma valve fits into the center of the disc,thereby holding it in place over the stoma.Tracheostomy tube: A tube worn in an opening thatgoes through the neck and into the trachea of a person who has not had their voice box removed, butwho needs to breathe through this opening to assurean adequate airway.Ventilation: Moving air into and out of the lungs.Voice prosthesis: Silicone tube worn in the surgicallycreated tunnel between the trachea and esophagus. Itacts as a one-way valve, shunting air from the lungsinto the esophagus where sound is generated for tracheoesophageal speech.19
International Association ofLaryngectomeesThe International Association of Laryngectomees(IAL) is a voluntary, nonprofit organization dedicatedto the total rehabilitation of laryngectomees. The purposes of the IAL are to promote and support the totalrehabilitation of laryngectomees by the exchange anddissemination of ideas and information to laryngectomee clubs and to the public; to facilitate the formationof new laryngectomee clubs; to foster improvement inhospital laryngectomee programs; and to upgrade theminimum standards for teachers of postlaryngectomyspeech. The IAL publishes educational materials and atri-annual newsletter, maintains a registry of postlaryngectomy speech instructors, and sponsors an annualvoice rehabilitation institute and annual general meeting for laryngectomees.The IAL was formed in 1952 by representatives of anumber of laryngectomee clubs to answer the need forcoordinating the joint actitivities of the clubs. Today,the IAL comprises nearly 300 member clubs locatedthroughout the United States and in several foreigncountries. These clubs usually meet once or twice amonth for informational programs and support. Mostclubs also maintain a patient visitation program coordinated with medical professionals in local hospitalsand clinics.20
International Association of LaryngectomeesBox 691060Stockton, CA 95269-1060Phone: 866-425-3678Website: http://www.larynxlink.com(website is translated into 8 foreign languages)Email: ialhq@larynxlink.com 2003, International Association of LaryngectomeesRev. 1/2005
Rescue breathing requires that the rescuer inflate the person's lungs adequately with each breath. It is useless to try mouth-to-mouth breathing in any indi-vidual who breathes through an opening in the neck. Direct your attention to getting air/oxygen through the opening or tube in the neck, and not the individual's .
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