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The Benefit of Heat And Moisture Exchangers in Post Larygectomy Patients in Warm and Humid Climate Click to edit

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By: Dr Fong Voon Hoong

Supervisor: Prof. Dr Abdullah Sani Mohamed Mr Iqbal Farim bin Rizal Wong

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Introduction
The function of upper respiratory tract in climate conditioning:
1)

2) 3)

heating and humidifying the inspired air providing airway resistance prevent dust entry through mucociliary mechanism

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Respiratory Heat and Water Exchange


Inspired air - is warmed by convection - is moistened by the evaporation from the mucosal epithelium Mucosa is cooled by evaporation

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During normal breathing, inhaled air reached body temperature 37C and 100% saturated with water vapour (44mgH2O/L) in the main bronchi a few cm below the carina (Walker JE et al,1961) saturation boundary

Isothermal

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During

ISB Heat is transferred back to the mucosa The cooler the air, the less water vapour it contains Hence, water vapour is released by condensation 20-25% of previously exchanged heat and moisture is returned to the mucosa (Rathgeber J & Zuchner K, 1999)
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expiration, alveolar air is similar to

Post

laryngectomy, part of the upper airway has been bypassed. Inspired air pass through a shorter respiratory tract ISB shifted lower down Longer part of respiratory tract not having optimal temperature and humidity

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Mucosa -

becomes too dry and too cold leading to hyperactivity of mucosa and goblet cells Increased sputum production, spontaneous coughing, forced expectoration, dyspnoea and recurrent pulmonary infections (Hilgers Fj et al 2000)

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Heat and Moisture Exchangers (HMES)

General

principle: condensation and evaporation of water to retain water from expired air

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During expiration, water vapour condenses on HME material, which has a lower temperature Condensation also releases heat Following inspiration, water from HME foam evaporated to the air, coupled with heat absorption

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Consistent

use of HMEs has been proven to reduce pulmonary symptoms and voice quality. (Ackerstaff AH et al) of HME is generally considered a standard in improvement of pulmonary function in laryngectomized individuals (Kaanders JH et al)

Use

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WHY this study


So

far all studies are done in Europe and United States, in cold and dry enviroment No data about effect of HMEs in warm and humid climate as in Malaysia and South East Asia in general The closest is a recent study on endotracheal temperature and humidity in patients in a warm and dry environment and the effect of a heat and moisture exchanger (Scheenstra et al, 2010)

- concluded that HMEs have beneficial clinical effect in warm and dry environment.
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Respiratory

symptoms worsens during wintertime and cold climate has been observed that a temporary stay in subtropical climate significantly improved peak expiratory flow in 61 Norwegian laryngectomees (Natvig et al, 1984)

It

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It

is argued that an HMEs are unlikely to be contributory in warm and humid climate as the environmental conditions are almost similar to the endotracheal climate No evidence-based recommendation This would be the first study in this region to evaluate the direct effect of HMEs in warm and humid climate

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Objectives
General

objective:

To evaluate the effect of HMEs on the pulmonary symptoms of laryngectomized patient

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Specific

objectives:

To document pulmonary symptoms in postlaryngectomy patients before HMEs use. To perform an assessment using a structured questionnaire on respiratory symptoms in postlarygectomy patients after HMEs.

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Hypothesis
The

use of HMEs improves the pulmonary complaints among post laryngectomy patient in warm and humid climate

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Methodology
Study

design: Prospective cohort Department of ORL-HNS, PPUKM Department of ORL-HNS, HKL of study: Dec 2011- Dec 2013 size: 20 method: Convenience sampling
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Venue:

Period

Sampling Sampling

Inclusion

criteria:

1) Post laryngectomy patients under ENT follow up at HKL and HUKM

Exclusion

criteria:

1) Patients with pre-existing chronic lung diseases or obstructive lung diseases prior to laryngectomy

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Methods
Study

tools:

Data collection form Questionnaire

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Data Collection Form


Name : RN no : Age : Sex : Race: Occupation : Medical illness : Date of diagnosis : Date of laryngectomy:
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Questionnaire 1 (Before HMEs)


Symptoms Grade (1-5) 1) Spontaneous cough _____ 2) Sputum production _____ 3) Dyspnoea _____
Grade 1- mild 2 mild moderate 3- moderate 4- moderately severe 5- severe

Frequency of sputum production The week before trial Monday - Tuesday ___x - Wednesday ___x - Thursday ___x ___x

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Questionnaire 2 (After HMEs)


Symptoms Grade (1-5) 1) Spontaneous cough _____ 2) Sputum production _____ 3) Dyspnoea _____
Grade 1- mild 2 mild moderate 3- moderate 4- moderately severe 5severe

Frequency of sputum production 4th week of trial Monday ___x


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Flow Chart
Study proposal approved by Ethics Committee Patients are recruited from ENT Clinic/ Ward UKMMC & HKL Explanation & obtain informed consent Patients provided with the questionnaire to fill up Fresh laryngectomees - at least 4 weeks post laryngectomy Old laryngectomees on the same setting when consent is taken HMEs are provided to patients after5/26/12 first

Follow up phone calls weekly again to ensure compliance Follow up after 4 weeks of HME use Patients to fill up the same questionnaire again Data collection and compilation Analysis of data with SPSS

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Budget Estimation

Provox HME Cassette HiFlow = 560 x RM 14 = RM 7840 LaryTube = 20 x RM 850 = RM 600 Stationary = RM 200 Phone calls = RM0.50 x 100 = RM 500 Total = RM 25540

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References

Walker JE, Wells REJ, Merrill EW: Heat and water exchanger in the respiratory tract. Am j Med 1961; 30: 259-267 Rathgeber J, Zuchner K: Foundations of artificial respiration. Manual for medical doctors and nurses. Ebelsbach, Aktiv Druck &Verlag Gmbh, 1999 Hilgers FJ, Ackerstaff AH: Comprehensive rehabilitation after total laryngectomy is more than voice alone. Folia Phoniatr Logop 2000; 52: 65-73 Ackerstaff AH, Fuller D, Irvin M, Maccracken E, Gaziano J, Stachowiak L: Multicenter study assessing effects of heat and moisture exchanger use on respiratory symptoms and voice quality in laryngectomized individuals. Otolaryngol Head Neck Surg 2003; 129:705-712

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References

Kaanders JH, Hordijik GJ: Carcinoma of the larynx: the Dutch national guidelines for diagnostic, treatment, supportive care and rehabilitatio. Radiother Oncol 2002; 63: 299-307 Scheenstra RJ, Muller SM, Hilgers FJM. Endotracheal temperature and humidity in laryngectomized patients in warm and dry environment and the effect of heat and moisture exchanger. Head Neck. Oct 27

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