www.bjorl.org
Brazilian
Journal
of
OTORHINOLARYNGOLOGY
ORIGINAL
ARTICLE
Evaluation
of
lung
function
in
patients
submitted
to
total
laryngectomy
夽,夽夽
Mario
A.
Castro
a,∗,
Rogério
A.
Dedivitis
a,
João
M.
Salge
b,
Leandro
L.
Matos
a,
Claudio
R.
Cernea
aaUniversidadedeSãoPaulo(USP),FaculdadedeMedicina,DepartamentodeCirurgiadeCabec¸aePescoc¸o,SãoPaulo,SP,Brazil bUniversidadedeSãoPaulo(USP),FaculdadedeMedicina,InstitutodoCorac¸ão(INCOR),DepartamentodePneumologia,São
Paulo,SP,Brazil
Received20February2018;accepted13May2018 Availableonline29June2018
KEYWORDS Respiratoryfunction tests; Spirometry; Plethysmography; Laryngectomy; Squamouscell Abstract
Introduction:Thepost-laryngectomystateischaracterizedbyseveralalterationsinlung func-tion.A reliableestimationoflungfunctioncanbevery usefulinlaryngectomeestoprevent postoperativecomplicationsandtoevaluatetheresultsofthetreatment.
Objective: Characterizethepresence ofrespiratory functionaldisordersandthe functional patternoflaryngectomeesthroughtheuseofanextratrachealdevice.
Methods:Thistransversalstudyincluded50patientssubmittedtototallaryngectomyatleast 6monthspriortothisinvestigation,asthetreatmentofchoiceforlaryngealcancer.
Results:56%percentoftheparticipantshadalteredbreathingpattern,distributedasfollows: 14withobstructivepatternwithnoairtrapping,11withobstructivepatternwithairtrapping andonly3withrestrictivepattern.On average,thediffusiondecreased(74.3%)andairway resistanceincreased(121.7%)whencomparedtotheexpectedaveragevaluesfortheBrazilian individuals.
Conclusion: Mostpatientssubmittedtototallaryngectomypresentalteredlungfunction, usu-allytheobstructivetype,frequentlyassociatedtoahistoryofsmoking.
© 2018 Associac¸˜ao Brasileira de Otorrinolaringologia e Cirurgia C´ervico-Facial. Published by Elsevier Editora Ltda. This is an open access article under the CC BY license (http:// creativecommons.org/licenses/by/4.0/).
夽 Pleasecitethisarticleas:CastroMA,DedivitisRA,SalgeJM,MatosLL,CerneaCR.Evaluationoflungfunctioninpatientssubmittedto
totallaryngectomy.BrazJOtorhinolaryngol.2019;85:623---7.
夽夽Institutions:FaculdadedeMedicinadeSãoPaulo,UniversidadedeSãoPaulo,SãoPaulo,SP,Brazil.
∗Correspondingauthor.
E-mail:[email protected](M.A.Castro).
PeerReviewundertheresponsibilityofAssociac¸ãoBrasileiradeOtorrinolaringologiaeCirurgiaCérvico-Facial. https://doi.org/10.1016/j.bjorl.2018.05.008
1808-8694/©2018Associac¸˜aoBrasileiradeOtorrinolaringologiaeCirurgiaC´ervico-Facial.PublishedbyElsevierEditoraLtda.Thisisanopen accessarticleundertheCCBYlicense(http://creativecommons.org/licenses/by/4.0/).
PALAVRAS-CHAVE
Testesdefunc¸ão respiratória; Espirometria; Pletismografia; Laringectomia; Célulaescamosa
Avaliac¸ãodafunc¸ãopulmonarempacientessubmetidosàlaringectomiatotal
Resumo
Introduc¸ão:A condic¸ão pós-laringectomia é caracterizada por várias alterac¸ões na func¸ão pulmonar. Uma estimativa confiável da func¸ão pulmonarpode ser muito útil em pacientes laringectomizados para prevenir complicac¸ões após as intervenc¸ões cirúrgicas e avaliar os resultadosdotratamento.
Objetivo:Caracterizarapresenc¸adedistúrbiosfuncionaisrespiratórioseopadrãofuncional depacienteslaringectomizadosatravésdousodeumdispositivoextratraqueal.
Método: Estudotransversal que incluiu 50 pacientessubmetidos àlaringectomia total pelo menos seis mesesantesdesta investigac¸ão,como tratamentode escolhapara ocâncer de laringe.
Resultados: Dos participantes, 56% apresentavam padrão respiratório alterado, assim dis-tribuídos:14compadrão obstrutivosemaprisionamentoaéreo,11compadrãoobstrutivoe aprisionamentoaéreoeapenastrêscompadrãorestritivo.Emmédia,verificou-sequeadifusão encontrava-sediminuída(74,3%)earesistênciadasviasaéreasaumentada(121,7%)emrelac¸ão aosresultadosesperadosembrasileiros.
Conclusão:A maioriadospacientessubmetidos àlaringectomia totalapresenta func¸ão pul-monaralterada,dotipoobstrutiva,quasesempreassociadaahistóriadetabagismo.
© 2018 Associac¸˜ao Brasileira de Otorrinolaringologia e Cirurgia C´ervico-Facial. Publicado por Elsevier Editora Ltda. Este ´e um artigo Open Access sob uma licenc¸a CC BY (http:// creativecommons.org/licenses/by/4.0/).
Introduction
Many patients with larynx cancer submitted to surgical treatmentpresent ahistoryofsmoking.Inthesepatients, pulmonarycomplications canleadtodeathinthe postop-erative period. Around 81% of them suffer from chronic obstructivepulmonarydisease(COPD).1,2
Theevaluationofrespiratoryfunctioninlaryngectomized patientshasbeenthesubjectofstudysinceHeyden’spaper of1950.3Duetotechnicaldifficultiesfortheperformance
ofthisevaluation,theliteratureonthissubjectis contro-versial.
Due to a history of smoking before laryngectomy as wellasthenon-physiologicalconditionsoftheairways,the post-laryngectomystatepresentsseveralalterationsinlung function,reflectedinthesumofventilatorychanges.Theair inhaledthroughthetracheostomaaftertotallaryngectomy doesnotgothroughthenatural conditioningoftheupper respiratorytract;hencethefiltrationofsolidparticles trans-mitted by both air andaerosols is reduced. Furthermore, theinhaled air is submitted neithertohumidification nor heating.Incomparisonwithrespiration throughtheupper respiratorytract,thetracheotomizedpatienthasan aero-dynamic reductionin the resistance tothe airflow during inspiration and expiration and this may cause a negative effectintheperipheralventilationofthelung.4,5Oneofthe
mostimportantprognosticfactorsin thesurvivalof laryn-gectomizedpatientsistheprogressivedeteriorationoftheir lungfunction.6,7
Areliable estimationoflung function canbevery use-ful in laryngectomees to preventcomplications occurring afterinsurgicalinterventions,toevaluatetheresultsofthe treatmentandevenforpreventivepurposes.8
Atrachealcannulawithacuffconnectedtothe spirom-eter is normally used to evaluate lung function in these patients.1,6,9 However, the use of a cannula is not the
ideal option. First, it is an uncomfortable experiencefor thepatientandleadstocoughing.5Furthermore,duetoa
decreaseintherealdiameterofthetrachea,theresultsof forcedexpirationandinspirationtestsarenotprecise.The useoftrachealmasksmanuallyplacedoverthetracheotoma hasalreadybeenreportedforthesamepurpose;however, theypermitairleakage.2
Fewofthepapersfoundintheliteraturehaveevaluated lung function in laryngectomized patients with extratra-chealdevicesmakinguseofthereproduciblemethodology.10
The aim of this study is to characterize the presence ofrespiratoryfunctionaldisordersandthelaryngectomees functional pattern through the use of an extratracheal device.
Methods
This research was approved by the Institutional Review Board,undernumber075/14,onMay12th,2014.
This transversal study included 56 patients who had undergonetotallaryngectomyatleast6monthspriortothis investigation,asthetreatmentofchoiceforlaryngeal can-cer. Thepatients wereenrolledbetweenMarchandJune, 2014.
Exclusionfactorswere:acuterespiratorydiseaseinthe previous 30days;theabsenceofclinicalconditionsatthe timethetestswerecarriedout;andtheinabilitytocarry outanytestinthestudy.
Demographic data were obtained, including a history of smoking prior to surgery and occasional respiratory
difficulties (Dyspnea Scale --- Medical Research Council),11
throughpatientrecollectionandmedicalrecords.
Tests were carried out with subjects in the sitting position, connected to the spirometer by an adhesive extratrachealdevicewithasiliconeadaptorforhands-free typevalves(Provox®,AtosMedical,Horby,Sweden)10 since
participants werelaryngectomized, thus making it impos-sible toperform a conventional lung function test with a nozzle.
The apparatususedfor thelung functiontestsand ple-tysmographywasEliteDX(MedicalGraphicsCorporation®, SaintPaul,MN,USA).Theperformanceofthemaneuversas wellastheselectionofresultsfollowedthecriteria estab-lishedintheGuidelinesforLungFunctionTests.12---14
Inspiratory and expiratory loops of the X-flow curve wereobtainedthroughmaneuversofForcedexpiratoryVital Capacity(FVC)inwhichthesubjectperformsaforced expi-ration, with no hesitation, starting from the Total Lung Capacity(TLC)uptotheResidualVolume(RV).Selected val-ues for FEV1 (ForcedExpiratory Volume in 1 second)/FVC were expressed as percentage of the normal values cal-culated according to the European Respiratory Society recommendation.15Inaddition,themaneuverofslowvital
capacitywascarriedout,inwhich thesubjectperforms a completeexpirationstartingfromthemaximumpulmonary insufflations,butwithoutusingmaximumexpiratoryeffort. Theresultsofthismaneuverwereusedinthecomposition ofthecalculationofpulmonaryvolumes.
Thetestswereinterpretedbyaspecialistinspirometry and classified as: normal, obstructive breathing disorders withnoarrest,obstructivebreathingdisorderswitharrest andrestrictivebreathingdisorders.
Thoracic Gas Volume (TGV) was measured using the whole body pletysmography technique for obtaining pul-monaryvolumes.16,17RVandTLCwerecalculatedfromTGV.
The obtainedresultswereexpressedaspercentageof the normal calculated values and later adjusted to the 2008 table of expected valuesfor Brazilians according to their gender.
Forthecharacterizationofthesubjects’sample regard-inglungparenchymaimpairment,themeasurementoflung diffusion was made through the classic technique of sin-gle breathusingcarbon monoxide (CO),16 associatedwith
the most recently incorporated recommendations.12 The
maneuver was repeated at least twice upto a maximum of five times. Results were expressed asa percentage of expected values for Brazilians according to their gender. The maneuver for measuring airway resistance was per-formedusingthewholebodypletysmographytechnique.18
The conductibility of the airways wascalculated (Gaw=1 raw) using the raw measure,as well as the specific con-ductibility of the airways obtained through its correction for the pulmonary volume in which the measurement wascarried out (sGaw=Gaw/TGV). Raw andsGaw values were expressed as cm H2O/L/s and 1cm H2O/s, respec-tively.
Thedistributionoffrequencieswasusedtodescribethe categoricalvariables(numberofcasesandpercentage)and themeasures ofcentraltendency(meanandmedian) and variability(minimum,maximumandstandarddeviation)for thecontinuousornumericalvariables.
Results
Ofthe56participantsofthisstudy,6wereexcluded;3for notbeingabletoperformtherequestedmaneuversduring thetestsandtheothersduetotheirdiminishedcognitive condition,whichimpededunderstandingofinstructions.
Table 1 describes the demographic characteristics and historyofsmoking(beforesurgery)oftheevaluated laryn-gectomized subjects. Average age was 64, with 88% of subjectsbeingmen;58%ofparticipantssmokedmorethan 40cigarettesaday.
Regarding the Dyspnea Scale (Medical Research Council),11 participants were stratified according to
Table2.Ofthe56participants,28presenteddyspneaonly withstrenuousexerciseand19whenhurryingonthelevel orwalkingupaslighthill.
Table1 Demographicandsmokingcharacteristicsofthe laryngectomized.
Variable Category/measures Freq. (%)/measures Age (years) Variation 41---87 Median 64.5 Mean(standard deviation) 64.2(10.3) Race Orientals 2(4) Afrodescendents 12(24) Caucasians 36(72) Bodymassindex
(kg/m2) Variation 15.7---32.6 Median 24.2 Mean(standard deviation) 24.4(3.8) Gender Female 6(12.0) Male 44(88.0)
Smoking Nonsmoker 6(12.0)
Lessthan10 cigarettes/day 4(8.0) 10to20 cigarettes/day 7(14.0) 21to40 cigarettes/day 4(8.0) Morethan40 cigarettes/day 29(58.0)
Table2 Estratificationoftheparticipantsregarding dysp-neascale.
Dyspneascale Freq.(%)
Breathlesswithstrenousexercise 28(56) Shortofbreathwhenhurryingonthelevel
orwalkingupaslighthill
19(38) Walksslowerthanpeopleofthesameage
onthelevelorstopsforbreathwhile walkingatownpaceonthelevel
2(4)
Table3 Respiratoryfunctionalmeasures.
Variable Category/measures Absolutvalues Percentagevalues
Spirometry FVC=Forced expiratoryvital capacity Variation 1.7---4.9 521---1096 Median 3.4 841
Mean(standarddeviation) 3.3(07) 833(126)
FEV1--- Forced
expiratoryvolume in1second
Variation 1.1---3.5 43.4---106.7
Median 2.5 77.5
Mean(standarddeviation) 2.4(0.6) 75.8(15.1)
FEV1/FVC Variation 49---90 66,6---109,5
Median 71.5 91.9
Mean(standarddeviation) 71.4(8.8) 91.1(11.1)
LungVolumes
RV=Residual volume
Variation 1.3---4.0 63.3---240.1
Median 2.4 112.3
Mean(standarddeviation) 2.5(0.6) 122(32.3)
TLC=Totallung capacity
Variation 3.4---8.1 71.39---126.4
Median 6.0 98.3
Mean(standarddeviation) 6.0(1.0) 99.2(12.3)
Diffusion
DLCOunc=Diffusing capacityofthe lungforcarbon monoxide
Variation 9.8---34.3 42.1---124.9
Median 20.6 20.6
Mean(standarddeviation) 21.0(6.5) 21.0(6.5)
Airwayresistance Sgaw=Specific airway conductance Variation 0.1---0.5 50---185 Median 0.2 105
Mean(standarddeviation) 0.2(0.1) 121.7(52.8)
ValuesinpercentagesofthoseexpectedforBrazilians.
Table4 Frequencyandpercentageofbreathingpatterns.
Interpretationpatterns Freq.(%)
Normal 22(44)
Obstructivepatternwithnoairtrapping 14(28) Obstructivepatternwithairtrapping 11(22)
Restrictive 3(6)
RespiratoryfunctionalmeasuresaredescribedinTable3, which demonstrates an average percentage of the FVC andFEV1belowthat expectedforBrazilians.On average, diffusion was found to be reduced and airway resistance increased.
The results obtained after interpretation and classifi-cation of breathing patterns are described in Table 4. 56% percent of the participants were found with altered breathingpattern,distributedasfollows:14with obstruc-tive pattern with no air trapping, 11 with obstructive pattern with air trapping and only 3 with restrictive pattern.
Discussion
Afterthe probabilityofdying of a second leadingcancer, pulmonary diseases are the second cause of mortality in
laryngectomizedpatientsandthiscouldsuggestthecarrying outofspirometryinthesepatients.7However,little
atten-tionhasbeengivenintheliteraturetotheevaluationoflung functioninpatientssubmittedtototallaryngectomy, espe-ciallyduetotechnicaldifficultiesassociatedwithexecution ofthetestandnottolackofindication.19
Severalstudies agreethat many laryngectomees could benefit from drug treatment due to the high percent-age of airway obstruction.2,6,7 According to the Medical
ResearchCouncilDyspneaScale,11 56%ofpatientsreported
fatigue only after strenuous exercise and 38% when hur-rying on the level or walking up a slight hill. This findingcouldberelatedtoquitting smokingafter surgery, since the effect of giving up smoking is relatively immediate.20
Evaluating the spirometry, several studies have found subnormal values in laryngectomized subjects.1,6,21,22 Our
results showed an average percentage of CVF and VEF1 belowthatexpectedforBrazilians,respectively83.3%and 75.8%.
These data confirm those collected by Duran et al.,23
whichfoundasignificantreductionintheseindexes. Data obtained in our investigation agree with other results,7 in which an increase in the residualvolume and
decreaseintheFEV1werefound,thusshowingan obstruc-tiverespiratorycondition.
On average, diffusion was found to have decreased (74.3%) and airway resistance increased (121.7%) in our resultsinrelationtoexpectedBrazilianresults.
After carrying out lung function tests, 44% of patients werefoundwithnormalbreathingpatternand56%altered, distributedamong14patientswithobstructivepatternwith noairtrapping, 11withobstructivepattern withair trap-pingandonly3 withrestrictivepattern.Ourfiguresagree withthosefoundbyDuranetal.23Theseauthorsfoundthat
intheir serieswith30 laryngectomizedpatients,47% pre-sentednormallungfunction,whereas53%hadalteredlung function.In theseriesbyVasquez etal.,781% ofpatients
werefoundwithlungfunctionofobstructivebreathing pat-tern.AsjustifiedbyAckerstaffetal.,5perhapsthegreatest
indexof respiratorydysfunctionfound in laryngectomized patientsisduetoagreaternumberofpossiblerespiratory infectionsduetothetracheostoma.
Our results agree with the study performed by Hess etal.,2showingthatitmightbenecessarytoreevaluatethe
roleofthelungfunctiontestinthemonitoringofpatients submittedtototallaryngectomy.
The use of a standardized extra-tracheal device with reproducible methodology is essential to guarantee the precision and accuracy of lung function tests in patients submittedtototallaryngectomy.
Conclusion
Most patients submitted to total laryngectomy present alteredlungfunction,oftheobstructivetype,mostofthe timeduetoahistoryofsmoking.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
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