Klaske van Sluis

114 7.1. Introduction it requires adjustments of the device and skills of the participants. Maximum expiratory pressure (MEP) and vocal functioning in loudness improved over time. After EMST no changes were seen in other objective and subjective out- comes. Conclusions: EMST appears to be feasible and safe after total laryngec- tomy. MEP improved over time but no improvement in the clinically relevant outcome measures were seen in this sample of relatively fit participants. Fur- ther investigation of the training in a larger group of participants who report specifically pulmonary complaints is recommended to investigate if the increase in MEP results in clinical benefits. 7.1 Introduction Total laryngectomy (TL), which involves surgical removal of the larynx, leads to lifelong changes in voice, swallowing and airway. Pulmonary driven speech can be re-established with insertion of a voice prosthesis, also called tracheoe- sophageal speech[1]. Compared to healthy individuals the voices of tracheoe- sophageal speakers have a rough voice quality, reduced loudness, and limited range [2]. After TL pulmonary condition is affected as air entering the lungs via the stoma is not warmed and humidified by the nose and upper respira- tory tract, which leads to impaired mucociliary clearance. Impaired mucocil- iary function is the main cause of pulmonary complaints such as increased mucus production and forced mucus expectoration after TL [3–5]. Warming and humidifying the inhaled air is a key factor in improving pulmonary con- dition. Over the years several options were developed: external humidifiers, stoma cloths (e.g. bibs) and heat-moisture-exchange devices (HME-devices) [5– 8]. Both stoma cloths and HME-devices are proved to be effective in everyday life and can reduce pulmonary problems in this patient group [9–11]. Neverthe- less, pulmonary complaints including increased mucus production and forced mucus expectoration are still present after TL [12, 13]. The altered anatomy results in an physiological altered cough function after TL. Removal of the lar- ynx eliminates the ability to generate subglottic pressure prior to cough onset. Cough requires high expiratory airflows to aerosolize and remove material that is unable to be removed by mucociliary action. Cough “strength” is determined by the ability to generate high expiratory pressures immediately prior to cough onset and by the volume of air that is expelled from the airways [14]. With the absence of the ability to build up subglottic pressure, it is assumed that after a TL increased cough strength can only be achieved by increasing the volume and speed of cough expiratory airflow. To date, cough function after TL and the potential benefit of rehabilitation techniques have not been studied. A well- known rehabilitation technique to improve cough function is expiratory muscle strength training (EMST). Recently, the use of EMST has been evaluated in several studies [15], including different patient groups such as Parkinson’s dis-