# Situation: A 60-year-old man who smokes and drinks alcohol daily undergoes total laryngectomy with a permanent tracheostoma for cancer of the larynx. An hour after he returns from the operating room, he stops breathing and does not respond, but he has a pulse. The nurse calls for help and starts rescue breathing with a bag-valve device. How should the ventilations be given?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=629840  
> language: ko  
> subject: Nursing Practice III — Care of Clients with Problems in Surgery, Oxygenation, Fluid and Electrolytes, Infectious, Inflammatory and Immunologic Response, Cellular Aberrations

## 문제

Situation: A 60-year-old man who smokes and drinks alcohol daily undergoes total laryngectomy with a permanent tracheostoma for cancer of the larynx.

An hour after he returns from the operating room, he stops breathing and does not respond, but he has a pulse. The nurse calls for help and starts rescue breathing with a bag-valve device. How should the ventilations be given?

## 보기

1. Over the stoma, with a small round face mask **✔ 정답**
2. Over the mouth and nose, with the stoma covered
3. Over the mouth, with the nose pinched closed
4. Over the mouth and nose, with the neck extended

**정답: 1**

## 해설

After total laryngectomy the trachea is brought out as a permanent stoma and no longer connects to the mouth and nose, so he breathes only through the stoma. Rescue breaths are given over the stoma with a small round (infant) face mask; air given through the mouth or nose cannot reach his lungs.

## 심화 해설

Core anatomy after total laryngectomy

In a total laryngectomy, the entire larynx is removed and the trachea is surgically brought to the anterior neck as a permanent tracheostoma. The airway is completely separated from the upper aerodigestive tract. The mouth, nose, and pharynx no longer communicate with the trachea or lungs. The patient breathes only through the tracheostoma, not through the mouth or nose.

Because of this permanent separation, any air delivered through the mouth or nose cannot reach the lungs. Even if the nose is pinched or the neck is extended, the upper airway is a blind passage above the stoma. Rescue breathing must therefore be delivered directly over the stoma.

Why a small round face mask is used

A standard adult face mask is designed to fit over the mouth and nose. It is too large to seal around a tracheostoma. A small round pediatric or infant face mask fits the circular stoma opening and creates an effective seal for positive-pressure ventilation. The bag-valve device is connected to the mask, and ventilations are given directly over the stoma.

If a small round mask is not immediately available, a pediatric mask may be used, or a tracheostomy mask if present. In an emergency, a pediatric bag-valve mask can also be connected directly to a tracheostomy tube if one is in place. The key principle is that the ventilation interface must seal the stoma, not the face.

Step-by-step emergency response

| Step | Action | Rationale |
| --- | --- | --- |
| 1 | Confirm unresponsiveness and check pulse | Pulse is present, so this is respiratory arrest, not cardiac arrest |
| 2 | Call for help and activate emergency response | Additional providers and airway equipment are needed |
| 3 | Expose the neck and inspect the stoma | Identify secretions, mucus plug, or displaced tube |
| 4 | Suction the stoma if secretions are visible | A mucus plug is a common cause of early obstruction after laryngectomy |
| 5 | Place a small round mask over the stoma | Creates a seal for bag-valve ventilation |
| 6 | Deliver breaths at 1 breath every 6 seconds for an adult with a pulse | Standard rescue breathing rate for respiratory arrest with a pulse |
| 7 | Watch for chest rise with each breath | Confirms air is entering the lungs through the stoma |

Key point! For a patient with a laryngectomy stoma, the correct ventilation site is the stoma, not the face. Mouth-to-stoma or bag-mask-to-stoma ventilation is the only route that delivers air to the lungs.

Why the other options are incorrect

| Option | Why it fails |
| --- | --- |
| 2. Over the mouth and nose, with the stoma covered | Covering the stoma does not reconnect the upper airway to the lungs. Air given through the mouth and nose cannot pass the surgical separation. |
| 3. Over the mouth, with the nose pinched closed | Pinching the nose only prevents air from escaping the nose. It does not create a path from the mouth to the trachea because the larynx has been removed. |
| 4. Over the mouth and nose, with the neck extended | Neck extension opens the upper airway in patients with an intact airway. After total laryngectomy, the upper airway is disconnected, so this maneuver has no effect on ventilation. |

Early postoperative respiratory arrest after laryngectomy

Respiratory arrest in the immediate postoperative period after total laryngectomy is most often caused by airway obstruction at the stoma. Common causes include mucus plugging, blood clots, edema of the stoma, or displacement of a tracheostomy tube if one was placed. The nurse should first look at the stoma, suction if needed, and then ventilate directly over the stoma.

A laryngectomy tube is often placed in the stoma immediately after surgery to maintain patency. If the patient has a laryngectomy tube, the bag-valve device can be connected directly to the 15-mm connector on the tube. If no tube is present, the small round mask is placed over the stoma itself.

Nursing implications for ongoing care

Patients with a permanent tracheostoma require specific emergency preparedness. The bedside should have suction equipment, a small round mask, a bag-valve device, and spare laryngectomy tubes of the correct size. Family members and caregivers must be taught that if the patient stops breathing, rescue breaths are given mouth-to-stoma, not mouth-to-mouth.

Humidification is also essential because the upper airway, which normally warms and humidifies inspired air, is bypassed. Without humidification, secretions become thick and increase the risk of mucus plugging and airway obstruction. This is a critical nursing intervention in the early postoperative period and throughout the patient's life with a permanent stoma.

Watch out! Do not attempt to ventilate a laryngectomy patient through the mouth or nose, even if the stoma appears obstructed. Clear the stoma first, then ventilate directly over it. The anatomical separation is permanent and cannot be bypassed by positioning or covering the stoma.

## 임상 시나리오

Emergency Ventilation After Total LaryngectomyRescue breaths must go directly over the tracheostoma
After total laryngectomy, the trachea is brought out to the anterior neck as a permanent tracheostoma. The mouth, nose, and pharynx are completely separated from the trachea and lungs, so the patient breathes only through the stoma.

Deliver ventilations directly over the stoma using a small round face mask connected to a bag-valve device. A standard adult mask is too large to seal around a circular stoma; a pediatric or infant mask provides an effective seal.

If a small round mask is not immediately available, use a pediatric mask or a tracheostomy mask. If a tracheostomy tube is in place, a pediatric bag-valve mask can be connected directly to the tube.

CautionNever ventilate over the mouth or nose after total laryngectomy. The upper airway is a blind passage above the stoma, so air delivered there cannot reach the lungs regardless of head position or nose pinching.

## 핵심 개념

- **Total laryngectomy** — Surgical removal of the entire larynx, resulting in permanent separation of the upper airway from the trachea; the patient breathes only through a tracheostoma.
- **Tracheostoma** — A permanent surgical opening of the trachea to the anterior neck surface, serving as the sole airway after total laryngectomy.
- **Bag-valve device** — A manual resuscitator used to deliver positive-pressure ventilations; it must be connected to an interface that seals the patient's actual airway.
- **Small round face mask** — A pediatric or infant-sized circular mask that fits over a tracheostoma to create an effective seal for ventilation.

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