Brachycephalic dogs commonly present to veterinary hospitals for a variety of reasons. Airway compromise is a common occurrence with even simple procedures making an argument for early intervention for brachycephalic airway surgery. Below is an example of what we see in our emergency rooms and ICU.
An Example of Brachycephalic Airway Compromise
A 7-year-old male neutered French Bulldog presents to the hospital for cutaneous mass removal. As many of his breed, he is obese with a body condition score of 7/9 and has inspiratory stertor. There are no other abnormalities identified pre-operatively.
The owners report that he makes snoring noises when he breathes quite frequently and vomits intermittently. Upon questioning, the owners tell the doctor that there is never abdominal heaving when he vomits, which suggests that he is regurgitating.
He does well under anesthesia and surgery is uncomplicated. Not long after extubating however, he develops respiratory distress.
Minimal breath sounds are auscultated despite marked inspiratory effort and pulse oximetry reveals hypoxemia. He has a respiratory obstruction. As he is being re-intubated, we note severe swelling of the caudal aspect of the soft palate and the oropharyngeal area. These were not present during the initial intubation. He now becomes eupneic and the pulse ox reading normalizes. He is treated with an anti-inflammatory dose of dexamethasone SP to reduce the inflammation but no improvement is seen and it is not possible to successfully extubate despite repeated attempts.
Treatment Options for Canine Brachycephalic Airway Compromise
This is not a theoretical case.
I have seen this repeatedly in Pugs, English Bulldogs, Frenchies, and other patients who are unlucky enough to have been born into the brachycephalic club. Sometimes, the mere act of getting excited by walking into the veterinary hospital is enough to put them into a respiratory crisis. Other times, respiratory compromise begins after flawless anesthesia and surgery that changes their ability to maintain their airflow to the sub-optimal level at which they exist in their normal life.
At this point, we have three options:
- This is a horrendous end for such a simple surgery. However, it is realistic when it comes to the resulting financial obligations should the owners opt to continue treatment.
- Maintain the patient sedated and intubated until the inflammation has reduced enough that successful extubation is possible. This could take days and requires intensive care and monitoring. We need to provide physical therapy, soft bedding, heat support, urinary bladder expression, and 24-hour nursing care. We need to medicate with intravenous fluids, prokinetics, anti-inflammatories, antacids, and possibly antibiotics.
A nasogastric tube will also be placed so that we can suction gastric residuals frequently (to minimize the chance of regurgitation) and provide nutrition. This is labor intensive and our patient could develop complications related to excessive sedation, aspiration pneumonia, or recumbency atelectasis.
- Our third and best option is to perform a temporary tracheostomy and hospitalize the patient until the inflammation has decreased enough for successful extubation. The patient can eat, breathe, and interact normally. There are still possible complications such as tracheal tube obstruction and pneumonia but when patients are awake, their normal protective physiology is able to work much better than when they are chemically sedated.
Case summary continuation: Throughout the period during which he is being extubated and re-intubated, he becomes hypoxemic despite the administration of 100% oxygen via endotracheal tube. Thoracic radiographs reveal bilateral aspiration pneumonia. He regurgitated while his trachea was unguarded. The treatment options above will not be effective. Now our Frenchie requires mechanical ventilation. This will provide him with his only chance of survival, but it is not a good one.
Common Brachycephalic Abnormalities
The desire to breed an adorable, forever wide-eyed infant-like dogs has resulted in the bracycephalic breeds with well-known anatomical abnormalities: stenotic nares, elongated soft palate, and hypoplastic trachea.
Because of these abnormalities, the effort required to simply breathe results in a marked increase in negative intrathoracic pressure. Over time, that change in pressure leads to everted laryngeal saccules, laryngeal collapse, and everted tonsils: all secondary problems that further contribute to increased airway resistance and obstruction. And it doesn’t just affect the respiratory system. The negative intrathoracic pressures generated by increased inspiratory effort is also believed to be a major cause of gastroesophageal reflux which occurs quite commonly in these patients and frequently leads to a number of undesirable sequelae (regurgitation, gagging, vomiting, aspiration pneumonia).
The post-operative period for brachycephalics is frequently fraught with complications. Most are respiratory in nature and include excessive respiratory noise, aspiration pneumonia, severe dyspnea, and perioperative death. Gastrointestinal complications, such as vomiting and regurgitation, are also relatively common following surgery for brachycephalic airway syndrome.
How to Help Your Brachycephalic Patients
There are things we can do to reduce the risk or severity of post-operative complications. We can counsel owners to keep their dogs slim. Obesity increases the amount of tissue crowding the oropharyngeal area and contributes to their problems breathing after surgery.
Some surgeons recommend treating with cisapride, omeprazole, and an easily digestible diet for a few weeks prior to surgery. In the immediate post-operative period, we try to leave the patient intubated until he/she is chewing the tube out – the more awake they are, the more control they will have over the airway. Many use a “bulldog rack” on which to hang the patient’s maxilla during recovery so the mouth will remain open allowing the airway to remain as open as possible.
Surgically, we can affect 2 of the 3 anatomic abnormalities these dogs are born with via staphylectomy and nasal fold resection. Except for the hypoplastic trachea, for which there is no intervention, the other abnormalities that compound the brachycephalic respiratory difficulties are secondary to these anatomic ones.
The secondary abnormalities only form because the primary ones have led to increased inspiratory pressures and they occur after prolonged exposure to these. So, if we perform the surgeries mentioned above before the development of the secondary abnormalities, (i.e. when the animal is young), we may not only prevent crises like the one described above but we may prevent the day to day suffering through which these animals must prevail.
I recommend that any practitioner, seeing brachycephalic puppies for wellness visits, counsel owners about having airway evaluation and, if needed, brachycephalic surgery done early – potentially at the time of ovariohysterectomy or neuter. We will not alleviate all possible problems but will be more likely to prevent a large amount of the daily suffering and post-operative complications in many of our brachycephalic patients, ultimately improving their quality of life.
References:
Brachycephalic Syndrome Gilles Dupré, Univ Prof Dr Med Vet*, Dorothee Heidenreich, Dr Med Vet. Vet Clin Small Anim 46 (2016) 691–707.
Complications of Upper Airway Surgery in Companion Animals Andrew Mercurio, DVM, MS . Vet Clin Small Anim 41 (2011) 969 –980.
