Surgical Approaches - Respiratory Flashcards
What does BOAS stand for?
Brachycephalic obstructive airway disease
How can the nares differ in dogs with BOAS?
Nares are stenotic
How can the soft palate differ in dogs with BOAS?
Overlong, interacts with epiglottis
How can the tonsils differ in dogs with BOAS?
Tonsils are hyperplastic
What can happen in the diaphragmatic region of dogs with BOAS?
Hiatal hernia due to force exerted trying to breathe
How can the trachea differ in dogs with BOAS?
Can be hypoplastic causing narrow airway
Everted laryngeal succules can be pulled into the trachea and cause obstruction
What is stertor?
Snoring noise caused by partial obstruction of the upper airways at the level of the pharynx and nasopharynx
What is stridor?
High-pitched breathing sound commonly associated with laryngeal disease
What can happen to the larynx in severe BOAS cases?
Laryngeal collapse
What are the risk factors for BOAS in bulldogs?
Males
Moderate/severe stenotic nares
Thicker neck
Wider and shorter skull
What are the risk factors for BOAS in french bulldogs?
Males Moderate/severe stenotic nares Thicker/shorter neck Shorter/wider skull Proportionally shorter muzzle
What are the risk factors for BOAS in pugs?
Female Moderate/severe stenotic nares Obese Proportionally wider distance between eyes Wider/shorter skull
How do narrow nares exacerbate symptoms of BOAS?
Dramatically increases the resistance to air flow into the nose
Cartilage support of nares tends to collapse during inspiration
How does an elongated soft palate exacerbate symptoms of BOAS?
Partially obstructs air flow into the trachea
Causes turbulent airflow in the larynx
Is laryngeal collapse progressive?
Yes
Which breed is most commonly affected by tracheal hypoplasia?
English bulldogs
What owner considerations should be made for BOAS patients?
Avoid stress/heat Use harness (not collars) Avoid obesity Carefully managed exercise regimes Oxygen therapy Awareness of signs of respiratory distress
What nursing assessments should be done with BOAS patients?
TPR
Mucous membranes
SpO2
BOAS grading assessment with vet
What 5 procedures are involved in the multilevel surgical correction of BOAS?
Soft palate resection Tonsil resection Nostril resection Removal of everted laryngeal saccules Laser-assisted turbinectomy
Why should a full biochem/haematology assessment be carried out before BOAS surgery?
Identify any extra risk factors for surgery
Why should patients be pre-oxygenated before BOAS surgery?
Pre-oxygenate for at least 5 mins - delays oxygen desaturation at induction
What ocular considerations should be taken with BOAS surgery patients?
Ocular lubrication regularly peri-operatively
How can intubation of BOAS patients be made easier?
Good lighting/laryngoscope
Urinary catheter can be used as a guide
Have rescue ET tube plus range of sizes
What is involved in patient prep for BOAS surgery?
Oral mouth rinse e.g. hexarinse
Nares - dilute clorhex/idodine
How should patients for BOAS surgery be positioned?
Sternal recumbency
Use 2 drip stands either side of table to tie mouth open
Tilted table helps prevent regurgitation
What should oxygen saturation be maintained at during BOAS surgery?
> 98%
What should end tidal CO2 be during BOAS surgery?
35-45mmHg - use capnography
Which breathing circuits are appropriate for BOAS surgery?
High flow rates - circle, T-piece, bain
What should blood pressure be maintained at during BOAS surgery?
> 60mmHg (mean)
What are the common complications of BOAS surgery?
Airway swelling
Vomiting and regurgitation
Aspiration pneumonia
When should BOAS surgery patients be extubated?
When they will no longer tolerate ET tube - keep in sternal recumbency with head elevated
Should BOAS surgery patients still be given oxygen supplementation after extubation?
Yes - mask/flow by
How should exercise be restricted during recovery from BOAS surgery?
5-10 mins twice daily for 6 weeks, always on harness
What food should be given to patients recovering from BOAS surgery?
Solid wet food for 6 weeks post-op - limit airway irritation
What is laryngeal paralysis?
A condition where the vocal cords are unable to abduct in response to exercise and respiratory demands
What are the possible causes of laryngeal paralysis?
Idiopathic
Ageing changes (degenerative)
Congenital disease
Trauma
Cancerous infiltration of nerve which controls laryngeal muscles
What are the signs of laryngeal paralysis?
Exercise intolerance
Noisy respiration
Coughing/gagging/dysphagia
Change/loss of vocal sounds (dysphonia)
Cyanosis and collapse (if severe)
How are mild cases of laryngeal paralysis managed?
Anti-inflammatories Antibiotics (where indicated) Sedatives Raised feeding Manage exercise, reduce stress
How are severe cases of laryngeal paralysis managed?
Laryngeal tie-back (Unilateral arytenoid lateralisation)
Where is the laryngeal tie-back surgery performed?
Left side of the neck
What is achieved during a laryngeal tie-back surgery?
Left arytenoid cartilage is permanently abducted
What should be considered for post-operative care after a laryngeal tie-back procedure?
Small regular soft meals
Avoid dusty feed/atmospheres
Raised food/water
Wound management
Why shouldn’t animals which have had a laryngeal tie-back surgery be allowed to swim?
Risk of aspiration of water too great - permanently open trachea
Where can palate defects occur?
Clefts of upper lip, hard and/or soft palates
What are the clinical signs of a palate defect?
Difficulty feeding
Nasal discharge
How are congenital palate defects managed?
Surgery performed at 3-4 months - closure of tissues separating the oral and nasal passages with minimal tension
How are acquired palate defects managed (e.g. RTA trauma)?
Primary/secondary closure depending on severity of damage caused
Which dogs are most likely to suffer with tracheal collapse?
middle aged small and toy breeds
how is tracheal collapse caused?
degeneration of the tracheal cartilage rings leads to dorsoventral flattening of the trachea
what re the signs of tracheal collapse?
dry, harsh, loud cough (goose honk) triggered by excitement/exercise/eating
stridor
may build up over weeks/months
how is tracheal collapse diagnosed?
through radiography, bronchoscopic imaging (endoscopy) and fluoroscopy
how is tracheal collapse graded?
according to percentage of collapse of lumen grade I = 25% grade II = 50% grade III = 75% grade IV = total loss
what are the management options for tracheal collapse?
weight loss management harness avoiding smoky atmospheres medical surgical
what is involved in medical management of tracheal collapse?
weight loss and controlled exercise programmes
removal of environmental irritants
pharmacological - antitussives, steroids, bronchodilators
(antibiotics only if secondary infection present)
what are the surgical methods for managing tracheal collapse?
only grade II or higher
extraluminal ring prosthesis
intraluminal stent placement
what are the complications of extraluminal ring prosthesis?
vascular damage
tracheal ring migration
coughing, dyspnoea
laryngeal paralysis due to iatrogenic nerve damage
what are the advantages of intra-luminal stent placement?
less invasive surgery than prosthesis
flexible materials available
what are the disadvantages/complications of intraluminal stent placement?
stent can fatigue under pressure (repeated coughing)
excessive inflammatory tissue around the trachea
what is involved in patient prep for extraluminal ring prosthesis?
dorsal recumbency - prep large area of ventral neck
pre-oxygenation
careful handling
calm/stress free
what is involved in patient prep for intraluminal stent placement?
lateral recumbency fluorosopic guidance pre-oxygenation careful handling calm/stress free
what are the key aspects of post-op care after respiratory surgery?
calm and quiet environment
monitor respiration constantly initially, give flow-by oxygen
analgesia and sedation
raised head to reduce aspiration risk
maintenance of IV access, access to crash box
suction equipment ICOE
what is a lateral thoracotomy?
surgical incision performed between the ribs - excellent view of one side of thorax
what are the indications for a lateral thoracotomy?
lung lobectomy
abscessation, lung lobe torsion, neoplasia
what is a median sternotomy?
surgical incision through sternum - provides view of bilateral thorax
what are the indications for a median sternotomy?
pyothorax
mediastinal masses
heart surgery
what is a tracheostomy?
emergency procedure to bypass the nares/pharynx/larynx/proximal trachea - artificial opening in the neck
what are the indications for a tracheostomy?
facilitate anaesthesia when airway is compromised
stabilise patient and allow airway management
provide definitive airway until swelling/obstruction is resolved
with which conditions may a tracheostomy be required?
BOAS
laryngeal paralysis
laryngeal trauma
foreign body
what is involved in the care of a tracheostomy?
24/7 high level monitoring for maintenance/comfort/asepsis
prevent buildup of secretions through suctioning/cleaning tube
tube care every 15 minutes until stable, then every 4-6 hours
what should you be continually checking for in patients with a tracheostomy tube?
harsh respiratory sounds
dyspnoea/coughing/distress
discharge
discomfort
stoma - pain/swelling/heat (clean 3-4x daily)
what is involved in suctioning of a tracheostomy tube?
always pre-oxygenate at least 5 mins before
aseptic technique
sterile, soft, pre-measured catheter placed and suction unit turned on for 15 seconds as withdrawing
why should you aid humidification in patients with a tracheostomy tube?
it bypasses normal humidification in the URT - can cause damage to mucosa and thick mucus
