Humphrey's tracheostomy, or Why brachycephalic dogs are so sad

Humphrey is a Pug who consumed most of my Thursday-Sunday this past week on Soft Tissue Surgery.

Pugs are one of several breeds of dogs that are considered brachycephalic. "Brachy-" means "short" and "cephalic" refers to the head. Hence, brachycephalic dogs are "short-headed" or "short-faced" dogs, also referred to colloquially as smush-faced dogs.

One of the biggest problems that we've created by breeding dogs with such a smushed-in face is that brachycephalic dogs often have serious respiratory difficulties. They are often born with two anatomical problems:

1. Stenotic nares, or overly narrowed nostrils, which allow for only very limited airflow through the nose.

2. An elongated soft palate, which interferes with the flow of air at the back of the throat.

Both the stenotic nares and elongated soft palate create extra resistance to what should be the normal passage of air through the upper airways. Think of it like trying to drink a thick milkshake through a straw -- you have to suck really hard, but you can probably do it. Now think about trying to drink that same milkshake through a coffee straw, which has a much smaller diameter and thus creates much more resistance and makes you work a lot harder.

So these brachycephalic breeds generally start out at a disadvantage when they have these congenital abnormalities. But the most serious trouble comes when the stenotic nares and elongated soft palate are not corrected early on.

After months or years of trying to breathe through such narrowed airways, the constant resistance to air flow and the excessive negative pressure that is created each time the dog breathes can lead to something called laryngeal collapse.

The larynx ("voice box," in humans) is a structure formed of several different cartilages that sits at the back of the throat and connects the oral cavity to the trachea (windpipe). Air passes through the nose and/or mouth, through the larynx, down the trachea, and into the lungs.

But with enough extra resistance in the airways for a long enough period of time, the cartilages that comprise the larynx begin to weaken and break down. Think of it like how you can suck your cheeks way into your face if your mouth is closed.

And like bending a paperclip back and forth enough times, eventually the laryngeal cartilages collapse. When this happens, they fall into what used to be the open space in the larynx where air passed, and create an obstruction to air flow.

Now, brachycephalic dogs are not born with laryngeal collapse. It is a sequela to years of increased resistance to air flow, resulting from their stenotic nares and elongated soft palate. So if the nares and palate are surgically corrected early enough in life, the increased resistance to air flow disappears, and the larynx does not undergo the stress that might have caused it to collapse.

However, often by the time an owner or veterinarian realizes that a brachycephalic dog might benefit from surgery to correct the nares and palate, it has already been a long-standing problem such that there is already some degree of laryngeal collapse. For this reason, more and more vets are now recommending that brachycephalic breeds have their nares and palate corrected at the time of spay or neuter, or as soon after that age as possible.

Here enters Humphrey, our dear 3 year old Pug. Humphrey was born with stenotic nares and an elongated soft palate, but nobody saw a need to do anything about it. Humphrey was a happy, healthy little Pug until he was about 2 1/2 years old, at which time he began to have difficulty breathing.

Humphrey's mom took him to her regular vet, and eventually to a specialist, who performed the surgery to correct the nares and palate (which, by the way, is a fairly minor surgery to do). Unfortunately, at the time of surgery, the surgeon noted that Humphrey already had a moderate to severe degree of laryngeal collapse.

Many dogs, even those that already have some degree of laryngeal collapse, will benefit from surgery to correct their nares and palate. Humphrey wasn't one of them. He had progressively more and more respiratory difficulty over the next several months, until eventually he ended up at my vet school's teaching hospital, after his regular veterinarian felt there was nothing more to offer than euthanasia.

At presentation, Humphrey was able to breathe adequately in the exam room, but was depressed and underweight. His owner reported that Humphrey's breathing was the worst when he was relaxed or trying to sleep, presumably because then he lost some of his conscious control over the accessory muscles that were helping to keep his airway open. As a result, Humphrey couldn't sleep well because whenever he relaxed, he'd be unable to breathe, which gave him no energy to do anything during the day.

We performed a laryngeal exam on Humphrey, which involved lightly anesthetizing him just to the point where he would let us open his mouth and look at his larynx. The exam confirmed severe (almost total) laryngeal collapse.

The only known solution is to perform a permanent tracheostomy. This surgery involves making an incision through the skin on the throat, then removing a rectangular piece of the cartilage that makes up the trachea, and finally suturing the inner lining of the trachea directly to the skin. The tracheostomy allows air to flow directly into and out of the trachea, bypassing all of the upper airways, including Humphrey's problematic larynx.

It's not a minor surgery to undertake, and obviously it requires somewhat of a lifestyle adaptation -- the most important aspect of which is no swimming for the remainder of the patient's life!

Humphrey's surgery went well, and he recovered okay. His owner will have 4-6 weeks of hard work ahead of her, while she learns how to clean the mucus from around the tracheostomy site multiple times a day, and while Humphrey learns how to position his body so that he can breathe well through the tracheostomy. But eventually, he should be able to enjoy most activities he liked to do before surgery, and he should have a fairly normal lifespan.

I intended this to be more of an amusing post, detailing some of the more hilarious aspects of Humphrey's surgery and our instructional sessions with his owner in how to care for him after surgery -- and maybe I'll have a chance to write about some of that later -- but although there are some amusing aspects to this tale, it's at heart a tragic story of how we humans have manipulated some breeds of dogs to such extremes of anatomy that they suffer so that we can remark how "cute" or "unique" they are. Some examples:

- Most English bulldogs cannot give birth naturally and automatically need a C-section
- Shar Peis have such excessive skin folds that many of them suffer from lifelong skin infections
- Cocker Spaniels' long, fluffy ears are a perfect environment for trapping yeast and bacteria, leading in some cases to ear infections so severe that surgery is required
- Great Danes and St Bernards have been bred to such enormous proportions that their average lifespan is only 6-8 years
- Italian greyhounds, with their petite, delicate skeletons, can fracture a leg at the drop of a hat
- Chihuahuas with their adorable apple-shaped heads often suffer from open fontanelles (failure of the skull to close completely, leading to an opening where the brain is not protected) and hydrocephalus (water on the brain)
- Dachshunds have elongated backs and stubby legs, resulting in frequent back injuries and neurologic disease
- Brachycephalic breeds, including Pugs, English bulldogs, French bulldogs, Shar Peis, Boston terriers, Shih Tzus, Boxers, and even Persian cats often suffer from anatomical abnormalities such as those discussed above that can cause such severe respiratory trouble that quality of life is drastically reduced

It is a cause for serious thought when we humans, who have such affection for the animals in our lives, and consider them members of our families, at the same promote breeding practices that aim to further exaggerate the smush-face-edness of Pugs, the enormity of Danes, the long backs of Dachshunds, and the wrinkles of Shar Peis that leave these poor dogs with diseases that could cause years of suffering or shorten their lifespans.

(Aaaaaaaand.... off my soapbox!)

Since we last spoke

Here are a few of the things that have happened in the last several weeks:

1. Stopped by 7 small animal vet practices in southeastern Minnesota and southwestern Wisconsin to drop off my resume and cover letter.

2. Had a phone interview with one of the aforementioned practices (alas, though I followed up by email, I've had no additional communication about the possibility of a job at that practice).

3. Found out I passed NAVLE. Huzzah!

4. Got my score report for NAVLE, which told me I scored a 598 on a scale of 200 to 800 with 425 being the minimum to pass, and an 86 on a scale of 0 to 99 with 75 being the minimum to pass. Nice scoring system, eh?

5. Visited the career counselor-type-person associated with the vet school who will edit resumes and cover letters; got plenty of suggestions I've not yet had time to implement.

6. Started my Soft Tissue Surgery rotation, which is one of those busy-busy-busy rotations that I've had the fortune of not experiencing for quite awhile (probably since I was on CCU in October, and Oncology in September).

After 4 weeks of "radiation vacation" followed by 3 weeks of actual vacation, it was a bit jarring to hit the ground running with a full caseload, long hours, on-call shifts, and weekend duties in Soft Tissue. I remain not the hugest fan of having to be at school from 7 am till 7 pm most weekdays. And on-call still stresses me out -- although I had my first on-call shift this past Friday night, and did not get called in (which for me is almost unheard-of!).

Anyway, the upside of being on a busy, interesting service with lots of neat patients, clients, and cases is that I have lots of things I'd like to blog about. The downside of said busy, interesting service is that I lack the time to write. But stay tuned -- I promise some good stories are on their way!

Uncomfortable

I've been on actual vacation for the last 10 days, and Radiation Vacation for 4 weeks before that. So, in lieu of having anything truly exciting that's happened recently in school that I can blog about, I thought I'd share this somewhat awkward anecdote from one of my final days on ultrasound.

We were really bored, so when an unexpected anesthetized ultrasound patient rolled past our door, we leapt up to investigate. And soon regretted it.

The patient was a young adult male hound mix, a research dog enrolled in a study of erectile dysfunction. The goal of the study was to investigate why radiation treatment of prostatic cancer in adult men invariably causes erectile dysfunction.

This was the first part of the study for this particular dog, so he had not yet had any radiation treatments and was just having a baseline prostatic, testicular, and penile ultrasound.

Which we completed.

Then injected a chemical into his penis to give him an erection.

Awkward.

Then ultrasounded him again. And called it quits.

Fortunately, it was only women in the room. Still felt like we had violated the poor anesthetized male dog, though!