Sleep has long proved to be a vital component in maintaining homeostasis, with recent research beginning to investigate pathological disruptions of the sleep-wake cycle in dogs.1–4 The term sleep-disordered breathing (SDB) includes any breathing problems that occur during sleep, ranging from hypopnea to periods of complete apnea.5 While no official veterinary classification of sleep disorders exists, SDB in humans is split into 4 main categories: obstructive sleep apnea (OSA), central sleep apnea, sleep-related hypoventilation, and sleep-related hypoxemia.5 These definitions have been similarly applied within veterinary medicine, with OSA thought to be the most common etiology of SDB in dogs.1–4,6
Obstructive sleep apnea occurs secondary to the dynamic obstruction of the upper airway leading to hypopneic and apneic events.1,3,5 In humans, OSA has been linked to anatomic abnormalities of the pharynx in combination with dysfunction of pharyngeal dilator muscles, which help maintain upper airway patency.7 Pharyngeal dilator myopathy during rapid eye movement sleep, leading to prolonged periods of oxygen desaturation, was demonstrated in English Bulldogs as an experimental model for SDB in the 1980s.6,8 Brachycephalic obstructive airway syndrome has since been extensively studied, with the associated anatomic abnormalities (eg, stenotic nares, elongated soft palate, hypoplastic trachea) suspected to predispose these dogs to develop SDB.3,4,9 This may be secondary to long-term negative pressure gradients associated with increased inspiratory upper airway resistance, leading to pharyngeal dilator myopathy and pharyngeal collapse.10,11 A reported 56% of brachycephalic dogs experience sleep problems, which can manifest as abruptly waking up in respiratory distress, general lethargy or abnormal sleep patterns, episodes of apnea while sleeping, screaming or gasping to wakefulness, an inability to fall asleep, and sleeping in abnormal positions (sitting, chin elevated, etc).1,3,4,12,13 Not only can SDB have physiological sequelae in dogs including somnolence, hypertension, and cardiovascular disease, but this disease can also take an emotional toll on pet owners.6,14,15
Historically diagnosis of SDB in dogs has been challenging and required polysomnography or whole-body barometric plethysmography.2,4,6 In addition, the authors have anecdotally observed variable responses in SDB clinical signs following brachycephalic airway surgery (BAS). While some cases showed improvement or even resolution of SDB signs, others experienced no change or an increase in frequency and severity of SDB signs shortly after BAS, further complicating the diagnosis. While sleep disturbances can resolve following corrective upper airway surgery (alarplasty, staphylectomy vs folded flap palatoplasty, laryngeal sacculectomy, tonsillectomy, and/or partial cuneiformectomy), further surgical intervention or medical management may be necessary for nonresponsive or recurrent SDB.2,9,12,16,17 However, the use of permanent (crico)tracheostomy (PT) as a treatment for SDB has not been described.
The primary objective of this case series was to assess the use of PT for the management of SDB diagnosis in 3 dogs.
Methods
Study overview and case identification
This study was a retrospective case series conducted at a single teaching hospital. Medical records were reviewed for dogs who underwent PT between January 2019 and December 2023. Cases were only included if PT occurred at the teaching hospital rather than an external facility. Dogs were excluded if PT was performed for reasons other than presumptive SDB or if a presumptive diagnosis of SDB could not be established. An IACUC exemption was granted (Clinical Studies No. 121823-13), and informed consent was obtained for all cases. As neither polysomnography nor plethysmography was available, a presumptive diagnosis of SDB was based on previously adapted criteria of Hinchcliffe et al2 in addition to abnormalities identified on sedated airway/laryngeal examination. An SDB diagnosis was defined as over 5 episodes of apnea or hypopnea observed during sleep with no alternative disorder or drug interaction explaining respiratory events and when at least 1 of the following was reported: waking up breath holding or in distress with gasping or choking, low activity levels or sleeping while sitting/standing or during periods of interaction, breathing interruptions or apneic episodes, and/or seeking a specific sleeping position (eg, chin elevated, seated position, toy in mouth).2
Survey
A 9-part survey with embedded multiple-choice questions (42 in total) was created to obtain standardized patient information regarding clinical signs and quality of life preoperatively, immediately postoperatively, and at the time of follow-up. The same questions were asked about each aforementioned time period and included severity of clinical signs in regard to overall quality of sleep, overall activity level while awake, overall alertness while awake, breathing noise while awake, breathing effort while awake, degree of snoring while asleep, and apneic events while asleep; frequency of clinical signs in regard to sudden awakening/gasping from a sound sleep, episodes of vocalization while sleeping, episodes of gagging while sleeping, inability to fall asleep, sleeping in unusual positions, and regurgitation/vomiting; and overall quality of life.
The severity of clinical signs was graded as not affected (neither myself nor others would notice an abnormality in my pet), mildly affected (while I notice an abnormality, the average person meeting my pet for the first time likely would not and this abnormality has no impact on my pet's quality of life), moderately affected (the average person meeting my pet for the first time would recognize an abnormality; however its impact on my pet's quality of life is minor), and severely affected (any person meeting my pet would recognize an abnormality; this abnormality is significantly impacting my pet's quality of life). The frequency of clinical signs was classified as occurring rarely if ever, multiple times per month, multiple times per week, nightly, or multiple times a night. Quality of life was graded as either poor (my pet's quality of life was so severely affected, I was considering euthanasia), fair (my pet's quality of life was negatively impacted by the disease process; however with my active management/support this impact was tolerable), good (my pet's quality of life was not impacted by the disease process; however, it did require my active management/support to mitigate), or excellent (my pet's quality of life was not impacted by the disease process and no additional support/management was needed).
A survey tool (Qualtrics XM; Qualtrics International Inc) was used for survey creation and administration, and the complete survey is included (Supplementary Material S1). The survey was distributed via email on January 4, 2024, and it was open for 1 week following initial dissemination. Survey response was incentivized with a $50 gift card to Amazon. Survey results were reported by frequency of respondents.
A final follow-up was conducted via email in November 2024 to determine if there were any changes in the survey-reported outcomes. Owners were also asked the final question of “Given everything you know now, would you choose to have a PT performed again if faced with the same situation?” to determine their ultimate satisfaction with a PT for SDB.
Data acquisition
Data were collected from medical records of each case for each relevant preoperative, operative, and postoperative appointment and/or hospital stay. Data collected included signalment, history, physical examination findings, diagnostic imaging, medical treatment, surgical treatment, and any adverse events related to surgical procedures. Adverse events were documented according to predefined criteria, categorized by timing (preoperative, intraoperative, or postoperative) and Accordion severity (mild, moderate, severe, or death).18 When follow-up procedures were required after the initial PT, the same data were collected. When a laryngeal exam was performed, the results were collected, including the stage of laryngeal collapse if noted.19
Permanent (crico)tracheostomy
A routine ventral midline approach was used to access the cranial aspect of the trachea in all patients. The sternohyoideus muscles were sutured dorsally to the trachea with a horizontal mattress pattern to position the trachea more superficially. The (crico)tracheostomy site was identified, and a segment of tracheal cartilage, including part of the cricoid cartilage if applicable, was removed while preserving the underlying tracheal mucosa.20–22 The width and length of the tracheal rings excised were determined based on patient conformation and surgical judgment. The tracheal mucosa was incised in an H shape, and mucosa-to-skin apposition was achieved with either 4-0 poliglecaprone 25 (Monocryl; Ethicon Inc) or 4-0 polydioxanone (PDS; Ethicon Inc) in a simple interrupted pattern.
After the PT, skin-fold resections were performed to remove redundant tissue. The extent of resection was determined to ensure that skin tension maintained the tracheal lumen opening and prevented the infolding of excess skin. Standard closure was carried out in 2 or 3 layers.
Results
A total of 5 dogs were identified as having undergone PT at the teaching hospital from January 1, 2019, to December 31, 2023. Of these, 3 were identified as having undergone PT primarily for presumptive SDB. No cases were lost to follow up and the owners of all 3 dogs completed the survey. A complete description of each case is provided as well as a pertinent clinical overview (Supplementary Table S1).
Case 1
A 4-year-old, male neutered Cavalier King Charles Spaniel was presented with clinical signs of SDB in May 2017. The dog exhibited apneic episodes during sleep, followed by abrupt waking, gasping, disorientation, and screaming. These episodes occurred exclusively in the evening around once a night, and the patient was otherwise normal during the day. A previously performed echocardiogram was reported to be normal. A full diagnostic workup, including an MRI and Holter monitor, was performed to rule out causes of syncope or atypical seizure-like episodes. The MRI revealed a mild Chiari-like malformation suspected to be a breed-related variation and deemed unrelated to the clinical signs by the attending neurologist while a Holter monitor showed parasympathetically mediated sinus pauses with atrial fibrillation, while sleeping, thought to be a vagal response. The patient was started on zonisamide (10 mg/kg orally every 12 hours) in case of seizure activity to no effect. Two weeks later, an upper airway exam showed a mildly elongated soft palate with no evidence of laryngeal collapse, leading to a staphylectomy, which improved clinical signs. Zonisamide was discontinued but was then restarted when the patient had 2 episodes of coughing, gagging, and screaming during sleep in November 2017.
Over the course of the following months, the patient's original clinical signs recurred, prompting a head CT in February 2018. This revealed a moderately leftward deviated nasal septum and severe periodontal disease, treated with tooth extractions, azithromycin (10 mg/kg orally every 24 hours for 7 days and then 10 mg/kg orally every 48 hours for 21 days), and meloxicam (0.1 mg/kg orally every 24 hours for 5 days). The nighttime episodes became more infrequent until February of 2021 when they recurred, this time accompanied by periods of cyanosis. In March 2021, an echocardiogram revealed stage B1 mitral valve disease, and a laryngeal exam revealed stage II to III dynamic laryngeal collapse. A partial laryngectomy via cuneiformectomy was performed with questionable improvement. Ondansetron (0.5 mg/kg orally every 12 hours) was started due to reports of improvement in the treatment of SDB but no effect was appreciated.16,17,23 Laser-assisted nasal turbinectomy (LATE) was discussed and considered due to the prior finding of a deviated nasal septum; however, a referral was unsuccessful.2 In May 2021, episodes became nightly and a static nasal septum deviation with a thickened soft palate was noted on repeat head CT scan, leading to a folded flap palatoplasty. The dog's condition acutely worsened postdischarge, to the extent that the owners were unable to sleep and were frequently waking the patient during the night to avoid episodes of cyanosis. A PT was performed 6 days later.
Case 1 underwent PT starting caudal to the first tracheal ring, with the site extending the length of 3 tracheal rings and half the circumference of the trachea. Bilateral skin-fold resections were performed along the lateral neck while in dorsal recumbency. Immediately postoperatively, the patient demonstrated improvement in almost all sleep parameters (Table 1). A tapering course of prednisolone was prescribed postoperatively (0.5 mg/kg orally every 24 hours for 2 weeks, and then 0.25 mg/kg orally every 24 hours for 2 weeks). The patient developed a moderate complication characterized by superficial dehiscence of the left-sided skin-fold resection. The incision healed by the second intention supported by antimicrobial therapy with amoxicillin/clavulanate potassium (18 mg/kg orally every 12 hours for 7 days). At last follow-up via email 41 months following PT, the patient had a good quality of life with persistent improvement in sleep outcomes. The owners reported that, if faced with a similar situation, they would choose to proceed with a PT for their pet again.
Summary of owner-reported severity of clinical signs, frequency of clinical signs, and quality of life preoperatively (Pre), immediately postoperatively (Post), and at the time of survey follow-up (Survey) for 3 dogs with obstructive sleep apnea treated with permanent (crico)tracheostomy.
| Case 1 | Case 2 | Case 3 | |||||||
|---|---|---|---|---|---|---|---|---|---|
| Question | Pre | Post | Survey | Pre | Post | Survey | Pre | Post | Survey |
| Quality of sleep | Severe | Not | Mild | Severe | Severe | Severe | Severe | Mild | Not |
| Degree of snoring | Severe | Moderate | Moderate | Severe | Severe | Severe | Severe | Not | Not |
| Activity level (awake) | Not | Not | Not | Severe | Severe | Mild | Mild | Not | Not |
| Alertness (awake) | Not | Not | Not | Severe | Severe | Mild | Mild | Not | Not |
| Breathing noise (awake) | Not | Not | Not | Severe | Severe | Severe | Mild | Not | Not |
| Breathing effort (awake) | Not | Not | Not | Severe | Severe | Severe | Mild | Not | Not |
| Apneic events | 5 | 1 | 1 | 5 | 1 | 1 | 5 | 1 | 1 |
| Sudden awakening | 5 | 1 | 2 | 5 | 5 | 1 | 5 | 1 | 1 |
| Vocalization | 5 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 |
| Gagging | 5 | 1 | 2 | 1 | 1 | 1 | 1 | 1 | 1 |
| Inability to fall asleep | 1 | 1 | 1 | 5 | 5 | 1 | 5 | 1 | 1 |
| Unusual sleep positions | 1 | 1 | 1 | 5 | 5 | 3 | 5 | 1 | 1 |
| Quality of life | Poor | Good | Good | Poor | Poor | Good | Poor | Good | Good |
Case 1 was an 8-year-old male castrated Cavalier King Charles Spaniel, case 2 was an 8-year-old female spayed English Bulldog, and case 3 was a 1-year-old male castrated French Bulldog at the time of permanent (crico)tracheostomy. All of the reported factors are in relation to sleep unless specified (awake). For quality of sleep, degree of snoring, activity level while awake, alertness while awake, breathing noise while awake, and breathing effort while awake, owners scored their dog's severity of clinical signs as not affected (Not), mildly affected (Mild), moderately affected (Moderate), and severely affected (Severe). For apneic events while asleep, sudden awakening from sleep, episodes of vocalization while asleep, gagging while sleeping, inability to fall asleep, and sleeping in unusual positions, owners reported frequency of clinical signs as rarely if ever occurred (1), occurred multiple times per month (2), occurred multiple times per week (3), occurred nightly (4), or occurred multiple times a night (5). For quality of life, owners scored their dog's overall quality of life as poor, fair, good, or excellent.
Case 2
A 2-year-old, female spayed English Bulldog was initially presented for respiratory distress following excitement and heat exhaustion in June 2017. Following stabilization, a physical examination revealed stenotic nares and moderate-to-severe stertor, while a laryngeal exam revealed an elongated soft palate and stage I laryngeal collapse. The patient underwent an alar wedge resection, staphylectomy, and laryngeal sacculectomy, which improved the condition. The patient was presented to the teaching hospital several times over the course of the following years for management of chronic dermatological disease (atopy, bacterial intertrigo, interdigital furunculosis, and otitis externa) without any evidence of respiratory compromise.
In August 2022, the patient was presented to the Internal Medicine Service for worsening respiratory effort and noise of a 2-month duration. Thoracic radiographs revealed a moderate-to-severely widened cranial mediastinum with dorsal displacement of the trachea and poor lung expansion. Differential diagnoses for the cranial mediastinal widening included adipose deposition and a cranial mediastinal mass; therefore, a thoracic ultrasound was performed, which revealed no evidence of a mass. The patient was prescribed fluoxetine (1 mg/kg orally every 24 hours) and trazodone (5 mg/kg orally every 8 to 12 hours) for mild sedation secondary to anxiety, which improved clinical signs for some time. The patient was represented in June of 2023 primarily for episodes of nighttime stridor, restlessness, and apneic episodes in addition to exercise intolerance that coincided with warmer weather. The owners also noted that the patient would fall asleep in a sternal position with the head lifted and neck fully extended. A laryngeal exam revealed stage II to III dynamic laryngeal collapse, and a PT was scheduled. Before the patient's PT procedure, the patient was hospitalized emergently for acute collapse and cyanosis. Following thoracic radiographs and an echocardiogram, the patient was diagnosed with left-sided congestive heart failure secondary to stage C degenerative mitral valve disease, along with a heart-based tumor with mild pericardial effusion. The patient's cardiac condition stabilized, and daytime clinical signs improved with furosemide (2 mg/kg orally every 8 to 12 hours), sotalol (2 mg/kg orally every 12 hours), and pimobendan (3 mg/kg orally every 12 hours); however, the patient's nighttime clinical signs persisted. Due to persistent nighttime clinical signs despite the resolution of the patient's congestive heart failure, a PT was performed 1 week after recovery from this episode.
Case 2 underwent PT, starting at the cranial aspect of the cricoid cartilage, extending through the first tracheal ring (3 cm in length), approximately one-third of the tracheal circumference. A PT was elected due to the patient's conformation and concern for increasing risk of dynamic occlusion the further caudal the tracheostomy was positioned. Bilateral skin-fold resections were performed along the lateral neck, with each resection being performed in lateral recumbency. The patient was discharged with carprofen for pain management (1.7 mg/kg orally every 12 hours for 5 days).
Case 2 developed both tracheal stenosis and skin-fold occlusion, both considered severe complications. Approximately 1 month after the initial PT, the patient was presented in respiratory distress, and stenosis of the tracheostomy site was noted. Revision of the previous PT to 50% of the airway circumference was required. Approximately 2 months after the initial surgery, continued SDB signs were noted, characterized by restlessness and the inability to sleep through the night. The placement of Lembert tacking skin sutures (Figure 1) provided substantial but transient improvement of SDB-related signs. Therefore, aggressive 4-quadrant skin-fold resection was performed (Figure 2). While the overall quality of sleep remained severely affected, significant improvement in the patient's clinical status and overall quality of life were achieved following these additional surgeries (Table 1). Of note, about 4 months after the initial surgery, the patient developed gastric dilatation and volvulus. Gastric derotation and a gastropexy were performed and the patient recovered uneventfully. At the last follow-up both in-person and via email 16 months following PT, the patient had a good quality of life with variable improvement in sleep outcomes. Importantly, although the SDB was not completely resolved, it was these changes in overnight clinical signs secondary to PT to which the owners attributed improved quality of life. The owners reported that, if faced with a similar situation, they would choose to proceed with a PT for their pet again.
Images depicting severe skin-fold occlusion of a permanent (crico)tracheostomy (PT) stoma site 2 months following PT in case 3, a 1-year-old male castrated French Bulldog that underwent treatment for sleep-disordered breathing via PT. Lembert tacking skin sutures (A) were placed bilateral to the stoma (B) to tack skinfolds and tension the stoma to maximize patency (C). Mild stenosis of the tracheal stoma site is identified following skin-fold tacking (C). This technique is used to assess the clinical response before revision surgeries.
Citation: American Journal of Veterinary Research 2025; 10.2460/ajvr.24.09.0270
Images of revision skin-fold resections performed following skin-fold occlusion of the tracheal stoma site for dogs undergoing PT for treatment of sleep-disordered breathing. Case 2, an 8-year-old female spayed English Bulldog, underwent 4-quadrant skin-fold resection (A), while case 3, a 1-year-old male castrated French Bulldog, underwent bilateral and caudal skin-fold resections as well as caudal stoma revision (B).
Citation: American Journal of Veterinary Research 2025; 10.2460/ajvr.24.09.0270
Case 3
A 1-year-old, male neutered French Bulldog was presented in July 2023 with increased upper airway noise, exercise intolerance, regurgitation while awake, and discomfort during sleep characterized by apneic episodes, rapid waking, and repositioning. Despite previous correction of stenotic nares with the primary veterinarian, the patient's clinical signs progressed. Thoracic radiographs were normal, but an upper airway exam revealed a severely elongated soft palate and stage II to III laryngeal collapse. The patient underwent a folded flap palatoplasty and laryngeal sacculectomy, which improved or resolved the patient's daytime signs including regurgitation, stertorous breathing, and exercise intolerance. However, the patient's SDB persisted to worsened. A tapering course of prednisone (beginning at 1 mg/kg/day orally) provided temporary relief, but nighttime episodes continued to unpredictably occur. Two months later, the sleep difficulties persisted, characterized by excessive snoring, apneic events, and the dog sleeping in a sternal position with an extended neck, prompting the decision to proceed with a PT.
Case 3 underwent PT starting at the caudal aspect of the cricoid cartilage and extending to the fifth tracheal ring, approximately one-third of the tracheal circumference. A reverse U-shaped incision was performed to remove skin redundancy both lateral and cranial to the stoma. An additional right lateral skin resection was performed. A tapering course of prednisone was prescribed postoperatively (0.5 mg/kg orally every 24 hours for 5 days and then 0.25 mg/kg orally every 24 hours for 5 days).
The patient demonstrated immediate and complete resolution of SDB-related clinical signs following PT (Table 1). However, within 2 months of surgery, mild stenosis of the tracheal stoma and redundant skinfolds caused the recurrence of SDB-related clinical signs. Complete but transient improvement was noted following the placement of Lembert tacking skin sutures bilateral to the stoma to tension skinfolds and maintain stoma patency (Figure 1). Bilateral and caudal skin-fold resections relative to the trachea stoma were performed as well as revision of the caudal aspect of the PT to lengthen the stoma, resulting in an immediate improvement in clinical signs (Figure 2). At last follow-up via email 13 months following PT, the patient had a good quality of life with persistent improvement in sleep outcomes. The owners reported that, if faced with a similar situation, they would choose to proceed with a PT for their pet again.
Survey results
Each dog had variable clinical signs related to their SDB, with owners reporting clinical signs occurring multiple times per night and poor quality of life in all cases (Table 1). Cases 1 and 3 were noted to have mild to nonexistent clinical signs while awake. Cases 1 and 3 demonstrated immediate improvement in the severity and frequency of the majority of clinical signs relating to SDB following PT, and overall quality of life improved immediately. Although overall sleep quality remained severely affected in case 2 at survey completion, PT and subsequent revision procedures led to improvement in several SDB-related clinical signs, and the owner reported a significant improvement in quality of life, shifting from poor to good, which they attributed directly to the PT.
Discussion
Sleep-disordered breathing remains a poorly understood and infrequently studied area of veterinary medicine, with few recent reports describing risk factors, diagnostic methods, and medical and/or surgical treatment of dogs with SDB.2–4,16,17 Brachycephaly is one of the only known predisposing factors to SDB and OSA in particular3,4; given that brachycephalic dog breeds are now among the most popular in the US, further research on diagnosis and treatment of SDB and OSA is warranted. All dogs in this case series were brachycephalic breeds that had previously undergone BAS (Supplementary Table S1), yet apneic events still occurred multiple times a night and the overall quality of sleep was severely affected. All dogs’ preoperative quality of life was reportedly poor, with all owners in this study heavily considering euthanasia primarily due to nighttime clinical signs. Notably, all cases experienced surgical complications ranging from moderate to severe following PT, with 2 of 3 dogs requiring revision surgeries. At time of last follow-up, apneic events rarely if ever occurred at night and owners reported quality of life as good in all cases, suggesting that PT is a viable treatment for nonresponsive or recurrent SDB following routine BAS.
The diagnosis of SDB has historically required the use of specialized equipment in a laboratory setting, although a portable neckband system was recently used to diagnose SDB in the home environment.2,4,6As this neckband system is a human medical product without widespread use in the veterinary field, and polysomnography and whole-body barometric plethysmography remain impractical outside of a research setting, none of the dogs in this case series had an official diagnosis of SDB; however, this neckband system shows promise for enhancing presurgical diagnostic capabilities. While aggressive, PT resulted in immediate improvement at home in 2 of 3 patients, supporting that underlying SDB should likely respond immediately following bypass of upper airway obstruction. Immediate resolution was not noted in case 2; however, challenges were encountered with maintaining stoma patency secondary to stoma stenosis and skinfolds. Once a patent stoma was achieved, a clinical response was obtained. This suggests that not only is PT a viable treatment for SDB, but it may have use in confirming a diagnosis of SDB when not otherwise available.
While a diagnosis of SDB is challenging, treatment options remain even more elusive. Medical treatments of SDB in veterinary literature16,17,23,24 are limited to the use of serotonin agonists/antagonists targeting pharyngeal musculature and a single report25 of continuous positive airway pressure (CPAP) in a Cavalier King Charles spaniel. Ondansetron, which is a serotonin antagonist acting on the 5-HT3 receptor subtype to counteract pharyngeal muscle relaxation, was used as a medical treatment for SDB in case 1 to no effect.23 It was not trialed in the remainder of cases in this series but may be worth attempting before aggressive surgical intervention. In case 2, fluoxetine and trazodone, which affect the serotonin pathway, were prescribed primarily for their antianxiety effects rather than for any potential impact on SDB.26 Mild, but transient improvements in nighttime symptoms were observed with these medications. CPAP is the first line treatment for OSA in humans; however, there are currently no CPAP machines intended for the treatment of SDB in veterinary patients.25 In the aforementioned case report, a human CPAP device was sourced and fitted to the dog using an induction mask and soft muzzle, and a prolonged period of positive reinforcement and desensitization occurred to acclimate the dog to the device.25 While CPAP was a successful management tool for SDB for the dog in that case report, limitations such as owner training investment, patient tolerance of the apparatus, and ability to fit some brachycephalic dog breeds to a mask must be considered.25 CPAP was not attempted as a treatment for SDB in any of our cases.
Surgical management of SDB is infrequently described and often relies on the routine components of BAS, including staphylectomy, alarplasty, and removal of everted laryngeal saccules. All dogs in this case series received variations of BAS (Supplementary Table S1) with differing impacts on the frequency and severity of clinical signs. In case 1, improvement in SDB was noted for several years following routine BAS. However, when a folded flap palatoplasty was performed after severe recurrence of SDB signs, the patient significantly declined, necessitating more urgent consideration of a PT just 6 days later. In case 2, significant improvement was noted in daily signs following routine BAS and clinical signs of SDB developed years after this treatment. In case 3, clinical signs of SDB remained static, if not worsened, following routine BAS. Of note, all 3 patients had stage II-III (dynamic) laryngeal collapse noted at the most recent laryngeal examination. Cases 1 and 2 were not initially noted to have laryngeal collapse at the time of their initial BAS. While no definitive conclusions can be made from this small case series, the association between clinical signs of SDB and laryngeal collapse warrants further investigation. Caution for improvement in clinical signs of SDB via treatment of routine BAS should be provided for patients presenting with laryngeal collapse.
A recent case series described the management of SDB in 5 Cavalier King Charles spaniels using a variety of corrective airway procedures (LATE, folded flap palatoplasty, tonsillectomy, laryngeal sacculectomy, and cuneiformectomy), with complete resolution of clinical signs noted in 4 out of 5 dogs.2 Notably, all dogs in this case series had severe nasal septal deviation, and 4 out of 5 received LATE.2 This case series was of particular interest when considering case 1, which was a Cavalier King Charles Spaniel that had moderate nasal septal deviation and received many of the aforementioned corrective airway surgeries aside from LATE.2 While LATE was heavily considered in this case, it is not offered at the teaching hospital in this study, and referral for this procedure was attempted without success. It should be noted that LATE is available at very few facilities across the US, can be technically difficult to perform, and has inherent risks and complications, with only the report mentioned above detailing its usefulness for the treatment of SDB.2,9
Permanent tracheostomy is infrequently performed in veterinary practice and is typically considered a salvage procedure for upper airway obstruction.27 Major complications have been reported in up to 56% of patients following PT and can include aspiration pneumonia, dyspnea, syncope, sudden death, and obstruction of the tracheostoma (skinfolds, stenosis, and collapse of stoma).27,28 However, a recent study27 found that despite these complications, owner satisfaction was nearly 90% with the majority stating they would have the procedure performed again.27 Consistent with previous studies, complications were encountered in all patients in our case series, with 2 of 3 cases having major complications requiring surgical revision(s) secondary to tracheal stoma stenosis and/or skin-fold occlusion of the stoma.27,28 Interestingly, the onset of stoma complications and worsening skin-fold occlusion, despite initial aggressive skin-fold resections, resulted primarily in the worsening of clinical signs of SDB as compared to clinical signs of daily function. In these cases, the use of Lembert sutures to tack skinfolds and tension the stoma to maximize stoma patency (either secondary to stenosis or skin-fold occlusion) resulted in immediate but transient improvement in the nighttime clinical signs (Figure 1). As revision surgery may be costly and aggressive, the authors found significant use in utilizing this technique to determine if the patients would respond to surgical intervention. These outcomes also underscore that while PT may be a successful surgical intervention for SDB, intensive postoperative monitoring may be required, and owners should be prepared for major complications necessitating revision surgeries.
Given that this study was a retrospective case series, there were several limitations. Retrospective data collection, small sample size, and variability among cases limited the ability to conduct comparative statistical analyses. Polysomnography and/or whole-body barometric plethysmography was not used to establish a diagnosis of SDB. There was also a lack of standardization of the diagnostic workup and medical and surgical treatment before the performance of PT. Specifically, lack of advanced imaging such as CT and fluoroscopy in most cases prevented the comparison of cases and understanding of the possible contribution of pharyngeal collapse in these cases. Case 1 had a mild, concurrent Chiari-like malformation, which was not treated preoperatively with neuropathic pain medications and may have confounded the diagnosis of SDB; however, the immediate response to PT makes this unlikely. Case 2 had significant comorbidities that may have confounded the diagnosis of SDB and/or the response to treatment. Owners responded to a nonvalidated retrospective survey sent by email, which could have led to recall bias. Finally, initial diagnoses and survey responses may not fully reflect the severity of the patients’ clinical signs, such as the assessment of activity level without objective measurements, due to potential cognitive dissonance among owners.29
Permanent (crico)tracheostomy may be considered as a treatment for nonresponsive or recurrent SDB following routine BAS and/or other medical or surgical management for SDB. All dogs in this study showed a decrease to complete cessation in clinical signs of SDB following PT and revision surgeries if applicable, with all patients improving from poor to good quality of life at the time of last follow-up. However, moderate or severe complications following PT occurred in all patients, and intensive postoperative monitoring of stoma patency is needed. Before pursuing PT for the treatment of OSA, owners should be educated on the possible complications of PTs and the likelihood of revision surgeries. Given that brachycephalic dogs are predisposed to developing SDB and the popularity of these breeds, further research on the diagnosis and treatment of SDB is needed.
Supplementary Materials
Supplementary materials are posted online at the journal website: avmajournals.avma.org.
Acknowledgments
None reported.
Disclosures
The authors have nothing to disclose.
ChatGPT was not used in the primary composition of this manuscript. However, ChatGPT was used as a tool to either check for appropriate grammar, suggest a more appropriate word within a sentence, or make already composed sentences more concise.
Funding
The authors have nothing to disclose.
ORCID
D. J. Lopez https://orcid.org/0000-0002-1087-1163
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