Addressing brachycephalic obstructive airway syndrome (BOAS) in general practice

Brachycephalic obstructive airway syndrome (BOAS) is a well-established condition that historically has been overlooked. However, BOAS has gained more attention since the French bulldog became the most popular breed in America in 2023.¹ Recent data from the American Kennel Club (AKC) show that approximately 1 in 7 of nearly 716,500 dogs registered in 2023 was a French bulldog.²

It’s hard to imagine that French bulldogs were not among the AKC’s top 75 breeds just 25 years ago. Their popularity may be attributed to their prominence on social media and a slew of celebrity owners.² In 2023, French bulldogs became the most-mentioned dog breed on Instagram, with more than 37 million posts featuring French bulldog hashtags.³ Celebrities who own French bulldogs, including Leonardo DiCaprio, Lady Gaga, and Megan Thee Stallion, also have helped promote the breed.

Boaz Man, DVM, with one of his patients. (All photos courtesy of Boaz Man, DVM)

The French bulldog dethroned the Labrador retriever, which had previously won the AKC popularity contest for 30 years in a row.¹ With the popularity of this “extreme brachycephalic” breed, veterinarians share a great responsibility in educating pet owners about the specific medical needs of these animals. We have come a long way from being reactive health care providers to being proactive in regard to BOAS. In the past 10 years, close to 200 clinical studies have focused on BOAS, according to PubMed and the National Library of Medicine. Compare this with the prior 10 years (2004-2014) when there were only 30 BOAS studies.

Unique medical needs of dogs with BOAS

In general practice, I used to be guilty of not doing enough to prioritize the obvious breathing issues of my clients’ brachycephalic pets. Too many times jokes were made about the breathing challenges these pets faced in the exam rooms because they were “expected for the breed.” As practitioners, we have often failed to tackle BOAS and address it at an early age. Too often we would accept the “let’s wait and see” conversation that was doomed from the start. It was more recently that I realized our responsibility is to either address these pets’ issues at our general practice or refer them directly to someone who would.

For many years, I was comfortable with routine soft tissue procedures that were considered predictable. After recently upgrading my old laser to newer surgical laser technology, I realized I could perform surgery with increased scalpel speed and a clear visual field because the new technology led to minimal bleeding and swelling. Although I used my laser to remove lumps, perform spays and neuters, and perform other elective surgeries, I did not initially entertain the idea of using it for BOAS as a soft tissue surgery.

Getting educated and generating awareness for clients

I had become comfortable with referring “less routine” surgeries to other surgical experts. Admittedly, I was fearful of taking on a surgical procedure that I had not performed on my own. The fears of treating patients with BOAS in general practice are multifactorial. They include the fear of dealing with the owner and their anxious pet who struggles to breathe, the fear that the respiratory-compromised pet could become a case of respiratory crisis, and the fear that having to deal with a respiratory crisis would disrupt everything else we needed to do at the clinic. These obstacles used to lead me to refer cases to other experts, but these popular pets need us all to overcome our fears.

Boaz Man, DVM, with 2 French bulldogs.

As a visual learner, I know the importance of sharing online educational videos. I decided to post a short and simple video of a French bulldog’s breathing before and after BOAS surgery on Instagram. After all the years I had been active on social media, never did I imagine that it would become my first viral video. Shortly after this video had gained so much attention, I knew I needed to take a more proactive approach to addressing BOAS in our practice. Although the BOAS surgeries performed at my hospital were successful, I remained anxious about taking them on exclusively.

I decided to reach out to the team at VetScalpel. The veterinary surgical laser designer and manufacturer provided me with the tools necessary to successfully perform BOAS laser surgery in my practice. It was very shortly after I had performed my first BOAS laser surgery that I realized how important this procedure was for our brachycephalic patients. There is nothing more satisfying than to have a pet who was struggling to breathe go home later that day breathing easier after BOAS corrective surgery. The long-term improvement in quality of life is equally appreciated by the owner, the patient, and our entire veterinary team.

Understanding BOAS

To address the medical needs of patients with BOAS, we must first understand some basic concepts.

Why brachycephalic breeds are so popular

Infantlike features (large forehead, large and low-lying eyes, bulging cheeks) are described in classical ethology as social releasers, simple stimuli that evoke a stereotyped response (in this case, nurturing). Researchers assessed the attractiveness of such features in the faces of dogs or cats, teddy bears, and human infants, and then related these preferences to the degree of attachment to a pet. Overall, pets that had faces with infantlike features were rated as more appealing than those without.^4,5

Educating clients about BOAS

We must start by educating every owner of a brachycephalic pet about the symptoms of BOAS that signify an active problem. These include some or all of the following: noisy breathing, open mouth breathing, panting, snoring, wheezing, grunting, squealing, snorting, regurgitation, exercise intolerance, gagging, choking, abdominal breathing, and change in gum color.

Early and proactive surgical intervention should be discussed and scheduled. We also should tell owners that breeding affected pets is unethical and that affected pets should be spayed and neutered.

Goals of BOAS surgery

BOAS surgery improves a pet’s ability to breathe, reduces exercise intolerance, reduces secondary gastrointestinal diseases, and improves their overall quality of life. Most important is that we, as general practitioners, can effectively reduce the risk of life-threatening complications such as aspiration pneumonia, hyperthermia, laryngeal paralysis, heart failure, and collapse.

Choosing the appropriate candidate

The patient is shown before (top) and after laser rhinoplasty (bottom).

When it comes to determining which patients are candidates for BOAS surgery, there are a few tools that are helpful. One is the BRisk Score, which assists with developing and validating a preoperative score to predict the risk of major complications in dogs undergoing corrective surgery. Appropriate screening is needed for brachycephalic breeds because it enables us to discover health concerns that may change our protocol or lead us to refer to another facility for postoperative monitoring or critical care. Included in my preanesthetic tests are an electrocardiogram, blood work, and a radiographic evaluation of the neck and thorax (upper and lower airways) and abdomen by a radiologist.

In screening many French bulldogs, I have found that they often have bradycardia and an atrioventricular block, so they may require preanesthetic atropine. Radiographs can help us confirm elongation and thickening of the soft palate and evaluate for other concerns such as tracheal collapse, pulmonary abnormalities, cardiovascular disease, pharyngeal/esophageal abnormalities, and hiatal hernias. As with any surgery, our goal is to minimize the risk of complications; the more we understand about the patient, the better the outcome will be.

Identifying BOAS-associated vomiting and regurgitation

With high resistance in the airway, extreme effort is needed for brachycephalic dogs to expand their chests to increase airflow into their lungs. This extra-strong expansion of the chest can cause stomach content or the stomach itself to be sucked into the chest, which often leads to vomiting and regurgitation. When acidic stomach content flows back into the esophagus it becomes irritated and inflamed and creates discomfort and heartburn. Another problem these brachycephalic pets have is retention of food in the stomach for prolonged periods. Pooling of food in the stomach creates a sensation of nausea and again increases the potential for vomiting and acid reflux.

Why the Poiseuille law is important to BOAS

Using the Poiseuille law, it has been determined that a 50% reduction in airway radius results in a 16-fold increase in airway resistance.⁶ The consequences of this resistance to airflow include restricted breathing, increased negative intraluminal pressure during inspiration, tonsillar hyperplasia, pharyngeal hyperplasia, eversion of laryngeal saccules, and laryngeal and bronchial collapse.^7,8

Takeaway

We must take a proactive role in general practice to help pets who suffer from BOAS. BOAS laser surgery is a soft tissue surgery that you are capable of performing. Once you learn to remove a lump with a laser, the soft palate will become a walk in the park. You will come to learn that a staphylectomy is less complicated than a lumpectomy. The tissue in the nares is no exception to this rule. Both procedures have no layers to close, no sutures needed, as well as no postoperative e-collar. Additionally, they have an advantage of minimal to no bleeding that is easily controllable.

Boaz Man, DVM, is owner and medical director of Boca Midtowne Animal Hospital, the only Fear Free certified practice in Boca Raton, Florida, and is also accredited by the American Animal Hospital Association.

References

1. Rice J. French bulldog knocks Labrador retriever out of number one
   spot, ending 31-year stay at the top. American Kennel Club. March 15,
   2023. Accessed March 6, 2024. https://www.akc.org/press-releases/ french-bulldog-knocks-labrador-retriever-number-one-spot-ending-31-year-stay-top/
2. Peltz J. Beloved and debated, French bulldog becomes top US dog breed. Associated Press. March 15, 2023. Accessed March 8, 2024. https://apnews.com/article/ dogs-breeds-popularity-frenchies-bulldogs-labrador-retrievers-983c17969c8b3efaf1b- 02f55a0d8f24b
3. Werner B. What are the 20 most Instagramable dog breeds? List Wire. April 4, 2023. Accessed March 8, 2024. https://thelistwire.usatoday.com/lists/ what-are-the-20-most-instagrammable-dog-breeds/
4. Lorenz K. Part and parcel in animal and human societies (1950). A methodological discussion. In: Studies in Animal and Human Behavior. Volume II. Harvard University Press; 1971:115-191.
5. Archer J, Monton S. Preferences for infant facial features in pet dogs and cats. Ethology. 2010;117:217-226. doi:10.1111/j.1439-0310.2010.01863.x
6. Lee L. Airway management and ventilation. Western University of Health Sciences. Accessed March 12, 2024. https://www.westernu.edu/mediafiles/veterinary/vet-anesthe- sia-analgesia/airway-management-Ventilation.pdf
7. Trappler M, Moore K. Canine brachycephalic airway syndrome: pathophysiology, diagnosis, and nonsurgical management. Compend Contin Educ Vet. 2010;33(5):E1-E4.
8. Fawcett A, Barrs V, Awad M, et al. Consequences and management of canine brachycephaly in veterinary practice: perspectives from Australian veterinarians and veterinary specialists. Animals (Basel). 2019;9(1):3. doi:10.3390/ani9010003