Approaching the brachycephalic dog in critical condition

On the second day of the Directions in Veterinary Medicine (DIVM) symposium in Miami, Florida, Adam Christman, DVM, MBA, dvm360® chief veterinary officer and Fred Wininger, VMD, introduced¹ a mock pain management case that served as a basis for discussion of when presented with a brachycephalic breed in potentially critical condition. The dog is a 5-year-old female, spayed French bulldog named Stella who is experiencing a 1-week history of slowing down. She has acute onset of hind limb paresis and yelps when her owner picks her up. There are no known previous health issues, and Stella is panting heavily for 2 hours when in the waiting area.

Feliza Lopez, LVT, VTS (ECC) (left) and Mariana Pardo, BVSc, MV, DACVECC (right) delivering their lecture on approaching a French bulldog in critical condition.

Following this presentation, Mariana Pardo, BVSc, MV, DACVECC, and Feliza Lopez, LVT, VTS (ECC) took the stage for a lecture entitled "Initial Triage and ER Management" to provide insight on how to approach this brachycephalic dog.²

Triage

According to Lopez, a complete triage should take no more than 2 minutes as you become more comfortable with recognizing what is normal versus abnormal. She advised attendees to start with signalment, history, and the chief complaint from the owner. She shared that it’s important to have a strong introduction with clients, “That way it's very clear to the owners who you are and that you're there and ready and prepared and professional and anxious to help their pet.”

There should also be a primary survey that covers the 4 main body systems: the respiratory system, cardiovascular system, neurologic system, and urinary system. “These systems provide clear guidelines to assess clinical needs and priority for care,” said Lopez. This consists of veterinary professionals taking vitals including weight, temperature, heart rate, respiratory rate, and blood pressure.

Last, Lopez stressed to ensure you have permission for stabilization and code status. It’s important to be transparent with clients about stabilization because it is often expensive. Additionally, code status is critical because if a patient is taken to the back, you don’t want to waste any time and take attention away from the pet by returning to the owner to ask them their wishes in worst-case scenarios. “We just want to make sure that we have an understanding of [the client’s] wishes if for some reason, [the dog] went into respiratory arrest or cardiac arrest,” noted Lopez.

Comorbidities

There are some comorbidities to keep in mind associated with brachycephalic breeds to consider when faced with this patient in critical condition. This includes brachycephalic syndrome (BCS) which can include:

• An elongated soft palate extending into the larynx
• Stenotic nares
• Everted laryngeal saccule
• Hypoplastic trachea
• Hypertrophic intranasal turbinates and caudal aberrant turbinates

The pet can also develop brachycephalic obstructive airway syndrome (BOAS). Pardo shared that 50% of brachycephalic dogs will have a degree of BOAS that causes clinical problems. Airway assessment and corrective surgery is recommended at 6-12 months.

Secondary signs of BCS include:

• Gastric reflux
• Regurgitation
• Retching
• Vomiting
• Aspiration pneumonia
• High parasympathetic tone
• Exercise intolerance

While secondary signs of BOAS include:

• Stertor/stridor
• Inspiratory dyspnea
• Increased RE
• Hyperthermia
• Syncope

Pardo said, about educating owners on brachycephalic breeds, “I think it's part of our responsibility to ensure that people know what are the major risks that these patients are going to have, how they can try to minimize it.” She added, “Make sure to talk about nutrition, that we keep these animals as slim and fit as possible because it's going to improve their airways as much as it can, is going to try to keep those muscles really nice and tight for potential back problems that they might have, and all the other issues that come with these types of breeds.”

Restraint

The duo emphasized properly approaching restraint with any patient. The most common causes for aggressive responses include fear, pain, and excessive physical restraint. Lopez said that it’s important to consider breed anatomy during restraint, such as in the French bulldog’s case, and incorporate Fear Free approaches. She recommended using barrier methods like blankets or towels for pets. “Less is more with bulldogs,” said Lopez. “I can't emphasize that enough. I think back in the day, we kind of taught restraint to each other without any rhyme or reason. And a lot of it was based on overpowering the animals…[however, in recent years] it's been really nice to step back and think about different methods of getting animals to do things and not necessarily fighting with them all the time.” She also shared that you can leverage the pet owner’s help as they have a good relationship with their dog and can assist you in making them comfortable in the hospital setting.

References

1. Christman A. Welcome, Opening Remarks and AM Case. Presented at: Directions in Veterinary Medicine; Miami, Florida. May 19-20, 2023.
2. Lopez F, Pardo M. Initial triage and management. Presented at: Directions in Veterinary Medicine; Miami, Florida. May 19-20, 2023.