You're a new grad, working in a busy general practice on a hectic midsummer Friday afternoon. Between the hustle and bustle of back-to-back appointments (some of which are already double-booked), you hear a voice over the loudspeaker say “I need a tech to the front, STAT!” 

Realizing that an emergency has just come through the door, you head to the treatment area. The room that you were about to go into will just have to wait a few minutes longer… Hopefully, the client will understand!

A vet tech meets you at the treatment table with Simba, a 7-year-old male neutered Pekingese. Simba’s owner is concerned that he is having trouble breathing. They went for a walk together this morning and, while on their walk, encountered a dog that Simba hadn’t met before. When Simba saw the other dog, he began whining and barking. For the rest of the walk, Simba remained “keyed up” and was panting more than usual. Simba’s owner expected him to calm down once he was home and in the air conditioning (it’s a very hot and humid day), but Simba’s breathing instead has worsened.

Physical Exam

You immediately observe that Simba has an elevated respiratory rate (80 bpm) with dramatic inspiratory stridor and increased respiratory effort, but his gums are pink. His temperature is 102.9° F and he has a BCS of 8/9. You struggle to auscult Simba’s heart over his increased respiratory sounds, but he has strong pulses and a pulse rate of 160 bpm. He has moderate dental calculus and nuclear sclerosis, but the remainder of your initial exam is unremarkable.

As your tech is restraining Simba, you note that he is becoming more agitated. The more excited he becomes, the more he struggles to breathe. You suspect brachycephalic obstructive airway syndrome (BOAS). 

Stabilization

After sending a vet assistant to update your waiting appointments, you speak briefly with Simba’s owner. You give him a quick update and get authorization to provide initial stabilization.

While you begin to create a detailed treatment plan for Simba, you ask your vet tech to do the following: 

• Place an IV catheter
• Administer butorphanol (0.2 mg/kg IV) and midazolam (0.2 mg/kg IV) for sedation
• Administer dexamethasone (0.5 mg/kg IV) to decrease laryngeal edema
• Administer oxygen (flow-by, or via face mask if Simba will tolerate it once sedated)

As you wait to see how Simba responds to these treatments, you try to quickly finish the appointment that you were about to begin when Simba arrived. Within four minutes of entering the room, however, a technician pokes her head in to say that they need you in treatment.

When you return to Simba, you note that his condition is not improving. In fact, he appears to be in even more distress than he was in when he arrived. His mucous membranes are now cyanotic. You speak quickly with Simba’s owner and then anesthetize Simba with propofol. As you insert an endotracheal tube, you notice severe swelling of the laryngeal tissues, in addition to an elongated soft palate and laryngeal collapse. These findings confirm your diagnosis of BOAS, but they’re not particularly reassuring!

You connect Simba’s endotracheal tube to oxygen with 2% isoflurane and his color improves almost immediately. You attach your practice’s monitoring equipment (ECG, oscillometric blood pressure cuff, pulse oximeter, and capnograph) and all values are within normal limits within the first five minutes of anesthesia. You monitor Simba’s temperature every five minutes and it also begins to fall rapidly once he is anesthetized, reaching 102.2° F after ten minutes. 

Meanwhile, your vet assistants explain to your appointments that you are working with an emergency. Clients are given the option to wait for you to become available, to drop their pet off for a few hours, or to reschedule their visit for another time. 

After twenty minutes, you decide to slowly and gradually begin weaning Simba off anesthesia. Over the course of another ten minutes, you gradually decrease Simba’s sevoflurane from 2% to 0.5%, then discontinue it completely. You keep Simba on oxygen for five minutes. Even after disconnecting oxygen, you keep Simba intubated for as long as possible, only removing his tube when he begins to show signs of chewing at it. 

When you remove Simba’s endotracheal tube, he is once again breathing normally. His respiratory rate and effort are normal, with minimal inspiratory stridor. You monitor him closely in recovery, ensuring that he remains calm and prepared to administer additional sedation if he becomes agitated. His recovery is calm and uneventful and he does not require additional oxygen or re-intubation during his stay. 

Long-Term Prognosis

Brachycephalic dogs are susceptible to acute upper airway obstruction, especially if they become excited on a hot, humid day. These dogs become victims of a vicious cycle, in which barking and heavy breathing lead to laryngeal edema, which leads to even heavier breathing, which leads to even worse laryngeal edema. 

Treatment of acute BOAS is often centered upon corticosteroids (to decrease inflammation) and sedation (to calm the pet). Anesthesia and intubation may be required in severe cases. Cooling measures may also be required, depending upon the dog’s temperature at presentation. 

The only long-term solution for brachycephalic syndrome is surgery. Correcting a brachycephalic dog’s stenotic nares, elongated soft palate, and everted laryngeal saccules will improve the dog’s quality of life and should effectively prevent further episodes of respiratory distress. 

If an owner is unwilling or unable to pursue surgery, treatment is centered on keeping the dog calm and avoiding high heat and humi

dity. 

True Story

This case is a more-or-less true story from my first year in practice. While I’d like to say that I remained as cool and calm as this case study implies, the truth is that I kind of panicked! I felt well-equipped to handle the dog’s medical needs, but juggling those medical needs with the need for client communication and a growing backup of appointments was a challenge. I managed, though… with some help from my fellow doctors and an excellent team of techs! The dog did well, the client was satisfied, and my scheduled appointments were patient and tolerant (well, most of them). 

When you get hit with an unexpected emergency in the midst of an already-busy day, take a deep breath. Focus on taking things one step at a time and don’t hesitate to use any and all resources that you have available to you.