French Bulldog BOAS Surgery and Management

Colleague,

This is a classic and severe presentation of BOAS; the syncopal event makes this a high-priority surgical case. My approach is to correct all amenable components in a single anesthetic event to maximize airway improvement.

1. Pre-operative Assessment:
Before inducing, I perform a sedated laryngeal exam to confirm the elongated soft palate and assess the grade of saccule eversion. Crucially, I obtain three-view thoracic radiographs to evaluate for aspiration pneumonia and measure the tracheal diameter to thoracic inlet ratio (TD:TI). A hypoplastic trachea (TD:TI < 0.16 in non-bulldogs, <0.14 in bulldogs) is a significant negative prognostic indicator that cannot be surgically corrected, and the owner must understand this limitation.

2. Surgical Plan (The "BOAS Package"):
My goal is functional improvement, addressing each obstruction point methodically.
* Stenotic Nares: I perform a wedge resection alaplasty to permanently widen the nares. This is the first and simplest step, but it significantly reduces inspiratory resistance.
* Elongated Soft Palate: My preferred technique is a folded flap palatoplasty or using a vessel-sealing device for a precise staphylectomy. The landmark for resection is the caudal margin of the tonsillar crypts. Over-resection risks rhinitis and nasal reflux; under-resection provides inadequate improvement. Precision here is key.
* Everted Laryngeal Saccules: Given the history of sleep apnea and syncope, I expect Grade II or III saccules. I will resect these by grasping them with Allis tissue forceps and excising them at their base with Metzenbaum scissors. This immediately opens the rima glottidis.

3. Peri-operative & Post-operative Management:
These cases are won or lost in recovery.
* Anesthesia: Pre-oxygenate thoroughly. I use a rapid-sequence induction and have multiple ETT sizes ready. I administer dexamethasone (0.1-0.2 mg/kg IV) intra-op to minimize swelling and maropitant to reduce regurgitation/aspiration risk.
* Recovery: This is a 100% mandatory overnight stay with close monitoring. We recover these patients in a cool, quiet environment, often with oxygen supplementation. I extubate very late, only once the patient is conscious and actively swallowing. We keep them NPO for 12 hours post-op, then introduce water and small meatballs of soft food.
* Discharge Meds: A short course of anti-inflammatories (tapering prednisone), gastroprotectants (omeprazole), and potentially trazodone for anxiety. Strict rest for 2 weeks and a harness (no neck leads) for life are non-negotiable.

The goal is to turn an emergency-prone patient into one with a functional, stable airway. The improvement is usually dramatic and life-changing for them. Let me know if you have the thoracic rads; I'd be happy to review them.

This is a classic, high-risk case that requires a tight collaboration between the surgical and critical care teams. The history of syncope elevates this from a standard BOAS correction to a high-urgency procedure. My focus is ensuring this patient is stable enough for anesthesia and, more importantly, can be safely recovered from it. James will handle the specifics of the surgery itself.

Pre-Operative Assessment & Stabilization:

The syncopal event is a critical data point; it signifies severe intermittent airway obstruction leading to hypoxia and cardiovascular collapse. This patient has minimal physiological reserve.

Airway Assessment: While the definitive assessment is under anesthesia, we need to be prepared. I want multiple endotracheal tube sizes (down to 2 sizes smaller than expected) ready at induction. A tracheostomy kit must be immediately available in the OR.

Pre-oxygenation: This is non-negotiable. At least 5-10 minutes of flow-by oxygen before any pre-meds are given to denitrogenate the lungs and buy us time during a potentially difficult intubation.

Pre-medication: The goal is anxiolysis without significant respiratory depression. My preferred protocol is butorphanol (0.2 mg/kg IM) for mild sedation and anti-tussive effects, maropitant (1 mg/kg SQ) to reduce regurgitation risk, and potentially a very low dose of acepromazine (0.005-0.01 mg/kg IM) if temperament allows and the patient is normotensive. We must avoid drugs like hydromorphone that cause excessive panting.

Post-Operative Management & Critical Care:

The surgery is only half the battle. The first 24 hours post-op are where these patients are most likely to decompensate.

Recovery: Extubation must be performed late. We wait until the patient is awake, sternal, and actively swallowing or resisting the tube. Have propofol and re-intubation supplies at the ready in case of an immediate post-extubation crisis ("crash" induction).

Anti-Inflammatory Protocol: I give a single dose of dexamethasone SP (0.1-0.2 mg/kg IV) right before extubation to minimize pharyngeal/laryngeal swelling.

Oxygen Support: The patient should recover in an oxygen cage or with nasal oxygen lines in place. We'll monitor SpO2 continuously and aim to keep it >95%.

Sedation & Anxiolysis: Keeping the patient calm is paramount. Panting and agitation increase airway swelling and thermal stress. I'll start trazodone (3-5 mg/kg PO) as soon as they can swallow and use injectable butorphanol or alfaxalone micro-doses as needed for breakthrough anxiety.

Monitoring: This patient requires 1:1 nursing care for at least the first 12 hours. Continuous ECG, SpO2, and respiratory rate/effort monitoring are essential. We'll watch closely for increased stertor, stridor, or paradoxical chest movement.

Emergency Plan: If severe swelling and obstruction occur despite these measures, the plan is immediate re-intubation. If intubation is impossible, we proceed to an emergency temporary tracheostomy. That decision needs to be made quickly, not after minutes of hypoxia.

I'll get this patient optimized for the procedure. James, over to you for the surgical plan.