Upper Respiratory Surgical Conditions

Transcription

1 Upper Respiratory Surgical Conditions STEVE GARNETT, DVM, DACVS-SA DOGS AND CATS VETERINARY REFERRAL BOWIE, MD APRIL 17, 2016 Overview Anatomy Review Brachycephalic Syndrome Temporary Tracheostomy Anatomy Review 1

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4 Causes Congenital Early onset demyelination and axonal loss of long nerves Endocrinopathy Myesthenia gravis Neoplasia Trauma Geriatric onset laryngeal paralysis and polyneuropathy - GOLPP Signalment Congenital Bouviers des Flandrs, Husky breeds Early Onset Dalmations, Rottweilers, White coated GSD, Pyrenean Mountain Dogs Acquired >10 years old Large breed Males have possible predilection History Usually progressive Inspiratory dyspnea Stridor Heat intolerant Change in bark Evidence of pneumonia Dysphagia pararecurrent laryngeal nerves to cranial thoracic and cervical esophagus Hind limb weakness Andrade et al, Vet Surg 2015 Stanley et al, Vet Surg

5 Physical Exam Mild stridor to respiratory crisis Thorough cervical palpation Paraparesis Hypersalivation Harsh lung sounds, crackles pneumonia Mild/early cases Diagnostics CBC, Chemistry, T4 Possible resting cortisol or ACTH stim, Ach esterase titers Thoracic and cervical radiographs Esophagram (owner education vs. change in recommendations?) Sedated laryngeal exam Propofol only - SLOW Paradoxical arytenoid movement Doxopram 1mg/kg IV PRN to supplement diagnosis Mild/Early Cases Treatment OWNER EDUCATION Weight loss Change to a harness Avoid stressful or hot/humid situations Anxiolytics or sedation PRN trazodone or acepromazine 5

6 Severe cases Emergent treatment Oxygen supplementation Body temperature regulation IV fluids Sedation Prokinetics +/- anti-inflammatory corticosteroids (<0.1mg/kg Dex SP) +/- intubation Acepromazine 0.01mg/kg Butorphenol 0.1mg/kg Give IV 6

7 Severe cases Diagnostics CBC, serum chemistry Thoracic and cervical radiographs Sedated laryngeal exam +/- PT/aPTT Sedated Laryngeal Exam Sedated Laryngeal Exam Doxopram 1mg/kg IV 7

8 Sedated Laryngeal Exam Surgical options Unilateral arytenoid lateralization Bilateral arytenoid lateralization Partial laryngectomy Castellated laryngofissure Permanent tracheostomy 8

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10 Post operative care NPO for 24 hours, then canned food meatballs for 2 weeks Long term dietary modifications Activity restriction for 2 weeks Consider antacids and prokinetics Harness Limited post op sedation and opiods Lifelong monitoring for pneumonia Complications Aspiration pneumonia (20-25%) Recurrence (5-10%) Immediately post op to several years later Death (3-10% w/in two weeks of surgery) Unresolved coughing or gagging (23%) Incision complications (7-10%) Change in phonation Laryngeal webbing Hammel et al, JAVMA 2006 Increased risk of complications Bilateral simultaneous procedures Increasing age Pre- and post operative megaesophagus Temporary tracheostomy Increased risk of death Bilateral simultaneous procedures Increasing age Partial laryngectomy Post operative megaesophagus Temporary tracheostomy MacPhail et al, JAVMA

11 Increased risk of aspiration pneumonia Post operative megaesophagus Post operative administration of opiods Wilson et al, JAVMA 2016 Aspiration Pneumonia Prognosis Median survival time with surgery days 1 year survival 94 2 year survival 89% 3 year survival 84% 4 year survival 75% 90% of owners report an improved quality of life Hammel et al, JAVMA 2006 Wilson et al, JAVMA 2016 MacPhail et al, JAVMA

12 Brachycephalic Syndrome Components Stenotic nares Elongated soft palate Everted saccules Hypoplastic trachea Laryngeal collapse Everted tonsils Brachycephalic Syndrome Cause Congenital Progression over time due to subatmospheric pressure within airway Signalment English bulldog, Pug, French bulldog, Boston Terrier All ages, but become more clinical with time 12

13 Brachycephalic Syndrome History Heat and exercise intolerant Stertor Snores Sleep apnea like signs Respiratory crisis Regurgitation Brachycephalic Syndrome Physical exam Stenotic nares Stertor Obesity Inspiratory dyspnea Brachycephalic Syndrome Diagnostics Thoracic radiographs CBC/Chemistry? PT/aPTT (especially if hyperthermic) Sedated laryngeal exam 13

14 Brachycephalic Syndrome Treatment non emergent Weight loss Avoid hot and humid situations Harness Brachycephalic Syndrome Treatment emergent Oxygen supplementation Light sedation Body temperature management Judicious IV fluids Anti-inflammatory corticosteroids Dexamethasone SP 0.1mg/kg Intubation Temporary tracheostomy Brachycephalic Syndrome Surgical therapy Nasoplasty Staphylectomy Saccule resection +/- tonsillectomy Temporary tracheostomy Permanent tracheostomy 14

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17 Brachycephalic Syndrome Post operative care Extubate as late as possible Keep sternal with head elevated Avoid over sedation, opiods +/- oxygen supplementation Flow by vs. nasotracheal catheter Prokinetics Monitor for pneumonia Brachycephalic Syndrome Complications Nasal bleeding Dyspnea, upper airway obstruction Aspiration pneumonia Dysphagia Brachycephalic Syndrome Prognosis Successful outcome 94.2% Excellent outcome 50% Perioperative mortality 3% Riecks et al, JAVMA

18 Temporary Tracheostomy Indications Upper airway obstruction Upper airway surgery Anesthesia when unable to orotracheal intubate Long term mechanical ventilation Temporary Tracheostomy Procedure Clip and scrub Midline incision from cricoid to mid cervical region Retraction helpful Split the muscles on midline Incise between tracheal rings, no more than 50% circumference Place stay sutures Place tube Close ends of incisions if needed Secure around neck 18

19 Temporary Tracheostomy Tube options Cannulated vs. non cannulated Cuffed vs. non cuffed Oxygen/suction channel vs. non Commercial vs. home-made 19

20 Temporary Tracheostomy Items Required Appropriate type and size tracheostomy tube Alternatively, standard endotracheal (ET) tube fashioned into tracheostomy tube, one size smaller than for ET intubation Appropriate-size ET tube for ET intubation, with cuff syringe Clippers with clean blade Surgical scrub supplies Barrier drapes Sterile surgical gloves Sterile gauze Surgical instruments Suture material Umbilical tape Assistant Suction capability Oxygen/standard anesthetic supplies and equipment Temporary Tracheostomy Instruments Two towel clamps Scalpel handle and blade Thumb forceps Metz Needle holders 2 mosquito hemostats Suture scissors 2 Gelpis 2-0 silk, 3-0 PDS, 3-0 nylon 20

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26 Temporary Tracheostomy Post placement management Close monitoring Oxygen supplementation Changing of the cannula Suctioning Nebulizing/humidifying Temporary Tracheostomy Complications Mucus formation - occlusion Dyspnea Coughing the tube out Infection Drainage Stricture/granulation tissue formation 26

27 Summary Laryngeal paralysis is progressive and most dogs benefit from surgery Brachycephalic syndrome should be discussed with owners early on and surgery considered early in life (before becoming clinical) in hopes of avoiding a crisis and/or laryngeal collapse Temporary tracheostomy requires few instruments, is technically simple and can be life saving Questions? 27