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Flashcards in Respiratory Surgery Deck (160)
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1
Q

in what animals is BOAS seen?

A

extreme brachycephallic breeds (e.g. french bull dogs/pugs)

2
Q

how can BOAS be assessed?

A

using scoring system from grades 1-3 which assesses dyspnoea and laryngeal auscultation before and after a period of controlled exercise

3
Q

what are the main features of BOAS?

A
stenotic nares
overlong soft palette
hyperplastic tonsils
everted laryngeal saccules
hypoplastic trachea
hiatal hernia
stertor
stridor
\+/- laryngeal collapse
4
Q

what is the effect on the BOAS patient of hyperplastic tonsils?

A

narrows the airway

5
Q

what is the effect on the BOAS patient of hypoplastic trachea?

A

narrows airway

6
Q

what is stertor in BOAS dogs caused by?

A

partial obstruction of the upper airways at the level of the pharynx and nasopharynx

7
Q

what condition is stridor associated with?

A

laryngeal disease

8
Q

how does BOAS lead to hiatal hernia?

A

increased negative pressure created by narrowed airways pulls abdominal tissue through the hiatus

9
Q

what were the main findings of the study by Ludlow et al (2018)?

A

observations that can be made about a patient before touching them which may indicate that they have BOAS

10
Q

what were the conformational risk factors for BOAS for bulldogs found by Ladlow (2018)

A

moderate to severe stenotic nares
thicker neck
wider and shorter skull
male

11
Q

what were the conformational risk factors for BOAS for french bulldogs found by Ladlow (2018)

A
moderate to severe stenotic nares
thicker and shorter neck
shorter and wider skull
proportionately shorter muzzle
male
12
Q

what were the conformational risk factors for BOAS for pugs found by Ladlow (2018)

A
moderate to severe stenotic nares
obese (BCS 7+)
proportionately wider distance between eyes
wider and shorter skull
female
13
Q

how do stenotic nares affect breathing?

A

increase resistance to flow through nose

cartilage supports of the nares tend to collapse during inspiration so more effort required to breathe

14
Q

how does an elongated soft palette affect breathing?

A

can partially obstruct air flow into the trachea and cause turbulent airflow in the larynx

15
Q

how is laryngeal collapse graded?

A

1-3, separate from BOAS grading

16
Q

what is the main brachycephalic breed that is affected by tracheal collapse?

A

english bulldog

17
Q

what are the key considerations when nursing/caring for BOAS animals?

A

avoid stress/heat
use harnesses not collars
achieve/maintain an ideal body weight
carefully manage exercise regimes to ensure resp effort is reduced
consider when O2 therapy may be needed
educate owner on how to recognise signs of respiratory distress and when their pet needs to come into practice

18
Q

when is it even more essential that a BOAS animal achieves or maintains its ideal body weight?

A

pre-surgery

19
Q

what is involved in the nursing assessment of BOAS breeds?

A

TPR
MM
SpO2
BOAS grading and ASA grading with vet

20
Q

what are the main surgical treatments for BOAS?

A
soft palate resection
tonsil resection
removal of everted laryngeal saccules
nostril resection to correct stenotic nares
laser assisted turbinectomy (LATE)
21
Q

what is a staphylectomy?

A

soft palate resection

22
Q

what may be involved in surgical correction of BOAS?

A

one or more/all (multi-level) of the surgical corrections may be performed to correct BOAS

23
Q

what is a key benefit of BOAS surgery?

A

enable easier breathing and prevent development of irreversible long term problems (e.g. hiatal hernia)

24
Q

what will discussion with the surgeon prior to BOAS surgery include?

A

ASA grading

25
Q

what key information must be given to an owner before they consent to BOAS surgery?

A

full explanation of procedures and risks

26
Q

what pre-surgical tests should be performed on all animals receiving BOAS surgery?

A

biochem

haem

27
Q

what must happen to all BOAS breeds before induction?

A

at least 5 mins of preoxygenation with O2 kennel or mask

28
Q

how long should animals be preoxygenated for?

A

5 mins

29
Q

what is the purpose of preoxygenation?

A

delays oxygen desaturation if there is post induction apnoea or intubation takes longer due to anatomy

30
Q

how can stress through handling of BOAS animals be reduced?

A

IV placed after pre-med if animal is becoming distressed

31
Q

what topical medication must be provided regularly to BOAS patients under sedation/GA?

A

occular lubricant

32
Q

what equipment may be needed for intubation of BOAS breeds?

A

good lighting
laryngoscope
urinary catheter to guide and ease intubation
rescue ET tube

33
Q

what is a rescue ET tube?

A

ET tube with small lumen that can be placed in an emergency if intubation is proving challenging

34
Q

what imaging should be performed prior to BOAS surgery?

A

thoracic radiography - ideally CT

35
Q

what elements of BOAS are assessed by thoracic radiography?

A

hiatal hernia

nasal turbinates

36
Q

what patient prep is required for BOAS surgery?

A

no clip and scrub
oral mouth rinse
nares wiped with dilute chlorhexadine/iodine

37
Q

what must be done when rinsing the mouth of an unconscious patient?

A

pack the throat to prevent aspiration

38
Q

how should an animal be positioned for BOAS surgery?

A

sternal recumbancy

2 drip stands at either side of table to attach mouth ties to which will hold the mouth open

39
Q

what event must you be prepared for during surgery particularly in brachycephalic breeds?

A

regurgitation

40
Q

how can you be prepared for regurgitation?

A

tilted table

prepare suction

41
Q

what SpO2 should animals remain at during BOAS surgery?

A

> 98%

42
Q

what EtCO2 should animals remain at during BOAS surgery?

A

35-45mmHg

43
Q

why may BOAS animals have elevated EtCO2 at the start of surgery?

A

as they have inherent breathing difficulties and may be hypercapnic at all times

44
Q

what should happen to high EtCO2 in brachycephalics following intubation?

A

should settle to normal range

45
Q

what considerations must be made when choosing a circuit for BOAS surgery?

A

IPPV or manual ventilation may be necessary

46
Q

what level should MAP be kept at during surgery?

A

not below 60 mmHG

47
Q

what should be done if BP falls below 60 mmHg during a procedure?

A

discuss the possibility of IVFT bolus with the vet

48
Q

what are the main complications following BOAS surgery?

A

airway swelling
vomiting and regurgitation
aspiration pneumonia

49
Q

what is the most high risk anaesthetic period for BOAS surgery?

A

extubation

50
Q

when should patients be extubated post BOAS surgery?

A

later than usual

51
Q

what should be supplemented in BOAS patients post extubation?

A

oxygen - mask or flowby

52
Q

what position should animals recover from BOAS surgery in?

A

sternal with head elevated

53
Q

what should be available during BOAS recovery?

A

suction in case of regurgitation

54
Q

how intensively must patients be monitored post op?

A

ICU monitoring chart with constant supervision

55
Q

what are the key areas of post op care for BOAS surgery?

A
calm, quiet and stress free environment
avoid hyperthermia
sedation if stressed
home as soon as safe
harness only
client verbal and written discharge info
56
Q

what sedation may be used if patient is stressed following BOAS surgery?

A

dexmedetomidine

57
Q

what exercise regime is required following BOAS surgery?

A

restricted to 5-10 mins twice daily for 6 weeks

58
Q

when are BOAS patients routinely examined post-op?

A

2 and 10 days

59
Q

how should animals be fed following BOAS surgery?

A

wet solid food for 6 weeks post op to limit airway irritation

60
Q

what are the key treatment elements of BOAS?

A

weight management

surgical correction

61
Q

what are brachycephailic breeds at increased risk of when under anaesthesia?

A

reflux and regurgitation

62
Q

what happens during laryngeal paralysis?

A

vocal chords are unable to abduct in response to exercise and respiratory demands

63
Q

what are the causes of laryngeal paralysis?

A

ageing changes (degenerative neuropathy)
congenital disease
trauma
cancerous infiltration of the nerve which controls associated muscles

64
Q

what breeds are predisposed to laryngeal paralysis as a result of degenerative neuropathy?

A

irish setters and labradors (median age = 9.5 years)

65
Q

what breeds tend to have congenital disease which leads to laryngeal paralysis?

A

dalmations and bull terriers

66
Q

what are the signs of laryngeal paralysis?

A
exercise intolerance
noisy respiration
coughing
gagging
change or loss of vocal sounds (dysphonia)
dysphagia
cyanosis and collapse if severe
67
Q

how can mild cases of laryngeal paralysis be managed?

A
anti-inflammatories
antibiotics where indicated
sedative
raised feeding
reduce stress and manage exercise
68
Q

how can severe cases of laryngeal paralysis be managed?

A

unilateral arytenoid lateralisation (tie back)

69
Q

how is laryngeal paralysis diagnosed?

A

under light anaesthesia

70
Q

where is unilateral arytenoid lateralisation (tie back) surgery performed?

A

left side of neck

71
Q

what happens during a unilateral arytenoid lateralisation (tie back) procedure?

A

left arytenoid cartilage is permanently tied open

72
Q

what is involved in post surgical care of unilateral arytenoid lateralisation patients?

A

small regular soft meals
avoid dusty food or atmospheres
raised feeding/water
wound management

73
Q

what must be discussed with the owner prior to unilateral arytenoid lateralisation surgery?

A

permenant change in phonation

no swimming due to aspiration risk

74
Q

what is the prognosis for animals undergoing unilateral arytenoid lateralisation surgery like?

A

positive unless there is systemic neuromuscular disorder involved

75
Q

what are the 2 key types of palate defects?

A

congenital

acquired

76
Q

what are the main congenital palate defects?

A

clefts of the upper lip, hard and/or soft palates

77
Q

what are the clinical signs of congenital palate defects?

A

difficulty feeding and nasal discharge

78
Q

how are palate defects most often acquired?

A

trauma (e.g. RTA)

79
Q

when is surgery to correct congenital palate defects usually performed?

A

3-4 months of age

80
Q

how are congential palate defects corrected?

A

closure of tissues separating oral and nasal passages with minimal tension

81
Q

how are acquired palate defects closed?

A

primary closure or second intention depending on damage

82
Q

what are the most common breeds affected by tracheal collapse?

A

small and toy breeds (e.g. yorkshire terriers/pomeranians)

83
Q

what occurs during tracheal collapse?

A

dorso-ventral flattening of the trachea

84
Q

what is tracheal collapse due to?

A

degeneration of tracheal cartilage rings

85
Q

what are the signs of tracheal collapse?

A

dry, harsh, loud cough (goose honk)
stridor
builds over weeks or months

86
Q

what is tracheal collapse often triggered by?

A

excitement, eating and exercise

87
Q

what imaging may be used to diagnose tracheal collapse?

A

right lateral radiographs taken under inspiration and expiration
bronchoscopy
fluroscopy

88
Q

what are the grades of tracheal collapse?

A

1-4

89
Q

describe grade 1 tracheal collapse

A

25% loss of lumen

90
Q

describe grade 2 tracheal collapse

A

50% loss of lumen

91
Q

describe grade 3 tracheal collapse

A

75% loss of lumen

92
Q

describe grade 4 tracheal collapse

A

total loss of lumen

93
Q

what is fluroscopy?

A

real time x-rays where images are gained through constant x-ray exposure

94
Q

what are the 2 main options for management of tracheal collapse?

A

medical

surgical

95
Q

what lifestyle management is involved in managing tracheal collapse patients?

A
weight loss/management
harness not collar
avoid smoky atmospheres
remove environmental irritants
controlled exercise
96
Q

what cases of tracheal collapse is medical management suitable for?

A

mild (grade I - II)

97
Q

what percentage of dogs with tracheal collapse respond well to medical management?

A

71-93%

98
Q

what percentage of dogs on medical management of tracheal collapse may be able to have medication gradually withdrawn?

A

50%

99
Q

what drugs are involved in the pharmacological management of tracheal collapse?

A

antitussive therapy
steroid therapy
bronchodilators

100
Q

when will antibiotics be used when treating tracheal collapse patients?

A

only if secondary infection is present

101
Q

what drugs may be used to provide antitussive therapy?

A

morphine
codine
butorphanol

102
Q

what is the role of steroids in the medical management of tracheal collapse?

A

reduction of inflammation

103
Q

what is the aim of surgical intervention into tracheal collapse?

A

improve tracheal anatomy and allow increased air flow

104
Q

what is usually required following surgical management of tracheal collapse?

A

long term medical management

105
Q

what grade of tracheal collapse may be treated using surgery?

A

grade II or higher

106
Q

what animals undergoing surgical treatment for tracheal collapse have the best prognosis?

A

those under 6 years old

107
Q

what are the 2 main surgical management techniques for tracheal collapse?

A

extraluminal ring prosthesis

intraluminal stent placement

108
Q

what percentage of patients undergoing extraluminal ring prosthesis procedures report good outcomes?

A

75-89%

109
Q

what are the downsides of extraluminal ring prosthesis procedures for tracheal collapse?

A

invasive
risk must be managed
complications are likely

110
Q

what are the main complications associated with extraluminal ring prosthesis procedures?

A
vascular damage
tracheal ring migration
coughing
dyspnoea
laryngeal paralysis
111
Q

what happens during tracheal ring migration following extraluminal ring prosthesis procedures?

A

sutures come loose on prosthesis and it is able to migrate

112
Q

why may laryngeal paralysis occur following extraluminal ring prosthesis procedures?

A

due to iatrogenic nerve damage

113
Q

what is the benefit of intra-luminal stent placement for treatment of tracheal collapse?

A

less invasive than prosthesis

114
Q

what are the disadvantages of intra-luminal stent placement?

A

stent may fatigue under pressure (e.g. coughing)

excessive inflammation of tissue around trachea post surgery

115
Q

what must be controlled post intra-luminal stent placement surgery?

A

coughing - may damage stent

116
Q

how may coughing be controlled post intra-luminal stent placement surgery?

A

antitussive medication

117
Q

what imaging technique is used for intra-luminal stent placement?

A

fluroscopy

118
Q

describe surgical prep for extraluminal ring prosthesis

A

clip and prep

large area of ventral neck

119
Q

what position must animals undergoing extraluminal ring prosthesis be placed in?

A

dorsal recumbancy

120
Q

what must be done for patients prior to induction for tracheal collapse surgery?

A

pre oxygenation for at least 5 mins

121
Q

what position must animals be placed in when intra-luminal stent placement is performed?

A

lateral recumbancy

122
Q

what are the key considerations about the environment pre and post extubation following respiratory surgery?

A

calm and quiet

maintain good ambient temp (not too hot!)

123
Q

what are the key considerations about the patient pre and post extubation following respiratory surgery?

A
monitoring is key
flow by O2
analgesia
consider sedation
soft food
124
Q

when should food be offered following respiratory surgery?

A

later than with normal patients (4-6 hours)

125
Q

what are the key considerations about the equipment pre and post extubation following respiratory surgery?

A
SpO2
temp management
crash box near
ET tube and laryngoscope
moisten mouth
suction
maintain IV access
126
Q

what is a lateral thoracotomy?

A

surgical incision performed between the ribs

127
Q

what is provided by a lateral thoracotomy?

A

excellent view of one side of the thorax

128
Q

what are the indications for lateral thoracotomy?

A

lung lobectomy (e.g. abscessation, neoplasia and lobe torsion)

129
Q

what ventilation is needed if a thoracotomy or sternotomy is performed?

A

IPPV throughout

130
Q

what is a median sternotomy?

A

surgical incision on the midline through the sternum

131
Q

what is provided by median sternotomy?

A

view of bilateral thorax

132
Q

what are the indications for a median sternotomy?

A

pyothorax (if drainage ineffective)
mediastinal masses
heart surgery

133
Q

what type of procedure is a tracheostomy?

A

emergancy

134
Q

when is a tracheostomy needed?

A

physical or functional obstruction of the upper airway tract

135
Q

what is bypassed by a tracheostomy?

A

nares, pharynx, larynx and proximal trachea

136
Q

what are the indications for tracheostomy?

A

facilitate anaesthesia when airway is compromised
stabilise patient and allow airway management
provide definitive airway until swelling or obstruction is resolved

137
Q

what conditions may require tracheostomy?

A

laryngeal paralysis
BOAS
foreign body
laryngeal trauma

138
Q

what level of monitoring is needed for patients with a tracheostomy?

A

24/7 high level

139
Q

what must be monitored relating to a tracheostomy?

A

maintenance of airway
comfort of patient
asepsis maintained

140
Q

what must be prevented from building up around the tracheostomy?

A

secretions

141
Q

why will respiratory secretions increase with the presence of a tracheostomy?

A

due to presence of tube causing irritation

142
Q

how can build up in secretions within a tracheostomy tube be prevented?

A

suctioning
regular cleaning
changing the tube

143
Q

when should tube cleaning occur when tracheostomy is first placed?

A

every 15 mins

144
Q

when can tracheostomy tube care occur once stable?

A

every 4-6 hours

145
Q

what must you be continually checking for when monitoring a patient with a tracheostomy?

A
harsh respiratory sounds
dyspnoea
distress
coughing 
discharge
discomfort
swelling, pain or heat in stoma
146
Q

how often should the stoma of a patient with a tracheostomy be cleaned?

A

3-4 times a day

147
Q

if not an emergency what should occur before cleaning or suctioning of the tracheostomy tube?

A

pre oxygenation for a minimum of 5 mins

148
Q

what level of sterility is required when suctioning a tracheostomy tube?

A

aseptic technique

149
Q

what catheter should be used to suction a tracheostomy tube?

A

sterile, soft and long

150
Q

what length should the suction catheter for a tracheostomy tube be?

A

pre measured so that it reaches no further than the tip of the trach tube

151
Q

describe how to perform suctioning of a tracheostomy tube

A

place catheter into trach
one in place turn on suction unit
move catheter in a circular motion while withdrawing for around 15 seconds
light and intermittent use

152
Q

when should a tracheostomy tube be changed?

A

if blocked

153
Q

how can some tracheostomy tubes be replaced?

A

inner lumen which is easily removed with outer left in place

154
Q

what happens during a full replacement of a tracheostomy tube?

A
aseptic technique
preoxygenate unless emergent
2 x team members
open stay sutures
insert new tube
155
Q

why is humidification of air inhaled through tracheostomy tubes necessary?

A

tubes bypass normal humidification found in the URT

156
Q

what can drying of the respiratory tract lead to?

A

damage to the mucosa leading to inflammation, irritation and thick mucus
dehydration as water is more rapidly lost through breathing

157
Q

what can aid humidification of air through trach tubes?

A

humidification filters that attach to tube
0.3-0.5 mls NaCl
nebulisation with sterile saline

158
Q

how much isotonic saline should be administered through a patients trach tube to aid humidification of air?

A

0.3-0.5 mls

159
Q

how often should sterile saline be administered through a nebuliser to aid tracheostomy patients?

A

10 mins every 2-3 hours

160
Q

what is the difference between humidification and nebulisation?

A

humidification is provision of moisture via aerosol, nebulisation provides medication via this method

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