Brachycephalic Airway Syndrome

Brachycephalic Airway Syndrome refers to a group of conditions that arise from the anatomical conformation of short nosed dogs and cats, known as Brachycephalic breeds. Brachycephalic breeds have intentionally been bred to shorten the length of their noses, and thus suffer from the consequential side effects of this breeding. Breeds with flattened noses have a compacted skeleton, resulting in multiple anatomical malformations to the breathing passages. Common examples of Brachycephalic dog breeds include Pugs, French Bulldogs, English Bulldogs, Pekingese and Boston Terriers. Persian cats are also a brachycephalic breed

Due to the shortening of the skeleton, the nares are compacted on their skull and consequently become narrowed. This is referred to as ‘Stenotic Nares’. This narrowing results in tortuous nasal passages, and increases the resistance of airflow through the nares. The end of the palate, known as the soft palate, can obstruct the back of the throat due to excessive length and thickness. Elongation of this soft palate can completely occlude the airway and result in complete respiratory obstruction. The last primary malformation is known as everted laryngeal saccules, protrusions of the airway mucosa that are pulled into the airway and can cause a partial obstruction. Some dogs with BAS may also have paralysis of the laryngeal cartilages, narrowing of the trachea (airway), and collapse of the larynx.

Due to a decreased ability to receive adequate airflow, brachycephalic breeds create a stronger negative airway pressure when breathing which can result in secondary respiratory and digestive problems. These include retching, vomiting and regurgitation.

All brachycephalic breeds suffer from some degree of BAS. The most common clinical history for presentation to the Emergency department of dogs with BAS is noisy breathing, particularly on inspiration, with varying levels of respiratory distress. Less commonly, dogs may present due to acute collapse following exercise or over-activity. Brachycephalic breeds may also present due to frequent retching or regurgitation.

Definitive diagnosis of BAS is performed via an upper airway examination under general anaesthesia, allowing for identification of these anatomical malformations. BAS is treated with surgical resection of the soft palate, nares and laryngeal saccules to open the airways and provide adequate flow of oxygen. Surgical correction of BAS often improves the quality of life and brachycephalic breeds, with significant improvement in breathing immediately noticeable.

Pancreatitis

What is the pancreas?

The pancreas is a gland located in front of the abdomen, lies below the stomach and directly beside the beginnings of the small intestine. Its main function is regulation of blood sugar through production of important hormones (one of which is insulin). Second function is production of enzymes that are essential for digestion of food. These enzymes are inactive in the pancreas until needed at meal times. When food is ingested theses enzymes are released into the small intestine where they become activated into potent chemicals that break down ingested food.

What is pancreatitis?

Acute pancreatitis occurs when digestive chemicals are activated inside the pancreas instead of the intestine. It causes severe inflammation and potential destruction of vital abdominal organs.

What causes pancreatitis?

Statistically, obesity and ingestion of fatty meals are the two main predisposing factors in the dog. Other suspecting causes in dogs and cats are abdominal trauma, medications and metabolic diseases. Many causes are listed as unknown or idiopathic because of the absence of any known predisposing conditions.

What are the symptoms?

Dogs:

Sudden onset of:

Vomiting
Abdominal discomfort
Loss of appetite
Mental depression
Diarrhoea
Fever
Dehydration

Cats:

Cats can show similar signs but are subtler and may only show:

Loss of appetite
Mental depression
Inactivity
Vomiting may or may not be present
In worst forms patients may present collapsed due to sudden drop in blood pressure and can affect on other organ systems including heart, liver, kidneys and the blood vessels.

How is it diagnosed?

Diagnosis of pancreatitis is achieved with a combination of physical examination, history, and several tests whose results increase the suspicion of pancreatitis. There is no test that can diagnose pancreatitis with 100% specificity and it is therefore easily misdiagnosed. Tests may include blood tests, imaging with radiographs, ultrasound examination and advanced imaging such as CTs or MRIs.

Ultrasound to visualise the pancreas is the most sensitive and specific and can detect up to 60-70% of the cases.

What is the treatment?

Initial:

The most severely affected patients will receive intravenous delivery of fluids to help restore blood pressure, hydrate the pancreas and other vital organs.
Other drugs that may be indicated: pain relief, insulin, antibiotics, anti-vomiting and anti-ulcer medications and special drugs to restore normal gut movement

Duration of treatment:

Duration of treatment on average has been shown to be 5-7 days but more severe cases have been shown to require treatments as long as 4-5 weeks.
Prognosis to full recovery is guarded unless they are treated aggressively and early.

Recurrence is common and possible sequelae to acute pancreatitis include acute recurrent pancreatitis, exocrine pancreatic insufficiency and diabetes mellitus. Because of the special needs required for a pancreatic patient you primary care veterinarian may suggest your pet be referred to a speciality facility that is adequately staffed and equipped for providing around the clock care of the critically ill animal.

Home care and possible long-term effects:

When will my pet be able to come home?

Your pet will be discharged from hospital once vomiting has ceased, food and water trials have been performed and your pet’s general well-being has returned.

Are there dietary changes?

Dietary changes are essential for the dog but not for cats.Dogs must receive a low fat diet, best provided with prescription diets available. 3-4 small feeds throughout the day will ease the workload on the pancreas.

Can pancreatitis be prevented?

Pets do not need and cannot digest large amounts of fat. Please remember that your pet is only 10th of your weight and so food required is only a 10th of our volume. Small square of cheese is equivalent to us eating the whole block!

Feed a good quality premium pet food
Dot not feed table scraps
Do not overfeed
Spread meals out over the day.

Pyometra

Pyometra occurs when the uterus (female reproductive organ) becomes infected and filled with pus. This generally only occurs in middle-aged to older females that have not been desexed. When females are desexed, generally, both ovaries and the uterus are removed. Rarely, if any of the ovary is left behind in the body, a “stump” pyometra can occur in desexed females.

Risk Factors:

Progesterone (medications) used to delay or suppress oestrus (heat)
Oestrogens (medications) used on mismated females
Post-insemination or post-copulation (post-mating/breeding) infection
Dioestrus (typically 4-6 weeks after heat)

Symptoms

Lethargy/quiet demeanour
Inappetence (not eating)
Polydipsia and polyuria (drinking and urinating more often)
Vomiting
Dehydration
Fever

Pyometra can be “open” or “closed”. When the cervix is open, purulent and bloody discharge will be seen from the vulva. When closed, no discharge is seen; instead, the abdomen may become swollen or distended from the uterus enlarging with fluid.

Diagnostics

Pyometra can be seen on radiographs (x-rays) and is typically confirmed with an ultrasound. The normal uterus is not seen on x-rays. Both x-rays and ultrasound show evidence of an enlarged, fluid filled uterus. Blood tests may also be performed, which typically shows an increased white cell count and increase in a protein called globulins, produced with inflammation or infection; and anaemia from chronic/long-term disease.

Treatment

While in the emergency hospital, overnight stabilisation will usually be performed. This often involves giving intravenous fluids for rehydration, and starting antibiotic therapy.
The best treatment is to have your patient desexed. This removes the source of infection, and prevents the condition from ever happening again. Antibiotics are also used to treat any remaining infection.
Occasionally, particularly if the patient is to be used for breeding in the future, medical treatment will be used. This typically involves a course of antibiotics, and administration of hormones including prostaglandin, which assists by contributing to expulsion of fluid in the uterus. Medical treatment is avoided, especially with closed pyometra, as it is associated with many side effects and may increase the risk of the uterus rupturing/breaking apart in the body.
Numerous studies report different recurrence rates following pyometra. This has ranged from no additional risk compared with dogs that have never had pyometra, to up to 77% within the first 27 months after treatment.

Prevention

The best prevention for animals not intended to be used for breeding is desexing. Assuming this is performed properly, this will prevent the possibility of pyometra ever occurring, and additionally prevents the possibility of developing uterine or ovarian cancer, and minimises the risk of developing mammary cancers, later in life.

Caesarean After Care

Once your pups are delivered by caesarean section, the real work begins!

Because of a caesarean, your bitch has had a major abdominal procedure and should be rested for 7 to 10 days. Rested means no running or jumping or playing. Preferably crated and taken on a lead to the toilet. When toileting, take her on a lead. Walking on a lead three times a day for 15 minutes encourages uterine involution and evacuation of residual uterine contents. Oxytocin injections are not required at this stage as the puppies nursing will produce large amounts of oxytocin naturally. Your bitch will also require her abdominal sutures to be removed at your Primary Care Clinic 7-10 days post-surgery. Here at QVS Reproduction we use interrupted mattress stitches which aid to prevent puppies getting caught up in a continuous suture line and if the sutures become inflamed, individual sutures can be examined by a veterinarian. Whilst at home keep the skin wound clean and dry by bathing with plain warm water as needed in first 48 hours after your caesarean. Avoid using cotton wool balls as this can get caught along the sutures, gauze swabs are recommended.

As your bitch has delivered a litter by caesarean section, she may not mother effectively in the first days of lactation. It is at least possible that she will actively reject the pups and could harm them. It is VITAL the interactions between mother and babies are VERY carefully monitored and supervised. At best, she will form maternal-neonatal bond over the next few hours, at worst she can be aggressive towards pups. Effective lactation and nursing are essential in the first two days and you should do whatever is necessary to encourage and facilitate this process. Pups that do not feed well in the first two days of life may die or be debilitated later. Bottle feeding is not a good substitute for correct nursing in pups.

So please do the following until she shows signs of normal mothering:

take your bitch home, allow her to urinate and defecate and eat and drink and settle her down and reduce all anxiety and stress so she is well settled before pups are introduced
separate the bitch and pups between feeds if necessary and put the pups on bitch for supervised feeding every 2 hours
feeding is accomplished by lying the bitch on her side and assisting the pups to find the nipples as needed. If the bitch tries to move, sitting behind her back, hold her legs closest to the ground, which will help comfortably restrain her for feeding
after feeding, please hold the pups for the bitch to lick their perineum if necessary and if the bitch doesn’t lick pups then you should stimulate the pup's perineum to induce defecation and urination with lanoline coated tissue or similar
between feeds, the pups should be kept in tented warmed environment until the bitch mothers properly.

Puppies should be weighed after birth. Weigh the pups twice a day and record weights - pups may lose a little body weight in the first day or so but should gain weight thereafter at a rate of 5-10% of their birth weight daily and have doubled their birth weight by 10 days of age.

If a neonate is not gaining weight, it may need supplementation. There is no better supplementation than mother’s milk, and if your bitch is not producing milk, she may need some assistance to help increase her production. Milk production requires a diet consisting of high protein, fats and carbohydrates. The diet should contain a protein level of 25-35%, a fat level of >18% as well as carbohydrates, vitamins and minerals. This formulation is available in most veterinary puppy diets and supplements should be avoided to prevent dietary imbalances and toxicities. Bitches with large litters for their breeds may also require additional calcium, as body calcium reserves are depleted in lactation. Oral calcium preparations are best as there are risks of overdosing toxicities for injectable preparations and should only be administered under supervision of a veterinarian.

If, after feeding a good quality diet your bitch is still not producing milk (agalactia), she may require medication to help increase her production. Oxytocin does not increase milk production, rather let down what is already being produced. A dopamine antagonist can be prescribed by your veterinarian to help increase milk production. A dopamine antagonist induces a rise in prolactin levels, leading to an increase in milk production at a dose of 2.2mg/kg orally daily. Common toxicities include oral mucosal dryness and gastrointestinal disorders. If this is required, talk to your primary care veterinarian.

If your pups are requiring supplementation, the development, strength and suckle reflex of the pups indicate the primary selection criteria. For example, if pups are weak, bottle feeding may not be the best option as their suckle reflex might be under developed which increases their risk of aspiration. So, a feeding tube might be a better option. To stomach tube a pup, talk to your primary care veterinarian or QVS Reproduction to help with equipment and the correct procedure.

Before supplementation begins, it is vital that the puppies are housed in a warm, tented environment. The pups body temperature needs to be above 35.5° - 36.5°C. If the pups body temperature falls below this, ileus will develop (gastrointestinal motility stops), which results in a bloated and distressed pup.

Normal temperatures for pups are lower than adult body temperatures:

The key to raising a successful litter is attention to detail, and this requires round the clock attention. Prior planning (gathering assistance, taking time off work) is required to ensure that a successful outcome is achieved resulting in a healthy litter with a healthy happy bitch

Total Hip Replacement

What is Total Hip Replacement?

Total hip replacement (THR) is reserved for animals that have painful conditions of the hip joint that have proved poorly responsive to conventional management using pain relief and rehabilitation.

Dogs with advanced osteoarthritis or dysplasia of the hip joint may in some cases benefit from replacement of the hip joint. Total hip replacement is an advanced surgical procedure and should only be performed by experienced orthopaedic surgeons. Total hip replacement is considered a routine surgical procedure performed by our orthopaedic surgeons based on tried and tested implants.

What does THR surgery involve?

Currently we are one of a few practices in Australia able to provide total hip replacement surgery routinely and we offer a number of different types of hip replacement prostheses.

Total hip replacement involves replacing the entire hip joint surface. The procedure involves removing the femoral head from the top of the femur, also referred to as the ‘ball,’ and replacing it with a metal ball (cobalt chrome). The acetabulum of the pelvis, also known as the ‘socket’ is resurfaced using a ‘cup’ implant to provide a seat for the new femoral head to sit in. The implants can be attached to the bone using bone cement, or may have a porous coating into which the bone can grow. To perform surgery, a vast surgical team is required.

Who needs THR?

Patients with painful hip disease which is non-responsive to medical therapy. This can be due to hip dysplasia causing arthritis, recurrent dislocations (luxation), fractures, developmental disorders (avascular necrosis) and failed FHO procedures. Our surgeons will need to evaluate your pet fully prior to considering them a suitable candidate. We will also need to talk through the potential risk and benefits prior to deciding to proceed.

What is the cost of THR?

We currently offer a fixed cost for a single uncomplicated hip replacement - $6800. This includes consultation, radiographic assessment, surgery, hospitalisation and routine follow up appointments.

Who performs the surgery?

As this is an act of veterinary surgery, only a veterinary surgeon can perform this. However, this is considered a specialist procedure and as such only certain vets will undertake this technique. This is a technically very demanding procedure and should only be performed by experienced and ideally specialist orthopaedic surgeons.

In our clinic, Dr Beierer and Dr Beck perform this surgery as a team. Having two surgeons performing the procedure gives 2 pairs of highly experienced eyes which leads to a successful outcome in the majority of our patients.

Are there different types of THR?

There are two main classes of THR technique, those using bone cement (cemented) and those that rely on other means of fixation (cementless). Different manufactures have developed numerous systems for performing veterinary THR. At QVS we use the BioMedtrix THR system. This product has been on the market since 1990 and is therefore the most widely studied. Currently, there is no scientific consensus as to which is the favoured technique, cemented or cementless. We have the availability to perform both techniques and which is used is decided on a case by case basis.

Does my pet need both hips treating?

Although the disease may be present in both hip joints, some patients will only require the procedure performing in one joint to significantly improve their quality of life. Others will need both hips replacing but this will be discussed at the time of consultation.

What is the outcome after THR?

This can be a life changing procedure, bringing comfort and improved mobility in many patients. The success rate for THR is approximately 90%, and most patients are more comfortable within a few days to weeks of surgery. We expect most patients to return to full activity assuming there are no complications.

What are the potential complications with Total Hip Replacement?

The major complications encountered with total hip replacement are dislocation of the hip joint in the post-operative period, fracture, implant loosening or infection. Infection is a rare but potentially devastating complication of any surgical procedure and we take every possible precaution to try and prevent the patient developing an infection. The risk of loosening is also rare.

What is the typical recovery after Total Hip Replacement?

Careful rehabilitation after total hip replacement is the key to success and it is vital that patients who undergo this surgery are managed diligently for the first 14 days after surgery to prevent damage to the operated hip. Exercise is progressively increases until off-lead exercise by approximately 6-12 weeks.

Patients will remain hospitalised for between 1-4 days post operatively depending on comfort, mobility and temperament. Once they are ready for home management, a dedicated rehabilitation and activity plan will be put in place.

Key elements of home management during the first 6 weeks include:

Room or cage confinement during unsupervised periods
Non slip flooring
Leash controlled walking activity

Are there alternatives to THR?

There may be certain situations where THR is not a viable option such as for financial reasons or variations in individual anatomy that preclude THR. In this case, Femoral Head Ostectomy (FHO) could be pursued. This procedure involves removal of the hip joint and a false hip joint is allowed to develop from scar tissue. Most patients undergoing this procedure will be left with a limp or gait abnormality but pain relief is usually satisfactory to improve the quality of life. Physical therapy (hydrotherapy and physiotherapy) can help maximise limb function for these patients.