Premedications/sedation at slightly lower doses can
minimize the possibility of heavy sedation while still
decreasing anxiety and hyperactivity. It is always possible to give more medications if there is not enough
sedation, but if it produces too much sedation the patient may be in respiratory distress and need emergent
intervention. Heavy sedation will intensify any respiratory difficulties the brachycephalic patient has.
Propofol is a good anesthetic agent because it provides
rapid induction with the ability for quick intubation.
Brachycephalic breeds have smaller tracheas than generally expected from other breeds of the same weight.
For example, a 40 pound bulldog may take only a 6fr
endotracheal tube, whereas a 40 pound Springer Spaniel would take a 10fr endotracheal tube. There should
always be multiple sizes of endotracheal tubes available
during induction. Because of their thick tongues and
long soft palate, a laryngeal scope is useful to aid in
pushing the back of the tongue down and out of the
way of the trachea. If needed, the endotracheal tube
can be used to push up the soft palate. This will aid in
visualization of the trachea for intubation. Care must
be taken when holding the upper jaw during intubation
or oral exams. The protruding eyes of the brachycephalc breeds make them much more susceptible to
eye ulcers. A piece of roll gauze that can be placed
behind both upper canines to hold the mouth open
while intubating will help prevent eye ulcers. Many of
these patients will also have a short neck so care should
be taken when intubating to ensure proper placement
of the endotracheal tube so that it does not go into the
bronchus.
Recovery is a critical period for the brachycephalic patient. If the narrow nares and elongated soft palate
have not been corrected, then there is a high risk of
complications after extubation. If corrective surgery
was performed, there is still an increased risk during
recovery due to swelling of the surgical sites. The patient should be kept in sternal position for recovery for
optimal lung expansion. The endotracheal tube should
be kept in the brachycephalic patient much longer than
the average patient would need. It is not enough for
the brachycephalic patient to have a good swallow reflex; these patients need to be able to hold their head
up on their own before extubating. The endotracheal
tube should be kept in until the last possible moment,
when he/she is starting to chew on the endotracheal
tube. Preparation for the possibility of needing to reintubate should always be done. Have a new endotracheal tube and some propofol available in case of
emergency. Once extubated, the patient should be
directly monitored for proper air exchange. Confirm
that the patient has good air exchange and has good
oxygen saturation. These patients should be monitored
closely for the next 12-24 hours to watch for any airway
swelling and respiratory distress.