10 Signs Your Patient Needs BOAS Surgery
Brachycephalic Obstructive Airway Syndrome (BOAS) is a common but serious condition affecting flat-faced dog breeds such as Bulldogs, Pugs, and French Bulldogs. It is a progressive disorder that leads to significant morbidity if left untreated. The clinical presentation varies, and while some patients may cope with mild airway compromise, many will require surgical intervention to improve their quality of life. Recognising the signs that indicate the need for BOAS surgery is critical in ensuring optimal patient outcomes and is an important skill for vets in general small animal practice. The 10 signs listed below can help you be more confident referring dogs for BOAS surgery.
Common Signs a Patient Requires BOAS Surgery
1. Increased Respiratory Effort and Stridor
A hallmark clinical manifestation of BOAS is an increase in respiratory effort, often apparent even at rest or with minimal exertion. Affected canines typically present with pronounced inspiratory stridor, indicative of partial upper airway obstruction. This auditory sign is exacerbated by environmental stressors such as heat, excitement, or physical activity. The underlying pathology frequently includes a combination of an elongated soft palate, stenotic nares, aberrant turbinates, and, in advanced cases, laryngeal collapse. The resultant airway turbulence fosters secondary mucosal inflammation and edema, perpetuating a cycle of progressive obstruction and respiratory distress.
2. Exercise Intolerance
Dogs suffering with BOAS exhibit limitations in exercise tolerance, often displaying excessive panting, marked fatigue, and reluctance to ambulate over even short distances. While brachycephalic breeds inherently possess reduced stamina due to their anatomical conformation, pronounced intolerance, particularly in temperate conditions, suggests critical airway compromise. Increased inspiratory resistance results in prolonged recovery periods post-exertion, with affected individuals frequently assuming compensatory behaviors such as resting in sternal recumbency to optimise airflow.
3. Heat Sensitivity
BOAS patients exhibit a heightened susceptibility to heat stress due to impaired thermoregulation. Panting, the primary mechanism for heat dissipation in canines, is severely compromised by airway obstruction, predisposing affected dogs to hyperthermia. These individuals frequently exhibit excessive panting, open-mouth breathing, and difficulty achieving thermal equilibrium, even in mild ambient temperatures. In severe cases, ineffective cooling mechanisms precipitate heat exhaustion or life-threatening heatstroke, necessitating urgent intervention.
4. Frequent Gagging, Regurgitation, or Vomiting
A significant proportion of BOAS patients present with concurrent gastrointestinal dysfunction, manifesting as chronic regurgitation, vomiting, or dysphagia. These clinical signs are often attributable to gastroesophageal reflux disease (GERD), hiatal hernia, or increased negative intrathoracic pressure secondary to airway resistance. Oesophageal inflammation, exacerbated by frequent regurgitation, may contribute to persistent discomfort and reduced appetite. Dogs displaying recurrent gastrointestinal signs should undergo thorough evaluation to determine the extent of concurrent issues.
5. Sleep Disruption and Apnoea
BOAS frequently precipitates sleep disturbances, with affected individuals assuming atypical sleeping postures, such as resting with their heads elevated or adopting a sitting position to maintain airway patency. Sleep apnoea episodes, characterized by transient cessation of respiration, are commonly observed, leading to fragmented sleep and resultant daytime lethargy. Clinical indicators include excessive snoring, sudden arousals with gasping or choking, and paradoxical respiratory effort during rest. Chronic hypoxemia associated with nocturnal airway obstruction may predispose affected dogs to systemic sequelae, including cardiovascular compromise.
6. Cyanosis and Collapse Episodes
Intermittent cyanosis, evidenced by a bluish discoloration of the mucous membranes, signals critical hypoxia and impending respiratory decompensation. These episodes are often precipitated by heightened respiratory demand during excitement, exertion, or stress. In severe cases, compromised oxygenation results in syncope or collapse, requiring immediate intervention. Recurrent cyanotic events indicate profound airway obstruction and require prompt diagnostic assessment to mitigate the risk of acute respiratory failure.
7. Severe Nostril Stenosis
Stenotic nares significantly impede airflow and serve as a primary contributor to increased upper airway resistance in BOAS patients. Dogs exhibiting severe nostril stenosis frequently display persistent open-mouth breathing, exaggerated respiratory effort, and audible stertor. Chronic nasal resistance necessitates compensatory oral breathing, predisposing affected individuals to further airway desiccation and inflammation. Addressing significant nostril stenosis can yield substantial improvements in airflow dynamics and respiratory function.
8. Laryngeal Collapse
Chronic upper airway resistance predisposes affected individuals to progressive laryngeal collapse, a severe sequela of untreated BOAS. This condition is classified into three stages, with initial manifestations involving laryngeal cartilage weakening and advanced stages resulting in near-complete airway obstruction. Clinical indicators include progressive inspiratory effort, pronounced stridor, and recurrent respiratory distress episodes. In later stages, compromised glottic patency leads to life-threatening obstruction, necessitating aggressive intervention to restore airway competency.
9. Failure to Improve with Lifestyle Modifications
While conservative management—including weight optimization, environmental modification, and pharmacologic intervention—may provide transient relief in mild cases, persistent respiratory distress despite these measures suggests significant anatomic airway pathology. Dogs that exhibit refractory clinical signs, including sustained exertional dyspnea, chronic regurgitation, or frequent airway obstruction, likely require further intervention to mitigate progressive respiratory deterioration.
10. Progressive Worsening with Age
BOAS is a dynamic disorder, with many patients experiencing progressive exacerbation of clinical signs over time. Chronic airway resistance precipitates ongoing structural and functional airway decline, culminating in increased respiratory effort, worsening stridor, and recurrent collapse episodes. Secondary complications, including tracheal and laryngeal collapse, exacerbate clinical deterioration. Regular reassessment of airway function is crucial to determining the trajectory of disease progression and implementing timely therapeutic strategies to optimise long-term respiratory health.
BOAS education: The need for enhanced BOAS training among first-opinion vets
Recognising the clinical signs of BOAS is the first step in optimising patient care. While referral to a specialist is ideal in complex cases, general practitioners can expand their surgical capabilities through additional training and veterinary CPD.
Improve Veterinary Education offers an exceptional BOAS course designed to equip vets with the necessary skills to diagnose, manage, and surgically correct BOAS cases. Their on-demand BOAS webinars, included in their Cambridge Academy series, provide in-depth theoretical knowledge. At the same time, their BOAS surgery practical course allows hands-on experience in performing airway corrective procedures. For those looking to advance further, the Improve Veterinary Education Small Animal Surgery certificate provides a comprehensive foundation in surgical techniques, including airway surgery.
For certificate-holding vets seeking to advance their expertise, the Advanced Soft Tissue Surgery Certificate provides a structured opportunity to refine and expand surgical skills beyond those covered in a normal surgery certificate. This modular programme is delivered by board-certified specialists (ECVS or ACVS diplomates), ensuring high-level instruction from leading experts in a wide range of surgical subjects.
Final Thoughts
While referral to a specialist is often the best course of action for dogs who may need BOAS surgery, further training and CPD can empower vets to manage these cases more effectively and improve outcomes for brachycephalic patients. Whether through prompt referral or direct surgical intervention, enhancing your expertise in BOAS management ensures a better quality of life for affected dogs and contributes to the ongoing advancement of veterinary medicine.
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Sources
https://pmc.ncbi.nlm.nih.gov/articles/PMC9673814/
https://pubmed.ncbi.nlm.nih.gov/38952039/
