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Surgery

Peer Reviewed

Tracheal Collapse in Dogs

Mary Dell Deweese, DVM
Karen M. Tobias, DVM, MS, DACVS
University of Tennessee

he trachea is composed of 35 to 45 cartilaginous, C-shaped rings joined dorsally by the trachealis muscle, mucosa, and connective tissue (dorsal tracheal membrane; see Trachea Facts).1,2

Tracheal collapse is progressive, dorsoventral flattening of the tracheal lumen. It

is most common in middle-aged, small-breed dogs (eg, Yorkshire terrier, toy poodle, Pomeranian, Chihuahua, pug)2 but has also been reported in large-breed
dogs, ponies, cows, cats, and a goat.3-7 Initially, laxity of the trachealis muscle
results in coughing and noisy breathing as the dorsal tracheal membrane billows
in and out of the tracheal lumen with each breath. As the condition progresses,
the cartilaginous rings become more ovoid and the distance between them
increases, resulting in dorsoventral flattening of the trachea and increasingly
severe episodes of coughing and exercise intolerance. The tracheal lumen diameter may become so narrow that the lumen is nearly obliterated, leading to respiratory distress and collapse.

Trachea Facts
n

Flexible, tube-like structure

Spans from the larynx to the mainstem bronchi

n Delivers

air to and from the lungs during

respiration

Transports debris to the larynx

Composed of 3545 cartilaginous, C-shaped rings

Rings joined dorsally by the trachealis muscle,
mucosa, and connective tissue (dorsal tracheal
membrane)1

Rings connected dorsally and ventrally by annular ligaments

n Bifurcates

at the level of the fourth or fifth thoracic vertebra into the principal (mainstem)
bronchi

n Receives

segmental blood supply from the cranial

and caudal thyroid arteries2

The cause of tracheal collapse is unknown but is thought to be a

combination of environmental and genetic factors.2 Histologically,
cartilaginous rings from affected dogs are hypocellular with
decreased glycoprotein and glycosaminoglycan and subsequent
reduced water retention.8-10 Obesity, pollutants, environmental
allergens, and kennel cough may be associated with disease
progression.2,10,11
Signs of tracheal collapse include coughing (eg, a goose honk);
noisy breathing; and, in severe cases, dyspnea, cyanosis, and
hyperthermia. Coughing episodes may increase with excitement,
tracheal pressure (eg, from a leash or collar), exercise, eating, or
drinking. A cough may be elicited by palpating the trachea at the
thoracic inlet, although tracheal collapse was successfully diagnosed in this manner in only 41% of affected dogs in a previous
study.12 In some dogs, it is possible to palpate flattened cartilages
along the cervical trachea. Hepatomegaly is another common concurrent finding, but the association is unclear.1

Diagnosis

Definitive diagnosis is based on imaging (eg, survey radiography,

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1
Lateral thoracic radiograph of a dog with tracheal collapse. The most
severe area of collapse is just caudal to the thoracic inlet.

fluoroscopy, ultrasonography, computed tomography, tracheobronchoscopy).13 Survey radiography should include dorsoventral and lateral views of the cervical region and thorax (Figure
1). Collapse of the trachea is best viewed in the cervical region
during inspiration and in the intrathoracic region during exhalation.1 Radiography is critical to rule out conditions that may
cause similar signs (eg, intrathoracic masses, pleural effusion)
and cardiovascular abnormalities (eg, heart enlargement) that
may complicate treatment. Radiography is noninvasive, cost
effective, widely available, and can be performed without the
risks associated with general anesthesia; however, false-positive
results have been reported in 25% of dogs,14 and sensitivity
ranges from 60% to 90%.2 In comparison, fluoroscopy allows
direct viewing of tracheal motion during all phases of respiration, is noninvasive, and is very sensitive, although false-positive findings have also been reported with fluoroscopy.14 In one
study, radiography underestimated the severity and frequency
of collapse as compared with fluoroscopy.15
Tracheoscopy, the gold standard for diagnosing tracheal collapse, enables direct viewing of the trachea and mainstem
bronchi, quantification of severity and extent of collapse, identification of concurrent inflammation, and collection of tracheal
or bronchial samples for culture and cytology. With tracheoscopy, tracheal collapse can be categorized based on the Tangner
and Hobson grading system with grades I, II, III, and IV characterized by 25%, 50%, 75%, and 100% collapse, respectively16
(Figure 2). Disadvantages include limited availability, cost, and
need for general anesthesia. Because veterinary patients may be
small, tracheoscopy is often performed under injectable anesthesia and without intubation; as such, ventilation cannot be

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Endoscopic view of tracheal collapse: Grades IIV (A-D) of

tracheal collapse, respectively. Used with permission from
Self-expanding nitinol stents for the treatment of tracheal
collapse in dogs: 12 cases (2001-2004). Sura P, Krahwinkel D. JAVMA
232:228-236, 2008.

assisted during the procedure, and oxygen must be supplemented through the endoscope or with an intratracheal catheter. Some dogs with severe tracheal collapse develop dyspnea
and cyanosis during anesthetic recovery.

Medical Management

Most dogs with tracheal collapse are managed medically; in one

study of 100 dogs, the success rate with medical management
alone was 71%.10 Dogs presenting with acute respiratory distress
are administered flow-by oxygen and mild sedation. Long-term
treatment for mildly to moderately affected dogs includes oral
antitussives and tapering doses of corticosteroids (Table).17,18
Concurrent respiratory infections are treated with antibiotics
based on culture and sensitivity testing of tracheal wash or
brush samples. More than 80% of dogs with tracheal collapse
test positive on bacterial culture16 (more commonly Pseudomonas spp; less commonly, Enterobacter spp and Citrobacter spp).19
Bacteria cultured from tracheal samples may not be pathogenic,
but infection should be suspected if supported by neutrophilic
inflammation on cytology.19 If antibiotics are chosen empirically, doxycycline, cephalexin, or amoxicillinclavulanate are
generally effective.17

Bronchodilators or antihistamines may also be prescribed. No

clinical trials currently demonstrate the safety and efficacy of
bronchodilators in medical management of tracheal collapse,
but their use can be justified in patients with concurrent lower
airway disease.17 In one study, 13 of 14 dogs with tracheal collapse were treated with the anabolic steroid stanozolol and
demonstrated improvement.20
In obese patients, weight loss is critical and can produce dramatic improvement. Other adjuncts include limiting tracheal
pressure (using a harness instead of a collar) and limiting exposure to respiratory irritants (eg, smoke, dust, other particulate
matter).

Structural Support

Prosthetic support of the tracheaplacement of extraluminal

tracheal rings or an intraluminal stentis recommended when
medical management fails. Extraluminal rings expand the
lumen diameter and prevent collapse from negative airway
pressure within the trachea and mechanical forces external
to the trachea. Rings are placed around the cervical trachea
through a ventral midline approach and the intrathoracic trachea through a lateral thoracotomy at the third intercostal
space. Dissection of neurovascular structures along the trachea
is required for ring placement, and associated complications can
be life threatening.2,12,16

Table

Common Medications for

Tracheal Collapse17,18

Type
Drug

Many surgeons prefer intraluminal stents because they can be

noninvasively placed in the cervical or thoracic trachea, reducing risk for complications and shortening anesthetic times. Vet
StentTrachea (infinitimedical.com) is a woven, reconstrainable, self-expanding, nitinol stent3-8 (Figure 3). Nitinol, a
nickeltitanium alloy, has thermal shape memory, super elasticity, and elastic hysteresis; the latter minimizes outward force on
the interior lumen of the trachea, regardless of stent size.24 The
undeployed intraluminal stent is secured within a low-profile
delivery system that has radiopaque markers to facilitate positioning. As it is released from the catheter, the stent expands
to meet the internal wall of the trachea, foreshortening as it
increases in diameter. Because the stent is reconstrainable, it
can be pulled back into the delivery system for repositioning
after partial release.

Dose Dosing
(mg/kg) Frequency (hr)

Anabolic steroid

Stanozolol

Antitussive

Diphenoxylate

Hydrocodone 0.22 612

Butorphanol

0.15

24

0.20.5

12

0.51

612

Codeine 0.52 12
phosphate
Bronchodilator

Theophylline

Albuterol 0.05 8

Terbutaline 1.255 812

Aminophylline

Glucocorticoid

Prednisolone
0.5
12
Prednisone 0.5 12

Damage to the recurrent laryngeal nerves resulted in laryngeal

paralysis in 11% to 30% of dogs that underwent extraluminal,
peritracheal placement of ring or spiral prosthetic devices in
previous studies.12,16 Damage to segmental blood supply can
result in partial- or full-thickness tracheal necrosis.21,22 Signs
include coughing and subcutaneous emphysema; death is
possible. Pneumothorax is another severe complication
reported with placement of extraluminal cervical prosthetics.2
Surgeons should be prepared to place a thoracostomy tube
intraoperatively.

1020

810

Fully (A) and

partially (B)
deployed stents

Courtesy of Infiniti Medical

12

12

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The flexibility of woven nitinol stents allows them to maintain

their cylindric shape along the length of the trachea, despite
changes in tracheal direction or diameter. Radial stress
applied to the interior lumen of the trachea prevents migration
of the stent, as long as an appropriate size is chosen.2,26
Preferred stent size is estimated from survey radiographs
taken with the patient under general anesthesia. A probe
marked with radiopaque lines at 1-cm increments is placed
within the esophagus to permit correction associated with
potential magnification. The endotracheal tube is retracted to
where the cuff is inflated within both the cricoid and thyroid
cartilages, and the trachea is expanded with positive pressure
to determine maximal lumen diameter. Length is measured
from the caudal surface of the cricoid cartilage to the cranial
edge of the carina. Tracheobronchoscopy can be used to
recheck the length of the trachea, determine the grade of
collapse, and obtain samples for culture and cytology.

Step-by-Step n Stent Placement

Stent placement is performed with the patient under general
anesthesia and is guided by fluoroscopy or tracheobronchoscopy. Tracheobronchoscopy with a rigid scope permits direct
viewing of the airway and more precise stent placement.
Step 1

Place the dog in left lateral recumbency with its head and neck
extended. Insert a 5-French red rubber catheter attached to an
oxygen source transorally into the trachea; carefully insert a
rigid scope alongside and advance it until the carina is visible.

Stent selection is based on matching the desired stent diameter

and length with measurements in the manufacturers foreshortening chart, which provides an estimate of final length
based on the predicted diameter of expansion. The stent
should span from just caudal to the cricoid cartilage to just
cranial to the tracheal bifurcation. Final stent width should
exceed the maximal diameter of the trachea by 10% to 20% to
prevent stent migration.
Because dogs anesthetized for tracheal measurements usually
have severe collapse, immediate stent placement is preferable.
However, the cost of the stents limits the sizes most practices
have on hand. If an appropriate size is not available, the clinician may attempt to recover the dog from anesthesia and manage it medically until the desired stent can be obtained. Dogs
that do not recover well from anesthesia may require overnight ventilation or immediate placement of a less-than-ideal
stent.

What You Will Need

86

General anesthesia

Fluoroscope or rigid bronchoscope

5-French red rubber catheter

Oxygen source

Stent and delivery system

cliniciansbrief.com May 2014

Stent placement guided by tracheobronchosopy; the tracheal lumen is viewed

with a rigid scope. Anesthesia is maintained with constant rate infusion, and
oxygen is delivered into the trachea through a red rubber catheter.

Step 2

Step 3

Insert the stent delivery system into the trachea and slowly
deploy the stent while the rigid scope is slightly retracted to
confirm the position of the caudal end of the stent. Once 25%
of the stent has been deployed, remove the red rubber catheter.
Completely release the stent into the tracheal lumen over the
surface of the scope. Retract the rigid scope from under the
stent and reinsert it into the stent and tracheal lumen to confirm that the stent spans the collapsed region but does not
extend into the carina or larynx. Allow the dog to recover
from anesthesia.

Obtain a final set of radiographs either immediately after stent

placement or before the patient is released to the client. The
stent may slightly change in size over time because nitinol
expands as it reaches body temperature.24,25

Postplacement radiograph with an esophageal marker in place. The stent spans

the trachea from the caudal edge of the cricoid cartilage to just cranial to the
tracheal bifurcation.

Radiographic view of a partially deployed stent. In this patient, fluoroscopy is

used to monitor placement.

Postsurgical Care & Follow-up

Patients are recovered in an oxygen cage and monitored for signs of respiratory distress. They are sent
home on a tapering dose of corticosteroids, 2 weeks
of antibiotics, and client instructions to administer
sedatives and antitussives as needed. In one study of
18 dogs, the mortality rate was 11.1% within 60 days
after stent placement; however, long-term improvement was observed in the remaining dogs.22 Stress,
excitement, and exercise need to be limited for 4
weeks. Patients should be reevaluated (ie, examination, survey radiography) at 1, 3, and 6 months
procedure. Because the stent initially irritates the
airway, coughing is expected but must be controlled
to prevent stent fracture (A, B) or granulation tissue
formation (C). Other potentially life-threatening
complications include stent migration, tracheal
rupture, and collapse of mainstem bronchi or nonstented regions of the trachea. Rare complications
include rectal prolapse and perineal hernia.23 Most
clients note immediate improvement in quality of
life and, despite the progressive nature of the condition, are satisfied with the procedure. ncb

Lateral radiograph (A) and

endoscopic view ( B) of a
fractured stent.

Endoscopic view of
granulation tissue
formation.

See Aids & Resources, back page, for

references & suggested reading.
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