TRACHEAL COLLAPSE IN DOGS

Dr. Karen Tobias, DVM, MS, Diplomate ACVS

University of Tennessee College of Veterinary Medicine

Tracheal collapse is a progressive, usually dorsoventral flattening of the tracheal lumen that occurs most
commonly in middle-aged, small breed dogs such as Yorkshire terriers, toy poodles, Pomeranians,
Chihuahuas, and pugs. 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 disease
progresses, the distance between the ends of the cartilaginous rings increases, and the rings become more
ovoid, resulting in a dorsoventral flattening of the trachea and increasingly severe episodes of coughing and
exercise intolerance. Tracheal lumen diameter may become so reduced in size that the lumen is nearly
obliterated, resulting in respiratory distress and collapse. The etiology of tracheal collapse is unknown but is
believed to be a combination of environmental and genetic factors. Histologically, cartilaginous rings from
affected dogs are hypocellular, and their glycoprotein and glycosaminoglycan contents are decreased,
resulting in reduced water retention. Additionally, environmental factors, such as obesity, pollutants,
environmental allergens, and kennel cough, may play a role in progression of the disease.

Clinical signs of tracheal collapse include coughing, sometimes characterized as a “goose honk”; noisy
breathing; and, in severe cases, dyspnea, cyanosis, and hyperthermia. Coughing episodes may increase with
excitement, tracheal pressure (e.g., from a leash or collar), exercise, and eating or drinking. On physical exam,
a cough can sometimes be elicited with palpation of the trachea at the level of the thoracic inlet; in one study,
however, tracheal collapse was successfully diagnosed with this method in only 41% of affected dogs. In some
dogs, it is possible to palpate flattened cartilages along the cervical trachea. Hepatomegaly is also a common
concurrent finding; however, the association is unclear.

Definitive diagnosis of tracheal collapse is based on results of imaging techniques, such as survey
radiography, fluoroscopy, ultrasonography, computed tomography, or tracheobronchoscopy. Survey
radiography should include dorsoventral and lateral views of the cervical region and thorax. Collapse of the
cervical portion of the trachea is best viewed during the inspiratory phase, while collapse of the intrathoracic
trachea is best viewed during exhalation. Radiographs are also important to rule out other conditions that may
cause similar clinical signs, such as intrathoracic masses or pleural effusion, and cardiovascular abnormalities
(e.g., heart enlargement) that may complicate medical or surgical treatment. Survey radiographic imaging is a
good screening test because it is non-invasive, cost effective, widely available, and can be performed without
the risk of general anesthesia. However, false-positives have been reported in 25% of dogs, and the sensitivity
is variable, ranging from 60% to 90%. By comparison, fluoroscopy allows direct viewing of tracheal motion
during all phases of respiration, is non-invasive, and has very high sensitivity. In one study comparing
radiographic and fluoroscopic diagnosis of tracheal collapse, radiographs underestimated the severity and
frequency of collapse compared with fluoroscopy. Radiographic analysis incorrectly identified the location of
collapse in 44% of dogs, and false negatives occurred in 5 of the 62 cases (8%). In one dog, collapse was
classified as 25% on survey radiographs and 100% on fluoroscopy. False positives have been reported with
fluoroscopy, as well.

The current gold standard for diagnosis of tracheal collapse is tracheoscopy. Tracheoscopy enables direct
viewing of the trachea and mainstem bronchi, quantification of severity and extent of the collapse, identification
of concurrent inflammation, and collection of tracheal or bronchial samples for culture and cytology. With
tracheoscopy, the degree of tracheal collapse can be categorized based on the Tangner and Hobson grading
scale, with grades I, II, III, and IV characterized by 25%, 50%, 75%, and 100% collapse, respectively.
Disadvantages of tracheoscopy include limited availability, cost, and need for general anesthesia. Because of
small patient size, tracheoscopy is usually performed under injectable anesthetics and without intubation;
therefore, ventilation cannot be 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: The majority of dogs with tracheal collapse are managed medically; in one study of
100 dogs, success rate of medical management alone was 71%. Dogs presenting with acute respiratory
distress are treated with flow-by oxygen and mild sedation. Long-term treatment for mildly to moderately
affected dogs includes weight loss, oral antitussives (e.g., hydrocodone), and tapering doses of corticosteroids.
Concurrent respiratory infections are treated with antibiotics based on culture and sensitivity of tracheal wash
or brush samples. Over 80% of dogs with tracheal collapse have positive bacterial cultures. The most common
bacteria isolated are Pseudomonas spp, with less common isolates including Enterobacter spp and Citrobacter
spp. Bacteria cultured from tracheal samples may not be pathogenic; however, infection should be suspected if
supported by neutrophilic inflammation on cytology. If antibiotics are chosen empirically, doxycycline,
cephalexin, or amoxicillin-clavulanate are generally effective. Some clinicians prescribe bronchodilators (e.g.,
theophylline); antihistamines; or anabolic steroids (e.g., stanozol). In one study, 13 of 14 dogs with tracheal
collapse treated with stanozol showed improvement in tracheal collapse grade. There are currently no clinical
trials that demonstrate the safety and efficacy of bronchodilators for the medical management of tracheal
collapse, but their use can be justified in cases with concurrent lower airway disease. In obese patients, weight
loss is critical and can produce dramatic improvement. Other adjuncts to medical management include
sedation during times of stress, limiting tracheal pressure by using a harness instead of a collar, and limiting
exposure to respiratory irritants (e.g., smoke, dust, and other particulate matter).

Providing Structural Support

Prosthetic support of tracheal collapse is recommended when medical management fails. The two main
approaches for tracheal support include placement of extraluminal prosthetic tracheal rings or an intraluminal
stent. Extraluminal rings expand lumen diameter and simultaneously prevent collapse from negative airway
pressure within the trachea and mechanical forces external to the trachea. Extraluminal 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. 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. Damage to the segmental blood supply can result in partial or full
thickness tracheal necrosis. Clinical signs include coughing, subcutaneous emphysema, and death. Another
severe complication reported with placement of extraluminal cervical prosthetics is pneumothorax. Surgeons
should be prepared to place a thoracostomy tube intraoperatively if necessary. Mortality rate is 12% within the
first 60 days after extraluminal tracheal ring placement within the cervical and thoracic inlet regions. Median
survival time is over 4 years, even when the intrathoracic trachea is involved.

Intraluminal stents are preferred by many clinicians because they can be placed noninvasively in the cervical
or thoracic trachea, reducing the risk of complications and shortening anesthetic times. Vet Stent – Trachea®
(Infiniti Medical, LLC™, Menlo Park, CA) is a woven, reconstrainable, self-expanding, nitinol stent specifically
designed for use in dogs and cats. Nitinol, an alloy of nickel and titanium, has thermal shape memory, super
elasticity, and elastic hysteresis. The elastic hysteresis results in very little outward force on the interior lumen
of the trachea, regardless of oversizing of the stent. The undeployed 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.
Flexibility of woven, nitinol stents allows them to maintain their cylindrical 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.

Preferred stent size is estimated using measurements obtained from survey radiographs taken under general
anesthesia. Tracheobronchoscopy is also performed to recheck the length of the trachea, determine the grade
of collapse, and obtain samples for culture and cytology. Stent selection is based on matching the desired
stent diameter and length with measurements in the manufacturer’s foreshortening chart, which provides an
estimate of final length based on the predicted diameter of expansion. Preferably, the stent should span the
entire trachea from just caudal to the cricoid cartilage to just cranial to the tracheal bifurcation. Final width of
the stent should exceed the maximal diameter of the trachea by 10-20% to prevent stent migration.

Because dogs anesthetized for tracheal measurements usually have severe collapse, immediate stent
placement is preferable. Unfortunately, stents are expensive; therefore, most clinics keep a limited number of
sizes on hand. If an appropriate stent size is not available, the clinician may attempt to recover the dog and
manage it medically until the desired stent can be delivered. Some dogs do not recover well from anesthesia
and may require ventilation overnight or immediate placement of a less-than-ideal stent.
Stent placement is performed under general anesthesia and guided by either fluoroscopy or
tracheobronchoscopy. Tracheobronchoscopy permits direct viewing of the airway and a more precise
placement of the stent. The dog is placed in left lateral recumbency with its head and neck extended. A red
rubber tube hooked to an oxygen source is inserted transorally into the trachea, and a rigid scope is carefully
inserted alongside. The scope is advanced until the carina is visible. The stent delivery system is inserted into
the trachea, and the stent is slowly deployed while the bronchoscope is retracted slightly to confirm the position
of the caudal end of the stent. Once 25% of the stent has been slowly deployed, the red rubber catheter is
removed, and the stent is completely released into the tracheal lumen over the surface of the scope. The
bronchoscope is then retracted from under the stent and reinserted into the stent and tracheal lumen to confirm
the stent spans the collapsed region but does not extend into the carina or the larynx. The dog is then
recovered from anesthesia. A final set of radiographs can be taken immediately after stent placement or before
the patient is released to the owner. The stent may change in size slightly over time because the nitinol
expands as it reaches body temperature.

Patients are recovered in an oxygen cage and monitored for signs of respiratory distress. They are sent home
on a one month tapering dose of corticosteroids, a 2-week course of antibiotics, and instructions to administer
sedatives and antitussives as needed. Stress, excitement, and exercise are limited for the first 4 weeks after
placement. Patients should be reevaluated at 1, 3, and 6 months with a physical examination and survey
radiographs. Because the stent initially causes irritation to the airway, coughing is expected after the
procedure. Coughing must be controlled to prevent stent fracture or granulation tissue formation; if coughing
occurs when the steroid dose is decreased, the dose is increased to the previous amount/frequency at which
coughing did not occur. Some dogs are on steroids for life. Other potentially life-threatening complications
include stent migration, tracheal rupture, and collapse of the mainstem bronchi or non-stented regions of the
trachea. Rare complications include rectal prolapse and perineal hernia. 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. Most owners note immediate improvement in quality of life and, despite the progressive nature
of the condition, are satisfied with the procedure.

These proceedings are excerpted from “Deweese MD, Tobias KM: Tracheal collapse in dogs. Clinician’s Brief,
In Press, May 2014, pp 83-87.”