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Collapsing Trachea

Collapsing Trachea. Mark Bohling, DVM Diplomate, American College of Veterinary Surgeons Assistant Professor of Surgery University of Tennessee College of Veterinary Medicine. What is Tracheal Collapse?. Normal airflow dynamics in respiration Inspiration

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Collapsing Trachea

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  1. Collapsing Trachea Mark Bohling, DVM Diplomate, American College of Veterinary Surgeons Assistant Professor of SurgeryUniversity of TennesseeCollege of Veterinary Medicine

  2. What is Tracheal Collapse? • Normal airflow dynamics in respiration • Inspiration • Expansion of chest by muscles of respiration • Pressure gradient - chest negative • Effect on the air conduit: • Thorax - expansion • Neck - compression • Expiration • Reverse effects

  3. History of Collapsing Trachea in Veterinary Medicine • Described as early as 1960 • Review of early treatments • Single plastic tube • Ventral chondrotomy • Modified ventral chondrotomy • Dorsal membrane plication

  4. Tracheal Collapse in Other Species • Tracheal collapse in human beings • History • Dates to 1930’s • Similarities • Softening of tracheal cartilage • Lateral collapse (same as dorsoventral in dogs) • Differences • Classification • Primary vs secondary collapse • Pediatric vs adult collapse

  5. Tracheal Collapse in Other Species • Tracheal collapse in large animals • Horses • Congenital • Secondary to laryngeal paralysis • Cattle • Acquired neonatal • Tracheal collapse in birds • Bordetella avium in turkeys

  6. Tracheal Collapse in the Dog • Miniature breeds • Middle aged to older • Other risk factors • More pronounced in obese individuals

  7. Levels of Collapse Normal G1 G2 G3 G4

  8. Levels of Collapse

  9. Clinical Signs • Chronic, dry nonproductive cough (honking) • Intermittent dyspnea (worsens with excitement) • Cyanosis & syncope in severe cases • Inspiratory/ expiratory dyspnea • Prone to heat stroke

  10. Clinical Signs

  11. Pathophysiology • Disease causes the trachea rings to weaken • Dorsal ligament and trachealis muscle weaken and stretch • Trachea changes from oval tube to a flattened conduit

  12. Etiology • Congenital • Nutritional tracheomalacia • Obesity • Bacterial infection • Neurologic • Chronic airway disease • Idiopathic – “who knows why”

  13. Diagnosis • Tracheal palpation • Radiographs (inspiratory / expiratory ) • Fluoroscopy • Tracheoscopy

  14. Radiographs

  15. Tracheoscopy

  16. Medical Management • Cough suppression(Hydrocodone, butorphanol) • Bronchial dilators(Aminophylline, terbutaline) • Sedation(Acepromazine) • Weight loss

  17. Medical Management • Help control symptoms • Can not be cured • Disease usually progressive

  18. Surgical Correction • External stenting with plastic rings

  19. Before After

  20. Surgical Correction • External spiral stent

  21. External Stent Complications • Collapse between rings

  22. External Stent Complications • Damage to recurrent laryngeal nerve

  23. External Stent Complications • Interruption of tracheal bloodsupply

  24. Internal Stenting • What is a stent? • History of stenting • History of tracheal stenting • Modern stents and stent materials • Stents in veterinary medicine

  25. Ultraflex® Stent • Radiopaque, self-deployed • 4 - 8 cm length, 10 - 20mm diameter • Made of nitinol (nickel-titanium alloy) • Proximal or distal deployment • Single strand, open loop knitted design (flexible, contourable) Boston Scientific/ Microvasive.

  26. Ultraflex® Stent

  27. Ultraflex® Stents

  28. SmartStent® • Nitinol tube • Laser cut • No overlapping wires • Less breakage in human vascular applications • Cordis Endovascular®

  29. Infiniti Stent • Also nitinol • Single woven wire • Only stent produced exclusively for vet use • Claims as yet unproven

  30. Stent Placement • Stent deployed under fluoroscopic guidance • Target – 5mm cranial to bifurcation • Placement checked with tracheoscopy

  31. Stent in Place

  32. Radiographs

  33. Postoperative Care • Perioperative antibiotics • Corticosteroids for 7 days • Sedation • Cough suppression • 24 hours oxygen if needed • Humidification

  34. 6 Month Post Implant

  35. Stent Results • The little girl with the curl syndrome… • Good outcomes… • Immediate improvement • Breathing near normal • Mild chronic cough • And the not-so-good outcomes…

  36. Stent Complications • Stent fracture • Granulation in stent • Tracheal exudate • Additional collapse at ends of stent

  37. Fractured Stent

  38. Fractured Stent

  39. Stent Fracture • Originally thought to be due to bending stresses • All brands/types of nitinol stents can fracture - there is NO unbreakable stent • At this time, removal is best option - BUT - not for the fainthearted!

  40. Granulation Tissue

  41. Tracheal Mucus

  42. Collapsed at Ends

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