We believe most brachycephalic breeds probably live with a degree of reflux pharyngitis. All these extreme flat faced breeds breathe with more effort than normal dogs. In many it’s subtle, not noticed by their owners or not acknowledged (every breeder in particular claims their dog breathes perfectly!). This increased effort forces their stomach into the diaphragm, pushing up into the chest more than normal dogs. This acts to reflux acid from the stomach to the oesophagus which causes mild oesophagitis and potentially mild nausea. In turn this results in a mild (to severe in some dogs), belching of fluid and acid to the mouth, usually swallowed again. You may or may not see physical signs of this. Lip smacking, gagging and coughing are some of the more significant signs. When it is severe, you actually start to see vomiting. This will usually just be phlegm and classically occurs after exercise or drinking water after exercise. Occasionally it can be food and often just one to two times per month. With the severe cases it can be two to three times per week or even more.
What is likely happening is that the mild reflux that most dogs live with occasionally becomes more exaggerated and reaches a threshold whereby a more significant pharyngitis and tonsilitis (inflamed pharynx and tonsils) cause increased gagging, coughing or possibly vomiting, which in itself causes more reflux, exacerbating the whole cycle.
It’s this process and cycle that needs to be understood when presented with these breeds seemingly in respiratory distress.
The ultimate concern of this process is the potential for aspiration pneumonia. The pharyngitis is so bad they aspirate some of the secretions and bacteria which can set up firstly a pneumonitis (inflammation of the lower airways) and then a true bacterial pneumonia (bacteria take hold in the lungs). However, we believe the vast majority of presenting cases that are treated for aspiration pneumonia are highly likely not aspiration pneumonia. The vast majority are just the first few phases of severe pharyngitis, or possibly the start of tracheitis and/or pneumonitis.
These episodes can come on quite suddenly with increased breathing effort (hence the misdiagnosis of aspiration pneumonia), gagging, coughing up phlegm and vomiting. We see hundreds of social media posts, and have many dogs with such a history present to our clinic, that have been in emergency for days having been diagnosed with aspiration pneumonia. We ask a series of questions, obtain the x-rays to look at ourselves as well as the relevant history from the emergency centre, only to potentially disagree with the diagnosis. We believe many of these were just the start of severe reflux pharyngitis, needing nothing more than a steroid injection and a few basic medications.
We feel there is a propensity for veterinarians to jump to conclusions when presented with these cases, presuming they are aspiration pneumonia and immediately placing dogs on oxygen, intravenous fluids and starting antibiotics. We feel often none of these are needed or helpful. Many are also started on Non-Steroidal Anti Inflammtories (NSAIDS), which are more often than not ineffective for this condition, but precludes the use of steroids, highly effective for this condition, given the two drugs cannot be used simultaneously, needing a 36 to 48 hour washout if you are wanting to change.
We feel our profession has a major misunderstanding of this process at this stage and are urging more discussion on this topic. The main way to initially differentiate the two possibilities of either just severe reflux pharyngitis (plus or minus the start of mild pneumonitis), and a true bacterial aspiration pneumonia is via the following:
– Still relatively bright and usually reasonably happy to eat
– Still reasonably active
– Gum colour and capillary refill time (CRT) is fine (this is key)
– Just gagging, retching even vomiting a lot and seemingly breathing with more effort
– Very lethargic
– Largely off food
– Poor gum colour
The main problem we feel with treatment of both problems is the lack of use of steroids as the mainstay of initial treatment.
Treating Suspect Reflux Pharyngitis:
We need to understand the following basic concepts when it comes to treating reflux pharyngitis/tonsilitis:
– Steroids reduce mucosal inflammation brilliantly. Nsaids do not.
– The pharyngeal and tonsillar inflammation in itself likely leads to far more reflux, so reducing this inflammation (steroids) is key.
– This increased reflux, acid rising from the stomach into the oesophagus, causes worsening pharyngitis and tonsilitis.
It’s a self-perpetuating cycle, so this is how we treat them:
– Steroids to rapidly and significantly reduce that inflammation which makes them feel better, so breathe with less effort which reduces the reflux
– Omeprazole antacid to reduce the acid production in the stomach
– Metoclopromide which has two actions: It moves stomach content forward, but more importantly, it increases the tightness of the lower oesophageal sphincter such that less acid refluxes into the oesophagus
Note: we do not use any of the following in most cases
– Intravenous fluids
– Occasionally we will do an initial X-ray to rule out obvious pneumonia in the more severe cases.
We have found over the years there are very few dogs that do not respond rapidly and well.
Steroids and Aspiration Pneumonia:
The main concern vets have with steroid use is the concern it lowers immunity potentially making aspiration pneumonia worse. For vets having those concerns we would recommend considering the following:
– We are not using immunosuppressive doses. We are using anti-inflammatory doses (much less).
– We are only starting them for 1-2 days, and if not vastly improved you can stop with no harm done. Hence with such a short course that is a low dose, the chance of immunosuppression is almost non existent.
– We would estimate that over 80% of diagnosed suspect aspiration pneumonia is wrong. The cause is actually just inflammatory pharyngitis or the possible start of pneumonitis as described above.
– Speaking with leading cardiopulmonary specialist veterinarians, they agree that a few days of anti-inflammatory doses of steroids is likely to help, not hinder, even if true aspiration pneumonia exists, given the anti-inflammatory properties they possess to reduce pulmonary inflammation that bacteria thrive in.
– Given our experience is that we have not yet had a single case get worse (but we do still advise it’s possible, so if so, we will stop), we feel the “risk” of not giving steroids is far higher than any minor risk of starting them. This is because if we don’t reduce symptoms significantly and quickly, then a true aspiration pneumonia may well progress.
Many young dogs, especially those with hypoplastic tracheas, will have intermittent gagging, coughing and vomiting episodes that we treat as above, using a combination of those three drugs. However, it’s very much a case by case basis upon which we treat. We may treat some with 3-5 days of steroids only. Others with all 3 drugs for 3-4 weeks or on an ongoing basis until airway improvement age. And anything in between! However, many mild to moderate concern dogs do seem to grow out of it, often those with hypoplastic tracheas, as their trachea does increase in ratio as they mature to around 12 months. So we don’t need to be drastic with any medical or surgical intervention unless we have a case that is significant, refractory to treatment or worsening. Ultimately surgical airway improvement at 8-14 months helps all dogs with their breathing for life, and many dogs significantly reduce their overt reflux/vomiting signs, or just their general feeling of well being.
Mild Ongoing Intermittent Nausea:
We feel many if not most brachycephalics probably live with a degree of reflux which causes mild intermittent nausea in those not actually gagging or vomiting. We feel this is likely the case for the following reason:
Many owners describe their dogs as seemingly much brighter and happier in the mornings after airway improvement, eating with gusto rather than picking, and with seemingly more energy and spark. These dogs were not necessarily vomiting beforehand, but they are showing the same lifestyle improvements that many of the vomiters are after they stop vomiting post airway improvement. It’s just another of the benefits rather than needs part of the equation for doing airway improvement in these breeds.