Plus-Hex CLINICAL decreased to 90 %, it was rapidly corrected to 97 % once the trachea was re-intubated and oxygen therapy was provided by manual IPPV. A urinary catheter could have been inserted in the airway and connected to a breathing system, as described earlier in this article, to deliver oxygen using gentle manual IPPV, or via a jet ventilator, to decrease the risk of hypoxaemia. However, there was an associated risk of catheter damage due to the proximity of the surgical site, and consequent aspiration of the device. If hypoxaemia persists, the literature suggests ceasing the procedure and performing ET intubation [ 12 ].
The accuracy of pulse oximeter readings can be affected by surgical manipulation, poor perfusion and bradyarrythmias caused by vasoconstrictive drugs [ 7 ] such as dexmedetomidine. An arterial blood gas analysis could have been helpful in this scenario, to assess the patient ' s oxygenation status. In severe states of hypoxaemia, cardiac arrythmias can also be detected on an ECG due to myocardial hypoxia [ 7 ]. Monitoring the heart rate and ECG in brachycephalic breeds is also recommended, as they have an increased vagal tone and a higher risk of developing bradycardia and bradyarrhythmias than other breeds [ 9 ].
An alternative to TIVA could have been the placement of a temporary cuffed tracheostomy tube before surgery to allow maintenance of anaesthesia with volatile agents, as was described in two case reports involving upper airway tissue resection [ 21, 22 ].
Airway management after anaesthesia
Late ET extubation in brachycephalic breeds is highly recommended to allow time for the patient to regain control of the airway, decreasing the likelihood of respiratory obstruction. In addition, it also protects the airway from aspiration of regurgitated contents [ 1 ]. Sedation might be beneficial in some cases to provide a smooth recovery, although too profound sedation might suppress the laryngeal muscle tone and respiratory function, contributing to hypoventilation and respiratory obstruction [ 6 ]. The patient was positioned in sternal recumbency with the head slightly elevated to enhance spontaneous ventilation, as recommended in the literature [ 6, 10 ]( Figure 4). A pulse oximeter was used to monitor oxygen saturation, as this method has been described as reliable when transitioning patients from an oxygen-enriched environment to room air [ 7 ].
The ET tube can be removed with the cuff slightly inflated to remove any fluid lodged in the airway [ 18 ]. After extubation, it is recommended to open the patient ' s mouth, or use a mouth gag, and to gently pull the tongue rostrally to facilitate the flow of air. Oxygen supplementation is required in some cases and the administration of corticosteroids is also often needed to reduce oedema at the surgical site [ 6 ].
Figure 4. A French bulldog receiving oxygen supplementation via face mask, while recovering from general anaesthesia. The patient is positioned in sternal recumbency with the head elevated to facilitate spontaneous breathing. Note that an emergency endotracheal intubation kit is ready( in the background) if needed.
An intubation kit, including an ET tube smaller than the one in place, a cuff syringe, a tie, a laryngoscope and an anaesthesia induction agent, must be ready to secure a patent airway in case of an emergency [ 6 ], which was helpful in this case. Although ET re-intubation was achieved quickly in this patient, in human medicine the insertion of an airway exchange catheter before retrieving the ET tube is suggested to facilitate reintubation if needed [ 13 ]. However, in small animals, this technique presents a high risk of catheter aspiration if the patient has a dysphoric recovery and damages the catheter. Having suction equipment ready is helpful in the event that there is a need to clear the airway in case of haemorrhage and / or regurgitationl [ 6 ].
This patient could have benefited from adrenaline nebulisation, as it has been shown to be effective in reducing mucosal oedema and haemorrhage, due to its vasoconstrictive effects, assisting in airway management postoperatively [ 23, 24 ]. Unfortunately, a nebuliser was not available for use in this case, but nebulisation with 0.05 mg / kg adrenaline is now part of the veterinary hospital ' s brachycephalic anaesthetic recovery protocol.
Some patients need a temporary tracheostomy tube to be placed to alleviate dyspnoea caused by an upper airway obstruction( Figure 5, page 30). However, this procedure is associated with a risk of further complications, such as obstruction, device displacement, infection, sinus bradycardia and death. It also requires intensive nursing care of the patient and financial investment by the owner [ 2 ]; it is therefore often performed only as a last option.
Nursing a patient with a tracheostomy tube in place requires close supervision to monitor for proper airflow and ensure the tube is securely in place and not obstructed or dislodged [ 25 ]. Signs of tube obstruction include increased respiratory effort and stridor, coughing, dyspnoea and hypoxaemia. If not addressed promptly, it can lead to asphyxia [ 25 ].
A sterile tracheostomy tube must be available and ready in case a replacement is needed. Regular tracheostomy
Volume 40( 3) • June 2025
29