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Vet Panel – Is BOAS surgery fair?


With increasing numbers of short-nosed (brachycephalic) dogs in the canine population, we’re getting increasing calls for BOAS surgery. A series of operations to help dogs with Brachycephalic Obstructive Airway Syndrome to breathe easily. Unfortunately, these cute dogs almost always suffer to some extent from obstruction to their airways, as a result of the breeding process to shorten their noses. But people are now starting to ask the question, is this invasive surgery really fair? 

So, we gathered a panel of vets to answer the question! On the panel are: 

What do we mean by “BOAS”, in more detail?

Nicola

BOAS stands for brachycephalic obstructive airway syndrome. Brachycephalic dogs are a group of dog breeds that have a flat faced appearance. ‘Brachy’ means short and ‘cephalic’ means head. It is these dogs that suffer with BOAS. The most common of these breeds are the Pug, French bulldog, and English bulldog.

David 

By shrinking these dog’s heads, we’ve compressed the soft tissues at the back of the throat. The result is a combination of problems, that all combine to make breathing difficult. In particular, they have an excessively large soft palate.

Nicola

The soft palate (which functions to separate the roof of the mouth from the nose) is often overlong and can extend down into the airways. This results in a snoring noise as the dog breathes in and out. There can also be narrowing of the nostrils and even extra tissue within the nose itself reducing the size of the airway and obstructing air flow. 

David

The other thing we quite often see is a narrowed trachea; although this on its own is less of a problem than the other issues. The problem is that, in the struggle to breathe, they often suck air down so hard that they “evert” – or turn inside-out – the folds of tissue in between the vocal cords. This is called “everted laryngeal saccules” and it makes breathing even harder.

Why are we seeing more BOAS dogs?

Sarah

In recent years the public demand for brachycephalic dogs has dramatically increased. There are multiple contributing factors for this. One key factor is about the features we relate to as humans. We are genetically programmed to feel affection towards young and small animals who possess certain characteristics; such as bug eyes, a large forehead, a large head to body ratio and a small nose. This is perhaps a driving force behind the direction of breeding dogs with these extreme features. 

David

Yes, I’d agree with that. There are actually a number of studies now that suggest that this love of “newborn-like” features is intrinsic and may even be hard wired into humans. It’s one of the reasons I don’t blame owners who take on even the most badly affected of these dogs. They’re responding to an inbuilt urge.

Nicola

Their cute faces and large eyes – which makes them appear almost baby-like. They can have great personalities. Celebrities have also fuelled the rise in the popularity of these breeds which have become fashionable with many high-profile personalities in recent times. 

Sarah

Brachycephalic breeds are used regularly in advertising, increasing their coverage to the public. Social media influencers create content with glamourised pictures of Frenchie and bulldog puppies. Which all drives public desire to follow the trend in “designer puppies”. 

Yvette

Basically, fashion. Owing to the popularity of brachycephalic (snub-nosed) breeds in the media and in popular culture – like when you see French Bulldog faces on everyday items like water bottles and clothing – these breeds are more and more often being sought out by owners. Breeds such as French Bulldogs, Pugs and Bulldogs have appealing, childlike features such as rounded faces, big bulgy eyes, short flattened noses and skin folds which are endearing to humans. It is unfortunately the same features that are characteristics that are representative of the presence of BOAS. 

Sarah

Ultimately, these desired characteristics are being bred for in high numbers to fulfil supply and demand, which then perpetuates the health issues we see, which are all linked to the very same anatomical characteristics.

Nicola

Throughout history humans have bred dogs with particular characteristics or traits that were felt to be desirable. In the past this might have been simply for dogs of a particular size; or who were especially good at performing certain tasks. Over the years this selective breeding has led to the vast number of dog breeds that are available today. Even within the breeds themselves, the appearance of dogs has changed enormously in recent history. This is true of brachycephalic dogs whose muzzles have become much shorter overtime. By changing their appearance in this way sadly we have caused more dogs to be affected by BOAS.

David

That’s a really good point. It’s not like hip dysplasia, for example, where the affected breeds have it almost as a coincidence. In BOAS, we have deliberately bred dogs to have a specific shape, that specifically causes the problem.

Nicola

So, in summary, more people are wanting to own flat faced dogs. AND over time we have changed the conformation of these dogs to make them more appealing for us to look at.

What is the welfare impact of BOAS on these dogs?

Nicola

Unfortunately, although brachycephalic dogs look cute, they can have significant health issues including BOAS. Their exaggerated features of significantly shortened noses also often come with extra soft tissues inside the nose and mouth which can cause tremendous problems with breathing. 

Yvette

The presence of BOAS means a variable combination of individual abnormalities each with their own associated discomfort or negative implication on the pet’s health. The narrowed external nares (nostrils) mean that taking in air is more like us breathing whilst almost pinching our nose closed; hence why they’re mostly seen panting. The overly long soft palate and excess of soft tissues in the throat get in the way of breathing. Tissues can even swell up further from the extra effort and panting, creating a vicious cycle. These can create the feeling of choking which causes further distress. They often have an overly narrow trachea or windpipe. Which means any air they can get, they have to pull in under further resistance down a very narrow tube. 

Sarah

There is no doubt that BOAS impacts the quality of life and welfare of dogs that are affected. There are numerous issues that obstruct the passage of air through the airways. The most obvious symptom we see is difficulty breathing, which sadly is often normalised by owners and in the media. Dogs with airway issues struggle to exercise, are more likely to faint or collapse, have difficulty eating and can quickly develop heat stroke.

Nicola

If for a moment you pinch your nose so that it is almost but not completely closed and try to breathe through this you will have a small understanding of how it is for these dogs on a permanent basis. Some dogs learn to use toys or chews to prop their mouths open before they sleep. This is an attempt to keep their airways open because they simply cannot get enough air in through their nose. 

Obstruction to the airways impacts the ability of affected dogs to exercise, play and sleep. They can also be difficult to handle in a veterinary environment. This is because they often do not cope well with stressful situations. Even something as simple as a nail trim may need to be managed very carefully in these dogs to reduce any stress to the patient. Secondary to the airway issues, these dogs can have gastrointestinal problems such as vomiting. In some cases this can be very regular and be a further welfare concern. 

Yvette

So, if these pets struggle even during normal temperatures, imagine when it’s warm. They don’t have a long enough snout to help cool the air before it gets to the lungs and have to pant even before they need to do so to cool off. This means that panting just isn’t efficient enough for them to maintain a normal body temperature like for other dogs. Therefore, even small increases in temperature can cause them a great deal of distress. They are common patients we see for heatstroke in warmer months. These dogs often can’t just relax which causes exhaustion.

David

And sadly, many people see this as “normal for the breed”. 

Nicola

It is really important that we try to breakdown the perception that the noisy breathing we see so frequently in these flat faced breeds is normal and realise that many of these animals are struggling.

Sarah

As well as respiratory disorders, brachycephalic breeds are also more likely to develop other conditions, such as skin and ear problems, stomach problems, eye ulcers, heart murmurs, spinal issues and complications giving birth.

The drive to produce these puppies in high numbers has consolidated these health concerns. We have seen bitches and litters kept in poor housing conditions and being transported abroad. Canine fertility clinics are beginning to open to keep up with demand, but these are currently unregulated. 

A VetCompass study conducted by the Royal Veterinary College, found “strong evidence that brachycephalic breeds are generally less healthy than their non-brachycephalic counterparts.” 

Yvette

Imagine that all this creates distress and discomfort; which for us veterinarians, goes against several of the 5 freedoms of animal welfare, freedom from distress, disease and discomfort.

David

None of this is the fault of the owners, of course. The problem is that we have bred these animals to such an extreme that these issues are “baked in” now. But hopefully it goes some way to explaining why we’re so worried about the surge in numbers of dogs with these problems!

How effective is surgery at alleviating these welfare impacts?

Nicola

It is reported that surgery can be expected to improve the breathing in about 90% of cases. Because most animals will be able to breathe more easily after surgery, there should be an improvement in their ability to exercise and they should also be able to sleep better. Surgery can often help reduce the severity of any vomiting that may be seen secondary to BOAS. But this is not always the case. 

David

While 90% will see some improvement, how dramatic is that? I seem to recall that in many cases the improvement is fairly small.

Sarah

Surgery is aimed at widening the airways in an attempt to help the breathing difficulties and improve quality of life. Over 50% of cases have a fair to good outcome following surgery. There is however no guarantee of success. 

Nicola

The effectiveness of surgery depends on several different factors including the age of the dog and the severity of the BOAS. It is a progressive condition. Over time if left untreated the soft tissues and cartilage at the back of the throat can start to deteriorate and collapse. This will worsen the clinical signs and reduce the potential for surgery to improve the animals breathing. It is important that we try to identify animals that will benefit from surgery early in life before these secondary changes have occurred. If you have any concerns about your own pet it is important to discuss these with your own vet at the earliest opportunity.

Sarah

In addition, there are some factors that cannot be treated surgically, such as tracheal hypoplasia (narrowing of the windpipe). Often, follow-up surgeries are required if the desired out is not seen with the first surgery, and even then, full resolution of symptoms is not expected. 

Yvette

Reconstructive surgery can go a way to improving some aspects of these dogs’ welfare, some more than others. But it can’t restore it completely. We can improve the comfort and air passage through the upper respiratory tract to varying degrees, so that hopefully they are more comfortable and relaxed in everyday breathing. But we can’t address their shortened snouts which prevent effective cooling. We are limited in the amount of tissue that can be removed from the nose and throat to improve the ease of air passage. And we cannot do anything about their tracheas being too narrow. They may still never be comfortable and will still struggle in warm weather.

Are there any alternative ways of managing BOAS, and how effective are they?

David

While I’m usually all in favour of “conservative” or medical management, this is one condition that definitely requires a surgical approach, if at all possible. At the end of the day, the problem is anatomical. The structure of the animal is “incorrect” in that it is preventing normal airflow. As a result, the best results are always going to come from surgery; which can amend or modify that anatomy so that it functions better.

Nicola

If there is excessive tissue in the throat or nose that is obstructing the airways then surgery is the only way to remove this. 

David

That’s not to say that there aren’t interventions that don’t improve the animal’s welfare short of surgery though… I’m thinking especially of dogs who aren’t stable enough for surgery, or where there are other issues making it impractical.

Yvette

For pet parents that aren’t keen to operate or when it’s just not appropriate, we do make certain recommendations to try and reduce the impact of BOAS on the dog’s life. Their effectiveness really depends on how severely affected the pet is. However, although these might help reduce the likelihood of acute crises happening, they probably won’t make a significant difference in their day-to-day discomfort. 

Nicola

There are some things that can help reduce the level of clinical signs that dogs suffer when surgery is not an option. Maintaining a healthy body weight is important as being overweight will worsen any BOAS signs. 

Sarah

Although the evidence is not yet conclusive, there are a number of studies that suggest a relationship between level of obesity and severity of BOAS. The theory behind this is that overweight dogs carry extra fat stores around the neck, which can amplify airway obstruction issues. It is advisable to attend weight clinics at your practice and focus on keeping your dog trim with controlled food intake.

Nicola

Stressful situations and strenuous exercise (both of which increase the demand of the body for oxygen) should be avoided. It is also particularly important to avoid walking these dogs in the middle part of the day during the summer and on really hot days to stop walks altogether. 

Yvette

Simple advice includes using a harness rather than a collar and limiting walks – keeping them shorter than for other breeds, so no hours-long jaunts in the countryside. We always advise to actively avoid the heat in warmer months, preparing the pet a cool, well ventilated place to rest, with ample cool water to drink to help them stay cool and not engaging in any kind of walks, play etc during sunny hours. Additionally, we would advise to minimise stress to these dogs, so avoiding long car journeys, aggravating encounters with other dogs or cats that stimulate them, and not engaging in over-active play. 

David

That said, there are other medical issues that brachycephalic dogs suffer from that are much more amenable to medical treatment. There are a lot more options for dealing with these secondary issues, such as acid reflux and oesophagitis. 

Sarah

The majority of cases will experience gastro-intestinal symptoms. Your vet may prescribe long-term off-licence ant-acid medication that may improve secondary symptoms, including reflux, regurgitation and aspiration pneumonia. 

So, the big question – is BOAS surgery fair on the dogs?

Nicola

BOAS surgery has potential to drastically improve the quality of life for affected dogs. Although any surgery comes with associated risks, the potential benefits that come from being able to breathe more easily should not be underestimated. Longer term we must strive to breed dogs who do not require surgery at all. This will take time. Vets, pet owners and breeders will need to work together to improve welfare for future generations of affected breeds.

Sarah

BOAS surgery is fairly commonplace in first opinion and referral practice. For the individuals suffering with the effects of the syndrome, surgery is a reasonable option in attempting to improve symptoms and their quality of life. 

However, it is important to note that BOAS is not classified as a ‘routine surgery’. General anaesthetic carries higher risk in brachycephalic dogs and, by nature, operating on the airway is a risky procedure. Complete obstruction from swelling in the post-operative period is also a big concern.

However, it is critical to not lose sight of the underlying reason we are witnessing an increasing number of BOAS surgeries. We are breeding dogs to express certain characteristics which mean they are unable to breathe, sleep, eat and exercise like a “normal” dog, and then paying a lot of money for high-risk surgery where the outcome is not guaranteed to resolve the issues. The wider question is whether it is fair to be breeding dogs that have to go through this traumatic process at all, irrespective of the surgical outcome. 

Yvette

These dogs aren’t born into fair situations. It’s unfair they’re destined to suffer from their BOAS signs, and it’s unfair they should have to undergo surgery just to obtain a reasonable quality of life. In my opinion, BOAS surgery is fair. It’s a short-term discomfort aimed at providing long-term improvement in health and welfare for those dogs which, without it, would endure chronic, unfair, life-limiting malaise.

A lot of people aren’t aware their pet is in discomfort, because they’ve always panted, they’ve seen no change in behaviour or they don’t appreciate the extent of their pet’s abnormalities because they’re seen as normal for the breed. As such, it can be a difficult topic to discuss and challenging to explain the rationale behind the desire to operate on what you might believe is a normal dog. As ever, surgery must be made on a case-by-case basis, each pet is unique. In many cases, owners can’t believe how changed the dog is after surgery, often noting changes in behaviour and activity, and are content with their pet’s improvement in quality of life.

David

I’d agree with all of my colleagues. BOAS surgery is the best solution to a problem that shouldn’t really exist. However, as we’re in the situation where we are, it’s definitely fair on the dog with moderate to severe BOAS. They can’t breathe, can’t sleep, and suffer constantly in a state of partial suffocation – which too many people think is “cute” and normal. Anything we can do to alleviate their suffering is worth it, in my opinion – including, sadly, euthanasia in badly affected dogs for whom surgery isn’t possible.

Is there any way of reducing the need for this surgery in the first place?

Nicola

Vets have been concerned for some time about the huge increase in dogs that we are seeing affected by BOAS. It is really important to try to reach out to potential puppy owners about the problems seen in these popular breeds. Before choosing a puppy you should always be able to see them with their mother and ideally also visit the father too if he doesn’t live in the same household. When seeing the parents ask yourself – are they noisy when they are breathing? Do they snore, snort or wheeze? Do they have nice open nostrils or do these appear pinched together?

The kennel club works closely with breeders to try to help improve the welfare of dogs by encouraging responsible breeding. A respiratory function grading scheme (launched in 2019) is now in place to try to reduce the number of dogs affected by BOAS. It involves a non-invasive test by a specially trained veterinary surgeon. This can be done from a year of age and be should be repeated every two years for breeding animals. Dogs are graded from zero (being unaffected) to three (severely affected) and these are recorded on the kennel club website. Breeding from dogs with lower scores should reduce the risk of puppies being severely affected. Pugs, French bulldogs and bulldogs can be graded under this scheme and you can view the scores of any graded dogs online.

Nicola

In addition, the Kennel Club have a wealth of information relating to all breeds. Whether you are considering getting a breed that can suffer from BOAS or any of the other amazing number of dog breeds available it is worth checking out the kennel club website to get advice and ensure any new dog you bring home has the best chance to be as healthy as possible. Finally, never be worried about asking for advice from your vet before you choose a new pet.

Sarah

Ultimately it comes down to improving the gene pool and out-breeding the extreme characteristics we are seeing today. Achieving this will take time and involve commitment from all parties involved, including owners, breeders and vets – and needs a change in both breeding practices and consumer demand.

Vets must work collectively with breeders to educate and avoid breeding dogs with severe conformational issues. Owners need to be informed on the health issues and financial implications of owning a dog with BOAS. Wider social pressure created by advertisements in the media must be addressed. Legislating against use of brachycephalics in advertising is a good start. 

Yvette

We need to reduce the population of pets needing the surgery because of their underlying BOAS and its welfare problems. It’s clear we need to alter the breeding of these dogs. Eliminating the breeds realistically wouldn’t be achievable and would likely create black-market breeding, causing a whole new welfare problem. 

There needs to be greater diversity in the breeding to breed-in reduced BOAS traits in order to work towards reducing the negative welfare implications suffered by brachycephalic breeds. Breeding of severely affected dogs must be stopped. We need to further increase the awareness of BOAS suffered by the affected breeds and defame the sought after snub-nosed pets in popular culture.

Owners should do plenty of research before committing to a breed affected by BOAS and when electing to buy must be mindful to select pets from responsible breeders committed to improving the welfare of these breeds. Pets can be submitted to the Respiratory Function Grading Scheme run in conjunction with the Kennel Club to help owners understand the grade of BOAS in their pet, and advise breeding decisions for future dams and sires. There isn’t a quick fix to this problem we have created, but in time we can work together to secure a brighter future for these lovely pets. 

David

We don’t want to get rid of Pugs, or Frenchies, or any of the other lovely dogs who are affected by this condition. What we need to do is return them to a conformation more like the one they had a hundred years ago – with a short, but still present and functional nose. And that means action at the level of the Kennel Club and the Breed Associations, but also action by people looking to buy a new puppy.

Choose the longest-nosed dogs to breed from; choose the longest-nosed dogs to buy, and lets get these dogs back to what they should be.

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