Symptoms of BOAS include snoring, inspiratory stridor (loud, open-mouth breathing, especially during inspiration), cyanosis (blue mucous-membrane color), rapid breathing, and even collapse. Additionally, patients may also experience concurrent gastrointestinal disease, which may or may not be related to the airway syndrome. 

A diagnosis is based on breed, characterization of breathing (inspiratory stridor), an exam of the upper airway (sedated exam visualizing the larynx and soft palate), and chest x-rays to evaluate the trachea and lungs. If available, a CT scan of the head and thorax is ideal to enable evaluation of the entire upper and lower respiratory system. 

The advanced stage of disease ultimately results in laryngeal collapse, when we are often forced to perform surgery to alleviate the obstruction. In the early stages of the disease process, options for surgery include trimming the soft palate, removing the saccules, and opening up the nares by removing wedges of tissue. Because most brachycephalics are born with BOAS, surgical interventions should be performed as early as possible in order to improve breathing. In the later stages of BOAS, patients develop complete collapse of the larynx and the aforementioned surgical procedures may not provide a long-term solution. Therefore, in certain cases, we may recommend bypassing the damaged upper airway and creating a permanent opening in the trachea (tracheostomy). 

Patient: Maggie, a 10-year-old, spayed, female Boston Terrier, was transferred to our hospital for severe respiratory distress and suspected cardiac disease. Upon arrival at our hospital, Maggie was sedated and placed in oxygen. Despite supplemental oxygen, Maggie continued to struggle and the work of breathing warranted placement of an endotracheal tube. Immediately upon intubation, her condition improved. An ultrasound of the heart was performed, and it was concluded that Maggie's heart was functioning normally. Chest x-rays, ultrasound of the heart (echocardiogram), ultrasound of the lungs, and an upper airway exam were performed. The chest x-rays showed changes consistent with chronic lower airway disease. The echocardiogram failed to show evidence of cardiac disease. The ultrasound of the lungs showed suspected pneumonia. The upper airway exam showed a severely elongated soft palate, swelling of the laryngeal tissues, and collapse of the larynx consistent with severe end-stage BOAS. Due to the severity of her condition, we felt it was in Maggie's best interest to completely bypass her upper airway by performing a permanent tracheostomy. Following surgery, Maggie did have complications, including pneumonia (which we had suspected on presentation), vomiting, and diarrhea. However, Maggie fought hard for six days until she was successfully discharged. According to Maggie's family, she is doing well at home and breathing better than ever.