Introduction

Permanent tracheostomy (PT) is rarely performed in veterinary medicine and is often reserved as a salvage procedure for various etiologies of upper respiratory obstruction. The most common indications for this procedure include laryngeal paralysis, laryngeal collapse, neoplasia of the larynx or pharynx, and trauma.^1–5 Tracheostomy can be an effective treatment for upper airway obstruction in dogs and may be indicated more frequently than it is performed. Risks and complications vary depending on the patient's status and underlying disease but may include excessive mucus secretion, stenosis, dehiscence, coughing, aspiration pneumonia, or acute death due to asphyxiation from obstruction.^3,4 Anecdotally, the authors feel veterinarians may be less likely to recommend permanent tracheostomy because of the perception that owners may find the outcome less than desirable.

A recent report evaluated long-term outcomes of 21 dogs with permanent tracheostomy and found that the median survival time (MST) was 328 days, with 26% of the dogs dying acutely at home, presumably from acute airway obstruction.⁴ However, there has not been any evaluation of owner satisfaction following permanent tracheostomies in dogs. The objective of this study was to evaluate owner perception of outcome after permanent tracheostomy in dogs. Our hypothesis was that the majority of owners would be satisfied with the outcome of this procedure in their dog.

Materials and Methods

Medical records at four veterinary teaching hospitals (University of Georgia, Texas A&M University, Auburn University, and North Carolina State University) were searched to identify dogs who received a permanent tracheostomy between January 2002 and June 2016. Dogs were included in the study if the owners could be contacted for follow-up, agreed to participate in the study, and a complete medical record was available for review. Dogs who died within 2 wk of permanent tracheostomy were excluded. Patient data obtained from the medical record included signalment, date of tracheostomy, pre-existing respiratory disease, reason for a permanent tracheostomy, presence of complications postoperatively, date of tracheostomy, date of discharge from the hospital, and survival time. Major complications were defined as those requiring revision surgery or affecting quality of life, whereas minor complications were defined as those that did not require revision surgery to resolve, or did not affect quality of life. For cases in which owners could not clarify severity of clinical signs (such as dyspnea or mild intermittent respiratory effort), complications were classified into the more severe category to ensure the most stringent reporting. All owners with available contact information and whose pets were discharged from the hospital were contacted via telephone or e-mail and asked cause of death and approximate date of death if not provided by the medical record.

A 14-question survey was developed using questions with multiple choice, yes-or-no answers, and open-ended questions. The questionnaire was submitted to the University of Georgia Institutional Review Board prior to study start, which stated that approval was not required to administer the questionnaire (STUDY00003920). The purpose of the questionnaire was to obtain information regarding the dog’s death unavailable in the medical record (if applicable), as well as the owner’s perception of the surgery, the dog’s adaptation to the procedure, and satisfaction with the dog’s daily life post tracheostomy. The specific questionnaire can be found in Supplementary Appendix I.

Continuous data were evaluated for normality by using the Kolmogorov-Smirnov test. Data with normal distribution were described as a mean ± SEM, and nonnormally distributed data were summarized as a median with range. Dogs who were alive at the time of contact for the questionnaire and those who died of unrelated causes were censored. Categorical and ordinal data were described as percentages of the total.

Results

A total of 78 dogs were identified that received a permanent tracheostomy. Seven dogs died or were euthanized within 2 wk of their procedure (aspiration pneumonia [n = 2], cardiac arrest in hospital [n = 2], neurological decline [n = 1], acute respiratory distress syndrome [n = 1], and unknown reasons [n = 1]) and were excluded from further analysis. Two additional dogs were lost to follow-up within 2 wk of surgery and were excluded from further analysis. In total, 39 owners (56.5%) successfully completed the questionnaire. Median time to owner contact after permanent tracheostomy surgery was 608 days (64–3,708).

The most common breed was Labrador retriever (n = 10), followed by pug (n = 4); Yorkshire terrier (n = 3); Jack Russell terrier (n = 3); two each of miniature pinscher and French bulldog; and one each of border collie, Boston terrier, Chihuahua, Australian shepherd, Pekingese, Cavalier King Charles spaniel, fox terrier, Chinese shar pei, Norwich terrier, Saint Bernard, cocker spaniel, Pomeranian, golden retriever, bullmastiff, and German shepherd. There were 17 neutered males (43.6%), 15 spayed females (38.5%), 6 intact males (15.4%), and 1 intact female (2.6%). Mean age on presentation was 8.26 years (±0.56).

The underlying disease requiring permanent tracheostomy in the 39 dogs was laryngeal paralysis in 23 dogs (59%), laryngeal collapse in 7 dogs (18%), laryngeal/pharyngeal mass in 5 dogs (12.8%), tracheal collapse in 2 dogs (5.1%), severe laryngeal edema and inflammation in 1 dog (2.6%), trauma from a dog attack in 1 dog (2.6%), severe laryngospasm post hemimandibulectomy in 1 dog (2.6%), and a snake bite in 1 dog (2.6%). Of these cases, the underlying reason for permanent tracheostomy was both laryngeal and tracheal collapse in one dog, and both laryngeal paralysis and laryngeal collapse in one dog,

Thirty-five owners (89.7%) responded that they were overall satisfied with the permanent tracheostomy procedure and how their pet did postoperatively. Common responses to why they were satisfied included their dog was "like new again," their dog could finally breathe, they enjoyed additional quality time together, and their dogs were more comfortable. Three owners (7.7%) said they were unsatisfied, and one owner (2.6%) was unsure. Reasons for owner dissatisfaction included inability to bark (n = 1), excessive mucus production (n = 1), and recurrent pneumonia and infections at the stoma site in a dog with concurrent megaesophagus (n = 1). The owner who was unsure about their satisfaction level was disappointed the dog was unable to swim.

Thirty-one owners (79.5%) responded that they would have the surgery performed again and recommend it to other pet owners if circumstances arose. Five owners (12.8%) said they would not go through with the procedure again, and three owners (7.7%) were unsure if they would have the procedure performed again. Of those who would not consider the procedure again, two had previously responded that they were unsatisfied with their pet’s outcome and one was unsure. Two owners reported they were satisfied with the procedure but would not have it performed again because they felt their other dogs at home wouldn’t tolerate the aftercare like their first dog (n = 1) and because of the intensive management required for a short survival time in a dog who lived 6 mo after permanent tracheostomy (n = 1). The three owners who were unsure if they would have the procedure performed again reported that they could not respond because the aftercare was more intensive than expected (n = 1), they would have the procedure performed again if their dog was healthy but if the dog had a pre-existing illness they would not (n = 1), and they were unsure because they were still struggling with their original decision (n = 1). One owner who had reported dissatisfaction with the procedure stated they would be willing to have it performed in the future because they would do anything possible to save their dog.

Twenty-seven owners (69.2%) reported that they changed the home environment to accommodate their dog with a tracheostomy, whereas 12 (30.8%) did not. Lifestyle changes included adding a humidifier or air filters in the house (n = 19), avoiding large bodies of water (n = 6), changing bathing techniques to limit water use (n = 2), nebulization of the stoma (n = 2), and keeping the dog inside during hot weather (n = 1), with some owners performing more than one lifestyle change.

Twenty-five owners (64.1%) reported their dog’s personality was the same after tracheostomy, 12 (30.8%) reported it had improved, and 2 (5.13%) reported it was slightly worsened. In dogs in whom the personality change was negative after surgery, one owner reported that recurrent infections were difficult for both them and the dog, and the other said the dog adjusted well but could not participate in his normal activities anymore (but did not elaborate). Sixteen owners (41.0%) reported their dog’s activity level increased, 14 (35.9%) reported that it stayed the same, and 9 (23.1%) reported a decreased activity level after permanent tracheostomy. In dogs with increased activity, seven owners stated their dog was able to be more active. For dogs who maintained the same activity level, three owners specifically stated their dog was already fairly active before surgery. For those who reported decreased activity, four dogs were older than 10 yr and already had a slow activity level prior to surgery; therefore, the owners were not concerned with the decrease. One dog had decreased activity from neurological decline and one had recurrent infections that the owner felt limited his ability to be active. Two owners reported a very limited decrease in activity. One dog was reported to sleep more and seemed too tired to partake in normal activity, and one owner reported that the dog did well at first, but as the underlying disease progressed (neoplasia), the dog’s activity slowed. One owner reported they restricted their dog despite their pet’s eagerness to be active, and one owner said his dog initially had decreased activity but maintained a steady active lifestyle after a revision surgery.

When asked if their relationship with their dog changed, 30 owners (76.9%) reported it stayed the same, 9 (23.1%) reported it improved, and none felt that it worsened. With owners who said their relationship improved, three owners explained it was because their dog was happier, three owners stated that with all the aftercare they were much closer, and two owners were much more protective of their dog after surgery. One owner stated she was less worried because her dog could breathe and they were still able to travel and do things together.

Thirty-two dogs (82.1%) had postoperative complications reported by the owner or the medical record. Major and minor complications occurred in 22 (56.4%) and 29 (74.4%) dogs, respectively. Major complications included skin occlusion of the stoma (n = 8), aspiration pneumonia (n = 7), dyspnea (n = 5), stenosis of the stoma (n = 4), syncope (n = 4), and collapse of the stoma (n = 3). Minor complications included mucus/discharge (n = 26), coughing (n = 17), infection (n = 2), and ring migration not requiring revision (n = 1). When asked if there was a change in the rate of tracheobronchial secretions from the stoma site, 18 (46.2%) owners stated there was a decrease over time at various time intervals. Eight owners stated the amount of secretions never changed, and six owners stated their dog had no to minimal secretions at any time. Decreased secretions were noted within the first 2 wk (n = 9), 4 wk (n = 3), 8 wk (n = 4), 6 mo (n = 1), and 1 yr (n = 1). One owner reported that mucus secretions were minimal initially but then increased significantly at 3 mo post tracheostomy. Twelve dogs (30.8%) required a revision surgery. The two main reasons for revision were skin occlusion (n = 8) and stenosis (n = 4). One owner specifically stated that after the revision surgery the mucus production became much worse, and this led to acute death from obstruction. One owner reported that after the revision surgery their dog’s personality greatly improved and their dog could bark again and felt more comfortable.

Thirty-three dogs were confirmed to be deceased at the time of the questionnaire. In 11 of these dogs (33.3%), the cause of death was related to the permanent tracheostomy, including mucus plugged stoma (n = 3, 9.1%), respiratory difficulty (n = 3, 9.1%), drowning (n = 2, 6.1%), stoma collapse (n = 2, 6.1%), and stoma infection (n = 1, 8.3%). Characteristics of these dogs were compared with complications and owner satisfaction (Table 1). Twenty-one (63.6%) dogs died of unrelated causes including general decline suspected from age (n = 6, 28.6%), neoplasia (n = 5, 23.8%), trauma (n = 3, 14.3%), neurological decline (n = 2, 9.5%), hepatic/prostatic infection (n = 1, 4.8%), septic peritonitis after percutaneous gastrostomy tube placement (n = 1, 4.8%), gastritis (n = 1, 4.8%), and peri-anesthetic death for an unrelated illness (n = 1, 4.8%). In two dogs, the cause of death was unknown (n = 2, 6%). Overall, the MST was 1,825 days (64–2,663), and the six pets who were alive at the time of contact had survival times of 259, 550, 651, 1,254, 1,493, and 1,608 days post tracheostomy.

TABLE 1 Dogs with Cause of Death Related to Permanent Tracheostomy or the Underlying Respiratory Disease Requiring a Permanent Tracheostomy

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Some owners provided additional comments, with eight having a positive view regarding communication of aftercare with permanent tracheostomy and three being disappointed in communication regarding the intensity of aftercare and mucus production. The majority of recommendations from owners of dogs with permanent tracheostomies to owners considering this procedure involved understanding the varied level of aftercare necessary to keep the stoma clear and the responsibility to adjust their dog’s lifestyle as necessary to keep their pet safe and to prevent obstruction or dyspnea.

Discussion

To the authors’ knowledge, this is the first paper to specifically assess owner perception of outcome in dogs with permanent tracheostomies. A large majority (89.7%) of owners were satisfied with having a permanent tracheostomy performed in their dog, supporting the hypothesis that the majority of owners would be satisfied after permanent tracheostomy in their dog.

Few owners saw a negative change in their pet’s personality, activity level, and relationship with the family after surgery, further supporting that dogs who receive permanent tracheostomies can adapt well to their new lifestyle and have a good quality of life. Many of the owners reporting a decreased activity level also commented that their dogs were older and this may have been more related to their age and general health decline than the permanent tracheostomy itself. The most common concerns expressed by owners after permanent tracheostomy were inability to bark and restricted access to large bodies of water. Approximately 60% of dogs lose the ability to vocalize after permanent tracheostomy, which should be discussed with owners prior to undergoing the procedure.²

Based on conversations with the owners, satisfaction with their pet’s outcome after surgery was greatly dependent on their experience with the aftercare. This was heavily influenced by their individual comfort level, as well as how prepared they felt from their interactions at the hospital. Several owners discussed the significant impact thorough explanations and demonstrations from the surgical staff on daily cleaning of the stoma site had on their ability to perform care at home, with many commenting that a demonstration of stoma care, rather than a verbal discussion, was more helpful. Three owners specifically stressed that they felt unprepared for the level of mucus production. Several factors influence mucus secretion, including the underlying disease process, degree of tracheal inflammation, and environmental factors.^2,6 In bypassing the nasal turbinates through the tracheostomy stoma, unhumidified and unfiltered air freely passes to the lower airways, which can lead to contamination, irritation, and increased mucus production.⁶ Immediately after surgery, the tracheal mucosa undergoes squamous metaplasia that leads to increased inflammatory infiltrates and mucus production that persists at a moderate level for at least 2 wk. From 4 to 16 wk postoperatively, the tracheal mucosa gradually returns to normal pseudostratified ciliated columnar epithelium.⁶ Acute death from a mucus plug is a known risk of this procedure; thus, compliance and understanding of the need for stoma care at home is imperative.

The MST for the dogs reported here was 1,825 days, almost 6 times as long as previously reported in dogs.^2–4 In this study, 33.3% of dogs died related to the tracheostomy, which is slightly less than previously reported studies (47%).⁴ In this population of dogs, 7.7% died from a mucus plug of the stoma, which is less than the previously reported 26–43% deaths due to mucus plugs.^4,5 This is difficult to assess in an owner survey, as presence of a mucus plug was not confirmed in all dogs, and more dogs may have died from a mucus plug than was reported. Additionally, questionnaires were only administered if the dog survived longer than 2 wk post tracheostomy; thus, dogs who may have died acutely in the postoperative period from a mucus plug were not included in this study. Only 46.2% of owners reported that tracheobronchial secretions decreased to a steady state over time, compared with previous reports closer to 80%.² This was a retrospective survey; thus, some owners may not have remembered clearly when or if the secretions changed and their interpretation of the amount of mucus was subjective.

Revision surgery was required in 30.8% of dogs, and was most commonly due to skin occlusion of the stoma, which is comparable to previous reports.^2,4 The overall complication rate in this study was 82.1%, which is higher than previously reported (60%); however, minor complications such as mucus production and coughing were included in the present study but were not included in previous studies.^2,4 Mucus production was the most common complication and occurred in approximately 66.7% of dogs. Aspiration pneumonia occurred in 17.9% of dogs post tracheostomy, which is lower than previously reported (23.8%).⁴ Aspiration may occur in these patients due to underlying neurological or esophageal dysfunction, making them prone to aspiration and infection, particularly in cases with laryngeal paralysis.⁷ This could also suggest that mucociliary clearance may not be as efficient as previously thought, that aspirated contents may not be expelled through the stoma site, and proper warning and education about aspiration pneumonia should be provided to owners when discussing postoperative risks.²

This study had several limitations associated with its retrospective nature. Although this was a larger case sample than previous reports, 78 dogs undergoing permanent tracheostomy were identified over a 14 yr period, supporting low prevalence of such a procedure. Only 39 of 69 eligible owners completed the questionnaire. The overall response rate was 56.5%, which is within the range typically seen for interview-survey study designs previously reported in the veterinary literature.⁸ The interview was voluntary, and owners who may have had negative experiences or who were opposed to the surgery may have chosen not to reply. Therefore, it is difficult to determine the exact proportion of owners who were or were not satisfied with their pet’s tracheostomy procedure. Further, the small number of owners who were unsatisfied made statistical analysis of factors associated with these outcomes impossible. Although the primary veterinarian was contacted, cause of death was not confirmed for all dogs and may have been biased by owner interpretation. Deaths were classified into related or unrelated to the permanent tracheostomy, and every attempt was made to classify deaths as related to the tracheostomy if uncertainty was present. Questionnaires are highly subjective in nature, and the time from permanent tracheostomy to contact of the owner was long in some cases; thus, inaccuracies may have been introduced.

Permanent tracheostomy is an uncommon surgical procedure that comes with significant risks and complications due to constant exposure of the trachea to the environment. Owners must be aware that management of dogs with permanent tracheostomies can be intensive, particularly in the first few months following surgery. Dogs can survive many years after permanent tracheostomy with diligent and attentive care to maintain stoma patency. Despite a high complication rate, owners showed a favorable response to their dog’s outcome and emphasized that with appropriate aftercare (as demonstrated by the surgery staff), their dogs were able to maintain a healthy, active, and content lifestyle.

Several owners felt that communication regarding aftercare could have been improved. A common recommendation was to have a demonstration of how to care for the stoma, rather than discussing it abstractly or writing it down on paper. Some owners felt that having pictures of what the stoma should look like would have been helpful for them to reference at home. Thorough communication is required for owners considering this procedure in their dog. Images of previous patients undergoing permanent tracheostomy may be helpful. Many owners recommended explicit instructions regarding what to expect from the procedure, including the inability for their dog to bark or swim. Recommendations for helping to limit mucus production may include keeping the dog in a cool area away from dust, ash, or air contaminants. A loose bandana around the neck may help to limit particle inhalation through the stoma. It is difficult to comment on the use of an air humidifier as some owners felt it didn’t provide a major benefit. Future studies should be performed to evaluate for additional factors that may help to limit the level of mucus production. It may be helpful to identify owners of dogs with permanent tracheostomies who would be willing to talk to owners considering the procedure about the requirements for aftercare.

Conclusion

Permanent tracheostomy is a viable procedure for surgical management of various upper airway diseases. A high percentage of owners are satisfied with their decision to pursue permanent tracheostomy in their dog despite postoperative complications, and survival times after permanent tracheostomy are longer than previously reported.