Brachycephalic Dogs: What it Means and How to Handle it

Brachycephalic dogs or Brachycephalic animals have a skull conformation that develops mainly in width rather than length.
They can have problems with various organs, which is good to know so as not to underestimate their importance. Let's examine them and determine their specific needs.

Brachycephalic dogs: what does it mean?

Brachycephaly refers to a particular bone constitution, a skull conformation that develops in width (towards the ears, for instance) rather than length (towards the tip of the nose).

The quintessential brachycephalic dog is the Pug and French Bulldog, which have the flattest snouts and are therefore called extreme brachycephalic.

Other brachycephalic dog breeds are:

• Cane Corso
• English Bulldog
• Neapolitan Mastiff
• Dogue de Bordeaux
• Boxer
• Shar Pei
• Shi-Tzu
• Cavalier King Charles Spaniel
• Boston Terrier 

Their funny, baby-like expression has made them particularly famous and popular worldwide. It is not so much the size that is decisive in the severity of the problem, but the shortness of the nasal passage.

The shorter their nasal passage, the more serious the problems.

This malformation leads to several consequences involving the first airways:

• Exuberant mucous membranes inside the nose – the internal mucous membranes are the same length as if contained in a ‘normal’ nose
• Stenotic (i.e. not open) nostrils – a frequently occurring anatomical feature that further complicates the airless condition
• Elongated or thick soft palate – that mucous membrane that continues the bony palate towards the tail (caudally) and, being too long, interferes with breathing, swallowing and normal function of the whole pharynx

Other problems these dogs may have are:

• Dermatological issues – recurrent paw dermatitis, nose creases
• Respiratory problems – frequent wheezing, heat stroke and hyperthermia even in average temperatures
• Recurrent allergies
• Gastrointestinal problems – due to respiratory effort
• Eye problems – as the eye lobe protrudes from the bone, it is more susceptible to trauma.
• Childbirth problems – the head is often too big at birth, which does not allow natural childbirth but necessitates planned caesarean sections to preserve the mother’s health. As a result, she, during labour, may become breathless and suffer.
• Dental problems – pronounced prognathism is a further congenital disability that can frequently occur in these dogs.

This anatomical diagram highlights the compressed airways and elongated soft palate typical in brachycephalic breeds like French Bulldogs, contributing to breathing difficulties and other health issues.

How to handle brachycephalic dogs: what does it mean?

Being a dog owner with a flattened snout is a great responsibility, as it implies the need to be aware of the pathologies they are more prone to than others.
Brachycephaly is considered an anatomical anomaly, especially when it is extreme, as dogs are born with an inefficient respiratory system. The following is a list of more or less serious situations they may encounter most frequently

Respiratory problems (Brachycephalic Syndrome – BAOS)

This video represents the difference in conformation between a dolichocephalic (long-snouted) dog and a highly brachycephalic one.

BAOS (upper airway obstructive syndrome) is caused by the conformation of the head's skeleton, which causes the mucous membranes of the first airways to become packed and thus unable to function correctly.

The parts involved with related malformations are:

• Stenotic nostrils (the shape of the nostrils, whether they are open or stenotic, i.e. closed),
• Undersized nasal conchae, resulting in an exuberant nasal mucosa (exuberant turbinates),
• Elongated soft palate,
• Trachea with a reduced diameter (hypoplastic trachea).

 

These malformations are genetically transmissible. If you think it’s false, look at this photo of the English Bulldog’s head modified over the last 50 years.

A consequence of these malformations is degenerative phenomena, mainly due to the respiratory effort that the animal has to make.

The air in the inspiratory passage is not linear. Instead, it creates turbulence with continuous sucking effects that, against the cell walls of the mucous membranes, become inflamed by swelling or losing tone. All situations can only worsen the already difficult breathing.

The complications of incorrect confirmation are thus:

• Eversion of the laryngeal sacculi (small anatomical parts next to the larynx that become inflamed and further occlude the laryngeal lumen.
• Laryngeal collapse.
• Tracheal collapse.

The more extreme the conformation, the sooner and with greater severity the problems manifest themselves, which must and can be assessed in stages (we speak of staging) of different severity. The truth is that this syndrome is not static.

Brachycephalic dog. What symptoms suggest BAOS in a dog?

It depends on the severity of the situation, and the most frequent are

• Intolerance to movement, with disorientation even after a few steps or a simple run
• Increased susceptibility to heat stroke
• Frequent reverse sneezing
• Breathing noises
• They were snoring at night
• Cyanosis
• Syncopes
• Collapse

Reverse sneezing

Reverse sneezing is complicated, noisy and hurried breathing that can last a few seconds to a few minutes. Instead of sneezing and expelling what bothers them, the dog inhales forcibly.
It is usually frequent in subjects with frequent irritation of the first respiratory tract.

It is a condition that worsens and progresses over time, especially if action is not taken to correct and help the passage of air in time. If they are sporadic, they are not symptoms of a problem, but it is good to investigate the cause if they are frequent conditions. When they happen, try to calm the dog by gently stroking his throat.

The brachycephalic dog also suffers from shortness of breath and snoring

Laboured and noisy breathing is typical of these dogs. Snoring is not necessarily indicative of a problem. Still, we must assess the correct constitution of the first airways to see whether the soft palate should be surgically reduced and thinned.

In addition to being long and protruding in the larynx, it is often too thick, which can severely interfere with breathing and cause nostril stenosis.

This visual comparison illustrates the progression of nostril stenosis across three brachycephalic breeds. As the nostrils narrow, from open to severely stenotic, breathing becomes increasingly complex, underscoring the respiratory challenges these dogs often face. Source: researchgate

A brachycephalic dog is also prone to heat and heat stroke

High temperatures are the natural enemy of brachycephalic dogs, who cannot cool themselves through breathing effectively and can more easily suffer heatstroke and hyperthermia.

For this reason, they should not be left in excessively hot or humid environments without adequate ventilation and cooling. In addition, it is good to remember that they may also go into apnoea simply because of agitation or breathlessness. In this case, the dogs may faint.

Some extreme brachycephalic dogs even faint if they are having a party because their owner comes home. All these situations lead to severe discomfort for the dog, which will then undergo surgery to make its first airways. The fainting spells are, in fact, due to the temporary absence of oxygen that causes breathlessness.

A brachycephalic dog suffers from poor digestion.

The gastroenteric apparatus of the brachycephalic is more delicate than that of others for two reasons:

• Poor oxygenation of the tissues does not allow a correct metabolism in general and, therefore, digestive metabolism.
• The respiratory effort during inhalation causes an internal pressure opposite to the physiological one, leading to gastritis, intestinal inflammations, and more or less severe gastroenteric symptoms.
• For this reason, the brachycephalic dog has, more than others, the need to be fed an adequate, correct, and high-quality diet to allow the organism to expel as little waste as possible.

Ocular pathologies

The eyes of these dogs are more at risk of ulcers and dryness than those of other dogs.
They are more exposed to the bulb, which consequently is less moistened by the tear film distributed each time the animal closes its eyelids. In addition, their more significant bulges lead to more frequent eye injuries.

If the skin on the nose is very thick, it can come into contact with the eye, causing severe discomfort for the animal. Therefore, surgery to remove the excess skin is essential.

Nose fold dermatitis

The nose wrinkles of Bulldogs and Pugs are notorious for being delicate parts that need special care.
The reason is that the area is often wet with saliva and soiled with food.
In addition, the skin is thick and heavy and, being ample, forms a fold that can quickly become inflamed due to continuous rubbing.
To remain healthy, they must be

• Clean
• Moisturised
• Dry

Keeping the dog as healthy as possible is necessary, but it should be cleaned with mild detergents that moisturise the skin.

In addition, aggressive disinfectants are always inadvisable as they eliminate the excellent skin bacterial flora that keeps the skin healthy. Grooming brachycephalic dogs is integral to caring for these cute, furry creatures.

Brachycephalic dog. How do we assess whether there are problems in the brachycephalic dog?

Let’s observe the nostrils: First, follow our dog’s nose from the front. As you can see from the photo below, there are different degrees of nostril closure.

This grading system helps assess the severity of nostril stenosis in brachycephalic dogs, ranging from Grade 1 (widely open nostrils) to Grade 4 (almost completely closed). Early identification of these levels is vital for managing breathing issues and planning potential surgical interventions. Source: pethealthcare

Nostril stenosis is a predisposition to brachycephalic syndrome.
Especially in the French bulldog, moderate and severe stenosis of the nostrils predisposes to the syndrome, with a 20-fold higher incidence than usual. [Source]

Air that cannot pass smoothly (because of animal strains) through the nostrils creates turbulence inside the nasal cavities, inflaming the congested mucous membranes.

Brachycephalic dogs. Stress assessment grades. But how do we assess whether it is appropriate to intervene?

This series of images demonstrates the impact of surgical correction for stenotic nostrils, a common issue in brachycephalic dogs like the French Bulldog. The "Pre-surgery" view highlights significantly narrow nostrils, a characteristic anatomical malformation contributing to Brachycephalic Obstructive Airway Syndrome (BAOS). The "Surgery this side only" image shows the immediate improvement in nostril size after one side has been operated on, allowing for better airflow. Finally, the "Post surgery" image illustrates both nostrils widened, which significantly facilitates breathing and reduces respiratory effort, a crucial intervention to improve the quality of life for brachycephalic breeds. Source: Melbourne Bulldog Clinic.

Here is another image that might help you. In this picture, one side has been opened, and the other still needs surgery. You can see how the dog can breathe in more air with each breath and how aesthetically pleasing it is.

The total size of the truffle (nose) should consist of three parts.
If the distance between the two nostrils and the inner septum is less than a third, the nostrils are too close and require surgery.

Brachycephalic dogs. Stress assessment grades

This test should be performed by an experienced veterinarian, but you could also do it independently (at least for some preliminary assessments).

The stress test subjects the subject to three minutes of movement at a trot.

Dogs that are already in a complicated respiratory situation at rest should not be tested. Particularly if they have already presented episodes of syncope, and/or cyanosis.

These parameters are observed before and after the exercise in all other cases.

• Presence or absence of respiratory noise (RN)
• Presence or absence of inspiratory effort (IE)
• Presence or absence of respiratory difficulty (D Dyspnoea), Cyanosis/ (C congestive gums and mucous membranes), Syncope (S fainting).

From the evaluation, you can have four situations that I have summarised in this diagram, taken from the Department of Veterinary Medicine, University of Cambridge’s Brachycephalic Obstructive Airway Syndrome (BOAS) Research.

Functional Grading of BOAS
(Veterinary examination instructions)

This table illustrates the functional grading system for Brachycephalic Obstructive Airway Syndrome (BOAS), a critical tool for assessing the severity of respiratory issues in brachycephalic dogs. The grading, from Grade 0 (no alteration of parameters) to Grade III (intense alteration of parameters), considers respiratory noise, inspiratory effort, and the presence of dyspnoea, cyanosis, or syncope, evaluated both at rest (Pre-ETT) and after a three-minute trot exercise (Post-ETT). This systematic assessment helps veterinarians determine the extent of the syndrome and guide appropriate management or surgical interventions to improve the dog's breathing and overall well-being.

The conditions that may occur are divided into four grades depending on whether or not these parameters are present:

• GRADE 0: no alteration of parameters
• GRADE 1: slight alteration of the parameters
• GRADE 2: moderate to severe alteration of parameters
• GRADE 3: Intense alteration of parameters

Respiratory noises are assessed by laryngeal-pharyngeal auscultation and are considered to be

• Mild: if audible only through auscultation (with phonendoscope)
• Moderate: if intermittently loud, even without an instrument
• Severe: always noisy, even without an instrument

Respiratory effort is considered abnormal when there is evidence of an increase in the forces required to inhale through the use of the diaphragmatic musculature and accessory muscles of the nostrils.

This parameter is therefore considered.

• Slight: when the use of the diaphragm for breathing is everyday and minimal
• Moderate: when the use of the diaphragm and accessory muscles is evident
• Severe: when the use of the diaphragm and accessory muscles is very marked

Dyspnoea is a situation in which the dog struggles to breathe. It demonstrates this by becoming agitated and having all the air hunger attitudes (gagging, diaphragmatic breathing, mouth wide open, front legs extended).

It is considered:

• Mild: when there are signs of agitation
• Moderate: when, in addition to frenzy, breathing becomes irregular
• Severe: when there are also signs of respiratory distress

Syncope and cyanosis are already extreme conditions if they occur at rest.
Subjects whose owners have reported witnessing these episodes should be considered without doing the grade 3 test.

Brachycephalic dogs. Instrumental diagnoses of the brachycephalic syndrome.

After assessing the nostrils and performing stress tests, performing instrumental tests highlighting the first airways’ internal conformation is helpful.

An initial X-ray examination can highlight the trachea's conformation, which, unfortunately, presents a very narrow lumen compared to what is expected in many subjects.

This condition can occur throughout the airway or at the point where air enters or leaves the throat or enters the lungs.

This malformation is typical of English Bulldogs and worsens with time due to respiratory effort. The consequence is the collapse of the trachea, whose cartilage loses tone and droops.

The examination that can highlight the presence of major malformations is endoscopy and laryngoscopy.

This examination can show several pathological situations:

• Excessive length of the soft palate
• Thickening of the tongue base and surrounding mucous membranes
• Eversion of the laryngeal saccules
• Laryngeal structure and function (must always take the evaluation of the possible presence of laryngeal paralysis into account for the outcome of any surgical intervention)
• Laryngeal collapse.

Rhinoscopy can also be performed to highlight the presence of possible nasal obstructions caused by excessive packing of the nasal turbinates, which prevents air from passing into the nasal cavities.

Prevention of respiratory syndrome in the brachycephalic dog.

If you have a purebred or cross-breed dog with a brachycephalic conformation, the best thing you can do is to have it evaluated as a puppy by a vet experienced in this condition.

If there is anatomical evidence of an elongated soft palate and stenosis of the nostrils, a surgical correction of the parts is certainly worthwhile, even if there are no pathological symptoms, which can be carried out as early as 6 to 8 months of age.

Why operate on dogs for brachycephalic syndrome even if it has no symptoms?

You might ask yourself whether you should operate on your dog if he has no problems.

The answer is quite simple.

• First, surgery on a healthy animal reduces the possibility of intra- and post-operative complications.
• Secondly, the disease worsens with time, especially if the first airways are not previously cleared.
• Thus, the longer one waits to reduce the soft palate or open the nostrils, the sooner the anatomical changes in the larynx, turbinates and tracheal cartilages will manifest themselves.
• These manifestations may also be present without real symptoms being evident to the owner, who may realise the problem too late.
• Intervening on an already compromised anatomy reduces the effectiveness of the intervention. Although it improves the patient’s quality of life, it does not succeed in resolving the problem; it only slows down its progress.
• Waiting for the pathology to be in place increases the risk of anaesthesia.
• The state of reduced oxygenation (hypoxia) that inevitably sets in with the pathology increases the risk of the onset of all those related pathologies (gastroenteric, cutaneous, cardiovascular, metabolic), drastically worsening the patient’s life.

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