64 | How to confidently manage laryngeal paralysis as a vet nurse

PodcastRespiratory
Written By Laura Jones

If you’ve ever seen an older Labrador struggling to breathe, a Retriever making that distinctive “roaring” noise, or an older dog with noisy breathing and vocal changes, there’s a good chance you’ve encountered laryngeal paralysis.

 

This disease - as the name suggests - affects the larynx, preventing it from opening properly and restricting airflow. In mild cases, it causes noisy breathing and exercise intolerance, but in severe cases, it leads to life-threatening respiratory obstruction.

But what else do we need to know about laryngeal paralysis? How can we stabilise these patients in an emergency, treat them effectively, and provide that all-important nursing care? That’s exactly what we’re covering in today’s episode.

So what IS laryngeal paralysis?

Laryngeal paralysis (or “LarPar”) occurs when the nerves controlling the muscles of the larynx progressively deteriorate. 

The larynx is made up of 6 paired cartilage structures connected and controlled by muscles and ligaments. It is attached to the first tracheal ring and guards the entrance to the trachea.

The main pair of cartilages you need to know about in LarPar patients are the arytenoids. These cartilages are the ones we see when intubating a patient and insert our ET tube through, and they’re also the ones that can’t move normally in cases of laryngeal paralysis.

In LarPar, the arytenoids can’t open properly during inspiration, meaning that the airway remains closed and airflow into the lungs is restricted as a result.

The degree of airflow restriction depends on several factors, including the severity of the paralysis and whether the patient has one or both arytenoids affected (i.e., unilateral or bilateral disease).

Ok, so that’s what laryngeal paralysis is. But which patients do we see it in, and what causes it?

LarPar is common in dogs and very rarely seen in cats - so we’ll focus on canine disease in this episode. It can be congenital or acquired in origin, with acquired disease seen more commonly. It’s most commonly seen in large-breed, older dogs - especially Labradors and Golden Retrievers. It’s also reported 2-4 times more frequently in male dogs compared with females.

Congenital disease is reported in Huskies, bull terriers, White-coated German Shepherds, and Bouvier de Flandres. Additionally, genetic predispositions to LarPar have been identified in several breeds, including Alaskan malamutes, Dalmatians, Rottweilers, Leonbergers, and Pyrenean mountain dogs. Many of these breeds can inherit polyneuropathies that cause laryngeal paralysis, among other neuromuscular signs.

The vast majority of LarPar cases are acquired, with neuromuscular diseases, cervical masses, and traumatic (including surgical trauma) and idiopathic causes reported. Many of these patients have LarPar as part of a broader progressive neuromuscular disorder known as Geriatric Onset Laryngeal Paralysis and Polyneuropathy (or GOLPP).

What signs do we see in these patients?

Laryngeal paralysis progresses gradually, but signs become more noticeable as airflow becomes increasingly restricted. Patients typically present with signs including:

  • Exercise intolerance, particularly in warm weather

  • Decreased activity level

  • Vocal changes (as the vocal folds are within the larynx, these can also be affected, causing a weaker or hoarser bark)

  • Coughing

  • Ptyalism (hypersalivation)

  • Gagging and dysphagia (as the cartilage and muscles that control swallowing may be affected)

  • Inspiratory stridor (an abnormal upper respiratory noise heard on inspiration, often described as a musical or ‘roaring’ sound)

In severe cases, patients will also present in respiratory distress, with signs such as collapse, severe inspiratory stridor and obstruction, hypoxia and even cyanosis reported.

Some patients may also present with wider neuromuscular signs or signs of a specific underlying disease, for example, generalised weakness in polyneuropathy patients, or signs of hyper/hypothyroidism in patients with thyroid neoplasia.

Our priority is stabilising the emergency LarPar patient - so how will we do this?

We know that laryngeal paralysis can be life-threatening when these patients present in acute respiratory distress or have severe obstruction. Usually, the classic time we see this is in the summer when a patient collapses due to the impact of heat and exercise on their pre-existing disease. So how will we stabilise them?

With OSCA: oxygen, sedation, cooling and airway protection.

Our priority in these patients is to prevent hypoxaemia, stress, hyperthermia and obstruction. So when we’re stabilising them, we need to:

  • Provide oxygen therapy through an appropriate method (whilst minimising stress)

  • Administer sedatives or anxiolytics as necessary to keep these patients calm (as we know that stress exacerbates respiratory distress)

  • Keep them cool - Many of these patients cannot thermoregulate effectively as their ability to pant is reduced, so they require active cooling.

  • Protect their airway. If severe obstruction occurs, these patients will need emergency intubation or, in severe cases, tracheostomy. Always have emergency equipment available!

Once these patients have been stabilised, we need to diagnose them - and nurses and technicians are instrumental in this process.

Though diagnosis is usually straightforward, it can be risky, so we need to be ready to intervene in an emergency.

We diagnose LarPar based on a combination of the patient’s clinical signs and physical examination, alongside a laryngeal examination and other testing where required.

Laryngeal examination is performed under a light plane of anaesthesia. It’s essential we avoid heavy sedative doses during this process, as this can also affect laryngeal movement. ACP has been associated with decreased laryngeal movement, as has methadone in some studies. Whilst no conclusive evidence exists around the perfect anaesthetic protocol in these patients, we do know one thing: the patient should be only as asleep as is needed to allow visualisation, with induction agents administered slowly to avoid associated apnoea.

We also know that this is a high-risk time for these patients - they’ll have received anaesthetic agents causing cardiorespiratory depression, and have a reduced ability to ventilate effectively. Always monitor SpO2 and provide flow-by oxygen during this time, and be ready to intubate if needed.

What other tests might these patients need?

As well as a laryngeal examination, these patients often require general bloodwork and urine analysis to investigate general body function and look for concurrent diseases, alongside thyroid function testing (as there is a link between hypothyroidism and laryngeal paralysis) and thoracic radiography (to look for secondary aspiration pneumonia).

Many patients also require neuromuscular testing to diagnose polyneuropathies or GOLPP.

Ok, so you’ve diagnosed your patient. What next?

Surgical treatment and medical management are both options for LarPar - and whilst it isn’t always an emergency, surgery IS required for patients with moderate-to-severe disease or bilateral disease.

This is achieved using a procedure called arytenoid lateralisation, aka a ‘tieback’ procedure.

A tieback surgery involves suturing one or both of the arytenoid cartilages open to improve airflow. Whilst these patients typically show a dramatic improvement in ventilation post-operatively, they are at risk of complications such as airway oedema, inflammation and swelling, risking airway obstruction in the acute postoperative period.

Another vital complication we must be aware of when caring for these patients is aspiration pneumonia. Aspiration is the most common complication noted in these patients, occurring in up to 21% of surgical cases.

Patients are at permanent risk of aspiration pneumonia following surgery, though this risk is highest in the first few weeks. Patients with GOLPP, concurrent megaoesophagus or concurrent oesophageal dysfunction are at highest risk.

And how will we nurse these patients?

Whether managing these patients in an emergency, postoperatively, or long-term, as nurses and technicians we play a huge role in their care. Here’s what we need to focus on:

In the emergency setting

  • Minimise stress and handle these patients calmly

  • Ensure oxygen support is available

  • Have emergency intubation equipment on hand in case of respiratory collapse or upper airway obstruction

  • Monitor temperature closely and actively cool your patient if needed.

Following surgery

  • Monitor the patient closely, particularly their respiratory rate, pattern and effort for signs of obstruction or aspiration

  • Keep the patient calm, since stress and excitement can lead to panting/vocalisation and airway swelling

  • Feed the patient carefully, from a height, slowly to reduce aspiration risk.

How will we manage these patients long-term?

Not all patients require surgery, and some may be managed medically. Client education is crucial for these cases - and we know how essential veterinary nurses and technicians are in providing this. Areas to discuss include:

  • Weight management - keeping the patient at a healthy bodyweight and ideal BCS.

  • Avoiding excessive heat and stress - these patients overheat quickly, so encourage clients to exercise them in cooler conditions.

  • Using a harness instead of a collar - this helps avoid pressure on the trachea.

  • Monitoring for complications like aspiration.


Laryngeal paralysis is a progressive, potentially life-threatening condition, but with early recognition, proper stabilisation, and appropriate treatment, we can significantly improve these patients’ quality of life. And just like so many of our other medical conditions, nurses and technicians are vital in every step of this process, from emergency care to long-term management and client education.

Did you enjoy this episode? If so, I’d love to hear what you think. Take a screenshot and tag me on Instagram (@vetinternalmedicinenursing) so I can give you a shout-out and share it with a colleague who’d find it helpful!

Thanks for learning with me this week, and I’ll see you next time!


References and Further Reading

Laura Jones
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63 | BOAS patients: How to manage them successfully as a vet nurse