6 – RAID NR 1 – 2025 In the first question, eight (89%) mentioned that the endotracheal tube is removed when the horse is breathing regularly, and seven (78%) that a nasal tube is used if the horse is snoring. Six respondents (67%) described that they are prepared to re-intubate if necessary, and four respondents (44%) commented that they usually let the mouth gag stay in the mouth for a little while after extubation. In the second question, seven respondents (78%) mentioned snoring as a common problem. Nasal bleeding and irregular breathing were mentioned by three respondents (33%) respectively. Four respondents (44%) described respiratory arrest when the horse enters the recovery room. Two respondents (22%) mentioned that the nasal tube can fall out from the nostril early in the recovery period leading to difficulties to breath properly during a long period of time before the horse is able to stand up. DISCUSSION AND REFLECTION The overall percentage of horses with respiratory related complications in the recovery was 68%. Compared to the literature, mentioned above, it is high percentage of the horses suffering from airway obstruction. Since the focus of this audit is on how many horses experiencing nasal congestion, the “complication rate” is higher than in the literature, since all horses that received a nasal tube is in the “complication group”. The difficulty of measure morbidity compared to mortality, leads to extremely varied results in the existing studies (Dugdale & Taylor, 2016). The complications were mainly snoring. The origin of the snoring in the horses from the journals is unknown, since the airways had not been examined during the recovery phase. In most cases, the abnormal inspiratory sounds during the recovery period which were heard by the respondents is probably due to nasal congestion since it is the most common complication following extubation of trachea (Auckburally & Senior, no date). There are several factors that predispose the horse for upper airway obstruction, these factors will be described below and discussed whether interventions can be made or not. DURATION OF ANESTHESIA A long duration of anesthesia can predispose the horse for airway obstruction (Auckburally & Flaherty, 2009; Doherty & Valverde, 2006; Laurenza et al., 2020). The study by Laurenza et al. (2020) showed that every additional hour of surgery, the risk of respiratory complications increased by a factor of 1,5. The group with a nasal tube had a median length of 97,5 minutes (ranging 40 to 305), and the group without a nasal tube had a median length of 70 minutes (ranging 20 to 125). The median length differs with almost 30 minutes between the group that required nasal tubes and the one that did not. To minimize anesthetic time, all horses should be clipped and washed prior to induction, as long as the horse tolerates it. Complete preparation of the operation room should also be done before bringing the horse down to surgery. WEIGHT OF THE HORSE Heavy weight of horses is related to an increase in respiratory complications (Auckburally & Senior, no date; Laurenza et al., 2020). In a study by Southwood et al. (2003), it was shown that heavy horses – above all draft horses – were at greater risk of airway obstruction, especially due to laryngeal hemiplegia. The group with a nasal tube had a median weight of 400,5 kg (ranging 125 to 680) while the group without a nasal tube had a median weight of 296 (ranging 80 to 512). The group who required nasal tubes was generally heavier. If possible, heavy horses can be operated standing. However, if that is not possible, these horses should be clipped and washed prior to induction as far as possible to reduce anesthetic time. RECUMBENCY It has been discussed previously that dorsal recumbency increases the risk of nasal congestion since the level of the head is lower than the heart (Doherty & Valverde, 2006; Muir & Hubbel, 2009; Thomas et al., 1987). Elevating the head during anesthesia can help since the severity of congestion is related to the position of the head in relation to the body (Muir & Hubbel, 2009). In the group with a nasal tube, 21/28 (75%) were in dorsal recumbency, and in the group without a nasal tube, 7/10 (70%) were in dorsal recumbency. There was only a slight difference between the two groups, this might be due to the small number of horses included. To get a more reliable result, a higher selection of horses is necessary. Since there was no difference in the results, there will be no intervention proposed in this audit. If, however, horses that had been in dorsal recumbency in greater occurrence tend to be more prone to nasal congestion than those who had been in lateral recumbency, the operation personnel may have to discuss if more surgeries can be made in lateral recumbency. EXTUBATION PHASE Eight out of nine respondents (89%) mentioned that the endotracheal tube is removed when the horse is breathing regularly. This is confirmed as an acceptable approach by Doherty and Valverde (2006). The endotracheal tube can also be removed once the horse swallows, or be left in place until the horse stands (Clark-Price, 2013), which they generally tolerate well (Doherty & Valverde, 2006; Wagner, 2009). This, however, is not mentioned by any of the respondents. There are some risks associated with recovering with an endotracheal tube – the horse may bite the tube and complete airway obstruction may occur if the tube gets kinked or if the horse pushes its head in the corner (Auckburally & Senior, no date). Placement of a nasal tube during the recovery period reduces the incidence of airway obstruction (Doherty & Valverde, 2006; Wagner, 2009). Despite that, complications may occur when using it. Nasal congestion of the upper airways can make it difficult to get the nasal tube in place (Muir & Hubbel, 2009). If the tube is forced into the nostril, it can not only cause damage to the structures in the upper airways, but also cause nasal bleeding, which can be aspirated and lead to pneumonia (Doherty & Valverde, 2006). Nasal tubes are also snorted out easily early in the recovery phase, which may leave the horse with airway obstruction (Auckburally & Senior, no date).
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