Protocol written by Dr Kathy:

Newbie Primer:
There is a lot of information, here, and you may have a lot to learn, so please do not be overwhelmed.

A. Here is a BASIC place to start – a through h: expanded, more detailed suggestions below – see E***** :
a – Feed 3-5 small meals per day and hold vertically for 15-30 minutes – NOTHING by mouth, including water or treats, unless held vertically.
b – metoclopromide (reglan) 3 times daily to promote stomach emptying so that material can empty into the stomach from the esophagus, which may help the stomach to empty more quickly. c – If esophagitis is suspected, carafate (liquid is best, but, is pricey, so crushed carafate tablets mixed with water can be used) 1-3 times daily (give 1 hour before or 2 hours after any food or medications).
d – Pepcid or Prilosec 1-2 times daily to minimize acidity of stomach material – this may not be required forever.
e – prescription veterinary low fat diets may be best to start with as many ME dogs can’t tolerate high fat diets
f – Cerenia may help minimize the regurg. Can be given with the metoclopromide (reglan).
g – Because Aspiration Pneumonia often cannot be HEARD, and many dogs with AP do NOT cough, 3-view x-rays are important to rule it out. See #E
#9 below.
h – Learn to administer injections so that if your pet requires medications during an episode of increased regurgitation/vomiting, loss of appetite, etc. many medications can be administered under the skin.

B. Also, please read all of the following:
Each dog with megaesophagus can be different, but, the suggestions that we currently make have been found to be tried and true for most dogs for over a decade. There is no SINGLE management protocol that works for every patient – there is usually trial and error with kind and consistency of food (most do best, at least initially with low fat diets like Royal Canin Lowfat made into a gruel), medications, etc. Please read the following so that we can help you. There are many suggestions below that you may want to discuss with your veterinarian. Many of these dogs can lead fairly normal lives once their ideal management protocol is discovered. Again, many, if not most, of the suggestions we make have been used successfully and SAFELY for many years. There are many management practices that we strongly oppose because of so many reports of negative results.

C Create a signature: If you are joining the yahoo megaesophagus support group (http://pets.groups.yahoo.com/group/megaesophagus/), if you could create a “signature” giving all or your pet’s particulars, and add it to EVERY future post we can help you more. Because there are so many members, here, it is difficult for many of us to remember everything about every pet:
Name (we like knowing the pet’s name)
age
breed
sex (spayed or neutered)
weight
medications including names, frequency and dosage
exact diet and consistency and how fed (for example: Bailey Chair for 20 minutes 3x/d)
diagnosis(es)

D. Most owners come to our yahoo support group and feel “overwhelmed.” Because each pet with megaesophagus can be different, there is trial and error with the feeding and other management techniques. The more that you read, the better. However, there is so much information in our files that that, ALONE, can be overwhelming. 

Here is a list of subjects that would be a good starting place:
Bailey chair (2 folders)
QUICK START management techniques
Esophagitis
Pro-collar elevating head
Medications used in managing Megaesophagus & Myasthenia Gravis
Regurgitation
Megaesophagus information —>a-Newbies information and Diagnosing Megaesophagus
Cervical collar…..
Here are some high points/BASICS, from the support group’s main files, that you may find helpful,

E. *****
1) Feed VERTICALLY and remain so for 20-30 minutes -“Elevated” food and water is not enough. MOST megaesophagus dogs need to be fed and given water, and held VERTICALLY, so that food and water can fall into the stomach. So many newbies try to get by with NOT doing so, only to finally relent when THEIR way doesn’t work. Aspiration Pneumonia is a big risk in these dogs. A “how to build” a BAILEY CHAIR for vertical feeding video or Internet link may be obtained by emailing Donna at matthew1@earthlink.com.

2) Metoclopromide pills or injection, and/or oral cisapride (requires compounding), may promote emptying of the stomach, allowing more space for for food/water to fall into the stomach without resistance (helps most dogs; makes a few dogs worse; ineffective in some dogs).

3) Many of these dogs have ESOPHAGITIS, which requires treatment with oral liquid carafate (one hour before food/medications or two hours after; it binds to many materials, so if given with most food or with other meds, both may be inactive). Additionally, esophagitis is painful, so could be making them restless and miserable.

4) Antibiotic Responsive Gastroenteropathy (ARG/IBD/SIBO) seems to be common in these dogs and to be responsible for increased regurgitation. Treatment with a combination of amoxicillin, amoxicillin, metronidazole and carafate, +/- cerenia, for nausea, or similar combination, for 2-4 weeks, may result in decreased regurgitation.

5) Nausea can be helped with injectable or oral Cerenia, or oral Zofran (may be given subcutaneously, although not labeled for such).

6) Keeping these pets well hydrated, especially if they are bringing up a lot of fluid (causes dehydration). Learning how to administer subcutaneous (under the skin) fluids is a good idea.

7) Many dogs benefit from using an acid-neutralizer (Zantac, Pepcid AC, Prilosec, etc. – NOT Tums or Tagamet) to reduce the acid that refluxes up into the esophagus from the stomach.

8) Having the pet either sleep on an incline with the front elevated and/or wear a Pro-collar (see the files, again) to elevate the head while laying down or sleeping, will also minimize “micro-aspiration” of refluxed material from the stomach..

9) If your pet has aspiration pneumonia (AP), go to http://www.veterinarypartner.com/Content.plx?
P=A&S=0&C=0&A=3471 for info on management. Pneumonia in normal dogs may be treated for a few weeks; it is suggested that dogs with megaesophagus may benefit from 4-6 weeks of antibiotic treatment, or to treat for 2 weeks PAST when 3-view x-rs are clear. Coupage (percussion therapy) can also be helpful – http://www.youtube.com/watch?v=mjPMjlhluQ4

Here is the empirical suggested doses for albuterol (0.83% 2.5 cc vial) administered with a nebulizer,  Note: ALWAYS CHECK WITH YOUR DVM PRIOR TO USE. ALSO, ANYONE IN THE HOUSE WITH A HEART PROBLEM SHOULD NOT BE NEAR THE ALBUTEROL MIST – SALINE IS OKAY :
-over 60# – 3cc (1 vial)
-45-60# – 2.5 cc
-30-45# – 2.0 cc
-20-30# – 1.0 cc (add 1.0 cc sterile saline)
-10-20# – 0.5 cc (add 1.0 cc sterile saline)
-under 10# – 0.25 cc (add 1.0 cc sterile saline)
(or, according to Plumb’s Veterinary Formulary:
-for dogs, 20–50 micrograms/kg PO 2-3 times daily by nebulization via face mask
-for cats, 0.5 mL of 2.5 mg/3 mL soln in 3.5 mL saline by nebulization via face mask 1-4 times daily)

10) If your pet is not eating, or is unable to keep food down, consider placement of a feeding tube SOONER RATHER THAN LATER. Too many owners wait too long. http://www.veterinarypartner..com/Content.plx?P=A&S=0&C=0&A=3504

11) Some owners have reported that treating with bethanechol may help with the motility of the esophagus. It will only help if there is some normal nerve function remaining. Trial treatment can be considered.

12) Sildenafil (Viagra) – has been found to loosen the Lower Esophageal Sphincter (LES) in dogs whose LES is too tight. which may allow material to drain into the stomach from the esophagus more easily.
Consider keeping a journal of what works and doesn’t work, and/or a day by day report to which you and your dvm can refer.
If your dvm belongs to VIN, here is some info available for professionals.
http://betavin.com/members/cms/project/defaultadv1.aspx?id=5269755&pid=5095&catid=&;;;

F. Following is a list of supplies that you may need for managing your pet with megaesophagus (the links below are only if you join/joined the Yahoo group or you can type them into your browser to see the info):
1. BAILEY CHAIR – or some other way of feeding and holding vertically for 20-30 minutes. Best to have one built by someone in your area, so that inevitable adjustments can be made easily. It is better to have a functional, well-fitting chair which your pet will accept and which can be easily modified close to home, than a pretty chair with your pet’s name engraved on it, that is difficult to have someone modify.

Here are some Bailey Chair substitutes that can be used until you do get a Bailey chair:
feeding/sleeping methods:
https://groups.yahoo.com/neo/groups/megaesophagus/photos/albums/1082975248

puppy feeding methods:
https://groups.yahoo.com/neo/groups/megaesophagus/photos/albums/962230155

2. NEBULIZER – To treat or help prevent Aspiration Pneumonia. Nebulizers can be purchased from ebay, Amazon.com, pharmacies and medical supply houses (eg. Binson’s) – nebulizer use, see https://veterinarypartner.vin.com/default.aspx?pid=19239&id=5860662. Ask family and friends if they have one they can lend, especially those who have had a child with asthma, who probably was treated using a nebulizer. When purchased, make sure the medicine cup and tubing are included. We suggest NOT using a travel or handheld model as they can be cumbersome when used with a face mask. Good manufacturers are Pulmonaide, Omron and many others. Steam, as in a bathroom with the shower on, does NOT form small enough moisture particles to get deep into the lungs. It may help the nose, sinuses and trachea, but NOT the lungs.

You will also need a mask to administer either saline and/or albuterol through the nebulizer:
http://www.petoxygenmasks.org/
http://yuckos.com/pet_oxygen_masks.htm
http://www.surgivet.com/pet-oxygen-masks/

You can temporarily use a red Solo drinking cup as a mask, or make one from a plastic cup: https://groups.yahoo.com/neo/groups/megaesophagus/files/Aspiration%20Pneumonia%20-%20Nebulizer%2C%20for%20treatment%20%26%20prevention/
scroll down to the 18th file for how to make a homemade mask.

You may also want to obtain a supply of saline that can be administered with the nebulizer. Do not use saline eye drops in the nebulizer. Your dvm can provide you with a supply, or, you may be able to find saline for nebulizers from a pharmacy. Nebulizer saline can be ordered from Amazon.com.

3. NECK COLLAR – Pet should wear when sleeping. Some dogs need to wear 24/7. Helps to elevate the pet’s head so that material that flows from the stomach into the esophagus when the pet is laying flat, cannot enter the trachea and result in “micro-aspiration.” Barb Lambert has a ministry in which she will make them for dogs with megaesophagus (rustymegae@yahoo.com). Wagtailfarms.com also has neck collars, but, make sure to order the Super Neck Hugs (http://www.wagtailfarms.com/superneckhugs.html). A Pro-collar can be purchased from many pet stores and may be successful for some dogs. Barbara can also provide instructions on how to make a neck collar.

4. THERMOMETER – consider taking and recording your pet’s temperature routinely for a few weeks, so that you know what it’s normal is. Your dvm team can demonstrate the various ways to collect the information. YouTube.com has good examples.

5. Learn to check your pet for dehydration. If you tap your pet’s mucous membranes/gums with your finger and they are tacky like chewing gum, they may be dehydrated.. If they are looking for water, they may be dehydrated. Catch a small sample of urine in a bowl, if it is bright yellow, they may be dehydrated. If the urine is clear or only slightly yellow, they are probably well-hydrated.

G. MEDICATIONS TO CONSIDER HAVING ON HAND:
1. Fluids for subcutaneous administration for when/if pet may be dehydrated. Have your dvm team demonstrate how to give. It is also a good idea, if your pet has frequent episodes of regurgitation, to learn how to administer medications by injection. When your pet is having issues keeping fluids down, the more medications/fluids that can be given by injection and not by mouth, the better.

2. Especially if your pet has had Aspiration Pneumonia (AP) it is a good idea to have a “starter supply” of antibiotics that you may start if you see obvious signs of AP which may be suggested by loss of appetite, increased regurgitation, coughing – note: many megaesophagus pets do not cough when they have AP.

3. Cerenia or Zofran for nausea which may be indicated by loss of appetite, vomiting or increased regurgitaion. Obtain from your dvm. If the injectable is used, it stings, so we suggest giving it into a bleb/bubble of subcutaneous fluids.

4. Albuterol vials for use with a nebulizer. Need a prescription from your dvm. Obtain at pharmacies. Dilates bronchioles. Aids in treating and minimizing Aspiration Pneumonia.

5. Sucralfate (carafate) LIQUID – a “bandage” for esophagitis which can occur due to the reflux of stomach acid into the esophagus. Tablets are less costly, but, the liquid may be more effective.

6. Saline for use in the nebulizer. Obtain intravenous saline from your veterinarian or purchase nebulizer saline from Amazon, etc. DO NOT USE CONTACT LENS SALINE.