Why Pugs Are the Worst: Is Brachycephalic Syndrome Allegedly to Blame?
A veterinarian breaks down what the largest UK study of pug health actually measured, from the 54-fold airway risk to the conditions pugs are protected against, plus the practical changes that make the biggest difference to a pug you already own.
BVMS, MRCVS
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Pugs are not the worst dogs. They are affectionate, comic, tolerant of children and, by the numbers, less likely than most breeds to have aggression recorded by a vet. What is genuinely wrong with pugs is anatomical, and the clinical name for the core of it is brachycephalic syndrome: the flattened skull that gives the breed its face also gives it an airway too small for the head it sits in.
I have spent a lot of consultations explaining brachycephalic syndrome to owners who were told their dog's snoring was just a pug thing. It usually is not. This piece sets out what the largest UK study of pug health actually measured, how to tell normal breed noise from a dog in trouble, and the handful of changes that make the biggest difference to a pug you already own.
If you are deciding whether to buy one, the evidence below should give you pause. If you already have one, none of this is a reason to feel guilty, and most of it is manageable.
- 1A UK study of 4,308 pugs found they had 1.86 times the odds of at least one recorded disorder in a single year compared with other dogs.
- 2The largest single risk is brachycephalic obstructive airway syndrome, at roughly 54 times the odds of non-pugs.
- 3The same study found pugs were significantly LESS likely to have heart murmurs, fatty lumps or aggression recorded.
- 4Heat is the most preventable serious risk a pug faces. Flat-faced dogs cannot cool themselves efficiently by panting.
- 5A harness rather than a collar, a lean body weight, and dry skin folds are three of the changes an owner directly controls. The full list is at the end.
Two kinds of information follow: the evidence on what pugs are actually at risk of, and the practical changes that reduce that risk. If you do only one thing after reading this, walk your pug on a padded body harness rather than a collar. The airway is already the narrowest part of a pug, and a collar loads every pull straight onto it. The evidence comes first below, then each fix in full.
A padded, reflective no-pull harness that spreads leash pressure across the chest instead of the throat, the switch most vets recommend for a dog with a cough, a collapsing trachea, or any airway irritation so the leash never presses on
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The 23 disorders pugs are more likely to get
The best evidence on pug health problems comes from a 2022 VetCompass study run by the Royal Veterinary College. O'Neill and colleagues compared 4,308 pugs against 21,835 non-pugs drawn from 905,544 dogs under UK primary veterinary care, then modelled the odds of the 40 most common disorders. It remains the largest and cleanest comparison available, and it is the source most other pug health pages are quoting second-hand.
The headline is blunt. Pugs had 1.86 times the adjusted odds of being diagnosed with at least one disorder in a single year (95% confidence interval 1.72 to 2.01). They carried higher risk for 23 of the 40 disorders examined and lower risk for only seven.
These are the odds ratios that matter most. An odds ratio of 13 means the odds of that diagnosis were about thirteen times higher in pugs than in other dogs during the study year. It is a comparison of relative risk across a population, not a prediction about your individual dog.
| Disorder | Odds vs non-pugs | What it means in practice |
|---|---|---|
| Brachycephalic obstructive airway syndrome | 53.92x | The airway itself. Noisy breathing, exercise intolerance, heat risk |
| Stenotic nares (narrowed nostrils) | 51.25x | Visible pinched nostril slits. Often surgically correctable |
| Corneal ulceration | 13.01x | Painful eye surface damage. Prominent eyes are exposed |
| Skin fold dermatitis | 10.98x | Infection inside the face and tail folds |
| Ear discharge | 9.60x | Narrow ear canals trap moisture and wax |
| Allergic skin disorder | 5.90x | Chronic itching and recurrent skin infection |
| Demodectic mange | 5.60x | Mite overgrowth, often linked to immune function |
| Retained baby teeth | 4.30x | Crowded jaws hold deciduous teeth too long |
| Obesity | 3.89x | Compounds every other problem on this list |
Look at the top two rows together. Stenotic nares and BOAS are not separate misfortunes, they are the same anatomical problem measured twice, and they dwarf everything else in the VetCompass study. Almost every other pug health problem on that list is either downstream of the flat face or made considerably worse by it: the eye conditions, the skin fold dermatitis, the ear disease and the dental crowding are all consequences of the same skull shape, which is why pug health issues cluster the way they do rather than appearing at random.
One caveat on reading any odds ratio. These figures describe how much more common a diagnosis was across a population of pugs in one year of UK veterinary records. They do not tell you that your dog is 54 times certain to develop anything, and a well-conformed pug with open nostrils sits in a very different place on that distribution from a severely flat-faced one. Treat the table as a map of where the risks concentrate, not as a forecast.
What the same study found pugs are protected against
This part almost never gets quoted, and leaving it out misrepresents the paper. Pugs were significantly LESS likely than other dogs to be diagnosed with several conditions, and one of them says something real about the breed's temperament.
- Heart murmur: odds ratio 0.23, so roughly a quarter of the odds seen in other dogs.
- Lipoma, the common benign fatty lump: odds ratio 0.24.
- Aggression: odds ratio 0.31. Pugs were recorded with aggression at about a third the odds of other dogs.
- Wounds: odds ratio 0.53, which likely reflects a small indoor dog that does not fight much.
The aggression figure is worth sitting with. The pug's temperament is genuinely, measurably good, and that is exactly why the breed keeps selling despite everything else in this article. The authors' conclusion was not that pugs are bad dogs. It was that "the Pug has diverged to such an extent from mainstream dog breeds that the Pug breed can no longer be considered as a typical dog from the perspective of its disorder profile."
Symptoms of brachycephalic syndrome in pugs
Brachycephalic syndrome is a stack of anatomical faults that all restrict airflow. Not every pug has all of them, and severity varies enormously between individuals with the same flat face.
- Stenotic nares: nostrils narrowed to slits rather than open ovals, so air struggles to get in at the very first step.
- An elongated soft palate: the soft tissue at the back of the roof of the mouth is too long for the shortened skull and hangs into the airway.
- Everted laryngeal saccules: small pouches near the voice box get sucked into the airway by years of straining, narrowing it further.
- A hypoplastic trachea: a windpipe narrower than it should be for the dog's size.
The pug nose is where you can assess your own dog in about five seconds. Look straight at the nostrils in good light. If they are thin vertical slits rather than open rounded holes, your dog is doing all of its breathing through a straw. That single observation predicts a lot about the rest of the pug face and how hard the airway is working.
The signs owners report are snoring at rest, snorting, gagging or retching, a rasping noise on the inhale, needing to stop on walks, sleeping with the head propped up or the neck extended, and blue-tinged gums or collapse in the worst cases. Many pugs also swallow a lot of air while eating, which causes burping, flatulence and reflux. Do pugs have breathing problems as a rule? Most have some degree of it, and the question is how much.
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Feeding is one small lever here. A pug that gulps its food while fighting for air swallows a great deal of it, so a raised bowl that brings the food closer to head height genuinely reduces the burping and reflux in some dogs. It does not fix the airway. It just stops you making it worse three times a day.
Use a harness, never a collar
This is the single easiest change to make today, and it is the kind of practical detail most pug health articles leave out entirely. If you take one thing from this article, take this one. A collar puts every ounce of pulling force directly onto the front of the throat, which on a pug is already the narrowest part of a compromised airway. A harness moves that load onto the chest and ribcage, where it belongs.
Harness fitting matters more than harness brand. You want the front strap sitting across the breastbone rather than riding up against the throat, and you want to fit two fingers flat under any strap without forcing them. A padded no-pull harness spreads the load over a wider area, which is what you are actually paying for, though a simpler padded design does the same job on a dog that does not pull hard. Our guide to choosing a dog harness covers fitting in more detail.
- A flat collar is still the sensible place for ID tags and a licence disc. The rule is not that pugs cannot wear collars, it is that nothing should ever pull against a pug's throat.
Are pugs in pain, or is this just how they sound?
Brachycephalic dogs are not usually in sharp pain from breathing, but many live with chronic breathing distress, which is its own welfare problem. The honest framing is that a lot of what owners have been taught to read as pug character is actually a dog working hard to get enough air, and the breathing effort required is the thing to watch.
A useful test is what the dog does when it wants to rest. Dogs that prop their chin on something, sleep sitting up, lie with the neck extended, or wake repeatedly through the night are managing an airway, not being endearing. This under-reporting has been measured. Packer, Hendricks and Burn, writing in Animal Welfare in 2012, found that 58 percent of owners whose dogs showed frequent, severe breathing signs still reported that their dog did not have a breathing problem, because they had absorbed the idea that it was normal for the breed.
Learning to recognise a breathing emergency is the most useful thing an owner of a flat-faced dog can do. Blue, grey or purple-tinged gums mean the dog is not getting enough oxygen. Breathing that stays laboured after several minutes of complete rest, collapse, fainting, or a dog that cannot settle and is panicking are all reasons to go straight to an emergency vet rather than wait. Heat makes every one of these dramatically more likely, so the same signs in hot weather are more urgent still.
- Blue, grey or purple-tinged gums or tongue. Collapse or fainting. Breathing that stays laboured after several minutes of rest. Choking or an inability to settle. Any of these in a flat-faced dog is an emergency, and heat makes all of them more likely.
Do pugs eyes really fall out?
This is the question people actually search, and the answer is that the eye does not fall out, but it can come forward out of its socket and become trapped there. Owners who ask whether pugs eyes pop out are describing something real. The clinical term is eye proptosis, and in a pug it can happen from surprisingly minor trauma: a scuffle with another dog, a hard pull on a collar, sometimes rough handling around the head. It is uncommon, but it is a true emergency vet situation when it happens.
The reason is structural. Selecting for a flat face shortened the bones that would normally form a deep eye socket, so a pug's eye sits proud of the skull with far less protection than a longer-muzzled dog has. That same exposure is why corneal ulceration came in at 13 times the odds of other dogs in the VetCompass data.
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For day-to-day eye care, the job is keeping the surface lubricated and the surrounding area clean. A veterinary eye lubricant helps dogs whose eyes dry out because the lids do not fully close, and sterile eye wash pads keep the fold beneath the eye clean. Ask your vet which is appropriate before starting, because a red or painful eye needs examining rather than lubricating.
- If an eye comes out of the socket, cover it with a clean damp cloth, do not attempt to push it back, and get to an emergency vet immediately. Sight is sometimes saved, and time is the deciding factor.
Heat is what actually kills pugs
Dogs cool themselves mainly by panting, which works by moving air fast over wet surfaces in the nose and mouth. A pug has been engineered to have very little of that surface and a restricted way of moving air across it. The result is a dog with a genuinely reduced ability to shed heat, and heatstroke risk that is completely different from a longer-muzzled breed of the same size.
- Walk early morning and late evening in summer, and skip the walk entirely on hot, humid days. A missed walk harms nothing.
- Give access to cool hard flooring and shade. Tile and stone do more than any gadget you can buy, and cost nothing.
- Never leave a pug in a car, a conservatory or a hot room, even briefly, and never with a window cracked as the compromise.
- Carry water on any outing, in a collapsible travel bowl or anything else that holds it.
- Learn the signs: frantic panting, thick ropey drool, staggering, vomiting, bright red gums, confusion or collapse.
Humidity matters as much as temperature, because panting relies on evaporation and humid air evaporates poorly. A muggy 24C day can be more dangerous to a pug than a dry 28C one, which is why a thermometer alone is a poor guide.
Travel deserves its own thought, because a hot car is where a great many of these cases begin. A pug in an air-conditioned cabin in a secure carrier is in a far better position than a loose dog in a warm boot, where airflow is poor and you cannot see it struggling. On any long summer journey, plan the stops around shade rather than around your own schedule.
- If you suspect heatstroke, start cooling before you set off for the vet. The old advice to use only tepid water is outdated: the Royal Veterinary College now advises cooling immediately, using cold water immersion for young healthy dogs, or pouring on any water cooler than the dog plus airflow from a fan or open windows for older dogs and those with existing health problems, which includes most pugs. Cool on the way, and phone ahead.
Weight is the one risk factor you fully control
Obesity came in at 3.89 times the odds of non-pugs, and of everything on that list it is the item most completely within an owner's power. Excess weight loads fat around the throat and chest of a dog that already cannot move air properly, and it worsens the airway, the joints and the heat tolerance simultaneously.
Assess body condition rather than trusting the scales, because breed weight ranges are wide. Stand over your dog and look for a waist behind the ribcage. Run your hands along the ribs: you should feel them easily under a thin layer of covering, like the back of your knuckles, without pressing. If you cannot find ribs without pushing, your pug is carrying too much.
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Portion control does most of the work, and measuring the food rather than eyeballing it is the single highest-yield change. A maze-style slow feeder helps a dog that inhales its dinner feel like it has eaten more, which makes a reduced portion far easier to sustain. Treats count toward the daily total, and for a dog this size a few biscuits is a meaningful share of it.
Skin folds, ears and the rest of the maintenance
Skin fold dermatitis showed up at almost 11 times the odds of other dogs, and ear discharge at 9.6 times. Both come down to the same thing: warm, moist, poorly ventilated spaces that the breed's conformation creates and that will reliably become infected if left alone. Skin fold dermatitis is not a hygiene failure on the owner's part, it is an anatomical consequence, but daily management is what keeps it from recurring.
Clean the facial folds a few times a week, and the tail fold too, which owners forget until it smells. The technique is simple: lift the fold, wipe gently with a hypoallergenic grooming wipe, then dry it thoroughly with a soft cloth. Damp left inside a fold is what causes the problem in the first place, so drying is not optional.
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- Ears: check weekly. Ear wipes for routine cleaning, or a veterinary ear cleaner if your vet recommends one. Never push anything into the canal.
- Teeth: pug jaws are shortened but the teeth are not, so crowding and dental disease are common. A dog toothbrush and dog toothpaste several times a week is worth more than any chew.
- Tear staining: the crease under a pug's eye catches overflow and stains, and it is a different job from the deep nose wrinkle. Tear-stain wipes are made for that shallow fold. Persistent heavy staining is worth a vet look, because it can mean the tear ducts are not draining.
- Nails and paws: short-legged, front-heavy dogs wear nails unevenly, so check them monthly and keep a pair of small-dog nail clippers or a grinder to hand.
Pug dog encephalitis, the one nobody warns you about
Pug dog encephalitis is a breed-associated inflammatory brain disease, sometimes called necrotising meningoencephalitis. It is uncommon, it is not on most pug health problem lists, and it is devastating when it happens: seizures, circling, blindness, behaviour change, usually in young adult dogs and often progressing quickly.
There is no cure. Treatment is immunosuppressive and aims to control the inflammation rather than resolve it, and the prognosis is guarded. A genetic component is well recognised in the breed and at-home DNA screening is offered commercially, though a test result is a risk indicator rather than a verdict, so ask a breeder what they screen for and how they use it. If a young pug has a seizure, pug encephalitis is one of the things a vet will be thinking about, which is a good reason to mention the breed explicitly at the appointment.
Hemivertebrae and the curly tail
The tight corkscrew tail that defines the breed is a spinal malformation. The same developmental process that twists the tail can affect vertebrae further up the spine, producing wedge-shaped bones called hemivertebrae that can compress the spinal cord.
Most pugs with hemivertebrae never show a problem. A minority develop weakness in the back legs, an unsteady gait, pain, or incontinence, usually before their first birthday. If a young pug starts knuckling over on its hind feet or dragging a toe, that is a neurological sign and needs investigating rather than watching.
How brachycephalic syndrome is diagnosed and treated
Diagnosis starts with an exam and a history, and a vet will usually want to see the dog breathe after mild exercise, because a pug at rest on a cool consulting table can look deceptively fine. Grading schemes exist that assess breathing noise and effort before and after a short trot. Confirming the internal components, the soft palate and laryngeal saccules, needs sedation or anaesthesia and a look at the back of the throat.
Treatment for brachycephalic syndrome in dogs is partly surgical and partly management. The common procedures widen the nostrils and shorten the overlong soft palate, and everted saccules can be removed at the same time. Results are generally better the earlier it is done, before years of straining have deformed the rest of the airway.
- Surgery does not make a pug into a normal-nosed dog. It reduces resistance in a system that stays abnormal.
- Weight loss before surgery improves both the anaesthetic risk and the outcome.
- Anaesthesia carries above-average risk in brachycephalics, so recovery is monitored more closely.
- Whether to operate is a genuine discussion about your individual dog, not a default. Ask your vet what grade of disease they are seeing.
So does surgery help? For a dog with meaningful stenotic nares and an elongated palate, it usually helps a great deal, and the improvement in exercise tolerance and heat safety can be dramatic. For a mildly affected dog it may not be worth the anaesthetic risk at all. That is exactly why it is worth booking a consultation to discuss it specifically rather than deciding from an article, and why asking your vet to grade the airway gives you something concrete to weigh.
Which other breeds carry the same risk
Pugs get named most often, but the breeds prone to BOAS all share one thing, and it is not ancestry. Brachycephalic obstructive airway syndrome is a conformation problem rather than a pug problem, so any breed selected for a shortened muzzle is prone to some version of it, and other flat-faced breeds carry the same kind of risk. The companion VetCompass paper on English Bulldogs (O'Neill et al. 2022) put their odds of a BOAS diagnosis at 19.2 times those of other dogs. That is lower than the pug figure, but it is the same problem arriving through the same route, so if you are considering a flat-faced dog of any kind the evidence in this article applies to your choice too.
- French Bulldogs and English Bulldogs, both frequently affected and both extremely popular.
- Boston Terriers, Boxers, Shih Tzus, Pekingese and Japanese Chins.
- Persian and Himalayan cats, which have their own flat-faced version of the same problem.
Our bulldog breed profile covers the same territory for that breed, and the way extreme conformation gets locked in by fashion is visible in the market for rare colours too, which we looked at in our guide to the merle French Bulldog.
Pug life expectancy, and what actually shortens it
Pugs are usually quoted as living somewhere in the region of 11 to 13 years, and plenty do reach that comfortably. What the average conceals is the spread: a well-conformed, lean pug with open nostrils and a good weight can live a full and unremarkable life, while a severely affected one may be limited by its airway from early on.
On how long a dog can live with BOAS, there is no single number, because BOAS is graded rather than binary. Mild disease managed well is compatible with a normal lifespan. Severe untreated disease tends to worsen over years as chronic straining deforms the airway further, and it raises the risk of a fatal heat or respiratory crisis at any age. The variable is severity and management, not the diagnosis itself.
What pugs actually die of
There is no single leading cause of death in pugs that applies universally, and any page giving you one number is overstating what the data supports. What veterinary experience and the breed risk profile together point to is a cluster of routes rather than one.
- Heat-related crisis, which is the one that most often kills an otherwise healthy pug suddenly and is almost entirely preventable.
- Airway failure in severe untreated brachycephalic disease, sometimes precipitated by excitement, exertion or anaesthesia.
- Neurological disease, including pug dog encephalitis in younger dogs.
- The ordinary causes that shorten any dog's life, cancer among them, compounded in pugs by obesity.
The pattern owners should take from that is not fatalism. Two of the four are strongly influenced by things done at home: heat exposure and body weight.
Long-snout and retro pugs: does breeding back work?
Interest in the long snout pug, sometimes marketed as a retro pug, comes from exactly the right instinct: if the flat face causes the problem, breed the muzzle back. The concept is sound and the execution varies enormously.
A pug with a normal snout is usually produced either by outcrossing to another breed, which makes it a crossbreed rather than a pug, or by selecting within pug lines for the longest muzzles available. Retro pug and similar labels are marketing terms with no agreed standard behind them, so a dog sold as one may or may not actually breathe better. Judge the individual animal: look at the nostrils, watch it move, listen to it at rest.
The broader fix is the one the RVC researchers called for, which is moving the breed standard itself toward a more moderate conformation. Their summary of the findings and the full open-access paper are both worth reading if you are choosing a puppy. If you are, our pug puppies profile covers what to ask a breeder.
Do pugs shed?
Yes, and considerably more than their size suggests. Pugs shed heavily year-round, and fawn pugs are generally described as double-coated and tend to shed more than the blacks, though that distinction is breed convention rather than a measured finding. It is a genuine consideration for a household but it is a grooming question rather than a health one, so we cover coat care, grooming frequency and what to expect in our full pug breed profile.
The honest verdict on pug welfare
The sad truth about pugs is not that they are bad dogs or that owners are bad people. It is that a century of selecting for a particular face produced an animal that is measurably less healthy than the average dog, and that the trait causing the harm is the trait people buy them for.
My position, as a vet who likes the breed and treats a lot of them, is this. If you are choosing a dog and health is a priority, choose a different breed, or at minimum insist on a pug with visibly open nostrils and a muzzle you can actually see. If you already have a pug, you are not doing anything wrong by loving it, and the practical things in this article genuinely change outcomes.
- Walk on a harness, never a collar. Keep the dog lean. Take heat seriously and skip walks on hot days. Keep folds clean and dry. Get noisy breathing assessed rather than accepting it as normal for the breed.
That last one is the change I would most like to see. Snoring, snorting and struggling on a short walk have been normalised into breed charm, and they are the symptoms of a treatable condition. Bring it up at your next appointment and ask directly whether your dog's breathing is worth investigating.
Frequently asked questions
Snoring and snorting at rest, noisy or rasping breathing, gagging or retching, exercise intolerance, sleeping with the head propped up or the neck extended, and swallowing air while eating. In severe cases, blue or grey-tinged gums and collapse. Blue gums or collapse in a flat-faced dog is an emergency.
Treatment combines surgery and management. Surgery typically widens the nostrils and shortens an overlong soft palate, and everted laryngeal saccules can be removed at the same time. Outcomes are generally better when it is done earlier. Alongside that, keeping the dog lean, walking on a harness rather than a collar, and avoiding heat all reduce the load on the airway.
Not usually in sharp pain from breathing itself, but many live with chronic breathing distress, which is a real welfare problem. Owners frequently under-report it because the noise has been normalised as typical for the breed. A dog that props its head up to sleep, wakes repeatedly, or cannot settle after mild exercise is managing an airway rather than being characterful.
The eye does not fall out, but it can come forward out of its socket and be trapped there, which is called proptosis. Pugs are vulnerable because selecting for a flat face left them with very shallow eye sockets. If it happens, cover the eye with a clean damp cloth, do not push it back, and get to an emergency vet immediately. Corneal ulceration is far more common, at about 13 times the odds of other dogs.
Pugs are generally quoted at around 11 to 13 years. The average hides a wide spread: a lean, well-conformed pug with open nostrils can live a full life, while a severely affected one may be limited by its airway. Weight and heat exposure are the two factors owners most influence.
There is no single figure, because BOAS is graded rather than all-or-nothing. Mild disease that is well managed is compatible with a normal lifespan. Severe untreated disease tends to worsen over years as chronic straining deforms the airway further, and raises the risk of a fatal respiratory or heat crisis.
Any breed selected for a shortened muzzle. French Bulldogs, English Bulldogs, Pugs, Boston Terriers, Boxers, Shih Tzus, Pekingese and Japanese Chins are the common dogs, and Persian and Himalayan cats have a feline version of the same problem.
No. The same VetCompass study that found pugs at 1.86 times the odds of a recorded disorder also found them significantly less likely than other dogs to be recorded with aggression, heart murmurs or fatty lumps. Their temperament is genuinely good. The problem is anatomical, and it is a problem of how the breed has been shaped rather than of the dogs themselves.
BVMS, MRCVS
Dr. Pippa Elliott, BVMS, MRCVS, is a veterinarian with nearly 30 years of experience in companion animal practice. Dr. Elliott earned her Bachelor of Veterinary Medicine and Surgery from the University of Glasgow. She was also designated a Member of the Royal College of Veterinary Surgeons. Married with 2 grown-up kids, Dr. Elliott has a naughty Puggle named Poggle, 3 cats and a bearded dragon.
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