January 2025

In this VETgirl online veterinary continuing education blog, we demonstrate how to intubate a cat in lateral recumbency. Being able to intubate in lateral is important in veterinary medicine, as your patient may accidentally become extubated during surgery or a patient may require intubation without interruption during cardiac compressions as described by the 2024 RECOVER guidelines.1

Cats are already challenging enough to intubate! Here are a few VETgirl pro-tips.

Supplies: Have all your supplies readily available. This should include the following:  laryngoscope with functioning light bulb, appropriate size Murphy endotracheal (ET) tubes, lubricant for the end of the ET tube and cuff (Be sure not to occlude the Murphy’s eye), a tie for securing the tube (e.g. tie-gauze, IV tubing), additional induction drugs if necessary, and +/- lidocaine spray (applied to the arytenoids to decrease laryngeal spasm).

Intubation supplies. Image courtesy of Elizabeth Hatton RVT

Patient Positioning: The KEY to lateral intubation is patient positioning! The assistant extends the head and neck outwards from the body so that the nose, larynx, and thorax are aligned. This position improves visualization through the oral cavity of the epiglottis, arytenoids, and trachea. The most common mistake during lateral intubation is improper positioning of the head and neck – often we end up pulling the nose toward the ventral midline, thus bending the neck and obscuring visualization of the back of the oropharynx.

Cat positioned for lateral intubation. Image courtesy of Amanda M. Shelby

Intubation: Once the patient is positioned, lateral intubation is fairly similar to sternal intubation in cats… just with the operator having to contort their own body into position! We premeasure the intended ET tube depth from the cat’s nose to the thoracic inlet, use the laryngoscope to visualize the larynx, apply a drop or spray of lidocaine to the arytenoids to limit spasm (optional step), and insert the ET tube between the vocal folds on inhalation in spontaneously breathing patients. In anesthetized cats, patience is key – wait for the patient to take a breath and gently yet deliberately, insert the beveled edge of the ET tube through the vocal folds (which are between the arytenoids on either side of the airway). In cardiopulmonary arrest (CPA) or in apneic patients, the arytenoids will not be moving, and here’s where a stylet can be incredibly helpful! Place the tip of the ET tube’s beveled edge between the arytenoids, and with a slight twist and gentle pressure, advance the ET tube into the trachea. Confirm placement via direct visualization during insertion, capnography, visualization of the chest rising with a delivered breath, and/or by auscultation of air sounds in the chest during manual breath. Be sure to secure the ET tube and then inflate the ET tube accordingly to create a seal to effectively deliver a breath up to a maximum inspiratory pressure of 20 cmH2O.

Confirming insertion depth of ET tube. Image courtesy of Amanda M. Shelby

Interested in more information on veterinary CPR? Check out this VETgirl continuing education blog to learn more.

Still struggling to intubate that challenging cat…check out this blog about laryngeal airway mask options.

References:
Hopper K, Epstein SE, Burkitt-Creedon JM, et al. 2024 RECOVER Guidelines: Basic Life Support. Evidence and knowledge gap analysis with treatment recommendations for small animal CPR. J Vet Emerg Crit Care. 2024;34(1):16-43.

  2. Cheyanne Hehman says:

    This was a very interesting read. As a fairly new RVT, i found this article to be easily comprehensive and very informative.

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