January 2025

In this VETgirl online veterinary continuing education blog, we demonstrate how to intubate a cat in sternal recumbency using a training model. This is a commonly performed procedure in clinical practice so it’s important for veterinary professionals to be adept at feline intubation. Cats are challenging to intubate, so practicing intubation will hone this life-saving skill.

First, grab your supplies!

  • laryngoscope with functioning light bulb
  • appropriately sized endotracheal (ET) tubes (Pro-tip: 4 kg cat typically takes a 4 mm ID ET tube)
  • lubricant
  • something to tie or anchor the tube in place (e.g., tie gauze)
  • +/- lidocaine or lidocaine spray

Intubation supplies. Image courtesy of Elizabeth Hatton RVT

1) Positioning: The cat is first induced to an appropriate plane of anesthesia for a stress-free experience and positioned into sternal recumbency. Premeasure the advancement depth of your  ET tube from thoracic inlet to nose. The holder extends the cat’s neck and head outward from the body to better align key anatomic features (e.g., nose, larynx, and thorax), which improves visualization of the arytenoids and vocal folds.

Sternal intubation positioning in cat. Image courtesy of Amanda M. Shelby

2) Preparation: Cats are prone to laryngeal spasm, so you may choose to apply a drop of lidocaine or aerosolized lidocaine spray on the arytenoids to numb this area. Since cats are also prone to mucous plugs, a cuffed, Murphy ET tube is recommended. The end of the ET tube and cuff should be lubricated, but be careful not to occlude the Murphy eye with lubricant!

3) Intubation: With the tip of the ET tube aimed at the trachea, hover just in front of the arytenoids/vocal folds; when the cat takes a breath, these vocal folds will open allowing you to gently, but deliberately, advance the ET tube into the trachea to the pre-measured depth.

Don’t be discouraged if the cat rejects your first intubation attempt! If the cat is gagging or swallowing, additional induction drugs may be necessary; wait for another breath and try again. Some may prefer using an endotracheal stylet for added support.

4) Placement: Next, confirm placement of the ET tube in the trachea.  Accidental placement in the esophagus could be deadly! Endotracheal tube placement can be confirmed by several methods:

  • visualization of the ET tube entering the trachea during intubation
  • capnography (end-tidal CO2)
  • observing the chest wall rise when delivering a manual breath to 10-15 cmH2O
  • auscultation of breath sounds during a delivered breath

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

5) Creating a tight seal: After securing the ET tube in place, you want to give a manual breath up to 20 cmH2O and watch the pressure manometer for signs of a leak. If the pressure starts to fall at the peak inspiratory pressure, 20 cmH2O, inflate the ET tube cuff. A leak occurring over a pressure of 20 cmH2O is OK! We want to avoid over inflation of the cuff which can cause pressure necrosis of the tracheal mucosa. Cat tracheas are comparatively more delicate than dogs, so be mindful when manipulating the head and neck of an intubated cat as they are more apt to developing tracheal tears.

Most importantly, this is a common procedure that veterinary professionals must feel comfortable with – and be accurate – when performing!  You can learn more about tracheal tears in cats HERE in this VETgirl continuing education podcast.

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