Evaluation of Two Methods of Endotracheal

Tube Selection in Dogs
This study evaluated two methods of endotracheal tube selection using 28 fresh canine carcasses of various ages, weights, and genders. The two selection methods were 1) nasal septal width pairing with outer diameter of an endotracheal tube, and 2) digital palpation of the
tracheal outer diameter to determine the endotracheal tube size. All dogs were dolichocephalic breeds. Results of this study showed that the canine nasal septal width method of endotracheal tube selection was correlated with the size of the tracheal internal (r=0.72) and outer
(r=0.73) diameters. However, evidence shows that the digital palpation method is slightly
more effective than the nasal width method in selecting the best-fitting endotracheal tube.
The percentage of the best-fit tube selection for the nasal septal width method was 21%,
while the digital palpation method was 46%. With these two methods, selecting an endotracheal tube that is too small is possible, especially when the tube internal diameter is ≥7 mm.
J Am Anim Hosp Assoc 2008;44:236-242.

Jim Lish, PhD
Jeff C. H. Ko, DVM, MS,
Diplomate ACVA
Mark E. Payton, PhD

O

From the Center for Veterinary
Health Sciences (Lish) and the
Department of Statistics (Payton),
College of Arts and Sciences,
Oklahoma State University,
Stillwater, Oklahoma 74078
and the Department of
Veterinary Clinical Sciences (Ko),
School of Veterinary Medicine,
Purdue University,
West Lafayette, Indiana 47908.
Address all correspondence to Dr. Ko.
236

Selection of a correctly sized endotracheal tube is important in practicing
anesthesia. Too large of an oral-tracheal tube may cause laryngotracheal
trauma during the intubation attempt or a complete failure to intubate.1
An inappropriately small tube may result in gas leakage and subsequent
pollution of the operation room. If a smaller cuffed endotracheal tube is
used, the cuff may require overinflation to maintain a seal, exerting high
pressure on the tracheal wall and thereby increasing the risk of tracheal
necrosis. Inappropriately small endotracheal tubes may also increase the
work of breathing because of increased airway resistance. For each 1-mm
decrease in the internal diameter (ID) of the endotracheal tube, the work
of breathing has been demonstrated to increase by 34% to 154%, and the
airway resistance increases by 25% to 100%.1,2 Therefore, when selecting an endotracheal tube for a dog, one must select as large of an ID as
possible in order to minimize the work of breathing and reduce airway
resistance during inhalant anesthesia.
Size selection of endotracheal tubes for oral-tracheal intubation in
dogs has not been standardized due to variations in age, breeds, and body
weights of animals. In addition to selecting the estimated optimum-sized
endotracheal tube, most practitioners also select two additional endotracheal tubes. One is a size larger and one is a size smaller than the estimated appropriate size. These additional tubes are kept at hand to ensure
a close fit.
In practice, several methods have been used to select endotracheal
tubes. The first commonly used method is based on the dog’s body
weight, with the assumption that the dog’s tracheal diameter is directly
proportional to its body mass. The accuracy of this method is highly
dependent on the experience of the anesthetist. The second method used
is based on direct digital palpation of the dog’s tracheal diameter just
above the thoracic inlet, with the assumption that the trachea’s outer
diameter (OD) will approximate the appropriate size of endotracheal tube
to be used. The third method of selecting endotracheal tubes is to hold an

Introduction

JOURNAL of the American Animal Hospital Association

over hair and other tissues situated around the trachea at that location. An endotracheal tube with an OD matching this septal width was then selected. McNemar’s test was used to compare the accurate selection rates between two methods based on the previous statistical result.. Endotracheal tubes are clinically indexed with their ID. As expected. and the rest were males. The ages of the mostly mixed-breed dogs were between 6 months and 5 years. Eight dogs were females.01) to assess the coefficient’s statistical significance. All dogs were dolichocephalic. and 2) endotracheal tube size selection is more accurate when using digital palpation of the dog’s tracheal OD than when using the dog’s nasal septal width. with body weights between 5. and the tube size was estimated at the septum’s narrowest point. and the linear correlations and P values for major variables are presented in Table 2. OD of endotracheal tube used for actual intubation. Furthermore. age of the dog. A review of current literature reveals no published information supporting the assumption of a direct anatomical correlation between the nasal septal width and the tracheal ID and OD.a A correlation analysis of the variables using PC SAS Version 9b was conducted. ID of endotracheal tube used for actual intubation. Vol. and cube root of body weight. This measure served as a calculation of the accuracy of the two endotracheal tube selection methods by dividing the number of estimates that matched the correct endotracheal tube by the total number of dogs. The first statistical method calculated an estimate of the percentage of “correct” endotracheal tube selection based on the ID of the best-fit endotracheal tube. each endotracheal tube selected by the OD had to be converted to the ID and recorded for comparison between the two methods. body weight of the dog. In addition.3 kg [Table 1]. tracheal ID. were to 1) evaluate the correlations between the nasal septal width. ID and OD of endotracheal tube selected by using digital palpation. and body weight of the dog. Two methods were used to select the endotracheal tubes for each dog. The first method used the nasal septal width as a guide. the midportion of the endotracheal tube was held against the nasal septum of the dog. In addition. The second statistical method for calculation of the accuracy was expressed as a mean absolute difference of the tube diameter determined by either method (i. Twenty-eight fresh dog cadavers were used in this study. in order to simulate the clinical situation. the endotracheal tube selected and inserted directly into the cadaver’s trachea was highly correlated with the trachea’s ID and OD. the nasal septal widths of these dogs were measured in millimeters with calipers between the two nostrils at the narrowest point. Because both methods of selection were based on the use of Materials and Methods Endotracheal Tube Selection 237 the OD. This method evaluates how much the proposed methods differ from what was considered “best. just as would be done in a clinical setting. All of the endotracheal tubes used were the polyvinyl chloride type.” Smaller values of this statistic would reflect a higher level of precision. the formula would be di = average(|pi – bi|). and 2) compare two methods of selecting endotracheal tube size in dogs using digital palpation of the tracheal OD and nasal septal width of the dog. tracheal ID and OD. The digital palpation of the tracheal OD was performed immediately cranial to the thoracic inlet. The null hypothesis tested with McNemar’s was that both methods are equally accurate in selecting the optimal size of tracheal tube. The age of the dog was poorly correlated with the trachea’s ID or OD. The variables used in this analysis were: nasal septal width. the whole airway was harvested. age. endotracheal selection methods were compared with two statistical methods using the “best-fit” endotracheal tube to the cadaver trachea as a standard for comparison. The same person recorded all measurements to ensure consistency. and the tracheal ID and OD were measured in millimeters with calipers at the approximate site immediately above the thoracic inlet where digital palpation occurred. therefore. For the digital palpation selection method. whereas the body weight of the dog was better correlated Results . pi is the diameter of the tube determined by palpation. and the second method used digital palpation of the tracheal OD as a guide.4 kg and 29. For the nasal septal width method. For actual measurement of the tracheal ID and OD. Statistical Analysis The results for major variables are presented in Table 1. and the size of the endotracheal tube that best fit the dog’s actual trachea was selected and recorded. The same calculation was applied to the nasal septal width selection method. tracheal OD.September/October 2008. 44 endotracheal tube up to the nasal septum (at the narrowest point between two nostrils) of the dog and match the width of the nasal septum with the endotracheal tube OD. palpation-selected ID or nasal septal width-selected ID) and the ID of the best-fit endotracheal tube directly inserted into the trachea. The endotracheal tube size selected for each dog with each method was then recorded. Different sizes of endotracheal tubes were used to actually perform tracheal intubation on the harvested cadaver trachea. The same person also selected an endotracheal tube using digital palpation by selecting the OD that most closely approximated the OD of the dog’s trachea. the authors hypothesized that 1) the correlation is low between nasal septal width of the dog and its tracheal ID or OD. and bi is the diameter of the tube determined to be the best fit for the ith dog.e. The authors calculated the Pearson’s linear correlation coefficient and reported a P value (P<0. ID and OD of endotracheal tube selected by using nasal septal width method. Following the selection of endotracheal tubes. In this study. no information has been published comparing the accuracies of nasal septal width versus direct palpation methods for endotracheal tube size selection. The objectives of this study. where di is the mean absolute difference.

P<0.5 29.0001) and OD (r=0.3±1. but it is “marginally significant” and is indicative of evidence that the digital palpation method is more effective than the nasal septal width method. nasal septal width correlated well with tracheal ID and OD. This is not statistically significant at the 0.0 15.05 level. The digital palpation of the tracheal OD was also significantly (P<0. The P value was 0. and 2) that endotracheal tube size selection is more accurate using digital palpation of the dog’s tracheal OD than using the dog’s nasal septal width. this study confirmed the hypothesis that digital palpation of the OD of the trachea is a more accurate method for selecting a best-fit endotracheal tube than using the width of the nasal septum. 44 Table 1 Tracheal Variables* of the Dogs Variables Mean ± SD Minimum Maximum Age (mo) 28. However.0 23.0 Nasal septal width (mm) 7.6±1. The nasal width of the dog was poorly correlated with the age of the dog but was significantly correlated with body weight. Vol.0001).7±20.07. For both methods.0 Tracheal ID‡ (mm) 16.9 6.5±2. The nasal septal width was significantly correlated with tracheal ID (r=0.9 8. analyzing the null hypothesis that both methods are equally accurate.84).5 5.5 Endotracheal tube OD (mm) 11. The percentages of correct estimates are presented in Tables 3 and 4.0 Nasal septal width selection of endotracheal tube—OD (mm) 9.75) method.857) is a more precise method to select the best-fit tube than the nasal septal width (mean difference = 1.0001) correlated with the dog’s tracheal OD.0 10.8 12.0 Palpation of neck selection of OD of endotracheal tube (mm) 10.0±4. The digital palpation method of selecting endotracheal tubes provided a higher percentage (46%) of correct estimates than the nasal septal width method (21%).7 Endotracheal tube ID (mm) 8.0 * Data are presented as mean ± standard deviation (SD) with maximum and minimum values.0 11.0 60. The results of this study did not support the first hypothesis.0 Weight (kg) 15.0 Tracheal OD† (mm) 20. P<0.1 Nasal septal width selection of endotracheal tube—ID (mm) 6. the percentage of correct estimates was calculated by dividing the number of correct estimates by the total number of dogs [Tables 3.0 11. † OD=outer diameter ‡ ID=internal diameter with the tracheal ID (r=0.0 28.1 5.2 5.238 JOURNAL of the American Animal Hospital Association September/October 2008. The absolute mean difference also showed that palpation of the tracheal OD (mean difference = 0.7 6.8 12. This study hypothesized that 1) the correlation was low between the nasal septal width of the dog and the tracheal ID or OD.4±7.5 Palpation of neck selection of ID of endotracheal tube (mm) 7.8 13.8±1.0 9.85) and OD (r=0.6 6.7 4.73.8±3. McNemar’s test was performed on the data in Tables 3 and 4.1 6.0±4.72.5±1.8±1.4 5. Discussion . 4].

0001 r=0.90 P<0.01 Palpation of Neck Selection of ID‡ of ET Tube (mm) r=0.0001 r=0.90 P<0.0001 r=0. 44 Endotracheal Tube Selection 239 .0001 r=0.0001 r=0.86 P<0.01 Palpation of Neck Selection of OD* of ET† Tube (mm) r=0.90 P<0.0001 r=0.0001 r=0.88 P<0.0001 r=0.82 P<0.87 P<0.0001 r=0.85 P<0.79 P<0.08 Age Nasal Septal Width r=0.86 P<0.0001 r=0.0001 r=0.46 P=0.0001 r=0.75 P<0.0001 r=0.00 r=0.0001 r=0.0001 r=0.81 P<0.88 P<0.0001 r=0.08 Nasal Septal Nasal Septal Width Selection of Width Selection of ET Tube—OD (mm) ET Tube—ID (mm) r=0.89 P<0.0001 r=0.r=0.76 P<0.51 P=0.0001 r=0.0001 r=0.72 P<0.87 P<0.79 P<0.82 P<0.88 P<0.88 P<0.92 P<0.0001 r=0.90 P<0.90 P<0.0001 r=0.0044 Body Volume (Cube Root of Body Weight) September/October 2008.93 P<0.88 P<0.52 P=0.0001 r=0.0001 r=0.34 P=0.0001 r=0.88 P<0.79 P<0.0001 1.00 r=0.0001 r=0.90 P<0.001 r=0.0001 r=0.0001 r=0.99 P<0.0001 r=0.0001 r=0.0001 r=0.0001 r=0.90 P<0.0001 r=0. Vol.80 P<0.0001 r=0.08 r=0.87 P<0.0001 r=0.34 P=0.87 P<0.0001 r=0.34 P=0.01 Body Weight (kg) The Linear Correlations (r) and P Values for Major Tracheal Variables in the Dog Table 2 1.0001 r=0.82 P<0.0001 Body weight Tracheal OD (mm) Tracheal ID (mm) Optimal ET tube OD (mm) Optimal ET tube ID (mm) Body volume (cube root of body weight) * OD=outer diameter † ET=endotracheal ‡ ID=internal diameter r=0.87 P<0.46 P=0.0001 r=0.73 P<0.84 P<0.99 P<0.87 P<0.

of dogs 5 6 8 8 1 28 * Note: The numbers marked with an asterisk represent a correct match of the internal diameter between the optimal endotracheal tube and the endotracheal tube selected by the nasal septal width method. 44 Table 3 Contingency Table Representing Accuracy of the Nasal Septal Width Method of Endotracheal Tube Selection Optimal Endotracheal Tube Internal Diameter Size (mm) 5 6 7 8 9 Total No. of Dogs 15 1* 1 0 0 0 0 2 1 5* 0 0 0 0 6 0 2* 0 0 0 2 0 3* 0 0 3 0 2 16 17 18 Endotracheal Tube Internal Diameter Size (mm) Selected by Digital Palpation 0 0 0 19 0 0 0 1 1* 10 0 0 0 1 4 1* 6 11 0 0 0 2 4 1 7 Total no. Table 4 Contingency Table Representing Accuracy of the Digital Palpation Method of Endotracheal Tube Selection Optimal Endotracheal Tube Internal Diameter Size (mm) 5 6 7 8 9 10 Total No.240 JOURNAL of the American Animal Hospital Association September/October 2008. . of Dogs 15 2* 0 0 0 0 2 2 4* 0 0 0 6 0 0 2 16 Endotracheal Tube Internal Diameter Size (mm) Selected by Nasal Septal Width 17 1 1 0* 18 0 0 3 0* 0 3 19 0 0 1 1 0* 2 10 0 0 2 4 0 6 11 0 1 2 3 1 7 Total no. Vol. of dogs 2 6 2 7 9 2 28 * Note: The numbers marked with an asterisk represent a correct match of the internal diameter between the optimal endotracheal tube and the digitally selected endotracheal tube.

For example. the difference in percentage of correct tube selection (46% for digital palpation versus 21% for nasal septal width) is significant. it is difficult to use body weight as a generalized method for selecting a proper endotracheal tube in a clinical setting. the data in Tables 3 and 4 show that a too-large tube was selected only once. McNemar’s test was able (with marginally statistical significance. Minimal impact was observed when the endotracheal tube size was <7 mm ID.5 A high value of the correlation coefficient means that the two variables change in a linear fashion. Vol. However. as an endotracheal tube ages. Temecula. Because of the clinical nature of these processes. These results show that the digital palpation method is more efficient in selecting a “best-fit” endotracheal tube than the nasal septal width method. P=0.7. such as size Endotracheal Tube Selection 241 limitation of the laryngeal openings or obesity of the dog.4% and 21. but with cube root of body weight. oral/nasal tracheal tube. In the current study. This would cause turbulent air flow and increase the work of breathing.07) to identify that the percentage of correct tube selection for the digital palpation method was greater than the percentage of correct tube selection for the nasal septal width method. endotracheal tubes are indexed by their ID. a slight increase in cuff pressure to achieve tracheal wall cuff sealing can transfer all the pressure to the tracheal wall membrane. Thus. resulting in a tendency for selecting smaller sizes of endotracheal tubes rather than optimal best-fit tubes as the size of the trachea increases. CA 92589-593 b SAS Institute. This inaccuracy rate increased as the optimal endotracheal tube ID sizes (that are approximate to the tracheal ID sizes) increased from 7 mm to 11 mm in both selection methods. NC 27511-513 Footnotes The authors thank Dr. cleaning and sterilizing an endotracheal tube for reuse can cause loss of pliable polymers.9 In this study. Clinical studies have suggested that endotracheal tube size can be estimated by palpating the dog’s trachea. Hudson Respiratory Care. Clinically. respectively. both endotracheal tube selection methods used in this study exhibit some error for estimating the optimal best-fit size of the endotracheal tube.4 The current results are similar to these studies. Some challenges were encountered in this study. whereas all other incorrectly matched endotracheal tubes were ones that were too small. yet clinical selections of endotracheal tubes are based on the tube’s OD. just because the correlation is high does not imply that the prediction is accurate. because of breed differences. the results of this study revealed that body weight correlated better with tracheal size than did the age of the dog. wall thickness is not the same in all endotracheal tubes. body weight. the endotracheal tube itself should also be considered.. In a clinical setting. Cuffed. The percentages of obtaining a correct estimate with the digital palpation and nasal septal width methods were 46. only dolichocephalic dogs were used. Murphy Eye. the tracheas of the cadaver dogs were measured with calipers after they were harvested. such as those in this study. therefore. ID will vary. clinicians use either the OD of the endotracheal tube for measuring against the nasal septal width of the dog. However. and size of the trachea in mixed-breed dogs. Inc. In other words. However. Some factors one would encounter in a clinical setting were not considered during the selection of the endotracheal tube. especially for brachycephalic dogs. a correlation was found between body size and nasal septal width for the dogs in this study. and the optimal endotracheal tube was selected by direct insertion of the best-fit tube into the trachea. Furthermore. such as tracheal diameter or nasal septal width. Future studies are needed in this area. including evaluation of dogs in different breeds and sizes.4%. which may increase its tendency to collapse under ordinary cuff pressure.6 Despite this range of variation. Conclusion a Sheridan/CF. Body masses of adult dogs vary dramatically between breeds. McNemar’s test has limited power when used with small sample sizes.8 The positive correlation seen with this study does not disprove this. and. nasal septal width of the dog correlated poorly with the age of the dog but did correlate well with the dog’s body weight. Besides the anatomical considerations. Review of literature revealed minimal information about the correlation among age. resulting in stiffening or hardening of the tube wall. or they use digital palpation of the tracheal OD for estimation against the OD of the endotracheal tube. Cary.September/October 2008. therefore. others consider this to be a subjective method. It has been suggested that mammalian linear dimension. Although body weight was not used as part of the endotracheal tube selection method. when the correct tube size exceeded 7 mm. where the fat surrounding the trachea might also affect the digital palpation of the trachea. Jennifer Hubbard and Meaghan McMonagle for their technical assistance. suppressing tissue blood flow. Also. mixed-breed dogs. For example.6 However. it is most likely related to the relatively limited range of body weights in the study sample. However. and both methods are relatively imprecise as tracheal size increases. The current results showed that digital palpation of the tracheal OD was a more precise method for selecting a properly fitting tube than the nasal septal width measurement method. it may lose wall rigidity. the tracheal size varies accordingly. Body mass variation among breeds poses a challenge for unifying a standard method of selecting endotracheal tubes for dogs. A strong correlation has been shown between tracheal diameter and body mass in Dalmatian puppies (<5 months of age)3 and in small. is not expected to vary with body weight. Acknowledgments . both methods exhibited a tendency to select tubes that were too small by 1 to 2 mm. 44 Based on the data from Tables 3 and 4.

Lumb and Jones’ Veterinary Anesthesia.65(8):853-859.40:555-558. Respir Physiol 1978. Jr. 15. Hartsfield SM. Fink EA.242 JOURNAL of the American Animal Hospital Association 11. In: Kirby RR. Baltimore: Williams & Wilkins. Vol. In: Thurmon JC. Brock N. Mortola JP. Healye TEJ. 44 16. Anest Analg 1989. Diameter. Airway management and ventilation. Tranquilli WJ. References September/October 2008. Bolder PM. Can Vet J 1998.39:297-302. Structural considerations in tracheal disease. Ozgel O. eds. Florete OG. 1994:298-319. J Am Anim Hosp Assoc 1982. Philadelphia: WB Saunders. Fisher JT. Tracheal diameter: analysis of radiographic measurements in brachycephalic and nonbrachycephalic dogs. 14. Am J Vet Res 1979. The extra work of breathing through adult endotracheal tubes. Comparative morphology of the trachea in newborn mammals. Harvey CE. Yigitarslan K. 18. 13. 17.18:570-576. Vet Anaesth Analg 2006.33: 213-218. length and branching angles of the upper airways in the dog lung.33:24-27. Woldehiwot Z. 12. Bolder AR. Respir Physiol 1980. eds. Airway devices and their application. Dallman MJ. Brown EM. Questions about anaesthetic equipment.39:311-312. Horsfield K. 19. Clinical Anesthesia Practice. Benson GJ. Gravenstein N. 1996:515-556. Comparison of airway size with some phenotypic parameters in Dalmatian puppies: a practical method to estimate endotracheal tube size. 3rd ed. . Avki S.