Paper

Ventral recumbency is crucial for fast and safe orotracheal

intubation in laboratory swine

M M Theisen1, M Maas1 , M A Grosse Hartlage1, F Ploner2, S M Niehues3, H K Van Aken1,

T P Weber1 and J K Unger4
1
Department of Anaesthesiology and Intensive Care, Münster University Hospital, Albert-Schweitzer-Strasse 33, D-48149 Münster,
Germany; 2Department of Anaesthesiology and Critical Care Medicine, Vipiteno Hospital, Vipiteno, Italy; 3Department of Radiology;
4
Department of Experimental Medicine (FEM), Campus Virchow-Klinikum, Charité-Universitätsmedizin, Berlin, Germany
*Both authors equally contributed to this paper
Corresponding author: Marc Michael Theisen. Email: theisen@anit.uni-muenster.de

Abstract
The aim of this study was to find the fastest, easiest and safest method of achieving orotracheal intubation for general
anaesthesia in laboratory pigs. Twenty-one Yorkshire  Landrace crossbreed male castrated pigs (32.9 + 4.8 kg) were
investigated. Dorsal and ventral recumbency are the alternatives most frequently described for animal positioning during
intubation procedures. Based on standardized induction of general anaesthesia using pentobarbital and remifentanil, the
dorsoventral and ventrodorsal positions were compared with regard to the time needed, changes in oxygenation and
circulatory response. Positioning was found to be crucial for fast orotracheal intubation. The time required for safe intubation
is significantly shorter with the ventrodorsal position (17.3 s) in comparison with the dorsoventral position (58.4 s; P , 0.001).
Hypoxia did not occur in either group. A significant drop in systolic blood pressure was observed in both groups. Diastolic and
mean arterial pressures were not influenced by intubation. A significant increase in heart rate was observed in pigs intubated
in ventral recumbency, but not after intubation in the dorsal position. Preoxygenation before intubation is vitally important
for preventing hypoxia. With regard to clinical practice, the haemodynamic changes observed in this investigation do not
appear to be relevant, as the mean arterial pressure was not altered and heart rates only increased moderately. It may be
concluded that the ventrodorsal position can be recommended for orotracheal intubation in pigs as the first choice for
providing a smooth and fast airway.

Keywords: Pig, intubation, laryngoscopy, anaesthesia, experimental surgery

Laboratory Animals 2009; 43: 96–101. DOI: 10.1258/la.2008.008044

John Hunter, in the 18th century, was the first to describe pigs
(Sus scrofa) as being suitable models for use in experimental
biomedicine.1 In recent years, domestic pigs have become
very popular for this purpose and have replaced the traditional
canine models for investigations on topics including transplan-
tation, shock, cardiology and gastrointestinal physiology.2 – 6
In accordance with animal welfare requirements and good
laboratory practice, adequate anaesthesia is required for surgi-
cal procedures and various examinations in swine. In this
context, safe and standardized orotracheal intubation is very
important. However, achieving endotracheal intubation in
pigs is still regarded as being technically difficult.5,7 – 9 Failed
endotracheal intubation after induction of anaesthesia, result-
ing in hypoxia and death, is regrettably common, even when
experienced scientists are performing the procedure.10 – 13
As intubation is challenging in pigs, many scientists avoid
the procedure.14 Various authors have strongly recommended
using spontaneously breathing animals and avoiding any
airway precautions, in order to prevent major problems devel-
oping due to intubation manoeuvres.9,15,16 Other groups
favour mechanical ventilation but prefer a primary tracheo-
tomy, as they consider that pigs easily develop laryngospasms
and other complications during intubation.16 – 18 Since
spontaneous respiration is associated with many risks and
tracheotomy is an invasive procedure, various techniques
have been proposed for managing the problems caused by
orotracheal intubation.6,19 – 23
These techniques differ particularly with regard to the
positioning of the animal during intubation. The present
study investigated the two positions most frequently used –
the ventrodorsal and dorsoventral positions. The aim was to
determine the influence of positioning on the time needed

Laboratory Animals 2009; 43: 96 –101


................................................................................................................................................
for the intubation manoeuvre, on changes in oxygenation
and finally on haemodynamic responses. In addition, the
anatomical structures were visualized during the intubation
procedure. The results have been summarized in this paper
in order to provide evidence-based procedural advice.
Materials and methods
Animals
The study was approved by the Institutional Animal
Use Committee (Department of Veterinary and Food
Surveillance, Regional Administration for Münster; G62/
2003). Twenty-one healthy Yorkshire  Landrace crossbreed
male castrated pigs (UPB Deutschland Ltd, Drensteinfurt,
Germany), which were free of endoparasites and ectopara-
sites, were included. Before the investigation, the pigs
were randomly assigned to one of two study groups invol-
ving intubation in either the dorsoventral position (n ¼ 10)
or ventrodorsal position (n ¼ 11). The randomization list
was generated by a special software program (RandList
version 1.0, DatInf Ltd, Tübingen, Germany).
The mean body weight of all the pigs was 32.9 + 4.8 kg.
There were no differences in body weight between the two
groups (dorsoventral position group 33.6 kg, interquartile
range 27.0 kg, 35.2 kg; ventrodorsal position group 33.6 kg,
interquartile range 31.1 kg, 35.2 kg). Equivalent baseline
conditions were thus ensured in both groups with regard to
anatomical characteristics, i.e. the width of the pharynx,
larynx and trachea.
Housing
To allow them to adapt to their new environment and to
prevent stress, the animals were housed in the University
of Münster’s animal facility for at least 14 days before the
investigation. Room temperature was maintained within
the range of 20 – 228C. The relative humidity was approxi-
mately 40 – 70%. The pigs were housed together with their
pen mates. The room was adjusted to make the animals
comfortable, and they were able to lie down with out-
stretched limbs or move around.
Feeding
The pigs were fed a commercially available standard ration
of pellets and water in open troughs and watering places.
Food, but not water, was withheld for 18 h before the induc-
tion of anaesthesia.
Premedication and sedation
Sedation was achieved by intramuscular administration
of 3.75 mg/kg tiletamine, 3.75 mg/kg zolazepam (Zoletil,
Virbac France SAS, Carros, France; contains tiletamine and
zolazepam) and 1.5 mg/kg xylazine (Xylazin 2%, Alvetra,
Neumünster, Germany).5,24 – 26 After the onset of sedation, the
pigs were placed on the operating table in the ventrodorsal or
lateral position. A 20-G intravenous (i.v.) line and a 22-G arterial
cannula (Insyte, Becton Dickinson, Heidelberg, Germany) were
inserted into an auricular vein and artery, respectively. Infusion
Theisen et al. Intubation in laboratory swine 97
of Ringer’s solution (Delta Select, Dreieich, Germany) was
started at a rate of 3 mL/kg/h. Vital signs were monitored
using pulse oximetry (PM 8050, Dräger, Lübeck, Germany),
invasive arterial pressure measurement and electrocardio-
graphy (SMK 154-9, Hellige, Freiburg, Germany).
Anaesthesia
All the animals were preoxygenated for at least 5 min via
a tight-fitting facemask with 100% oxygen delivered at
a flow rate of 15 L/min from an anaesthetic machine (AV-1,
Dräger). Anaesthesia was induced by i.v. administration of
22.5 mg/kg pentobarbital (Narcoren, Merial, Hallbergmoos,
Germany) and continuous infusion of 0.25 mg/kg/min remi-
fentanil (Ultiva, GlaxoSmithKline, Munich, Germany) in
accordance with general practice.27 – 32 No neuromuscular
blocking agents were used. At the onset of apnoea, the
animals were moved into either dorsal or ventral recumbency
in accordance with their randomization. Depending on the
position, the head (dorsal position) or the legs (ventral pos-
ition) were allowed to overhang the operating table slightly.
All of the intubation manoeuvres were carried out by the
same investigator (MMT) in accordance with the technique
described previously.8,19,21,33 In summary, an assistant
opened the pig’s mouth widely using two loops made of
gauze and applied to the animal’s upper and lower jaws.
The neck was moderately dorsiflexed during this procedure.
The tongue was extracted using a gauze compress for
improved grip. The laryngoscope was then carefully intro-
duced until the soft palate became visible, with the palatal
velum and ventral surface of the epiglottis. The epiglottis
was drawn into the oropharynx by capturing it gently with
the tip of the laryngoscope blade. Aligning the epiglottis in
this way exposes the entrance to the larynx. An orotracheal
Magill-type tube (Super Safety Clear, Rüsch PLC, Kernen,
Germany) with an inner diameter of 6.5 mm was inserted
into the laryngeal entrance. The convex side of the tube was
placed facing upwards, as this makes introduction into the
entrance of the larynx easier due to the anatomical structures.
While the tube was being advanced, it was rotated 1808 to
allow a smooth procedure. After the tube had been inserted,
the cuff was blocked immediately and the animal was
connected to the anaesthetic machine for ventilation. Correct
positioning was verified by confirmation of carbon dioxide
indicated by the anaesthetic gas monitoring system (PM
8050, Dräger) and by auscultation of the thorax. Initially, the
tidal volume was set at 10 mL/kg and the respiratory rate
was 12–18 breaths/min; the peak inspiratory pressure did
not exceed 20 cmH2O. During anaesthesia, ventilation was
adjusted according to the results of blood gas analyses and
end-tidal capnometry.
Measurements
Immediately before and after successful intubation, the per-
ipheral pulse oximetric oxygen saturation, heart rate and
mean arterial pressure were recorded. The time needed for
the complete intubation procedure was recorded using
an electronic stopwatch. The time measurement was
started at the beginning of the laryngoscope insertion and
98 Laboratory Animals Volume 43 January 2009
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detection of carbon dioxide was defined as the endpoint of
the intubation procedure.
Statistics
Statistical data were collected and computed using commer-
cially available statistical and graphic software (SigmaStat
2.0, SigmaPlot 2000, Jandel Scientific Corp, Erkrath,
Germany). For normal distributions, t-tests were carried out
for intragroup and intergroup comparisons. For data that
did not have a normal distribution or had equal variance,
the Mann-Whitney rank sum test was used for intragroup
and intergroup comparisons. A Pearson product moment
correlation was carried out to verify the correlation between
heart rate and the length of the intubation manoeuvre.
Visualization of anatomy during intubation
For detailed anatomical and procedural visualization, pictures
were taken with a digital camera (Exilim Zoom EX-Z40, Casio,
Norderstedt, Germany). The images were edited using free-
ware photo-processing software (iPhoto Plus 4.0, Ulead
Corp, Corel Ltd, Unterschleissheim, Germany; SnagIt 8.2.3,
TechSmith Corp, Okemos, MI, USA).
Computed tomography (CT) scans were obtained from
comparable pigs that were originally scheduled for CT inves-
tigations in another porcine model.34 A 64-slice device was
used for CT (LightSpeed VCT, GE Medical Systems,
Milwaukee, IL, USA). The examination protocol consisted
of an arterial contrast-enhanced scan and a supplementary
venous phase with automatic i.v. injection of 100 mL non-
ionic iodinated contrast medium (370 mg/mL iodine). The
scan parameters were standardized (tube current 120 kV
and 140 mAs; collimated slice thickness 64  0.64 mm; total
detector width 40 mm; rotation speed 0.5 s; table feed per
rotation 40 mm), resulting in a scan speed of approximately
8 s for a 30 cm scan length on the z-axis. Image analysis was
carried out using Advantage Windows 4.2 (GE Medical
Systems, USA) and AccuLite (AccuImage Diagnostics Corp,
South San Francisco, CA, USA).
Table 1 Duration of orotracheal intubation manoeuvres in 21
laboratory pigs
Intubation time (s)
Dorsoventral position 58.4 (47.4; 118.0)
Ventrodorsal position 17.3 (13.6; 29.9)
Data are medians and interquartile ranges

P , 0.001 for dorsoventral vs. ventrodorsal position
successful in all the animals. Using the technique described
above, no tube displacements or other intubation-related
complications were observed.
Intubation manoeuvres in the ventrodorsal position took sig-
nificantly less time than those in dorsal recumbency. The mean
duration in the ventral recumbency group was 17.3 s vs. 58.4 s in
the dorsal recumbency group; the power of the test performed
was 0.986 (Table 1). No hypoxia was observed in either group
(Table 2). Heart rates in pigs intubated in the ventrodorsal pos-
ition increased significantly after intubation, but did not signifi-
cantly exceed the values monitored for animals intubated in the
dorsoventral position (Table 2). Analysis of the correlation
between the total time needed for intubation and the heart
rate after intubation was carried out for both groups, but did
not show any significant relationship between these two vari-
ables (correlation coefficient 0.066, P value 0.86 in the dorsoven-
tral position group; 0.26 and 0.45 in the ventrodorsal position
group, respectively). After intubation, systolic blood pressure
decreased in both groups, but diastolic blood pressure
decreased only in the dorsoventral group. In both groups, the
mean arterial pressure was not influenced by intubation.
Since ventral recumbency provides a clear view of the
larynx, compared with a Cormack and Lehane grade 1 situ-
ation in humans, images for illustration (Figures 1 and 2)
were easily obtained.35 In contrast, it was not possible to take
any pictures showing the exposed larynx during conventional
laryngoscopy in dorsal recumbency. This emphasizes the fact
that visualization of the larynx is significantly reduced and
that the oropharyngeal space is narrowed with the dorso-
ventral position.

Results Discussion
Data from all 21 animals were obtained for analysis in this The main result of this study is the finding that orotracheal
study. The first attempt of orotracheal intubation was intubation of pigs can be performed much faster and therefore

Table 2 Haemodynamic and oxygenation variables during orotracheal intubation in 21 pigs

Before After
Recumbency intubation intubation
SpO2 (%) Dorsoventral 100.0 (99.3; 100.0) 100.0 (100.0; 100.0)
Ventrodorsal 100.0 (100.0; 100.0) 100.0 (100.0; 100.0)
HR (beats/min) Dorsoventral 89.5 (76.0; 96.0) 95.0 (85.0; 120.0)
Ventrodorsal 80.0 (70.0; 90.0) 100.0 (94.0; 110.0)
SAP (mmHg) Dorsoventral 130.0 (116.8; 142.5) 118.0 (104.0; 125.0)
Ventrodorsal 130.0 (122.5; 134.5) 114.0 (100.5; 119:5)
DAP (mmHg) Dorsoventral 82.0 (73.5; 85.3) 71.0 (62.0; 80.5)
Ventrodorsal 76.0 (72.3; 84.5) 71.0 (67.8; 80.0)
MAP (mmHg) Dorsoventral 95.5 (86.3; 102.0) 83.0 (71.7; 95.0)
Ventrodorsal 91.7 (70.0; 100.0) 85.3 (79.0; 92.9)

Data are medians and interquartile ranges. SpO2: peripheral oxygen saturation; HR: heart rate; SAP: systolic arterial pressure; DAP: diastolic arterial pressure;
MAP: mean arterial pressure

Significant at P , 0.05 vs. the value before intubation

................................................................................................................................................
Figure 1 Essential anatomical characteristics during intubation in pigs: ana-
tomical transections and computed tomograms (CTs). (a) The tube becoming
stuck at the thyroid or cricoid cartilage (arrow). (b) 1808 rotation of the tube
during advancement to the trachea solves the problem (arrow). (c) Close-up
view of the lateral ventricle of the larynx. (d) The arrow indicates the tube
becoming trapped in the lateral laryngeal ventricle. (e) The wrong direction
for ‘tracheal’ intubation: view into the recessus piriformis. (f ) View from the
trachea towards the larynx. The arrows indicate the subglottic constriction
of the trachea, a potential problem in advancing the tube. (g and h) The
anatomy shown in the corresponding CT scans
ca: cartilago arytenoidea; cc: cartilago cricoidea; cl: ‘corona laryngis’; ct: car-
tilago thyreoidea; dp: diverticulum pharyngeum; e: epiglottis; o: oesophagus;
pa: plica aryepiglottica; pc: processus corniculatus; pg: plica glossoepiglot-
tica mediana; pv: plica vocalis; rl: radix linguae; rp: recessus piriformis; tr:
trachea; v: velum palatinum; vll: ventriculus laryngis lateralis; vlm: ventriculus
laryngis medianus
more easily in the ventrodorsal position than in the dorsoven-
tral position. This is due to better visualization of the pharyn-
geal and laryngeal structures during laryngoscopy, as well as
the greater extension that can be provided by the technical
assistant. In addition, optimal handling of the equipment is
ensured by the ergonomic working position of the researcher
that is achieved when intubation is carried out with the
animal in the ventral recumbency position.
The animal’s oropharyngeal anatomy has been described
as being the main reason why orotracheal intubation is
more complicated in pigs than in any other domestic
animal.11,19,21,36 The major anatomical characteristics respon-
sible for potential problems during orotracheal intubation are
the long, beak-like snout and the small, narrow and long
oropharyngeal cavity filled with a wide and thick tongue.
The epiglottis is usually hidden by a large and floppy soft
Theisen et al. Intubation in laboratory swine 99
Figure 2 Orotracheal intubation in pigs. Demonstration of the procedure,
with the corresponding anatomical sagittal sections. (A/a) The view along
the tongue; the soft palate and back of the epiglottis, which obstructs a
clear view of the entrance to the larynx. (B/b) The epiglottis, dislocated in
the oropharynx; the ‘corona laryngis’ is visible. (C/c) The epiglottis has
been captured by the laryngoscope blade. This manoeuvre improves the
view of the deeper laryngeal structures. (D/d) The vocal folds are dimly
visible in the deep larynx after slight forward movement of the laryngoscope.
(E/e) The situation after correct intubation: the tube is in place. See Figure 1
for abbreviations
palate, in such a way that the elongated epiglottis reaches
the epipharynx, closely fitting the velum of the soft palate.
A pharyngeal diverticulum and a narrow larynx with one
large ventral and two lateral ventricles are other very special-
ized characteristics. The larynx is long, narrow and easily
relocatable, lying at an angle to the trachea. The distance
between the laryngeal entrance and the glottis is elongated
in comparison with many other laboratory animals.
Angular, caudoventrally positioned, slit-like vocal cords
and a sigmoidal laryngeal passage are further characteristics
of porcine laryngeal anatomy. The tendency of the pig to
develop laryngospasm easily also has to be taken into
account (Figure 1).7,8,10 – 12,15,21,22,37 – 42 These anatomical
characteristics are clearly substantial obstacles to porcine
orotracheal intubation. However, if the procedure is carried
out with the animal in ventral recumbency, most of these
100 Laboratory Animals Volume 43 January 2009
................................................................................................................................................
hindrances are alleviated. The positioning of the animal is
therefore crucial for completing the procedure in the majority
of animals with these anatomical peculiarities.
In general, the findings of the present study confirm the
results published by other groups, who have pointed out
that intubation in the ventrodorsal position is associated
with better results and a lower complication rate.8,33 Many
reports have strongly recommended using the ventrodorsal
position for orotracheal intubation of swine, although
without presenting any evidence-based data for the
recommendation.4,7 In contrast to these authors, as well as
to his own earlier publications, Swindle6 has stated in his
latest monograph that the position used is not relevant to
successful intubation in swine. He only suggests dorsal
recumbency in pigs with a total body weight of less than
50 kg.6 Earlier studies by authors favouring the dorsoventral
position should also be mentioned.36,37,43 The preference for
dorsal recumbency is probably due to the fact that clinicians
are accustomed to performing intubation in this position
in humans.44 However, it should be noted that none of
the authors concerned have provided support for this
recommendation with any objective data.
Evaluation of haemodynamic parameters in the present
study revealed interesting results. Heart rate in the ventro-
dorsal group was significantly higher after intubation in
comparison with the dorsoventral group. As the same
anaesthesia regimen was used in both groups, and
hypoxia was strictly prevented by preoxygenating the
animals via a facemask, the differences appear to be due
to the different positioning of the animals. Higher heart
rates would usually be attributed to higher levels of stress
and/or hypercapnia.45 However, hypercapnia was not
observed as a cause of the increased heart rate in the pigs.
In addition, the total time needed for intubation was
longer in the dorsoventral group. It may therefore be
hypothesized that vagal nerve stimulation was distinctly
less intense in the ventrodorsal group due to the signifi-
cantly faster intubation manoeuvre. As a result of the fast
intubation manoeuvre, no relevant vagal nerve stimulation
took place. It is possible that an absence of vagally mediated
heart rate depression caused the increased heart rate in the
ventrodorsal group. Vagal nerve stimulation is very often
accompanied by bradycardia, which probably counteracts
an increase in heart rate and in turn masks potential
changes in haemodynamics during intubation in dorsal
recumbency. There was no correlation between the total
time needed for intubation and the heart rate. However,
turning the pig from the dorsoventral to the lateral or ven-
trodorsal position during instrumentation caused a signifi-
cant drop in heart rate. This may have been due to a shift
in the blood volume, particularly as a result of reduced
cardiac preload after compression of the caval vein by the
intestines. This hypothesis is supported by the results
reported by Nakao et al. 46 who investigated the effects of
different animal positions on cardiac output in dogs and
pigs. Turning the animals from lateral recumbency to
a dorsoventral position induced a 32% drop in cardiac
output.46 As the animals were not subjected to any interven-
tion apart from the positional change, no vagal nerve stimu-
lation took place. It may be assumed that this was why
Nakao and colleagues46 did not observe any difference in
heart rate.
In addition, a decrease in systolic blood pressure during
intubation was observed in both groups in the present
study. They both had a significantly higher systolic arterial
pressure before orotracheal intubation than afterwards,
without any intergroup difference. As this occurred in
both groups, it may be concluded that it is not a specific
effect of the positioning of the animals, but rather a
general response derived from a reduction in sympatho-
adrenal reactions by two mechanisms – the onset of an ade-
quate depth of anaesthesia and lower levels of stress due to
the cessation of mechanical stimuli. It is well known that
this phenomenon occurs during general anaesthesia.44,47
In the present study, comparing ventral and dorsal
recumbency, none of the animals suffered hypoxia during
the entire intubation procedure. This is due to adequate
preoxygenation before intubation, as well as experience
and skill on the part of the investigators. Good preparation
is the reason why no complications occurred even during
the more challenging intubation procedures in dorsal
recumbency.
Both swine and other mammals are susceptible to respir-
atory depression during general anaesthesia, and safe
airway management is therefore crucial.8,11,48 – 50 It was
demonstrated as long ago as 1964 that intubation can be a
fast and safe method of protecting the airways. Schmitz
and co-workers reported a study in pigs undergoing
general anaesthesia. Intubation was achieved in 30 –120 s
without any fatal complications.37 Marshall12 also showed
that the mortality rate decreases if pigs are intubated
before surgical intervention. Whenever appropriate pre-
medication and depth of anaesthesia are achieved, together
with proper preoxygenation before intubation, we have not
observed any laryngospasm during the entire procedure.
In our 10 years’ experience with pigs of different breeds,
ages, weight and sex, as well as with differences in the
technical equipment used, we have not encountered the
findings reported by Rodriguez Montes and co-workers,16
who described laryngospasms as a common problem.
In earlier experimental protocols, we demonstrated that
even pigs with cardiopulmonary compromise tolerate the
procedure quite well when preoxygenation and a ventral
recumbent position are used. The orotracheal intubation
procedure using the method described is illustrated in
Figure 2.
In summary, our own results and experience do not
support the view that orotracheal intubation endangers
pigs to a greater extent than spontaneous respiration or tra-
cheotomy. After some training, all investigators should be
able to carry out quick and successful orotracheal intubation
with the animal in the ventrodorsal position in accordance
with the method described. From our point of view, com-
plete preparation of the animal and ensuring an adequate
depth of anaesthesia, extensive practical experience and
assistance from a trained assistant (if available) will help
avoid almost all of the complications associated with orotra-
cheal intubation. Finally, it should be emphasized that
gentle and fast orotracheal intubation is the gold standard
for airway management in pigs.

................................................................................................................................................
ACKNOWLEDGEMENTS
Financial support for this study was provided by the
German Federal State of North Rhine– Westphalia
(grant HBFG-112-470) and, in part, from the Else
Kröner-Fresenius Foundation, Germany (grant P52/05//
A32/05//F01). We are indebted to the perfusionists
T Erker and G Kock of the Department of Thoracic and
Cardiovascular Surgery at Münster University Hospital
for their excellent technical assistance.
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