Anaesth Intensive Care 2010; 38: 1029-1033

Vocal cords-carina distance in anaesthetised Caucasian

adults and its clinical implications for tracheal intubation
G. PANG*, M. J. EDWARDS†, K. B. GREENLAND‡
Department of Anaesthesia and Perioperative Medicine, Royal Brisbane and Women’s Hospital, Brisbane, Queensland, Australia

SUMMARY
Previous work has assessed vocal cords-carina distance in Chinese patients and compared it to commonly
used tracheal tubes. In addition, an attempt was made to identify surface anatomy measurements with short
tracheas. We have examined the length of tracheas in Caucasian patients and compared it with currently used
tracheal tubes. We have investigated a wider range of surface anatomy measurements in an attempt to correlate
measurements with vocal cords-carina distance and identifying patients who may be at risk of endobronchial
intubation. In this study, the vocal cords-carina distance was measured in 150 anaesthetised Caucasian patients
with a fibreoptic bronchoscope. We also attempted to correlate height and various surface anatomy measurements
on the patients’ chest, neck and limb regions to predict those patients at risk of endobronchial intubation. The
mean vocal cords-carina distance was 12.7 cm (standard deviation 1.6 cm). The best predictors in our study of
vocal cords-carina distance less than 11.3 cm were a height of ≤182 cm, an ulnar length of ≤31.2 cm or a thyroid
to xiphisternum distance of ≤31.8 cm. This correlation is poor however, and prediction of vocal cords-carina
distance remains difficult clinically. It was therefore concluded that surface anatomy measurements are a poor
predictor of vocal cords-carina distance.
Key Words: tracheal length, vocal cords-carina distance, Caucasians, tracheal tube, trachael tube cuff, fibreoptic bronchoscope

Placement of a tracheal tube can result in
significant complications if the tube is positioned
incorrectly. The tracheal tube cuff must be placed
distal to the glottic opening to seal the airway
reliably and avoid direct damage to the vocal cords,
nerve compression and accidental extubation1,2.
Endobronchial intubation may occur if the tip of
the tracheal tube is too close to the carina,
particularly with pneumoperitoneum, Trendelenburg
positioning3 or movement of the head and neck4,5.
Unfortunately, there is considerable variation
in vocal cords-carina distances (VCD) between
individuals and there is no good bedside predictor
of a short trachea6. Formulae have been suggested
to guide depth of insertion of the tracheal tube7-9
and some tracheal tube manufacturers also place
one or two black marks proximal to the cuff as a
guide to correct depth of insertion. In a recent study
* M.B., B.S., F.A.N.Z.C.A., Staff Anaesthetist, Department of Intensive
Care Medicine.
† M.B., B.S., F.A.N.Z.C.A., Staff Anaesthetist.
‡ M.B., B.S., F.A.N.Z.C.A., F.H.K.A.M., Senior Specialist.
Address for correspondence: Dr G. Pang, Staff Intensivist, Department of
Intensive Care Medicine, Royal Brisbane and Women’s Hospital, Butterfield
St, Herston, Brisbane, Qld 4006.
Accepted for publication on June 19, 2010.
Anaesthesia and Intensive Care, Vol. 38, No. 6, November 2010
comparing several methods of tracheal tube
placement, although marking the tube proximal
to the cuff resulted in the lowest number of
tube malpositions, there were still a number of
endobronchial intubations10.
This study was performed as a follow-up to a
study performed in a Chinese population6. Previous
work suggests that height is a significant predictor of
tracheal length11 and given the Caucasian population
are on average taller than the Chinese population12,13,
one would expect that Caucasian VCD would
therefore be longer. We wished to examine the
appropriateness of currently used tracheal tubes in
the Caucasian population and whether the short-
comings found in the Chinese population still
applied. We also examined a wider range of surface
anatomy markings in an attempt to identify a
clinically useful predictor of patients who may
have short tracheas, which would predispose to
endobronchial intubation.
METHODS
Following local institutional ethics committee
approval, informed written consent was obtained
from 150 adult patients presenting for elective
surgery requiring tracheal intubation. Patients with
1030 G. Pang, M. J. Edwards, K. B. Greenland

a past history of difficult tracheal intubation or
with clinical signs of potential difficulty with tracheal
intubation (i.e. a modified Mallampati score of 3 or
4, limited mouth-opening, thyromental distance
<4 cm, limited neck movement or upper airway
disease) were excluded.
Patient age, gender, weight, height and surface
anatomy measurements were all recorded peri-
operatively. The surface anatomy measurements
were thyromental distance, thyrosternal distance,
sternomental distance, sternal length, phalangeal
length of the middle finger, ulnar length, foot length
and thyroid to xiphisternum distance. Measurements
of the head and neck were taken while the patient was
in the classic ‘sniffing position’.
Routine non-invasive monitoring was established
and the patient was placed in the sniffing position.
Following induction of anaesthesia, tracheal
intubation was performed using a Profile Soft-Seal
Cuff™ (Portex Ltd, Hythe, Kent, UK) tracheal tube
with the black intubating guide mark placed at the
vocal cords. Tracheal tubes of 7 and 8 mm internal
diameter (ID) were used in females and males,
respectively. Once the tube was inserted an assistant
strictly maintained the head and neck in the sniffing
position to avoid any movement of the tube while
laryngoscope was removed. All patients in the
study were laryngoscopy graded Cormack-
Lehane 1 or 2, which allowed visual confirmation
that the intubating guide mark was at the level of
the cords. When the investigators were satisfied
that the patient was being adequately ventilated
and anaesthetised, the tracheal tube was
disconnected from the circuit and a fibreoptic
bronchoscope (LF-GP, Olympus, Tokyo, Japan) was
passed down the tube.
The fibreoptic bronchoscope was inserted to the
carina and a marker placed on the bronchoscope
where it entered the connector of the tracheal tube.
The bronchoscope was then withdrawn until the
tip of the tube was visualised and a second marker
was placed on the scope. The VCD was then
calculated by adding the distance from the tip to
carina to the distance from the tip to the black
intubating mark.
Comparisons between groups were examined
using the t-test. Correlation coefficients were used
to investigate the relationships between surface
anatomy and VCD. Sensitivity, specificity and
positive predictive values were applied to evaluate
the detection power of the various anatomic
measurements for short VCDs. The statistical
software used was SPSS for Windows, Release 16.0
(SPSS Inc., USA).

Table 1
Patient demographics and anatomy measurements. Values are in mean ± SD (95% CI) or % (number).

Female (n=70) Male (n=79) Total (n=149) P value

(H0:F=M)
Vocal cords-carina (cm) 11.8±1.3 (11.5, 12.1) 13.6±1.4 (13.3, 13.9) 12.7±1.6 (12.5, 13.0) <0.001*
Age, y 48.7±18.4 (44.3, 53.1) 51.0±18.5 (46.9, 55.2) 49.9±18.5 (46.9, 52.9) 0.44
Weight, kg 74.3±19.1 (69.8, 78.9) 84.4±18.6 (80.2, 88.5) 79.7±19.4 (76.5, 82.8) 0.001*
Height, cm 163±8 (161, 164) 179±8 (177, 181) 171±12 (170, 173) <0.001*
BMI, kg.m-2 28.1±6.9 (26.4, 29.7) 26.2±5.0 (25.1, 27.3) 27.1±6.04 (26.1, 28.1) 0.06
CL
1 36.9% (55) 40.9% (61) 83.5% (116)
2 6.0% (9) 9.4% (14) 16.6% (23)
Unrecorded – – 6.8% (10)
Thyromental distance, cm 7.4±1.4 (7.1, 7.8) 7.7±1.5 (7.3, 8.0) 7.6±1.5 (7.3, 7.8) 0.29
Thyrosternal distance, cm 6.6±1.5 (6.2, 6.9) 7.6±1.7 (7.2, 8.0) 7.1±1.7 (6.9, 7.4) <0.001*
Sternomental distance, cm 13.4±2.0 (12.9, 13.9) 14.3±2.3 (13.8, 14.8) 13.9±2.2 (13.5, 14.2) 0.01*
Sternal length, cm 17.6±2.5 (17.0, 18.2) 21.6±2.7 (21.0, 22.2) 19.7±3.3 (19.2, 20.3) <0.001*
Phalangeal length, cm 10.1±0.6 (9.9, 10.2) 11.3±0.7 (11.1, 11.4) 10.7±0.9 (10.6, 10.8) <0.001*
Ulnar length, cm 25.3±1.8 (24.8, 25.7) 28.6±1.7 (28.2, 29.0) 27.0±2.4 (26.6, 27.4) <0.001*
Foot length, cm 23.5±1.7 (23.1, 23.9) 26.5±1.7 (26.1, 26.9) 25.1±2.3 (24.8, 25.5) <0.001*
Thyroid to xiphisternum distance, cm 24.2±3.2 (23.4, 25.0) 29.2±3.4 (28.4, 30.0) 26.9±4.1 (26.2, 27.5) <0.001*
* significant at 0.05 level. CI=confidence interval, F=female, M=male, BMI=body mass index, CL=Cormack-Lehane laryngoscopy
grading.
Anaesthesia and Intensive Care, Vol. 38, No. 6, November 2010
 Vocal cords-carina distance in Caucasians 1031

RESULTS Specificity and the positive predictive values were

One hundred and fifty patients were studied.
One patient was excluded from analysis due to
incomplete data collection. Table 1 shows the
patients’ demographics and surface anatomy
measurements. Table 2 shows the VCD
measurements, with 13 patients (8.7%) in our study
having a VCD of 10.5 cm or less. On two occasions,
the shortest female trachea measured was 9.8 cm,
while the shortest male trachea was 10.7 cm.
The correlations of the different anatomic
measurements with VCD are shown in Table 3. The
best correlations to VCD were height, ulnar length
and thyroid-xiphisternal distance with r=0.5444,
r=0.5101 and r=0.4817 respectively. The Chinese
study did not include phalangeal, ulnar or foot
length. The two variables used in both the Chinese
and our studies, which correlated with the patients’
VCD were height and thyroid to xiphisternum
distance.
Table 2
Frequencies of VCD
calculated for the various anatomic measurements
(Table 4). These were constructed assuming a
sensitivity of 100%. A ‘very short’ VCD of ≤10.5 cm
occurred in individuals with height ≤170 cm,
ulnar length ≤28.2 cm, sternal length ≤20.3 cm or
thyroid to xiphisternum distance ≤27.6 cm.
DISCUSSION
The length of the trachea in a ‘normal’ adult
patient is usually quoted as approximately 15 cm14.
Many studies which examine the length of patients’
tracheas use such methods as chest X-rays or
cadaver specimens. However, these methods may
be inaccurate due to such errors as magnification of
the X-ray images or shrinkage of the specimen. We
have chosen to measure the vocal cord-carina
distance in end-expiration using a flexible broncho-
scope to closely mirror the clinical situation during
anaesthesia.
In this study, the mean VCD was 12.7 cm overall
for both genders, with a range of 11.8±1.3 cm and

VCD (cm) Frequency % Cumulative Cumulative % Table 3

frequency Correlations of measurements with VCD
≤10.0 6 4.0 6 4.0
Measurements Correlation P value
>10.0-10.5 7 4.7 13 8.7 coefficient (r) (H0:r=0)
>10.5-11.0 12 8.1 25 16.8 Age 0.0177 0.83
>11.3-11.5 16 10.7 41 27.5 Weight 0.1463 0.08
>11.5-12.0 14 9.4 55 36.9 Height 0.5444 <0.0001*
>12.0-12.5 11 7.4 66 44.3 Body mass index -0.1764 0.03*
>12.5-13.0 19 12.8 85 57.1 Thyromental distance 0.0962 0.24
>13.0-13.5 18 12.1 103 69.2 Thyrosternal distance 0.3118 <0.0001*
>13.5-14.0 19 12.8 122 82 Sternomental distance 0.1426 0.08
>14.0-14.5 11 7.4 133 89.4 Sternal length 0.4486 <0.0001*
>14.5-15.0 4 2.7 137 92.1 Phalangeal length 0.4712 <0.0001*
>15.0-15.5 5 3.4 142 95.5 Ulnar length 0.5101 <0.0001*
>15.5-16.0 4 2.7 146 98.2 Foot length 0.4655 <0.0001*
>16.0 3 2.0 149 100 Thyroid to xiphisternal distance 0.4817 <0.0001*
Short VCD defined as 11.3 cm. VCD=vocal cords-carina distance. * significant at 0.05 level. VCD=vocal cords-carina distance.

Table 4
Cut-off value, specificity and positive predictive values of the various measurements when sensitivity of the test is 100%

VCD Height Ulnar length TXD

10.5 cm ≤170 cm (Spec=56.6%, PPV=18.1%) ≤28.2 cm (Spec=36.0%, PPV=13.0%) ≤27.6 cm (Spec=46.3%, PPV=15.1%)
11.0 cm ≤182 cm (Spec=19.4%, PPV=20.0%) ≤31.2 cm (Spec=3.2%, PPV=17.2%) ≤31.8 cm (Spec=15.3%, PPV=19.2%)
11.3 cm ≤182 cm (Spec=21.1%, PPV=28.0%) ≤31.2 cm (Spec=3.5%, PPV=24.1%) ≤31.8 cm (Spec=16.7%, PPV=26.9%)
11.5 cm ≤183 cm (Spec=18.5%, PPV=31.8%) ≤31.2 cm (Spec=3.7%, PPV=28.3%) ≤31.8 cm (Spec=17.6%, PPV=31.5%)
12.0 cm ≤185 cm (Spec=14.9%, PPV=40.7%) ≤31.2 cm (Spec=4.3%, PPV=38.0%) ≤31.8 cm (Spec=20.2%, PPV=42.3%)
VCD=vocal cords-carina distance, TXD=thyroid to xiphisternum distance, Spec=specificity, PPV=positive predictive value.
Anaesthesia and Intensive Care, Vol. 38, No. 6, November 2010
1032 G. Pang, M. J. Edwards, K. B. Greenland
13.6±1.4 cm in females and males respectively.
These measurements are remarkably similar to
those of the Chinese female and male population6,
12.0±1.2 cm and 13.4±1.3 cm, respectively. The
overall mean was similar to the previous Chinese
study, 12.6±1.4 cm. The shortest female VCD
measured was 9.8 cm and the shortest male VCD
was 10.7 cm.
Modern tracheal tubes are marked with one or
more intubation guide marks usually 2 to 3 cm
proximal to the tracheal cuff to assist in correct
placement. Manufacturers recommend that the
marks be level with the vocal cords. One of the
commonly used tracheal tubes in our institution is
the 7 and 8 mm ID Portex tube. Previous work by
Chong and workers6 indicates that the dimensions
of this tube are similar to many other commercially
available brands. The 7 mm ID Portex tube extends
8.8 cm beyond the black intubating mark. The cuff
is approximately 2.9 cm below this mark.
Therefore it can be expected that in patients with
short tracheas (i.e. less than 11.3 cm), there will be
a low margin of safety for positioning of tracheal
tubes.
The use of surface anatomy measurements
appears to be of little help clinically in detecting
patients with short VCD. Previous studies have
suggested that the vocal cords-carina distance is
related to the height of the patient11, sternal length15
and thyrosternal length6. In this study there was a
poor correlation between height and VCD and this
was almost identical to the previous Chinese study6
(r=0.54 vs r=0.55). In addition to previously
measured indices such as thyromental distance,
sternomental distance, sternal length and
thyrosternal distance, several extra-cervicothoracic
measurements were included, such as ulnar length,
phalangeal length of the middle finger and foot
length. Both external chest measurements and
peripheral measurements provided only mild to
moderate correlation. Based on our data, patients
with a height ≤1.82 m, an ulnar length ≤31.2 cm or
a thyroid to xiphisternum distance ≤31.8 cm should
be monitored with a high level of vigilance to avoid
the risk of inadvertent endobronchial intubation.
However, a high index of suspicion should be
maintained for all patients, especially if they are
female.
The presence of an easily visible intubating guide
mark at or above the vocal cords coupled with a
short sub-vocal cord segment will allow verification
of correct tracheal tube placement. Currently
available tracheal tubes have relatively long sub-
vocal cord segments and as this study suggests, may
be inappropriately designed. A suggested design of
a tracheal tube, based on a sample of the Australian
Caucasian and Hong Kong Chinese populations,
would be a tube with an intubating guide mark to
tip distance of 8.0 cm. This would allow safe
intubation in 92% of this study population and 95%
of the Chinese study population.
Based on our results, we make the following
observations and recommendations:
1. Caucasian VCDs are similar to those measured
in the Chinese population, despite possible
variations in the heights of the different
population groups.
2. Many surface anatomy measurements are poor
predictors of short VCD.
3. The European standard for tracheal tubes
(British Standard EN 1782:1998 “Tracheal tubes
and connectors”) specifies the maximum distance
from the distal end of the tubes to the proximal
end of the inflatable length of the cuff is 6.6, 6.9,
7.2 and 7.5 cm for 7.0, 7.5, 8.0 and 8.5 mm ID
tracheal tubes, respectively. Our measurements
show that the tracheal tubes used comply with
this requirement.
We suggest that further investigations into this
area should occur to ensure that the standard
is appropriate. In the meantime, tracheal tube
manufacturers should be aware of these results and
consider shortening the distance from the intubation
mark to the cuff, the length of the cuff and the cuff
to the tip of the tube.
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