There are excellent papers showing that cricoid pressure is not indicated at all.

I suppose to read Priebe et al. (Cricoid pressure: an expert's opinion. Priebe HJ.Minerva Anestesiol. 2009 Dec;75(12):710-4.)

In our clinic we do not use cricoid pressure at all.

The American heart Association Advanced Cardiac Life Support 2010 states

"The safety and value of using cricoid pressure during emergency intubation has been questioned. It is therefore recommended that the application of cricoid pressure should be modified or discontinued if it impedes ventilation or the speed or ease of intubation".

In respect of cardiac arrest it recommends the routine use of cricoid pressure during airway management of patients in cardiac arrest is no longer recommended.

I hope that this might be of some help to you

Richard

Thank you - very useful reaction. In the UK (I spent six years working there as an anaesthetist) still many people believe in cricoid pressure in any emergency intubation. And all trainee doctors are taught how to perform it correctly.

I have been doing anesthesia for 30+ years, I never believed nor practiced cricoid pressure in a single patient. I strongly support the current views that it is useless and actually might be harmful in situations like difficult intubation.

Cricoid force is widely accepted as a "standard of care" in UK anaesthetic practice and culturally engrained. It is difficult to change practice (despite evidence of increasing C&L grade, lack of efficacy etc). So what to do? Teach pragmatic approach; poor view/difficult intubation - optimise vector, half then remove force. I'm not aware of any medico-legal cases where NOT using cricoid force has been criticised - greater minds may know more.

Currently in UK practice cricoid pressure in the circumstance of presumed "full stomach" is the standard of care. There is little data to support its ongoing use but those of us who have been in practice long enough can all recount episodes where criciod was used, the patient was intubated and when the cricoid came off, a large volume of gastric contents flooded into the mouth. It isn't common and by defintion is a problem only seen in retrospect. So cricoid does something in some people sometimes!!

For me in the context of anaesthesia and critical care that I work in I am aware that the evidence for criciod pressure is poor, but pragmatically it is more defensible to have used it in the currently accepted circumstances and have it removed- (not half removed or relaxed but taken away all together), then not use it at all. In fact i find in the critically ill patient in my ICU work that i rarely use it as i often need to maintain ventilation and oxygenation throughout with bag valve mask oxygenation, and cricoid pressure makes this impossible. I find that sitting the patient up or using reverse trendeleburg position if they need to stay in spinal aligment is useful twofold for potentially increasing FRC and also providing a larger gradient against regurgitation of gastric contents.

NAP4 from the Uk demonstrated real harm from aspiration of stomach contents into the airway so it is a real issue- although i accept fully that criciod pressure may not be the solution.

I think that the real issue here is that especially outwith a theatre enviroment the person applying the cricoid often has absolutely no idea what they are doing and therefore distorts the anatomy and for the occasional intubator this makes things even more difficult. It is certainly true that poorly applied cricoid pressure can make the view more difficult than it needs to be but equally external laryngeal manipulation directed by the intubator can make all the difference.

Ive read the papers - and can understand the position that if ineffectively applied it is a useless manuever that can complicate airway intubation. However, I do perform it in patients considered full stomach - and to re-iterate what one responder already shared - I have had one case where after cuff inflation when the pressure was removed - gastric contents did regurgitate into the mouth. So- while cricoid pressure may distort visualization - Id argue that Id take a distorted view of the glottis over a submerged one anyday. I dont like taking the risk in full stomach patients - In them it makes practical sense (supported by experience) to take the precaution during an emergent RSI.

In my residency days we were taught to apply cricoid pressure as part of RSI in all the patients presenting for emergency laprotomy and caesarean section.I still use this procedure in cases where i find the chances of regurgitation are high.Properly applied cricoid pressure does not much affect the airway,though studies are coming up against its effectiveness we teach all our residents to learn this useful practice.

I read with interest all the concerns regarding cricoid pressure, I still think it is useless and actually may be harmful for the following reasons:

1. Thinking that cricoid pressure will prevent stomach contents from flooding the view is a false security feeling, if active vomiting occurs, obstructing the oesophagus by heavy cricoid pressure may lead to its rupture with catastrophic outcome. On the other hand, active vomiting means improper RSI technique with inadequate dose of sux.

2. In order for aspiration to happen, the pressure in the pharynx should be higher than that in the lungs, this can happen if the patient is breathing spontaneously, if the patient is fully paralyzed, flooding of the pharynx doesn't mean aspiration, thorough suctioning will take care of this problem.

3. A good technique of RSI , without cricoid pressure, should be very safe in the patient with full stomach who is not expected to be difficult intubation, otherwise an awake intubation is the technique of choice.

I thank for the question. In Poland to the intubation in emergency cesarean section one should always apply RSI. And what reality is? One should search it.

I think that in spite of recommendations not everyone apply RSI.

Pawel

I shall go for the current views that questions the efficiency of cricoid pressure.

Poorly applied cricoid pressure will not only potentially distort the airway but it often, when applied with only one hand, cause head flexion and therefore create a less than optimal head position for intubation. This is not always noticed by less experienced anaesthetists and will create a more difficult view on laryngoscopy. It is therefore important to often use 2 hands for cricoid pressure (with one hand behind the neck) to prevent this tilting forward of the head and maintain an optimal head position for intubation.

So-called cricoid pressure is really an effort at collapsing the mucosa of the esophageal inlet or upper esophageal sphincter. I agree with Dr. Clarke, the maneuver, if done poorly can actually decrease the ability of the endoscopist to see the airway let alone intubate it. As a surgeon of these structures I will say that almost always the inlet is to the left of the cricoid by several millimeters. Thus if one presses GENTLY on the cricoid and biases the pressure to the left, this is more effectively helping the process without distorting the airway. Worse yet is that vigorous pressure is actually CLOSING the airway and preventing bag mask ventilation in preparation for intubation. This decreases the effective time for safe endoscopy and intubation…a lose-lose proposition.

"Before all, do no harm"...

Wise words, indeed!

Gentle cricoid pressure may improve intubation, it is not harmful and prevent damage from the blade of laryngoscope. However in cesarean section experienced and skilled anesthesiologist make the difference, in the other cases better to have an Igel mask or  a glidescope.

The data supporting cricoid pressure is very weak. I feel that it is much more likely to obscure your view than it is to prevent aspiration. Here is a nice little debate on the issue.

https://www.youtube.com/watch?v=0oXdDOBsRm8

no cricoid pressure.