Cricoid pressure (CP) was first described by Sellick in 1961, when he demonstrated a decreased chances of aspiration when posterior pressure was applied on the cricoid cartilage with the aim of occluding esophagus by compressing it between cricoid and cervical vertebrae. It was widely accepted into practice and has become a standard of care as a part of rapid sequence induction and intubation (RSII).
But five decades later there is still no consensus on the recommendations on the routine use of CP. Recent studies have shown that esophagus resides posterolateral to cricoid and CP results in further lateral displacement, so the possibility of complete esophageal occlusion is doubtful. The ethical issues related to conducting studies has led to lack of robust evidence of the utility or lack of it. The adverse effects of CP include airway obstruction, making mask ventilation difficult, worsening of glottic view, relaxation of lower esophageal sphincter, potential for cervical spine trauma and possible risk of aspiration despite proper application. A 2015 Cochrane review highlights the lack of benefits of CP application and concluded that the available evidence didn’t strongly support CP.
International surveys have shown that there is wide variation in how RSII is performed. The Project for Universal Airway Management (PUMA) is a collaboration of experts who have put together a set of universal principles for the conduct of RSI. It includes the recommended,suggested and optional components to be followed during RSI. This allows the clinician to decide on which all components to be used depending on the clinical scenario.
Routine use of CP in RSI is controversial. Several guidelines published by the international societies no longer recommend routine use of CP, but it is mentioned in Difficult Airway Society guidelines.
Paratracheal pressure is another alternative being explored as an alternative to CP. It seems a plausible alternative, considering the posterolateral position of esophagus.
Written By
Dr. Priyanka Pavithran
Senior Consultant Anesthesiologist
Aster MIMS, Calicut