Abstract
Purpose
Although encoid pressure (CP) is a superficially simple and appropriate mechanical method to protect the patient from regurgitation and gastnc insufflation, in practice it is a complex manoeuvre which is difficult to perform optimally. The purpose of this review is to examine and evaluate studies on the application of (CP). It deals with anatomical and physiological considerations, techniques employed, safety and efficacy issues and the impact of CP on airway management with special mention of the laryngeal mask airway.
Source of material
Three medical databases (48 Hours, Medline, and Reference Manager Update) were searched for citations containing key words, subject headings and text entnes on CP to October 1996.
Principle Findings
There have been no studies proving that CP is beneficial, yet there is evidence that it is often ineffective and that it may increase the nsk of failed intubation and regurgitation. After evaluation of all available data, potential guidelines are suggested for optimal use of CP in routine and complex situations.
Conclusions
If CP is to remain standard practice dunng induction of anaesthesia, it must be shown to be safe and effective. Meanwhile, further understanding of its advantages and limitations, improved training in its use, and guidelines on optimal force and method of application should lead to better patient care.
Résumé
Objectif
Bien qu’elle sort une méthode mécanique en apparence simple et appropnée exécutée pour protéger contre la régurgitation et l’insufflation gastrique, la compression du cricoïde (CC), en pratique, constitue une manoeuvre complexe et difficile à réaliser parfaitement. Cette revue vise l’analyse et l’évaluation des études publiées sur son usage. Elle porte sur les considérations anatomiques et physiologiques, les techniques utilisées, les problèmes de sécunté et d’efficacité et l’impact de la CC sur la gestion des voies aériennes avec une attention spéciale envers le masque laryngé.
Source
Trois bases de données médicales (48 Hours, Medline etReference Manager Update) ont été scrutées au regard des citations contenant les mots clés, les titres des sujets et les entrées de texte concernant la CC jusqu’au mois d’octobre 1996.
Principales constatations
Aucune étude n’a prouvé les bienfaits de la CC, alors qu’il est démontré qu’elle est souvent inefficace et qu’elle peut augmenter l’incidence des intubations échouées et des régurgitations. Après une évaluation de toutes les données disponibles, des lignes de conduites sont suggérées en vue d’une pratique optimale de la CC dans les situations courantes et complexes.
Conclusions
Si la CC dort demeurer une manoeuvre standard pendant l’induction de l’anesthésie, il faut faire la preuve qu’elle est sûre et efficace. En attendant, une meilleure compréhension de ses avantages et de ses limitations, un enseignement amélioré et des données plus précises sur la pression exercée idéale et son mode d’utilisation devraient nous aider à fournir de meilleurs soins.
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References
Rosen M. Anaesthesia for obstetrics (Editorial). Anaesthesia 1981; 36: 145–6.
Standards and guidelines for cardiopulmonary resuscitation (CPR) and emergency cardiac care (ECC). JAMA 1985; 255: 2905–84.
Gwinnutt CL, Smurthwaite GJ, Elcock DH. Cricoid pressure and advance life support (Letter). Anaesthesia 1995; 50: 912–3.
Kron SS. Questionable effectiveness of cricoid pressure in preventing aspiration (Letter). Anesthesiology 1995; 83: 431.
Schwartz DE, Cohen NH. Questionable effectiveness of cricoid pressure in preventing aspiration (Letter). Anesthesiology 1995; 83: 432.
Howells TH, Chamney AR, Wraight WJ, Simons RS. The application of cricoid pressure. An assessment and a survey of its practice. Anaesthesia 1983; 38: 457–60.
Lawes EG. Cricoid pressure with or without the “cricoid yoke.” Br J Anaesth 1986; 58: 1376–9.
Vanner RG, O’Dwyer JP, Pryle BJ, Reynolds F. Upper oesophageal sphincter pressure and the effect of cricoid pressure. Anaesthesia 1992; 47: 95–100.
Schwartz DE, Mathhay MA, Cohen NH. Death and other complications of emergency airway management in critically ill adults. Anesthesiology 1995; 82: 367–76.
Tournadre JP, Chassard, D, Berrada K, Boulétreau P. Lower oesophageal sphincter pressure during application of cricoid pressure in conscious volunteers. Br J Anaesth 1996; 76: A50.
Ralph SJ, Wanham CA. Rupture of the oesophagus during cricoid pressure. Anaesthesia 1991; 46: 40–1.
Caplan RA, Posner KL, Ward RJ, Cheney FW. Adverse respiratory events in anesthesia: A closed claims analysis. Anesthesiology 1990; 72: 828–33.
Jackson SH. Efficacy and safety of cricoid pressure needs scientific validation (Letter). Anesthesiology 1996; 84: 751–2.
Benhamou D. Controversies in obstetric anaesthesia. Cricoid pressure is unnecessary in obstetric general anaesthesia. Int J Obstet Anesth 1995; 4: 30–3.
Vanner RG. Mechanisms of regurgitation and its prevention with cricoid pressure. Int J Obstet Anesth 1993; 2: 207–15.
Hawthorne L, Wilson R, Lyons G, Dresner M. Failed intubation revisited: 17-yr experience in a teaching maternity unit. Br J Anaesth 1996; 76: 680–4.
Warner MA, Warner ME, Webber JG. Clinical significance of pulmonary aspiration during the perioperative period. Anesthesiology 1993; 78: 56–62.
Benhamou D. French obstetric anaesthetists and acid aspiration prophylaxis. Eur J Anaesthesiology 1993; 10: 27–32.
Salem MR, Sellick BA, Elam JO. The historical background of cricoid pressure in anesthesia and resuscitation. Anesth Analg 1974; 53: 230–2.
Sellick BA. Cricoid pressure to prevent regurgitation of stomach contents during induction of anaesthesia. Lancet 1961; ii: 404–6.
Ruben H, Knudsen EJ, Carugati G. Gastric inflation in relation to airway pressure. Acta Anaesthesiol Scand 1961; 5: 10714.
Salem MR, Wong AY, Mani M, Sellick BA. Efficacy of cricoid pressure in preventing gastric inflation during bag-mask ventilation in pediatric patients. Anesthesiology 1974; 40: 96–8.
Salem MR, Wong AY, Fizzotti GF. Efficacy of cricoid pressure in preventing aspiration of gastric contents in paediatric patients. Br J Anaesth 1972; 44: 401–4.
Salem MR, Joseph NJ, Heyman HJ, Belani B, Paulissian R, Ferrara TP. Cricoid compression is effective in obliterating the esophageal lumen in the presence of a nasogastric tube. Anesthesiology 1985; 63: 443–6.
Salem MR, Heyman HJ, Livschultz V, Mahdi M. Cephalad displacement of the larynx facilitates tracheal intubation. Anesthesiology 1987; 67: A453.
Lawes EG, Duncan PW, Bland B, Gemmel L, Downing JW. The cricoid yoke — a device for providing consistent and reproducible cricoid pressure. Br J Anaesth 1986; 58: 925–31.
Lawes EG, Campbell I, Mercer D. Inflation pressure, gastric insufflation and rapid sequence induction. Br J Anaesth 1987; 59: 315–8.
Lawes EG, Baskett PJF. Pulmonary aspiration during unsuccessful cardiopulmonary resuscitation. Intensive Care Med 1987; 13: 379–82.
Vanner RG, Pryle BJ. Nasogastric tubes and cricoid pressure (Letter). Anaesthesia 1993; 48: 1112–3.
Vanner RG, Pryle BJ. Regurgitation and oesophageal rupture with cricoid pressure: a cadaver study. Anaesthesia 1992; 47: 732–5.
Benumof JL. Difficult laryngoscopy: obtaining the best view (Editorial). Can J Anaesth 1994; 41: 361–5.
Baxter AD. Cricoid pressure in the sniffing position (Letter). Anaesthesia 1991; 46: 327.
King TA, Adams AP. Failed tracheal intubation. Br J Anaesth 1990; 65: 400–14.
Vanner RG, Pryle BJ, O’Dwyer JP, Reynolds F. Upper oesophageal sphincter pressure and the intravenous induction of anaesthesia. Anaesthesia 1992; 47: 371–5.
Whittington RM, Robinson JS, Thompson JM. Fatal aspiration (Mendelson’s) syndrome despite antacids and cricoid pressure. Lancet 1979; ii: 228–30.
Sellick BA. Rupture of the oesophagus following cricoid pressure? (Letter). Anaesthesia 1982; 37: 213–4.
Vanner RG. Tolerance of cricoid pressure by conscious volunteers. Int J Obstet Anesth 1992; 1: 195–8.
Cook TM. Cricoid pressure: are two hands better than one? Anaesthesia 1996; 51: 365–8.
Veall GRQ Swinhoe CF. A good reason to employ ambidextrous ODAs (Letter). Anaesthesia 1994; 49: 556–7.
Cowling J. Cricoid pressure — a more comfortable technique (Letter). Anaesth Intensive Care 1982; 10: 93–4.
Crowley DS, Giesecke AH. Bimanual cricoid pressure (Letter). Anaesthesia 1990; 45: 588–9.
Williamson R. Bimanual cricoid pressure — another version (Letter). Anaesthesia 1991; 46: 510.
Wraight WJ, Chamney AR, Howells TH. The determination of an effective cricoid pressure. Anaesthesia 1983; 38: 461–6.
Crawford JS. The ‘contracricoid’ cuboid aid to tracheal intubation (Letter). Anaesthesia 1982; 37: 345.
Hartley M. Cricoid pressure and potential spine injuries (Letter). Anaesthesia 1993; 48: 1113.
Mills P, Poole T, Curran J. Cricoid pressure and the pressor response to tracheal intubation. Anaesthesia 1988; 43: 788–91.
Dent J, Dodds WJ, Friedman RH, et al. Mechanism of gastroesophageal reflux in recumbent asymptomatic human subjects. J Clin Invest 1980; 65: 256–67.
Holloway RH, Hongo M, Berger K, McCallum RW. Gastric distension: a mechanism for postprandial gastroesophageal reflux. Gastroenterology 1985; 89: 779–84.
Smith G, Dalling R, Williams TIR. Gastrooesophageal pressure gradient changes produced by induction of anaesthesia and suxamethonium. Br J Anaesth 1978; 50: 1137–43.
Marchand P. A study of the forces productive of gastro-ocsophageal regurgitation and herniation through the diaphragmatic hiatus. Thorax 1957; 12: 189.
Vanner RG, Pryle BJ, O’Dwyer JP, Reynolds F. Upper oesophageal sphincter pressure during inhalational anaesthesia. Anaesthesia 1992; 47: 950–4.
Fanning GL. The efficacy of cricoid pressure in preventing regurgitation of gastric contents. Anesthesiology 1970; 32: 553–5.
Petito SP, Russell WJ. The prevention of gastric inflation — a neglected benefit of cricoid pressure. Anaesth Intensive Care 1988; 16: 139–43.
Admani M, Teh TF, Jain R, Mora A, Pildes RS. Prevention of gastric inflation during mask ventilation in newborn infants. Crit Care Med 1985; 13: 592–3.
Moynihan RJ, Brock-Utne JG, Archer JH, Feld LH, Kreitzman TR. The effect of cricoid pressure on preventing gastric insufflation in infants and children. Anesthesiology 1993; 78: 652–6.
Vyas H, Milner AD, Hopkin IE. Face mask resuscitation: does it lead to gastric distension? Arch Dis Child 1983; 58: 373–5.
Allen JG, Burnstein RM. Laparoscopic cholecystectomy and cricoid pressure (Letter). Anesth Analg 1994; 78: 405.
Fisher RS, Malmud LS, Roberts GS, Lobis IF. Gastroesophageal (GE) scintiscanning to detect and quantitate GE reflux. Gastroenterology 1976; 70: 301–8.
Satiani B, Bonner JT, Stone HH. Factors influencing intraoperative gastric regurgitation. A prospective random study of nasogastric tube drainage. Arch Surg 1978; 113: 721–3.
Allman KG. The effect of cricoid pressure application on airway patency. J Clin Anesth 1995; 7: 197–9.
Lyons G. Failed intubation. Six years’ experience in a teaching unit. Anaesthesia 1985; 40: 759–62.
Davies JM, Weeks S, Crone LA, Pavlin E. Difficult intubation in the parturient. Can J Anaesth 1989; 36: 668–74.
Rose DK, Cohen MM. The airway: problems and predictions in 18,500 patients. Can J Anaesth 1994; 41: 372–83.
Williamson JA, Webb RK, Szekely S, Gillies ERN, Dreosti AV. Difficult intubation: an analysis of 2000 incident reports. Anaesth Intensive Care 1993; 21: 602–7.
Shorten GD, Alfille PH, Gliklich RE. Airway obstruction following application of cricoid pressure. J Clin Anesth 1991; 3: 403–5.
Georgescu A, Miller JN, Lecklitner ML. The Sellick maneuver causing complete airway obstruction. Anesth Analg 1992; 74: 457–9.
Shorten GD. Airway obstruction on cricoid pressure is not glottic (Letter). Anesth Analg 1994; 78: 1203.
Brimacombe JR, Berry AM, Brain AIJ. The laryngeal mask airway.In: Sandier AN, Doyle DJ, (Eds.). The Difficult Airway I. Philadelphia: WB Saunders, 1995; 411–37.
Brimacombe J. Cricoid pressure and the laryngeal mask airway (Letter). Anaesthesia 1991; 46: 986–7.
Brimacombe J, White A, Berry A. Effect of cricoid pressure on ease of insertion of the laryngeal mask airway. Br J Anaesth 1993; 71: 800–2.
Asai T, Barclay K, Power I, Vaughan RS. Cricoid pressure impedes placement of the laryngeal mask airway. Br J Anaesth 1995; 74: 521–5.
Gabbott DA, Sasada MP. Laryngeal mask airway insertion using cricoid pressure and manual in-line neck stabilisation. Anaesthesia 1995; 50: 674–6.
Brimacombe J, Berry A, White A. Single-compared with double-handed cricoid pressure for insertion of an LMA (Letter). Br J Anaesth 1994; 72: 732–4.
Brimacombe J, Berry A, Asai T, Barclay K, Power I, Vaughan RS. Cricoid pressure and the LMA: efficacy and interpretation (Letter). Br J Anaesth 1994; 49: 862–5.
Strang TI. Does the laryngeal mask airway compromise cricoid pressure? Anaesthesia 1992; 47: 829–31.
Asai T, Barclay K, McBeth C, Vaughan RS. Cricoid pressure applied after placement of the laryngeal mask prevents gastric insufflation but inhibits ventilation. Br J Anaesth 1996; 76: 772–6.
Asai T, Barkley K, Power I, Vaughan RS. Cricoid pressure impedes placement of the laryngeal mask airway and subsequent tracheal intubation through the mask. Br J Anaesth 1994; 72: 47–51.
Gabbott DA, Sasada MP. Tracheal intubation through the laryngeal mask using a gum elastic bougie in the presence of cricoid pressure and manual in line stabilisation of the neck. Anaesthesia 1996; 51: 389–90.
Salem MR, Heyman HJ, Mahdi M. Facilitation of tracheal intubation by cephalad displacement of the larynx — rediscovered. J Clin Anesth 1994; 6: 167–8.
Brimacombe J, Berry A. Mechanical airway obstruction after cricoid pressure with the laryngeal mask airway. Anesth Analg 1994; 78: 604–5.
Asai T. Use of the laryngeal mask for tracheal intubation in patients at increased risk of aspiration of gastric contents. Anesthesiology 1992; 77: 1029–30.
Morch-Siddal J, Hall IA. Cricoid pressure during resuscitation (Letter). Anaesthesia 1995; 50: 568.
Melker RJ. Recommendations for ventilation during cardiopulmonary resuscitation: time for change? Crit Care Med 1985; 13: 882–3.
Notcutt W. Oesophageal rupture and cricoid pressure (Letter). Anaesthesia 1991; 46: 424–5.
Stoddart PA, Brennen L, Hatch DJ, Bingham R. Postal survey of paediatric practice and training among consultant anaesthetists in the UK. Br J Anaesth 1994; 73: 559–63.
McMorland GH, Jenkins LC, Douglas MJ. A survey of obstetric anaesthesia practice in British Columbia. Can Anaesth Soc J 1986; 33: 185–94.
Tiret L, Desmonts JM, Hatton F, Vourc’h G. Complications associated with anaesthesia — a prospective survey in France. Can Anaesth Soc J 1986; 33: 336–44.
Moir DD. Maternal mortality and anaesthesia (Editorial). Br J Anaesth 1980; 52: 1–3.
Scott DB. Mendelson’s syndrome (Editorial). Br J Anaesth 1978; 50: 977–8.
Williamson R. Cricoid pressure (Letter). Can J Anaesth 1989; 36: 601.
Herman NL, Carter B, Van Decar TK. Cricoid pressure: teaching the recommended level. Anesth Analg 1996; 83: 859–63.
Liew E, Chan-Liao M. Experience of using laryngeal mask anesthesia for Caesarean section. 11th World Congress of Anesthesiology, Sydney. 1996; D771.
Vanner RG. Laryngeal mask airway in the failed intubation drill. Int J Obstet Anesth 1995; 4: 191–2.
Pace NA, Gajraj NM, Pennant JH, Victory RA, Johnson ER, White PF. Use of the laryngeal mask airway after oesophageal intubation. Br J Anaesth 1994; 73: 688–9.
Criswell JC, Parr MJA, Nolan JP. Emergency airway management in patients with cervical spine injuries. Anaesthesia 1994; 49: 900–3.
O’Leary SD, Maryniak JK, Tucker JH. Teaching effective cricoid pressure application using a force measuring device. Can J Anaesth 1996; A5.
Heath ML, Allagain J. Intubation through the laryngeal mask. A technique for unexpected difficult intubation. Anaesthesia 1991; 46: 545–8.
Ansermino JM, Blogg CE. Cricoid pressure may prevent insertion of the laryngeal mask airway. Br J Anaesth 1992; 69: 465–7.
Heath KJ, Palmer M, Fletcher SJ. Fracture of the cricoid cartilage after Sellick’s manoeuvre. Br J Anaesth 1996; 76: 877–8.
Kain ZN, O’Connor TZ, Berde CB. Management of tracheobronchial and esophageal foreign bodies in children: a survey study. J Clin Anesth 1994; 6: 28–32.
Canter RJ, Gath AM, Harris D. Cricoid pressure and sharp foreign bodies. Clin Otolarygol 1985; 10: 343–4.
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Brimacombe, J.R., Berry, A.M. Cricoid pressure. Can J Anaesth 44, 414–425 (1997). https://doi.org/10.1007/BF03014464
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DOI: https://doi.org/10.1007/BF03014464