Cricoid pressure

Cricoid pressure, also known as the Sellick manoeuvre or Sellick maneuver, is a technique used in endotracheal intubation to try to reduce the risk of regurgitation. The technique involves the application of pressure to the cricoid cartilage at the neck, thus occluding the esophagus which passes directly behind it.[1]

Cricoid pressure should not be confused with the "BURP" (Backwards Upwards Rightwards Pressure) manoeuvre, which is used to improve the view of the glottis during laryngoscopy and tracheal intubation, rather than to prevent regurgitation.[2] As the name implies, the BURP manoeuvre requires a clinician to apply pressure on the thyroid cartilage posteriorly, then cephalad (upwards) and, finally, laterally towards the patient's right.[3]

History and techniqueEdit

In 1961 Brian Arthur Sellick (1918–1996), an anaesthetist, published the paper Cricoid pressure to control regurgitation of stomach contents during induction of anesthesia—preliminary communication, describing the application of cricoid pressure for the prevention of regurgitation. The technique involves the application of backward pressure on the cricoid cartilage with a force of 20–44 newtons[4] to occlude the esophagus, preventing aspiration of gastric contents during induction of anesthesia and in resuscitation of emergency victims when intubation is delayed or not possible. Some believe that cricoid pressure in pediatric population, especially neonates, improves glottic view and aids tracheal intubation apart from its classical role in rapid sequence intubation for aspiration prophylaxis.[5]


Rapid sequence inductionEdit

In many countries, cricoid pressure has been widely used during rapid sequence induction for nearly fifty years, despite a lack of compelling evidence to support this practice.[6] The initial article by Sellick was based on a small sample size at a time when high tidal volumes, head-down positioning and barbiturate anesthesia were the rule.[7] Beginning around 2000, a significant body of evidence has accumulated which questions the effectiveness of cricoid pressure, and the application may in fact displace the esophagus laterally[8] instead of compressing it as described by Sellick.

Cricoid pressure may also compress the glottis, which can obstruct the view of the laryngoscopist and actually cause a delay in securing the airway.[9] Some clinicians believe the use of cricoid pressure should be abandoned because of the lack of scientific evidence of benefit and possible complications.[10]

Prevention of gas insufflationEdit

The technique is also important in possibly preventing insufflation of gas into the stomach. A study concluded that appropriate application of cricoid pressure prevents gastric gas insufflation during airway management via mask up to 40 cm H2O PIP in infants and children. An additional benefit of cricoid pressure occurs in paralyzed patients in whom gastric insufflation occurs at lower inflation pressures.[11]


Anterior cricoid pressure was considered the standard of care during Rapid Sequence Intubation for many years.[12] The American Heart Association, until the 2010 science update, advocated the use of cricoid pressure during resuscitation using a BVM, and during emergent oral endotracheal intubation;[13] effective 2010, use of Cricoid Pressure is now discouraged during the routine intubation of cardiac arrest victims.[14]

Cricoid pressure may frequently be applied incorrectly.[15][16][17][18][19] Cricoid pressure may frequently displace the esophagus laterally, instead of compressing it as described by Sellick.[20][21] Several studies demonstrate some degree of glottic compression[22][23][24] reduction in tidal volume and increase in peak pressures.[25]

The initial proposal of cricoid pressure as a useful clinical procedure, its subsequent adoption as the lynchpin of patient safety, and its current decline into disfavor represents a classic example of the need for evidence-based medicine, and the evolution of medical practice.[citation needed]

Side effectsEdit

As all techniques, cricoid pressure has indications, contraindications and side effects. It is associated with nausea/vomiting and it may cause esophageal rupture and also may make tracheal intubation and make ventilation difficult or impossible. Cricoid force greater than 40 N can compromise airway patency and make tracheal intubation difficult. Cricoid pressure may displace the esophagus, make ventilation with a facemask or with a laryngeal mask airway (LMA) more difficult, interfere with LMA placement and advancement of a tracheal tube and alter laryngeal visualization by a flexible bronchoscope. However, other investigators have found that cricoid pressure does not increase the rate of failed intubation.[26]

See alsoEdit


  1. ^ "Sellick's maneuver".
  2. ^ Takahata, O; Kubota, M; Mamiya, K; Akama, Y; Nozaka, T; Matsumoto, H; Ogawa, H (1997). "The efficacy of the "BURP" maneuver during a difficult laryngoscopy" (PDF). Anesthesia & Analgesia. 84 (2): 419–21. doi:10.1097/00000539-199702000-00033. PMID 9024040. S2CID 16579238.
  3. ^ Knill, RL (1993). "Difficult laryngoscopy made easy with a "BURP"". Canadian Journal of Anesthesia. 40 (3): 279–82. doi:10.1007/BF03037041. PMID 8467551.
  4. ^ Barash, Paul (2009). Clinical Anesthesia (6th ed.). Lippencott Williams & Wilkins. p. 1223.
  5. ^ Moied, AS; Jyotishka, P (2010). "Cricoid pressure – A misnomer in pediatric anaesthesia". J Emerg Trauma Shock. 3 (1): 96–97. doi:10.4103/0974-2700.58650. PMC 2823158. PMID 20165735.
  6. ^ Salem, MR; Sellick, BA; Elam, JO (1974). "The historical background of cricoid pressure in anesthesia and resuscitation". Anesthesia & Analgesia. 53 (2): 230–2. doi:10.1213/00000539-197403000-00011. PMID 4593092.
  7. ^ Maltby, JR; Beriault, MT (2002). "Science, pseudoscience and Sellick". Canadian Journal of Anesthesia. 49 (5): 443–7. doi:10.1007/BF03017917. PMID 11983655.
  8. ^ Smith KJ, Dobranowski J, Yip G, Dauphin A, Choi PT (2003). "Cricoid pressure displaces the esophagus: an observational study using magnetic resonance imaging". Anesthesiology. 99 (1): 60–4. doi:10.1097/00000542-200307000-00013. PMID 12826843. S2CID 18535821.
  9. ^ Haslam, N; Parker, L; Duggan, JE (2005). "Effect of cricoid pressure on the view at laryngoscopy". Anaesthesia. 60 (1): 41–7. doi:10.1111/j.1365-2044.2004.04010.x. PMID 15601271. S2CID 42387260.
  10. ^ "Cricolol by John Hinds". 28 May 2014.
  11. ^ Moynihan, RJ; Brock – Utne, JG; Archer, JH; Feld, LH; Kreitzman, TR (Apr 1993). "The effect of cricoid pressure on preventing gastric insufflation in infants and children". Anesthesiology. 78 (4): 652–656. doi:10.1097/00000542-199304000-00007. PMID 8466065. S2CID 38041710.
  12. ^ Salem, MR; Sellick, BA; Elam, JO (Mar–Apr 1974). "The historical background of cricoid pressure in anesthesia and resuscitation". Anesthesia and Analgesia. 53 (2): 230–2. doi:10.1213/00000539-197403000-00011. PMID 4593092.
  13. ^ American Heart Association (2006). Textbook of Advanced Cardiac Life Support. Dallas, TX: American Heart Association.
  14. ^ American Heart Association's BLS (Basic Life Support) Provider training, as of 2013-05-19
  15. ^ Escott MEA, Owen H, Strahan AD, Plummer JL. Cricoid pressure training: how useful are descriptions of force? Anaesth Intensive Care 2003;31:388–391
  16. ^ Owen H, Follows V, Reynolds KJ, Burgess G, Plummer J. Learning to apply effective cricoid pressure using a part task trainer. Anaesthesia 2002;57(11):1098–1101
  17. ^ Walton S, Pearce A. Auditing the application of cricoid pressure. Anaesthesia 2000;55:1028–1029
  18. ^ Koziol CA, Cuddleford JD, Moos DD. Assessing the force generated with the application of cricoid pressure. AORN J 2000;72:1018–1030
  19. ^ Meek T, Gittins N, Duggan JE. Cricoid pressure: knowledge and performance amongst anaesthetic assistants. Anaesthesia 1999;54(1):59–62.
  20. ^ Smith, K. J., Dobranowski, J., Yip, G., Dauphin, A., & Choi, P. T. (2003). Cricoid pressure displaces the esophagus: an observational study using magnetic resonance imaging. Anesthesiology, 99(1), 60–64;
  21. ^ Smith, K. J., Ladak, S., Choi, Pt L., & Dobranowski, J. (2002). The cricoid cartilage and the oesophagus are not aligned in close to half of adult patients. Canadian Journal of Anesthesia, 49(5), 503–507.
  22. ^ Palmer, JHM, Ball, D.R. The effect of cricoids pressure on the cricoids cartilage and vocal cords: An endoscopic study in anaesthetized patients. Anaesthesia (2000): 55; 260–287
  23. ^ Hartsilver, E. L., Vanner, R. G. Airway obstruction with cricoids pressure. Anesthesia (2000): 55: 208–211
  24. ^ Haslam, N., Parker, L., and Duggan, J.E. Effect of cricoid pressure on the view at laryngoscopy. Anesthesia (2005): 60: 41–47
  25. ^ Hocking, G., Roberts, F.L., Thew, M.E. Airway obstruction with cricoids pressure and lateral tilt. Anesthesia (2001), 56; 825–828
  26. ^ Ovessapian, A; Salem, MR (Nov 2009). "Sellick's Maneuver: To Do or Not Do". Anesthesia & Analgesia. 109 (5): 1360–1362. doi:10.1213/ane.0b013e3181b763c0. PMID 19843769. Retrieved 2012-05-12.