General Articles

Cricoid Pressure Impedes Insertion of, and Ventilation

Through, the ProSeal Laryngeal Mask Airway in
Anesthetized, Paralyzed Patients
Cheng W. Li, PhD BACKGROUND: We designed this prospective self-controlled study to assess whether
cricoid pressure hampers placement of and ventilation through the ProSeal
Fu S. Xue, MD laryngeal mask airway (ProSeal LMA) in anesthetized, paralyzed adult patients.
METHODS: After induction of anesthesia, the ProSeal LMA was inserted using the
introducer tool with cricoid pressure advanced as far as possible, and the cuff
Ya C. Xu, MD
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pressure was set at 60 cm H2O. Ventilation adequacy and anatomic position were
scored using measures previously described for ProSeal LMA assessment. Airway
Yi. Liu, MD seal pressure was recorded. Cricoid pressure was then released, the ProSeal LMA
further advanced and reseated, and the assessment repeated.
Peng Mao, MD RESULTS: Lung ventilation scores, anatomic position scores, and airway seal pres-
sure were significantly better after release of cricoid pressure and reseating of the
Kun P. Liu, MD ProSeal LMA than in the first position, where the ProSeal LMA was seated with
cricoid pressure (P ⬍ 0.05). Expiratory tidal volume during intermittent positive
Quan Y. Yang, MD pressure ventilation was similar with and without cricoid pressure, but peak
inspiratory pressure decreased from 28 cm H2O with cricoid pressure to 14 cm H2O
without cricoid pressure (P ⬍ 0.05).
Guo H. Zhang, PhD CONCLUSIONS: Cricoid pressure applied before insertion hampered proper place-
ment of the ProSeal LMA. Temporary cricoid pressure release during insertion
Hai T. Sun, MD allowed the device to be advanced to the proper position. After correct placement
of the ProSeal LMA, application of cricoid pressure did not change tidal volume,
but produced a significant increase in peak inspiratory pressure.
(Anesth Analg 2007;104:1195–8)

F ailed tracheal intubation after rapid sequence induc-

tion of anesthesia puts patients at risk for regurgitation
and aspiration of gastric contents. Cricoid pressure, first
described by Sellick in 1961 (1), has become standard
practice to prevent regurgitation and aspiration. The
laryngeal mask airway (LMA) is an useful rescue
device to maintain oxygenation in such a situation,
especially for patients who are difficult to ventilate with
a conventional facemask (2–5). The American Society of
Anesthesiologists Task Force on Management of the
Difficult Airway recommends that the LMA be the first
choice in the “cannot ventilate cannot intubate” situation
after induction (6). Studies have shown that cricoid
From the Department of Anesthesiology, Plastic Surgery Hospi-
tal, Chinese Academy of Medical Sciences and Peking Union
Medical College, Beijing, People’s Republic of China.
Accepted for publication January 19, 2007.
This manuscript has been presented as a Poster Discussion at the
2006 Annual Meeting of the American Society of Anesthesiologists
in Chicago, IL.
Address correspondence and reprint requests to Prof. Fu S. Xue,
MD, Department of Anesthesiology, Plastic Surgery Hospital, Chinese
Academy of Medical Sciences and Peking Union Medical College,
Ba-Da-Chu Road, Shi-Jing-Shan District, Beijing 100041, People’s Re-
public of China. Address e-mail to fruitxue@yahoo.com.cn.
Copyright © 2007 International Anesthesia Research Society
DOI: 10.1213/01.ane.0000260798.85824.3d
pressure impedes proper placement of, and ventilation
through, the classic LMA (7–11).
The ProSeal LMA is a modified laryngeal mask
device with a double-cuffed design, which improves
the seal around the glottis. The ProSeal LMA incorpo-
rates a drainage tube to provide a channel for regur-
gitated fluid and placement of an orogastric tube (12).
The ProSeal LMA achieves a more effective seal than
the classic LMA, facilitating orogastric tube placement
and isolating the glottis from the esophagus when
correctly positioned (12–14). The mucosal pressures
exerted by the ProSeal LMA are similar to those
exerted by the classic LMA (15).
There are no published data to assess whether
cricoid pressure reduces ease of ProSeal LMA place-
ment and hampers ventilation through it. This pro-
spective cross-over study was designed to assess the
influence of cricoid pressure on insertion of, and
ventilation through, the ProSeal LMA in anesthetized,
paralyzed adult patients.
METHODS
After ethical committee approval and written in-
formed consent, 50 adult patients, ASA physical status
1, aged 18 –51 yr, undergoing elective plastic surgery
under general anesthesia, were included in this study.

Vol. 104, No. 5, May 2007 1195

The exclusion criteria were: age ⬍18 yr or ⬎60 yr,
nonfasted patients, pregnancy, prone position, airway
surgery, reactive airway disease, gastroesophageal
reflux diseases, and a body mass index ⬎30 kg/m2.
On arrival at the operating room, standard moni-
tors (AS/3;Datex, Helsinki, Finland) were applied. In
this study, a ProSeal LMA (LMA-PS, The Laryngeal
Mask Company Ltd., Henley-on-Thames, UK) of suit-
able size for each patient was determined according to
the manufacturer’s instructions (16). Three investiga-
tors were needed during each observation. The first
one, a trained anesthesiologist (CWL or YCX), pro-
vided the cricoid pressure. Before study, they prac-
ticed cricoid pressure by producing a force of 3 kg (30
N) on a scale before each case, and revalidated the force
afterwards by reproducing the same force with an inde-
pendent observer recording the reading on the scale. The
second anesthesiologist (FSX) ventilated the patient’s
lungs with a facemask, inserted the ProSeal LMA, and
assessed lung ventilation and LMA position. The third
anesthesiologist recorded the observed variables.
After routine administration of oxygen, anesthesia
was induced with fentanyl 2 ␮g/kg and propofol 2
mg/kg injected IV. Neuromuscular block was pro-
duced with vecuronium 0.1 mg/kg administered IV.
The patient’s head was placed in the sniffing position
with a firm pillow (6 cm in height) under the occiput.
A 10 cm-diameter gauze roll was placed under the
patient’s neck for support. Cricoid pressure was applied
with one hand (modified bimanual cricoid pressure)
before induction at a force that could be tolerated by
the patient. After loss of consciousness, the force was
increased to 30 N. Two minutes after vecuronium
injection, the ProSeal LMA was inserted with the intro-
ducer tool according to the manufacturer’s instruc-
tions (12) until obvious resistance was felt. With
cricoid pressure and the introducer tool in place, the
cuff was inflated with air to a pressure of 60 cm H2O
using a calibrated aneroid manometer. The inflation
volume was recorded. The ProSeal LMA was con-
nected to the breathing circuit and ventilation quality
was assessed as described by Keller et al. (17). A
3-point ventilation score was assigned as follows: 1 ⫽
excellent, chest expansion obvious without gas leak-
age, 2 ⫽ adequate, chest expansion with obvious gas
leakage, and 3 ⫽ impossible, minimal chest expansion
and considerable gas leakage.
After assessment of ventilation, the anatomic posi-
tion of the cuff was examined visually using a fiber-
optic bronchoscope according to the scoring system
described by Brimacombe and Berry (18). A 4-point
anatomic position score was assigned as follows: 1 ⫽
only vocal cords visible, 2 ⫽ vocal cords plus posterior
epiglottis visible, 3 ⫽ vocal cords plus anterior epi-
glottis visible, and 4 ⫽ vocal cords invisible.
After anatomic position assessment, the airway seal
pressure was determined by setting the pop-off valve
to limit peak airway pressure to 40 cm H2O and
allowing airway pressure to increase at a fresh gas
1196 Cricoid Pressure and the ProSeal Laryngeal Mask Airway
flow of 3 L/min until no further increase in pressure
was observed. When a stable airway pressure was
reached, the locations of gas leak were determined as
the drainage tube [bubbling of soap solution (19)],
mouth (audible), or stomach (epigastric auscultation).
Afterwards, cricoid pressure was released and the
ProSeal LMA was further advanced with the intro-
ducer tool until obvious resistance was felt again (the
proper position). Then the introducer tool was with-
drawn, the cuff was inflated to 60 cm H2O, and the
final volume of air inflated was noted. Lung ventila-
tion, anatomic position, and airway seal pressure were
assessed again as described above.
After the ProSeal LMA was further advanced, if
ventilation was impossible, the ProSeal LMA was
removed and reinserted. A maximum of three at-
tempts was permitted. After three failures, the ProSeal
LMA was replaced by an endotracheal tube.
If no gas leaked from the drainage tube during the
airway seal pressure measurement, a lubricated oro-
gastric tube (F14) was placed through the drainage
tube. The position of the orogastric tube was con-
firmed by epigastric auscultation with a stethoscope
during the injection of 30 mL air. A failed attempt was
defined as failure to advance the orogastric tube.
Three attempts at orogastric tube placement were
allowed. The orogastric tube was removed immedi-
ately after insertion.
After the above evaluation was completed, inter-
mittent positive pressure ventilation (IPPV) was per-
formed with a tidal volume of 10 mL/kg, a ventilatory
frequency of 12 breaths/min, an inspiratory time-
respiratory cycle time ratio of 0.33, and a fresh gas
flow of 2.5 L/min. Expiratory tidal volumes and peak
inspiratory pressures were measured over five con-
secutive breaths during IPPV with or without cricoid
pressure, respectively. The mean expiratory tidal vol-
ume and peak inspiratory pressure under each cir-
cumstance were then calculated.
At the end of the operation, the ProSeal LMA was
removed when protective reflexes recovered and
adequate spontaneous breathing was reestablished.
Complications relating to insertion, maintenance, and
removal of the ProSeal LMA such as laryngospasm,
respiratory tract obstruction, breath holding, cough-
ing, aspiration, gastric inflation, nausea, vomiting, and
trauma to the lips, tongue, or teeth, and blood staining
the device were recorded.
The data obtained were analyzed with SPSS statis-
tical software (Version 11.5, SPSS Inc., Chicago, IL).
Parametric data were analyzed with paired Student’s
t-test. Nonparametric data were analyzed using a ␹2
test. Previous studies showed that the success rate of
excellent ventilation via the ProSeal LMA without
cricoid pressure was 81%–100% (9). We considered
that a clinically important difference in the success
rate would be 25%. At least 50 patients would be
required to detect this difference with a power of
0.8 – 0.9. Unless otherwise stated, data are expressed as
ANESTHESIA & ANALGESIA
Table 1. Lung Ventilation and Anatomic Position Scores
Lung
ventilation*
ProSeal LMA position with Score ⫽ 1:5
cricoid pressure Score ⫽ 2:9
Score ⫽ 3:36
ProSeal LMA position after Score ⫽ 1:49‡
reseating following Score ⫽ 2:1‡
cricoid pressure release Score ⫽ 3:0‡
* Ventilation scores. 1 ⫽ excellent, chest expansion obvious without gas leakage; 2 ⫽
adequate, chest expansion with obvious gas leakage; 3 ⫽ impossible, minimal chest
expansion and considerable gas leakage (17).
† Anatomic position scores based on fiberoptic visualization of cuff position. 1 ⫽ only vocal
cords visible; 2 ⫽ vocal cords plus posterior epiglottis visible; 3 ⫽ vocal cords plus anterior
epiglottis visible; 4 ⫽ vocal cords invisible (18).
‡ P ⬍ 0.05, compared with after ProSeal LMA insertion under cricoid pressure.
mean ⫾ sd or number of patients. P ⬍ 0.05 was
considered significant.
RESULTS
We studied 50 patients: 22 men and 28 women.
Age, weight, height, and body mass index ranged
from 18 to 51 yr, 50 to 70 kg, 150 to 180 cm, and 16 to
28 kg/m2, respectively.
Releasing cricoid pressure and advancing the ProSeal
LMA significantly improved the ventilation and ana-
tomic position scores (P ⬍ 0.05, Table 1). The inflation
volume required to obtain a cuff pressure of 60 cm H2O
was significantly lower when the ProSeal LMA was
inserted with cricoid pressure than the volume required
after cricoid pressure was released and the ProSeal LMA
advanced and reseated (20 ⫾ 5 vs 25 ⫾ 5 mL, P ⬍ 0.05).
When the ProSeal LMA was inserted with cricoid
pressure, airway seal pressure obtained with a cuff
pressure of 60 cm H2O was 21 ⫾ 7 cm H2O. After the
ProSeal LMA was advanced to the proper position
following release of cricoid pressure, the airway seal
pressure increased to 27 ⫾ 7 cm H2O (P ⬍ 0.05).
When airway seal pressure was measured under
two circumstances, there was no gas leakage from the
drainage tube or gastric insufflation in any patient.
After further advancement of the ProSeal LMA to the
proper position, orogastric tube placement via the
drainage tube was successful on the first attempt in all
patients. After the ProSeal LMA was reseated follow-
ing release of cricoid pressure, the tidal volume with
cricoid pressure was not different from that without
cricoid pressure (501 ⫾ 83 vs 498 ⫾ 81 mL, P ⬎ 0.05),
but the peak inspiratory pressure decreased from 28 ⫾
5 cm H2O with cricoid pressure to 14 ⫾ 2 cm H2O
without cricoid pressure (P ⬍ 0.05).
After device removal in the operating room, blood
staining on the ProSeal LMA was found in 13 patients
(26%). There were no other complications relating to
insertion, maintenance, and removal of the device in any
patient.
Vol. 104, No. 5, May 2007
DISCUSSION
Anatomic The primary goals of this investigation were to
position† assess whether cricoid pressure reduces ease of the
Score ⫽ 1:8
ProSeal LMA placement and impedes ventilation.
Score ⫽ 2:9 Differences in the method of applying cricoid pressure
Score ⫽ 3:26 have been proposed as the reason for the discrepan-
Score ⫽ 4:7 cies in the effect of cricoid pressure on placement of
Score ⫽ 1:18‡ the classic LMA (20,21). During our pilot study, we
Score ⫽ 2:20‡
Score ⫽ 3:8‡ also found that when the patient was placed at the
Score ⫽ 4:4‡ sniffing position, a single-handed cricoid pressure
without support of the neck interfered with extension
of the head and neck and opening of the mouth, which
made facemask ventilation and ProSeal LMA insertion
more difficult. In contrast, these procedures were easier
when modified bimanual cricoid pressure was applied
with support of the neck. The operators also felt that it
was easier to maintain a stable cricoid pressure of 30 N
during a prolonged observation period with the modi-
fied method than with the method described by Vanner
et al. (22). Therefore, this modified bimanual cricoid
pressure was used in our study.
Our results showed that after the ProSeal LMA was
inserted with cricoid pressure, only 28% of patients
had excellent or adequate ventilation. The reason for
impaired ventilation in the remaining patients was
excessive leakage and/or airway obstruction. Fiberop-
tic visualization showed that the ProSeal LMA was
not positioned deeply enough, so that the seal around
the larynx was not complete. In contrast, after further
advancement of the ProSeal LMA following release of
cricoid pressure, ventilation was possible and orogas-
tric tube placement via the drainage tube was success-
ful in all patients. Additionally, the glottis was also
seen through the fiberoptic bronchoscope in most
patients. These results suggested that cricoid pressure
applied before insertion impeded the ProSeal LMA
advanced to the proper position. This is in agreement
with the results of previous studies on the classic LMA
(7–10,20,21).
Positioning the ProSeal LMA correctly in the hypo-
pharynx is the key to preventing regurgitation and
aspiration of gastric contents (12–14). A cadaveric
study showed that with the drainage tube of the
ProSeal LMA unclamped, aspiration occurred only
when the cuff was fully deflated, suggesting that cuff
inflation was necessary to isolate the glottis from the
esophagus and to correctly align the drainage tube
with the esophagus (23). In the present study, the
results from airway seal pressure measurement, scores
of the cuff anatomic positions, and orogastric tube
placement indicated that the air inflated into the cuff
under cricoid pressure did not impede further ad-
vancement of the ProSeal LMA to the proper position
with the introducer tool after release of cricoid pres-
sure in most patients.
Previous works confirmed that cricoid pressure
harmed ventilation through the classic LMA when ap-
plied before insertion (7) and significantly decreased
© 2007 International Anesthesia Research Society 1197
tidal volume during pressure-controlled ventilation
when applied after the classic LMA was inserted to the
proper position (11). The decrease in the tidal volume
during IPPV with the classic LMA was attributed to
gas leak because of the increase in the airway resis-
tance caused by cricoid pressure (7). However, our
results showed that, when applied after further ad-
vancement of the ProSeal LMA to the proper position,
cricoid pressure caused a significant increase in peak
inspiratory pressure, but no significant change in tidal
volume. The lack of difference in tidal volume with
and without cricoid pressure may account for the
higher airway seal pressure obtained with the ProSeal
LMA. The airway seal pressure obtained with the
classic LMA has been reported to be 6 to 12 cm H2O
lower than that with the ProSeal LMA (12–14,24 –27).
Although use of the ProSeal LMA is generally
contraindicated in patients at risk of aspiration (16),
when confronted with the “cannot intubation cannot
ventilate” scenario ProSeal LMA insertion with tran-
sient release of cricoid pressure may save the patient’s
life (3–5). Therefore, we consider that, for these pa-
tients, the ProSeal LMA may be inserted and inflated
under cricoid pressure, then further advanced to the
proper position with the introducer tool after tempo-
rary release of cricoid pressure. Cadaver and clinical
studies have confirmed that when the drainage tube
was correctly positioned, the ProSeal LMA should be
able to provide protection from fluid regurgitation
(23,28), which suggests that cricoid pressure reappli-
cation after the ProSeal LMA insertion might be
unnecessary. In addition, orogastric tube insertion via
the drainage tube may also prevent gastric insufflation
that may follow difficult ventilation by conventional
facemask.
In our study, the incidence of blood staining on the
ProSeal LMA after removal was 26%, which was
higher than the results reported in previous studies
(9% (25) to 18% (24)). This was possibly related to the
application of the rigid introducer tool and the resis-
tance to the ProSeal LMA advancement caused by
cricoid pressure in this study.
In summary, the present study demonstrates that
cricoid pressure applied before insertion hampers
placement of the ProSeal LMA. Temporarily releasing
cricoid pressure facilitates proper placement of the
ProSeal LMA. After correct placement of the ProSeal
LMA, cricoid pressure does not change tidal volume
during IPPV, but produces a significant increase in
peak inspiratory pressure.
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ANESTHESIA & ANALGESIA