Cricoid Pressure

• To reduce gastric insufflation and

regurgitation.
• To prevent pulmonary aspiration in those at
risk.
 Anatomy of
Hypopharyngeal/oesophageal
compression
• According to Sellick:
– The position of the oesophagus relative to the
cricoid ring in the axial plane was immediately
posterior to the cricoid ring.
• Esophageal position was also investigated
using MRI imaging with and without cricoid
pressure in awake patients.

– Showed similar findings of posterolateral

positioning of the esophagus, mainly on the left
side with an increase in the lateral displacement
of the esophagus from 53% to 91% with cricoid
pressure.
 Further MRI studies
• On awake volunteers:
– The hypopharynx not the esophagus lay behind
the cricoid ring and it was the hypopharynx not
the esophagus that was compressed by cricoid
pressure.
Does cricoid pressure reduce the risk
of regurgitation and aspiration?
• In Mendelson’s 1946 paper:
– Describes obstetric patients under going face
mask ventilation with ether and nitrous oxide
• The incidence of aspiration was 1:667, with a mortality
rate of 1:22,000.
 Is cricoid pressure performed
optimally and is it harmless?
• Most problems with cricoid force occur when
too much force is applied.
• Cricoid pressure is uncomfortable in the
awake patient, particularly when force is
greater than 20N (2kg) causing Retching and
leading to pulmonary aspiration or esophageal
rupture.
• Current guidelines recommend a 10N (1kg)
force initially to the awake patient increasing
to 30N (3kg) after loss of consciousness.

• The application of cricoid pressure may also

influence the lower esophageal sphincter
causing relaxation and an increased potential
for vomiting, regurgitation and aspiration.
 Cricoid Pressure can affect:
• Facemask ventilation
• Direct laryngoscopy
• Laryngeal mask airway placment
 Facemask Direct Laryngoscopy Laryngeal mask
Ventilation airway placement

- Increasing - Causing distortion - Impending

inspiratory of laryngeal successful
pressures, reducing structures. placement and
tidal volumes, and - Failed intubation is ventilation.
may even cause almost eight times
complete airway as frequent in
obstruction. patients having a
rapid sequence
induction.
 Preoxygenation and increasing safe
apnea time.
• From the 1940’s onwards preoxygenation has
been recognised as an important technique
before the induction of general anesthesia to
delay the onset of hypoxia, allowing more
time for larygoscopy, tracheal intubation and
airway rescue.
 Techniques of administering oxygen to
optimise the oxygen reservoir Before the
induction of anesthesia.

1. Tidal volume breathing

2. Single tidal capacity breathing
3. One vital capacity breath followed by tidal volume
breathing
4. Four deep (inspiratory capacity) breaths
5. Eight deep (inspiratory capacity) breaths
6. Extended deep breathing (12-16 inspiratory
capacity breaths)
 Other techniques to increase the oxygenation
reservoir before the induction of anesthesia
include:
1. Continuous positive airway pressure.
2. Non-invasive bilevel positive airway pressure.
3. Head-up positioning.
 Prolongation of apnea time after
induction of anesthesia
1. Pharyngeal insufflation of oxygen (3-10
liter/min).
2. Nasal oxygen delivered at flow rates of <15
liter/min.
3. High flow humidified nasal oxygen at 30-70
liter/min.
 Conclusion
• NAP4 reported that anesthetists are almost
defined by their ability to manage the airway.
• Regardless of the clinical and scientific
discoveries of the present and the future
anesthesist must continue to make an airway
management plan for every patient that
includes a second plan if their primary plan
fail.