Cricoid pressure, also known as the Sellick manoeuvre or Sellick maneuver, is a technique used in

endotracheal intubation Tracheal intubation, usually simply referred to as intubation, is the placement of a flexible plastic tube into the trachea (windpipe) to maintain an open airway or to serve as a conduit through which to administer certain drugs. It is frequently ...

to try to reduce the risk of regurgitation. The technique involves the application of pressure to the

cricoid cartilage The cricoid cartilage , or simply cricoid (from the Greek ''krikoeides'' meaning "ring-shaped") or cricoid ring, is the only complete ring of cartilage around the trachea. It forms the back part of the voice box and functions as an attachment si ...

at the neck, thus occluding the

esophagus The esophagus (American English) or oesophagus (British English; both ), non-technically known also as the food pipe or gullet, is an organ in vertebrates through which food passes, aided by peristaltic contractions, from the pharynx to the ...

which passes directly behind it. 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 Laryngoscopy () is endoscopy of the larynx, a part of the throat. It is a medical procedure that is used to obtain a view, for example, of the vocal folds and the glottis. Laryngoscopy may be performed to facilitate tracheal intubation during ge ...

and

tracheal intubation Tracheal intubation, usually simply referred to as intubation, is the placement of a flexible plastic catheter, tube into the vertebrate trachea, trachea (windpipe) to maintain an open airway or to serve as a conduit through which to administer ce ...

, rather than to prevent regurgitation. As the name implies, the BURP manoeuvre requires a clinician to apply pressure on the

thyroid cartilage The thyroid cartilage is the largest of the nine cartilages that make up the ''laryngeal skeleton'', the cartilage structure in and around the trachea that contains the larynx. It does not completely encircle the larynx (only the cricoid cartilage ...

posteriorly, then cephalad (upwards) and, finally, laterally towards the patient's right.

History and technique

In 1961 Brian Arthur Sellick (1918–1996), an

anaesthetist Anesthesiology, anaesthesiology, or anaesthesia is the medical specialty concerned with the total perioperative care of patients before, during and after surgery. It encompasses anesthesia, intensive care medicine, critical emergency medicine, ...

, 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

with a force of 20–44 newtons to occlude the

, preventing aspiration of gastric contents during induction of

anesthesia Anesthesia is a state of controlled, temporary loss of sensation or awareness that is induced for medical or veterinary purposes. It may include some or all of analgesia (relief from or prevention of pain), paralysis (muscle relaxation), ...

and in

resuscitation Resuscitation is the process of correcting physiological disorders (such as lack of breathing or heartbeat) in an acutely ill patient. It is an important part of intensive care medicine, anesthesiology, trauma surgery and emergency medicine. W ...

of emergency victims when

intubation Intubation (sometimes entubation) is a medical procedure involving the insertion of a tube into the body. Patients are generally anesthetized beforehand. Examples include tracheal intubation, and the balloon tamponade with a Sengstaken-Blakemo ...

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 In advanced airway management, rapid sequence induction (RSI) – also referred to as rapid sequence intubation or as rapid sequence induction and intubation (RSII) or as crash induction – is a special process for endotracheal intubation that is ...

for aspiration prophylaxis.

Usage

Rapid sequence induction

In many countries, cricoid pressure has been widely used during

rapid sequence induction In advanced airway management, rapid sequence induction (RSI) – also referred to as rapid sequence intubation or as rapid sequence induction and intubation (RSII) or as crash induction – is a special process for endotracheal intubation that is ...

for nearly fifty years, despite a lack of compelling evidence to support this practice. The initial article by Sellick was based on a small sample size at a time when high

tidal volume Tidal volume (symbol VT or TV) is the volume of air moved into or out of the lungs during a normal breath. In a healthy, young human adult, tidal volume is approximately 500 ml per inspiration or 7 ml/kg of body mass. Mechanical vent ...

s, head-down positioning and

barbiturate Barbiturates are a class of depressant drugs that are chemically derived from barbituric acid. They are effective when used medically as anxiolytics, hypnotics, and anticonvulsants, but have physical and psychological addiction potential as we ...

anesthesia were the rule. 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 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. Some clinicians believe the use of cricoid pressure should be abandoned because of the lack of scientific evidence of benefit and possible complications.

Prevention of gas insufflation

The technique is also important in possibly preventing insufflation of gas into the

stomach The stomach is a muscular, hollow organ in the gastrointestinal tract of humans and many other animals, including several invertebrates. The stomach has a dilated structure and functions as a vital organ in the digestive system. The stomach i ...

. A study concluded that appropriate application of cricoid pressure prevents gastric gas insufflation during

airway The respiratory tract is the subdivision of the respiratory system involved with the process of respiration in mammals. The respiratory tract is lined with respiratory epithelium as respiratory mucosa. Air is breathed in through the nose to th ...

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.

Controversy

Anterior cricoid pressure was considered the standard of care during Rapid Sequence Intubation for many years. The

American Heart Association The American Heart Association (AHA) is a nonprofit organization in the United States that funds cardiovascular medical research, educates consumers on healthy living and fosters appropriate cardiac care in an effort to reduce disability and death ...

, until the 2010 science update, advocated the use of cricoid pressure during resuscitation using a BVM, and during emergent oral endotracheal intubation; effective 2010, use of Cricoid Pressure is now discouraged during the routine intubation of

cardiac arrest Cardiac arrest is when the heart suddenly and unexpectedly stops beating. It is a medical emergency that, without immediate medical intervention, will result in sudden cardiac death within minutes. Cardiopulmonary resuscitation (CPR) and possib ...

victims. Cricoid pressure may frequently be applied incorrectly. Cricoid pressure may frequently displace the esophagus laterally, instead of compressing it as described by Sellick. Several studies demonstrate some degree of glottic compression reduction in tidal volume and increase in peak pressures. 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 Evidence-based medicine (EBM) is "the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients". The aim of EBM is to integrate the experience of the clinician, the values of t ...

, and the evolution of medical practice.

Side effects

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

difficult. Cricoid pressure may displace the

, make ventilation with a facemask or with a

laryngeal mask airway A laryngeal mask airway (LMA), also known as laryngeal mask, is a medical device that keeps a patient's airway open during anaesthesia or while they are unconscious. It is a type of supraglottic airway device. They are most commonly used by anae ...

(LMA) more difficult, interfere with LMA placement and advancement of a

tracheal tube A tracheal tube is a catheter that is inserted into the trachea for the primary purpose of establishing and maintaining a patent airway and to ensure the adequate exchange of oxygen and carbon dioxide. Many different types of tracheal tubes are a ...

and alter laryngeal visualization by a flexible

bronchoscope Bronchoscopy is an endoscopic technique of visualizing the inside of the airways for diagnostic and therapeutic purposes. An instrument (bronchoscope) is inserted into the airways, usually through the nose or mouth, or occasionally through a trac ...

. However, other investigators have found that cricoid pressure does not increase the rate of failed

References

{{reflist Airway management Emergency medical procedures