RT Cricoid Presentation

Cricoid Pressure: Are We Really Doing
it Right?
Nichole M. Doyle, MD
University of Kansas SOM Wichita
Cricoid Pressure Study
Cricoid Pressure Basics
Cricoid vs BURP procedure
Cricoid Study Design
• 143 Anesthesiolgists,
Residents,CRNA’s, OR Staff and
•Pre-didactic questionairre
•Simulated RSI/Emergent
•Short power point presentation
•Allowed to practice on simulator
• Returned 2 months later for
repeat testing
Yrs of experience
Formal training
How cricoid pressure was learned
Indications and Contraindications for
When is CP released
How many Newtons should be applied
What is a Newton
Did person feel adequately trained
Results From Questionnaire
• 100% found the didactic training
• 99% of participants found the
simulation beneficial
• 55% of participants learned to apply
cricoid pressure from observation or
• 72% had not received formal training
Results from Questionnaire Cont.
• 20% incorrectly believed primary
function was to improve
• 7% Knew the proper amount of
pressure to apply
• 11% Knew what a Newton was
• 67% Felt inadequately trained
Results From Simulation
• Correct Location Improved from 45%88%
• Correct amount of pressure before LOC
improved from 68%-74%
• Correct amount of pressure after LOC
improved from 3%-56%
• Drop in Pressure during DL decreased
from 100% to 29%
• Cricoid pressure released appropriately
increased from 94%-98%
Cricoid Pressure
• Pressure applied to cricoid cartilage
with goal of occluding hypopharynx
and prevent aspiration
• Still controversial but still a
medicolegal standard of care
• Cricoid cartilage is used because
it’s the only complete ring
• Often confused with BURP
 Using the thumb and index finger on either side of
the cricoid cartilage apply 10 Newtons of pressure
directly backwards prior to induction of anesthesia
 Increase pressure to 30 Newtons upon loss of
 Maintain pressure until position of endotracheal
tube is confirmed by breath sounds and permission
is given by intubating personnel
 10 Newtons is the force of gravity on an object with
a mass of approx 1kg
 Therefore approx 2-3lbs for awake pts and
approx 7lbs-10lbs for unconscious pts
Demonstration of application
• Code/Emergent Intubation
• Full Stomach/Recent Meal
• Delayed gastric emptying
• Trauma, acute abdomen
• Incompetent lower esophageal
• Hiatal hernia, pregnancy, severe
symptomatic GERD
Suspected cricotracheal injury
Active vomiting
Unstable cervical spine injuries
Foreign body in upper airway
• Cricoid Pressure may….
• Interfere with ventilation
• Make passage of ETT difficult
• Alter laryngeal visualization
• Esp at pressures > 40 N
• In awake pts has promoted vomiting
• Esophageal rupture
• Decreased lower esophageal sphincter
• Cricoid Cartilage fracture
BURP Procedure
• BURP (Backward, upward, rightward,
• Is done with the objective of improving
view of intubator during direct
• Pressure applied to thyroid cartilage
• Much less pressure than what is
applied during application of cricoid
Final Points
• Pressure amounts given are for adults
• Release cricoid pressure if it interferes with
ventilation or visualization
• Maintain constant pressure after LOC occurs
until ETT position confirmed
• BURP and cricoid pressure are different
maneuvers with different goals
• Training improves location and amount of
pressure applied
• Participants felt more comfortable applying
CP after teaching
Neilipovitz DT, Crosby ET. No evidence for decreased incidence of aspiration after rapid sequence induction. Can J Anaesth
Brimacombe JR, Berry AM. Cricoid pressure. Can J Anaesth 1997;44:414–25
Palmer JH, Mac G, Ball DR. The effect of cricoid pressure on the cricoid cartilage and vocal cords: an endoscopic study in anaesthetized
patients. Anaesthesia 2000;55:263–8
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
Ashurst N, Rout CC, Rocke DA, Gouws E. Use of mechanical simulator for training in applying cricoid pressure. Br J Anaesth 1996
Herman NL, Carter B, Van Decar TK. Cricoid pressure: teaching the recommended level. Anesth Analg 1996;83:859–63
Schmidt A, Akeson J. Practice and knowledge of cricoid pressure in southern Sweden. Acta Anaesthesiol Scand 2001;45:1210–4
Meek T, Gittins N, Duggan JE. Cricoid pressure: knowledge and performance amongst anaesthetic assistants. Anaesthesia 1999; 54:59–
Rice MJ, Mancuso AA, Gibbs D, Morey TE, Gravenstein N, Deitte LA. Cricoid Pressure Results in Compression of the Postcricoid
Hypopharynx: The Esophageal Position is Irrelevant. International Anesthesia Research Society 2009;109:1546-1552.
Matthews, GA. Survey of cricoid pressure application by anaesthetists, operating department practitioners, intensive care and accident
and emergency nurses. Anaesthesia 2001;56:915-917.
Marcus, Adam. Legal, Clinical Data Paint Conflicting Picture of Cricoid Pressure. Anesthesiology News 2010;36.

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