Birenbaum A, Hajage D, Roche S Effect of cricoid pressure compared with a sham procedure in the rapid sequence induction of anesthesia: the IRIS randomized clinical trial. JAMA Surg.. 2019; 154:(1)9-17

Black SJ, Carson EM, Doughty A. How much and where: assessment of knowledge level of the application of cricoid pressure. J Emerg Nurs.. 2012; 38:(4)370-374

Bohman JK, Kashyap R, Lee A A pilot randomized clinical trial assessing the effect of cricoid pressure on risk of aspiration. Clin Respir J.. 2018; 12:(1)175-182

Burns B, Habig K, Eason H, Ware S. Difficult intubation factors in prehospital rapid sequence intubation by an Australian helicopter emergency medical service. Air Med J.. 2016; 35:(1)28-32

Caruana E, Chevret S, Pirracchio R. Effect of cricoid pressure on laryngeal view during prehospital tracheal intubation: a propensity-based analysis. Emerg Med J.. 2017; 34:(3)132-137

Aspiration: a liability hazard for the anesthesiologist?. 2000. https// (accessed 5 December 2020)

Cook TM. The cricoid debate—balancing risks and benefits. Anaesthesia.. 2016; 71:(6)721-722

Cormack RS, Lehane J. Difficult tracheal intubation in obstetrics. Anaesthesia.. 1984; 39:(11)1105-1111

Deakin CD, King P, Thompson F. Prehospital advanced airway management by ambulance technicians and paramedics: is clinical practice sufficient to maintain skills?. Emerg Med J.. 2009; 26:(12)888-891

Dyson K, Bray JE, Smith K Paramedic intubation experience is associated with successful tube placement but not cardiac arrest survival. Ann Emerg Med.. 2017; 70:(3)382-390.e1

Gwinnutt MT, Gwinnutt JA. Abandoning cricoid pressure—2. Anaesthesia.. 2016; 71:(11)

Greater Sydney area HEMS prehospital RSI manual. 2011. https// (accessed 5 December 2020)

Harris T, Ellis DY, Foster L, Lockey D. Cricoid pressure and laryngeal manipulation in 402 pre-hospital emergency anaesthetics: essential safety measure or a hindrance to rapid safe intubation?. Resuscitation.. 2010; 81:(7)810-816

Haslam N, Parker L, Duggan JE. Effect of cricoid pressure on the view at laryngoscopy. Anaesthesia.. 2005; 60:(1)41-47

Jensen AG, Callesen T, Hagemo JS Scandinavian clinical practice guidelines on general anaesthesia for emergency situations. Acta Anaesthesiol Scand.. 2010; 54:(8)922-950

JRCALC clinical guidelines 2019.Bridgwater: Class Professional Publishing; 2019

Kojima T, Harwayne-Gidansky I, Shenoi AN Cricoid pressure during induction for tracheal intubation in critically ill children: a report from National Emergency Airway Registry for Children. Pediatr Crit Care Med.. 2018; 19:(6)528-537

Moher D, Liberati A, Tetzlaff J, Altman DG Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med.. 2009; 6:(7)

Noll E, Shodhan S, Varshney A Trainability of cricoid pressure force application: a simulation-based study. Anesth Analg.. 2019; 128:(1)109-116

Schober P, Schwarte LA. Put pressure on the cricoid pressure. Emerg Med J.. 2017; 34:(3)

Sellick BA. Cricoid pressure to control regurgitation of stomach contents during induction of anaesthesia. Lancet.. 1961; 278:(7199)404-406

Turgeon AF, Nicole PC, Trépanier CA Cricoid pressure does not increase the rate of failed intubation by direct laryngoscopy in adults. Anesthesiology.. 2005; 102:(2)315-319

Younger P, Pilbery R, Lethbridge K. A survey of advanced airway practice in the UK. Br Paramedic J.. 2016; 1:(3)9-22

Does cricoid pressure have a detrimental impact on laryngoscopy and intubation?

02 December 2020
Volume 10 · Issue 4



Cricoid pressure is used in anaesthetic practice to prevent regurgitation during anaesthetic induction; it is also used by some paramedics. However, it may have a detrimental impact upon laryngoscopy and intubation. Paramedics need to remove barriers to safe and prompt intubation of critically unwell patients.


To determine if cricoid pressure has a detrimental effect on laryngoscopy and intubation.


The PubMed and Cochrane Library databases were searched with a time frame filter between 1 January 2003 and 31 December 2018 and screened, leaving seven studies.


Cricoid pressure is detrimental to laryngoscopy and intubation success rates for patients in the care of experienced providers in environments more optimal than those in which paramedics practise. One study produced statistically significant results; when cricoid pressure was applied, median intubation time was longer (27 seconds versus 24 seconds; p<0.001) and incidence of Cormack and Lehane grade III and intravenous views were doubled (10% versus 5%; p<0.001). Other studies were inconclusive.


Cricoid pressure makes intubation more difficult, which may lead to higher rates of failed intubation and adverse events, especially when carried out by less proficient clinicians such as paramedics. Further pragmatic research is needed to test this hypothesis.

Cricoid pressure is used in anaesthetic practice to prevent the regurgitation of gastric contents into the oropharynx during the induction of anaesthesia. This prevents primary adverse events, such as a soiled airway, as well as secondary adverse outcomes such as aspiration pneumonia. The practice was proposed by Brian Arthur Sellick in 1961 (Sellick, 1961).

To apply cricoid pressure, approximately 30N of force should be applied anteriorly to the cricoid cartilage. The cricoid cartilage is the only complete ring of cartilage in the larynx and applying this force causes compression to the posterior structures. This occludes the oesophagus and thus prevents regurgitation.

Some research has suggested that cricoid pressure may be ineffective, even when carried out correctly. Cheney (2000) reports that in a cohort of 67 anaesthetic deaths, 17 experienced aspiration despite cricoid pressure being applied. A recent multicentre, transnational study found a higher rate of regurgitation when cricoid pressure was applied in children at 1.9% versus 1.2% (Kojima et al, 2018).

Subscribe to get full access to International Paramedic Practice

Thank you for visiting International Paramedic Practice and reading our archive of expert clinical content. If you would like to read more from the only journal dedicated to those working in emergency care, you can start your subscription today for just £48.

What's included

  • CPD Focus

  • Develop your career

  • Stay informed