Qualifications to Perform Cricoid Pressure for Rapid Sequence Induction
There are no formal credentialing requirements or specific qualifications mandated to perform cricoid pressure, but the person applying it must have received proper training in the technique, understand the correct force application (10 N awake, increasing to 30 N after loss of consciousness), and be prepared to release pressure immediately if intubation becomes difficult. 1
Training Requirements
Essential Knowledge Components
The person performing cricoid pressure must understand that the recommended force is 10 N (1 kg) initially in the awake patient, increasing to 30 N (3 kg) after loss of consciousness 1, 2
Training should include hands-on practice with force measurement devices, as knowledge around how much force to apply is consistently inconsistent among practitioners 1
The assistant must recognize that excessive force (>30 N) causes patient discomfort, retching, and can trigger the very aspiration event the maneuver aims to prevent 1, 3
Critical Decision-Making Skills
The person applying cricoid pressure must be empowered and trained to release pressure immediately if the laryngoscopist reports difficult visualization of the larynx 1, 2
They must understand that if active vomiting occurs, cricoid pressure should be removed immediately to prevent oesophageal rupture 1, 4, 3
The assistant should recognize that cricoid pressure can worsen airway obstruction, impede facemask ventilation, distort laryngeal structures, and make intubation nearly eight times more difficult during rapid sequence induction 1
Practical Considerations in Emergency Settings
Operating Room Context
In the operating room for emergency laparotomy, anesthesiologists should be suitably experienced and familiar with managing emergency general surgery patients 1
The anesthesia team should follow their country's current standard practice regarding cricoid pressure use, recognizing international variation exists 1
Pre-Hospital and Emergency Department Settings
Pre-hospital organizations must have written and well-rehearsed protocols for cricoid pressure application and release 1
The practitioner with the most anesthetic experience should usually perform the first intubation attempt, while a trained assistant applies cricoid pressure 1
Every effort should be made to ensure successful first-pass intubation, as the number of attempts is limited to three 1
Common Pitfalls and How to Avoid Them
Anatomical Misunderstanding
The oesophagus sits posterolateral to the cricoid ring (mainly on the left side) in 50-91% of patients, not directly posterior as originally assumed 1
Traditional midline cricoid pressure may not achieve oesophageal compression; paralaryngeal pressure may be more effective, though this is not standard practice 1
Force Application Errors
Most problems occur when too much force is applied (>30 N), causing airway distortion and making intubation more difficult 1
Cricoid pressure is uncomfortable in awake patients, particularly when force exceeds 20 N, and can cause retching and aspiration 1, 3
The force can be reduced to 20 N (2 kg) if the patient is positioned head-up 1
Communication Failures
The assistant must maintain clear communication with the laryngoscopist throughout the procedure 1
There should be no hesitation to release cricoid pressure if requested by the intubating clinician 1, 2
Contraindications the Assistant Must Recognize
Cricoid pressure is contraindicated in patients with suspected cricotracheal injury or unstable cervical spine injuries 3
Active vomiting is an absolute contraindication—pressure must be released immediately 1, 3
In patients with known difficult airways or laryngeal trauma, cricoid pressure may cause complete airway obstruction 4, 3
Evidence Quality and Controversy
A Cochrane review found no RCT evidence supporting cricoid pressure's effectiveness in preventing aspiration, and the technique may not be necessary to undertake RSI safely 5, 6
Despite lack of evidence, cricoid pressure remains standard practice in many countries (particularly the UK) because aspiration, though rare, carries extremely high mortality and morbidity risk when it occurs 1
The 4th National Audit Project (NAP4) identified cases where omission of cricoid pressure led to patient harm or death from aspiration, but also found no cases where cricoid pressure itself caused major complications 1