What are the qualifications for a person to apply cricoid pressure during a Rapid Sequence Intubation (RSI)?

Qualifications for Applying Cricoid Pressure During RSI

The person applying cricoid pressure must be a trained healthcare provider who has received hands-on instruction with force measurement devices and understands the critical decision points for releasing pressure immediately when requested by the laryngoscopist. 1

Essential Training Requirements

The assistant performing cricoid pressure requires specific competencies that go beyond basic clinical knowledge:

Force Application Knowledge

• The practitioner must know to apply 10 N force initially in the awake patient, increasing to 30 N after loss of consciousness. 2, 3, 1 This is not intuitive—most practitioners apply either too little or too much force without proper training. 1
• Training must include hands-on practice with force measurement devices, as knowledge about appropriate force application is consistently inconsistent among practitioners without this specific training. 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, 4

Critical Decision-Making Authority

• The person must be empowered and trained to release pressure immediately if the laryngoscopist reports difficult visualization of the larynx. 1 This requires both technical knowledge and the confidence to act decisively during a high-stress procedure.
• They must understand that if active vomiting occurs, cricoid pressure should be removed immediately to prevent oesophageal rupture. 1, 5
• 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, 5

Practical Experience Requirements

Clinical Context Understanding

• In the operating room for emergency procedures, the person applying cricoid pressure should ideally be part of an experienced anesthesia team familiar with managing high-risk patients. 1
• Pre-hospital organizations must have written and well-rehearsed protocols for cricoid pressure application and release, suggesting that the assistant needs protocol-specific training for their practice environment. 1

Team Communication Skills

• The assistant must maintain clear communication with the laryngoscopist throughout the procedure and have no hesitation to release cricoid pressure if requested by the intubating clinician. 1, 5
• This communication requirement is critical because cricoid pressure can cause complete airway obstruction in up to 50% of patients and makes failed intubation nearly 8 times more frequent. 5

Common Pitfalls to Avoid

Force-Related Errors

• Most problems occur when too much force is applied (>30 N), causing airway distortion and making intubation more difficult. 1 Without training on force measurement devices, practitioners cannot reliably apply the correct pressure.
• Cricoid pressure is uncomfortable in awake patients, particularly when force exceeds 20 N, and can cause retching and aspiration—the opposite of the intended effect. 1, 4

Anatomical Misconceptions

• The assistant should understand that 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 While this doesn't change the midline application technique in standard practice, it explains why the maneuver may not always be effective.

Special Considerations

Pediatric Patients

• In pediatric RSI, there is insufficient evidence to recommend routine cricoid pressure application, and it should not be continued if it interferes with ventilation or the speed or ease of intubation. 2 The person applying cricoid pressure in pediatric cases needs additional training to recognize these interference patterns quickly.

High-Risk Scenarios

• For patients with high-grade small bowel obstruction or other aspiration risks, the assistant must be prepared to release pressure immediately if airway difficulties arise, as failed intubation is more immediately life-threatening than aspiration. 5
• The force can be reduced to 20 N if the patient is positioned head-up. 1

In summary, there is no formal certification requirement, but the person applying cricoid pressure must have documented training in force application using measurement devices, understand the mandatory release criteria, and be empowered to act independently when complications arise. 1 This typically means a nurse, paramedic, respiratory therapist, or physician who has completed specific cricoid pressure training within their institution or organization.