Cricoid pressure no help during endotracheal intubation in large trial

Pressing fingers against the cricoid cartilage (the Sellick maneuver) during rapid sequence intubation compresses the esophagus beneath the firmer trachea. It has long been espoused that this prevents aspiration (emesis or reflux of gastric contents into the supraglottic space and airway, obscuring the operator's view and harming the patient). The Sellick maneuver is believed to be particularly helpful if a patient has not fasted.

Cricoid pressure is a time-honored maneuver based in decades of dogma, but had never been tested in randomized trials.

Authors in France randomized 3,471 adults undergoing rapid-sequence intubation for surgery (not emergency department or ICU patients) to get either cricoid pressure or a sham maneuver by a trained anesthesiologist whose actions were shielded from the intubating team by a drape.

All the patients had fasted <6 hours or had another risk factor for aspiration. There was no difference in the primary endpoint (pulmonary aspiration seen during intubation or by suctioning immediately following intubation.) Patients also had no difference in aspiration pneumonia rates. Most patients intubated with cricoid pressure took longer to intubate (median 27 seconds vs 23), and the operators had poorer views of the vocal cords, on average. Although the study excluded ICU and emergency department patients, its large size is persuasive. To be justified, any maneuver that reduces visualization of the glottis during intubation must provide significant benefits in return. Cricoid pressure does not appear to have any.

Source: JAMA Surgery