Cricoid pressure, also known as the Sellick Maneuver, is a manual technique applied to the neck during emergency airway management. This technique involves an assistant placing pressure on the cricoid cartilage, the only complete ring of cartilage in the trachea. The main goal is to compress the esophagus against the spine, physically blocking the passage to the stomach. This compression was intended to prevent pulmonary aspiration—the inhalation of gastric contents—a serious complication during intubation in critically ill patients undergoing Advanced Cardiovascular Life Support (ACLS) protocols.
The Original Rationale and Technique
The concept of applying pressure to the cricoid cartilage was popularized by British anesthesiologist Dr. Brian Arthur Sellick in 1961. He initially described the maneuver as a measure to prevent the regurgitation of stomach contents during the induction of anesthesia. The foundational theory was that pressure on the cricoid ring would occlude the esophagus, which lies immediately behind it, against the cervical vertebrae.
The technique quickly became a widely accepted component of Rapid Sequence Intubation (RSI) protocols. RSI involves the rapid administration of sedatives and paralytics to facilitate endotracheal tube placement in patients at high risk for aspiration, often those considered to have a “full stomach.” The required force for the Sellick Maneuver was initially described as approximately 30 to 44 Newtons (3 to 4.5 kilograms of force).
A trained assistant would locate the cricoid cartilage and apply this backward force, maintaining it until the endotracheal tube was correctly placed and its cuff inflated. This manual pressure was considered a standard of care for nearly five decades, especially during emergency intubations when patients had not fasted. Acceptance of this practice was based solely on the theoretical benefit of creating a protective seal against passive regurgitation.
Current Recommendations in Emergency Airway Management
The routine application of cricoid pressure has largely been phased out of modern resuscitation guidelines, including those for Advanced Cardiovascular Life Support (ACLS). Major international bodies, such as the American Heart Association (AHA) and ILCOR, no longer recommend its routine use during emergency endotracheal intubation. This change reflects a shift toward evidence-based practice and away from interventions lacking clear scientific support.
The 2020 guidelines explicitly state that routine cricoid pressure does not reduce the risk of regurgitation and may impede intubation success. This guidance is based on clinical studies indicating the maneuver frequently fails to achieve its intended goal of completely occluding the esophagus. Furthermore, the routine use of cricoid pressure is specifically not recommended in pediatric patients, as it provides no benefit.
Current recommendations advise that if cricoid pressure is applied, it must be discontinued immediately if it interferes with ventilation or complicates endotracheal tube placement. Clinician discretion may allow for temporary consideration in non-arrest situations, such as during bag-mask ventilation, to reduce gastric insufflation. However, this is a selective approach, not a standard protocol, and the pressure must be released if it compromises the primary goal of securing the airway.
Potential Interference and Safety Concerns
The shift away from routine cricoid pressure stems from documented issues with its application and its detrimental effect on the airway procedure. A significant concern is that the pressure interferes with the physician’s view of the vocal cords during laryngoscopy. The resulting distortion of the laryngeal anatomy makes it more difficult and time-consuming to correctly place the breathing tube, delaying definitive airway establishment.
Studies using advanced imaging have shown that the maneuver often displaces the esophagus laterally rather than compressing it directly against the vertebral column. This lateral displacement means the supposed protective seal is not formed, compromising the intended anti-aspiration benefit. Furthermore, excessive or misdirected force can lead to potential trauma, including pain, vomiting, or esophageal rupture.
The pressure can also impede other rescue maneuvers necessary for emergency airway management. For instance, cricoid pressure may obstruct the passage of the endotracheal tube or make effective bag-mask ventilation difficult. In a time-critical emergency like cardiac arrest, any intervention that delays securing the airway or introduces complications outweighs the unproven benefit of aspiration prevention.