title: Cricoid pressure and laryngeal manipulation in 402 pre-hospital emergency anaesthetics: essential safety measure or a hindrance to rapid safe intubation?
abstract: OBJECTIVE
  This is the first study to look at the effects of cricoid pressure/laryngeal manipulation on the laryngeal view and intubation success in the emergency or pre-hospital environment. Cricoid pressure is applied in the hope of reducing the incidence of aspiration. However the technique has never been evaluated in a randomized trial and may adversely affect laryngeal view. In order to improve intubating conditions cricoid pressure may be released and the larynx manipulated into a more favourable position.
  
  
  METHODS
  We carried out a prospective observational study to evaluate the effects of cricoid pressure and laryngeal manipulation on laryngeal view in our physician led pre-hospital trauma service.
  
  
  RESULTS
  402 patients were included over a 16-month period. We intubated 98.8% patients on the first or second attempt. In 61 intubations (in 55 patients, 13.6%) the larynx required manipulation to facilitate intubation. In 22 intubations cricoid pressure was removed with the laryngeal view improving in 50%. Bimanual laryngeal manipulation was used in 25 intubations and the larynx better visualised in 60% of these. Backwards upwards rightwards pressure was applied to the larynx in 14 intubations and the laryngeal view improved in 64%. Two patients regurgitated when cricoid pressure was released. Both had prolonged periods of bag valve mask ventilation and difficult intubations.
  
  
  CONCLUSIONS
  The results suggest that cricoid pressure should be removed if the laryngeal view obtained is not sufficient to allow immediate intubation. Further manipulation of the larynx is likely to improve the chances of successful tracheal tube placement.
authors.affiliation: Dept of Emergency Medicine and Pre-hospital Care, Royal London Hospital, Whitechapel, London, UK. tim.harris@bartsandthelondon.nhs.uk
authors.forename: Tim
authors.initials: T
authors.lastname: Harris
authors.forename: Daniel Y
authors.initials: DY
authors.lastname: Ellis
authors.forename: Liz
authors.initials: L
authors.lastname: Foster
authors.forename: David
authors.initials: D
authors.lastname: Lockey
mesh_terms: D017732:Air Ambulances; D000777:Anesthetics / Q000008:administration & dosage; D016009:Chi-Square Distribution; D015331:Cohort Studies; D016001:Confidence Intervals; D003413:Cricoid Cartilage / Q000502:physiology*; D003422:Critical Care / Q000379:methods; D016638:Critical Illness / Q000401:mortality / Q000628:therapy; D004632:Emergency Medical Services / Q000379:methods*; D005260:Female; D006801:Humans; D007442:Intubation, Intratracheal / Q000009:adverse effects / Q000379:methods*; D007828:Laryngoscopy / Q000379:methods; D007830:Larynx / Q000502:physiology*; D008297:Male; D016017:Odds Ratio; D011312:Pressure; D011446:Prospective Studies; D012121:Respiration, Artificial / Q000379:methods*; D018570:Risk Assessment; D017751:Safety Management; D015996:Survival Rate; D016896:Treatment Outcome; D006113:United Kingdom
chemical_list: D000777:Anesthetics