Journal of Emergencies, Trauma, and Shock
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LETTER TO EDITOR Table of Contents   
Year : 2010  |  Volume : 3  |  Issue : 1  |  Page : 96-97
Cricoid pressure - A misnomer in pediatric anaesthesia


Department of Anaesthesiology and Critical Care, Jawaharlal Nehru Medical College Hospital, Aligarh Muslim University, Aligarh, Uttar Pradesh, India

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Date of Web Publication5-Jan-2010
 

How to cite this article:
Moied AS, Pal J. Cricoid pressure - A misnomer in pediatric anaesthesia. J Emerg Trauma Shock 2010;3:96-7

How to cite this URL:
Moied AS, Pal J. Cricoid pressure - A misnomer in pediatric anaesthesia. J Emerg Trauma Shock [serial online] 2010 [cited 2019 Aug 17];3:96-7. Available from: http://www.onlinejets.org/text.asp?2010/3/1/96/58647


Sir,

Cricoid pressure, sometimes called Sellick's maneuver (or even 'The Sellicks'), is the application of backward pressure on the cricoid cartilage to occlude the esophagus [Figure 1]. This maneuver prevents aspiration of gastric contents during induction of anesthesia and in resuscitation of emergency victims when intubation is delayed or not possible.

Although the application of cricoid pressure was originally described by Dr. Munro in 1774, it was not until 1961 when Dr. Brian Arthur Sellick, an eminent anesthetist, published his original paper "Cricoid pressure to control regurgitation of stomach contents during induction of anesthesia-preliminary communication" that the maneuver gained widespread acceptance. The recommended pressure to prevent gastric reflux is between 30 and 40 N (equivalent to 3-4 kg). However, pressures higher than 20 N cause pain and retching in awake patients and a pressure of 40 N can distort the larynx and complicate intubation.

Contrary to Arthur Sellick's concept, various authors were of the opinion that cricoid pressure in pediatric population, particularly neonates, improved glottic view and aided tracheal intubation apart from its classical role in rapid sequence intubation for aspiration prophylaxis. [1],[2],[3],[4],[5],[6] However, other references quoted differently on the same topic with different and varied nomenclature, for example, pressure over hyoid cartilage, pressure over larynx, pressure over thyroid cartilage, etc. [7],[8],[9],[10],[11],[12]

Should the term 'cricoid pressure' with the range of pressure and purpose, as per the original article, be applicable in all age groups, especially neonates and pediatrics? Further, does it have a dual purpose when applied to them?

Various modifications have evolved over the manipulation of cricoid with different intent, over the past few years.

'BURP' maneuver (consisting of backward, upward, and right-sided pressure on the thyroid and cricoid cartilages) was introduced by Knill in 1993 [13] to improve the glottic view during endotracheal intubation. Takahata et al. in their study proved the efficacy of BURP by demonstrating significant improvement of the glottic view during the attempts at endotracheal intubation in 630 cases. [15]

In 'Modified BURP' maneuver', the patient lies supine with a sniffing position. The thumb and middle finger are applied to the cricoid cartilage and the index finger is applied to the left hand side of the thyroid cartilage. Pressure is applied to both of these structures, downwards, superiorly, and to the right hand side. This maneuver was intended to be a combination of both Sellick's and the burp maneuvers. [13] Snider et al. were of the opinion that 'modified BURP' maneuver not only failed to enhance the glottic view during RSI but actually worsened it in 30% of cases, and that was because of improper application of cricoid pressure. [13]

However, understanding the basic purpose of two different maneuvers, the cricoid pressure and the laryngeal manipulation, Benumof coined a new term-OELM (optimal external laryngeal manipulation). He suggested that during laryngoscopy, the operator should manipulate the larynx (hyoid and thyroid cartilages only) with the free hand in an effort to improve the laryngoscopic view.[Figure 2] In a study of 181 patients acting as their own controls, he demonstrated a significant improvement in the laryngoscopic view when OELM was applied. [13]

Hence, confusion, both among practicing anesthesiologists as well as trainee student medics of anesthesia and pediatric medicine, has to arise when one mentions that the most effective maneuver is the application of external pressure at the level of cricoid cartilage to push the larynx into view, [14] whereas another reference quotes that vigorous cricoid pressure can distort the laryngeal anatomy or inadvertently flex the neck, impairing intubation. [6] Further, some say that cricoid pressure prevents regurgitation; others mention that it improves laryngoscopic view.

The concept of the use of 'cricoid pressure' was originally intended to prevent aspiration particularly in the setting of emergency intubation. But now, pressure or manipulation of cricoid for whatever and however confusing its purpose may be is being designated the same term of 'cricoid pressure'. This is the unwarranted jargon, as one specific maneuver intended for a specific purpose is being implemented in other case scenarios with different intent.

To put matters into their right perspective, we opine that apart from its classical role of aspiration prevention, the term 'cricoid pressure' should not be used in other scenarios. Rather, a different terminology such as 'cricoid manipulation' may be more suitable for external manipulation done over the cricoid for better laryngoscopic view of the glottis, especially in pediatric population.

 
   References Top

1.Green T, Franklin H. Wayne, Tanz R. Robert. Neonatal resuscitation. Illustrated Edition. Pediatrics: just the facts. McGraw-Hill Professional; 2004. p. 85.  Back to cited text no. 1      
2.Vener DF, Lermans J. Managing the pediatric airway. Rev Col Anest 1998;26:317.  Back to cited text no. 2      
3.Airway Management. Alan AR, Smith G, David RJ. 5th Edition. Textbook of Anaesthesia. Churchil Livingstone Elsevier; 2007. p. 664.  Back to cited text no. 3      
4.Berry FA, Barbara CA. Neonatal Anesthesia. Paul BG, Bruce CF, Robert SK, 5th Edition. Clinical Anesthesia. Lippincott William Wilkins; 2006. P. 1186.  Back to cited text no. 4      
5.McLean B, Janice L. Factors that affect endotrachael intubation in children. Zimmerman, 4th Edition. Fundamental critical care support USA; 2007. p. 6-16.  Back to cited text no. 5      
6.Kotur PF. Sellick's Manouevre to be employed or dismissed from the armamentarium of anaesthetic practice? Indian J Anaesth 2006;50:488.  Back to cited text no. 6      
7.Richard EA. The Newborn Intensive Care. Julia MA, Catherine DD, Ralph FD, Frank OA, 3rd Edition. Oski's Pediatrics: Principles and Practice. Place: Lippincott Williams and Wilkins; 1999.  Back to cited text no. 7      
8.Common Neonatal Procedures. John CP, Eric EC, Ann SR, 6th Edition. Manual of Neonatal Care. Lippincott Williams and Wilkins; 2008. p. 654.  Back to cited text no. 8      
9.Intubation in an awake infant. Etsuro MK, Peter DJ, 7th Edition. Smith's anesthesia for infants and children. Mosby Elsevier; 2006. p. 346.  Back to cited text no. 9      
10.George A. Gregory. Resuscutation of the newborn. Miller RD, 6th edition. Miller's Anesthesia. USA: Elsevier Churchill Livingstone; 2005. p. 2353.  Back to cited text no. 10      
11.Obstetric Anesthesia - Care of the depressed neonate. Morgan EG Jr, Mikhail MS, Murray MJ, 4th Edition. Clinical Anesthesiology. New York: Lange Medical Books / McGraw-Hill Medical Publishing Division; 2006. p. 917.  Back to cited text no. 11      
12.Lerman J. Airway; Neonatal Anesthesia. Healy TE, Knight PR, 7th Edition. Wylie and Churchill- Davidson's A practice of Anesthesia. London: Arnold Publishers; 2003. p. 948.  Back to cited text no. 12      
13.Snider DD, Clarke D, Finucane BT. The "BURP" maneuver worsens the glottic view when applied in combination with cricoid pressure. Can J Anaesth 2005;52:100-4.  Back to cited text no. 13      
14.Meakin GH, Welborn LG. Airway maintainence and tracheal intubation. Thomas EJ, Paul H, Knight R. 7th Edition. Wylie and Churchill- Davidson's A practice of Anesthesia. London: Arnold Publishers; 2003. p. 972.  Back to cited text no. 14      
15.Takahata O, Kubota M, Mamiya K, Akama Y, Nozaka T, Matsumoto H, et al. The efficacy of the "BURP" maneuver during a difficult laryngoscopy. Anesth Analg 1997;84:419-21.  Back to cited text no. 15      

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Correspondence Address:
Ahmed Syed Moied
Department of Anaesthesiology and Critical Care, Jawaharlal Nehru Medical College Hospital, Aligarh Muslim University, Aligarh, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0974-2700.58647

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