Cricoid pressure in contemporary airway management: a structured narrative review and call for competency-based implementation

Cricoid Pressure (CP) remains one of the most debated interventions during rapid sequence induction. Although traditionally used to reduce Pulmonary Aspiration (PA), its effectiveness remains uncertain because of conflicting clinical evidence and considerable variability in its application. This structured narrative review critically evaluates contemporary evidence regarding the anatomical rationale, clinical effectiveness, safety, guideline recommendations, performance errors, simulation-based training, and competency-based education for CP. A comprehensive literature search was conducted in PubMed/MEDLINE, Scopus, and Web of Science through July 2026, including randomized controlled trials, systematic reviews, meta-analyses, anatomical studies, clinical guidelines, and educational research. Current evidence does not conclusively demonstrate that CP reduces pulmonary aspiration, while inappropriate anatomical localization, excessive or insufficient force, incorrect timing, and delayed release may adversely affect airway management. Contemporary guidelines increasingly recommend selective rather than routine use of CP and emphasize prompt release whenever ventilation or tracheal intubation is compromised. Educational evidence consistently demonstrates that simulation incorporating objective force-feedback improves immediate technical performance; however, evidence for long-term skill retention, clinical transfer, and patient-centered outcomes remains limited. A six-stage competency-based simulation training curriculum is proposed to standardize training, objective assessment, and periodic reassessment of CP performance. The review also discusses opportunities for implementing CPE within Bulgarian medical training.

1 Cook TM, Woodall N, Harper J, Benger J; Fourth National Audit Project. Major complications of airway management in the UK: results of the Fourth National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society. Part 2: intensive care and emergency departments. Br J Anaesth 2011;106(5):632–642. DOI: https://doi.org/10.1093/bja/aer059

2 Sellick BA. Cricoid pressure to control regurgitation of stomach contents during induction of anaesthesia. Lancet 1961;278(7199):404–406. DOI: https://doi.org/10.1016/S0140-6736(61)92485-0

3 Birenbaum A, Hajage D, Roche S, et al.; IRIS Investigators Group. Effect of cricoid pressure compared with a sham procedure in the rapid sequence induction of anesthesia: the IRIS randomized clinical trial. JAMA Surg 2019;154(1):9–17. DOI: https://doi.org/10.1001/jamasurg.2018.3577

4 White L, Thang C, Hodsdon A, Melhuish T, Vlok R. Cricoid pressure during intubation: a systematic review and meta-analysis of randomised controlled trials. Heart Lung 2020;49(2):175–180. DOI: https://doi.org/10.1016/j.hrtlng.2019.10.001

5 Lee D, Czech AJ, Elriedy M, Nair A, El-Boghdadly K, Ahmad I. A multicentre prospective cohort study of the accuracy of conventional landmark technique for cricoid localisation using ultrasound scanning. Anaesthesia 2018;73(10):1229–1234. DOI: https://doi.org/10.1111/anae.14399

6 Johnson RL, Cannon EK, Mantilla CB, Cook DA. Cricoid pressure training using simulation: a systematic review and meta-analysis. Br J Anaesth 2013;111(3):338–346. DOI: https://doi.org/10.1093/bja/aet121

7 Baethge C, Goldbeck-Wood S, Mertens S. SANRA—a scale for the quality assessment of narrative review articles. Res Integr Peer Rev 2019;4:5. DOI: https://doi.org/10.1186/s41073-019-0064-8

8 Smith KJ, Ladak S, Choi PTL, Dobranowski J. The cricoid cartilage and the esophagus are not aligned in close to half of adult patients. Can J Anaesth 2002;49(5):503–507. DOI: https://doi.org/10.1007/BF03017931

9 Smith KJ, Dobranowski J, Yip G, Dauphin A, Choi PTL. Cricoid pressure displaces the esophagus: an observational study using magnetic resonance imaging. Anesthesiology 2003;99(1):60–64. DOI: https://doi.org/10.1097/00000542-200307000-00013

10 Rice MJ, Mancuso AA, Gibbs C, Morey TE, Gravenstein N, Deitte LA. Cricoid pressure results in compression of the postcricoid hypopharynx: the esophageal position is irrelevant. Anesth Analg 2009;109(5):1546–1552. DOI: https://doi.org/10.1213/ane.0b013e3181b05404

11 Hartsilver EL, Vanner RG. Airway obstruction with cricoid pressure. Anaesthesia 2000;55(3):208–211. DOI: https://doi.org/10.1046/j.1365-2044.2000.01205.x

12 Haslam N, Parker L, Duggan JE. Effect of cricoid pressure on the view at laryngoscopy. Anaesthesia 2005;60(1):41–47. DOI: https://doi.org/10.1111/j.1365-2044.2004.04010.x

13 Smitha CB, Singh K, Kumar A, Sahay N, Kumar A, Kumar N. Effect of cricoid pressure on tracheal intubation time during C-MAC video laryngoscopy: a randomized controlled trial. Anaesth Crit Care Pain Med 2026:101840. DOI: https://doi.org/10.1016/j.accpm.2026.101840

14 Won D, Kim H, Chang JE, et al. Comparison of the effects of paratracheal pressure and cricoid pressure on placement of the i-gel supraglottic airway: a randomized clinical trial. Can J Anaesth 2024;71(7):996–1003. DOI: https://doi.org/10.1007/s12630-024-02741-1

15 Ralph SJ, Wareham CA. Rupture of the oesophagus during cricoid pressure. Anaesthesia 1991;46(1):40–41. DOI: https://doi.org/10.1111/j.1365-2044.1991.tb09314.x

16 Heath KJ, Palmer M, Fletcher SJ. Fracture of the cricoid cartilage after Sellick’s manoeuvre. Br J Anaesth 1996;76(6):877–878. DOI: https://doi.org/10.1093/bja/76.6.877

17 Ahmad I, El-Boghdadly K, Iliff H, et al. Difficult Airway Society 2025 guidelines for management of unanticipated difficult tracheal intubation in adults. Br J Anaesth 2026;136(1):283–307. DOI: https://doi.org/10.1016/j.bja.2025.10.006

18 Mushambi MC, Kinsella SM, Popat M, et al. Obstetric Anaesthetists’ Association and Difficult Airway Society guidelines for the management of difficult and failed tracheal intubation in obstetrics. Anaesthesia 2015;70(11):1286–1306. DOI: https://doi.org/10.1111/anae.13260

19 Lockey D, Weegenaar C, Ahmad I, et al. Safer prehospital anaesthesia: updated guidelines from the Association of Anaesthetists. Anaesthesia 2026;81:1132–1147. DOI: https://doi.org/10.1111/anae.70191

20 Soar J, Böttiger BW, Carli P, et al. European Resuscitation Council Guidelines 2025: Adult Advanced Life Support. Resuscitation 2025;215 (Suppl1):110769. DOI: https://doi.org/10.1016/j.resuscitation.2025.110769

21 Zdravkovic M, Berger-Estilita J, Sorbello M, Hagberg CA. An international survey about rapid sequence intubation of 10,003 anaesthetists and 16 airway experts. Anaesthesia 2020;75(3):313–322. DOI: https://doi.org/10.1111/anae.14867

22 Sajayan A, Wicker J, Ungureanu N, Mendonca C, Kimani PK. Current practice of rapid sequence induction of anaesthesia in the UK: a national survey. Br J Anaesth 2016;117(Suppl 1):i69–i74. DOI: https://doi.org/10.1093/bja/aew017

23 Walker RWM, Ravi R, Haylett K. Effect of cricoid force on airway calibre in children: a bronchoscopic assessment. Br J Anaesth 2010;104(1):71–74. DOI: https://doi.org/10.1093/bja/aep337

24 Knill RL. Difficult laryngoscopy made easy with a “BURP.” Can J Anaesth 1993;40(3):279–282. DOI: https://doi.org/10.1007/BF03037041

25 Williams P, Umranikar A. A comparative prospective cohort study comparing physical exam to ultrasound for identifying the cricoid cartilage. J Perioper Pract 2017;27(9):186–190. DOI: https://doi.org/10.1177/175045891702700902

26 Meek T, Gittins N, Duggan JE. Cricoid pressure: knowledge and performance amongst anaesthetic assistants. Anaesthesia 1999;54(1):59–62. DOI: https://doi.org/10.1046/j.1365-2044.1999.00706.x

27 Andruszkiewicz P, Zawadka M, Kosińska A, Walczak-Wieteska P, Majerowicz K. Measurement of cricoid pressure force during simulated Sellick’s manoeuvre. Anaesthesiology Intensive Therapy 2017;49(4):283–287.

28 Thwaites AJ, Rice CP, Smith I. Rapid sequence induction: a questionnaire survey of its routine conduct and continued management during a failed intubation. Anaesthesia 1999;54(4):376–381. DOI: https://doi.org/10.1046/j.1365-2044.1999.00738.x

29 Meek T, Vincent A, Duggan JE. Cricoid pressure: can protective force be sustained? Br J Anaesth 1998;80(5):672–674. DOI: https://doi.org/10.1093/bja/80.5.672

30 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(1):100–104. DOI: https://doi.org/10.1007/BF03018589

31 Owen H, Follows V, Reynolds KJ, Burgess G, Plummer J. Learning to apply effective cricoid pressure using a part task trainer. Anaesthesia 2002;57(11):1098–1101. DOI: https://doi.org/10.1046/j.1365-2044.2002.02836.x

32 Escott MEA, Owen H, Strahan AD, Plummer JL. Cricoid pressure training: how useful are descriptions of force? Anaesth Intensive Care 2003;31(4):388–391. DOI: https://doi.org/10.1177/0310057X0303100406

33 Flucker CJR, Hart E, Weisz M, Griffiths R, Ruth M. The 50-millilitre syringe as an inexpensive training aid in the application of cricoid pressure. Eur J Anaesthesiol 2000;17(7):443–447. DOI: https://doi.org/10.1097/00003643-200007000-00006

34 Hee HI, Wong CL, Wijeweera O, Sultana R, Sng BL. Sellick maneuver assisted real-time to achieve target force range in simulated environment—a prospective observational cross-sectional study on manikin. PLoS One 2020;15(2):e0227805. DOI: https://doi.org/10.1371/journal.pone.0227805

35 Domuracki KJ, Moule CJ, Owen H, Kostandoff G, Plummer JL. Learning on a simulator does transfer to clinical practice. Resuscitation 2009;80(3):346–349. DOI: https://doi.org/10.1016/j.resuscitation.2008.10.036

36 Beckford L, Holly C, Kirkley R. Systematic review and meta-analysis of cricoid pressure training and education efficacy. AORN J 2018;107(6):716–725. DOI: https://doi.org/10.1002/aorn.12150

37 Ashurst N, Rout CC, Rocke DA, Gouws E. Use of a mechanical simulator for training in applying cricoid pressure. Br J Anaesth 1996;77(4):468–472. DOI: https://doi.org/10.1093/bja/77.4.468

38 Medical Simulation Training Centre at Medical University of Plovdiv. Available from: https://mu-plovdiv.bg/en/about-us/centres/simulation-centre/general-information/.Accessed July 20, 2026.

39 ACS Accredited Education Institutes. Setting the Standard of Excellence and Innovation. Available from: https://www.facs.org/find-an-accredited-education-institute/.Accessed Sept 02, 2026.

40 Sakakushev BE, Marinov BI, Stefanova PP, Kostianev SS, Georgiou EK. Striving for Better Medical Education: the Simulation Approach. Folia Med (Plovdiv) 2017;59(2):123–131. DOI: https://doi.org/10.1515/folmed-2017-0039