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Note: conundrums are not meant to have a “right” answer – they are to see how most people are practicing. Would love your comments also regarding your thought processes and the evidence behind your decisions. We can learn from each other!
It’s the day after Thanksgiving, and your patient just ate a bunch of leftovers before getting into an automobile accident. You are intubating, and hoping the patient doesn’t aspirate during the procedure. A medical student asks whether he should apply cricoid pressure for you.
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November 23, 2018 at 11:31 pm
The use of cricoid pressure recently received two death knells in the literature.
Kojima et al Pediatr Crit Care Med 2018;19:5.28-537 describes a NEAR registry (non-randomized) study of pediatric patients intubated with direct laryngoscopy in 35 PICUs. Of 7,825 intubations, cricoid pressure was used in 23%. Regurgitation occurred in 1.4% and aspiration in 0.7% overall. Regurgitation occurred in 1.9% with cricoid pressure, and 1.2% without. Multivariate analysis did not show an association between use of cricoid pressure and lack of regurgitation.
Birenbaum et al JAMA Surgery, in press (published online October 17, 2018) conducted a randomized, double-blind, noninferiority trial of cricoid pressure vs sham cricoid pressure in 3,472 adults undergoing anesthesia with RSI. Pulmonary aspiration occurred in 0.6% of the cricoid pressure group, and 0.5% of the sham group. Although this study failed to establish noninferiority of the sham procedure, the risk of aspiration was very low, and this large study did not demonstrate cricoid pressure to be definitively more effective. The observed risk difference was -0.06% (95% CI -0.57 to 0.42%).
The BURP maneuver, or backwards, upwards, rightwards pressure on the caudal end of the thyroid cartilage has been advocated instead to improve laryngoscopy view, but not to prevent aspiration. A video of the BURP technique is found here: https://www.youtube.com/watch?v=odTYa1t7JfY
Now, however, airway gurus advocate use of ELM (External laryngeal manipulation), which is basically pushing around the lower thyroid cartilage, manipulating the position of the larynx, to get the best view possible. This FOAMed site is a great discussion with videos http://www.airwayappetizers.com/external-laryngeal-manipulation.html
The whole site is great, although directed more to adult patients.