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Does Cricoid Pressure Interfere with Bougie-Facilitated Intubation?

Summary and Comment |
June 29, 2007

Does Cricoid Pressure Interfere with Bougie-Facilitated Intubation?

  1. Aaron E. Bair, MD, MSc, FAAEM, FACEP

It can, particularly in women.

  1. Aaron E. Bair, MD, MSc, FAAEM, FACEP

Gum elastic bougie-assisted intubation is a valuable adjunct in the management of difficult airways. However, endotracheal tube advancement occasionally can be difficult, as the bevel of the tube can hang up at the level of the glottis. Rotating the tube 90 degrees counterclockwise often relieves this impingement. Researchers assessed the frequency of such impingement and the efficacy of the rotation maneuver in 120 patients who were randomized to intubation performed with a bougie and either sham cricoid pressure or true cricoid pressure applied in routine fashion.

The frequency of impingement was 38% with sham pressure and 60% with true cricoid pressure. This statistically significant difference was entirely attributable to an effect in female patients. The rotation maneuver was successful in relieving impingement in 100% of the sham pressure group but in only 89% of the true cricoid pressure group. The authors conclude that impingement is common and that cricoid pressure might limit the efficacy of the counterclockwise rotation maneuver.

Comment

Cricoid pressure (i.e., Sellick’s maneuver) commonly is employed to limit passive reflux of stomach contents and thereby lessen the risk of intubation-related aspiration. However, there is little evidence to support the routine use of cricoid pressure. These results confirm those of other studies suggesting that cricoid pressure can worsen laryngoscopic view and make intubation more difficult. From this study, we recognize that impingement might not be relieved with counterclockwise rotation in a small subset of patients. If impingement occurs and is unrelieved by rotation, release the cricoid pressure and advance the tube!

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