2025/07/21 by A. Higgs, Kariem El‐Boghdadly · 1 voice · 1 citation
Medicine · #Airway Management and Intubation Techniques #Cardiac Arrest and Resuscitation #Respiratory Support and Mechanisms
paper · pdf · doi:10.1111/anae.16714
openalex publication_date 2025/07/21 · openalex created_date 2025/10/10 · openalex updated_date 2026/07/15
The widespread use of novel anti-hyperglycaemic drugs, such as glucagon-like peptide-1 receptor agonists, has re-ignited interest in when to use rapid sequence intubation (RSI) techniques [1]. Over half a century after it was described [2, 3], the elements that constitute an RSI are still debated [4] and, specifically, the perennial argument about the role of cricoid force continues. We would like to draw attention to a contextual distinction in the use of cricoid force. As traditionally understood, cricoid force is applied immediately after onset of anaesthesia and neuromuscular block to prevent potential regurgitation of gastric contents and pulmonary aspiration. However, we believe that experienced airway operators who ordinarily eschew the potential benefits of such preventative ‘prophylactic’ cricoid force might consider applying it during laryngoscopy if gastric contents (or other materials) are actually detected around the larynx or when real-time regurgitation and/or aspiration occurs. This ‘therapeutic’ application might reduce the volume of regurgitated gastric content that may soil the lower airway when applied correctly. Of note, this therapeutic procedure should not be used if the patient is actively vomiting. Even when large numbers of anaesthetists are asked open-ended questions about how real-time aspiration should be managed, they fail to mention cricoid force [5]. We suggest that all future debate recognise the different contexts in which cricoid force is deployed. Pulmonary aspiration risk assessment should be conducted for all patients, but this can be challenging at times [1]. The risk of pulmonary aspiration must be assumed to be high when gastric fluid is identified near the upper airway in an unconscious patient. The role of therapeutic cricoid force to achieve initial control in an aspiration crisis, for instance, may be considerably less controversial than its prophylactic cousin, although it is accepted that conducting prospective randomised controlled trials will be impossible (as with other aspects of this technique). We encourage clinicians to consider applying cricoid force in the event of regurgitation during laryngoscopy and tracheal intubation attempts. In times of crisis, cricoid force may not be obsolete, just overdue.