Cricoid pressure is a technique where someone pushes firmly on the front of your neck, over a ring of cartilage called the cricoid, to compress the passage behind it and prevent stomach contents from rising into your airway. It’s most commonly used during emergency intubation, when a breathing tube is being placed while a patient is unconscious and unable to protect their own airway. The technique is also called the Sellick maneuver, after the anesthesiologist Brian Sellick, who described it in 1961.
How It Works Anatomically
The cricoid cartilage is a firm, complete ring of cartilage that sits at the base of your voice box, roughly at the level of the C5 vertebra in your spine. Unlike the other cartilage rings in your airway, which are C-shaped and open at the back, the cricoid forms a full circle. That rigidity is what makes the technique possible: when pressed backward, the ring doesn’t collapse. Instead, it compresses the soft tissue between it and the spine.
Sellick originally believed the pressure squeezed the esophagus shut between the cricoid and the vertebra behind it, like pinching a garden hose against a wall. The anatomy turns out to be slightly different. The esophagus actually begins below the cricoid ring, so what’s really being compressed is the lower part of the throat (the hypopharynx) and a band of muscle called the cricopharyngeal muscle that wraps around the back of the airway at that level. When pressed, this muscle collapses into a kidney shape, blocking the path that stomach contents would take to reach the throat.
When It’s Used
Cricoid pressure comes up most often during rapid sequence intubation, a fast method of placing a breathing tube that skips the usual period of mask ventilation. It’s designed for people who are at high risk of vomiting and inhaling stomach contents into their lungs, a dangerous event called aspiration. Aspiration can cause severe pneumonia or even be fatal, so preventing it during intubation is a major concern.
The situations that raise aspiration risk are varied: someone who just ate, a person who has been vomiting, anyone heavily intoxicated, patients with conditions that slow stomach emptying, or those with a weakened barrier between the stomach and esophagus. Emergency rooms and intensive care units see these scenarios constantly, which is why cricoid pressure became a staple of emergency airway management.
Pregnant patients undergoing emergency anesthesia are considered one of the highest-risk groups for aspiration. Pregnancy increases abdominal pressure and slows stomach emptying, so cricoid pressure has been especially emphasized in obstetric anesthesia for decades.
What It Feels Like for the Patient
If you’re awake when cricoid pressure is applied, you’ll feel a firm push on the front of your lower throat. The recommended force starts at about 10 newtons while the patient is still conscious, which feels like moderate finger pressure. Once you lose consciousness from anesthesia medications, the person applying the pressure increases to 30 newtons, roughly the force you’d use pressing down on a kitchen scale to read 3 kilograms (about 6.6 pounds). It stays in place until the breathing tube is secured and its cuff is inflated, sealing the airway.
Getting that force right is harder than it sounds. Medical staff train using biofeedback simulators that display real-time force readings. A typical training sequence involves practicing on a device until the provider feels “calibrated,” then testing themselves without looking at the display to confirm they can hit the target consistently. Some institutions recommend providers recalibrate at the start of each shift and again briefly before each use.
The Controversy Over Effectiveness
Despite being standard practice for over 60 years, cricoid pressure has become one of the most debated techniques in airway management. The core question: does it actually prevent aspiration?
A systematic review and meta-analysis of 12 randomized controlled trials involving 4,862 patients found no difference in aspiration rates between patients who received cricoid pressure and those who did not. The relative risk was 1.18, meaning the technique provided no measurable protection. Notably, only three of those studies focused specifically on high-risk patients, so the evidence in the population that needs it most remains thin.
What the data did show was a downside. Cricoid pressure significantly reduced first-attempt intubation success by about 6%, added an average of nearly 7 extra seconds to intubation time, and worsened the clinician’s view of the vocal cords. A poor view of the vocal cords makes it harder and riskier to place the breathing tube, which is exactly the situation you want to avoid during an emergency.
The impact on visualization varies by equipment. One study comparing different types of laryngoscopes found that cricoid pressure had no negative effect, or even slightly improved the view, with standard and some video laryngoscopes. But with one commonly used video device (the GlideScope), the view worsened in 30% of patients. This inconsistency adds to the difficulty of writing blanket guidelines.
Current Guidelines and Practice
Professional organizations have shifted from treating cricoid pressure as mandatory to treating it as conditional. The Difficult Airway Society’s 2015 guidelines, widely referenced in the UK, still include it as a standard component of rapid sequence intubation but with important caveats. If the first attempt at placing the breathing tube is difficult, clinicians are told to release the pressure. This should be done carefully, with suction equipment ready in case releasing the pressure triggers regurgitation.
The guidelines also note that cricoid pressure reduces the space in the lower throat and interferes with placing alternative airway devices, like supraglottic airways (the kind that sit above the vocal cords rather than passing through them). If a clinician can’t get a breathing tube in and needs to switch to a backup device, cricoid pressure should stay off unless the patient is actively vomiting.
In practice, the technique remains widely used in the UK and many other countries, but its application has become more flexible. Rather than holding pressure rigidly through every intubation attempt, clinicians now release it sooner if it appears to be making intubation harder. The emphasis has shifted from “always apply it” to “apply it if you can, but don’t let it compromise the airway.”
Risks and Limitations
Cricoid pressure is not risk-free. Applied too forcefully, it can cause retching in a conscious or semiconscious patient, which increases the very aspiration risk it’s meant to prevent. Excessive force can also fracture the cricoid cartilage, though this is rare. If a patient is actively vomiting and the pressure is maintained, there is a theoretical risk of esophageal injury because the stomach contents have nowhere to go.
The technique also assumes the anatomy is straightforward. In patients with neck abnormalities, cervical spine injuries, or prior throat surgery, the landmarks may be distorted or the pressure may not compress the right structure. In these situations, the risks of applying cricoid pressure can outweigh the uncertain benefits.
Perhaps the most practical limitation is simply that it’s hard to do well. The person applying the pressure needs to hold a precise force, in the right spot, at the right angle, for the entire duration of the intubation, all while the rest of the team is managing medications and airway equipment in what is often a high-stress situation. Studies using force sensors have repeatedly shown that even trained providers frequently apply too much or too little pressure.