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Sellick Maneuver – Cricoid Pressure in Anesthesia

The Sellick maneuver is a technique used in anesthesia where pressure is applied to the cricoid cartilage to prevent aspiration of stomach contents during intubation.

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Things worth knowing about "Sellick Maneuver"

The Sellick maneuver is a technique used in anesthesia where pressure is applied to the cricoid cartilage to prevent aspiration of stomach contents during intubation.

What is the Sellick Maneuver?

The Sellick maneuver (also known as cricoid pressure or cricoid compression) is a technique used in anesthesia in which targeted pressure is applied to the cricoid cartilage of the larynx. The goal is to compress the esophagus lying directly behind it against the cervical spine, thereby preventing gastric contents from entering the airways – a life-threatening complication known as pulmonary aspiration. The technique was first described in 1961 by British anesthesiologist Brian Arthur Sellick and has carried his name ever since.

Application and Technique

The Sellick maneuver is most commonly used during a Rapid Sequence Induction (RSI) – a fast-track method of anesthesia induction used in patients at high risk of aspiration. Typical indications include:

Emergency surgery in patients who have not fasted
Pregnancy
Obesity
Gastroesophageal reflux disease (GERD)
Bowel obstruction (ileus)

To perform the maneuver, a trained assistant places the thumb and index finger (or thumb and middle finger) on the patient´s cricoid cartilage and applies a defined posterior pressure of approximately 30 Newtons. This compresses the esophagus against the vertebral column and keeps it occluded until the airway has been secured with an endotracheal tube.

Mechanism of Action

The cricoid cartilage is the only complete cartilaginous ring of the larynx. By applying pressure to this structure, the esophagus running directly posterior to it is compressed against the cervical spine. This is intended to prevent stomach contents – such as acid or partially digested food – from regurgitating into the pharynx and subsequently entering the lungs, which can cause a severe condition known as aspiration pneumonia.

Controversies and Current Clinical Role

Although the Sellick maneuver was considered a standard of care for decades, its clinical value has increasingly been questioned in modern anesthesia. Several studies have highlighted that:

Evidence for its effectiveness in preventing aspiration is not conclusive
Excessive pressure can impair intubation conditions
Correct execution is highly training-dependent
The esophagus may not always be fully occluded

Despite this, the Sellick maneuver remains part of many clinical protocols and guidelines – particularly in emergency medicine and obstetric anesthesia – provided it is performed correctly by trained personnel. Several current guidelines recommend releasing the pressure immediately if intubation becomes difficult.

Risks and Contraindications

When incorrectly applied, the Sellick maneuver can carry disadvantages:

Worsening of laryngoscopy (direct visualization of the larynx) and intubation conditions
Reduced visibility of the vocal cords
Potential injury to the cricoid cartilage if excessive force is used

The maneuver is contraindicated in patients with known or suspected cervical spine injury, an unstable cervical spine, or in actively vomiting patients, where there is a risk of esophageal rupture.

References

Sellick B.A. - Cricoid pressure to control regurgitation of stomach contents during induction of anaesthesia. Lancet, 1961; 2(7199): 404-406.
Algie C.M. et al. - Effectiveness and risks of cricoid pressure during rapid sequence induction for endotracheal intubation. Cochrane Database of Systematic Reviews, 2015.
Higgs A. et al. - Guidelines for the management of tracheal intubation in critically ill adults. British Journal of Anaesthesia, 2018; 120(2): 323-352.

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