Effect of cricoid pressure on the view at laryngoscopy

The impact of cricoid pressure on laryngoscopy is unknown. We have developed a quantitative method of recording the laryngoscopic view using a rigid, zero-degree endoscope. We found that an image matching the laryngoscopist's view could be obtained by positioning the endoscope along the laryngoscopist's 'line of sight'. Photographing this image allowed us to measure laryngeal exposure. We set out to define the effect of cricoid pressure on laryngoscopy using this method. In 40 patients undergoing elective surgery, laryngoscopy was performed with cricoid pressures of 0-60 N, increasing by increments of 10 N. We photographed the laryngoscopic view at each force and recorded dynamic images as cricoid pressure was released. The change in laryngoscopic view with increasing cricoid pressure fell into one of four broad patterns: little change (11 subjects); gradual deterioration (10 subjects); improvement at low force (< 20 N) followed by deterioration (9 subjects); improvement at high force (> 30 N) (10 subjects). We identified five subjects with a good initial view (anteroposterior length of the rima glottidis > 5 mm) who showed a marked deterioration in laryngoscopic view as cricoid pressure increased; in three of these subjects this progressed to obscure the larynx completely at a force of 30 N, 40 N and 60 N, respectively. We conclude that the effect of cricoid pressure on laryngoscopy is complex. However, in some individuals, a force close to that currently recommended (30 N) may cause a complete loss of the glottic view.