Cricoid pressure training using simulation: a systematic review and meta-analysis

Cricoid pressure (CP) is commonly applied during rapid sequence intubation and may be protective during induction of anaesthesia; however, CP application by untrained practitioners may not be performed optimally. The objective of this systematic review was to synthesize the evidence regarding effectiveness of technology-enhanced simulation training to improve efficacy of CP application. Electronic databases from inception through May 11, 2011 were searched. Eligible studies evaluated CP simulation training. Independent reviewers working in duplicate extracted study characteristics, validity, and outcomes data. Pooled effect size (ES) with 95% confidence intervals (CIs) were estimated from each study that compared technology-enhanced simulation with no intervention or with other methods of CP training using random-effects model. Twelve studies (772 trainees) evaluated CP training as an outcome. Nine studies reported information on baseline skill, with 23% of providers being able to achieve the target CP before training. In a meta-analysis of 10 studies (570 trainees), CP training resulted in a large favourable impact on skills among trainees compared with no intervention (pooled ES 1.18; 95% CI 0.85-1.51; P<0.0001). Four studies found evidence of skills retention for CP application after training, but for a limited time (<4 weeks). Comparative effectiveness research shows beneficial effects to force feedback training over training without feedback. Simulation training significantly improves the efficacy of CP application. Future studies might evaluate the clinical impact of training on CP application during rapid sequence intubation, and the comparative effectiveness of different training approaches.