Cricoid pressure in contemporary airway management: a structured narrative review and call for competency-based...

Cricoid Pressure (CP) remains one of the most debated interventions during rapid sequence induction. Although traditionally used to reduce Pulmonary Aspiration (PA), its effectiveness remains uncertain because of conflicting clinical evidence and considerable variability in its application. This structured narrative review critically evaluates contemporary evidence regarding the anatomical rationale, clinical effectiveness, safety, guideline recommendations, performance errors, simulation-based training, and competency-based education for CP. A comprehensive literature search was conducted in PubMed/MEDLINE, Scopus, and Web of Science through July 2026, including randomized controlled trials, systematic reviews, meta-analyses, anatomical studies, clinical guidelines, and educational research. Current evidence does not conclusively demonstrate that CP reduces pulmonary aspiration, while inappropriate anatomical localization, excessive or insufficient force, incorrect timing, and delayed release may adversely affect airway management. Contemporary guidelines increasingly recommend selective rather than routine use of CP and emphasize prompt release whenever ventilation or tracheal intubation is compromised. Educational evidence consistently demonstrates that simulation incorporating objective force-feedback improves immediate technical performance; however, evidence for long-term skill retention, clinical transfer, and patient-centered outcomes remains limited. A six-stage competency-based simulation training curriculum is proposed to standardize training, objective assessment, and periodic reassessment of CP performance. The review also discusses opportunities for implementing CPE within Bulgarian medical training.