Cricoid force – therapeutic, prophylactic or routine: a reply

We welcome the interest in our description of the difference between prophylactic and therapeutic cricoid force [1, 2]. Chrimes emphasises the limited evidence-based validity of cricoid force primarily, especially compared with less controversial elements of rapid sequence intubation techniques [3]. Although there are randomised controlled trials assessing the efficacy of cricoid force [4], there are few high-quality data on the efficacy or safety with contemporary anaesthesia techniques (e.g. videolaryngoscopy) or when correctly applied (e.g. ultrasound localisation) [5]. Chrimes criticises our suggestion that clinicians who choose not to apply cricoid force should reconsider its risk–benefit balance if regurgitation or pulmonary aspiration occurs. He makes an argument that cricoid force should be applied routinely in all patients undergoing tracheal intubation, including in fasted, elective settings. We agree that the disregard for cricoid force in contemporary practice is not evidence-based and warrants reconsideration [5]. However, Chrimes ignores the fact that many airway practitioners around the world have already chosen not to deploy this potentially useful intervention [6]. Our suggestion accepts this inescapable reality but encourages the focused use of therapeutic cricoid force application, which we believe must have a clear risk–benefit advantage in the context of witnessed regurgitation. We believe that our more nuanced approach would gain greater support among airway practitioners than a blanket call for universal application of cricoid force, when perhaps a global majority has already dismissed this intervention [6], even when there is a documented risk of pulmonary aspiration. Extreme swings in practice are often erroneous, and it is possible that an all-or-none decision-making process for cricoid force application is one of these errors. Some patients require prophylactic application of cricoid force; some warrant therapeutic application; all warrant a considered and balanced approach.