sellick maneuver, BURP , OELM

1. DR . ZIKRULLAH

2. SELLICK’S MANEUVER
CRICOID PRESSURE (CP)
 Introduction
 Brian Arthur Sellick was a consultant
anesthesiologist at Middlesex hospital, London.
 His description of CP to prevent regurgitation of
gastric contents during induction and intubation
of trachea made him famous world over
 Cricoid pressure during induction of anesthesia
was first described in his paper in Lancet in 1961

3. He demonstrated,
 C P must be exerted by an assistant.
 Before induction the cricoid is palpated and lightly
held between the thumb and second finger.
 As induction begins pressure is exerted on cricoid
cartilage mainly by the index finger.
 It should be maintained until the ETT is secured.

4. Cricoid Pressure
 CP presses cricoid cartilage against the cervical
vertebrae(C6)and so compresses lumen of
pharynx.
 It counteracts a reduction in OESP during
induction and prevents regurgitation.
 The pressure applied should be backward and
in mid line.
 The CP is a force and is therefore measured in
newtons (1Kg=9.8N).

5.  The cricoid cartilage (CC) is signet ring shaped
and is a complete ring.
 It is attached superiorly to the thyroid cartilage
by the cricothyroid ligament and inferiorly to the
first tracheal ring.
 The esophagus begins at the lower border of the
CC, and the cricopharyngeus muscle guards the
esophageal opening.
 The CC differs in size and location in adults and
children.

6. Indications
 During RSI, CP is used to protect the paralyzed
patient from passive regurgitation.
 These are :
1) Non fasted patients
2) Esophageal pathology
3) Hiatus hernia
4) Bowel pathology
5) Vomiting prior procedure

7.  Sellick Maneuver


8. Technique of cricoid pressure
Single-Handed Cricoid Pressure
Double-Handed Cricoid Pressure

9. Single-Handed Cricoid Pressure
 For single-handed CP, the thumb and middle
finger are placed on either side of the CC, and
the index finger is placed above to prevent
lateral movement of the cricoid.[ The
laryngoscopic view is better with the head in
the Magill position and with single-handed CP
as compared with double-handed CP.
 It is recommended that the application of CP
should be performed with the left hand from
the left side of the patient, thus preventing
interference with laryngoscopy, specifically
when the laryngoscope blade is inserted from
the right corner of the mouth.

10.  Double-Handed Cricoid Pressure
 The bimanual or two-handed CP technique
uses the single-handed technique, as
previously described, in addition to using the
assistant's right hand to provide
counterpressure beneath the cervical vertebra
for neck support. The purpose of this
maneuver is to provide support to the
hyperextended arch of the vertebral column to
maintain the efficacy of CP and optimize the
laryngoscopic view. Variations of this
technique include placing the left hand behind
the head and holding the extended head to
maintain the Magill intubating position.

11. Timing of C P
 It should be explained to the patient.
 CP should be applied by assistant before the
induction.
 Pressure should be increased to 30N as patient
loses consciousness.
 And maintained until airway is secured.

12. How much cricoid force prevent
regurgitation
 It has been assessed by cricoid yoke.
 30N cricoid force prevent regurgitation in all cases
with eosophageal pressure of 42mm Hg due to
saline in cadavers.
 Therefore 30N CF will prevent regurgitation of
eosophageal contents and replaces the function of
UOS, when it relaxes from its mean awake value
about 40 mm Hg.
 30N force provide a pressure of 200 mm Hg below
the 10 cm square area of lamina of cricoid.

13. CRICOID YOKE
 Is a mechanical device that is known to provide
optimal cricoid pressure consistently .
 It is designed to deliver 44 Newtons of pressure to the
cricoid cartilage.
 Device is held by grasping ends of the stainless steel
wings with thumb and forefinger of each hand and
pressing down with molded foam cushion againts
cricoid cartilage.

14. Nasogastric tube and C P
 Sallick originally suggested that eosophageal tube can 
the risk of regurgitation by breaching both upper and
lower sphincters and interfere the application of CP.
 However there has been little evidence to support this
 So if nasogastric tube is inserted it need not to be
removed before a RSI.
 Further more NGT is not occluded by CP, they should be
left open to atmosphere to vent liquid and gases to limit
the  in gastric pressure during induction.

15. LMA and C P
 LMA does not prevent regurgitation.
 Despite this, LMA is recommended as an airway in
failed intubation drill for paralyzed patient who can
not be intubated or even ventilated by face mask, but
the CP should be maintained.
 LMA does not reduce the efficacy of CP.

16. Complications
 Some conscious patient feel difficulty in breathing
mainly during inspiration when applied pressure is
more than 20N.
 But most patient tolerate 20N force without being
uncomfortable.
 It should be in range of 10 – 20N not more than that
when the patient is awake.

17. Difficulty in intubation
 CP causes
1) Compression of airway
2) Displacing the larynx
3) Collapsing the thyroid cartilage and distorting
the larynx
4) If force > 40N can prevent even mask
ventilation.
In such conditions applied force is reduced until
airway is secured with ETT.

18. Eosophageal rupture
 CP maintained during retching would allow
eosophageal pressure to rise, which may result in
eosophageal rupture.
 Sellick originally advised that CP should be released if
retching occurs during induction.
 But it is recommended now that CP should be
continued as this complication has not been reported
till date.

19. Guidelines for C P
 After preoxygenation CP with a force of 10N should
be applied to awake patient in ideal head and neck
position for intubation.
 If retching occurs pressure should be maintained.
 With loss of consciousness the force should be
increased to 30N and continued until airway is
secured.
 CP should only be applied by trained assistant
with correct level of force.

20. Cricoid Pressure in Clinical Practice
 In clinical practice, the application of a
predetermined CP can be sustained for only a
short period of time.
 The application of CP with a flexed arm could be
sustained only for a mean time of 3.7 minutes at
40 N, with considerable onset of pain at 2.3
minutes.

21. In view of the fact that sustained CP
cannot be maintained for more
than a few minutes, it has
important clinical implications in
the situation of failed endotracheal
intubation in the presence of a full
stomach.

22.  . Further, an important clinical
limitation to the application of CP in
clinical practice is that it may interfere
with airway management (endotracheal
intubation, face mask ventilation, and
LMA placement), and failure to manage
the airway appropriately is a more
frequent cause of morbidity and
mortality compared with the risk of
pulmonary aspiration

23. BURP
 “BURP”-backwards, upwards, right,
pressure
 May help with difficult intubation

24. “BURP” – also known as “External
Laryngeal Manipulation”
 Backward, Upward,
Rightward Pressure:
manipulation of the
trachea
 90% of the time the best
view will be obtained by
pressing over the thyroid
cartilage
Differs from the Sellick Maneuver

25. Thyroid versus Cricothyroid Cartilage
 Thyroid cartilage used in
“BURP” maneuver. Does
not form a complete ring
around the trachea.
 Cricothyroid Cartilage
used in CricoidPressure,
does form a full ring
around the trachea
allowing for the
compression of the
esophagus.

26.  90% of the time the best view will be obtained by
pressing over the thyroid cartilage – because,
anatomically, the vocal cords are connected here.
 This maneuver is known to improve Cormack &
Lehane laynngoscopic grade by 1

27. DIFFERENCE B/W
 SELLICK
MANEUVER
 1.Pressure over CRICOID
cartilage.
 2.Deteriorate
laryngoscope view.
 BURP
 1. Pressure over
THYROID cartilage.
 2. Improve Cormack &
Lehane’s laryngoscopic
grade by 1 y 1

28. OELM
 OPTIMAL EXTERNAL LARYNGEAL MANEUVER
 DONE TO IMPROVE LARYNGOSCOPIC VIEM

29.  THANK YOU