{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,14]],"date-time":"2026-10-14T15:47:24Z","timestamp":1791992844159,"version":"4.4.0"},"reference-count":40,"publisher":"PAGEPress Publications","license":[{"start":{"date-parts":[[2026,10,14]],"date-time":"2026-10-14T00:00:00Z","timestamp":1791936000000},"content-version":"unspecified","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by-nc\/4.0"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Eur J Transl Myol"],"abstract":"<jats:p>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.<\/jats:p>","DOI":"10.4081\/ejtm.2026.16055","type":"journal-article","created":{"date-parts":[[2026,10,14]],"date-time":"2026-10-14T15:11:48Z","timestamp":1791990708000},"source":"Crossref","is-referenced-by-count":0,"title":["&lt;a&gt;&lt;\/a&gt;&lt;a&gt;Cricoid pressure in contemporary airway management: a structured narrative review and call for competency-based implementation&lt;\/a&gt;"],"prefix":"10.4081","author":[{"ORCID":"https:\/\/orcid.org\/0009-0003-2930-0162","authenticated-orcid":true,"given":"Zlatina","family":"Stoyanova","sequence":"first","affiliation":[{"name":"Department of Healthcare, Faculty of Public Health and Healthcare, State University of Burgas \u201cProf. Dr. Asen Zlatarov\u201d, Burgas"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Petya","family":"Trendafilova","sequence":"additional","affiliation":[{"name":"Department of Health Care, Faculty of Public Health \"Prof. Dr. Tzecomir Vodenicharov, DSc\", Medical University of Sofia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Hristo","family":"Bozov","sequence":"additional","affiliation":[{"name":"University Hospital \"Medica Rousse\""}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-7289-0829","authenticated-orcid":true,"given":"Milena","family":"Sandeva","sequence":"additional","affiliation":[{"name":"Department of Midwifery Care, Faculty of Public Health, Medical University of Plovdiv, Bulgaria; Medical Simulation Training Centre, Medical Faculty, Medical University of Plovdiv"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Atanas","family":"Petkov","sequence":"additional","affiliation":[{"name":"Department of Propaedeutic Surgery, Faculty of Medicine, Medical University of Plovdiv"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Georgi","family":"Gelov","sequence":"additional","affiliation":[{"name":"Surgical Department, Multiprofile Hospital for Active Treatment, Haskovo"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0000-9942-9357","authenticated-orcid":true,"given":"Plamen","family":"Penchev","sequence":"additional","affiliation":[{"name":"Medical University of Plovdiv"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-2557-5508","authenticated-orcid":true,"given":"Jannis","family":"Papathanasiou","sequence":"additional","affiliation":[{"name":"Department of Physical and Rehabilitation Medicine, Medical University of Plovdiv, Bulgaria; Department of Physical Medicine & Rehabilitation, Medical University of Sofia"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"2549","published-online":{"date-parts":[[2026,10,14]]},"reference":[{"key":"255773","doi-asserted-by":"crossref","unstructured":"1 Cook TM, Woodall N, Harper J, Benger J; Fourth National Audit Project. Major complications of airway management in the UK: results of the Fourth National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society. Part 2: intensive care and emergency departments. Br J Anaesth 2011;106(5):632\u2013642.","DOI":"10.1093\/bja\/aer059"},{"key":"255774","doi-asserted-by":"crossref","unstructured":"2 Sellick BA. Cricoid pressure to control regurgitation of stomach contents during induction of anaesthesia. Lancet 1961;278(7199):404\u2013406.","DOI":"10.1016\/S0140-6736(61)92485-0"},{"key":"255775","doi-asserted-by":"crossref","unstructured":"3 Birenbaum A, Hajage D, Roche S, et al.; IRIS Investigators Group. Effect of cricoid pressure compared with a sham procedure in the rapid sequence induction of anesthesia: the IRIS randomized clinical trial. JAMA Surg 2019;154(1):9\u201317.","DOI":"10.1001\/jamasurg.2018.3577"},{"key":"255776","doi-asserted-by":"crossref","unstructured":"4 White L, Thang C, Hodsdon A, Melhuish T, Vlok R. Cricoid pressure during intubation: a systematic review and meta-analysis of randomised controlled trials. Heart Lung 2020;49(2):175\u2013180.","DOI":"10.1016\/j.hrtlng.2019.10.001"},{"key":"255777","doi-asserted-by":"crossref","unstructured":"5 Lee D, Czech AJ, Elriedy M, Nair A, El-Boghdadly K, Ahmad I. A multicentre prospective cohort study of the accuracy of conventional landmark technique for cricoid localisation using ultrasound scanning. Anaesthesia 2018;73(10):1229\u20131234.","DOI":"10.1111\/anae.14399"},{"key":"255778","doi-asserted-by":"crossref","unstructured":"6 Johnson RL, Cannon EK, Mantilla CB, Cook DA. Cricoid pressure training using simulation: a systematic review and meta-analysis. Br J Anaesth 2013;111(3):338\u2013346.","DOI":"10.1093\/bja\/aet121"},{"key":"255779","doi-asserted-by":"crossref","unstructured":"7 Baethge C, Goldbeck-Wood S, Mertens S. SANRA\u2014a scale for the quality assessment of narrative review articles. 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Anesth Analg 2009;109(5):1546\u20131552.","DOI":"10.1213\/ane.0b013e3181b05404"},{"key":"255783","doi-asserted-by":"crossref","unstructured":"11 Hartsilver EL, Vanner RG. Airway obstruction with cricoid pressure. Anaesthesia 2000;55(3):208\u2013211.","DOI":"10.1046\/j.1365-2044.2000.01205.x"},{"key":"255784","doi-asserted-by":"crossref","unstructured":"12 Haslam N, Parker L, Duggan JE. Effect of cricoid pressure on the view at laryngoscopy. Anaesthesia 2005;60(1):41\u201347.","DOI":"10.1111\/j.1365-2044.2004.04010.x"},{"key":"255785","doi-asserted-by":"crossref","unstructured":"13 Smitha CB, Singh K, Kumar A, Sahay N, Kumar A, Kumar N. Effect of cricoid pressure on tracheal intubation time during C-MAC video laryngoscopy: a randomized controlled trial. Anaesth Crit Care Pain Med 2026:101840.","DOI":"10.1016\/j.accpm.2026.101840"},{"key":"255786","doi-asserted-by":"crossref","unstructured":"14 Won D, Kim H, Chang JE, et al. Comparison of the effects of paratracheal pressure and cricoid pressure on placement of the i-gel supraglottic airway: a randomized clinical trial. Can J Anaesth 2024;71(7):996\u20131003.","DOI":"10.1007\/s12630-024-02741-1"},{"key":"255787","doi-asserted-by":"crossref","unstructured":"15 Ralph SJ, Wareham CA. Rupture of the oesophagus during cricoid pressure. Anaesthesia 1991;46(1):40\u201341.","DOI":"10.1111\/j.1365-2044.1991.tb09314.x"},{"key":"255788","doi-asserted-by":"crossref","unstructured":"16 Heath KJ, Palmer M, Fletcher SJ. Fracture of the cricoid cartilage after Sellick\u2019s manoeuvre. Br J Anaesth 1996;76(6):877\u2013878.","DOI":"10.1093\/bja\/76.6.877"},{"key":"255789","doi-asserted-by":"crossref","unstructured":"17 Ahmad I, El-Boghdadly K, Iliff H, et al. Difficult Airway Society 2025 guidelines for management of unanticipated difficult tracheal intubation in adults. Br J Anaesth 2026;136(1):283\u2013307.","DOI":"10.1016\/j.bja.2025.10.006"},{"key":"255790","doi-asserted-by":"crossref","unstructured":"18 Mushambi MC, Kinsella SM, Popat M, et al. Obstetric Anaesthetists\u2019 Association and Difficult Airway Society guidelines for the management of difficult and failed tracheal intubation in obstetrics. Anaesthesia 2015;70(11):1286\u20131306.","DOI":"10.1111\/anae.13260"},{"key":"255791","doi-asserted-by":"crossref","unstructured":"19 Lockey D, Weegenaar C, Ahmad I, et al. Safer prehospital anaesthesia: updated guidelines from the Association of Anaesthetists. Anaesthesia 2026;81:1132\u20131147.","DOI":"10.1111\/anae.70191"},{"key":"255792","doi-asserted-by":"crossref","unstructured":"20 Soar J, B\u00f6ttiger BW, Carli P, et al. European Resuscitation Council Guidelines 2025: Adult Advanced Life Support. Resuscitation 2025;215 (Suppl1):110769.","DOI":"10.1016\/j.resuscitation.2025.110769"},{"key":"255793","doi-asserted-by":"crossref","unstructured":"21 Zdravkovic M, Berger-Estilita J, Sorbello M, Hagberg CA. An international survey about rapid sequence intubation of 10,003 anaesthetists and 16 airway experts. Anaesthesia 2020;75(3):313\u2013322.","DOI":"10.1111\/anae.14867"},{"key":"255794","doi-asserted-by":"crossref","unstructured":"22 Sajayan A, Wicker J, Ungureanu N, Mendonca C, Kimani PK. Current practice of rapid sequence induction of anaesthesia in the UK: a national survey. Br J Anaesth 2016;117(Suppl 1):i69\u2013i74.","DOI":"10.1093\/bja\/aew017"},{"key":"255795","doi-asserted-by":"crossref","unstructured":"23 Walker RWM, Ravi R, Haylett K. Effect of cricoid force on airway calibre in children: a bronchoscopic assessment. Br J Anaesth 2010;104(1):71\u201374.","DOI":"10.1093\/bja\/aep337"},{"key":"255796","doi-asserted-by":"crossref","unstructured":"24 Knill RL. Difficult laryngoscopy made easy with a \u201cBURP.\u201d Can J Anaesth 1993;40(3):279\u2013282.","DOI":"10.1007\/BF03037041"},{"key":"255797","doi-asserted-by":"crossref","unstructured":"25 Williams P, Umranikar A. A comparative prospective cohort study comparing physical exam to ultrasound for identifying the cricoid cartilage. J Perioper Pract 2017;27(9):186\u2013190.","DOI":"10.1177\/175045891702700902"},{"key":"255798","doi-asserted-by":"crossref","unstructured":"26 Meek T, Gittins N, Duggan JE. Cricoid pressure: knowledge and performance amongst anaesthetic assistants. Anaesthesia 1999;54(1):59\u201362.","DOI":"10.1046\/j.1365-2044.1999.00706.x"},{"key":"255799","unstructured":"27 Andruszkiewicz P, Zawadka M, Kosi\u0144ska A, Walczak-Wieteska P, Majerowicz K. Measurement of cricoid pressure force during simulated Sellick\u2019s manoeuvre. 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Learning to apply effective cricoid pressure using a part task trainer. Anaesthesia 2002;57(11):1098\u20131101.","DOI":"10.1046\/j.1365-2044.2002.02836.x"},{"key":"255804","doi-asserted-by":"crossref","unstructured":"32 Escott MEA, Owen H, Strahan AD, Plummer JL. Cricoid pressure training: how useful are descriptions of force? Anaesth Intensive Care 2003;31(4):388\u2013391.","DOI":"10.1177\/0310057X0303100406"},{"key":"255805","doi-asserted-by":"crossref","unstructured":"33 Flucker CJR, Hart E, Weisz M, Griffiths R, Ruth M. The 50-millilitre syringe as an inexpensive training aid in the application of cricoid pressure. Eur J Anaesthesiol 2000;17(7):443\u2013447.","DOI":"10.1097\/00003643-200007000-00006"},{"key":"255806","doi-asserted-by":"crossref","unstructured":"34 Hee HI, Wong CL, Wijeweera O, Sultana R, Sng BL. Sellick maneuver assisted real-time to achieve target force range in simulated environment\u2014a prospective observational cross-sectional study on manikin. PLoS One 2020;15(2):e0227805.","DOI":"10.1371\/journal.pone.0227805"},{"key":"255807","doi-asserted-by":"crossref","unstructured":"35 Domuracki KJ, Moule CJ, Owen H, Kostandoff G, Plummer JL. Learning on a simulator does transfer to clinical practice. Resuscitation 2009;80(3):346\u2013349.","DOI":"10.1016\/j.resuscitation.2008.10.036"},{"key":"255808","doi-asserted-by":"crossref","unstructured":"36 Beckford L, Holly C, Kirkley R. Systematic review and meta-analysis of cricoid pressure training and education efficacy. AORN J 2018;107(6):716\u2013725.","DOI":"10.1002\/aorn.12150"},{"key":"255809","doi-asserted-by":"crossref","unstructured":"37 Ashurst N, Rout CC, Rocke DA, Gouws E. Use of a mechanical simulator for training in applying cricoid pressure. Br J Anaesth 1996;77(4):468\u2013472.","DOI":"10.1093\/bja\/77.4.468"},{"key":"255810","unstructured":"38 Medical Simulation Training Centre at Medical University of Plovdiv. Available from: https:\/\/mu-plovdiv.bg\/en\/about-us\/centres\/simulation-centre\/general-information\/.Accessed July 20, 2026."},{"key":"255811","unstructured":"39 ACS Accredited Education Institutes. Setting the Standard of Excellence and Innovation. Available from: https:\/\/www.facs.org\/find-an-accredited-education-institute\/.Accessed Sept 02, 2026."},{"key":"255812","doi-asserted-by":"crossref","unstructured":"40 Sakakushev BE, Marinov BI, Stefanova PP, Kostianev SS, Georgiou EK. Striving for Better Medical Education: the Simulation Approach. Folia Med (Plovdiv) 2017;59(2):123\u2013131.","DOI":"10.1515\/folmed-2017-0039"}],"container-title":["European Journal of Translational Myology"],"original-title":[],"link":[{"URL":"https:\/\/www.pagepressjournals.org\/bam\/article\/download\/16055\/14570","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/www.pagepressjournals.org\/bam\/article\/download\/16055\/14570","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,10,14]],"date-time":"2026-10-14T15:12:07Z","timestamp":1791990727000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.pagepressjournals.org\/bam\/article\/view\/16055"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,10,14]]},"references-count":40,"URL":"https:\/\/doi.org\/10.4081\/ejtm.2026.16055","relation":{},"ISSN":["2037-7460","2037-7452"],"issn-type":[{"value":"2037-7460","type":"electronic"},{"value":"2037-7452","type":"print"}],"subject":[],"published":{"date-parts":[[2026,10,14]]}}}