Effect of Cricoid Pressure Compared With a Sham Procedure in the Rapid Sequence Induction of Anesthesia: The IRIS Randomized Clinical Trial.

Importance: The use of cricoid pressure (Sellick maneuver) during rapid sequence induction (RSI) of anesthesia remains controversial in the absence of a large randomized trial. Objective: To test the hypothesis that the incidence of pulmonary aspiration is not increased when cricoid pressure is not performed. Design, Setting, and Participants: Randomized, double-blind, noninferiority trial conducted in 10 academic centers. Patients undergoing anesthesia with RSI were enrolled from February 2014 until February 2017 and followed up for 28 days or until hospital discharge (last follow-up, February 8, 2017). Interventions: Patients were assigned to a cricoid pressure (Sellick group) or a sham procedure group. Main Outcomes and Measures: Primary end point was the incidence of pulmonary aspiration (at the glottis level during laryngoscopy or by tracheal aspiration after intubation). It was hypothesized that the sham procedure would not be inferior to the cricoid pressure. The secondary end points were related to pulmonary aspiration, difficult tracheal intubation, and traumatic complications owing to the tracheal intubation or cricoid pressure. Results: Of 3472 patients randomized, mean (SD) age was 51 (19) years and 1777 (51%) were men. The primary end point, pulmonary aspiration, occurred in 10 patients (0.6%) in the Sellick group and in 9 patients (0.5%) in the sham group. The upper limit of the 1-sided 95% CI of relative risk was 2.00, exceeding 1.50, failing to demonstrate noninferiority (P = .14). The risk difference was -0.06% (2-sided 95% CI, -0.57 to 0.42) in the intent-to-treat population and -0.06% (2-sided 95% CI, -0.56 to 0.43) in the per protocol population. Secondary end points were not significantly different among the 2 groups (pneumonia, length of stay, and mortality), although the comparison of the Cormack and Lehane grade (Grades 3 and 4, 10% vs 5%; P <.001) and the longer intubation time (Intubation time >30 seconds, 47% vs 40%; P <.001) suggest an increased difficulty of tracheal intubation in the Sellick group. Conclusions and Relevance: This large randomized clinical trial performed in patients undergoing anesthesia with RSI failed to demonstrate the noninferiority of the sham procedure in preventing pulmonary aspiration. Further studies are required in pregnant women and outside the operating room. Trial Registration: ClinicalTrials.gov Identifier: NCT02080754.

The effect of force applied to the left paratracheal oesophagus on air entry into the gastric antrum during positive-pressure ventilation using a facemask.

Cricoid force is widely applied to decrease the risk of pulmonary aspiration and gastric antral insufflation of air during positive-pressure ventilation, yet its efficacy remains controversial. We compared manual oesophageal compression at the low left paratracheal and cricoid levels for the prevention of gastric antral air insufflation during positive-pressure ventilation by facemask in patients scheduled for elective surgery under general anaesthesia. After gaining written consent, participants were randomly allocated by sealed envelope to one of three groups: oesophageal compression by 30 N paratracheal force (paratracheal group); oesophageal compression by 30 N cricoid force (cricoid group); or no oesophageal compression (control group). Gastric insufflation of air was assessed before and after positive-pressure ventilation by ultrasound measurement of the antral cross-sectional area and/or presence of air artefacts in the antrum. The primary outcome measure was the proportion of participants with ultrasound evidence of gastric insufflation. We recruited 30 patients into each group. Before facemask ventilation, no air artefacts were visible in the antrum in any of the participants. After facemask ventilation of the participant's lungs, no air artefacts were seen in the paratracheal group, compared with six subjects in the cricoid group and eight subjects in the control group (p = 0.012). Our results suggest that oesophageal compression can be achieved by the application of manual force at the low left paratracheal level and that this is more effective than cricoid force in preventing air entry into the gastric antrum during positive-pressure ventilation by facemask.

Ideal Cricoid Pressure Is Biomechanically Impossible During Laryngoscopy.

OBJECTIVE: This study was a prospective, randomized controlled trial of rapid sequence intubation (RSI) with cricoid pressure (CP) within the emergency department (ED). The primary aim of the study was to examine the link between ideal CP and the incidence of aspiration. METHOD: Patients > 18 years of age undergoing RSI in the ED of two hospitals in New South Wales, Australia, were randomly assigned to receive measured CP using weighing scales to target the ideal CP range (3.060-4.075 kg) or control CP where the weighing scales were used, but the CP operator was blinded to the amount of CP applied during the RSI. A data logger recorded all CP delivered during each RSI. Immediately after intubation, tracheal and esophageal samples were taken and underwent pepsin analysis. RESULTS: Fifty-four RSIs were analyzed (25 measured/29 control). Macroscopic contamination of the larynx at RSI was observed in 14 patients (26%). During induction (0-50 seconds), both groups delivered in-range CP. During intubation (51-223 seconds), laryngoscopy was associated with a reduction in mean CP below 3.060 kg in both groups. When compared, there was no statistically significant difference between the groups. For 11 patients, pepsin was detected in the oropharyngeal sample, while three were positive for tracheal pepsin. Seven patients (four control/three measured) were treated for clinical aspiration during hospitalization. As a result of the finding that neither group could maintain ideal range CP during laryngoscopy, the trial was abandoned. CONCLUSION: Laryngoscopy provides a counter force to CP, which is negated to facilitate tracheal intubation. The concept that a static 3.060 to 4.075 kg CP could be maintained during laryngoscopy and intubation was rejected by our study. Whether a lower CP range could prevent aspiration during RSI was not explored by this study.

Cricoid pressure impedes tracheal intubation with the Pentax-AWS Airwayscope®: a prospective randomized trial.

BACKGROUND: It is unclear how cricoid pressure affects tracheal intubation with the Pentax-AWS Airwayscope(®) (AWS). We conducted a prospective randomized clinical trial in anaesthetized patients. METHODS: Sixty patients were allocated to either the cricoid pressure (CP) group (n=30) or the sham group (n=30). We compared the two groups with regard to intubation time, number of attempts required for insertion of the Intlock blade (disposable blade of the AWS) and tracheal intubation, percentage of glottic opening (POGO) score, and subjective difficulty of both laryngoscopy and passage of a tube through the glottis. RESULTS: Intubation time was significantly longer in the CP group (median 45[IQR40-59] s) than in the sham group (32[28-45] s) (P=0.003, 95% CI for median difference 5-24 s). The number required for insertion of the Intlock blade did not differ between the groups (P=0.08), but the number for tracheal intubation was significantly higher in the CP group (1 attempt in 14 patients, 2 in 7, 3 in 9) than in the sham group (1 attempt in 24 patients, 2 in 6; P=0.002). POGO score did not differ significantly between the groups (P=0.60), nor did the subjective difficulty of laryngoscopy (P=0.06). The visual analogue scale score for passage of a tube through the glottis was significantly higher in the CP group than in the sham group (P<0.001). CONCLUSIONS: Cricoid pressure impedes tracheal intubation using the AWS, and is associated with longer intubation time, which can be attributed to increased difficulty in the passage of a tube through the glottis. CLINICAL TRIAL REGISTRY NUMBER: UMIN000018209.

Cricothyroid Articulation in Elderly Japanese With Special Reference to Morphology of the Synovial and Capsular Tissues.

OBJECTIVE: The present study aimed to clarify individual variations in the cricothyroid joint (CT joint). METHODS: Using 30 specimens of the CT joint obtained from elderly donated cadavers, we examined the composite fibers of the capsular ligament as well as the morphology of the synovial tissue. RESULTS: The capsular ligament consistently contained abundant thick elastic fiber bundles on the anterior side of the joint (anterior band) and an elastic fiber-made mesh on the posterior side (posterior mesh). The synovial membrane, lined by synovial macrophages, was usually restricted to the recesses in the medial or inferior end of the joint cavity. Without the synovial lining, elastic fibers of the capsular ligament were subsequently detached, dispersed, and exposed to the joint cavity. We also observed a folded and thickened synovial membrane and a hypertrophic protrusion of the capsular ligament. In six specimens, the joint cavity was obliterated by debris of synovial folds and elastic fiber-rich tissues continuous with the usual capsular ligament. Notably, with the exception of two specimens, we did not find lymphocyte infiltration in the degenerative synovial tissue. DISCUSSION: We considered the CT joint degeneration to be a specific, silent form of osteoarthritis from the absence of lymphocyte infiltration. For high-pitched phonation, the elderly CT joint seemed to maintain its anterior gliding and rotation with the aid of elastic fiber-rich tissues compensating for the loss of congruity between the joint cartilage surfaces. Conversely, however, high-pitched phonation may accelerate obliteration of the joint.

The effectiveness of cricoid pressure for occluding the esophageal entrance in anesthetized and paralyzed patients: an experimental and observational glidescope study.

BACKGROUND: In the last 2 decades, the effectiveness of cricoid pressure (CP) in occluding the esophageal entrance has been questioned. Recent magnetic resonance imaging studies yielded conflicting conclusions. We used real-time visual and mechanical means to assess the patency of the esophageal entrance with and without CP in anesthetized and paralyzed adult patients. METHODS: One hundred seven, nonobese ASA physical status I and II patients were recruited for the study. A cricoid force of 30 N was used. This force was standardized by using a weighing scale before application of CP in each patient. After oxygen administration, anesthetic induction, neuromuscular blockade, and establishment of manual ventilation with FIO2 = 1.0, the view of the glottis and esophageal entrance was visualized, and video recordings were obtained by using a Glidescope video laryngoscope. Attempts to insert 2 gastric tubes (GTs), size 12 and 20 F, into the esophagus were made by a "blinded" operator without and with CP, the timing of which was randomized. A successful insertion of a GT in the presence of CP was considered evidence of a patent esophageal entrance (ineffective CP), whereas an unsuccessful insertion of a GT was considered evidence of an occluded esophageal entrance (effective CP). After the attempts to insert the GTs were completed, tracheal intubation was performed while CP was applied. The position of the esophageal entrance in relation to the glottis (midline versus lateral) was assessed from the video recordings, with and without CP. RESULTS: We stopped the study when 79 patients (41 men and 38 women) qualified for and completed the study (2-sided Clopper-Pearson confidence interval (CI) 95% to 100%, n = 72). Advancement of either size GT into the esophagus could not be accomplished during CP in any patient but was easily done in all subjects when CP was not applied. This occurred whether the esophageal entrance was in a midline position or in a left or right lateral position relative to the glottis. Esophageal patency was visually observed in the absence of CP, whereas occlusion of the esophageal entrance was observed during CP in all patients. Without CP, the esophageal entrance was in a left lateral position in relation to the glottis in 57% ([95 % CI, 45%-68%)] of patients, at midline in 32% (CI, 22%-43%), and in a right lateral position in 11% (CI, 5%-21%). The position did not change with CP. CONCLUSIONS: The current study provides additional visual and mechanical evidence supporting a success rate of at least 95% by using a cricoid force of 30 N to occlude the esophageal entrance in anesthetized and paralyzed normal adult patients. The efficacy of the maneuver was independent of the position of the esophageal entrance relative to the glottis, whether midline or lateral.

Videographic analysis of glottic view with increasing cricoid pressure force.

STUDY OBJECTIVE: Cricoid pressure may negatively affect laryngeal view and compromise airway patency, according to previous studies of direct laryngoscopy, endoscopy, and radiologic imaging. In this study, we assess the effect of cricoid pressure on laryngeal view with a video laryngoscope, the Pentax-AWS. METHODS: This cross-sectional survey involved 50 American Society of Anesthesiologists status I and II patients who were scheduled to undergo elective surgery. The force measurement sensor for cricoid pressure and the video recording system using a Pentax-AWS video laryngoscope were newly developed by the authors. After force and video were recorded simultaneously, 11 still images were selected per 5-N (Newton; 1 N = 1 kg·m·s(-2)) increments, from 0 N to 50 N for each patient. The effect of cricoid pressure was assessed by relative percentage compared with the number of pixels on an image at 0 N. RESULTS: Compared with zero cricoid pressure, the median percentage of glottic view visible was 89.5% (interquartile range [IQR] 64.2% to 117.1%) at 10 N, 83.2% (IQR 44.2% to 113.7%) at 20 N, 76.4% (IQR 34.1% to 109.1%) at 30 N, 51.0% (IQR 21.8% to 104.2%) at 40 N, and 47.6% (IQR 15.2% to 107.4%) at 50 N. The number of subjects who showed unworsened views was 20 (40%) at 10 N, 17 (34%) at 20 and 30 N, and 13 (26%) at 40 and 50 N. CONCLUSION: Cricoid pressure application with increasing force resulted in a worse glottic view, as examined with the Pentax-AWS Video laryngoscope. There is much individual difference in the degree of change, even with the same force. Clinicians should be aware that cricoid pressure affects laryngeal view with the Pentax-AWS and likely other video laryngoscopes.

Analogy between laryngeal gesture in Mongolian Long Song and supracricoid partial laryngectomy.

This article reports the results of a multiparametrical analysis of Mongolian Long Song, characterised by multiple ornamentation and shows the similarities between the laryngeal behaviour observed during these ornamentations and the compensatory gesture produced by patients after supracricoid partial laryngectomy. This study includes (1) a physiological analysis of videofiberscopic laryngeal data from a healthy Mongolian singer and from three non-singer French-speaking clinical patients; and (2) an acoustical analysis (fundamental frequency and intensity). For the singer, the fiberoptic analysis showed two main laryngeal behaviours in producing ornamentations: (1) 'lyrical' vibratos mobilising the entire laryngeal block; (2) 'Mongolian' trills with essentially supraglottic movements, the arytenoids being mobilised independently of the rest of the laryngeal block. Patients demonstrated similar aryepiglottic trilling to fulfil a function of voicing. The acoustic analysis showed that the fundamental frequency and the intensity were in phase for vibrato, contrary to the 'Mongolian' trills which were in opposite phase, underlying a change of laryngeal vibratory mechanisms.

The use of adalimumab for cricoarytenoid arthritis in ankylosing spondylitis--an effective therapy.

This report describes cartilaginous regeneration in a cricoarytenoid joint affected by spondyloarthropathy using tumor necrosis factor-alpha (TNF-α) blockade, monitored by magnetic resonance (MR) and computed tomography (CT) imaging. This case is interesting for several reasons. It is only the eighth case of destructive ankylosing spondylitis-related cricoarytenoid arthritis published in the English language literature. It describes, for the first time, full recovery of vocal cord mobility following TNF-α blockade. It is also the first case to be published with MR imaging demonstrating regeneration of the cricoarytenoid cartilage following treatment. This case represents a landmark in the treatment of patients presenting with destructive arthritis involving the cricoarytenoid joint.

The role of the cricothyroid joint anatomy in cricothyroid approximation surgery.

OBJECTIVES/HYPOTHESIS: Cricothyroid approximation (CTA) surgery aims at raising the voice pitch in male-to-female transsexuals. However, 30% of the patients are not satisfied with the result. The purpose of our study was to examine the cricothyroid joint (CTJ) biomechanics and to analyze if (and how) the CTJ anatomy influences the movement of the cricoid and, consequently, the elongation of the vocal fold and the voice pitch after CTA. METHODS: Twenty-four cadaver larynges were examined with high-resolution computerized tomography and MIMICS three-dimensional imaging software (Materialise Interactive Medical Image Control System, Leuven, Belgium). After superimposing the two scans taken in "neutral" and in "CTA" positions, vector geometrical analysis was used to determine the effective rotation axis of the CTJ and to calculate the elongation of the vocal folds after CTA. RESULTS: Our results showed that the cricoid rotates around an axis, the position of which depends on the anatomical structure of the CTJ. Based on the location of this effective rotation axis, we could distinguish three groups. In group I (N=13), the rotation axis was located in the lower third; in group II (N=5), it was located in the middle third; and in group III (N=6), it was located in the upper third of the cricoid. The elongations of the vocal fold were 12%, 8%, and 3%, in groups I, II, and III, respectively. CONCLUSIONS: The anatomical structure of the CTJ influences directly (1) the position of the effective rotation axis and (2) the elongation of the vocal folds.

Biomechanics of the cricoarytenoid joint: three-dimensional imaging and vector analysis.

OBJECTIVES/HYPOTHESIS: Laryngeal framework surgery requires a good understanding of the biomechanics of the cricoarytenoid (CA) joint, the precise function of which is still only poorly understood. The aim of the study was (1) to show that, by superimposing two or more three-dimensional (3D) images, we can visualize the exact position of the arytenoid cartilages within the larynx at different phases of their movement; and (2) to demonstrate that it is possible to analyze the arytenoid cartilage movements mathematically with the help of vector analysis. STUDY DESIGN: In vitro cadaver study. METHODS: Twenty fresh and intact cadaver larynges were scanned by high-resolution computerized tomography with the arytenoid cartilages in "respiratory" position and in "phonatory" position. The two positions were superimposed and rendered in 3D with MIMICS (Materialise Interactive Medical Image Control System, Leuven, Belgium). The spatial trajectory of the arytenoid cartilage movements was calculated with vector analysis. RESULTS: The movement from the "respiratory" to the "phonatory" position has three components: (1) an inward rocking action around the longitudinal CA joint; (2) a forward sliding movement along the longitudinal axis of the CA joint; and (3) an inward rotation around a virtual axis that runs perpendicular to the CA joint axis. CONCLUSIONS: Superimposing 3D images of the larynx with the help of the software package MIMICS allows us to visualize and to analyze mathematically the trajectory of the arytenoid cartilage. The arytenoid cartilages rock inward, slide forward, and rotate inward when they move from the "respiratory" to the "phonatory" position.

Cricoid pressure and laryngeal manipulation in 402 pre-hospital emergency anaesthetics: essential safety measure or a hindrance to rapid safe intubation?

OBJECTIVES: This is the first study to look at the effects of cricoid pressure/laryngeal manipulation on the laryngeal view and intubation success in the emergency or pre-hospital environment. Cricoid pressure is applied in the hope of reducing the incidence of aspiration. However the technique has never been evaluated in a randomized trial and may adversely affect laryngeal view. In order to improve intubating conditions cricoid pressure may be released and the larynx manipulated into a more favourable position. METHODS: We carried out a prospective observational study to evaluate the effects of cricoid pressure and laryngeal manipulation on laryngeal view in our physician led pre-hospital trauma service. RESULTS: 402 patients were included over a 16-month period. We intubated 98.8% patients on the first or second attempt. In 61 intubations (in 55 patients, 13.6%) the larynx required manipulation to facilitate intubation. In 22 intubations cricoid pressure was removed with the laryngeal view improving in 50%. Bimanual laryngeal manipulation was used in 25 intubations and the larynx better visualised in 60% of these. Backwards upwards rightwards pressure was applied to the larynx in 14 intubations and the laryngeal view improved in 64%. Two patients regurgitated when cricoid pressure was released. Both had prolonged periods of bag valve mask ventilation and difficult intubations. DISCUSSION: The results suggest that cricoid pressure should be removed if the laryngeal view obtained is not sufficient to allow immediate intubation. Further manipulation of the larynx is likely to improve the chances of successful tracheal tube placement.

Anterior cervical osteophyte dysphagia: manofluorographic and functional outcomes after surgery.

BACKGROUND: Our aim was to investigate the clinical and manofluorographic findings of patients with anterior cervical osteophyte (ACO) dysphagia before and after surgery. METHODS: Chart review including manofluorography (MFG) data of patients undergoing ACO removal was undertaken. RESULTS: Thirteen patients underwent transcervical ACO removal over a 10-year period. A postoperative hematoma was the only surgical complication. Overall, there was a significant postoperative decrease in Functional Outcome Swallowing Scale (FOSS). MFG data showed an elevated preoperative intrabolus pressure gradient across the osteophyte (IB-Gra), 39.78 mm Hg, and IB-Gra significantly decreased to 19 mm Hg 6 months after surgery. CONCLUSION: Functional (FOSS) and objective MFG (IB-Gra) improvements occurred in patients who had ACO dysphagia and underwent surgery. These findings support high IB-Gra as a reliable objective indicator for surgical intervention for ACO dysphagia and IB-Gra as an appropriate parameter for follow-up after ACO removal. In selected patients, ACO removal by anterolateral-transcervical approach is a safe and highly effective treatment.

Pitch synchronous changes of the anterior cricothyroid gap by using ultrasonography.

OBJECTIVES: The purpose of this study was to describe changes of the anterior cricothyroid space during respiration and phonation by using ultrasonography. Furthermore, to assess and correlate laryngeal dimensions in a large cohort of voice healthy men. STUDY DESIGN: Epidemiological study. METHODS: Ultrasound examinations of the laryngeal skeleton, as well as of the cricothyroid space were performed in 64 voice healthy, elderly male subjects. This was done during respiration, phonation in midrange, and high phonation. RESULTS: We could not find any significant correlation concerning lengths of the cricothyroid space when correlated with voice range, highest or lowest frequency. General anthropometric parameters such as body height, weight, or body mass index did not show any considerable correlation with dimensions of the laryngeal skeleton. CONCLUSION: Functionally orientated surgery of the larynx requires exact knowledge of the anatomy and landmarks of the laryngeal skeleton. Topographic relations and dimensions between the thyroid and cricoid cartilages play an important role in cricoid approximation.

In situ tissue engineering of the cricoid and trachea in a canine model.

OBJECTIVES: The purpose of the current study was to demonstrate the efficacy of in situ tissue engineering of the cricoid and trachea in a canine model. METHODS: Marlex mesh tube reinforced with polypropylene threads and covered by collagen sponge was used as a tissue scaffold for airway regeneration in 9 beagle dogs. The anterior half of the cricoid cartilage was resected in 5 dogs, whereas the cricoid cartilage and cervical trachea were simultaneously resected in 4 dogs. The tissue scaffold was implanted into the resultant defect. RESULTS: Endoscopic examination showed no airway obstruction for a postoperative period of 3 to 40 months in all dogs. Granulation tissue was observed in 2 dogs, and slight mesh exposure in 1 dog, although all were asymptomatic. Light microscopy and electron microscopy showed the endolaryngeal and endotracheal lumen to be covered by ciliated epithelium. According to strain-force measurement, the framework was firmly supported by regenerated tissue, as well as the normal cricoid and trachea. CONCLUSIONS: Our current tissue scaffold provides a rigid framework for the airway, and the collagen coating invites tissue regrowth around the tube. This study presents the possibility of successful reconstruction of the cricoid and trachea with epithelial regeneration by means of in situ tissue engineering.

[Preliminary report: observation by video laryngoscope of glottal narrowing due to cricoid pressure].

BACKGROUND: When the applied cricoid pressure is too strong, or the place or direction of the pressure application is not appropriate, glottal closure may occur, but its details are unclear. METHODS: We evaluated possible changes in the size of the rima glottides due to backward pressure on the cricoid cartilage or backward pressure or backward, upward, and rightward pressure (BURP) on the thyroid cartilage using a video laryngoscope (Fine View' Laryngoscope, Tray Medical, Tokyo) in 6 adult males and 6 females with Cormack and Lehane grade 1. RESULTS: The right-to-left distance of the rima glottides was 5.1 +/- 1.2 mm without pressure application but was reduced to 3.8 +/- 1.7, 3.5 +/- 1.8, 2.8 +/- 1.9, 2.4 +/- 1.8, and 2.6 +/- 1.2 mm by 20 N and 30 N backward pressure on the cricoid cartilage and 20 N and 30 N backward pressure and BURP on the thyroid cartilage, respectively. Compared with the absence of pressure application, 20 N and 30 N backward pressure and BURP on the thyroid cartilage significantly reduced it. It was reduced to 1 mm by 30 N backward cricoid pressure in 1 patient while glottal closure occurred due to 30 backward thyroid pressure in 1 patient. CONCLUSIONS: The right-to-left distance of the rima glottides was significantly reduced by backward pressure or BURP on the thyroid cartilage, and was also markedly reduced by cricoid pressure in 1 of the 12 patients.

[Video laryngoscopy for modified rapid sequence induction of anaesthesia: Sellick manoever with and without video laryngoscopic control]. / Videolaryngoskopie zur modifizierten "Rapid-sequence-Narkoseeinleitung" : Sellick-Manöver mit und ohne videolaryngoskopische Kontrolle.

BACKGROUND: There is evidence that cricoid pressure, one of the key elements of rapid sequence induction (RSI) in patients at risk of aspiration, can distort the glottic view obtained by direct laryngoscopy (DL) and consequently impair or delay endotracheal intubation (ETI). The fact that cricoid pressure is applied by an assistant "blindly", i.e. without any visual feedback, is believed to be a contributing factor. Video laryngoscopy (VIL) offers the advantage that both the anaesthetist and the assistant can follow laryngoscopy. This could be useful for ETI during RSI. METHODS: We used VIL for a simulated RSI in 170 adult patients randomised to either video laryngoscopy-guided application of cricoid pressure (group I) or conventional, i.e. "blind", application of cricoid pressure (group II). Time to ETI was compared between groups. The laryngoscopy view obtained by VIL was compared with the view of conventional DL obtained before, in all patients. RESULTS: Time to ETI did not differ between groups (p=0.2): 25.1+/-14.2 s (group I) vs. 23.7+/-12.1 s (group II). Laryngoscopy scores were significantly better for VIL than conventional DL (p<0.001). CONCLUSIONS: Visualisation of the larynx during RSI can be improved using VIL. Time to ETI is not decreased by use of video laryngoscopy-guided application of cricoid pressure.