In a perspective article published in Frontiers in Anesthesiology, Daniele Salvatore Paternò of the “Giovanni Paolo II” Hospital in Ragusa and colleagues from the “Kore” University of Enna examined the 2025 guidelines from the Difficult Airway Society (DAS), the most detailed description of emergency front-of-neck access ever produced. What they found is striking: of the nineteen numbered steps in the recommended scalpel–bougie–tube technique, eleven specify exactly which hand must perform which action. The operator’s non-dominant hand is assigned to find the midline of the neck, stabilize the larynx, and identify the cricothyroid membrane, while the dominant hand wields the scalpel. A fundamental principle states that incisions must be made away from the operator’s non-dominant hand, and the sequence even requires an explicit mid-procedure hand swap, in which the scalpel is transferred to the non-dominant hand so the dominant hand can advance a flexible bougie into the trachea.

Each of these prescriptions is anatomically sensible, the authors acknowledge. But together they embed an assumption that has never been stated, let alone tested: that the operator is free to occupy whichever side of the patient their handedness dictates. The guidelines themselves admit the evidence base is thin, noting that “there is currently little evidence for this approach and many of the steps in the eFONA technique.” Remarkably, the same document contains two opposite answers to the question of where a right-handed operator should stand—the left side in the recommended sequence, and the right side in a surgical alternative it reports. No study of any design has ever compared front-of-neck access performed in the dominant versus the non-dominant configuration.

The stakes of this gap are highest precisely where the procedure is most often needed. The Fourth National Audit Project (NAP4), the most systematic account of major airway complications in the United Kingdom, found that at least one in four major airway events occurred in an intensive care unit or emergency department rather than an operating theatre—and outcomes there were dramatically worse. Sixty-one percent of intensive care events and thirty-one percent of emergency department events led to death or permanent neurological injury, and such events were more likely to occur out of hours and be managed by clinicians with less anesthetic experience. In an operating theatre, an anesthetist declaring a CICO emergency usually has clear access to both sides of the neck. At the bedside of an intensive care unit, the geometry of the room decides instead: the head of the bed may be against a wall, ventilator circuits and infusion pumps crowd one side, a colleague maintains oxygenation at the head, and the bed may not be quickly movable. The side of approach is not a free variable—it is dictated by the room, and the room does not consult the operator’s hand preference.

Outside the hospital, the constraint becomes structural rather than occasional. In the largest published series of physician-delivered prehospital intubations, covering 7,256 attempts on trauma patients, surgical airway management was required in 0.7 percent of cases—three orders of magnitude more frequent than during anesthesia, where the incidence sits around 0.001 percent. Prehospital guidance is explicit that when an airway cannot be secured by less invasive means, a surgical airway should be performed without delay, and that open scalpel techniques succeed more often than needle-based ones. The patient may be on the ground, trapped in a vehicle, or reachable from one side only. Working from the non-preferred side is not a rare contingency in that setting; it is a routine condition of work. An operator who cannot reach the prescribed side has only two options: rearrange the environment in a situation where the tolerable delay is measured in tens of seconds, or proceed mirrored, performing with the non-dominant hand what the guidance assigns to the dominant one. Neither option has ever been quantified, and the choice is currently made on instinct.

What can existing research tell us? Hand dominance is one of the most robust asymmetries in human motor behavior, and its effects on fine dexterity are well documented. In surgical education, a systematic review of nineteen studies found that instruments are rarely adapted for left-handed use and that trainees face significant pressure to switch hands during training. But the evidence on the actual cost of operating with the non-dominant hand is contradictory: in one virtual-reality endoscopic task, right-handed men outperformed left-handed men, while in a laparoscopic curriculum, left-handed residents showed smaller differences between their two hands than right-handed peers. The most plausible interpretation, the authors argue, is that the penalty attached to the non-dominant hand is not a fixed biological quantity but a function of prior exposure—which is precisely why it deserves measurement in a procedure almost nobody practices bilaterally. The best meta-analytic estimate puts the prevalence of left-handedness at 10.6 percent, meaning a substantial minority of clinicians in any department already work with equipment configured around the opposite preference.

The research group has practical experience with the procedure itself. In a recent simulation study using a single dual-technique device called Cricospeed, personnel without prior eFONA experience completed five consecutive attempts with each of two techniques, the scalpel–bougie and the Seldinger wire-based method. Success rates on the manikin approached ceiling—100 percent for Seldinger and 95.3 percent for scalpel–bougie at the first attempt—meaning that any future study relying on success rates alone would be underpowered by construction. Procedural time, however, differed sharply: 23.7 seconds on average for scalpel–bougie versus 47.1 seconds for Seldinger, with far greater variability in the wire technique. The learning curve was steep and statistically significant in both, with mean times falling from 56.3 to 38.8 seconds and from 28.2 to 18.2 seconds respectively over five attempts. This creates a methodological trap: the effect of practice is of the same order of magnitude as any plausible effect of handedness, so a poorly balanced study would measure learning and mistake it for laterality.

To settle the question, the team has designed the HANDS study—Handedness Assessment in emergency front-of-Neck Devices Skills—now under ethical amendment at their institution. The question cannot be answered in real patients: eFONA is rare, unplanned, and lethal when it fails, making randomization of the operator’s configuration inconceivable. Simulation is not second best here; it is the only setting in which the question is answerable at all. The study uses a fully within-participant 2×2 factorial design, crossing dominant versus non-dominant configuration with scalpel–bougie versus Seldinger technique, so that each operator serves as their own control on both factors. This design allows a few dozen participants to achieve what a parallel-group trial would need several hundred for. Block order follows a balanced Williams Latin square, and attempt number enters the analysis as a covariate, so that order effects, carryover, and learning are estimated rather than assumed away. The primary endpoint is time to effective ventilation, analyzed with a linear mixed-effects model, while first-attempt success, complications, incision length, and final device position serve as secondary outcomes. Hand dominance itself is measured with the Edinburgh Handedness Inventory as a continuous laterality quotient, allowing each individual’s asymmetry to be related to the size of their performance decrement.

The implications cut both ways, and either answer would change practice. If a substantial penalty for the mirrored configuration is demonstrated, guidance would shift from prescribing a side to prescribing a hierarchy—what to do when the preferred side is unavailable, and whether repositioning is worth the seconds it costs. Training would become explicitly bilateral, with competence assessed in both configurations, a cheap addition to existing airway courses that is currently absent from all of them. Device design would acquire a testable requirement: symmetry of handling and elimination of the steps most sensitive to which hand holds the instrument. If no difference is demonstrated, that is far from a null result of no consequence: it would license operators to proceed from whichever side the room allows, removing the hesitation that currently attends that decision and stripping one item from the cognitive load of a scenario with no capacity to spare. Hesitation in a cannot-intubate-cannot-oxygenate situation is itself a recognized mechanism of harm.

The authors are careful not to argue for more prescription. Operators differ in handedness, prior training, habitual technique, and adaptation to either configuration, and the guidelines themselves hold both poles of that tension—demanding a predetermined technique with no scope for indecision while simultaneously telling clinicians to use the approaches most likely to succeed in their own hands. Without measurement, that tension cannot be calibrated, and a firm but thinly supported prescription leaves any clinician who reasonably departs from it exposed if the outcome is poor. Measurement is what allows a recommendation to be graded: a firm default where the penalty is large, and explicit permission to individualize where it is not. The answer to “one size does not fit all,” the authors conclude, is not less guidance, but guidance calibrated to the size of the difference it regulates. In the most high-stakes procedure in airway medicine, the choreography of the hands may matter enormously, or not at all—but after a decade of practice, no one has thought to find out.

Subject of Research: The final rescue step in failed airway management: handedness is included in front-of-neck access guidance but has not been measured

Article Title: The final rescue step in failed airway management: handedness is included in front-of-neck access guidance but has not been measured

Article References: Paternò, D. S., La Via, L., Piccitto, F., Calà Lesina, B. D., Moltisanti, R., Putaggio, A., Lo Giudice, E. C., & Sorbello, M. (2026). The final rescue step in failed airway management: handedness is included in front-of-neck access guidance but has not been measured. Frontiers in Anesthesiology, 5, Article 1983825. https://doi.org/10.3389/fanes.2026.1983825

Image Credits: AI Generated

DOI: 10.3389/fanes.2026.1983825

Keywords: airway management, emergency front-of-neck access, cricothyroidotomy, handedness, cannot intubate cannot oxygenate, simulation, critical care, Difficult Airway Society, final, rescue, step, failed