A narrative review of acute airway management in tracheostomy and total laryngectomy patients

Introduction

Emergency airway management in patients with tracheostomies or total laryngectomies presents a unique challenge due to altered airway anatomy (1,2). These patients face an increased risk of airway obstruction and respiratory distress, most often due to mucus plugging, tube dislodgment, or stenosis, and are particularly vulnerable to harm if not managed properly (2). Their management requires special expertise and timely intervention to minimize the risk of morbidity and mortality (2). Despite the availability of general acute airway management guidelines, many are designed for patients with native upper airways and often fail to address the specific considerations required in those with surgically altered airways (2). There also exists a fragmentation in the literature with existing guidelines often being scattered across subspecialties, including otolaryngology, anesthesia, and critical care. Furthermore, much of the existing literature assumes a high-level of airway expertise and does not provide simple and readily implementable frameworks for non-airway specialists. Therefore, a reliable algorithm to differentiate between emergencies for clinicians with limited airway experience is lacking and is critical as delayed or inappropriate management in these populations can lead to rapid degeneration.

Objectives

This clinical review aims to synthesize available evidence, best practices, and current protocols for the emergency airway management of tracheostomy and laryngectomy patients while evaluating the strengths and weaknesses of available guideline limitations. To answer these questions, we will first explore the differences in the surgically altered anatomy of both laryngectomy and tracheostomy patients. We will then look at the common emergency situations and their causes for both populations. Finally, we will examine the current clinical practices used in these emergency situations, discuss their merits, review existing guidelines, present a readily implementable algorithm, and explore possible improvements in care delivery for these vulnerable patient populations. We present this article in accordance with the Narrative Review reporting checklist (available at https://joma.amegroups.com/article/view/10.21037/joma-2025-22/rc).

Methods

The database for this narrative review was searched on PubMed, Embase, Google Scholar, MEDLINE, and Google for peer-reviewed articles. English language articles pertaining to acute airway management in human tracheostomy and laryngectomy patients published between January 1, 2000, and March 1, 2025, were considered. Study design and publication status were not restricted to ensure the capture of all available evidence. The studies for the review encompassed all types of publications, including clinical guidelines, retrospective and prospective studies, case series, and expert opinions. Key search terms included: tracheostomy OR laryngectomy AND emergency airway OR airway management OR complication; the specific search strategy can be found in Table 1. Additional references were identified by manually searching the bibliographies of key articles or through the use of related articles feature. To include niche but clinically relevant topics, three additional papers from September 1991 to November 1999 were added.

Neck, trachea, and larynx anatomy

Effective management of these patients requires an understanding of both the normal and the surgically altered airway anatomy. The trachea conduits the larynx to the bronchi and extends from the cricoid cartilage at the level of the C6 vertebra to the carinal bifurcation at approximately T5 (3). In most adults, the trachea measures 10–12 cm in length and has an average diameter of about 2 cm (3). The larynx, the link of the pharynx to the trachea that houses the vocal folds, also consists of the thyroid cartilage, epiglottis, and the cricoid cartilage, a complete cartilaginous ring that contributes to the cricothyroid joint (3).

Tracheostomy

With more than 100,000 adults undergoing tracheostomy procedures in the United States each year, it is a commonly performed procedure (4). A tracheostomy procedure consists of creating a stoma in the anterior neck connecting to the trachea, which provides direct access to the airway for aid in respiration (5). Tracheostomies can be temporary or permanent, depending on the indication, and may be performed using either an open surgical or percutaneous technique (6). Indications include anatomic or physical upper airway obstruction, prolonged intubation, extensive head & neck or airway surgery, airway protection following neurologic injury or deficit, enabling weaning of or long-term mechanical ventilation, and a need for pulmonary toilet, along with other less common circumstances (7). Anatomic causes of upper airway obstruction can be tumors, inflammation/edema, trauma, bleeding, and/or stenosis (8). The inserted tube facilitates ventilation, but this device also poses various risks, including tube displacement, obstruction, and mucus plugging (5).

Tracheostomies are conventionally viewed as potentially ‘difficult’ airways, since the stoma and airway tube are more dynamic and prone to shifting. This is particularly true for early or immature tracheostomies under 72–96 hours of age (1). Initially, the pretracheal fascial planes have not fully healed or matured, leaving the tracheostomy tube prone to misalignment with the skin and underlying airway, increasing the risk of airway compromise if the tube becomes displaced or dislodged (9). Coughing or other movement can cause inadvertent dislodgement or false passaging anteriorly (9). As the stoma matures, the airway becomes more stable, making the tube and the airway more straightforward to manage (10). The maturation is mainly due to soft tissue structural changes that accommodate the tube. Risk factors for accidental decannulation have been explored in the pediatric population (11,12). Implementing hospital-based education and using dislodgement bundles have been shown to improve provider confidence in managing airway emergencies (13). While a tracheostomy can be reversed, it may need to be permanent depending on the patient’s underlying condition, such as mechanical ventilation dependency or fixed anatomical obstruction (4). In the early postoperative period, managing a tracheostomy airway can be more involved than a laryngectomy airway, which has more direct access and is less prone to movement (14). Complications following tracheostomy may include hemorrhage, accidental dislodgement, infection, mucus plug, or tracheoesophageal fistula (TEF) (15).

Multiple tracheostomy methods, both surgical and percutaneous, can be used in practice. Percutaneous tracheostomy is a minimally invasive option performed extra-operatively using a needle and catheter with local anesthesia (16). Techniques include Blue Rhino and Griggs, which are examples of percutaneous dilatational tracheostomy (PDT), and percutaneous dilatation guided by a bronchoscope (17). Surgical techniques for tracheostomy, however, typically require general anesthesia and involve making an incision in the neck. Surgical techniques include the Björk flap, slit, and window (18). The choice of technique depends on patient factors such as body mass index (BMI), existing anatomy, previous surgeries, and diagnosis (18). Surgical techniques allow for better access and visibility, and thus superior control of the airway and surrounding anatomy (18). Both approaches carry risk of stenosis, malacia, and fistulas (19).

Although the overall complication rate for tracheostomy exceeds 50%, the incidence of serious complications remains low. The critical issues that may arise are decannulation, hemorrhage, and obstruction (20). If the tube becomes dislodged, the primary goal is to restore airflow. Bleeding may result from the friability of tissue adjacent to the tube and plate, incomplete hemostasis, and small or large vessel injury/involvement (21). Obstruction is often due to mucus plugging or issues with tube patency, and positioning, which may result in tube dislodgement and respiratory distress (22). Finally, while rare, subcutaneous emphysema can occur due to the formation of a tissue tract anterior to the trachea, resulting from positive pressure ventilation or forced coughing against a tightly sutured or packed wound. This condition can extend into the pleural space, ultimately leading to the development of a pneumothorax (19). Posterior tracheal wall injury, while very rare, is also a possible complication of tracheostomy placement that could result in emergent airway compromise (19). These urgent situations can all lead to an emergency, resulting in serious complications or mortality if not identified and promptly treated.

Laryngectomy

Total laryngectomy is a less commonly performed procedure than tracheostomy, but similar strategies can be applied when approaching urgent or emergent airway situations (23). Unlike tracheostomies, laryngectomies are irreversible procedures. Although the number of tracheostomy procedures performed each year is significant, most patients do not require lifelong airway management. In contrast, roughly 3,000 new laryngectomy patients are added to the population annually (4). While a laryngectomy ensures a “safe” airway due to the stoma being directly accessible at the anterior aspect of the neck, this growing patient population requires more attention regarding airway care, especially when urgent or emergent (24). A total laryngectomy involves the removal of the larynx and upper airway, resulting in structural changes where the upper airway no longer connects with the trachea (23). The remaining trachea is sutured to the skin. Surgical techniques for total laryngectomy differ significantly from those for tracheostomy, as many are done for cancer, severe trauma, or chondronecrosis of the larynx (18). There are a variety of partial laryngectomies; however, due to the rarity of these procedures, this review will focus solely on airway management in patients who have undergone a total laryngectomy. These procedures are meant to maintain stable access to the airway and are thought to be easier to manage in clinical settings. Caregivers, however, often misunderstand the gross anatomical changes and can attempt inappropriate methods during emergencies, such as facemask or nasal cannula oxygen supplementation (24).

Total laryngectomy patients lack functioning vocal cords and a normal cough reflex, altering their airway management since conventional transoral intubation is not feasible (6). Complications following a total laryngectomy procedure may include bleeding, postoperative edema with subsequent stoma obstruction, and aspiration (6). Unlike tracheostomy patients, a total laryngectomy creates a stable lifelong airway (25). Despite this, approximately 40% of all patients develop a postoperative complication after total laryngectomy, but once stable, the laryngectomy airway will be fixed (26). Mismanagement, therefore, is more often the product of ignorance rather than of the airway itself (27).

In laryngectomy patients, the altered anatomy and impaired natural airway clearance mechanisms precipitate the acute airway event. After a total laryngectomy procedure, the upper airway becomes permanently separated from the lower respiratory tract, which precludes the oral or nasal route of intubation (28). Fortunately, laryngectomy airway access is straightforward. The stoma connects directly with the trachea, which allows for the placement of a cuffed tracheostomy or endotracheal tube (29). However, after the removal of the vocal cords, epiglottis, hyoid bone, and strap muscles, patients are unable to cough up or swallow secretions, which presents a challenge (30). Mucus can therefore build up and dry in the distal trachea (31). Along with the loss of nasal humidification and filtration, this mucus buildup can be accelerated (32). Accumulated secretions can partially or completely obstruct the airway, requiring urgent or even emergent intervention (22). This mucus buildup can also contribute to infection, which can exacerbate airway edema (33).

Postoperative architectural changes, such as stomal stenosis, present additional challenges during the healing process. Tracheal stoma stenosis typically develops gradually and is often associated with the presence of peristomal granulation tissue (34). Tissue scarring can also cause abnormal stenosis of the airway (35). This abnormal tissue formation and subsequent tightening of the stoma can hinder cannula exchange, potentially result in bleeding into the lower airway, and even inability to maintain patency with a laryngectomy tube (34,36).

Emergency airway management

The primary objective in emergency airway management is ensuring patency of and access to a patient’s airway in instances of respiratory distress or failure. This is typically associated with sudden respiratory failure or obstruction, altered consciousness or impaired airway protection, and airway procedures or interventions. Proper airway management prevents hypoxia and ensures effective ventilation in critical care and emergency settings (37,38).

Management of tracheostomy airway urgencies and emergencies

Appropriate emergency tracheostomy airway management requires rapid identification, proper staff education, readily available equipment, and strong clinical governance (39).

Initial management of mucus plugging should be endotracheal suctioning, which often relieves the blockage without additional intervention. In patients using a cap or speaking valve, such as a Passy-Muir Valve (PMV), these devices should be removed to assist in restoring airflow. When mucus plugging occurs, replacement of the inner cannula should be trialed (40). If secretions are becoming thick or adherent, moisturization via normal saline followed by repeat suctioning may effectively loosen and clear the mucus obstruction (41). This strategy highlights the importance of preliminary airway humidification, such as with heat and moisture exchangers (HMEs), which typically prevent secretions from thickening excessively. Medications can also reduce mucus production, which prevents blockages and improves airway patency.

Airway obstruction may also be positional, particularly when an improperly sized or positioned tracheostomy tube is used. In patients with a large body habitus or increased soft tissue around the neck, a standard-length tracheostomy tube may be insufficient, increasing the risk of decannulation or the creation of a false passage, most often anterior to the trachea (42). In these cases, a proximal or extended-length tracheostomy tube may be more appropriate to ensure proper intraluminal positioning (43). Another underrecognized complication is ‘back-walling’, where the distal tip of the tracheostomy tube becomes retroflexed and abuts the posterior tracheal wall (44). This malposition can cause partial or even complete obstruction that varies with neck position and patient movement, when malposition is suspected—whether due to persistent respiratory distress, poor airflow despite a patent stoma, or difficulty passing a suction catheter—fiberoptic bronchoscopy should be performed to directly visualize the tracheostomy tube’s position and assess for obstruction before attempting tube manipulation or replacement (45). A standard laryngoscope can be used as well (46).

When airway obstruction or tracheostomy tube malfunction is suspected, and the tracheostomy stoma has matured, tubal exchange can typically be performed without complications. However, premature tracheostomies, especially those less than a week old, particularly within the first 72 to 96 hours, carry a higher risk of complications during tube exchange (47). Early tracts are not well-formed, and attempting tube replacement too soon can result in false passaging or inability to access the trachea, leading to loss of airway (48). If it can be tolerated by the patient, additional stoma maturation time is recommended prior to any exchange. If urgent exchange is required as in unique cases like a blown cuff in a ventilator-dependent patient with worsening oxygenation, the procedure should be approached with caution (49). Additional personnel, appropriate backup equipment, and readiness for advanced airway support are essential. In particular, suction, a tracheostomy or neck tray, different-sized endotracheal tubes, bougie catheters, fiberoptic cameras, and other tools needed for a safe and efficient intervention should be readily available (2). It is also important to remember that in the event of airway loss during a tracheostomy exchange or accidental decannulation, transoral intubation may still be a viable option, depending on the original indication for the tracheostomy and whether the upper airway remains anatomically and functionally intact (2). In cases where the tracheostomy was placed for prolonged ventilation or secretion management rather than upper airway obstruction, oral intubation may serve as an effective temporary airway until the tracheostomy can be safely re-established (2). Supplemental oxygenation or positive pressure, even administered through the nose/mouth, may assist in temporizing relatively stable patients (1). Again, this is case selective.

In response to bleeding from a tracheostomy, providers must first evaluate the severity and source of the bleeding. Minor bleeding is often due to local tissue irritation, granulation tissue, or mucosal trauma during suctioning or tube exchanges; providers can typically inflate the cuff (if using a cuffed tracheostomy tube) and sit the patient upright, apply oxygen if needed, and ensure wide-bore intravenous access (39). External bleeding can usually be managed with conservative measures, such as the application of gauze, hemostatic clotting agents of various make, or local cauterization and/or ligation (1,50). Conversely, persistent or recurrent bleeding usually indicates a more serious etiology. For instance, a tracheoinnominate fistula (TIF) is a rare but potentially fatal complication resulting from the erosion of the tracheal wall into the innominate artery (51). TIF is associated with pressure necrosis from the tracheostomy cuff, extended use of steroids or immunosuppressants, positioning of the tracheostomy below the third tracheal ring, tracheitis, prolonged intubation, an unusual or elevated anatomical location of the innominate artery, and the migration of a skin infection at the stoma site to deeper tissues (52). TIF typically presents with a sentinel bleed followed by massive hemorrhage, most typically in the first 3 weeks of tracheostomy placement. This is a surgical emergency requiring immediate airway stabilization, overinflation of the tracheostomy cuff to tamponade bleeding, and emergent transfer to the operating room for definitive surgical management (4). Early recognition and intervention are critical for survival in such cases. Other sources of bleeding that fail to respond to conservative management or result in clinical instability also prompt immediate operative exploration. Surgery may also be necessary in rare cases to address anatomical or structural causes of the obstruction (53).

Management of laryngectomy airway urgencies and emergencies

Management of difficult airways in total laryngectomy patients may share similarities with tracheostomy patients, but key anatomical differences must be recognized. The absence of the larynx and altered anatomy in laryngectomy patients precludes the use of standard upper airway approaches as a back-up. However, it should be realized that a permanent laryngectomy stoma provides superior airway access when compared to a tracheostomy (22).

Hemorrhage into the airway is an emergency airway event that requires rapid response. Bedside interventions like cauterization may manage the hemorrhaging tissue, while placing a cuffed tracheostomy tube lower in the airway can temporarily protect the distal trachea and lungs from an active hemorrhage (54,55). A smaller tracheostomy tube or silicone stent may also temporize stomal stenosis (56). When these complications arise, management includes optimizing the positioning of the new tube and selecting an appropriately sized, often smaller, tube (57). Prolonged decannulation after surgery can lead to stoma narrowing due to incomplete maturation or scarring of the peristomal tissue and reflects the importance of patient and provider education. This is essential to ensure long-term stoma stabilization and reduce the likelihood of stenosis, which can also trigger an urgent or emergent situation if airway patency is lessened or even lost.

As with tracheostomy patients, mucus plugging is a potential complication and similarly gentle endotracheal suctioning can lessen mucus plugging in minor cases (41). In more severe instances or with total mucus plugging, temporary removal of the laryngectomy tube is an important next step (58). This is in contrast with tracheostomies, where removal of the tube is controversial, though this may be an option in patients with a well-matured tract. Normal saline can be used to soften thick secretions, while HMEs or medications can prevent increased coughing, mucus production, and expectoration seen in total laryngectomy patients (59). Revision surgery may also be necessary for laryngectomy patients.

Stomal stenosis after laryngectomy is common, generally progressive, and needs active intervention (60). A stomaplasty involves the excision of scar tissue and the interposition of the defect (60). One final area to consider with laryngectomy patients is complications arising from the installation of tracheoesophageal voice prosthesis. These artificial fistulas can result in prosthesis leakage, fistula leakage, granulation, and prosthesis extrusion (61). Leakage into the trachea may result in aspiration, and if the prosthesis ejects become lodged in the bronchi, this can transform the situation into an airway foreign body management scenario (62). Placement of a cuffed tracheostomy tube and inflation of the cuff can protect from fistula leakage (1). In event of emesis or spillage of other fluid care must be taken to protect the stoma (1). Introduction of fluids such as emesis or water into the stoma can result in significant aspiration, potentially resulting in respiratory failure (63). Prompt intervention and caregiver education are critical for reducing the risk. In cases where aspiration occurs, bronchial lavage may be indicated as a therapeutic measure (64).

Clinical guidelines and protocols—synthesis and appraisal

The generalized protocols outlined below for managing airway emergencies in patients with tracheostomies or laryngectomies are published by the New South Wales (NSW) Agency for Clinical Innovation. These standards are summarized below and supplemented by recommendations from other sources, such as Austin Health and the National Tracheostomy Safety Project (65-68). While there are additional standards, they are generally confined to niche subspecialties—e.g., neonatal care or pediatrics—or to specific events like tracheostomy decannulation, as developed by the World Federation of Societies of Anesthesiologists (69). While these guidelines provide concise, adaptable recommendations, they are limited in scope and lack outcome-based evidence for comprehensive airway management guidance.

In any airway emergency, the first step is to call for immediate assistance. This includes activating rapid response teams, code alerting, and involving specialized airway personnel. The provider must then check whether the patient is breathing and confirm airway patency. In either instance of airway manipulation, the clinician managing it must perform a risk assessment based on medical history, surgical interventions, environmental factors, and anesthetic implications (2). If the patient is breathing, provide both the mouth and the tracheostomy or laryngectomy stoma with high-flow oxygen.

If the patient is unresponsive and either fails to breathe or exhibits abnormal respirations, it is crucial to initiate cardiopulmonary resuscitation (CPR) immediately. Assessment of airway patency is followed if the patient is breathing. Mucus plugging, bleeding, tube dislodgement, or mispositioning can be identified. Removing the speaking valve and inner cannula, where applicable, are subsequent steps. For patients undergoing laryngectomy, remove the stoma cover and inner cannula but not the tracheoesophageal prosthesis. Suctioning is a natural next step and can assist in identifying obstruction or mispositioning. Use of saline can assist in breaking down accumulated mucus to facilitate plug removal with a suction or forceps (26). Instruments like fiberoptic laryngoscopy, bronchoscopy, or bedside endoscopy should be brought to the bedside as these can be beneficial in assisting evaluation of the situation to better identify the cause of respiratory compromise (2).

For bleeding, inflate the cuff if applicable and apply tamponade pressure around the plate with gauze. Avoid removal of the tracheostomy tube. In the event of decannulation, replacement of the tracheostomy tube may be trialed. Stomal intubation with a smaller endotracheal tube may also be attempted. If this fails, cover the stoma and use normal oral airway maneuvers such as bag masking. As a last resort and if anatomically applicable, perform transoral intubation. Whereas in patients with laryngectomy, ventilation via the stoma should be initiated immediately, followed by direct intubation of the distal airway. Placement of a cuffed tracheostomy tube or endotracheal tube are crucial to protect the lower airway in event of aspiration of outside liquids, emesis, fistula secretions, or hemorrhage. If these interventions fail CPR, and even emergency surgical intervention may be considered.

While multiple protocols exist for airway emergency management in patients with tracheostomy and laryngectomy, guidelines from the NSW Agency for Clinical Innovation are among the most well-organized and suitable for both groups. By concentrating on the first evaluation of airways, ensuring adequate oxygenation, implementing systematic decision-making, and calling for expertise help, the protocol serves as an effective and reliable guide in high-stakes conditions. However, this review is meant for first responders such as nursing staff and medical specialties not accustomed to regular airway management, and has a limited applicability outside well-resourced settings. Similarly, the Austin Health and National Tracheostomy Safety Project guidelines provide clear algorithms tailored for bedside use, but they only include tracheostomy emergencies, are based on expert consensus rather than clinical outcome data, lack generalizable external validation, and also may assume resource availability and staffing models not generalizable to all other institutions. Notably, although not exhaustive, standardized, evidence-based protocols like these offer more uniform and timely care, which has been shown to improve outcomes in critically ill patients by reducing variability and allowing for a coordinated response (70). Please see Figure 1 for a template that institutions may utilize.

Figure 1 Tracheostomy emergency institutional protocol template. PRN, as needed.

Discussion

This narrative review assessed the emergency management of airway complications in tracheostomized and total laryngectomized patients, two groups with surgically altered airways that present unique clinical challenges. Key findings highlighted in the literature identified frequent and life-threatening complications, including tube dislodgment, hemorrhage, mucus plugging, and stomal stenosis.

In tracheostomy patients, guidelines suggest administering oxygen to both face and stoma; attempt to clear cannula via suction; replace tracheostomy tube, using a guidewire if available, if obstruction persists; perform endoscopic or fiberoptic visualization for further evaluation and treatment. Table 2 provides an at a glance for common airway complications and management in tracheostomy patients.

In laryngectomy patients, all interventions must occur solely via the stoma. The stoma cover or laryngectomy tube may be removed if obstructed; saline and gentle suction can clear mucus; a smaller tube or stent can relieve stenosis; and bleeding should prompt placement of a cuffed tube and surgical evaluation. Table 3 provides an at a glance for common airway complications and management in laryngectomy patients.

Current literature remains limited in directly evaluating outcomes associated with different equipment availability (2). Similarly, there is a notable lack of studies addressing preoxygenation strategies, sedative or local anesthetic use, and appropriate monitoring protocols in these patients (2). Much of the guidance that exists is derived from anecdotal experience and clinical dogma, reflecting the urgent and high-stakes nature of many airway emergencies—where any viable means of securing the airway may be considered to prevent immediate harm or death.

Beyond identifying complications, this review underscores that effective management depends not only on readily accessible difficult airway equipment, but also that healthcare providers are familiar with its proper use. Training and education should emphasize not only the identification and deployment of appropriate tools but also the recognition of high-risk airway scenarios. Simulation-based education, standardized facility protocols, and interdisciplinary drills can significantly enhance preparedness, reduce hesitation, and improve outcomes in airway emergencies. Please see Figures 2,3 for our proposed protocols for emergency airway management in tracheostomy and laryngectomy patients.

Figure 2 Stepwise algorithm for the emergency management of tracheostomy-related airway complications. CPR, cardiopulmonary resuscitation.

Figure 3 Stepwise algorithm for the emergency management of laryngectomy-related airway complications. CPR, cardiopulmonary resuscitation.

There is an urgent need for future studies to strengthen the evidence base in this field. Prospective studies evaluating standardized protocols, airway simulation performance, and interdisciplinary training effectiveness would enhance the evidence base and provide direction on optimal practices.

Conclusions

Emergent airway management of tracheostomy and total laryngectomy patients is a subspecialty of difficult airway management. Their management necessitates a knowledge of the patient’s anatomy distorted by surgical history and a unique set of risks from direct tracheal airways. This review integrates existing evidence to clarify the distinct mechanisms of airway failure in each group and highlights strengths and weaknesses in current guidance. As we have highlighted, numerous clinical nuances and situational complexities must be explored in greater depth to inform the development of integrated guidelines to facilitate the delivery of safe, consistent, and timely emergency airway management. Such advancements could potentially revolutionize care delivery and outcomes for this growing and vulnerable patient population.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the Narrative Review reporting checklist. Available at https://joma.amegroups.com/article/view/10.21037/joma-2025-22/rc

Peer Review File: Available at https://joma.amegroups.com/article/view/10.21037/joma-2025-22/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://joma.amegroups.com/article/view/10.21037/joma-2025-22/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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