Factors influencing health professionals' management of tracheal intubation in oral and maxillofacial malignancies patients after surgery: A qualitative study

Factors influencing health professionals' management of tracheal intubation in oral and maxillofacial malignancies patients after surgery: A qualitative study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Factors influencing health professionals' management of tracheal intubation in oral and maxillofacial malignancies patients after surgery: A qualitative study Zhixia Xu, Qinhan Zou, Yuelai Yang, Fen Gu This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4897098/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 07 Feb, 2025 Read the published version in Supportive Care in Cancer → Version 1 posted 9 You are reading this latest preprint version Abstract Background Tracheal intubation is significant for patients with Oral and maxillofacial malignancies (OMMs) after surgery. Despite the development of practice guidelines and training programs, the current management of tracheal intubation by healthcare professionals (HCPs) is inadequate. This study aimed to explore factors that hinder HCPs in managing the tracheal intubation of patients with OMMs after surgery in the intensive care unit (ICU). Methods Semi-structured interviews were conducted with 12 experienced HCPs in three clinical units at a tertiary hospital in Shanghai, China, from February to May 2024. Purposive sampling was used. The data were organized and analyzed using NVivo 12.0 software and Braun and Clarke's reflective thematic analysis. Results Two themes and seven sub-themes emerged: (1) institutional factors: lack of a risk assessment system for airway obstruction, lack of a tracheal intubation emergency team, preparations for delayed extubation were inconsistent, and inadequate reintubation training for airway obstruction, and (2) individual factors: normativity of airway humidification, reserve of knowledge on the risk of airway obstruction, and attitude about learning about airway obstruction. Conclusion HCPs' inadequate management of tracheal intubation in patients with OMMs after surgery is influenced by multiple factors. Designing targeted interventions utilizing these influencing factors will improve HCPs' ability to manage tracheal intubation and ensure the life safety and effective treatment of patients with OMMs following surgery. Oral and maxillofacial malignancies Tracheal intubation Influencing factors Qualitative study Figures Figure 1 1. Introduction Oral and maxillofacial malignancies (OMMs) refers to cancers of the lip, cheek, tongue, gingiva, floor of the mouth, hard palate and other unspecified parts of the oral cavity, with the overall incidence rates up to 21.2% [ 1 ] . With a 5-year survival rate of less than 60% and poor prognosis, OMMs has become a public health disease of global concern [ 2 ] . Currently, surgery is the main treatment for OMMs [ 3 ] , including primary lesion excision and flap repair. Postoperative patients with OMMs are usually transferred to the ICU with the tacheal intubation for follow-up treatment. Tracheal intubation is the insertion of a catheter through the nose or mouth into the trachea to help the patient breathe effectively [ 4 ] . Due to the large flap, airway edema or hematoma, tracheal intubation is an important means to help patients with OMMs reconstruct airway and ventilate [ 5 ] . And delayed extubation (DE) after overnight ventilation in ICU can follow time to reduce or subside airway edema, prevent immediate postoperative complications from damaging the airway and prevent potential complications from occurring [ 6 , 7 ] . Patients with oral and maxillofacial malignancies (OMMs) frequently present with altered airway anatomy prior to surgery. As a result, managing the airway after intubation and extubation can be particularly challenging due to surgical resections and the transplantation of flaps into the oral cavity. [ 8 ] . Currently, guidelines, training programs, and interventions have been developed to help HCPs manage tracheal intubation [ 9 – 11 ] , such as airway assessment, airway profiling, intubation team building, equipment training and bedside simulation. However, bleeding, obstruction of tracheal intubation, and failure of tracheal intubation extubation are more common in patients with OMMs, which increases the length of hospital stay and negatively affects the quality of life of these patients [ 12 , 13 ] . Previous studies have shown that post-intubation management and routine ICU extubation management can effectively prevent the occurrence of airway obstruction and reduce the rate of tracheotomy [ 14 , 15 ] . Therefore, understanding HCPs experiences with clinical practice of tracheal intubation and extubation in patients with OMMs after surgery during the ICU period is critical for practice implementation and improvement. This study designed to purposefully sample with HCPs including doctors and nurses in ICU, oral oncology and the surgical anesthesiology department. Semi-structured interviews were conducted to gain insight into healthcare professionals' clinical experiences with airway management in the ICU. The aim was to explore the factors that hinder their ability to manage tracheal intubation and extubation in postoperative patients with with OMMs. 2. Methods 2.1 Study design Phenomenological methods were used to conduct this qualitative study. Individualized semi-structured interviews were used to explore the factors influencing improper management of the tracheal intubation by HCPs in OMMs patients after surgery during the ICU period in a tertiary hospital in Shanghai, China. Descriptive phenomenology provided a detailed description of the clinical practice experiences of HCPs in tracheal intubation and extubation management and their understanding of these experiences [ 16 ] . 2.2 Participants and recruitment Participants in this study included doctors and nurses, from three clinical units at a tertiary hospital in Shanghai, China, between February and May 2024. The eligibility criteria for participation consisted of participants who: (1) have engaged in oral cancer patients treatment or nursing care more than seven years; (2) volunteer to participate in this study; and (3) have good verbal communication skills. We used a snowball sampling technique to recruit participants, with initial participants recommending other doctors or nurses with extensive experience in oral cancer care or airway management. The potential participants were contacted via email. All participants had clinical experience, expressed confidence in the integrity of the study, and provided informed consent.Data collection ceased once the interview information was saturated with no new topics emerged. Twelve HCPs were eventually interviewed, with no dropouts during the study. In addition, the researcher had no prior direct working relationship with the participants. This absence of pre-existing professional connections ensured that interactions during the interviews remained fair and focused solely on research purpose. 2.3 Data collection Interviews were audio recorded, and field notes were kept and incorporated in the analysis process. To maximum the sample variation, participants with different position, professional qualifications, and education were accessed. The interviews were conducted in the hospital' meeting room to ensure a relaxing environment. We collected data through face-to-face in-depth, semi-structured interviews, each lasting 30 to 40 minutes. During the interviews, the focus was controlling the topic of the interviews, avoiding deviation from the purpose of the study, and adjusting the interview time appropriately according to the actual situation of the interviews. The interview outlines designed based on literature reviews, the researcher's clinical experience and expert consultation, tested and revised in pilot interviews with three participants (shown in Table 1 ). To ensure accuracy, transcripts were confirmed with participants at the end of the interviews. In appreciation of their valuable time and effort, each participant received a hand cream. Table 1 Interview outlines No. Questions 1 What do you think is the importance of tracheal intubation in patients with oral and maxillofacial malignancies during ICU after surgery? Can you tell me more about it? 2 What shortcomings do you think exist in tracheal intubation management of patients with oral and maxillofacial malignancies during the ICU treatment period? Can you give me some detailed examples? 3 What difficulties have you encountered in the clinical practice of tracheal intubation management? Can you elaborate on that? 4 In your opinion, what should be done to improve the management of tracheal intubation in patients with oral and maxillofacial malignancies in ICU? Do you have any good suggestions? Can you elaborate on that? Prior to the study, all researches have experience in qualitative research and were trained in qualitative research methodology. The interviews were conducted by the major researcher (ZX-X), a female nurse with an extensive background in the field. Her experience included thirteen years in the ICU and another eight years as an ICU clinical nurse specialist, alongside participation in the American Heart Association Basic Life Support Instructor Training teaching. At the same time, she further developed her expertise, especially qualitative research methods, through a master studying programme in Nursing. 2.4 Data Analysis Interviews were transcribed within 24 hours, analyzed using NVivo 12.0 software, and non-verbal behaviors were combined with written transcriptions. Two researchers independently conducted a comprehensive thematic analysis using the six steps of Braun and Clarke's reflective thematic analysis [ 17 ] , as detailed in the Table 2 . Through thematic analysis, which involves systematically identifying, analyzing, and interpreting patterns or themes in the data, we can gain a comprehensive understanding of the current inadequacy of tracheal intubation management by HCPs in patients with oral cancer after surgery. In oder to improve the reliability of the data coding and reduce potential biases in the interpretation of the data, the findings will be discussed with the research team. Table 2 six steps of Braun and Clarke's reflective thematic analysis No. Steps 1 After the data collection phase, we read and re-read transcripts of interviews with HCPs to familiarize ourselves with the data. 2 Initial codes were then generated, which involved labeling and categorizing data related the clinical practice of HCPs in tracheal intubation management during ICU treatment after oral cancer surgery. 3 Theses codes were organized into potential themes, which captured meaningful patterns or recurring topics in the data. 4 Researchers review and refine themes by collating relevant codes, comparing and considering their consistency and relevance to research questions. 5 To ensure that themes accurately represented the data and reflected HCPs' clinical practice experiences, we also conducted multiple iterations of the analysis. 6 The final step involved defining and naming the themes and creating a coherent and comprehensive framework to understand the HCPs' clinical practice experience. 2.5 Ethical considerations This study meet the requirements of Helsinki Declaration [ 18 ] . Data collection and qualitative interviews were approved by the hospital ethics committee (No. **). Before the study, participants were fully informed of the study's purpose, methodology, benefits, and risks. Written informed consent was obtained prior to conducting the interviews. To protect privacy, their names have been replaced by numbers. Participants had the right to withdraw from the study at any time. 2.6 Rigor Four criteria were used to ensure the rigor of the research [ 19 ] : credibility, dependability, confirmability and transferability. To enhance the credibility of the data, 'researcher triangulation' was incorporated into the analytical strategy to reduce the potential pitfalls of a single analytical perspective. Dependability was ensured by providing independently checked data to two external researchers with qualitative experience. Confirmability was ensured by using audit tests to verify whether the authors are biased against the findings. Transferability was ensured by the researchers' clarity on the research background, purpose, methods and analytical processes, as well as participants' information. The study followed the Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines [ 20 ] . 3. Results Twelve participants were interviewed, and their basic characteristics are shown in Table 3 . Participants were aged between 32 and 56 years (average years 39.9 years). Seven identifed as nurses and five as doctors. They came from three clinical units, three of whom worked in oral oncology, five in ICU and four in surgical anesthesiology department. Their total clinical experience varied from 7 to 28 years, averaging 13.3 years. The identified themes and sub-themes are shown in Fig. 1 and detailed below: (1) institutional factors: lack of a risk assessment system for airway obstruction; insufficient personnel in tracheal intubation emergency team; preparation for delayed extubation are inconsistent; and inadequate reintubation training for airway obstruction; and (2) individual factors: normativity of airway humidification; reserve of knowledge on the risk of airway obstruction;and attitude about learning about airway obstruction. Table 3 Characteristics of twelve participants Participants Clinical units Gender Age (years) Education Professional qualifications Position Seniority (years)* Nurse 1 Oral oncology ward female 42 university nurse in charge chief nurse 16 Nurse 2 ICU female 38 master's degree nurse in charge teaching nurse 14 Nurse 3 Oral oncology ward female 34 university nurse practitioner nurse 8 Nurse 4 ICU female 37 master candidate nurse in charge chief nurse 14 Nurse 5 ICU female 38 university nurse practitioner nurse 15 Nurse 6 Surgical anesthesiology department female 32 university nurse practitioner nurse 8 Nurse 7 Surgical anesthesiology department female 34 university nurse practitioner nurse 9 Doctor 1 Oral oncology ward male 48 doctoral degree associate professor director 13 Doctor 2 ICU male 41 doctoral degree attending doctor doctor 14 Doctor 3 ICU male 56 doctoral degree associate professor deputy director 28 Doctor 4 Surgical anesthesiology department female 43 master's degree attending doctor doctor 14 Doctor 5 Surgical anesthesiology department female 36 master's degree attending doctor doctor 7 Note : *: years of work in the above clinical units; ICU: intensive care unit. 3.1 Theme one-institutional factors 3.1.1 Sub-theme-lack of a risk assessment system for airway obstruction Although patients with OMMs remain at risk for airway edema, bleeding, and airway obstruction post-surgery.However, there is no standardized risk assessment system for airway obstruction in clinical practice. " Although we can assess the postoperative risk for certain patients by examining the surgical site and the procedure performed, there are still limitations to our predictions.. The patient's condition changes too fast, there is a risk of bleeding at any time, coupled with postoperative edema, which increases the difficulty of judgment. We urgently need to improve the evaluation system " ( Doctor 3 ). It is difficult for HCPs to properly assess whether a patient has airway obstruction. In the absence of a risk assessment system for airway obstruction, HCPs rely primarily on clinical experience. " In cases where it is difficult to assess a patient, I use ultrasound to assist in assessment. However, not all clinical units have ultrasound equipment. At present, there is no requirement that patients with oral and maxillofacial malignancies should undergo an ultrasound scan before tracheal intubation removal. So, for the most part, I rely on experience " ( Doctor 4 ). They also noted that the current airway obstruction assessment scale is insufficient and suggested that developing a comprehensive airway obstruction assessment scale is essential for establishing a reliable airway obstruction risk assessment system. " At present, there are Morse Fall Scale, Pressure Ulcer Risk Assessment Scale, and so on. But the airway obstruction assessment scale was inadequate.. Having a systematic evaluation index, including an airway evaluation scale, can help us make an accurate judgment on the timing of extubation " ( Nurse 5 ). 3.1.2 Sub-theme-lack of a tracheal intubation emergency team In this study, the participants proposed that patients with OMMs have more abnormalities in airway anatomy than other patients, which increased the difficulty for doctors to deal with airway problems. " Most young doctors have little clinical experience. When they dealt with airway problems in patients with oral and maxillofacial malignancies, the airway could not be established. They tried to intubate twice before they called me for help. Due to the urgency of the situation, my only option was to perform an emergency tracheotomy to avoid the patient dying of acute asphyxia " ( Doctor 4 ). The HCPs expressed helplessness in dealing with the intubation and recommended the formation of an airway emergency team. "In an emergency situation, it is necessary to quickly judge the patient's situation and choose the appropriate intubation method, which is a great test for our psychological quality and intubation proficiency. Most patients after surgery have a visual field of blood or even blood clots for airway intubation, which makes me more panicked and helpless. I was desperate to have an emergency response team behind me so that I could take the plunge" ( Doctor 5 ). 3.1.3 Sub-theme-preparation for delayed extubation are inconsistent Patients with oral and maxillofacial malformations (OMMs) are at a higher risk of extubation failure due to alterations in the physiological structure of the maxillofacial airway. While guidelines for managing these patients exist, they have been developed in different ways and vary in quality, resulting in inconsistent implementation by healthcare doctors. " I've worked with a lot of doctors, and their protocols for intubation extraction are different. They rely on habit, and some doctors will do leak checks, perform pre-oxygenation, or prepare emergency airway management vehicles in advance. Some doctors just check for swelling and bleeding and pull out the tube " ( Nurse 2 ). 3.1.4 Sub-theme-inadequate reintubation training for airway obstruction Some nurses believed that inadequate training has resulted in HCPs not recognizing airway obstruction symptoms in a timely manner, which puts patients' lives at risk. " Lack of training may cause us not to recognize airway obstruction symptoms in a timely manner. When a patient develops complete airway obstruction, he may become unconscious within minutes due to lack of oxygen, and serious consequences may follow " ( Nurse 3 ). The training enhances the professional knowledge and operational proficiency of the HCPs. However, some doctors pointed out that current airway obstruction training is simple and lacks emergency drill training. " I have noticed that the most of the theoretical knowledge and practical training of HCPs is one-to-one. In my opinion, although this method is well targeted, it lacks emergency drills and cannot meet the real teaching needs " ( Doctor 2 ). Some doctors noted that inadequate reintubation training in airway obstruction also resulted from limited equipment and training sites. " Due to equipment and classroom limitations, airway obstruction reintubation training currently relies mainly on simulated-patient teaching and video laryngoscopy " ( Doctor 5 ). 3.2 Theme two-individual factors 3.2.1 Sub-theme-normativity of airway humidification Although there are clinical recommendations for airway humidification, including selection of humidifying devices and fluids, indications, contraindications, complications, evaluation, monitoring, and so on. In this study, part of the participants still conducted airway humidification based on personal habits rather than adhering to standardized protocols. This lack of normalization may impact the consistency and effectiveness of the interventions. " When I toured the wards, I noticed that some nurses always use drip humidification. When I asked the reason, the nurse replied that she heard the patient coughing and thought the sputum was thick and sticky. In order to reduce the number of sputum aspiration times, she chose the temporary infusion to increase the dose of humidifying fluid " ( Nurse 1 ). " For patients who require deep sputum aspiration, even if I have used a continuous humidifier, I am used to injecting a small amount of humidification solution before sputum aspiration. Because this can stimulate the patient to cough, and promote the patient's deep sputum cough out " ( Doctor 2 ). 3.2.2 Sub-theme-reserve of knowledge on the risk of airway obstruction Insufficient knowledge was observed among nurses, some of them were not familiar with the specific manifestations and emergency measures of airway obstruction. " I can't describe the specific manifestation of airway obstruction. In clinical work, if I feel that something is wrong with a patient, I inform the doctor immediately. I carry out whatever the doctor orders, such as emergency measures for airway obstruction " ( Nurse 6 ). Mixed knowledge was founded among doctors. In particular, they raised questions about postoperative airway obstruction in patients with OMMs. " As an intensive care physician, I have dealt with airway obstruction in many patients. However, I still can't accurately identify airway problems in patients with oral and maxillofacial malignancies, such as whether they are due to a true airway obstruction or an uncomfortable experience caused by a large flap " ( Doctor 3 ). 3.2.3 Sub-theme-attitude about learning about airway obstruction Lack of active attitude about learning about airway obstruction was an evident when a few participants reported that they found most HCPs learn knowledge only for exams. " I found that HCPs study for exams. They spend less time learning about airway obstruction and practicing it " ( Doctor 4 ). Also, the doctors and nurses showed no interest in learning new guidelines or documents, which reflected the attitude toward learning. " Chief Nurse will use the morning meeting to brief us on the new guidelines, and updated documents are available at nurses' stations and doctors' offices for everyone's reference. But I rarely see doctors or nurses actively discussing content and asking for documents " ( Nurse 6 ). 4. Discussions It is necessary to explore the factors that influence HCPs' management of the tracheal intubation in OMMs patients after surgery, so as to improve HCPs' clinical practice skills and help these patients survive ICU treatment. The insights provided in this study contribute to the existing literature on tracheal intubation management and ICU care after OMMs surgery. The results showed that HCPs were aware that extubation difficulties and inadequate risk assessment were associated with the lack of a risk assessment system for postoperative tracheal intubation extraction in OMMS patients. Our findings align with those of Patel et al. [ 21 ] ,indicating that conducting a thorough risk analysis of airway obstruction is challenging for HCPs. This process necessitates the integration of clinically objective data to inform decision-making, which, at present, often relies heavily on their clinical experience. Therefore, it is necessary to establish a risk assessment system for postoperative airway obstruction in OMMs patients to help HCPs make the right decisions. Recent computer technology has been introduced into airway analysis, for example to assess septal deviation [ 22 ] and airway resistance and respiratory distress in patients with laryngeal cancer [ 21 ] . Therefore, the postoperative airway risk assessment system for OMMs patients can be combined with computer technology. In clinical practice, as described by some participants, scales such as Morse Fall Scale (MFS) [ 23 ] , and Pressure Ulcer Risk Assessment Scale (PURAS) [ 24 ] were used to assess risk factors and develop interventions. So, a risk assessment scale for airway obstruction in patients with OMMs should be included into the risk assessment system. DE in ICU has been shown to be effective in managing postoperative airway problems and promoting recovery in OMMS patients [ 15 , 25 ] . In clinical practice, we follow the strategy of DE after overnight ventilation in ICU. Through interviews, we found that the majority of HCPs rely on experience or habit to perform DE. Inconsistent preparations for DE may result in extubation failure. Once extubation fails, the patient will have a second tracheal intubation or tracheotomy. It is well known that tracheotomy brings a significant negative impact on patients' lives, with complication rates as high as 45% [ 5 ] . Therefore, it is necessary to make a checklist of DE preparation for OMMS patients after surgery to standardize the preparation work of HCPs. This checklist includes the preparation of equipment, medications, personnel, and other relevant factors. Its contents will be tailored and refined based on future clinical practice summaries. In this study, the challenges faced by nurses and doctors in airway management after tracheal intubation removal is that they lack knowledge of the risk of airway obstruction and a positive attitude towards learning. This can be explained by the Knowledge-Attitude-Practice theoretical model, which holds that knowledge and attitude affect individual practical behavior [ 26 ] . A recent study showed that adequate knowledge and a positive attitude toward learning improved newly graduated dentists' awareness of oral cancer risk factors and diagnosis [ 27 ] . Building appropriated knowledge is of utmost importance for HCPs to effectively manage airways problems in patients with OMMs. Therefore, it is necessary to carry out regular training in OMMs and airway obstruction to improve the expertise of HCPs. Based on participants' description, we found that HCPs were less active in learning about airway obstruction. The learning attitude of HCPs may be related to the implementation of airway obstruction training. At present, the clinical culture mode mainly relies on one-to-one teaching, and the training methods of tracheal intubation include simulated-patient teaching and video laryngoscopy [ 28 ] . Traditional teaching methods lead to a lack of positive thinking among students and a weaker sense of participation throughout the rescue process. In order to meet the teaching needs and improve the independent thinking ability, clinical decision-making ability and emergency situation handling ability of HCPs, situational simulation teaching [ 29 ] can be used in the teaching and training of airway management. Considering the urgency of dealing with airway problems, clinical guidelines and experts recommendations suggested building the tracheal intubation emergency team [ 9 , 30 , 31 ] . We established an emergency team for tracheal intubation.However, the team did not apply to OMMs patients. The possible reason was that patients with OMMs might have abnormal airway anatomy, making them more prone to airway difficulties compared to the general population.Therefore, knowledge of airway management combined with specialized knowledge of OMMs should be included in the education and training of HCPs. The tracheal intubation emergency team can be optimized to better meet clinical needs. Limitations The study has some potential limitations. Firstly, the findings are qualitative data drawn from in-depth interviews with the clinical experience of HCPs at one hospital, which means they may not be more broadly representative. Secondly, participants in the clinical practice of management of postoperative tracheal intubation in OMMs patients may have been influenced by different educational backgrounds and position restrictions, although attempts were made to minimize this influencing in the interviews. 5. Conclusions In this qualitative semi-structured interview study with doctors and nurses, findings suggested that HCPs' management of postoperative tracheal intubation in OMMs patients can be improved from both institutional and individual factors. Establishing a risk assessment system for airway obstruction after OMMs and strengthening the training of airway obstruction knowledge can effectively guide the clinical practice of HCPs. In addition, HCPs should be guided to adopt a positive learning attitude. The insights gained from this study will inform clinical practice and training aimed at enhancing the quality of management of postoperative tracheal intubation management in patients with OMMs. Declarations Acknowledgements The authors would like to thank the staff at the Shanghai Ninth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine who facilitated this study and express gratitude to all the participants who participated in the study. Author contributions Zhixia Xu and Fen Gu designed the study. Material preparation and data collection were performed by Zhixia Xu, Qinhan Zou and Yuelai Yang. Analysis was performed by Zhixia Xu, Qinhan Zou, Yuelai Yang and Fen Gu. The first draft of the manuscript was written by Zhixia xu and Qinhan Zou, and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript. Funding The study was supported by Shanghai Shenkang Hospital Development Center project (SHDC2022CRS011B), 2023 Shanghai anti-Cancer Association Cancer Care Committee "Escort" program (SHHH-HL-202333) and Linkedin program of "Excellent Nursing Talents Program" of Shanghai Ninth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine (JYHR22-L01). Data availability The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions. Ethics approval The study was approved by the institutional review board at the Shanghai Ninth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine (No. SH9H-2024-TK530-1). Consent to participate Informed consent was obtained from all individual participants included in the study. Consent for publication All authors agreed to submit this version of paper for publication. Conflict of interests The authors declare no competing interests. References Miranda-Filho A, Bray F. Global patterns and trends in cancers of the lip, tongue and mouth[J]. Oral Oncol, 2020,102:104551. Ng J H, Iyer N G, Tan M H, et al. Changing epidemiology of oral squamous cell carcinoma of the tongue: A global study[J]. Head Neck, 2017,39(2):297–304. Montero P H, Patel S G. Cancer of the oral cavity[J]. Surg Oncol Clin N Am, 2015,24(3):491–508. Mouzat L. [Tracheal intubation][J]. Rev Infirm, 2007(127):19–20. Madgar O, Livneh N, Dobriyan A, et al. Airway management following head and neck microvascular reconstruction: is tracheostomy mandatory?[J]. Braz J Otorhinolaryngol, 2022,88 Suppl 4(Suppl 4):S44-S49. Mukherjee S, Jain A, S S, et al. Clinical outcome of perioperative airway and ventilatory management in patients undergoing surgery for oral cavity cancer: a prospective observational study[J]. J Korean Assoc Oral Maxillofac Surg, 2024,50(3):146–152. Huang S, Feng Y, Li S, et al. Application of delayed extubation for the free-flap reconstruction of oral and maxillofacial defects in patient with oral diseases[J]. J Stomatol Oral Maxillofac Surg, 2023,124(6S):101527. Myatra S N, Gupta S, D'Cruz A K, et al. Identification of patients for a delayed extubation strategy versus elective tracheostomy for postoperative airway management in major oral cancer surgery: A prospective observational study in seven hundred and twenty patients[J]. Oral Oncol, 2021,121:105502. Higgs A, McGrath B A, Goddard C, et al. Guidelines for the management of tracheal intubation in critically ill adults[J]. Br J Anaesth, 2018,120(2):323–352. Mussa C C, Gomaa D, Rowley D D, et al. AARC Clinical Practice Guideline: Management of Adult Patients with Tracheostomy in the Acute Care Setting[J]. Respir Care, 2021,66(1):156–169. Umobong E U, Mayo P H. Critical Care Airway Management[J]. Crit Care Clin, 2018,34(3):313–324. Nakarada-Kordic I, Patterson N, Wrapson J, et al. A Systematic Review of Patient and Caregiver Experiences with a Tracheostomy[J]. Patient, 2018,11(2):175–191. Cipriano A, Mao M L, Hon H H, et al. An overview of complications associated with open and percutaneous tracheostomy procedures[J]. Int J Crit Illn Inj Sci, 2015,5(3):179–188. Riekert M, Rempel V, Keilwerth S, et al. Airway-Associated Complications With and Without Primary Tracheotomy in Oral Squamous Cell Carcinoma Surgery[J]. J Craniofac Surg, 2023,34(1):279–283. Meerwein C, Pézier T F, Beck-Schimmer B, et al. Airway management in head and neck cancer patients undergoing microvascular free tissue transfer: delayed extubation as an alternative to routine tracheotomy[J]. Swiss Med Wkly, 2014,144:w13941. Sundler A J, Lindberg E, Nilsson C, et al. Qualitative thematic analysis based on descriptive phenomenology[J]. Nurs Open, 2019,6(3):733–739. Braun V, Clarke V. Toward good practice in thematic analysis: Avoiding common problems and be(com)ing a knowing researcher[J]. Int J Transgend Health, 2023,24(1):1–6. [The Helsinki Declaration of the World Medical Association (WMA). Ethical principles of medical research involving human subjects][J]. Pol Merkur Lekarski, 2014,36(215):298–301. Guba E G, Lincoln Y S. Epistemological And Methodological Bases Of Naturalistic Inquiry[J]. Ectj-Educational Communication And Technology Journal, 1982,30(4):233–252. Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups[J]. Int J Qual Health Care, 2007,19(6):349–357. Patel P N, Valmadrid A C, Hong D Y, et al. Immediate Use of Uncuffed Tracheostomy after Free Flap Reconstruction of the Head and Neck[J]. Otolaryngol Head Neck Surg, 2018,159(2):242–248. Casey K P, Borojeni A A, Koenig L J, et al. Correlation between Subjective Nasal Patency and Intranasal Airflow Distribution[J]. Otolaryngol Head Neck Surg, 2017,156(4):741–750. Morse J M, Black C, Oberle K, et al. A prospective study to identify the fall-prone patient[J]. Soc Sci Med, 1989,28(1):81–86. Jansen R, Silva K, Moura M. Braden Scale in pressure ulcer risk assessment[J]. Rev Bras Enferm, 2020,73(6):e20190413. Coyle M J, Tyrrell R, Godden A, et al. Replacing tracheostomy with overnight intubation to manage the airway in head and neck oncology patients: towards an improved recovery[J]. Br J Oral Maxillofac Surg, 2013,51(6):493–496. Wang Q, Wu Y, Wang D, et al. The impacts of knowledge and attitude on behavior of antibiotic use for the common cold among the public and identifying the critical behavioral stage: based on an expanding KAP model[J]. BMC Public Health, 2023,23(1):1683. Nazar H S, Ariga J, Shyama M. Oral Cancer Knowledge, Attitudes, and Practices among Newly Graduated Dentists in Kuwait[J]. Asian Pac J Cancer Prev, 2022,23(2):459–465. Sakles J C, Mosier J M, Chiu S, et al. Tracheal intubation in the emergency department: a comparison of GlideScope® video laryngoscopy to direct laryngoscopy in 822 intubations[J]. J Emerg Med, 2012,42(4):400–405. Wu J H, Lin P C, Lee K T, et al. Situational simulation teaching effectively improves dental students' non-operational clinical competency and objective structured clinical examination performance[J]. BMC Med Educ, 2024,24(1):533. Law J A, Duggan L V, Asselin M, et al. Canadian Airway Focus Group updated consensus-based recommendations for management of the difficult airway: part 2. Planning and implementing safe management of the patient with an anticipated difficult airway[J]. Can J Anaesth, 2021,68(9):1405–1436. Mosier J M, Sakles J C, Law J A, et al. Tracheal Intubation in the Critically Ill. Where We Came from and Where We Should Go[J]. Am J Respir Crit Care Med, 2020,201(7):775–788. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 07 Feb, 2025 Read the published version in Supportive Care in Cancer → Version 1 posted Editorial decision: Revision requested 21 Oct, 2024 Reviews received at journal 21 Oct, 2024 Reviewers agreed at journal 12 Oct, 2024 Reviews received at journal 10 Oct, 2024 Reviewers agreed at journal 24 Sep, 2024 Reviewers invited by journal 22 Sep, 2024 Editor assigned by journal 22 Sep, 2024 Submission checks completed at journal 13 Aug, 2024 First submitted to journal 11 Aug, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4897098","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":368711387,"identity":"9ef14786-d1dd-4c8c-9744-35998a3e88cb","order_by":0,"name":"Zhixia Xu","email":"","orcid":"","institution":"Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Zhixia","middleName":"","lastName":"Xu","suffix":""},{"id":368711388,"identity":"a5b251fe-3e36-4a19-ad97-b27cb246662a","order_by":1,"name":"Qinhan Zou","email":"","orcid":"","institution":"Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Qinhan","middleName":"","lastName":"Zou","suffix":""},{"id":368711393,"identity":"e2584ea1-782e-4a5d-bb39-a54b43a1d4e9","order_by":2,"name":"Yuelai Yang","email":"","orcid":"","institution":"Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Yuelai","middleName":"","lastName":"Yang","suffix":""},{"id":368711395,"identity":"a752b268-db22-44e8-b8cd-86011e6e4033","order_by":3,"name":"Fen Gu","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAyklEQVRIiWNgGAWjYFACxgcMDBU29f3MzIcfEKmF2YCB4Uwa48x2tjQD4rUwth1m3HCeR0GCKA3yEcmMjwvbmJmND/MwGDDU2EQT1GJ4I5nZeMY5Njazw7wHHjAcS8ttIKhlRv4xaZ4yHh6zw3wJBowNh4nRksz+m4dNQsK4mcdAgigt8hLJbMw8bQYGBszEajHgecwszXMmIUHiMDCQE4jxi3x7MuNnnor/Cfz9hw8/+FBjQ4QtB5B5CYSUg20haOgoGAWjYBSMAgDz1zojGWuApQAAAABJRU5ErkJggg==","orcid":"","institution":"Huadong Hospital affiliated to Fudan University","correspondingAuthor":true,"prefix":"","firstName":"Fen","middleName":"","lastName":"Gu","suffix":""}],"badges":[],"createdAt":"2024-08-12 02:36:11","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4897098/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4897098/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s00520-025-09224-z","type":"published","date":"2025-02-07T15:58:21+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":68653805,"identity":"e7e61b7f-eb2c-487d-a71f-1bf8bab48039","added_by":"auto","created_at":"2024-11-10 13:47:00","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":37251,"visible":true,"origin":"","legend":"\u003cp\u003eThemes and sub-themes\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-4897098/v1/e74e3608d8adaea0f6238f4d.png"},{"id":75930552,"identity":"33aa89de-be68-4380-9654-f385d0dabad6","added_by":"auto","created_at":"2025-02-10 16:13:08","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":972246,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4897098/v1/e0f055e2-eace-4c79-82e1-649720f73aa1.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Factors influencing health professionals' management of tracheal intubation in oral and maxillofacial malignancies patients after surgery: A qualitative study","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eOral and maxillofacial malignancies (OMMs) refers to cancers of the lip, cheek, tongue, gingiva, floor of the mouth, hard palate and other unspecified parts of the oral cavity, with the overall incidence rates up to 21.2%\u003csup\u003e[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]\u003c/sup\u003e. With a 5-year survival rate of less than 60% and poor prognosis, OMMs has become a public health disease of global concern\u003csup\u003e[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]\u003c/sup\u003e. Currently, surgery is the main treatment for OMMs\u003csup\u003e[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/sup\u003e, including primary lesion excision and flap repair. Postoperative patients with OMMs are usually transferred to the ICU with the tacheal intubation for follow-up treatment.\u003c/p\u003e \u003cp\u003eTracheal intubation is the insertion of a catheter through the nose or mouth into the trachea to help the patient breathe effectively\u003csup\u003e[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/sup\u003e. Due to the large flap, airway edema or hematoma, tracheal intubation is an important means to help patients with OMMs reconstruct airway and ventilate\u003csup\u003e[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]\u003c/sup\u003e. And delayed extubation (DE) after overnight ventilation in ICU can follow time to reduce or subside airway edema, prevent immediate postoperative complications from damaging the airway and prevent potential complications from occurring\u003csup\u003e[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/sup\u003e. Patients with oral and maxillofacial malignancies (OMMs) frequently present with altered airway anatomy prior to surgery. As a result, managing the airway after intubation and extubation can be particularly challenging due to surgical resections and the transplantation of flaps into the oral cavity.\u003csup\u003e[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eCurrently, guidelines, training programs, and interventions have been developed to help HCPs manage tracheal intubation\u003csup\u003e[\u003cspan additionalcitationids=\"CR10\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]\u003c/sup\u003e, such as airway assessment, airway profiling, intubation team building, equipment training and bedside simulation. However, bleeding, obstruction of tracheal intubation, and failure of tracheal intubation extubation are more common in patients with OMMs, which increases the length of hospital stay and negatively affects the quality of life of these patients\u003csup\u003e[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]\u003c/sup\u003e. Previous studies have shown that post-intubation management and routine ICU extubation management can effectively prevent the occurrence of airway obstruction and reduce the rate of tracheotomy\u003csup\u003e[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]\u003c/sup\u003e. Therefore, understanding HCPs experiences with clinical practice of tracheal intubation and extubation in patients with OMMs after surgery during the ICU period is critical for practice implementation and improvement.\u003c/p\u003e \u003cp\u003eThis study designed to purposefully sample with HCPs including doctors and nurses in ICU, oral oncology and the surgical anesthesiology department. Semi-structured interviews were conducted to gain insight into healthcare professionals' clinical experiences with airway management in the ICU. The aim was to explore the factors that hinder their ability to manage tracheal intubation and extubation in postoperative patients with with OMMs.\u003c/p\u003e"},{"header":"2. Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1 Study design\u003c/h2\u003e \u003cp\u003ePhenomenological methods were used to conduct this qualitative study. Individualized semi-structured interviews were used to explore the factors influencing improper management of the tracheal intubation by HCPs in OMMs patients after surgery during the ICU period in a tertiary hospital in Shanghai, China. Descriptive phenomenology provided a detailed description of the clinical practice experiences of HCPs in tracheal intubation and extubation management and their understanding of these experiences\u003csup\u003e[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2 Participants and recruitment\u003c/h2\u003e \u003cp\u003e Participants in this study included doctors and nurses, from three clinical units at a tertiary hospital in Shanghai, China, between February and May 2024. The eligibility criteria for participation consisted of participants who: (1) have engaged in oral cancer patients treatment or nursing care more than seven years; (2) volunteer to participate in this study; and (3) have good verbal communication skills. We used a snowball sampling technique to recruit participants, with initial participants recommending other doctors or nurses with extensive experience in oral cancer care or airway management. The potential participants were contacted via email. All participants had clinical experience, expressed confidence in the integrity of the study, and provided informed consent.Data collection ceased once the interview information was saturated with no new topics emerged. Twelve HCPs were eventually interviewed, with no dropouts during the study. In addition, the researcher had no prior direct working relationship with the participants. This absence of pre-existing professional connections ensured that interactions during the interviews remained fair and focused solely on research purpose.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e2.3 Data collection\u003c/h2\u003e \u003cp\u003eInterviews were audio recorded, and field notes were kept and incorporated in the analysis process. To maximum the sample variation, participants with different position, professional qualifications, and education were accessed. The interviews were conducted in the hospital' meeting room to ensure a relaxing environment. We collected data through face-to-face in-depth, semi-structured interviews, each lasting 30 to 40 minutes. During the interviews, the focus was controlling the topic of the interviews, avoiding deviation from the purpose of the study, and adjusting the interview time appropriately according to the actual situation of the interviews. The interview outlines designed based on literature reviews, the researcher's clinical experience and expert consultation, tested and revised in pilot interviews with three participants (shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). To ensure accuracy, transcripts were confirmed with participants at the end of the interviews. In appreciation of their valuable time and effort, each participant received a hand cream.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eInterview outlines\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo.\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eQuestions\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWhat do you think is the importance of tracheal intubation in patients with oral and maxillofacial malignancies during ICU after surgery? Can you tell me more about it?\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWhat shortcomings do you think exist in tracheal intubation management of patients with oral and maxillofacial malignancies during the ICU treatment period? Can you give me some detailed examples?\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWhat difficulties have you encountered in the clinical practice of tracheal intubation management? Can you elaborate on that?\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIn your opinion, what should be done to improve the management of tracheal intubation in patients with oral and maxillofacial malignancies in ICU? Do you have any good suggestions? Can you elaborate on that?\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003ePrior to the study, all researches have experience in qualitative research and were trained in qualitative research methodology. The interviews were conducted by the major researcher (ZX-X), a female nurse with an extensive background in the field. Her experience included thirteen years in the ICU and another eight years as an ICU clinical nurse specialist, alongside participation in the American Heart Association Basic Life Support Instructor Training teaching. At the same time, she further developed her expertise, especially qualitative research methods, through a master studying programme in Nursing.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e2.4 Data Analysis\u003c/h2\u003e \u003cp\u003e Interviews were transcribed within 24 hours, analyzed using NVivo 12.0 software, and non-verbal behaviors were combined with written transcriptions. Two researchers independently conducted a comprehensive thematic analysis using the six steps of Braun and Clarke's reflective thematic analysis\u003csup\u003e[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]\u003c/sup\u003e, as detailed in the Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. Through thematic analysis, which involves systematically identifying, analyzing, and interpreting patterns or themes in the data, we can gain a comprehensive understanding of the current inadequacy of tracheal intubation management by HCPs in patients with oral cancer after surgery. In oder to improve the reliability of the data coding and reduce potential biases in the interpretation of the data, the findings will be discussed with the research team.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003esix steps of Braun and Clarke's reflective thematic analysis\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo.\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSteps\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAfter the data collection phase, we read and re-read transcripts of interviews with HCPs to familiarize ourselves with the data.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInitial codes were then generated, which involved labeling and categorizing data related the clinical practice of HCPs in tracheal intubation management during ICU treatment after oral cancer surgery.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTheses codes were organized into potential themes, which captured meaningful patterns or recurring topics in the data.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eResearchers review and refine themes by collating relevant codes, comparing and considering their consistency and relevance to research questions.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTo ensure that themes accurately represented the data and reflected HCPs' clinical practice experiences, we also conducted multiple iterations of the analysis.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThe final step involved defining and naming the themes and creating a coherent and comprehensive framework to understand the HCPs' clinical practice experience.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003e2.5 Ethical considerations\u003c/h2\u003e \u003cp\u003eThis study meet the requirements of Helsinki Declaration\u003csup\u003e[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]\u003c/sup\u003e. Data collection and qualitative interviews were approved by the hospital ethics committee (No. **). Before the study, participants were fully informed of the study's purpose, methodology, benefits, and risks. Written informed consent was obtained prior to conducting the interviews. To protect privacy, their names have been replaced by numbers. Participants had the right to withdraw from the study at any time.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003e2.6 Rigor\u003c/h2\u003e \u003cp\u003eFour criteria were used to ensure the rigor of the research\u003csup\u003e[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]\u003c/sup\u003e: credibility, dependability, confirmability and transferability. To enhance the credibility of the data, 'researcher triangulation' was incorporated into the analytical strategy to reduce the potential pitfalls of a single analytical perspective. Dependability was ensured by providing independently checked data to two external researchers with qualitative experience. Confirmability was ensured by using audit tests to verify whether the authors are biased against the findings. Transferability was ensured by the researchers' clarity on the research background, purpose, methods and analytical processes, as well as participants' information. The study followed the Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines\u003csup\u003e[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003c/div\u003e"},{"header":"3. Results","content":"\u003cp\u003eTwelve participants were interviewed, and their basic characteristics are shown in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. Participants were aged between 32 and 56 years (average years 39.9 years). Seven identifed as nurses and five as doctors. They came from three clinical units, three of whom worked in oral oncology, five in ICU and four in surgical anesthesiology department. Their total clinical experience varied from 7 to 28 years, averaging 13.3 years. The identified themes and sub-themes are shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e and detailed below: (1) institutional factors: lack of a risk assessment system for airway obstruction; insufficient personnel in tracheal intubation emergency team; preparation for delayed extubation are inconsistent; and inadequate reintubation training for airway obstruction; and (2) individual factors: normativity of airway humidification; reserve of knowledge on the risk of airway obstruction;and attitude about learning about airway obstruction.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCharacteristics of twelve participants\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParticipants\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eClinical\u003c/p\u003e \u003cp\u003eunits\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003cp\u003e(years)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eEducation\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eProfessional\u003c/p\u003e \u003cp\u003equalifications\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003ePosition\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eSeniority\u003c/p\u003e \u003cp\u003e(years)*\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNurse 1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOral oncology ward\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003efemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003euniversity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003enurse in charge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003echief nurse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNurse 2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eICU\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003efemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003emaster's degree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003enurse in charge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eteaching nurse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNurse 3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOral oncology ward\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003efemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003euniversity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003enurse practitioner\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003enurse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNurse 4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eICU\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003efemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003emaster candidate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003enurse in charge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003echief nurse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNurse 5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eICU\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003efemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003euniversity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003enurse practitioner\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003enurse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNurse 6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSurgical anesthesiology department\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003efemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003euniversity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003enurse practitioner\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003enurse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNurse 7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSurgical anesthesiology department\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003efemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003euniversity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003enurse practitioner\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003enurse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDoctor 1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOral oncology ward\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003emale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003edoctoral degree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eassociate professor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003edirector\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDoctor 2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eICU\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003emale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003edoctoral degree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eattending doctor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003edoctor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDoctor 3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eICU\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003emale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003edoctoral degree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eassociate professor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003edeputy director\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDoctor 4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSurgical anesthesiology department\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003efemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003emaster's degree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eattending doctor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003edoctor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDoctor 5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSurgical anesthesiology department\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003efemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003emaster's degree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eattending doctor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003edoctor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"8\"\u003e\u003cb\u003eNote\u003c/b\u003e: *: years of work in the above clinical units; ICU: intensive care unit.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003e3.1 Theme one-institutional factors\u003c/h2\u003e \u003cdiv id=\"Sec11\" class=\"Section3\"\u003e \u003ch2\u003e3.1.1 Sub-theme-lack of a risk assessment system for airway obstruction\u003c/h2\u003e \u003cp\u003eAlthough patients with OMMs remain at risk for airway edema, bleeding, and airway obstruction post-surgery.However, there is no standardized risk assessment system for airway obstruction in clinical practice.\u003c/p\u003e \u003cp\u003e\" \u003cem\u003eAlthough we can assess the postoperative risk for certain patients by examining the surgical site and the procedure performed, there are still limitations to our predictions.. The patient's condition changes too fast, there is a risk of bleeding at any time, coupled with postoperative edema, which increases the difficulty of judgment. We urgently need to improve the evaluation system\u003c/em\u003e\" (\u003cb\u003eDoctor 3\u003c/b\u003e).\u003c/p\u003e \u003cp\u003eIt is difficult for HCPs to properly assess whether a patient has airway obstruction. In the absence of a risk assessment system for airway obstruction, HCPs rely primarily on clinical experience.\u003c/p\u003e \u003cp\u003e\"\u003cem\u003eIn cases where it is difficult to assess a patient, I use ultrasound to assist in assessment. However, not all clinical units have ultrasound equipment. At present, there is no requirement that patients with oral and maxillofacial malignancies should undergo an ultrasound scan before tracheal intubation removal. So, for the most part, I rely on experience\u003c/em\u003e\" (\u003cb\u003eDoctor 4\u003c/b\u003e).\u003c/p\u003e \u003cp\u003eThey also noted that the current airway obstruction assessment scale is insufficient and suggested that developing a comprehensive airway obstruction assessment scale is essential for establishing a reliable airway obstruction risk assessment system.\u003c/p\u003e \u003cp\u003e\"\u003cem\u003eAt present, there are Morse Fall Scale, Pressure Ulcer Risk Assessment Scale, and so on. But the airway obstruction assessment scale was inadequate.. Having a systematic evaluation index, including an airway evaluation scale, can help us make an accurate judgment on the timing of extubation\u003c/em\u003e\" (\u003cb\u003eNurse 5\u003c/b\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section3\"\u003e \u003ch2\u003e3.1.2 Sub-theme-lack of a tracheal intubation emergency team\u003c/h2\u003e \u003cp\u003eIn this study, the participants proposed that patients with OMMs have more abnormalities in airway anatomy than other patients, which increased the difficulty for doctors to deal with airway problems.\u003c/p\u003e \u003cp\u003e\"\u003cem\u003eMost young doctors have little clinical experience. When they dealt with airway problems in patients with oral and maxillofacial malignancies, the airway could not be established. They tried to intubate twice before they called me for help. Due to the urgency of the situation, my only option was to perform an emergency tracheotomy to avoid the patient dying of acute asphyxia\u003c/em\u003e\" (\u003cb\u003eDoctor 4\u003c/b\u003e).\u003c/p\u003e \u003cp\u003eThe HCPs expressed helplessness in dealing with the intubation and recommended the formation of an airway emergency team.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"In an emergency situation, it is necessary to quickly judge the patient's situation and choose the appropriate intubation method, which is a great test for our psychological quality and intubation proficiency. Most patients after surgery have a visual field of blood or even blood clots for airway intubation, which makes me more panicked and helpless. I was desperate to have an emergency response team behind me so that I could take the plunge\"\u003c/em\u003e (\u003cb\u003eDoctor 5\u003c/b\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section3\"\u003e \u003ch2\u003e3.1.3 Sub-theme-preparation for delayed extubation are inconsistent\u003c/h2\u003e \u003cp\u003ePatients with oral and maxillofacial malformations (OMMs) are at a higher risk of extubation failure due to alterations in the physiological structure of the maxillofacial airway. While guidelines for managing these patients exist, they have been developed in different ways and vary in quality, resulting in inconsistent implementation by healthcare doctors.\u003c/p\u003e \u003cp\u003e\"\u003cem\u003eI've worked with a lot of doctors, and their protocols for intubation extraction are different. They rely on habit, and some doctors will do leak checks, perform pre-oxygenation, or prepare emergency airway management vehicles in advance. Some doctors just check for swelling and bleeding and pull out the tube\u003c/em\u003e\" (\u003cb\u003eNurse 2\u003c/b\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section3\"\u003e \u003ch2\u003e3.1.4 Sub-theme-inadequate reintubation training for airway obstruction\u003c/h2\u003e \u003cp\u003eSome nurses believed that inadequate training has resulted in HCPs not recognizing airway obstruction symptoms in a timely manner, which puts patients' lives at risk.\u003c/p\u003e \u003cp\u003e\"\u003cem\u003eLack of training may cause us not to recognize airway obstruction symptoms in a timely manner. When a patient develops complete airway obstruction, he may become unconscious within minutes due to lack of oxygen, and serious consequences may follow\u003c/em\u003e\" (\u003cb\u003eNurse 3\u003c/b\u003e).\u003c/p\u003e \u003cp\u003eThe training enhances the professional knowledge and operational proficiency of the HCPs. However, some doctors pointed out that current airway obstruction training is simple and lacks emergency drill training.\u003c/p\u003e \u003cp\u003e\"\u003cem\u003eI have noticed that the most of the theoretical knowledge and practical training of HCPs is one-to-one. In my opinion, although this method is well targeted, it lacks emergency drills and cannot meet the real teaching needs\u003c/em\u003e\" (\u003cb\u003eDoctor 2\u003c/b\u003e).\u003c/p\u003e \u003cp\u003eSome doctors noted that inadequate reintubation training in airway obstruction also resulted from limited equipment and training sites.\u003c/p\u003e \u003cp\u003e\"\u003cem\u003eDue to equipment and classroom limitations, airway obstruction reintubation training currently relies mainly on simulated-patient teaching and video laryngoscopy\u003c/em\u003e\" (\u003cb\u003eDoctor 5\u003c/b\u003e).\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003e3.2 Theme two-individual factors\u003c/h2\u003e \u003cdiv id=\"Sec16\" class=\"Section3\"\u003e \u003ch2\u003e3.2.1 Sub-theme-normativity of airway humidification\u003c/h2\u003e \u003cp\u003eAlthough there are clinical recommendations for airway humidification, including selection of humidifying devices and fluids, indications, contraindications, complications, evaluation, monitoring, and so on. In this study, part of the participants still conducted airway humidification based on personal habits rather than adhering to standardized protocols. This lack of normalization may impact the consistency and effectiveness of the interventions.\u003c/p\u003e \u003cp\u003e\"\u003cem\u003eWhen I toured the wards, I noticed that some nurses always use drip humidification. When I asked the reason, the nurse replied that she heard the patient coughing and thought the sputum was thick and sticky. In order to reduce the number of sputum aspiration times, she chose the temporary infusion to increase the dose of humidifying fluid\u003c/em\u003e \" (\u003cb\u003eNurse 1\u003c/b\u003e).\u003c/p\u003e \u003cp\u003e\"\u003cem\u003eFor patients who require deep sputum aspiration, even if I have used a continuous humidifier, I am used to injecting a small amount of humidification solution before sputum aspiration. Because this can stimulate the patient to cough, and promote the patient's deep sputum cough out\u003c/em\u003e\" (\u003cb\u003eDoctor 2\u003c/b\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section3\"\u003e \u003ch2\u003e3.2.2 Sub-theme-reserve of knowledge on the risk of airway obstruction\u003c/h2\u003e \u003cp\u003eInsufficient knowledge was observed among nurses, some of them were not familiar with the specific manifestations and emergency measures of airway obstruction.\u003c/p\u003e \u003cp\u003e\"\u003cem\u003eI can't describe the specific manifestation of airway obstruction. In clinical work, if I feel that something is wrong with a patient, I inform the doctor immediately. I carry out whatever the doctor orders, such as emergency measures for airway obstruction\u003c/em\u003e\" (\u003cb\u003eNurse 6\u003c/b\u003e).\u003c/p\u003e \u003cp\u003eMixed knowledge was founded among doctors. In particular, they raised questions about postoperative airway obstruction in patients with OMMs.\u003c/p\u003e \u003cp\u003e\"\u003cem\u003eAs an intensive care physician, I have dealt with airway obstruction in many patients. However, I still can't accurately identify airway problems in patients with oral and maxillofacial malignancies, such as whether they are due to a true airway obstruction or an uncomfortable experience caused by a large flap\u003c/em\u003e\" (\u003cb\u003eDoctor 3\u003c/b\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section3\"\u003e \u003ch2\u003e3.2.3 Sub-theme-attitude about learning about airway obstruction\u003c/h2\u003e \u003cp\u003eLack of active attitude about learning about airway obstruction was an evident when a few participants reported that they found most HCPs learn knowledge only for exams.\u003c/p\u003e \u003cp\u003e\"\u003cem\u003eI found that HCPs study for exams. They spend less time learning about airway obstruction and practicing it\u003c/em\u003e\" (\u003cb\u003eDoctor 4\u003c/b\u003e).\u003c/p\u003e \u003cp\u003e Also, the doctors and nurses showed no interest in learning new guidelines or documents, which reflected the attitude toward learning.\u003c/p\u003e \u003cp\u003e\"\u003cem\u003eChief Nurse will use the morning meeting to brief us on the new guidelines, and updated documents are available at nurses' stations and doctors' offices for everyone's reference. But I rarely see doctors or nurses actively discussing content and asking for documents\u003c/em\u003e\" (\u003cb\u003eNurse 6\u003c/b\u003e).\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"4. Discussions","content":"\u003cp\u003eIt is necessary to explore the factors that influence HCPs' management of the tracheal intubation in OMMs patients after surgery, so as to improve HCPs' clinical practice skills and help these patients survive ICU treatment. The insights provided in this study contribute to the existing literature on tracheal intubation management and ICU care after OMMs surgery.\u003c/p\u003e \u003cp\u003eThe results showed that HCPs were aware that extubation difficulties and inadequate risk assessment were associated with the lack of a risk assessment system for postoperative tracheal intubation extraction in OMMS patients. Our findings align with those of Patel et al. \u003csup\u003e[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]\u003c/sup\u003e ,indicating that conducting a thorough risk analysis of airway obstruction is challenging for HCPs. This process necessitates the integration of clinically objective data to inform decision-making, which, at present, often relies heavily on their clinical experience. Therefore, it is necessary to establish a risk assessment system for postoperative airway obstruction in OMMs patients to help HCPs make the right decisions. Recent computer technology has been introduced into airway analysis, for example to assess septal deviation\u003csup\u003e[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]\u003c/sup\u003e and airway resistance and respiratory distress in patients with laryngeal cancer\u003csup\u003e[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]\u003c/sup\u003e. Therefore, the postoperative airway risk assessment system for OMMs patients can be combined with computer technology. In clinical practice, as described by some participants, scales such as Morse Fall Scale (MFS)\u003csup\u003e[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]\u003c/sup\u003e, and Pressure Ulcer Risk Assessment Scale (PURAS)\u003csup\u003e[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]\u003c/sup\u003e were used to assess risk factors and develop interventions. So, a risk assessment scale for airway obstruction in patients with OMMs should be included into the risk assessment system.\u003c/p\u003e \u003cp\u003eDE in ICU has been shown to be effective in managing postoperative airway problems and promoting recovery in OMMS patients\u003csup\u003e[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]\u003c/sup\u003e. In clinical practice, we follow the strategy of DE after overnight ventilation in ICU. Through interviews, we found that the majority of HCPs rely on experience or habit to perform DE. Inconsistent preparations for DE may result in extubation failure. Once extubation fails, the patient will have a second tracheal intubation or tracheotomy. It is well known that tracheotomy brings a significant negative impact on patients' lives, with complication rates as high as 45%\u003csup\u003e[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]\u003c/sup\u003e. Therefore, it is necessary to make a checklist of DE preparation for OMMS patients after surgery to standardize the preparation work of HCPs. This checklist includes the preparation of equipment, medications, personnel, and other relevant factors. Its contents will be tailored and refined based on future clinical practice summaries.\u003c/p\u003e \u003cp\u003eIn this study, the challenges faced by nurses and doctors in airway management after tracheal intubation removal is that they lack knowledge of the risk of airway obstruction and a positive attitude towards learning. This can be explained by the Knowledge-Attitude-Practice theoretical model, which holds that knowledge and attitude affect individual practical behavior\u003csup\u003e[\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]\u003c/sup\u003e. A recent study showed that adequate knowledge and a positive attitude toward learning improved newly graduated dentists' awareness of oral cancer risk factors and diagnosis\u003csup\u003e[\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]\u003c/sup\u003e. Building appropriated knowledge is of utmost importance for HCPs to effectively manage airways problems in patients with OMMs. Therefore, it is necessary to carry out regular training in OMMs and airway obstruction to improve the expertise of HCPs. Based on participants' description, we found that HCPs were less active in learning about airway obstruction. The learning attitude of HCPs may be related to the implementation of airway obstruction training. At present, the clinical culture mode mainly relies on one-to-one teaching, and the training methods of tracheal intubation include simulated-patient teaching and video laryngoscopy\u003csup\u003e[\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]\u003c/sup\u003e. Traditional teaching methods lead to a lack of positive thinking among students and a weaker sense of participation throughout the rescue process. In order to meet the teaching needs and improve the independent thinking ability, clinical decision-making ability and emergency situation handling ability of HCPs, situational simulation teaching\u003csup\u003e[\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]\u003c/sup\u003e can be used in the teaching and training of airway management.\u003c/p\u003e \u003cp\u003eConsidering the urgency of dealing with airway problems, clinical guidelines and experts recommendations suggested building the tracheal intubation emergency team\u003csup\u003e[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]\u003c/sup\u003e. We established an emergency team for tracheal intubation.However, the team did not apply to OMMs patients. The possible reason was that patients with OMMs might have abnormal airway anatomy, making them more prone to airway difficulties compared to the general population.Therefore, knowledge of airway management combined with specialized knowledge of OMMs should be included in the education and training of HCPs. The tracheal intubation emergency team can be optimized to better meet clinical needs.\u003c/p\u003e \u003cp\u003e \u003cb\u003eLimitations\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThe study has some potential limitations. Firstly, the findings are qualitative data drawn from in-depth interviews with the clinical experience of HCPs at one hospital, which means they may not be more broadly representative. Secondly, participants in the clinical practice of management of postoperative tracheal intubation in OMMs patients may have been influenced by different educational backgrounds and position restrictions, although attempts were made to minimize this influencing in the interviews.\u003c/p\u003e"},{"header":"5. Conclusions","content":"\u003cp\u003eIn this qualitative semi-structured interview study with doctors and nurses, findings suggested that HCPs' management of postoperative tracheal intubation in OMMs patients can be improved from both institutional and individual factors. Establishing a risk assessment system for airway obstruction after OMMs and strengthening the training of airway obstruction knowledge can effectively guide the clinical practice of HCPs. In addition, HCPs should be guided to adopt a positive learning attitude. The insights gained from this study will inform clinical practice and training aimed at enhancing the quality of management of postoperative tracheal intubation management in patients with OMMs.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors would like to thank the staff at the Shanghai Ninth People\u0026apos;s Hospital Affiliated to Shanghai Jiao Tong University School of Medicine who facilitated this study and express gratitude to all the participants who participated in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eZhixia Xu and Fen Gu designed the study. Material preparation and data collection were performed by Zhixia Xu, Qinhan Zou and Yuelai Yang. Analysis was performed by Zhixia Xu, Qinhan Zou, Yuelai Yang and Fen Gu. The first draft of the manuscript was written by Zhixia xu and Qinhan Zou, and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was supported by Shanghai Shenkang Hospital Development Center project (SHDC2022CRS011B), 2023 Shanghai anti-Cancer Association Cancer Care Committee \u0026quot;Escort\u0026quot; program (SHHH-HL-202333) and Linkedin program of \u0026quot;Excellent Nursing Talents Program\u0026quot; of Shanghai Ninth People\u0026apos;s Hospital Affiliated to Shanghai Jiao Tong University School of Medicine (JYHR22-L01).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was approved by the institutional review board at the Shanghai Ninth People\u0026apos;s Hospital Affiliated to Shanghai Jiao Tong University School of Medicine (No. SH9H-2024-TK530-1).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInformed consent was obtained from all individual participants included in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors agreed to submit this version of paper for publication.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eMiranda-Filho A, Bray F. Global patterns and trends in cancers of the lip, tongue and mouth[J]. Oral Oncol, 2020,102:104551.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNg J H, Iyer N G, Tan M H, et al. Changing epidemiology of oral squamous cell carcinoma of the tongue: A global study[J]. Head Neck, 2017,39(2):297\u0026ndash;304.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMontero P H, Patel S G. Cancer of the oral cavity[J]. Surg Oncol Clin N Am, 2015,24(3):491\u0026ndash;508.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMouzat L. [Tracheal intubation][J]. Rev Infirm, 2007(127):19\u0026ndash;20.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMadgar O, Livneh N, Dobriyan A, et al. Airway management following head and neck microvascular reconstruction: is tracheostomy mandatory?[J]. Braz J Otorhinolaryngol, 2022,88 Suppl 4(Suppl 4):S44-S49.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMukherjee S, Jain A, S S, et al. Clinical outcome of perioperative airway and ventilatory management in patients undergoing surgery for oral cavity cancer: a prospective observational study[J]. J Korean Assoc Oral Maxillofac Surg, 2024,50(3):146\u0026ndash;152.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHuang S, Feng Y, Li S, et al. Application of delayed extubation for the free-flap reconstruction of oral and maxillofacial defects in patient with oral diseases[J]. J Stomatol Oral Maxillofac Surg, 2023,124(6S):101527.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMyatra S N, Gupta S, D'Cruz A K, et al. Identification of patients for a delayed extubation strategy versus elective tracheostomy for postoperative airway management in major oral cancer surgery: A prospective observational study in seven hundred and twenty patients[J]. Oral Oncol, 2021,121:105502.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHiggs A, McGrath B A, Goddard C, et al. Guidelines for the management of tracheal intubation in critically ill adults[J]. Br J Anaesth, 2018,120(2):323\u0026ndash;352.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMussa C C, Gomaa D, Rowley D D, et al. AARC Clinical Practice Guideline: Management of Adult Patients with Tracheostomy in the Acute Care Setting[J]. Respir Care, 2021,66(1):156\u0026ndash;169.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eUmobong E U, Mayo P H. Critical Care Airway Management[J]. Crit Care Clin, 2018,34(3):313\u0026ndash;324.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNakarada-Kordic I, Patterson N, Wrapson J, et al. A Systematic Review of Patient and Caregiver Experiences with a Tracheostomy[J]. Patient, 2018,11(2):175\u0026ndash;191.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCipriano A, Mao M L, Hon H H, et al. An overview of complications associated with open and percutaneous tracheostomy procedures[J]. Int J Crit Illn Inj Sci, 2015,5(3):179\u0026ndash;188.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRiekert M, Rempel V, Keilwerth S, et al. Airway-Associated Complications With and Without Primary Tracheotomy in Oral Squamous Cell Carcinoma Surgery[J]. J Craniofac Surg, 2023,34(1):279\u0026ndash;283.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMeerwein C, P\u0026eacute;zier T F, Beck-Schimmer B, et al. Airway management in head and neck cancer patients undergoing microvascular free tissue transfer: delayed extubation as an alternative to routine tracheotomy[J]. Swiss Med Wkly, 2014,144:w13941.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSundler A J, Lindberg E, Nilsson C, et al. Qualitative thematic analysis based on descriptive phenomenology[J]. Nurs Open, 2019,6(3):733\u0026ndash;739.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBraun V, Clarke V. Toward good practice in thematic analysis: Avoiding common problems and be(com)ing a knowing researcher[J]. Int J Transgend Health, 2023,24(1):1\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e[The Helsinki Declaration of the World Medical Association (WMA). Ethical principles of medical research involving human subjects][J]. Pol Merkur Lekarski, 2014,36(215):298\u0026ndash;301.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGuba E G, Lincoln Y S. Epistemological And Methodological Bases Of Naturalistic Inquiry[J]. Ectj-Educational Communication And Technology Journal, 1982,30(4):233\u0026ndash;252.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups[J]. Int J Qual Health Care, 2007,19(6):349\u0026ndash;357.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePatel P N, Valmadrid A C, Hong D Y, et al. Immediate Use of Uncuffed Tracheostomy after Free Flap Reconstruction of the Head and Neck[J]. Otolaryngol Head Neck Surg, 2018,159(2):242\u0026ndash;248.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCasey K P, Borojeni A A, Koenig L J, et al. Correlation between Subjective Nasal Patency and Intranasal Airflow Distribution[J]. Otolaryngol Head Neck Surg, 2017,156(4):741\u0026ndash;750.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMorse J M, Black C, Oberle K, et al. A prospective study to identify the fall-prone patient[J]. Soc Sci Med, 1989,28(1):81\u0026ndash;86.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJansen R, Silva K, Moura M. Braden Scale in pressure ulcer risk assessment[J]. Rev Bras Enferm, 2020,73(6):e20190413.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCoyle M J, Tyrrell R, Godden A, et al. Replacing tracheostomy with overnight intubation to manage the airway in head and neck oncology patients: towards an improved recovery[J]. Br J Oral Maxillofac Surg, 2013,51(6):493\u0026ndash;496.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWang Q, Wu Y, Wang D, et al. The impacts of knowledge and attitude on behavior of antibiotic use for the common cold among the public and identifying the critical behavioral stage: based on an expanding KAP model[J]. BMC Public Health, 2023,23(1):1683.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNazar H S, Ariga J, Shyama M. Oral Cancer Knowledge, Attitudes, and Practices among Newly Graduated Dentists in Kuwait[J]. Asian Pac J Cancer Prev, 2022,23(2):459\u0026ndash;465.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSakles J C, Mosier J M, Chiu S, et al. Tracheal intubation in the emergency department: a comparison of GlideScope\u0026reg; video laryngoscopy to direct laryngoscopy in 822 intubations[J]. J Emerg Med, 2012,42(4):400\u0026ndash;405.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWu J H, Lin P C, Lee K T, et al. Situational simulation teaching effectively improves dental students' non-operational clinical competency and objective structured clinical examination performance[J]. BMC Med Educ, 2024,24(1):533.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLaw J A, Duggan L V, Asselin M, et al. Canadian Airway Focus Group updated consensus-based recommendations for management of the difficult airway: part 2. Planning and implementing safe management of the patient with an anticipated difficult airway[J]. Can J Anaesth, 2021,68(9):1405\u0026ndash;1436.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMosier J M, Sakles J C, Law J A, et al. Tracheal Intubation in the Critically Ill. Where We Came from and Where We Should Go[J]. Am J Respir Crit Care Med, 2020,201(7):775\u0026ndash;788.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"supportive-care-in-cancer","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jscc","sideBox":"Learn more about [Supportive Care in Cancer](https://www.springer.com/journal/520)","snPcode":"520","submissionUrl":"https://submission.nature.com/new-submission/520/3","title":"Supportive Care in Cancer","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Oral and maxillofacial malignancies, Tracheal intubation, Influencing factors, Qualitative study","lastPublishedDoi":"10.21203/rs.3.rs-4897098/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4897098/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eTracheal intubation is significant for patients with Oral and maxillofacial malignancies (OMMs) after surgery. Despite the development of practice guidelines and training programs, the current management of tracheal intubation by healthcare professionals (HCPs) is inadequate. This study aimed to explore factors that hinder HCPs in managing the tracheal intubation of patients with OMMs after surgery in the intensive care unit (ICU).\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eSemi-structured interviews were conducted with 12 experienced HCPs in three clinical units at a tertiary hospital in Shanghai, China, from February to May 2024. Purposive sampling was used. The data were organized and analyzed using NVivo 12.0 software and Braun and Clarke's reflective thematic analysis.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eTwo themes and seven sub-themes emerged: (1) institutional factors: lack of a risk assessment system for airway obstruction, lack of a tracheal intubation emergency team, preparations for delayed extubation were inconsistent, and inadequate reintubation training for airway obstruction, and (2) individual factors: normativity of airway humidification, reserve of knowledge on the risk of airway obstruction, and attitude about learning about airway obstruction.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eHCPs' inadequate management of tracheal intubation in patients with OMMs after surgery is influenced by multiple factors. Designing targeted interventions utilizing these influencing factors will improve HCPs' ability to manage tracheal intubation and ensure the life safety and effective treatment of patients with OMMs following surgery.\u003c/p\u003e","manuscriptTitle":"Factors influencing health professionals' management of tracheal intubation in oral and maxillofacial malignancies patients after surgery: A qualitative study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-11-10 13:46:55","doi":"10.21203/rs.3.rs-4897098/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-10-21T17:55:50+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-10-21T11:23:10+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"284263026905227301686852408982505511239","date":"2024-10-12T12:23:11+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-10-10T16:33:06+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"43681177264614336130712147670314100044","date":"2024-09-24T20:49:16+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-09-22T18:52:20+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-09-22T16:00:54+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-08-14T02:32:48+00:00","index":"","fulltext":""},{"type":"submitted","content":"Supportive Care in Cancer","date":"2024-08-12T02:33:44+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"supportive-care-in-cancer","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jscc","sideBox":"Learn more about [Supportive Care in Cancer](https://www.springer.com/journal/520)","snPcode":"520","submissionUrl":"https://submission.nature.com/new-submission/520/3","title":"Supportive Care in Cancer","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"4b8d793d-8479-431d-b094-92f5e489ec34","owner":[],"postedDate":"November 10th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-02-10T16:06:00+00:00","versionOfRecord":{"articleIdentity":"rs-4897098","link":"https://doi.org/10.1007/s00520-025-09224-z","journal":{"identity":"supportive-care-in-cancer","isVorOnly":false,"title":"Supportive Care in Cancer"},"publishedOn":"2025-02-07 15:58:21","publishedOnDateReadable":"February 7th, 2025"},"versionCreatedAt":"2024-11-10 13:46:55","video":"","vorDoi":"10.1007/s00520-025-09224-z","vorDoiUrl":"https://doi.org/10.1007/s00520-025-09224-z","workflowStages":[]},"version":"v1","identity":"rs-4897098","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4897098","identity":"rs-4897098","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}