Emergency Ventilation Through a Misplaced Esophageal Occlusion Catheter: A Novel Airway Salvage Technique

Emergency Ventilation Through a Misplaced Esophageal Occlusion Catheter: A Novel Airway Salvage Technique | 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 Case Report Emergency Ventilation Through a Misplaced Esophageal Occlusion Catheter: A Novel Airway Salvage Technique Fenfen Kou, Bin Zhang, Yanhua Luo, Bao Lang, Jun Hu This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6515609/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: While esophageal occlusion with urinary catheters shows promise in preventing aspiration, catheter misplacement poses ventilation challenges. This case demonstrates an innovative ventilation salvage technique. Case report: An 80-year-old male with intestinal obstruction and septic shock underwent emergency abdominal surgery. A urinary catheter was mistakenly inserted into the trachea instead of the esophagus, causing severe coughing and reflux. We describe the emergency management strategy using the catheter as an endotracheal tube to maintain ventilation. Results: Mechanical ventilation through the catheter was effective, with stable vital signs and no significant complications. The patient’s condition improved after the obstruction was relieved, and the tracheal tube was replaced successfully. Conclusion: In the absence of a dedicated esophageal sealing device, a double-lumen silicone urinary catheter can be safely and effectively repurposed as an endotracheal tube in emergency situations. This case highlights the importance of preparedness and quick decision-making in managing anesthesia-related complications and underscores the potential utility of alternative tools in critical scenarios. Esophageal occlusion Misplacement Emergency ventilation Airway management Figures Figure 1 Introduction General anesthesia induction is a high-risk stage for patients to experience reflux and aspiration 1 , 2 . Esophageal occlusion using a sterile silicone double-lumen catheter has been shown to be effective in preventing aspiration in high-risk patients. However, accidental catheter misplacement into the trachea can lead to severe complications, including respiratory distress and aspiration. This case report highlights an innovative approach to managing such a situation by using the misplaced catheter for emergency ventilation. Case Report An 80-year-old male patient with a history of hypertension and diabetes mellitus presented with intestinal obstruction and septic shock. Preoperative ultrasound evaluation of the gastric antrum showed high echogenicity and significant dilation, indicating a high risk of aspiration 3 , 4 . During anesthesia induction, a 22Fr sterile silicone double-lumen catheter (Fig. 1 ) was inserted through the nose to occlude the esophagus 5 , 6 . However, upon inflation of the catheter balloon, the patient experienced severe coughing and difficulty breathing, indicating accidental tracheal placement. Immediate action was taken to adapt a 7.0 mm ETT connector to the catheter, establishing mechanical ventilation. Ventilation parameters were monitored closely, with peak pressure at 26 cmH₂O, tidal volume at 450 ml, and normal blood oxygen saturation. Fiberoptic bronchoscopy confirmed the absence of residual reflux in the trachea. The patient’s condition stabilized, and the tracheal tube was replaced after ensuring airway cleanliness. Technical Considerations Catheter Modification The 7.0 mm ETT connector was successfully interfaced with the 22Fr catheter, allowing for effective mechanical ventilation. Pressure Monitoring Ventilation parameters were closely monitored, with peak pressure at 26 cmH₂O, tidal volume at 450 ml, and normal blood oxygen saturation. Safety Protocol Fiberoptic bronchoscopy was used to confirm the absence of residual reflux in the trachea. Secretions were managed to prevent further complications. Discussion In summary, our case demonstrates a novel and effective approach to managing a critical airway complication resulting from accidental tracheal placement of an esophageal occlusion catheter. The successful repurposing of a double-lumen silicone urinary catheter as an endotracheal tube highlights the importance of adaptability and resourcefulness in emergency situations. This technique not only provided immediate and effective ventilation but also ensured patient safety by maintaining stable hemodynamics and preventing further complications. Our findings suggest that in the absence of a dedicated esophageal sealing device, a double-lumen silicone urinary catheter can serve as a viable alternative for emergency ventilation. This method offers several advantages, including the availability of standard catheter materials in most clinical settings and the potential for rapid implementation without the need for specialized equipment. Additionally, the use of fiberoptic bronchoscopy to confirm tracheal clearance and manage secretions further enhances the safety and efficacy of this technique. We recommend that future studies investigate the feasibility and safety of this method in a broader patient population. Furthermore, training programs for anesthesiologists and emergency care providers should include scenarios involving alternative airway management techniques to enhance preparedness and quick decision-making in high-stress situations. Limitations: This technique has only succeeded in one elderly patient with standard anatomical and physiological characteristics. Its generalizability to other populations (e.g., pediatric patients, those with airway abnormalities) requires further validation. Additionally, unlike cuffed endotracheal tubes, the urinary catheter balloon design may elevate barotrauma risks during extended use. In conclusion, this case underscores the critical importance of being prepared to adapt and utilize alternative tools when faced with anesthesia-related complications. The innovative use of a double-lumen silicone urinary catheter for emergency ventilation represents a valuable addition to the armamentarium of airway management strategies. Declarations Ethics approval and consent to participate: Not applicable Consent for publication: The manuscript contains personal data related to the patient described in the case report. Given the patient's advanced age, written informed consent was obtained from both the patient and the legal guardian to allow the use of personal information and images of intraoperative instruments for the publication of this case report. Availability of data and materials: The datasets used and analysed during the current study are available from the corresponding author on reasonable request. Competing Interests: No potential confilct of interest was reported by the authors. Funding: self-financing Authors' contributions: Jun Hu , and Bin Zhang underwent anesthesia for this surgery. Fenfen Kou drafted the manuscript. Yanhua Luo and Bao Lang guided the writing of the article. Acknowledgements: Thanks to the department teachers and director for their guidance. References Lee AS, Ryu JH. Aspiration Pneumonia and Related Syndromes. Mayo Clin Proc. 2018;93(6):752–62. Green SM, Mason KP, Krauss BS. Pulmonary aspiration during procedural sedation: a comprehensive systematic review. Br J Anaesth. 2017;118(3):344–54. Van de Putte P, Perlas A. Ultrasound assessment of gastric content and volume. Br J Anaesth. 2014;113(1):12–22. Cubillos J, Tse C, Chan VW, et al. Bedside ultrasound assessment of gastric content: an observational study. Can J Anaesth. 2012;59(4):416–23. Zhang L. Peilin He,Quanyun Wang.The method of esophagus-occlusion to prevent pulmonary gastric contents aspiration in tracheal intubation with full stomach. Sichuan Med J 2005(08):838–9. Shuping Cao,Mingzhou Liu,Ping Cai. The application of Foley catheter occlusion method in general anesthesia for patients with satiety of the stomach. Clin Anesthesiol September2009,25,9. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted 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-6515609","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":456876738,"identity":"d134ad21-d1b4-4b94-bc61-4f5a9b58a40d","order_by":0,"name":"Fenfen Kou","email":"","orcid":"","institution":"Affiliated Hospital of Shandong Second Medical University","correspondingAuthor":false,"prefix":"","firstName":"Fenfen","middleName":"","lastName":"Kou","suffix":""},{"id":456876739,"identity":"b4554443-4b8a-4e41-9a59-250676f944b0","order_by":1,"name":"Bin Zhang","email":"","orcid":"","institution":"Weifang People's Hospital","correspondingAuthor":false,"prefix":"","firstName":"Bin","middleName":"","lastName":"Zhang","suffix":""},{"id":456876740,"identity":"ab412366-bdb6-4e03-be74-6ed7d06032cb","order_by":2,"name":"Yanhua Luo","email":"","orcid":"","institution":"Weifang People's Hospital","correspondingAuthor":false,"prefix":"","firstName":"Yanhua","middleName":"","lastName":"Luo","suffix":""},{"id":456876741,"identity":"b28a3508-cf14-4e71-b6ed-27b70d4e9cde","order_by":3,"name":"Bao Lang","email":"","orcid":"","institution":"Weifang People's Hospital","correspondingAuthor":false,"prefix":"","firstName":"Bao","middleName":"","lastName":"Lang","suffix":""},{"id":456876742,"identity":"c6eba176-c090-458e-9689-89fc74367eb7","order_by":4,"name":"Jun Hu","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA3klEQVRIiWNgGAWjYPACCTA68MHAxo40LQdnFKQlk2YRM8+HQ4wNhBTKR+SYSXxss8iTj+4xPGxjcICZgf3w0Q34tBjeyDGTnNkmUWx454zB4RyDO3wMPGlpN/BqmZFjJs3bJpG4cUYOSMszZgYJHjPCWv7CtFgYHGZsIKRFXgKohRGoZb4EUAsDMVoMeJ4VW/ack0jcIJFWcLDHIC2ZjZBf5NuTN974UVaXOH9G8uYPP/7Y2PGzHz6G35YDHAYMjGwgBlSEDZ9ysC0N7A8YGP6AGISUjoJRMApGwYgFAB11TPjmy10oAAAAAElFTkSuQmCC","orcid":"","institution":"Weifang People's Hospital","correspondingAuthor":true,"prefix":"","firstName":"Jun","middleName":"","lastName":"Hu","suffix":""}],"badges":[],"createdAt":"2025-04-23 21:53:07","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6515609/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6515609/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":82900678,"identity":"255c557f-68d0-4917-b01a-752d7d56afd2","added_by":"auto","created_at":"2025-05-16 13:23:45","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":36234,"visible":true,"origin":"","legend":"\u003cp\u003eThe picture shows a single-use sterile silicone catheter (double-lumen standard type, 22Fr). A No. 7.0 endotracheal tube interface was inserted into the drainage port of the urinary catheter.\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6515609/v1/5c2a120b6e09ea2c22102d4b.jpg"},{"id":85198768,"identity":"c6957dc5-421f-4409-8c1a-25ad9ca63d2a","added_by":"auto","created_at":"2025-06-23 10:02:07","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":379643,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6515609/v1/064767f9-815d-4c15-b2e3-ceb7d0d9df59.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Emergency Ventilation Through a Misplaced Esophageal Occlusion Catheter: A Novel Airway Salvage Technique","fulltext":[{"header":"Introduction","content":"\u003cp\u003eGeneral anesthesia induction is a high-risk stage for patients to experience reflux and aspiration\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e. Esophageal occlusion using a sterile silicone double-lumen catheter has been shown to be effective in preventing aspiration in high-risk patients. However, accidental catheter misplacement into the trachea can lead to severe complications, including respiratory distress and aspiration. This case report highlights an innovative approach to managing such a situation by using the misplaced catheter for emergency ventilation.\u003c/p\u003e"},{"header":"Case Report","content":"\u003cp\u003eAn 80-year-old male patient with a history of hypertension and diabetes mellitus presented with intestinal obstruction and septic shock. Preoperative ultrasound evaluation of the gastric antrum showed high echogenicity and significant dilation, indicating a high risk of aspiration\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e,\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e. During anesthesia induction, a 22Fr sterile silicone double-lumen catheter (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e) was inserted through the nose to occlude the esophagus\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e,\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e. However, upon inflation of the catheter balloon, the patient experienced severe coughing and difficulty breathing, indicating accidental tracheal placement. Immediate action was taken to adapt a 7.0 mm ETT connector to the catheter, establishing mechanical ventilation. Ventilation parameters were monitored closely, with peak pressure at 26 cmH₂O, tidal volume at 450 ml, and normal blood oxygen saturation. Fiberoptic bronchoscopy confirmed the absence of residual reflux in the trachea. The patient\u0026rsquo;s condition stabilized, and the tracheal tube was replaced after ensuring airway cleanliness.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eTechnical Considerations\u003c/h2\u003e \u003cdiv id=\"Sec4\" class=\"Section3\"\u003e \u003ch2\u003eCatheter Modification\u003c/h2\u003e \u003cp\u003eThe 7.0 mm ETT connector was successfully interfaced with the 22Fr catheter, allowing for effective mechanical ventilation.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e\n\u003ch3\u003ePressure Monitoring\u003c/h3\u003e\n\u003cp\u003eVentilation parameters were closely monitored, with peak pressure at 26 cmH₂O, tidal volume at 450 ml, and normal blood oxygen saturation.\u003c/p\u003e\n\u003ch3\u003eSafety Protocol\u003c/h3\u003e\n\u003cp\u003eFiberoptic bronchoscopy was used to confirm the absence of residual reflux in the trachea. Secretions were managed to prevent further complications.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn summary, our case demonstrates a novel and effective approach to managing a critical airway complication resulting from accidental tracheal placement of an esophageal occlusion catheter. The successful repurposing of a double-lumen silicone urinary catheter as an endotracheal tube highlights the importance of adaptability and resourcefulness in emergency situations. This technique not only provided immediate and effective ventilation but also ensured patient safety by maintaining stable hemodynamics and preventing further complications.\u003c/p\u003e \u003cp\u003eOur findings suggest that in the absence of a dedicated esophageal sealing device, a double-lumen silicone urinary catheter can serve as a viable alternative for emergency ventilation. This method offers several advantages, including the availability of standard catheter materials in most clinical settings and the potential for rapid implementation without the need for specialized equipment. Additionally, the use of fiberoptic bronchoscopy to confirm tracheal clearance and manage secretions further enhances the safety and efficacy of this technique.\u003c/p\u003e \u003cp\u003eWe recommend that future studies investigate the feasibility and safety of this method in a broader patient population. Furthermore, training programs for anesthesiologists and emergency care providers should include scenarios involving alternative airway management techniques to enhance preparedness and quick decision-making in high-stress situations.\u003c/p\u003e \u003cp\u003eLimitations: This technique has only succeeded in one elderly patient with standard anatomical and physiological characteristics. Its generalizability to other populations (e.g., pediatric patients, those with airway abnormalities) requires further validation. Additionally, unlike cuffed endotracheal tubes, the urinary catheter balloon design may elevate barotrauma risks during extended use.\u003c/p\u003e \u003cp\u003eIn conclusion, this case underscores the critical importance of being prepared to adapt and utilize alternative tools when faced with anesthesia-related complications. The innovative use of a double-lumen silicone urinary catheter for emergency ventilation represents a valuable addition to the armamentarium of airway management strategies.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe manuscript contains personal data related to the patient described in the case report. Given the patient's advanced age, written informed consent was obtained from both the patient and the legal guardian to allow the use of personal information and images of intraoperative instruments for the publication of this case report.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo potential confilct of interest was reported by the authors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eself-financing \u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors' contributions:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eJun Hu , and Bin Zhang underwent anesthesia for this surgery. Fenfen Kou drafted the manuscript. Yanhua Luo and Bao Lang guided the writing of the article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThanks to the department teachers and director for their guidance.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eLee AS, Ryu JH. Aspiration Pneumonia and Related Syndromes. Mayo Clin Proc. 2018;93(6):752\u0026ndash;62.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGreen SM, Mason KP, Krauss BS. Pulmonary aspiration during procedural sedation: a comprehensive systematic review. Br J Anaesth. 2017;118(3):344\u0026ndash;54.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVan de Putte P, Perlas A. Ultrasound assessment of gastric content and volume. Br J Anaesth. 2014;113(1):12\u0026ndash;22.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCubillos J, Tse C, Chan VW, et al. Bedside ultrasound assessment of gastric content: an observational study. Can J Anaesth. 2012;59(4):416\u0026ndash;23.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhang L. Peilin He,Quanyun Wang.The method of esophagus-occlusion to prevent pulmonary gastric contents aspiration in tracheal intubation with full stomach. Sichuan Med J 2005(08):838\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShuping Cao,Mingzhou Liu,Ping Cai. The application of Foley catheter occlusion method in general anesthesia for patients with satiety of the stomach. Clin Anesthesiol September2009,25,9.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Esophageal occlusion, Misplacement, Emergency ventilation, Airway management","lastPublishedDoi":"10.21203/rs.3.rs-6515609/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6515609/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eBackground: While esophageal occlusion with urinary catheters shows promise in preventing aspiration, catheter misplacement poses ventilation challenges. This case demonstrates an innovative ventilation salvage technique.\u003c/p\u003e\n\u003cp\u003eCase report: An 80-year-old male with intestinal obstruction and septic shock underwent emergency abdominal surgery. A urinary catheter was mistakenly inserted into the trachea instead of the esophagus, causing severe coughing and reflux. We describe the emergency management strategy using the catheter as an endotracheal tube to maintain ventilation.\u003c/p\u003e\n\u003cp\u003eResults: Mechanical ventilation through the catheter was effective, with stable vital signs and no significant complications. The patient’s condition improved after the obstruction was relieved, and the tracheal tube was replaced successfully.\u003c/p\u003e\n\u003cp\u003eConclusion: In the absence of a dedicated esophageal sealing device, a double-lumen silicone urinary catheter can be safely and effectively repurposed as an endotracheal tube in emergency situations. This case highlights the importance of preparedness and quick decision-making in managing anesthesia-related complications and underscores the potential utility of alternative tools in critical scenarios.\u003c/p\u003e","manuscriptTitle":"Emergency Ventilation Through a Misplaced Esophageal Occlusion Catheter: A Novel Airway Salvage Technique","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-05-16 13:23:22","doi":"10.21203/rs.3.rs-6515609/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"a6686039-83a4-4da8-b99f-bfa8736a54ab","owner":[],"postedDate":"May 16th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-06-23T09:53:54+00:00","versionOfRecord":[],"versionCreatedAt":"2025-05-16 13:23:22","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6515609","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6515609","identity":"rs-6515609","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}