Theme. Airway.
Introduction. Tracheostomy is a common surgical procedure associated with increased respiratory tract infections, contributing to significant morbidity, mortality, and healthcare utilisation. Biofilm formation on tracheostomy tube surfaces is a likely contributor, as biofilms detach and seed into the airway. There is limited consensus in the literature and clinical guidelines regarding how material design and reprocessing choices influence biofilm burden.
Methods. Following PRISMA systematic review guidelines, a search was conducted across Medline, EMBASE, CINAHL, and CENTRAL databases, yielding 581 unique articles. Inclusion criteria were studies assessing biofilms on adult or paediatric tracheostomy tubes via colony counts, crystal violet assays, electron microscopy, or infrared spectroscopy, in relation to tube material, surface additives, or reprocessing methods. Case reports, animal studies, and review articles were excluded.
Results. 16 studies published between 2002 and 2025, across nine countries, were included (8 in vitro, 8 in vivo). Across five studies, no tube material, including PVC or silicone, consistently demonstrated superior biofilm resistance. Four studies evaluated biomaterial additives: antimicrobial and nanoparticle-based coatings, such as octenidine dihydrochloride, gentamicin nanoparticles, and silver oxide dual-nanostructure coatings, showed promising in vitro efficacy with acceptable cytocompatibility. Nine studies examined reprocessing methods, finding chlorhexidine consistently outperformed saline and sterile water for biofilm removal, although repeated reprocessing cycles may degrade tube surfaces and increase subsequent biofilm susceptibility.
Conclusion. Advanced biomaterial coatings represent a promising avenue for reducing tracheostomy biofilms. Chemical disinfectants can be more decisively recommended for biofilm removal. Larger-scale trials are needed to confirm safety, clinical impact, and optimal reprocessing protocols.