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The primary study aim was to determine if there were differences in biofilm formation above and below the cuff using microbial community profiling.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>In this prospective observational study, ETTs were collected following extubation of mechanically ventilated critically ill adults. The biofilm community composition and structure on ETT segments were examined by culture-independent (Illumina MiSeq 16S\u00a0rRNA marker-gene sequencing) and -dependent (extended-quantitative culture) methods and related to clinical variables.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>\n                      Sixty-four participants were recruited following a median (IQR) of 3.77 (1.56\u20137.49) days intubation. Although participant-level differences in communities were observed, most had evidence of multispecies biofilm development on the ETT surface. Community profiling indicated that there was no difference in alpha- and beta-diversity metrics or density in paired segments from above and below the ETT cuff. Culture-independent analysis detected a greater biofilm richness and more often identified microorganisms reported with clinically-directed culture of respiratory secretions than extended-quantitative culture (82.35% vs. 52.94%). At extubation a higher community density was associated with increased richness (\n                      <jats:italic>p<\/jats:italic>\n                      \u2009=\u20090.01) and diversity (\n                      <jats:italic>p<\/jats:italic>\n                      \u2009=\u20090.03) and reduced evenness (\n                      <jats:italic>p<\/jats:italic>\n                      \u2009=\u20090.01) and dominance (\n                      <jats:italic>p<\/jats:italic>\n                      \u2009=\u20090.03), but not bacterial pathogen or yeast presence\/abundance by culture. Participant characteristics were not associated with the extent of biofilm community density.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>Biofilm communities forming above and below the ETT cuff are highly individual but conserved suggesting that an inflated ETT cuff does not provide an effective microbial barrier.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1186\/s12931-025-03485-2","type":"journal-article","created":{"date-parts":[[2026,1,22]],"date-time":"2026-01-22T07:23:31Z","timestamp":1769066611000},"update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":2,"title":["Biofilm communities above and below the cuff of endotracheal tubes are spatially homogenous"],"prefix":"10.1186","volume":"27","author":[{"given":"Gisli G.","family":"Einarsson","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sujata","family":"Das","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jonathan A.","family":"Silversides","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Nerielle","family":"Fundano","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Elliott","family":"Lonsdale","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ronan","family":"McMullan","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Daniel F.","family":"McAuley","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Nicola J.","family":"Irwin","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Colin P.","family":"McCoy","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Matthew P.","family":"Wylie","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Laura J.","family":"Sherrard","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2026,1,22]]},"reference":[{"issue":"2","key":"3485_CR1","doi-asserted-by":"publisher","DOI":"10.1186\/cc13775","volume":"18","author":"AA Kalanuria","year":"2014","unstructured":"Kalanuria AA, Ziai W, Mirski M. 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Biomater Sci. 2020;8(5):1464\u201377.","journal-title":"Biomater Sci"}],"container-title":["Respiratory Research"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/link.springer.com\/article\/10.1186\/s12931-025-03485-2","content-type":"text\/html","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1186\/s12931-025-03485-2.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1186\/s12931-025-03485-2.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,6,16]],"date-time":"2026-06-16T16:57:06Z","timestamp":1781629026000},"score":1,"resource":{"primary":{"URL":"https:\/\/link.springer.com\/10.1186\/s12931-025-03485-2"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,1,22]]},"references-count":40,"journal-issue":{"issue":"1","published-online":{"date-parts":[[2026,12]]}},"alternative-id":["3485"],"URL":"https:\/\/doi.org\/10.1186\/s12931-025-03485-2","relation":{},"ISSN":["1465-993X"],"issn-type":[{"value":"1465-993X","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,1,22]]},"assertion":[{"value":"26 August 2025","order":1,"name":"received","label":"Received","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"29 December 2025","order":2,"name":"accepted","label":"Accepted","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"22 January 2026","order":3,"name":"first_online","label":"First Online","group":{"name":"ArticleHistory","label":"Article History"}},{"order":1,"name":"Ethics","group":{"name":"EthicsHeading","label":"Declarations"}},{"value":"Written informed consent from a patient representative was obtained. The study was approved by the Social Care Research Ethics Committee (20\/IEC08\/0025).","order":2,"name":"Ethics","group":{"name":"EthicsHeading","label":"Ethics approval and consent to participate"}},{"value":"Not applicable.","order":3,"name":"Ethics","group":{"name":"EthicsHeading","label":"Consent for publication"}},{"value":"DFM reports grants from NIHR, MRC, Wellcome Trust, Innovate UK, Northern Ireland Health and Social Care Research and Development Office, Novavax and Randox unrelated to this work. DFM has a patent issued to his institution for a novel anti-inflammatory agent (US8962032), has received consulting fees from Bayer, Aptarion, Direct Biologics, MSD, Healios, and Novartis, participates on a Data Safety Monitoring Board for Vir Biotechnology and Faron, is a previous Director of Research, Intensive Care Society, and is a MRC\/NIHR Director for the EME Programme and a NIHR Scientific Director for Programmes. DFM\u2019s spouse reports consultancy fees from Insmed and has served on the grant review committee for the California Institute for Regenerative Medicine. The remaining authors declare that they have no competing interests.","order":4,"name":"Ethics","group":{"name":"EthicsHeading","label":"Competing interests"}}],"article-number":"74"}}