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BackgroundThe trachea, a vital conduit in the lower airway system, can be affected by various disorders, such as tracheal neoplasms and tracheoesophageal fistulas, that often necessitate reconstruction. While short-segment defects can sometimes be addressed with end-to-end anastomosis, larger defects require tracheal reconstruction, a complex procedure with no universally successful replacement strategy. Tissue engineering offers a promising solution for tracheal repair, particularly focusing on regenerating its epithelium, which plays a critical role in protecting the respiratory system and facilitating mucociliary clearance. However, replicating the complex structure and functionality of the tracheal epithelium remains a significant challenge, with key hurdles including proper cell differentiation, functional mucociliary clearance, and addressing the relative lack of vascular supply to the trachea.SummaryCurrent tissue engineering approaches, including biomaterial scaffolds, decellularized tissues, and scaffold-free methods, have shown varying levels of success, while in vitro air-liquid interface (ALI) cultures have provided valuable insights into epithelial modeling. Despite these advances, translating these findings into effective in vivo applications remains difficult due to challenges such as immune responses, inadequate integration with host tissue, and limited longterm functionality of engineered constructs. Overcoming these barriers requires further refinement of cell sources, scaffold materials and bioactive factors that promote vascularization and sustained epithelial function.Key MessagesThis review evaluates the current strategies and modeling, biomaterial scaffolds, cells, and bioactive factors used in tracheal epithelium regeneration, as well as the methods employed to assess their success through histological, functional, and molecular analyses. While significant progress has been made, the development of a safe, functional, and clinically viable trachealgraft remains elusive, underscoring the need for continued innovation in airway tissue engineering. Future advancements in biomaterial design, stem cell technology, and bioreactor-based tissue maturation hold promise for addressing challenges. 

ObjectiveTo examine the impact of increased body mass index (BMI) on (1) tracheotomy timing and (2) short‐term surgical complications requiring a return to the operating room and 30‐day mortality utilizing data from the Multi‐Institutional Study on Tracheotomy (MIST). MethodsA retrospective analysis of patients from the MIST database who underwent surgical or percutaneous tracheotomy between 2013 and 2016 at eight institutions was completed. Unadjusted and adjusted logistic regression analyses were used to assess the impact of obesity on tracheotomy timing and complications. ResultsAmong the 3369 patients who underwent tracheotomy, 41.0% were obese and 21.6% were morbidly obese. BMI was associated with higher rates of prolonged intubation prior to tracheotomy accounting for comorbidities, indication for tracheotomy, institution, and type of tracheostomy (p = 0.001). Morbidly obese patients (BMI ≥35 kg/m²) experienced a longer duration of intubation compared with patients with a normal BMI (median days intubated [IQR 25%–75%]: 11.0 days [7–17 days] versus 9.0 days [5–14 days];p < 0.001) but did not have statistically higher rates of return to the operating room within 30 days (p = 0.12) or mortality (p = 0.90) on multivariable analysis. This same finding of prolonged intubation was not seen in overweight, nonobese patients when compared with normal BMI patients (median days intubated [IQR 25%–75%]: 10.0 days [6–15 days] versus 10.0 days [6–15 days];p = 0.36). ConclusionBMI was associated with increased duration of intubation prior to tracheotomy. Although morbidly obese patients had a longer duration of intubation, there were no differences in return to the operating room or mortality within 30 days. Level of Evidence3Laryngoscope, 134:4674–4681, 2024