Authors: Dong et al.
BMC Anesthesiology, published March 17, 2026
Key Points
Percutaneous dilatational tracheostomy is commonly used for critically ill patients requiring prolonged ventilatory support.
Whether bronchoscopic guidance is necessary during percutaneous dilatational tracheostomy remains debated.
This systematic review and meta-analysis included 7 randomized controlled trials with 639 patients.
Bronchoscopic guidance reduced bleeding, tube misplacement, and posterior tracheal wall injury compared with procedures performed without bronchoscopy.
Bronchoscopic guidance also improved first-attempt success of tracheal puncture without a clear increase in operating time.
Summary
This systematic review and meta-analysis evaluated whether bronchoscopic guidance improves the safety and effectiveness of percutaneous dilatational tracheostomy. Percutaneous dilatational tracheostomy is widely used in intensive care patients with respiratory failure, but it can be associated with complications such as bleeding, tube misplacement, posterior tracheal wall injury, stomal infection, subcutaneous emphysema, tube obstruction, and tube dislodgement.
Bronchoscopy allows real-time visualization during needle puncture, guidewire placement, dilation, and tube insertion. This can help confirm midline puncture, guide selection of the intercartilaginous space, and reduce blind injury to the posterior tracheal wall. However, bronchoscopy can also add cost, require additional expertise, increase logistical complexity, and may carry its own risks such as transient airway obstruction, hypoxemia, arrhythmias, infection introduction, and airway reactivity.
The authors performed a systematic search of PubMed, Embase, the Cochrane Library, and Web of Science. They included randomized controlled trials comparing percutaneous dilatational tracheostomy performed with versus without bronchoscopic guidance in adult patients. The primary outcomes were complications, including bleeding, tube misplacement, and posterior tracheal wall injury. Secondary outcomes included operating time and first-attempt success of tracheal puncture.
Seven randomized controlled trials involving 639 patients were included. Of these, 320 patients underwent percutaneous dilatational tracheostomy with bronchoscopic guidance, and 319 underwent the procedure without bronchoscopy. The studies were published between 2013 and 2022 and included patients from 5 countries.
The main finding was that bronchoscopic guidance reduced several important complications. Bleeding was significantly less common with bronchoscopic guidance. Tube misplacement, defined as paratracheal placement of the tube, was also significantly reduced. Posterior tracheal wall injury was markedly less frequent in the bronchoscopic guidance group. The certainty of evidence for these complication outcomes was rated as moderate.
Bronchoscopic guidance also improved procedural success. Patients in the bronchoscopy group had a significantly higher first-attempt success rate for tracheal puncture. The certainty of evidence for this outcome was rated as high, supporting the idea that real-time visualization improves procedural accuracy.
Operating time did not differ significantly between groups. Although bronchoscopy adds steps such as insertion and positioning, it may also reduce time lost to repeated adjustments, inaccurate localization, or procedural difficulty. However, the evidence for operating time was rated as very low certainty because of substantial heterogeneity and inconsistent definitions across studies.
The authors noted that complication event rates were low overall, which limits the precision of the estimates. They also emphasized that larger randomized trials are still needed to confirm the findings. Other limitations included variability in procedural protocols, unclear operating time definitions, restriction to English and Chinese publications, exclusion of gray literature, and differences in patient populations and indications for tracheostomy.
The authors concluded that bronchoscopic guidance during percutaneous dilatational tracheostomy may improve both safety and efficacy. It was associated with fewer common complications and better first-attempt puncture success. However, they recommended that clinicians individualize its use based on patient risk, operator experience, available resources, and procedural circumstances.
What You Should Know
This article supports bronchoscopic guidance as a useful safety tool during percutaneous dilatational tracheostomy. The strongest practical benefit appears to be improved first-attempt tracheal puncture success and reduced risk of tube misplacement and posterior tracheal wall injury.
For anesthesia and critical care providers, the key message is that visualization matters. Bronchoscopy may help avoid blind puncture errors and improve procedural confidence, especially in patients with difficult anatomy or higher procedural risk.
At the same time, bronchoscopy should not be viewed as risk-free or universally mandatory in every situation. It requires equipment, trained personnel, and attention to possible airway obstruction or hypoxemia during the procedure. The best approach is to balance the safety advantages of visualization against patient-specific and institutional factors.
Overall, this meta-analysis suggests that bronchoscopic guidance can make percutaneous dilatational tracheostomy safer and more reliable, but larger high-quality trials are still needed to define exactly when it provides the greatest benefit.
Thank you to BMC Anesthesiology for allowing us to summarize and share this article.