Percutaneous dilatational tracheostomy with versus without bronchoscopic guidance: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND: Percutaneous dilatational tracheostomy (PDT) is a critical intervention for patients with respiratory failure. However, the value of bronchoscopic guidance during PDT remains clinically debated. We conducted a systematic review and meta-analysis to evaluate the role of bronchoscopy during PDT by assessing its impact on complication rates and other clinically relevant outcomes. METHODS: A systematic search was conducted in PubMed, Embase, the Cochrane library and Web of Science. Randomized controlled trials (RCTs) comparing PDT performed with versus without bronchoscopic guidance were included. The risk of bias of the RCTs was rated using the revised Cochrane risk of bias, version 2 tool (RoB 2) and the certainty of evidence was assessed by the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework. The primary outcomes were complications including bleeding, misplacement (paratracheal placement of the tube), and posterior tracheal wall injury. The secondary outcomes included operating time and first-attempt success of tracheal puncture. Pooled effect estimates were calculated using risk ratios for dichotomous outcomes and mean differences for continuous outcomes, with 95% confidence intervals. RESULTS: Seven studies (n = 639 patients) were included. The bronchoscopic guidance group showed reduced incidence of bleeding (RR 0.57, 95% CI, 0.37 to 0.88), misplacement (RR 0.17, 95% CI, 0.06 to 0.49), and posterior tracheal wall injury (RR 0.08, 95% CI, 0.02 to 0.32) compared to the non-bronchoscopic group with moderate-certainty evidence. Additionally, the bronchoscopic guidance group had a higher first-attempt success rate of tracheal puncture (RR 1.33, 95% CI, 1.21 to 1.46, high-certainty evidence). No significant difference in operating time was found between the two groups (MD 1.14, 95% CI, -1.52 to 3.79, very low-certainty evidence). CONCLUSION: Compared with the non-bronchoscopic method, bronchoscopic guidance during PDT may improve procedural safety and efficacy. However, high-quality, larger RCTs are required to draw more definitive conclusions. TRIAL REGISTRATION: PROSPERO (registration number: CRD42024508516).