Ultrasound-guided percutaneous dilatational tracheostomy versus landmark- and bronchoscopy-guided techniques in critically ill patients: a systematic review and meta-analysis of randomized controlled trials

Background Percutaneous dilatational tracheostomy (PDT) is widely performed in critically ill patients. In contemporary intensive care units (ICUs), multimodal image-guided PDT (particularly the combination of ultrasound and bronchoscopy) is increasingly advocated to maximize procedural safety. However, randomized data comparing single-modality guidance strategies remain clinically relevant, especially where one modality is unavailable. Methods We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) comparing ultrasound-guided PDT with anatomical landmark-guided PDT or bronchoscopy-guided PDT. Four databases were searched from inception to February 16, 2026. Primary outcome was overall procedural complication rate. Secondary outcomes included first-attempt success rate, bleeding events, and procedure time. Random-effects models were used to pool risk ratios (RRs) or mean differences (MDs) with 95% confidence intervals (CIs). Results A total of 11 RCTs (1,035 patients) were included. Compared with other percutaneous PDT techniques, ultrasound-guided PDT significantly reduced the risk of overall procedural complications (RR 0.56, 95% CI 0.46 to 0.69, p < 0.00001, I 2 = 75%) improved the first-attempt success rate (RR 1.23, 95% CI 1.08 to 1.42, p = 0.003, I 2 = 54%), and reduced the incidence of bleeding events (RR 0.44, 95% CI 0.29 to 0.67, p < 0.0001, I 2 = 0%). No significant difference in procedure time was observed between ultrasound-guided and comparator techniques (MD −1.20, 95% CI −4.13 to 1.74, p = 0.42, I 2 = 98%). Conclusion In critically ill adults undergoing percutaneous tracheostomy, ultrasound guidance is associated with higher first-attempt success, lower risks of overall complications and bleeding, without prolonging procedure duration. These findings support ultrasound-guided PDT as a preferred percutaneous approach. Nevertheless, these findings should be interpreted within modern practice, where combined ultrasound plus bronchoscopy is often considered the preferred safety strategy in well-equipped ICUs, particularly for high-risk anatomy and re-intervention cases. Systematic review registration https://osf.io/7wgzu , identifier.