A Synergy of Ultrasound and Bronchoscopy in Enhancing Safety in Percutaneous Tracheostomy Procedures: A Systematic Review and Meta-Analysis

Abstract

Bronchoscopy-guided percutaneous dilatational tracheostomy (BPDT) and ultrasound-guided percutaneous dilatational tracheostomy (USPDT) are widely employed techniques. However, USPDT provides better vascular mapping and reduces bleeding risk, while BPDT offers better tracheal entry and fewer airway complications. Their comparative efficacy and safety were systematically evaluated, with special consideration for high-risk patients, including obese and critically ill individuals with complex airway anatomy. Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, an in-depth literature search was conducted in Embase, PubMed, Scopus, and Cochrane Library, focusing on adult patients undergoing percutaneous tracheostomy with USPDT, BPDT, or both. Quality assessment indicated that most studies exhibited a low risk of bias, though concerns regarding randomization and selective reporting were noted in some cases. A meta-analysis was conducted using pooled effect sizes, procedural success rates, complication rates, and heterogeneity (I²), applying a random-effects model. Ten studies involving 1,069 patients were analyzed. The pooled analysis demonstrated a moderate positive association between USPDT and BPDT in improving procedural success and reducing complications (CI: 0.41 to 0.55, standardized mean difference = 0.48, 95%, p < 0.05). However, significant heterogeneity (I² = 72.95%) was observed, likely due to variations in study design and patient populations. USPDT and BPDT are both practical and safe for percutaneous tracheostomy, with unique advantages for different clinical scenarios. The findings support a hybrid approach integrating both modalities to enhance procedural safety and efficiency, particularly in high-risk populations. Future large-scale trials should focus on reducing heterogeneity, assessing long-term outcomes, and improving cost-effectiveness to establish best-practice guidelines for broader clinical implementation.

Keywords: bronchoscopy; intensive care unit; percutaneous tracheostomy procedures; safety; ultrasound.

Figure 1. Identification of studies from databases and register.

Figure 2. Intra-review bias assessment using the Risk of Bias (RoB) in the trials (for RCTs).

Ravi & Vijay (2015) [19], Gobatto et al. (2016) [20], Shen et al. (2019) [22], Nazir et al. (2022) [24], Majid et al. (2014) [18], Pilarczyk et al. (2016) [21], Tariparast et al. (2022) [23]. RCTs: randomized controlled trials.

Figure 3. Intra-review bias assessment using the Newcastle-Ottawa Scale (NOS) in the trials (for observational studies).

Carboni Bisso et al. (2023) [25], Kollig et al. (2000) [16], Chacko et al. (2012) [17].

Figure 4. Funnel plot.

CES: combined effect size.

Figure 5. Forest plot showing individual study correlation estimates and the pooled correlation under a random-effects model.

Kollig et al. (2000) [16], Chacko et al. (2012) [17], Majid et al. (2014) [18], Ravi & Vijay (2015) [19], Gobatto et al. (2016) [20], Pilarczyk et al. (2016) [21], Shen et al. (2019) [22], Tariparast et al. (2022) [23], Nazir et al. (2022) [24], Carboni Bisso et al. (2023) [25].

Figure 6. Subgroup analysis of the included studies showing pooled correlation estimates for procedural success and complications in USPDT and BPDT, stratified by patient characteristics, study design, and operator expertise.

Kollig et al. (2000) [16], Chacko et al. (2012) [17], Majid et al. (2014) [18], Ravi & Vijay (2015) [19], Gobatto et al. (2016) [20], Pilarczyk et al. (2016) [21], Shen et al. (2019) [22], Tariparast et al. (2022) [23], Nazir et al. (2022) [24], Carboni Bisso et al. (2023) [25]. USPDT: ultrasound-guided percutaneous dilatational tracheostomy; BPDT: bronchoscopy-guided percutaneous dilatational tracheostomy; CI: confidence interval; PI: prediction interval; LL: lower limit; UL: upper limit.