Complications of Percutaneous Tracheostomy-Assisting Techniques in Critically Ill Patients: A Systematic Review and...

Background/Objectives: Percutaneous dilatational tracheostomy (PDT) is a commonly performed procedure in critically ill patients. Various guidance techniques, including anatomical landmark-guided (ALG), ultrasound-guided (USG) and bronchoscopy-guided (BG), aim to enhance procedural safety and efficacy. This systematic review and meta-analysis aimed to compare the safety and efficacy across ALG, USG, and BG techniques in PDT, focusing on complications and procedure times. Methods: A systematic review and meta-analysis of randomized controlled trials (RCTs) was conducted. Studies identified through PubMed, CENTRAL, Scopus, and Web of Science databases up to July 2025 comparing ALG, USG, and BG PDT were included. Primary outcomes were minor and major bleeding, with transient hypoxia, transient hypotension, endotracheal tube cuff puncture, pneumothorax, and procedure time as secondary outcomes. Data were pooled using random-effects models, with risk ratios (RR) and 95% confidence intervals (CI) for complications and mean differences for procedure times. Heterogeneity was assessed using I² statistics, with Bonferroni correction for multiple comparisons. Results: This meta-analysis included five RCTs (568 patients) comparing USG vs. ALG, six RCTs (404 patients) comparing USG vs. BG, and five RCTs (448 patients) comparing ALG vs. BG. USG significantly reduced minor bleeding compared to ALG (RR 2.30, 95% CI 1.38-3.84, p = 0.001) and BG (RR 0.42, 95% CI 0.20-0.91, p = 0.02), and major bleeding compared to ALG (RR 2.62, 95% CI 1.00-6.86, p = 0.04). ALG was associated with higher minor bleeding risk than BG (RR 1.81, 95% CI 1.05-3.12, p = 0.03). No significant differences were found for transient hypoxia, hypotension, endotracheal tube cuff puncture, or pneumothorax across comparisons, though trends suggested lower hypoxia risk with USG and higher pneumothorax risk with ALG. Procedure times were similar (ALG: 10.4 min, USG: 11.7 min, BG: 12.7 min; p = 0.493). Some rare complications, like paratracheal placement and mediastinitis, were too infrequent for analysis. Conclusions: USG PDT significantly reduces the risk of minor and major bleeding relative to ALG and minor bleeding compared to BG, without prolonging procedure time. USG and BG show comparable safety for most non-bleeding outcomes. No significant differences in procedure times. Future research should focus on larger RCTs to assess rare complications and explore hybrid USG-BG approaches to optimize PDT safety and efficacy.