Bronchoscopy for Percutaneous Tracheostomy

OVERVIEW

Bronchoscopy is widely used during percutaneous dilatational tracheostomy (PDT) to improve safety and accuracy, and to facilitate procedural supervision.

RATIONALE

Bronchoscopy provides real‑time visual confirmation of key steps and hazards during PDT. As such it can provide answers to the following questions:

• Is ETT withdrawn adequately prior to commencing?
• Is the wire/sheath in the right place?
• Is the guide wire advancing correctly?
• Is it safe to commence ventilation?
• Are there any complications?

Key benefits

• ETT position confirmation
  • ensures the endotracheal tube is withdrawn enough to expose the tracheal puncture site without losing the airway.
• Midline puncture and sheath placement
  • Bronchoscopy confirms the introducer needle, cannula, wire, and dilator are entering the trachea at an appropriate angle and depth.
• Guidewire tracking
  • Prevents false passage, posterior wall injury, or oesophageal misplacement.
• Ventilation safety (tube patency and position)
  • Confirms that the tracheostomy tube is patent and correctly positioned in the trachea prior to ventilation.
• Complication detection
  • Early recognition of malposition, bleeding, posterior wall injury, or tracheal ring disruption.
• Teaching and supervision
  • Allows trainers to see exactly what the trainee is doing and provide immediate corrective feedback.

OPTIMAL POSITIONING

Midline (12 o’clock) positioning of the tracheostomy tube is optimal as it:

• Minimises coughing
• Reduces risk of tracheostomy tube occlusion from twisting
• May reduce long‑term tracheal stenosis

If the trachea is imagined to be a clock face, with the most anterior curve of the tracheal ring at 12 o’clock, acceptable positioning is between 11 o’clock and 1 o’clock.

Bronchoscopy also allows direct measurement of the distance between the carina and the distal tip of the tracheostomy tube. Maintaining a minimum 2–3 cm gap is ideal to prevent the tube tip from abutting the carina or entering a main bronchus during patient movement.

After the tracheostomy tube is inserted, this distance can be measured by:

• Advancing the bronchoscope until the carina is visualised.
• Keeping the scope steady, pinch the bronchoscope between finger and thumb at the external opening of the tracheostomy tube.
• Withdraw the bronchoscope until the distal tip of the tracheostomy tube comes into view.
• The distance between your finger‑and‑thumb and the external opening of the tube corresponds to the carina‑to‑tube‑tip distance.

COMPLICATIONS DETECTABLE BY BRONCHOSCOPY

These include:

• Posterior tracheal wall injury
• False passage
• Bleeding
• Tracheal ring fracture
• Tube malposition (e.g. anterior to trachea in subcutaneous tissue or mediastinum) or obstruction (e.g. tip against tracheal wall or carina)
• Carinal or bronchial trauma (rare)

DOWNSIDES OF BRONCHOSCOPY

Downsides of bronchoscopy include:

• Increased procedural complexity
  • requires additional equipment and personnel, as well as coordination between bronchoscopist and proceduralist.
• Potential for hypoventilation or gas trapping
  • especially with small ETTs or high PEEP.
• Equipment risk
  • needle injury to the bronchoscope is a a real hazard (much less expensive with the use of disposable bronchoscopes)
• Cognitive load
  • dividing attention between bronchoscopy and the external field can impair situational awareness.

EVIDENCE

Dong et al, 2026

• A systematic review of seven RCTs (n = 639 patients)
  • methodologically sound, transparent, and used modern tools (PRISMA, RoB 2, GRADE).
• Findings:
  • Bronchoscopic guidance during PDT significantly reduced bleeding (RR 0.57), misplacement (RR 0.17), and posterior tracheal wall injury (RR 0.08), all with moderate‑certainty evidence
  • it also improved first‑attempt puncture success (RR 1.33, high‑certainty evidence)
  • operating time showed no meaningful difference (MD 1.14 min, very low‑certainty evidence)
  • all primary outcomes showing consistent direction of benefit and minimal heterogeneity except for operating time.
• Limitations:

• small, single‑centre RCTs
• imprecision (few events)
• heterogeneity in secondary outcomes
• lack of long‑term follow‑up
• Conclusion
  • While the certainty of evidence is subject to limitations,the direction of effect is consistent across trials, and the findings are clinically plausible: bronchoscopy improves accuracy and reduces complications. 

Some RCTs (e.g. Nachson et al, 2026, published after Dong et al, 2026) have failed to show patient outcome benefits from bronchoscopy use during PDT, and show increased procedural time and increased rates of correctable adverse effects such as hypotension and dynamic hyperinflation. However, such studies usually include experienced proceduralists and lack sufficient numbers to detect differences in catastrophic adverse effects (e.g. tracheo-oseophageal fistula formation due to oesophageal malposition of the tracheostomy tube).

PRACTICAL TIPS

• Use a large‑bore ETT (≥8.0 mm) when possible to reduce obstruction from the bronchoscope.
• Withdraw the ETT just enough to visualise the anterior tracheal wall without losing the airway. The inflated ETT balloon should sit just above the vocal cords. Alternatively, the ETT may be removed completely and replaced with a supragottic airway device.
• If there is a risk of gas trapping do not leave the bronchscope in the ETT during the procedure, insert and remove when needed to answer specific questions at the different phases of the procedure.
• Maintain continuous communication between bronchoscopist and proceduralist.
• Keep the bronchoscope centred to monitor needle entry and avoid posterior wall injury.
• Watch for dynamic hyperinflation if ventilation pressures rise.
• Adjust ventilator alarms (e.g. peak pressure alarms) prior to insertion of bronchscope down the ETT.
• After insertion, confirm tracheostomy tube position and check for complications.

CONCLUSION

Bronchoscopy is widely used during PDT:

• Enhances safety, accuracy, and supervision
• Helps avoid major complications (especially rare events such as oesophageal misplacement that are catastrophic if they occur)
• Adds complexity and time but is likely beneficial overall
• Should be used deliberately to answer specific questions during the procedure

REFERENCES

Journal articles

• Dong X, Guan X, Zhu Y. Percutaneous dilatational tracheostomy with versus without bronchoscopic guidance: a systematic review and meta-analysis of randomized controlled trials. BMC Anesthesiol. 2026 Mar 17;26(1):260. doi: 10.1186/s12871-026-03759-2. PMID: 41845239; PMCID: PMC13107874.
• Nachshon A, Shapiro A, Goldfarb S, Kuzmina N, Romain M, Schwartz A, Abutbul A, Vilchik I, Beil M, van Heerden PV; Tracheostomy Study Group. The impact of bronchoscopy on the safety of percutaneous tracheostomy: a randomized controlled trial. Crit Care. 2026 Mar 18;30(1):218. doi: 10.1186/s13054-026-05912-2. PMID: 41851791; PMCID: PMC13127085.