Does using endoscopic guidance for tracheostomy reduce complications in critical illness?

Tracheostomy is a common procedure in the intensive care unit (ICU) for patients who need prolonged mechanical ventilation. Endoscopic guidance (using a small camera) is sometimes used during the procedure to help visualize the airway. The key question is whether this extra step reduces complications. A large, recent randomized trial provides the best evidence so far: it found no significant difference in complication rates between endoscopic-guided and nonendoscopic-guided percutaneous dilatational tracheostomy ¹. This suggests that for experienced clinicians, routine endoscopic guidance may not be necessary to prevent perioperative complications.

What the research says

A multicenter randomized trial published in 2024 enrolled 442 critically ill adults undergoing tracheostomy for prolonged mechanical ventilation ¹. Patients were randomly assigned to receive either endoscopic-guided or nonendoscopic-guided percutaneous dilatational tracheostomy, both performed by experienced clinicians using the same single-dilatation method. The primary outcome was the rate of perioperative complications. The results showed that 11.3% of patients in the endoscopic group and 13.1% in the nonendoscopic group had complications — a difference that was not statistically significant (p = 0.663) ¹. This means the trial did not find evidence that endoscopic guidance reduces complications.

Earlier studies had suggested potential benefits of bronchoscopic (endoscopic) guidance. One older case series of 162 patients reported a 2.5% rate of major complications and 3.1% minor complications with bronchoscopic guidance, but it did not have a comparison group ⁹. Another study focused on obese patients found that ultrasound-guided tracheostomy reduced operation time and bleeding compared to bronchoscopic guidance, but did not compare endoscopic versus no guidance ¹⁰. A 1998 case series of bedside procedures, including tracheostomy, reported a low major complication rate (0.8%) but did not specifically compare guidance methods ¹¹.

The most reliable evidence — the 2024 randomized trial — directly compared endoscopic guidance to no guidance and found no significant difference ¹. This suggests that for experienced clinicians, the routine use of endoscopy may not lower complication rates. However, the trial excluded patients with certain risk factors, so results may not apply to all ICU patients.

What to ask your doctor

• What is the standard approach to tracheostomy in this ICU — is endoscopic guidance used routinely or selectively?
• Does the evidence from the 2024 randomized trial change how you decide whether to use endoscopic guidance?
• Are there specific patient factors (such as obesity, difficult anatomy, or coagulopathy) that would make you more likely to use endoscopic guidance?
• What is the experience level of the clinicians performing tracheostomies here, and how does that affect complication rates?
• What are the main risks of tracheostomy in my specific situation, and how are they monitored and managed?