Tracheostomy is one of the most frequently performed operations in critically ill patients. Indications are relief of airway obstruction, airway protection, provision of long-term positive pressure ventilation, and pulmonary toilet. The appropriate timing of tracheostomies is controversial. Tracheostomy should be performed as soon as it can be determined that the patient will need a long-term artificial airway. However, recent reports suggest that early tracheostomy is beneficial. Bedside percutaneous dilational tracheostomy is a recently described alternative to standard surgical tracheostomy. Percutaneous dilational tracheostomy makes operating room use unnecessary, thereby providing logistic benefits. The risks of patient transport are eliminated, and tracheostomy can be done more expeditiously once the decision is made to perform tracheostomy.Percutaneous dilational tracheostomy is a faster procedure to perform, has lower postoperative complication rates, and costs less than operative tracheostomy. These considerations make percutaneous dilational tracheostomy the procedure of choice in most critically ill patients who require a tracheostomy.