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Background Bedside percutaneous tracheostomy (PT) placement in critically ill patients is performed in a variety of ways, largely driven by institutional preference. We have recently transitioned to primarily extubating the patient and placing a laryngeal mask airway (LMA) before tracheostomy insertion in lieu of retracting the endotracheal tube (ETT) in place. This allows for lower sedative use and provides a superior view of the operative field. Here, we seek to describe the safety and efficiency of that approach. Methods This is a single-center cross-sectional study from 2014 to 2016 comparing patients who underwent PT with the ETT in place retracted to the proximal larynx versus those who were extubated and had a LMA placed. Procedural length, sedative totals, and safety outcomes were recorded. Results In total, 125 patients underwent PT during the study period, 75 via a LMA and 50 via existing ETT. There was no difference in procedural duration (LMA: 53.5±21.4 min vs. ETT: 50.4±16.8; P=0.41), total complications (LMA: 29.3% vs. 16%; P=0.09) or major complications (4% in both groups). Cisatracurium use was significantly lower in the LMA arm (LMA: 1.0±3.6 mg vs. ETT: 11.5±5.9 mg; P Conclusion Replacing the ETT with an LMA before PT is equally safe, does not increase total procedural duration, and all but eliminates the need for paralytic agents.