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Background: Bedside percutaneous dilational tracheostomy, a relatively new method of tracheal cannulation, provides safe and ready access to the trachea to relieve airway obstruction and tracheopulmonary secretions. The dilational technique has undergone various modifications during the past decade. Complications of this procedure are primarily related to the lack of direct visualization during tracheostomy tube placement and to poor patient selection., Objective: To report the utility of percutaneous dilational tracheostomy with bronchoscopic guidance in 162 critically ill patients., Main Outcome Measures: Mortality rates and complications associated with this technique., Results: Twenty-five patients (15.4%) died while hospitalized. No deaths were related to tracheostomy. There were four (2.5%) major complications: one pneumothorax and three posterior tracheal tears, which healed spontaneously. There were five (3.1%) minor complications: one posterior mucosal disruption, one minor bleeding episode, and three minor episodes of cellulitis. One hundred thirty-seven patients (84.6%) were discharged. Twenty-nine patients (21.2%) were available for follow-up and were experiencing no significant problems or complications following the procedure. Compared with standard open tracheostomy, charges were reduced by $1628.20 per patient ($263,768.40 total savings)., Conclusions: Bedside percutaneous tracheostomy with bronchoscopic guidance is safe and cost-effective. Complications compare favorably with that of open tracheostomy. Major complications should be avoided with continuous bronchoscopic observation during the procedure.