OBJECTIVE To compare the safety, availability, and long-term sequelae of percutaneous vs. surgical tracheostomy. METHODS Prospective, randomized, controlled study. METHODS Combined medical/surgical intensive care unit in a tertiary referral hospital. METHODS Two hundred critically ill mechanically ventilated patients who required tracheostomy. METHODS Tracheostomy by either percutaneous tracheostomy or surgical tracheostomy performed in the intensive care unit. RESULTS The primary outcome measure was the aggregate incidence of predefined moderate or severe complications. The secondary outcome measures were the incidence of each of the components of the primary outcome. Long-term follow-up included clinical assessment, flow volume loops, and bronchoscopy. Both groups were well matched for age, gender, admission Acute Physiology and Chronic Health Evaluation II score, period of endotracheal intubation, reason for intubation, and admission diagnosis. There was no statistical difference between groups for the primary outcome. Bleeding requiring surgical intervention occurred in three percutaneous tracheostomy patients and in no surgical tracheostomy patient (p = .2). Postoperative infection (p = .044) and cosmetic sequelae (p = .08) were more common in surgical tracheostomy patients. There was a shorter delay from randomization to percutaneous tracheostomy vs. surgical tracheostomy (p = .006). Long-term follow-up revealed no complications in either group. CONCLUSIONS Both percutaneous tracheostomies and surgical tracheostomies can be safely performed at the bedside by experienced, skilled practitioners.