Over a 24-month period, tracheostomy was performed in 55 patients using a percutaneous, wire-guided, dilatational technique. All such procedures were undertaken at the patient's bedside in the intensive care unit, with the patient under local anesthesia and mechanically ventilated through an oral endotracheal tube. A variety of wire-guides, dilators, and tracheal tubes were used as experience and proficiency were gained with the approach, and eventually, a simple modification of a standard low-pressure cuffed endotracheal tube was found to facilitate the procedure. The percutaneous method was found to be rapid and simple, to leave almost no cosmetic deformity, and to be almost totally free from infectious complications. This technique should be considered for routine use in critically ill, ventilator-dependent patients.