To review the indications and complications of the percutaneous tracheostomy compared with the standard surgical tracheostomy in the critically ill patient.A review of studies reported from 1966 to 1998 and identified through a MEDLINE search on percutaneous tracheostomy.A tracheostomy is often performed in the critically ill patient when airway access, airway protection and mechanical ventilation are required for a prolonged period. The percutaneous dilatational technique rather than the standard surgical technique is now often used as it can be easily and rapidly performed at the bedside. The two percutaneous tracheostomy procedures most often used are the progressive dilatational and the guide wire dilational forceps techniques. The complications associated with both methods include misplacement of the insertion needle, Seldinger wire or dilator, insertion failure, fracture of the tracheal ring, bleeding, barotrauma, bacteraemia and death. The incidence of these complications often depends on the experience of the operator and while bronchoscopic guidance has been used to reduce the number of complications, it prolongs the procedure, requires a separate operator and may cause hypercapnoea.In the critically ill patient who requires a tracheostomy, the percutaneous rather than the standard surgical technique is the method of choice as it can be performed at the bedside, leaves a smaller scar after decannulation and may be associated with fewer complications compared with the standard surgical technique.