Percutaneous tracheostomy was initiated as an alternative to open tracheostomy at our institution in December 1993. To assess safety, operative time, and cost, a comparative analysis of percutaneous and open tracheostomies was performed. A retrospective evaluation of all patients who underwent percutaneous tracheostomy (P) from December 1993 to March 1996 was completed. Patients were evaluated for indications for tracheostomy, length of operation, morbidity, and cost. The results were compared with patients who underwent open tracheostomy (O) during the 12 months prior to introduction of the percutaneous technique. Tracheostomy was performed percutaneously in 74 patients and by a standard open technique in 109 patients. Indications for tracheostomy includedchronic ventilator dependence (P, 49 vs O, 58); airway protection (P, 19 vs O, 42); laryngeal dysfunction (P, 2 vs O, 7); and facial trauma (P 6 vs O, 2). The length of operation was 21 +/- 6 minutes and 46 +/- 21 minutes for percutaneous and open tracheostomy, respectively (P < 0.05). Perioperative morbidity occurred in 2 patients (3%) following percutaneous tracheostomy compared to 10 patients (9%) following open tracheostomy (P > 0.05). The mean operating room costs per patient were $1093 and $1370 for percutaneous and open tracheostomy, respectively. Percutaneous tracheostomy is a safe procedure that can be performed in less time and at a lower cost than standard open tracheostomy.