Percutaneous tracheostomy (PT) is an ancient procedure that has recently attracted increasing interest. While there are numerous publications in the literature, there remains confusion due to the large variety of techniques and instruments with which it has been performed and the wide disparity in clinical outcome. This study evaluates the international literature on over 1,500 cases, classifies the techniques that have been used, analyzes the safety of each method, and reports a prospective outcome and cost analysis of 130 cases undergoing what we determined to be the safest method. We found that PT performed with the correct instruments and technique under bronchoscopic surveillance has a lower incidence of complications than open tracheostomy (OT). Cost estimation demonstrated that PT may be significantly more expensive than bedside OT. While we recommend PT as a relatively safe and expedient method of tracheostomy for selected intubated patients in an intensive care unit, it does not offer an advantage for patients who must be taken to the operating room, and should not deprive house officers of necessary experience in OT in this setting.