The timing of tracheostomy presents an ongoing debate. Studies are inconsistent on what is considered early or late. Studied populations are relatively small and meta-analysis is flawed as the criteria of tracheostomy timing vary from paper to paper. The risk of the surgical procedure is not insignificant. Direct procedural complications (such as bleeding), long-term complications (such as tracheal stenosis), and indirect complications (such as risks of transporting critically ill patients to the operating room for open tracheostomy) should be balanced against the benefits of better oral and pulmonary toilet, easier weaning, and reduction of airway resistance. The risks of transportation from the intensive care unit (ICU) to the operating room include tube and line dislodgment, suboptimal monitoring during transport, and inability to manage critical events. Bedside tracheostomy by the percutaneous dilatational technique has emerged as a safe alternative to open tracheostomy. All would agree that if a tracheostomy is eventually needed, it would better be done earlier than later. The problem lies in our inadequacy to predict accurately the duration of mechanical ventilation. For patients who would need prolonged mechanical ventilation (usually defined as longer than 2 weeks), most surgeons agree that an early tracheostomy is beneficial.