Tracheotomy is commonly performed in ventilator-dependent patients. Disadvantages to the procedure are perioperative complications, long-term airway injury, and the cost of the procedure. Benefits ascribed to tracheotomy vs prolonged translaryngeal intubation include improved patient comfort, more effective airway suctioning, decreased airway resistance, enhanced patient mobility, increased potential for speech, ability to eat orally, a more secure airway, accelerated ventilator weaning, reduced ventilator-associated pneumonia, and the ability to transfer ventilator-dependent patients from the ICU. None of these benefits, however, have been demonstrated in large-scale, prospective, randomized studies. It is proposed that there should be an anticipatory approach wherein tracheotomy is considered after an initial period of stabilization with the patient receiving mechanical ventilation when it becomes apparent that the patient will require prolonged ventilator assistance. Tracheotomy then is performed when the patient appears likely to gain one or more of the benefits ascribed to the procedure.