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To assess the value of endoscopic guidance in bedside percutaneous dilational tracheostomy. The medical critical care unit of a large community hospital. 71 consecutive adult patients who required prolonged mechanical ventilation. 72 elective percutaneous dilational tracheostomies using the Ciaglia technique were performed under view of a flexible fiberoptic bronchoscope. Patients were examined during tracheostomy and on days 2 and 7 after the procedure, at discharge and after half a year if they were still alive. A correct median puncture was observed by endoscopic control in 59 interventions. an initial paramedian puncture was detected in 13/72 (18%) procedures and was corrected by renewed insertion in all cases. No severe complications related to percutaneous dilational tracheostomy were noticed. Minor complications occurred in 4/71 (5.6%) patients including minor bleeding in 2, inflammatory infiltration in 1 and one superficial lesion of the posterior tracheal mucosa. Long-term follow-up revealed stomal granulation in 3 patients including one at the tracheal site. At the end of the observation period the tracheostomy still was in use in 14/71 (20%) patients and 12/71 (17%) patients were decannulated. Due to their severe underlying diseases 45/71 (63%) patients had died. To facilitate weaning from the tracheostomy a minitracheostomy tube was used in 3 patients. Percutaneous dilational tracheostomy is a simple bedside procedure associated with a low complication rate. We recommend the use of endoscopic guidance to increase the safety of tracheal puncture and dilation procedure.