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Background: To determine whether fibre optic bronchoscopy-guided percutaneous dilatational tracheostomy (FOB-PDT) is a better option in critically ill patients, we compared the efficacy and incidence of procedure complications between PDT with and without FOB., Methods: We included 90 patients with oral intubation and mechanical ventilation who received PDT with (n = 45, FOB-PDT group) and without (n = 45, PDT group) FOB. For all patients, a simplification of the Griggs technique was used in this study with a central venous catheter set and dilating forceps. Demographic data, body mass index (BMI), Sequential Organ Failure Assessment (SOFA) score, Acute Physiology and Chronic Health Evaluation II (APACHE II) score, rate of first-time success, complication rate and time of procedure were evaluated in both groups. PDT was performed guided by FOB only in the FOB-PDT group., Results: The rate of major complications, including minor or major haemorrhage requiring intervention and subcutaneous emphysema in the neck or pneumothorax, was significantly higher in the PDT group than in the PDT-FOB group (40% vs. 20%, P < 0.05). Significant differences were observed between the two groups with respect to the rate of first-time success (64.4% vs. 93.3%, P < 0.05); the rate of first-time success puncture with the puncture needle in the PDT-FOB group was higher than that in the PDT group (93.3% vs. 75.6%, P < 0.05). The mean procedure duration was significantly longer in the PDT group than in the PDT-FOB group (12.9 ± 1.1 vs. 9.8 ± 1.2 min, P < 0 .05)., Conclusions: PDT with FOB offers the advantages of a high rate of first-time success, a low complication rate and short-procedure duration. Thus, FOB-PDT is a better option in critically ill patients.