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Objective: To compare procedure efficacy and postoperative complications of ultrasound-guided vs. bronchoscopy guided percutaneous dilatational tracheostomy, among obese ICU patients. Study type, settings & duration: The prospective, randomized & comparative study was conducted in Critical Care Department of Services Hospital, Lahore from April 2020 to April 2021. Methodology: A total of 52 ICU patients were assigned into two groups (Group A-25 patients, and Group B-27 patients). Group A patients underwent ultrasound-guided percutaneous dilatational tracheostomy (PDT) and group B under conventional bronchoscopy guidance. In both groups, Ciaglia's method of PDT was used among both groups. Patients were monitored for procedure time, number of punctures, peri and post-procedural complications: Bleeding, injury to nearby structures, hypoxemia, arrhythmias, difficulty to ventilate, pneumothorax, surgical emphysema, loss of airway, tracheal cartilage fracture and a new lung infiltrate, etc. Results: Intra-procedural complications were noted among four obese patients from both groups, i.e 1/15 (6.6%) in group A, and 3/14 (21.4%) in group B. The operation time was comparatively less in A as compared to group B. However, hospitalization duration in both the groups remained the same i.e 28 days. No postoperative complications were noted in either group. There were no conversions to surgical tracheostomy and deaths. Conclusion: Ultrasound-guided procedure is superior to bronchoscopy guided PDT among obese ICU patients with a low percentage of intra- and post-operative complications. [ABSTRACT FROM AUTHOR]