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To estimate the prevalence of, the risk factors associated with, and the outcome of tracheostomy in a heterogeneous population of mechanically ventilated patients.Prospective, observational cohort study.A total of 361 intensive care units from 12 countries.A cohort of 5,081 patients mechanically ventilated for >12 hrs.None.A total of 546 patients (10.7%) had a tracheostomy during their stay in the intensive care unit. Tracheostomy was performed at a median time of 12 days (interquartile range, 7–17) from the beginning of mechanical ventilation. Variables associated with the performance of tracheostomy were duration of mechanical ventilation, need for reintubation, and neurologic disease as the primary reason of mechanical ventilation. The intensive care unit stay of patients with or without tracheostomy was a median of 21 days (interquartile range, 12–32) vs. 7 days (interquartile range, 4–12; p < .001), respectively, and the hospital stay was a median 36 days (interquartile range, 23–53) vs. 15 days (interquartile range, 8–26; p < .001), respectively. Adjusting by other variables, tracheostomy was independently related with survival in the intensive care unit (odds ratio, 2.22; 95% confidence interval, 1.72–2.86). Mortality in the hospital was similar in both groups (39% vs. 40%, p = .65).Tracheostomy is a common surgical procedure in the intensive care unit that is associated with a lower mortality in the unit but with a longer stay and a similar mortality in the hospital than in patients without tracheostomy.