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To compare the efficacy, safety, and incidence of complications between fiber-optic bronchoscopy-guided percutaneous dilatational tracheostomy (FOB-PDT) and ultrasound-guided percutaneous dilatational tracheostomy (US-PDT) and to determine whether US-PDT is a viable alternative to FOB-PDT.This randomized prospective study was carried out in 80 patients who were randomly divided into US-PDT and FOB-PDT groups. Demographic data and Acute Physiology and Chronic Health Evaluation II (APACHE II), procedure duration, hemorrhage status, complications, procedure difficulty, displacement of entry location after US, and hemodynamic data were evaluated in both groups. Tracheal incision was performed with real-time US and a transverse probe position in the out-of-plane mode.No significant differences were observed between the 2 groups in terms of demographic data, oral intubation time, APACHE II values, difficulty of the procedure, or the number of needle interventions (P > .05). The mean hemorrhage ratio of the FOB-PDT group was significantly higher than that of the US-PDT group (P < .05). The entry location was changed in 6 patients in the US-PDT group following neck examination with US. The mean duration of the procedure for the FOB-PDT group was significantly longer than that for the US-PDT group (P < .05).Ultrasound-guided percutaneous dilatational tracheostomy is a safe procedure for critically ill patients and has the advantages of a low complication rate, short duration of procedure, being informative with regard to neck anatomy, and facilitating prevention of vascular puncture. Thus, US-PDT can be used as an alternative to FOB-PDT.