With the large and increasing population of mechanically ventilated patients, critical care physicians frequently face the dilemma of whether to perform tracheotomy. The decision is a complex one, requiring a detailed understanding of the risks and benefits of both tracheotomy and prolonged translaryngeal intubation (TLI). It also must be individualized, taking into consideration the patient's preferences and expected clinical course. This article reviews the medical literature regarding the benefits and risks of tracheotomy as compared with TLI. The authors then discuss current data regarding the optimal timing for the procedure and propose an algorithm that may aid intensivists in clinical decision making.