Although some studies have reported improved outcomes in patients who receive early tracheotomy (generally between the first 3 to 6 days of mechanical ventilation) compared with late (after about 2 weeks), others have found no difference between early and late timing of the procedure. In 2004, one group reported that early tracheotomy decreased mortality by 50% (1). Furthermore, the unconventional early timing of this intervention decreased duration of mechanical ventilation, length of ICU stay, incidence of pneumonia, and requirements for sedation (1). However, other studies, including the large multicenter TracMan (Tracheostomy Management in Critical Care) trial, have not been able to consistently reproduce all of these benefits (2–4). In this issue, Trouillet and colleagues (5) attempt to resolve the controversy surrounding optimal timing of tracheotomy in a randomized trial that studied patients who were likely to require prolonged mechanical ventilation after cardiac surgery.