Background: There are studies comparing USG guided percutaneous dilatational tracheostomy (PDT) with bronchoscopy guided PDT. We have compared USG guided PDT to conventional landmark guided PDT using bronchoscopy in both the groups. Objective: The primary outcome was the time of procedure and the secondary outcome was incidence of complications in USG guided PDT in comparision to the conventional PDT. Materials and Methods: Seventy adult patients were randomly allocated in two groups, i.e., conventional landmark percutaneous dilatational tracheostomy (PDT) and ultrasonography (USG) guided PDT. Demographic data, injury severity score, time taken for the procedure, attempts of tracheal puncture, major and minor complications, and outcome were compared. Results: The median time taken for the procedure was 12 minutes [min., max.; 8, 20] in conventional group 1 and 16 minutes [9, 24] in group 2 (USG guided) which was statistically significant. Minor bleeding was seen in 7 (20%) patients in group 1 and only in 4 patients (11.5%) in group 2. The rate of other complications and the long term outcome were similar in both the groups. Conclusion: The use of real time USG during PDT may confer advantage over conventional PDT when using bronchoscopy in terms of decreasing the incidence of minor bleeding but duration of the procedure gets prolonged.