〔Abstract〕 Objective To investigate the effect of fibronchoscope guided percutaneous dilatation tracheotomy (FBPDT) in patients with severe difficult tracheotomy. Methods A total of 158 critically ill patients who underwent tracheotomy in the Fifth Affiliated Hospital of Sun Yat-sen University from January 2018 to December 2020 were selected and divided into open tracheotomy (OT) group with 50 cases, percutaneous dilatation tracheotomy (PDT) group with 87 cases and FBPDT group with 21 cases, according to the difference of methods. The clinical effect of each group was compared. Results The operation time of FBPDT group and PDT group was shorter than that of OT group, and the intraoperative blood loss was less than that of OT group, with statistical significance (P < 0.05). There were no significant differences in operation time and blood loss between FBDPT group and PDT group (P > 0.05). Complications in PDT group were less than OT group, the difference was statistically significant (P < 0.05). There was no postoperative complication in FBPDT group. From 2018 to 2020, OT surgery had a decreasing trend year by year, and the proportion decreased year by year, while the number of PDT cases increased gradually, and the proportion increased year by year, with statistical significance (P < 0.05). The number of FBPDT increased year by year, and the difference was statistically significant (P < 0.05). From 2018 to 2020, the operation time of PDT and FBPDT showed a trend of gradually shortening, especially the operation time of PDT and FBPDT significantly shortened, and the difference was statistically significant (P < 0.05). The amount of intraoperative PDT blood loss showed a trend of gradual decrease from 2018 to 2020, with statistical significance (P < 0.05). The incidence of postoperative complications of OT and PDT in 2020 was lower than that in 2018 and 2019, with statistical significance (P < 0.05). Conclusion FBPDT has significant application value in patients with severe and difficult tracheotomy.