Abstract Background Some patients on extracorporeal membrane oxygenation (ECMO) require prolonged mechanical ventilation. An early tracheostomy strategy while on ECMO has appeared to be beneficial for these patients. This study aims to explore the safety of tracheostomy in ECMO patients. Methods This is a retrospective observational single‐center study. Results Hundred and nine patients underwent tracheostomy (76 percutaneous and 33 surgical) during V‐V ECMO support over an 8‐year period. Patients with a percutaneous tracheostomy showed a significantly shorter ECMO duration 25.5 (17.3–40.1) vs 37.2 (26.5–53.2) days, p  = 0.013 and a shorter ECMO‐to‐tracheostomy time 13.3 (8.5–19.7) vs 27.8 (16.3–36.9) days, p  < 0.001 compared to those who underwent a surgical approach. There was no difference between the two strategies regarding both major and minor/no bleeding ( p  = 0.756). There was no difference in survival rate between patients who underwent percutaneous or surgical tracheostomy ( p  = 0.173). Patients who underwent an early tracheostomy (within 10 days from ECMO insertion) showed a significantly shorter hospital stay ( p  < 0.001) and a shorter duration of V‐V ECMO support ( p  < 0.001). Our series includes 24 patients affected by COVID‐19, who did not show significantly higher rates of major bleeding when compared to non‐COVID‐19 patients ( p  = 0.297). Within the COVID‐19 subgroup, there was no difference in major bleeding rates between surgical and percutaneous approach ( p  = 1.0). Conclusions Percutaneous and surgical tracheostomy during ECMO have a similar safety profile in terms of bleeding risk and mortality. Percutaneous tracheostomy may favor a shorter duration of ECMO support and hospital stay and can be considered a safe alternative to surgical tracheostomy, even in COVID‐19 patients, if relevant clinical expertise is available.