This chapter discusses tracheostomy, which refers to an opening in the anterior tracheal wall that allows air to enter the trachea and lungs directly without passing through the nose, pharynx and larynx. Percutaneous dilatation tracheostomy is an elective procedure and, in contrast to a surgical tracheostomy, is not suitable for the management of an acute emergency airway. Since a tracheostomy bypasses the upper airway, warming, humidification, and filtering of air does not occur naturally. A rigid ventilating bronchoscope may be inserted into the trachea but this requires great expertise in handling the bronchoscope during a period of increasing hypoxia. Subglottic laryngeal pathology may prevent the use of cricothyroidotomy. When a tracheostomy is needed to manage obstructive sleep apnea a fenestrated tube is used. Fenestrated tracheostomy facilitates spontaneous speech in patients who are being weaned from mechanical ventilation or are spontaneously breathing. Regular suctioning and chest physiotherapy are essential in the early postoperative period.