OBJECTIVE: Tracheostomy remains one of the most commonly performed surgical procedures in adults with acute respiratory failure and identifies a patient cohort which is among the most resource-intensive to provide care. The objective of this concise definitive review is the synthesis of current knowledge regarding tracheostomy practice in this context. DATA SOURCE: Peer-reviewed, English language publications pertaining to tracheostomy indications, timing, technique, and management. RESULTS: Contemporary literature concerning tracheostomy use predominately focuses on two aspects: procedure timing and technical considerations. Three recent, large, randomized controlled trials failed to demonstrate an effect of "early" tracheostomy on mortality, infectious complications, intensive care unit, or hospital length of stay. Relative to continued translaryngeal intubation, tracheostomy was associated with less sedation use and earlier mobility. An accumulating body of literature suggests that, relative to conventional surgical methods, percutaneous dilational techniques are advantageous with respect to cost and complication profile. Literature addressing management following tracheostomy placement consists largely of single institution, nonrandomized reports, limiting the ability to formulate specific recommendations regarding this aspect of care. CONCLUSIONS: In patients who otherwise lack indication for surgical airway, clinicians should defer tracheostomy placement for at least 2 wks following the onset of acute respiratory failure to insure need for ongoing ventilatory support. Subpopulations of patients (e.g., those with acute neurological injury or stroke) may benefit from earlier tracheostomy. Percutaneous dilational tracheostomy should be considered the preferred technique for this intervention in the appropriately selected individual. Future investigations should include efforts to optimize post-tracheostomy management and to quantify tracheostomy effects on patient-centric outcomes.