This chapter provides an overview of tracheostomy procedures, particularly for patients with obstructive sleep apnea (OSA). Initially, it discusses the historical use of tracheostomy for OSA and its continued relevance for patients unresponsive to other treatments. The chapter emphasizes the complexities of performing tracheostomies in OSA patients, especially those with obesity, due to anatomical challenges such as thick neck tissue, which increases surgical risks. The preoperative section focuses on optimizing patient health, including managing comorbidities like hypertension and diabetes, and highlights the importance of careful airway management with minimal sedative use. It also stresses collaboration with anesthesiology to prevent airway complications. During surgery, proper patient positioning, tissue retraction, and tube selection are crucial for success, especially in obese patients where extended-length tracheostomy tubes may be required. The postoperative care section discusses stoma management, the importance of education for patients and families, and the need for vigilant monitoring to prevent complications such as granulation tissue and infections. The chapter also outlines potential complications, such as bleeding, tube dislodgment, and infections, with obese patients facing a higher risk. It concludes with a review of postoperative care protocols and the importance of individualized tube selection to optimize patient outcomes.