Tracheotomy is one of the oldest known surgical procedures, and one of the most common procedures for patients in the intensive care unit (ICU). The development of endotracheal tubes with low-pressure/high-volume cuffs pushed back the timing of tracheotomy due to concerns that the risk of injury from the procedure had become greater than the risk of prolonged orotracheal intubation. Spinal cord lesions are associated with a high incidence of severe respiratory failure and pneumonia, with increased risk generally corresponding to a higher level of injury. The number of tracheotomies performed on elderly and chronically ill patients due to ongoing respiratory failure has increased considerably in recent years, possibly due to the success of critical care treatment. Retrospective studies that examine the timing of tracheotomy describe three groups of patients undergoing tracheotomy in a mixed medical-surgical pediatric ICU: prolonged mechanical ventilation; elective tracheotomy; and emergent tracheotomy.