Patients who require long-term mechanical ventilation typically have progressed through multiple phases of an illness, each of which needs thoughtful decisions regarding airway support. Most ventilator-dependent patients first undergo respiratory stabilization with a translaryngeal endotracheal tube in a critical care setting. At some time during the course of their disease, translaryngeal tubes are converted to a tracheostomy to provide long-term airway access for ventilatory support. Once patients achieve stabilization of their critical illnesses sufficient to allow transfer to a chronic ventilator setting, the importance of expert care in airway support does not diminish. In fact, as critically ill patients improve and achieve higher levels of mentation, their need for skilled airway management to enhance comfort, mobility, and an ability to communicate increases. Such patients benefit from a systematic approach to airway management that provides the greatest opportunity for a high degree of psychologic well-being and a successful outcome of weaning from ventilatory support. This article reviews approaches to managing artificial airways for patients who require long-term mechanical ventilation.