A patient rolls into the OR with a tracheostomy—do you maintain the current tube, intubate orally, or go through the stoma? We break down the decision tree that keeps patients safe, from assessing tract maturity and surgical needs to choosing cuffed vs uncuffed strategies and planning for positive pressure ventilation. Then we shift to a critical safety pivot: total laryngectomy. When the trachea is sutured to the skin, the mouth and nose no longer connect to the lungs, and attempts at oral intubation can be deadly. We explain how to recognize the anatomy fast, oxygenate at the neck, and advance through a stepwise algorithm that reduces risk in time‑sensitive emergencies.Drawing on practical pearls and human‑factors design, we highlight why bedside signs and EMR alerts matter, how standardized language improves handoffs, and where airway exchange catheters, bougies, and wire‑reinforced tubes fit into safe practice. You’ll hear clear guidance on cuff placement relative to the stoma, avoiding mainstem intubation, using waveform capnography for continuous confirmation, and preventing false passages in fresh tracheostomies. We also review eye‑opening data on attempted oral intubations after laryngectomy, underscoring the need for staff education, patient engagement, and systems that make the right move the easy one.If you manage airways in perioperative or emergency settings, this conversation strengthens your mental models and your muscle memory. Tune in for concise, actionable steps, download the signage and algorithms from the show notes, and share the episode with your team. If this helped sharpen your airway plan, subscribe, leave a review, and tell us your go‑to approach for trach and laryngectomy cases.For show notes & transcript, visit our episode page at apsf.org: https://www.apsf.org/podcast/275-tracheostomy-and-laryngectomy-patient-safety/© 2025, The Anesthesia Patient Safety Foundation

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