Tracheostomy care is evolving, with the majority of procedures now performed percutaneously to facilitate weaning from mechanical ventilation in the critically ill. Traditional surgical indications remain, but surgical tracheostomies are increasingly performed in more complex patients. This brings unique challenges for the multidisciplinary team (MDT) in which speech and language therapists (SLTs) have a key role. Comprehensive tracheostomy care is a truly multidisciplinary process, and the roles of medical, nursing and allied health staff in safely managing and rehabilitating all patients with tracheostomies has been reinforced in the UK by the National Tracheostomy Safety Project (NTSP). Reviews of tracheostomy-related critical incidents have identified recurrent themes associated with adverse outcomes for this high-risk population. The vast majority of adverse incidents occur more than one week after initial tracheostomy tube insertion and many of these events are due to factors that are amenable to prospective system improvement strategies. Recent research has highlighted the impact of tracheostomy on communication and swallowing, along with the contribution of SLTs to the MDT, prompting new guidance for SLTs. The UK NTSP has developed educational and practical resources that have been shown to improve care. Similar approaches from around the world led to the newly formed Global Tracheostomy Collaborative. SLT-specific expertise in assessing and managing communication and swallowing needs is a vital part of this process.