Permanent tracheostomy, described first in the 1960s as a treatment for obstructive sleep apnea (OSA), was one of the earliest methods used in the treatment of OSA before the popularization of positive pressure methods in the 1980s. It was reported that tracheostomy in patients with OSA resulted in complete resolution of the systemic and pulmonary hypertension as well as hypersomnia. Studies have shown that tracheostomy remains the only consistently effective method for relieving OSA in treating patients with body mass index >40 kg/m2. However, given the quality-of-life changes associated with a tracheostomy, it has remained a surgical option of last resort. In this article, we discuss the indications and techniques of permanent tracheostomy.