Severe traumatic brain injury (TBI) patients are constantly submitted to interventions to cope secondary injury and insults. Oxygen therapy is mostly initiated by endotracheal intubation at the scene of the accident. Due to the severity of the trauma, prolonged mechanical ventilation is expected and tracheostomy (TQT) is often indicated. TQT became one of the most common bedside surgical procedure performed in an Intensive Care Unit (ICU). However, discussion regarding the optimal time for TQT placement to improve outcomes of severe TBI patients remains under discussion. This chapter aims to review TBI’s physiopathology and enlighten early tracheostomy’s role in severe TBI management.