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Background Tracheostomy care is a critical aspect of respiratory therapy, requiring specialized knowledge and adherence to standardized protocols to ensure optimal patient outcomes. However, variations in practice and a lack of formalized guidelines may contribute to inconsistencies in tracheostomy management. Therefore, this study aimed to assess clinical practices, self-confidence, and perceived barriers in tracheostomy care among respiratory therapists (RTs) in Saudi Arabia. Methods A cross-sectional descriptive survey was distributed from June to October 2024 among RTs in Saudi Arabia. Descriptive and inferential statistical analyses were performed to identify key trends and associations. Results A total of 1,012 RTs participated in the study, with the majority being male (588, 58.1%). Tracheostomy care was available in 90.7% of hospitals, although 22.4% reported the absence of specific protocols. Formal training in tracheostomy care was limited, with only 42.3% of RTs receiving 1–5 h of instruction. Attitude of evidence-based practices was generally positive, as 59.9% of respondents felt up to date with current guidelines. Confidence levels in managing tracheostomy patients were notably low (20.9%) and slightly higher for ventilator-assisted patients (23.6%). To enhance skills, 53.6% of RTs visited specialist centers, and many participated in conferences (52.2%) and workshops (49.2%). The most significant barriers to incorporating tracheostomy care into RT services included lack of knowledge (70.7%), inadequate training (59.7%), and the absence of standardized protocols (59.6%). Conclusion Although RTs demonstrated a solid understanding of tracheostomy care, variations in clinical practices and confidence levels were observed, primarily due to the absence of standardized protocols and formal training. Implementing targeted educational initiatives and developing clear protocols could significantly improve the quality of tracheostomy care and enhance patient outcomes.