Cardiopulmonary complication after ruptured abdominal aortic aneurysm (rAAA) repair is an important cause of mortality. Early tracheostomy promotes patient recovery from respiratory morbidities. A policy of routine immediate tracheostomy was adopted in 1999 at our institution. This study investigates the trend of hospital mortality of rAAA patients over 12 years with particular reference to immediate tracheostomy. Consecutive rAAA patients operated during 1993-2004 were divided into two groups (first group, 1993-1998; second group, 1999-2002). Intra- and postoperative care was the same for all patients except that immediate tracheostomy was performed routinely in the second group and only selectively in the first. Hospital mortality of the two groups was examined. Patient characteristics, biochemical parameters, aneurysm feature, operative details, and clinical outcomes of the two groups (excluding 48 hr perioperative mortalities) were compared to identify prognostic factors of hospital mortality. Sixty-three patients were operated during the study period. The overall hospital mortality for the first and second groups was 62.5% (20/32) and 22.6% (7/31) (p=0.001), respectively. Excluding the 48 hr mortalities, 57.1% (12, n=21) of patients in the first group and 85.7% (24, n=28) of those in the second group survived to be discharged from hospital (p=0.048). The pre-, intra-, and postoperative parameters were comparable between the two groups. Immediate tracheostomy was performed for all patients in the second group and only 52.4% (11) in the first group. Male gender, high creatinine level on presentation, postoperation cardiac morbidity, renal failure, and bowel ischemia were found to be associated with a higher mortality. Immediate tracheostomy is a significant factor associated with improved survival. In conclusion, a significant improvement of rAAA patients' in-hospital mortality was achieved during the study period. Tracheostomy performed immediately following rAAA repair is associated with better hospital survival.