BACKGROUND Patients who fail noninvasive ventilation are generally intubated and are then subjected to complications of invasive mechanical ventilation. With transtracheal open ventilation, ventilator support is delivered through an uncuffed small bore minitracheostomy tube, which eliminates pooling of secretions above the cuff and thus reduces the risk of tracheobronchial microbial colonization. OBJECTIVE To compare transtracheal open ventilation (treatment group) with conventional invasive ventilation (control group) in patients with exacerbation of chronic obstructive pulmonary disease who initially failed noninvasive ventilation. METHODS Patients were randomized to receive trans-tracheal open ventilation (n=19) or conventional invasive ventilation (n=20). RESULTS There was no difference in arterial blood gases after 1 and 30 h between the two groups. Two patients receiving transtracheal open ventilation and 13 undergoing conventional ventilation had complications (p<0.0001). Compared with conventional ventilation, transtracheal open ventilation significantly decreased both the duration of mechanical ventilation (7.6+/-4.7 vs. 18.6+/-10.6 d, p<0.0001) and length of stay in the intensive care unit (10.2+/-4.5 vs. 21.3+/-9.7 d, p<0.0001). CONCLUSIONS Transtracheal open ventilation was as effective as conventional ventilation in maintaining adequate gas exchange and reducing complications, duration of mechanical ventilation, and intensive care unit length of stay.