Purpose <p>The optimal management of enteral nutrition before tracheostomy in mechanically ventilated patients in the intensive care unit (ICU) remains uncertain, and pre-procedural fasting is widely practiced in clinical settings to reduce the risk of aspiration. However, interruption of enteral nutrition (EN) may adversely affect metabolic stability and caloric intake in critically ill patients. This study aimed to prospectively evaluate whether continuation of EN before tracheostomy increases aspiration risk or influences clinical outcomes in mechanically ventilated ICU patients.</p> Patients and methods <p>This prospective observational study was conducted in the anesthesiology and resuscitation intensive care units of a tertiary care center. Adult mechanically ventilated patients scheduled for elective percutaneous tracheostomy were included. Patients were divided into two groups according to the enteral nutrition strategy applied before the procedure: the continuous feeding group and the fasting group. The primary endpoint was the incidence of aspiration pneumonia within 72&#xa0;h after tracheostomy. Secondary endpoints included respiratory parameters, arterial blood gas measurements, delta (Δ) changes in physiological variables, procedure-related complications, and ICU and hospital outcomes.</p> Results <p>A total of 110 patients were assessed for eligibility, and 91 patients were included in the final analysis (continuous feeding group <i>n</i> = 45; fasting group <i>n</i> = 46). Baseline demographic characteristics, disease severity scores, and pre-tracheostomy respiratory parameters were comparable between groups. The incidence of aspiration pneumonia was 6.7% in the continuous feeding group and 4.4% in the fasting group, corresponding to an absolute risk difference of 2.3% (95% CI, − 6.6 to 11.2) and a crude odds ratio of 1.57 (95% CI, 0.25–9.88). Post-tracheostomy FiO₂ requirements were higher in the fasting group (<i>p</i> = 0.005), while other respiratory and arterial blood gas parameters were similar. Delta analyses showed greater increases in PaO₂ and more stable lactate levels in the continuous feeding group (<i>p</i> = 0.024 and <i>p</i> = 0.033). ICU and hospital length of stay, complication rates, and mortality were comparable.</p> Conclusions <p>Continuation of EN before tracheostomy with passive nasogastric drainage was not associated with a statistically significant increase in aspiration pneumonia or adverse outcomes compared with conventional fasting. However, the small number of events and wide confidence intervals indicate that clinically relevant differences cannot be excluded. Larger, adequately powered studies are needed to confirm safety and clarify the clinical implications of pre-tracheostomy feeding strategies.</p> Trial registration <p>ClinicalTrials.gov, NCT07508293. Registered on March 21, 2026, retrospectively registered.</p>