Objective To investigate the relationship between heart rate variability (HRV) and pulmonary infection after tracheotomy in patients with hypertensive cerebral hemorrhage (HICH), to provide reference for clinical diagnosis and treatment. Methods The clinical data of 101 HICH patients who underwent tracheotomy from February 2018 to December 2022 were analyzed retrospectively. The patients were divided into infection group and non-infection group according to the complicated pulmonary infection. The general data, inflammatory markers and HRV indexes of the two groups were compared. Pearson correlation was used to analyze the relationship between HRV and pulmonary infection after tracheotomy in HICH patients. Results In 101 patients with HICH, there were 54 cases (53.5%) developed pulmonary infection within 7 d after tracheotomy. There was a statistically significant difference in preoperative Glasgow coma scale (GCS) between the two groups (P<0.05). The cytokines such as interleukin-6 (IL-6), C-reactive protein (CRP), tumor necrosis factor-α (TNF-α) and procalcitonin (PCT) in the infected group were higher than those in the non-infection group. The HRV indexes including the standard deviation of RR interval for all sinus beats within 24 h standard deviation of normal to normal interval (SDNN), 24 h average SDNN (SDANN), the root mean square of successive differences in adjacent RR interval(RMSSD), the percentage of beats with percentage of adjacent normal to normal intervals differing by more than 50 ms(PNN50), high frequency power (HF) low frequency power (LF) were all lower than those of non-infection group (P<0.05). The Pearson correlation test showed that HRV was negatively correlated with IL-6, CRP, TNF-α and PCT (P<0.05). Conclusions HRV in patients with HICH is associated with pulmonary infection after tracheotomy. The lower values of SDNN, SDANN, RMSSD, PNN50, HF, LF suggest an increased risk of pulmonary infection.