Ventilator-associated pneumonia (VAP) remains a common complication within the intensive care unit. Despite identification of the patients at highest risk for developing VAP, the actual incidence appears to be unchanged over the past two decades. Colonization of the oral pharynx with pathogenic organisms and ongoing aspiration appear to be necessary in the development of VAP. Thus, prevention strategies targeted at interrupting these factors should decrease VAP. In the few randomized prospective studies in the literature, both continuous aspiration of the subglottic space and the prevention colonization of the oral pharynx have been proven successful in decreasing VAP. The main problem in interpreting these results is that they have been generally single reports and need to be replicated in larger multicenter trials. Studies of "early" tracheostomy have been unable to define both the optimal timing of tracheostomy and its effect in decreasing VAP. Other modalities, such as rotating or kinetic beds, early bronchoscopy, and changes in ventilator management, have not been shown to be useful.