Ventilator-associated pneumonia (VAP) is an acquired infection related primarily to the consequences of prolonged endotracheal intubation. It is considered the most important infectious chal-
lenge in the critical care setting. Preventable complications of hospital care are considered an
important source of wasted health-care costs believed to consume up to 47% of annual expenditures
in the United States. Whether VAP is preventable has become a highly contentious debate since
public reporting commenced a decade ago. This selective review focuses on specific aspects of this
debate, including the inherent vagaries in the diagnosis of VAP and the marked disparities between
VAP rates based on clinical diagnosis versus surveillance data. Also discussed is how this debate has
impacted public policy, leading to the new paradigm of ventilator-associated events. The limited
ability of artificial airways to prevent microaspiration and biofilm build-up, as well as non-modi-
fiable conditions increasing the risk of VAP, is described in detail. In addition, the origins of the
mistaken but widely embraced notion that zero VAP is a realistic achievement are examined.