Ventilator-associated pneumonia (VAP) is one of the most common infections in the intensive care unit (ICU) and is associated with high morbidity, mortality and costs. As a result, prevention of VAP is highly relevant in critical care settings. Pulmonary aspiration of colonised oropharyngeal secretions across the tracheal tube cuff is the main pathogenic mechanism for development of VAP. Recently, several strategies have been applied to improve the design of tracheal tubes and reduce the likelihood of aspiration of pathogen-laden secretions across the cuff. The use of endotracheal tubes that allow aspiration of subglottic secretions have demonstrated a decrease in the rate of VAP. In critically ill patients, following tracheal intubation oral flora frequently shifts into a predominance of aerobic Gram-negative pathogens. Extensive efforts have been devoted to reducing the risks of oropharyngeal colonisation with pathogens, including selective digestive decontamination (SDD). Although SDD is a controversial measure, it reduces the incidence of VAP and respiratory infections. The long-term effects of SDD on the emergence of bacterial resistance and risk of superinfections are still controversial.