Ventilator-associated pneumonia (VAP) is defined aspneumonia that develops 48 h or longer after initiation ofmechanical ventilation via an endotracheal tube (ET). Theincidence of VAP is high, ranging from 10 to 30%. VAPis associated with significantly increased morbidity andmortality, hospital length of stay, and costs [1]. Preven-tion of VAP is therefore one of the foremost aims inmechanically ventilated critically ill patients.The pathogenesis of VAP usually requires that twoimportant processes take place: bacterial colonization ofthe aerodigestive tract and the aspiration of contaminatedsecretions into the lower airway across the ET cuff [2].Controversy exists on the relevance of bacterial coloni-zation of the stomach and gastroesophageal aspiration inthe pathogenesis of VAP [3]. About 20 years ago,experimental studies with radioactive-labeled enteralfeeding suggested that endotracheal aspiration of gastriccontents occurred more frequently when patients wereplaced in the supine rather than semirecumbent position[4]. Thus, placing a patient in the semirecumbent posi-tion—with the head elevated at a 30–45 position—seemed a logical solution to prevent VAP.Nowadays, the semirecumbent position is consideredone of the most effective, easy to implement, and inex-pensive methods for the prevention of VAP inmechanically ventilated patients in the ICU. For thisreason it has been widely adopted not only in practiceguidelines but, recently, in most of the care bundles aimedat preventing VAP [5, 6]. Surprisingly, data supportingthe effectiveness of the semirecumbent position are rela-tively few and conflicting, resulting only from three,rather small, randomized controlled trials [7–9]. More-over, this intervention has an important drawback: Thefeasibility of a 45 bed orientation in ICUs is debatedbecause it depends on nursing tasks, medical interven-tions, and the patient’s wishes [10]. Apart from thisdisadvantage, the semirecumbent position has also beenimplicated in some complications such as venous stasis inthe lower extremities with the risk of venous thrombo-embolism, caudal shift of blood with the risk ofhemodynamic instability, and the risk of bed sores [11].Hence, no clear conclusions about the effect of thesemirecumbent position on VAP prophylaxis can bedrawn.In this issue of Intensive Care Medicine Zanella et al.[12] examine the incidence of VAP in swine placed in aprone position with the orientation of trachea and ETabove horizontal (at 45 ) and below horizontal (at -10 ).Pigs were randomized into four groups and ventilated for72–168 h with and without enteral feeding. At the end ofthe study period, all pigs were killed and the clinicaldiagnosis of VAP was microbiologically evaluated. Thislong-term study, as Zanella et al. note, aimed to modelsome of the determinants of VAP: intubation, deepsedation, mechanical ventilation, and enteral feeding.Their findings were really impressive! All pigs kept ori-ented with trachea 45 above horizontal developed VAP.In contrast, none of the pigs kept oriented with the tracheabelow horizontal developed VAP. Here, we mustemphasize that the above animal model is one of the most