Ventilator-associated pneumonia (VAP) is a frequentcomplication of patients undergoing invasive mechanicalventilation and its occurrence is associated with considerable morbidity and mortality [1–3]. Te key factor inthe pathogenesis of VAP is the endotracheal tube (ETT)[4]. Its presence compromises the natural anatomicalbarriers (larynx) and functional mechanisms (mucusclearance and cough), and it expedites the formation ofbioflm as well as macro- and microaspiration of oropharyngeal secretions. As a result, several strategies havebeen successfully implemented, namely subglottic secretion drainage or cuf pressure control [3, 4].One of the current recommendations for VAP prevention is elevation of the head of bed to 30–45° to preventthe refux of colonized gastric contents that has a potential role in VAP pathogenesis. Tis strategy has beenevaluated in three randomized controlled trials (RCT)enrolling 337 patients, one positive and two negatives [5–7], and in a meta-analysis pooling these three studies thatfound a signifcant impact on prevention [8]. However,the quality of evidence is low, being considered a basicpractice because of its simplicity, ubiquity, low cost, andpotential beneft