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ISSUE: The undesirable clinical outcomes and high mortality rates of Ventilator Associated Pneumonia (VAP) have been well documented. Cost containment strategies are correctly aimed at nosocomial infection reduction. Hand washing, hand hygiene and CHG mouth care have been shown to reduce the incidence of nosocomial infections. However, more is needed. A back-to-basics approach to VAP prevention was explored. The lost art of Pulmonary Toileting was felt to be a viable solution; but it needed to be delivered in a time effective and consistent manner. This challenge and its solution in the era of increased needs and decreased staff is the clinical challenge we addressed in this study. PROJECT: In March 2005 a high frequency chest wall oscillation device (HFCWO) was introduced to the vent unit of an 889 bed long term care facility. The facility had sustained a VAP rate of <4/1000 device days for several months; and in an effort to lower that rate the clinical team started a trial of a clinically accepted HFCWO therapy with the expectation of preventing pneumonia by eliminating pooled secretions from the tracheo bronchial tree. Both nursing and respiratory therapy enthusiastically embraced their responsibilities to this therapy. Criteria for patient selection was established based on clinical presentation and diagnosis. Procedure for treatment was established using manufacture recommendations and clinical practice guidelines for conventional pulmonary toileting. RESULTS: We experienced an almost immediate 50% decrease in our pneumonia rates(>2/1000 device days) and sustained this throughout the length of the study. Immediately following the conclusion of our study and discontinuing HFCWO therapy, our VAP rates rose to <5/1000 device days suggesting a clear link between Pulmonary Toileting and prevention of VAP. LESSONS LEARNED: Use of the HFCWO devices has proved reduction of vent associated pneumonia. This modality appears to hold great promise for all at risk populations.