Insertion of a breathing tube to enable treatment with mechanical ventilation (respirator) is often associated with complications, such as infection and lung injury. Leakage of secretions around the breathing tube (microaspiration) is a major factor leading to complications. The investigators propose that a standardized, enhanced oral suction protocol will be effective in reducing microaspiration and harms associated with mechanical ventilation. The investigators hypothesize that those randomized to the enhanced oral suction protocol will have less microaspiration and other ventilator-associated conditions than those in the usual care, standard suction group.

Inclusion Criteria:

• 18 years of age or older
• orally intubated with endotracheal tube and treated with mechanical ventilation
• 24 hours or less since intubation
• expected to be intubated for at least 36 hours after enrollment

Exclusion Criteria:

• documented aspiration at time of intubation
• intubation to treat known aspiration
• treatment with rescue mechanical ventilation therapies (oscillator)
• re-intubation
• contraindications to receiving the intervention (e.g., oral injuries)
• history of lung or head/neck cancers that may produce amylase in the lungs
• history of disease that affects saliva production (e.g., Sjögren's syndrome)
• prisoners

Data were collected for the duration of participant enrollment in study (mean 5.4 days); range 1.5 to 14.0 days.