Background While continuous cuff pressure monitoring (CCPM) offers theoretical advantages in patients with ventilator-associated pneumonia (VAP), its clinical benefits remain controversial.This study aimed to investigate whether CCPM reduces VAP incidence compared with intermittent cuff pressure monitoring (ICPM) and its impact on nursing workload. Methods We conducted a multicentre, open-label randomised controlled trial across eight tertiary hospitals in China. Adult intensive care unit (ICU) patients requiring mechanical ventilation for >= 48 h were randomly assigned (1:1) to CCPM (n = 105) or ICPM (n = 108). Patients with tracheotomy, nasotracheal intubation or contraindications for semi-recumbent positioning were excluded. Randomisation was conducted using sealed opaque envelopes. The primary outcome was VAP incidence, diagnosed per Chinese Respiratory Society guidelines. Secondary outcomes included nursing workload, the percentage of time cuff pressure (Pcuff) was maintained at the target range (25-30 cm H2O), the duration of mechanical ventilation, ICU stay and ICU mortality. Results The VAP incidence did not differ significantly between the CCPM and ICPM groups (16.2% vs. 17.6%; P = 0.79), but the CCPM group significantly reduced the cumulative time spent on Pcuff adjustments within 48 h (85 s vs. 660 s; P < 0.001). The percentage of Pcuff determinations within the target range was higher with CCPM (96.9% vs. 70.7%; P < 0.001). No significant differences were found in mechanical ventilation duration, ICU stay or ICU mortality (all P > 0.05). Conclusion Continuous cuff pressure monitoring did not reduce VAP incidence compared with ICPM but significantly decreased nursing workload and improved Pcuff control, suggesting that CCPM may serve as an efficient alternative for Pcuff management, thereby benefiting clinical workflow without compromising patient outcomes.