More than a decade has passed since the first international consensus conference on VAP. Despite progress in the field, the “gold standard” for the diagnosis of VAP has still eluded us. Even the histologic diagnosis of VAP is far from perfect, as evidenced by studies showing disagreement among pathologists.7We have known for decades that the clinical criteria for the diagnosis of VAP lack adequate specificity.8 Realizing the futility of the pro and con debates in the absence of a diagnostic “gold standard,” studies have focused on the impact of the diagnostic approaches on outcome. In addition to Johanson’s conventional clinical criteria, the Clinical Pulmonary Infection Score (CPIS) and criteria based on bronchoscopic and nonbronchoscopic sampling of lower respiratory tract specimen are used in guiding the management of VAP.8–12 In the last 5 years, several studies have described the impact of different approaches to VAP on patient outcome. Singh et al13showed that management of suspected VAP based on the CPIS can decrease the antibiotic cost and the development of antimicrobial resistance and superinfection, without altering patient outcome. In the only adequately powered multicentered randomized clinical trial,14 in which clinical management strategy was compared with an invasive approach, consisting of the bronchoscopic sampling of lower airway secretions for quantitative culture, the latter was associated with a lower 14-day mortality, more rapid resolution of organ failure, and less antibiotic use.