There are scenarios where a patient’s respiratory status is compromised due to an undiagnosed pulmonary disease which poses an increased risk for TBLB, yet empirical long-term treatments for pulmonary diseases without obtaining a tissue diagnosis (the alternative to TBLB or surgical lung biopsy) may carry an even greater risk. For example, long-term empirical moderate to high-dose steroids may predispose patients to opportunistic infections or any of a myriad of steroid-induced complications, and certain antibiotics or antifungals may lead to drug resistance, nephrotoxicity, or hepatotoxicity. On the other hand, part of the skillset of a bronchoscopist is to understand when a less invasive approach may lead to the same positive outcome as a more invasive one. A classic example is the patient with HIV and ARDS who is on positive pressure ventilation. Pneumocystis jirovecii pneumonia (PJP) will need to be ruled out, and BAL can attain this diagnosis approximately 95% of the time, so TBLB need not be the initial diagnostic test. However, the conundrum occurs in the same situation when the patient is HIV negative yet has risk factors for PJP. In such cases, BAL has a lower yield for PJP (approximately 82%), and TBLB may be needed to attain the diagnosis. Such cases with varied or competing approaches to management typically require pulmonary expertise to establish the best course.