Which diagnostic strategy is most effective for ventilator-associated pneumonia (VAP) in critically ill patients? This multicenter trial by the Canadian Critical Care Trials Group randomized 740 patients on mechanical ventilation for at least 4 days, with suspected VAP, to undergo either bronchoalveolar lavage with quantitative cultures or endotracheal aspiration with nonquantitative cultures. Patients colonized or infected with methicillin-resistant Staphylococcus aureus or Pseudomonas species were excluded. Empirical antibiotics were initiated in all patients and later tailored based on culture results. The primary outcome, 28-day mortality, showed no significant difference between the bronchoalveolar lavage group and the endotracheal aspiration group. Secondary outcomes, including rates of targeted therapy, antibiotic-free days, maximum organ dysfunction scores, and ICU or hospital stay lengths, were also similar between the groups. This study demonstrated that, despite theoretical advantages of bronchoalveolar lavage in pathogen identification, it did not result in superior clinical outcomes compared to the less invasive endotracheal aspiration. The findings suggest that endotracheal aspiration, which is simpler and less invasive, may be an equally effective diagnostic strategy for suspected VAP in critically ill patients.