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Recent publications suggest that pleural ultrasound (U/S) should be performed routinely at the time of thoracentesis. This prospective study seeks to define the contemporary risks of not using ultrasound when performed in a private, nonacademic setting by an experienced pulmonologist. Consecutive thoracentesis procedures without U/S guidance were prospectively analyzed for success and morbidity in a pulmonary practice. The end point of fluid removal was cessation of drainage, removal of 1500 to 2000 mL, or symptoms of severe cough, chest tightness, and dyspnea. In 85 patients, 123 thoracenteses were performed. Large effusions (>1000 mL) were removed in 32 instances (26%). A prior chest computed tomography scan had been done in only 16 patients (13%). There were 4 (3%) small pneumothoraces, 2 of which were associated with pleural biopsy. None required placement of a chest tube. No patient had “reexpansion pulmonary edema.” Four “failings” occurred: a dry tap with 30 mL hemoptysis indicating an inaccurate choice of site for puncture required further imaging to localize an anteriorly loculated parapneumonic effusion. Three dry or insufficient taps required a second puncture at the same sitting to reach the fluid. The first case (1%) and possibly the last 3 (2%) might have benefitted from ultrasonic guidance. In this real-world setting of inpatient and outpatient thoracenteses done by an experienced pulmonologist, situations in which U/S could benefit patients were rare. Although U/S is helpful in difficult presentations of pleural disease and in training programs, this study suggests it is superfluous for routine cases in a pulmonary practice.