There are some realities one needs to face, however, prior to embracing ultrasound for all thoracenteses. First, there are no blinded randomized trials proving improved outcome. As these trials would be extremely difficult, if not impossible, to design, we will likely need to rely on the current grade B evidence. Clearly, experienced pulmonologists can perform thoracentesis safely without ultrasound guidance.35 At this time, each of the relevant risks and benefits of performing thoracentesis with or without ultrasound guidance need to be assessed on a case-by-case basis. The obvious benefits of the pulmonologist performing the thoracentesis, as opposed to having the procedure performed by a radiologist, in an off-site location include patient continuity, the guarantee that the appropriate procedure is performed (diagnostic vs therapeutic tap), and the fact that the pulmonologist has been trained in the interpretation of pleural fluid results and can provide pleural-specific follow-up. There are, however, cases in which the pulmonologist who does not perform ultrasound would clearly want his/her radiology colleagues to perform the procedure. Additionally, some small/loculated effusions would be better drained by CT as opposed to ultrasound guidance. Secondly, there are numerous ultrasound machines available, each with their own advantages and disadvantages, and although “bells and whistles” may be nice to have, they are not required, and simple/older machines can be adequate for most needs. The initial financial investment can be quite significant (approximately $25,000 to $40,000), although new and used equipment can even be found on Internet sites such as “e-Bay” for significantly less money. Additionally, maintenance costs and costs of additional supplies such as sterile sheaths and a printer need to be budgeted. Thirdly, and perhaps most importantly, quality assurance needs to be high on all of our priorities. Although easily learned, both didactic and real-time education is required. As with other procedures, competence is likely partly numbers based; in order to maintain proficiency, a certain number of examinations should be performed on a regular basis.