Big thanks to senior author and VERITAS champion @fabienmaldonado.bsky.social and all our collaborators.

Manometry uncommonly - need to define elastance (pleurodesis considerations), effusion + central airway obstruction, especially if pt is incapacitated (is it all ex-vacuo/trapped physiology from central obstruction or comorbid malignant effusion?), maybe a few other niche situations.

Also often see this - patients are often leaning forward while sitting. Needle should be perpendicular to the plane of the chest, not parallel to the floor, which would carry you into the bundle in a lean-forward situation.

Often I see this - intending to strafe just over the rib, but starting too low (out of fear of being too high), so the needle ends up directing toward the bundle to get over the rib.

I try to start mid-interspace with slight downplane angle. Safe and if obese, will promote contact with the inferior rib, then landmark is achieved and can retract and adjust accordingly.

Don't mind hitting rib if can't feel rib margins, but if I can, prefer straight in. Don't like walking up a rib - needle is getting bent and cutting tissue. Retract to near skin and adjust angle there. Know rib trajectory to get over with smallest adjustment - usually not just a cranial deflection

Manual syringe if by myself, wall suction if someone with non-sterile hands in the room, vacuum bottle expense doesn't seem worth it. For bilateral thora will start with larger effusion and start draining to gravity while accessing the other side.