Thoracentesis using suction is perceived to have increased risk of complications including pneumothorax and re-expansion pulmonary edema (REPE). Current guidelines recommend limiting drainage to 1.5 L to avoid REPE. Our purpose was to examine the incidence of complications with symptom limited drainage of pleural fluid using suction and identify risk factors for REPE.A retrospective cohort study of all adult patients who underwent symptom limited thoracentesis using suction at our institution between 1/1/2004 and 8/31/2018 was performed, and a total of 10 344 thoracenteses were included.Pleural fluid ≥1.5 L was removed in 19% of the procedures. Thoracentesis was stopped due to chest discomfort (39%), complete drainage of fluid (37%), and persistent cough (13%). Pneumothorax based on chest radiograph was detected in 3.98%, but only 0.28% required intervention. The incidence of REPE was 0.08%. The incidence of REPE increased with Eastern Cooperative Oncology Group performance status (ECOG) ≥3 compounded with ≥1.5 L (0.04 to 0.54%, 95% CI 0.13-2.06). Thoracentesis in those with ipsilateral mediastinal shift did not increase complications, but less fluid was removed (p<0.01).Symptom limited thoracentesis using suction is safe even with large volumes. Pneumothorax requiring intervention and REPE are both rare. There were no increased procedural complications in those with ipsilateral mediastinal shift. REPE increased with poor performance status and drainage ≥1.5 L. Symptom limited drainage using suction without pleural manometry is safe.