Decortication involves stripping of a thick fibrin "rind or peel" from the pleural surface, which permits the underlying entrapped lung to expand. Though decortication is primarily performed for empyema thoracis (parapneumonic, postoperative, and posttraumatic) other indications include hemothorax, chylothorax, and pleural thickening in association with rheumatoid arthritis. It is a major surgical procedure, and patient outcome can be adversely affected by underlying comorbidities. In addition to assessing functional capacity of the patient, it is essential to rule out significant lung parenchymal damage before surgical intervention. Currently there are no data available that indicate the exact time a patient with pleural disease should undergo decortication. Although late-stage empyema characterized by a constrictive peel often requires decortication, management of patients with multiloculated fibrinopurulent effusion is controversial. In these cases, intrapleural fibrinolyrics, video-assisted thoracoscopic surgery, and decortication as primary therapeutic interventions have shown excellent outcomes. Similarly, controversy exists on the exact time patients with retained hemothorax or chylothorax should undergo surgery. Pleural disease in association with rheumatoid arthritis requires decortication, especially when it is associated with lung entrapment.