OBJECTIVE Therapeutic thoracentesis is one of the most commonly performed medical procedures. The availability of handheld ultrasound machines has greatly enhanced the evaluation and management of patients with pleural effusions, with advantages including the absence of radiation, ease of use, portability and real-time/dynamic imaging. Pleural manometry refers to the measurement of pleural pressure during thoracentesis. Though described more than 122 years ago, most physicians do not measure pleural pressure, or even consider the role pleural pressures plays in the development of pleural effusions. This review summarizes the relevant data behind the use of ultrasound and manometry and explores their use during therapeutic thoracentesis RESULTS The use of ultrasound has been associated with a higher sensitivity for identifying pleural effusions, avoiding 'near misses' and a lower pneumothorax rate for thoracentesis. Pleural manometry can be used to distinguish patients with lung entrapment from those with trapped lung. Manometry is also able to predict the ability to pleurodesis patients with malignant effusions, and possibly minimize the risk of reexpansion pulmonary edema when large volumes of pleural fluid are removed. CONCLUSIONS The use of ultrasound and pleural manometry enhances the understanding of pleural disease and is associated with clinical benefit that will lead to improved patient care.