Point-of-care ultrasound (POCUS) is an essential critical care tool for the identification, characterization and management of pleural effusions and offers advantages over both chest radiography (CXR) and computed topography (CT). POCUS examination of pleural effusions and ultrasound guidance for bedside pleural procedures can both be performed with the critically ill patient in the supine position. As many as 62% of patients in the ICU have pleural effusions; and the identification of pleural fluid can be a key diagnostic finding impacting clinical management regardless of whether sampling or drainage is required (Mattison et al., Chest 111:1018–1023, 1997). Compared to chest radiography, POCUS is a more sensitive instrument than CXR for identifying the presence of a pleural effusion, with studies showing that fluid collections as small as 20 mL can be reliably detected (Rothlin et al., J Trauma. 34:488–495, 1993; Grimberg et al., Sao Paulo Med J. 128:90–95, 2010). Pleural effusion volume can be estimated using POCUS and can be performed serially to measure the effect of interventions such as diuretic administration or procedural drainage. Bedside, ultrasound imaging can also reveal essential fluid characteristics not always visible with CT imaging, which can in turn impact management (Kearney et al., Clin Radiol 55:542–547, 2000; Esmadi et al., Am J Case Rep. 14:63–66, 2013). Ultrasound image characteristics have also been used to predict whether an effusion is transudative, exudative, if the fluid has loculated characteristics such as debris and septations, or whether the fluid collection is an empyema. Thus, ultrasound imaging—both estimation of volume and fluid characteristics—can play a critical role in the decision to perform a thoracentesis or place a chest tube; however, the role of ultrasound to inform more complicated management decisions has not yet been resolved. Future investigations may explore the possibility of using ultrasound image characteristics to guide the decision to proceed to chest tube placement versus video-assisted thoracoscopic surgery.