Ultrasound is a very useful adjunct to medical thoracoscopy. It allows a real-time assessment of the complexity of the pleural space at the bedside. This in turn minimizes complications and maximizes safety. Traditionally, the induction of a pneumothorax was necessary prior to beginning the medical thoracoscopy in order to minimize the risk of injury to the lung or adjacent solid organs at the time of insertion of the trocar. Unfortunately, this also required a chest radiograph to confirm that the lung did indeed fall away from the chest wall. The induction and documentation of the pneumothorax incurred unnecessary risk, expense and delays. Ultrasound is useful prior to medical thoracoscopy as it allows the physician to evaluate the pleural space at the time of the procedure in the thoracoscopy position. This facilitates the identification of a safe entry site into the thorax even in more complex cases such as those with multiloculated effusions.