Pleural diseases are a commonly encountered problem by general physicians and chest specialists alike. Despite this, there has been a lack of research over the last few decades in this important field. This review focuses on new developments in the management of pleural effusions. We have restricted our attention, in the main, to randomised controlled trials. The review is evidence-based with practical suggestions from the authors to practicing clinicians. Specific areas focused on are pleural infection and malignant pleural disease. In pleural infection, the importance of pleural pH is emphasised and we have incorporated the latest evidence on the use of fibrinolytics from the recent multi-centre randomised controlled MIST trial. In malignant pleural effusion, the best way of obtaining closed pleural biopsy is discussed. With regard to pleurodesis, recent data on the importance of knowing your talc particle size is highlighted, as well as the role of fibrinolytics, thoracoscopy and when to use Pleurx catheters. Finally, the latest developments on newer diagnostic markers such as mesothelin in mesothelioma and newer anti-pleural agents such as transforming growth factor-beta (TGF-β) and vascular endothelial growth factor (VEGF) antagonists have been reviewed.