Abstract Background: Despite advances in antimicrobial therapy and a range of drainage techniques for the infected pleural area, thoracic empyema continues to be a serious reason behind morbidity and mortality. Although chest ultrasonography has been found to be an efficient diagnostic tool for pleural effusion features, it is rarely utilized to predict the outcomes of pleural illnesses. Aim of the work: To determine the impact of sonographic patterns in predicting the outcomes of thoracic empyema patients. Patients and methods: In this retrospective study, patients were divided into four groups based on their sonographic patterns: (I) complex non-septated effusions (plankton sign), (II) complex fixed septated effusions, (III) complex mobile septated effusions, and (IV) homogenously echogenic effusions (hematocrit sign). These sonographic patterns were compared to the patients’ co-morbidities, length of stay in the hospital, chest tube drainage, and medicinal or surgical therapy effectiveness. Results: In comparison with other sonographic pattern groups, patients in group I (70.6%) and group IV (45.5%) had effective thoracic tube drainage with a very high statistically significant difference (P value < 0.001). For patients in group II (75%) (P value < 0.001), open thoracotomy was a very highly significant effective therapy (P value 0.001). Conclusion: The sonographic pattern of thoracic empyema is a useful tool for guiding treatment decisions in these patients. Keywords: Chest ultrasonography, Thoracic empyema, Tube drainage, Medical thoracoscopy, Video-assisted thoracic