Children with empyema are managed differently depending on local practice. There are 2 main approaches: a primary surgical debridement using either a video-assisted thoracoscopic surgical (VATS) approach or an open procedure and primary medical treatment using a chest drain plus intrapleural fibrinolytic drugs. This difference in approach has engendered sufficient passion to produce 2 head-to-head randomized controlled trials (VATS versus fibrinolytics), and neither trial could demonstrate a difference in length of stay or other outcome measure. Other evidence shows that fibrinolytics are successful in between 85% and 95% of cases and that a primary medical management strategy is less costly than surgery.
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