How should we manage empyema: Antibiotics alone, fibrinolytics, or primary video-assisted thoracoscopic surgery (VATS)?

Empyema is a well-recognized complication of pneumonia and its prevalence is increasing in the childhood population. The management of these patients requires a strategy for diagnosis and treatment that results in prompt resolution of infection and discharge with minimal morbidity. Traditionally conservative treatment has been the standard with insertion of a chest drain and intravenous antibiotics and, for those who fall to respond, an open thoracotomy and formal decortication. Since the 1990s two new treatment modalities have been described; fibrinolysis (promoting pleural drainage and circulation) and early VATS (video-assisted thoracoscopic surgery). Many institutions are now using one of these methods as first-line therapy. Both of these treatments result in shorter hospital stay and fewer complications than the conservative approach. In this review we will appraise the evidence for all three treatments and consider which treatment is optimal in children.