Non-Operative Management of Pediatric Empyema.

BACKGROUND: Primary fibrinolysis is the standard treatment for pediatric empyema at our institution. A prior randomized trial demonstrated no clinical benefit of video-assisted thoracoscopic surgery (VATS) compared with fibrinolysis. After garnering more experience, subsequent protocol refinement reduced progression to VATS to 4.5%. This study aims to report outcomes following further maturation of our protocol. METHODS: A retrospective review was performed of patients ≤18 years treated for empyema between March 1, 2019 and July 1, 2025. The protocol includes placement of a ≤12Fr thoracostomy tube and administration of three daily doses of tissue plasminogen activator (tPA), 4 mg in 40 mL normal saline. Patients with immunocompromised status, alternative indications for thoracostomy, or contraindications to VATS at presentation were excluded. The primary outcome was progression to VATS. Secondary outcomes included examining potential factors associated with repeat fibrinolysis. RESULTS: 70 patients met inclusion criteria. Median age was 4.6 years [IQR 2.1-7.4]. Median chest tube duration was 5 days [IQR 4-7]. Median number of tPA doses was 3 [IQR 3-3]. Median length of stay (LOS) was 8 days [IQR 5-11]. All patients were treated with intrapleural fibrinolysis. No patients subsequently required VATS. Fifteen patients (21%) underwent repeat fibrinolysis. On multivariable analysis, persistent oxygen requirement after one course of tPA (OR 5.819, 95% CI 1.230-27.521; p=0.026) was independently predictive of repeat therapy. There were no 30-day readmissions. CONCLUSION: With a standardized protocol emphasizing primary and repeat intrapleural fibrinolysis, operative intervention was not required for pediatric empyema.