Surgery should be the first line of treatment for empyema.

Few thoracic conditions present such considerable challenges as pleural space infections, herein termed 'empyema' as a general term. Patients may present with free-flowing infected pleural effusions that readily drain by catheter or, at the other extreme, with organized intrapleural collections of pus with thick pleural peels that require open decortication. In the transition from a simple to complex empyema, patients pass through the intermediary, or 'fibrinopurulent' stage. Such patients require careful assessment to determine the ideal management approach. Although existing trials provide insufficient evidence to standardize drainage approaches, an accepted principle directs clinicians to drain empyemas promptly and completely. In this pro-con presentation, two recognized experts on empyema--a thoracic surgeon and an interventional radiologist-approach management from decidedly opposite perspectives. The surgeon prefers video-assisted thoracoscopic surgery as primary therapy for fibrinopurulent empyemas. The radiologist counters that imaging-guided, small-bore catheters, sometimes with adjunctive fibrinolytic drugs, provide effective therapy for select patients. In the absence of high-quality data to settle this debate, both experts present reasoned and thoughtful approaches, which produce superior clinical outcomes in their own institutions. So readers should recognize that controversy exists in empyema management and carefully review each expert's comments. Within each are essential elements of care that can be integrated into a multidisciplinary approach. Readers may conclude from this debate that each institution should develop a collaborative model for managing empyemas that integrates differing expertise to customize care for individual patients and continuously measure and improve their patients' outcomes.