Initial management of empyema in the pediatric population poses a substantial clinical challenge to pediatric surgeons, and considerable variation in practice exists. Although early surgical debridement with video-assisted thoracoscopic surgery (VATS) was historically utilized, this can impose substantial cost, morbidity, and potentially prolong hospitalization for patients. Pleural drainage with intrapleural instillation of fibrinolytic agents has garnered enthusiasm in recent decades and been prospectively evaluated in several randomized controlled trials. Overall, initial thoracic drainage and chemical debridement strategies have been shown to have equivalent or somewhat superior complication profiles, failure rates, and length of stay compared to VATS and may minimize the need for surgery for many patients.