The appropriate management of pediatric empyema thoracis remains controversial. The authors reviewed 47 cases of empyema thoracis over a 26-year period. The management of empyema included initial diagnostic thoracentesis and classification as acute, fibropurulent, or chronic. If the empyema was "acute," therapeutic tap, tube thoracostomy, or no surgical intervention was performed. "Fibropurulent" empyemas were uniformly treated with tube thoracostomy. The lung was decorticated when the empyema was encased by a thick peel, had recurred and was multiloculated, was refractory and the patient remained clinically unwell, or had occurred as a complication of previous thoracotomy. All patients with acute empyemas responded to antibiotics irrespective of drainage (average duration of fever, 17 days; average stay in hospital, 27 days). Of the fibropurulent empyemas in our review, complete drainage was attained in seven of 39 (18%), and decortication was not required in any empyema that was completely drained. Loculations persisted in 25 of 39 (64%) after tube thoracostomy but nonetheless resolved. The remaining seven of 39 (18%) with persistent loculations required formal decortication. Of the patients with fibropurulent empyemas that responded to tube thoracostomy, the average duration of fever was 13 days and hospitalization, 23 days. Of those requiring decortication the average duration of fever was 24 days and hospitalization, 40 days. These results will allow a baseline for comparison of new strategies (fibrinolytics and early thoracoscopy) that may reduce days of fever, hospitalization, and risk of formal decortication.