Editor,—We were disappointed that Careyet al’s recent article on surgical management of empyema thoracis1 was not balanced by a commentary providing the contrary view that surgery is rarely, if ever, needed in the modern management of empyema. Careyet al described the outcome of 18 children with empyema treated by open thoracotomy and decortication. The outcome in all 18 was good, with a mean length of stay in hospital after surgery of four days. They rightly emphasise that this treatment needed to be carried out in a regional cardiothoracic centre with experienced paediatric anaesthetists and surgeons and a paediatric intensive care unit, where several of the “younger” patients in this study spent the night still intubated. This treatment is then not readily available to most children who develop empyema.

We agree that, in expert hands, surgery can be an excellent treatment for empyema, however, we do not believe that this report advances the current management …