Background and aim In the paediatric population, secondary to the lack of evidence-based studies, management of pleural empyema raises numerous controversies. A notable debate is the choice between video-assisted thoracoscopy and chest drainage as an initial treatment.

The aim of the case reports is to outline a comparison between the two management options.

Methods We report two paediatric cases, aged between 18 and 36 months, with noncontributory personal history, who were admitted for severe parapneumonic pleural empyema complicated with sepsis. Initial antibiotherapy provided both Streptococcus pneumoniae and Staphylococcal coverage. After 72 hours, both patients exhibited unfavourable clinical and laboratory response along with enlarging pleural effusion on repeated ultrasound. Therefore, while for one patient, simple chest drainage was chosen, the other patient underwent video-assisted thoracoscopic surgery (VATS).

Results Blood and pleural fluid cultures isolated Streptococcus pneumoniae and Staphylococcus aureus strains, respectively. Both patients developed bronchopleural fistula, pneumatoceles and pachypleuritis. However, except for the higher hospitalisation costs, the patient who underwent surgery, overall, had a better outcome. VATS offered a shorter length of stay (42 days versus 62 days), shorter chest drain duration (4 weeks versus 7 weeks) and less extensive antibiotherapy duration (47 days versus 72 days). Upon follow-up, evolution was favourable with complete resolution of both the pneumatoceles and the residual pachypleuritis.

Conclusions The case reports highlight the advantages of VATS used as a primary management option in paediatric pleural empyema. Early surgery could ensure a better outcome. Nevertheless, each case requires a personalised therapeutic approach.