The basic principles of empyema management center on the initiation of antibiotics and effective pleural space drainage. For patients with empyemas in the exudative or fibrinopurulent stage, image-guided chest tubes have markedly improved patient care. These catheters can be placed into ideal positions within the chest by the use of various imaging techniques to promote effective drainage. Because of a minimal need for tissue dissection, patients tolerate image-guided catheters well with only local anesthetics. Multiple techniques exist to augment tube drainage if necessary. Available approaches include tube exchange with placement of a larger-caliber catheter, tube manipulation, and fibrinolytic therapy. However, success of image-guided catheters depends on proper patient selection, the skills of the operator, and the ability to monitor daily chest tube function to ensure adequacy of drainage. Open surgical procedures can be avoided in most treated patients.