Although most children with empyema respond to antibiotics and pleural drainage, a recognizable number fail to improve. This study reviews experience with ten children over the past 7 years who have been selected for lung decortication for refractory empyema. Decortication was performed because of lack of clinical improvement despite drainage and multiple antibiotics during an average 20-day preoperative hospitalization. Responsible organisms included beta-hemolytic Streptococcus, Streptococcus pneumoniae, and Hemophilus influenzae. A computerized tomographic (CT) scan of the chest was performed in the last eight patients and showed at least a 50% limitation of lung expansion by the products of the empyema in each case. Following decortication, chest tubes were removed, antibiotics stopped, and temperature and white blood cell count returned promptly to normal. The advantages of early decortication in selected patients with empyema who do not respond to antibiotics and drainage include low morbidity, shorter hospitalization, and excellent long-term results.