Randomized Clinical Trial Algorithm 
serous, infection, opacity, inadequate lung re-expansion
INFECTION, OPACITY, CAVITY
IPFT indicates intrapleural fibrinolytic therapy.Effectiveness of drainage and/or lung re-expansion was determined on protocol image 1, defined as imaging (chest radiography or chest computed tomography) the day following chest tube placement. Patients with complete pleural fluid drainage and adequate lung re-expansion were followed up with usual clinical care without randomization and were observed until discharge. Patients with incomplete drainage and/or inadequate lung re-expansion as assessed by the attending physician underwent a thoracic surgery consultation to determine surgical candidacy. Those patients deemed ineligible for surgical intervention received guideline-appropriate nonsurgical care and were observed until discharge.Those eligible for surgical management underwent randomization with a 1:1 allocation using the sealed envelope technique, generated by the research coordinator, to either IPFT or surgery. The primary intervention was required to be initiated within 48 hours. Those patients randomized to the IPFT group received 5 to 6 doses of IPFT with 10 mg of tissue plasminogen activator and 5 mg of deoxyribonuclease delivered twice a day through the chest tube, which was then clamped, allowing the IPFT to remain in the pleural cavity for 1 hour. Patients randomized to the surgical group underwent surgical decortication with either an open or a video-assisted thoracoscopic surgery (VATS) approach at the discretion of the surgeon.The morning following intervention completion (last dose of IPFT or surgery), protocol image 2 was obtained to categorize drainage as satisfactory improvement of the pleural fluid collection (>75% improvement in opacity on imaging), unsatisfactory improvement (≤75% improvement without clinical evidence of infection), or treatment failure (≤75% improvement and evidence of ongoing infection, defined below). In patients with satisfactory improvement without ongoing signs and symptoms of infection, chest tubes were removed once fluid was serous and output was less than 200 mL in 24 hours. In patients with unsatisfactory improvement without ongoing signs and symptoms of infection, and in those with treatment failure, further clinical management was at the discretion of the managing physician.