Background: Pediatric pleural effusion, particularly empyema, is a serious cause of childhood morbidity and prolonged hospitalization. Objective: This study objective was to evaluate the effectiveness of pigtail catheter placement plus alteplase (tPa) instillation intrapleural in treatment of parapneumonic effusion. Methods: A two-arm study was inducted to compare children who treated by pigtail catheter plus intarpleura tissue plasminogen activator (tPa) with children who were treated by thoracostomy tube drainage alone. Also, a cost effectiveness analysis was conducted on the basis of clinical outcomes and cost data available about each treatment strategy group. Result(s): Over the preiod of our study, 46 children were involved in group I with parapneumonic effusion treated by pigtail catheter plus intrapleural TPA and 24 children were involved in group II who were treated by thoracostomy tube drainage alone. The Length Of hospital Stay (LOS) was significantly shorter for 1st treatment strategy (group I) in addition to 0% failure rate (no surgical intervention needed). Group I strategy of management was the least expensive. Conclusion(s): Pigtail cathter plus intrapleural tPa is the more effective least expensive treatment strategy in management of children with parapneumonic effusion.