ArticlesSafety of pleurodesis with talc poudrage in malignant pleural effusion: a prospective cohort study
Introduction
Talc is hydrated magnesium silicate, and was first used for pleurodesis in 1935 by the surgeon Norman Bethune.1 In the second half of the 20th century, talc became increasingly popular for induction of pleurodesis in many pleural diseases—eg, spontaneous pneumothorax, benign pleural effusion, and malignant pleural effusion.2, 3, 4, 5, 6 Compared with other agents for chemical pleurodesis, talc seemed to give the best results in terms of effectiveness, with least recurrence of effusion, after both talc poudrage, and instillation of talc slurry through a chest tube.7 The effectiveness of talc pleurodesis compared with other forms of pleurodesis has also been supported by animal studies.8 Additionally, talc is inexpensive and widely available.
However, the safety of intrapleural application of talc has been debated since cases of respiratory failure and acute respiratory distress syndrome after talc pleurodesis were reported.4, 9, 10, 11 Other authors noted no complications at all, even in large series of patients.6, 12, 13 The occurrence of acute respiratory distress syndrome in some series and its absence in others was independent of the underlying disease (malignant pulmonary effusion or pneumothorax),6, 10, 11 the quantity of talc used (2–10 g),4, 6, 10, 11, 12 or the technique of talc instillation (slurry or poudrage).4, 6, 10, 11, 12 Several researchers have reported results that suggest that acute respiratory distress syndrome after talc pleurodesis is mainly related to the particle size of the talc used.14, 15
Our aim was to assess the safety of large-particle talc applied as poudrage for pleurodesis in patients with malignant pleural effusion.
Section snippets
Patients
We did a prospective cohort study to measure the side-effects of thoracoscopy and pleurodesis by poudrage with large-particle talc for treatment of recurrent malignant pleural effusions. 14 centres (all departments of pulmonary diseases) participated in the study, 13 in Europe and one in South Africa, between Oct 1, 2002, and Oct 31, 2005. Our primary endpoint was the occurrence of acute respiratory distress syndrome after talc pleurodesis. Secondary endpoints were other side-effects (eg,
Results
558 patients aged 30–96 years, (mean 64·4 years) were recruited. Table 1 shows the patients' baseline characteristics and the contribution of each institution. Table 2 shows details of the thorascopic procedures. Non-steroidal anti-inflammatory drugs were used in 178 (32%) patients. Parietal pleural biopsies were obtained in 475 (85%) patients (range 1–30, mean 6·3, mode 5 per patient). Visceral biopsies (range 1–10, average 3·7, mode 3) were obtained in 23 (4%) patients. If no biopsy sample
Discussion
The absence of acute respiratory distress syndrome in patients with malignant pulmonary effusion supports our hypothesis that pleurodesis with large-particle talc is safe. Side-effects from thoracoscopic pleurodesis were mild in our study. The small increases in temperature and oxygen use after talc pleurodesis were not clinically significant, and might be due to mild systemic and lung inflammation caused by talc.14, 19 Our results also accord with the hypothesis that acute respiratory distress
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