Talc Should Not Be Used for Pleurodesis

Richard W. Light

Saint Thomas Hospital, Vanderbilt University, Nashville, Tennessee

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At the present time, talc is one of the agents most commonly used for producing a pleurodesis in patients with either a spontaneous pneumothorax or a recurrent pleural effusion. However, questions have been raised concerning the safety of talc administered intrapleurally. In particular, there have been reports of acute respiratory distress syndrome (ARDS) occurring after talc is administered intrapleurally either as a slurry (1) or as an insufflation (5). There are at least 32 cases in the literature of ARDS occurring after administration of intrapleural talc, 17 after the use of talc slurry and the remaining 15 after talc insufflation (1). Within the first 48 h of receiving the talc, the patients developed ARDS and required mechanical ventilation. In eight instances the patient died (1, 4, 8).

The incidence of ARDS occurring after administration of intrapleural talc has varied markedly from series to series. Most of the reported cases have been from the United States. The highest incidence was that reported by Rehse and associates (6), who retrospectively reviewed 89 talc pleurodesis procedures in 78 patients. They reported that the incidence of respiratory complications or death was 33%; eight patients developed acute respiratory distress syndrome, one patient died, six patients developed dyspnea, and three patients developed re-expansion pulmonary edema (6). Although it has been suggested (10) that respiratory failure might be more common after larger doses of talc or talc slurry, Campos Milanez and coworkers reported that acute respiratory failure developed in 4 of 338 patients (1.2%) who received 2 g of insufflated talc for either recurrent pleural effusion or pneumothorax (5). It should be noted, however, that the reported incidence of respiratory complications is zero in some large series. Weissberg (10), from Israel, reported no incidences of acute respiratory distress in 360 patients who received talc pleurodesis, whereas Rodriguez-Panadero and Antony from Spain reported no cases of acute respiratory distress in 299 patients (11).

The mechanism or mechanisms by which talc produces acute lung injury is unknown. Talc is a pulverized, natural, foliated, hydrated magnesium silicate with the approximate chemical formula Mg₃(Si₂O₅)₂(OH)₂. Calcium, aluminum, and iron are always present in variable amounts. Every talc deposit is unique with regard to both chemistry and morphology. When talc is processed, it is passed through mesh to eliminate the larger sized talc particles. The size of the final talc preparation depends on the size of the mesh through which it has been passed. There are more than threefold differences in the median particle size of various talc preparations used for pleurodesis, and there are also marked variations in the contaminants present in various talc preparations (12). One hypothesis is that the acute pneumonitis is related to the systemic absorption of talc, with the subsequent elaboration of inflammatory mediators, and that smaller particles are more likely to be absorbed. This hypothesis is supported by the observations in the one case reported by Rinaldo and coworkers (1) and by Campos Milanez and associates (5), who reported that there were large quantities of talc in the bronchoalveolar fluid of their patient, who presented with acute pneumonitis after talc pleurodesis. In addition, the one patient reported by Milanez Campos and colleagues, and who underwent an autopsy, had talc crystals present in almost every organ, including the ipsilateral and contralateral lung, brain, liver, kidney, heart, and skeletal muscle. Moreover, after talc is administered intrapleurally to rabbits (13) or rats (14), talc particles are found throughout the body.

From the above, it is evident that the intrapleural administration of talc, either as a slurry or as an insufflation, induces ARDS in a small percentage of patients and leads to the death of an occasional patient. Is the superiority of talc administration over other available methods of producing a pleurodesis sufficiently great to justify its continued used? Let us consider the cases separately for pleurodesis done in association with tube thoracostomy and pleurodesis done in association with thoracoscopy.

When pleurodesis is performed in conjunction with tube thoracostomy for a recurrent pleural effusion or pneumothorax, the main alternatives to talc slurry are a tetracycline derivative or bleomycin. Although it is generally accepted that talc slurry is most effective at producing a pleurodesis, there is no strong evidence that this is true. Two randomized studies (15, 16) comparing the efficacy of talc slurry and bleomycin were unable to demonstrate any significant difference in the success rates with the two agents. Heffner and associates, in reviewing the results of pleurodesis in 570 patients, were unable to demonstrate any significant difference in the success rates between talc, bleomycin, or the tetracycline derivatives (17).

Thoracoscopy plus the placement of a chest tube will lead to a pleurodesis in more than 50% of patients with a malignant pleural effusion. When two studies with 61 patients were combined, thoracoscopy plus a chest tube for a few days resulted in a pleurodesis in 38 patients (62%) (18, 19). The insufflation of talc in conjunction with thoracoscopy will result in successful pleurodesis in at least 90% of patients. An alternative to talc insufflation is mechanical abrasion of the pleura. Although there are no large series evaluating thoracoscopy with pleural abrasion in the treatment of malignant pleural effusion, it has been shown in dogs that mechanical abrasion is at least as good as talc in producing a pleurodesis when the pleura is normal (20). On the basis of the above, when an attempt is made to produce pleurodesis in conjunction with a thoracoscopic procedure, pleural abrasion followed by tube thoracostomy for a couple of days is recommended.

In conclusion, the administration of talc intrapleurally, either insufflated or as a slurry, can lead to the development of the acute respiratory distress syndrome and even death. Similar problems are not seen after the intrapleural administration of the tetracycline derivatives or bleomycin or after mechanical abrasion of the pleura. Because there is no convincing evidence that talc slurry is superior to either the tetracycline derivatives or bleomycin administered via a tube thoracostomy or that talc insufflation is superior to mechanical abrasion of the pleura, talc should not be used for pleurodesis.

	References

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