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Intrapleural talc has been used in humans for 65 years (1), with the first reported series in 1947 (2). The greater than 3,100 patients reported who received talc pleurodesis for malignant and nonmalignant pleural effusions and pneumothorax greatly exceed those reported with all other agents combined. Thus, one would expect to see some adverse events that may or may not be associated with talc. Although Dr. Light cites 32 instances of ARDS after talc pleurodesis, scrutiny of these retrospective reports suggests that only 17 actually had ARDS that appeared likely to be related to standard techniques for administering talc. For example, Dr. Light cites that 5 of the 75 patients undergoing talc pleurodeses developed respiratory failure in the Memorial Sloan-Kettering series. Of these five patients, however, one had hypercapnic respiratory failure from excess narcotics, one developed contralateral pneumonia 48 h after pleurodesis, one had simultaneous bilateral talc instillations (which is not recommended), and two recovered without ventilation, indicating a lesser degree of lung injury than ARDS (3). Rinaldo and coworkers (4) reported three patients who developed the insidious onset of respiratory distress 72 h after the administration of 10 g (an unnecessarily high dose) of talc. They also reported, in the same article, that 1 of 10 patients who received tetracycline pleurodesis died 72 h later. The abstract by Todd and associates (5), which reported seven instances of respiratory failure and/or pneumonia after 197 talc poudrages, did not provide sufficient details to determine a cause.
The literature clearly confirms the superiority of talc as a pleurodesis agent (6, 7). The two comparative studies of talc and bleomycin (8, 9) mentioned by Dr. Light as showing no differences included only 59 patients, with a trend toward talc's greater effectiveness. The study by Heffner and associates (10) was not designed to compare pleurodesis agents, as suggested by Dr. Light, in that data from multiple centers, each using a single agent, were pooled to examine predictive properties of pleural fluid pH.
Finally, talc anecdotally found in BAL fluid or in other organs does not prove that it is the cause of respiratory failure as any substance, such as lidocaine or tetracycline, instilled intrapleurally can be found in BAL fluid and blood.
In conclusion, the available data support talc as the most effective pleurodesis agent. A patient rarely develops respiratory failure from talc, and death is an even rarer occurrence. The risks and benefits of talc should be discussed with patients who need rapid and effective pleurodesis. Although we should not discard talc on the basis of retrospective, anecdotal reports of respiratory failure, we should continue to search for better approaches to pleurodesis.
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1. Bethune N. A new technique for the deliberate production of pleural adhesions as a preliminary to lobectomy. J Thorac Surg 1935; 4: 251-261 .
2. Steele JD. Production of pleural adhesions for therapeutic purposes. Am Rev Tuberc 1947; 56: 299-302 .
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4. Rinaldo JE, Owens GR, Rogers RM. Adult respiratory distress syndrome following intrapleural instillation of talc. J Thorac Cardiovasc Surg 1983; 85: 523-526 [Abstract].
5. Todd TRJ, Delarue NC, Ilves R, Pearson FG, Cooper JD. Talc poudrage for malignant pleural effusion [abstract]. Chest 1980; 78: 542-543 .
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Walker-Renard PB,
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8. Noppen M, Degreve J, Mignolet M, Vincken W. A prospective, randomised study comparing the efficacy of talc slurry and bleomycin in the treatment of malignant pleural effusions. Acta Clin Belg 1997; 52: 258-262 [Medline].
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Zimmer PW,
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