Am. J. Respir. Crit. Care Med.,
Volume 162, Number 6, December 2000, 2026a-2026
REBUTTAL FROM DR. LIGHT
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ARTICLE |
I agree the ideal agent for pleurodesis should be highly effective, easy to administer, inexpensive, and not associated with serious adverse events. Dr. Sahn maintains that talc is the
ideal agent. I disagree with this.
Dr. Sahn asserts that talc is clearly the most effective agent.
I beg to differ. Heffner and associates reviewed the results of
pleurodesis in 420 patients who received talc, tetracycline derivatives, bleomycin, or Corynebacterium parvum and, using
multiple regression analysis, were unable to show that the
agent selected was significantly related to pleurodesis failure
(1). The failure rate with each of the agents was about 20%
(1). The two studies, referenced in the original editorial, in
which patients were randomized to receive talc or bleomycin,
did not show a significant advantage for talc (2, 3). In general,
the results with talc are slightly better than with bleomycin or
a tetracycline derivative, but are they enough better to take the
risk of inducing acute respiratory distress syndrome (ARDS)?
It is suggested that the ARDS picture seen after talc may
not be due to talc per se. However, it is infrequent with other agents. At a symposium on pleurodesis at the 1999 American
College of Chest Physicians meeting, which I cochaired with
Dr. John Heffner, the audience was polled concerning their
experience with talc for pleurodesis. The majority of the audience raised their hand when asked if they had seen ARDS after the administration of talc intrapleurally. When the same
question was asked concerning bleomycin or the tetracycline
derivatives, none raised their hands.
In conclusion, the ideal agent for pleurodesis is yet to be
discovered. Talc is not the ideal agent. This inhomogeneous
agent produces life-threatening respiratory failure in some individuals and therefore should not be used. The ideal agent is
still to be developed. I believe that the ideal agent will not injure the pleura but will, rather, induce the mesothelial cells to
produce collagen and induce a pleurodesis. Support for this
contention is our observation that the intrapleural injection of
transforming growth factor 
can induce an excellent pleurodesis in rabbits without producing an inflammatory pleural effusion (4).
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References |
1.
Heffner JE,
Nietert PJ,
Barbieri C.
Pleural fluid pH as a predictor of
pleurodesis failure: analysis of primary data.
Chest
2000;
117:
87-95
[Abstract/Free Full Text].
2.
Noppen M,
Degreve J,
Mignolet M,
Vincken W.
A prospective, randomized study comparing the efficacy of talc slurry and bleomycin in the
treatment of malignant pleural effusions.
Acta Clin Belg
1997;
52:
258-262
[Medline].
3.
Zimmer PW,
Hill M,
Casey K,
Harvey E,
Low DE.
Prospective randomized trial of talc slurry vs bleomycin in pleurodesis for symptomatic malignant pleural effusions.
Chest
1997;
112:
430-434
[Abstract/Free Full Text].
4.
Light RW,
Cheng D-S,
Lee YC,
Rogers J,
Davidson J,
Lane KB.
A single
intrapleural injection of transforming growth factor-2 produces excellent pleurodesis in rabbits.
Am J Respir Crit Care Med
2000;
162:
98-104
[Abstract/Free Full Text].
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