0
Original Research: PLEURAL DISEASE |

Lung Injury Following Thoracoscopic Talc Insufflation: Experience of a Single North American Center FREE TO VIEW

Anne V. Gonzalez, MD, MSc; Vishnu Bezwada, MD; John F. Beamis, Jr, MD, FCCP; Andrew G. Villanueva, MD, FCCP
Author and Funding Information

From the Montreal Chest Institute (Dr Gonzalez), McGill University Health Centre, Montreal, QC, Canada; the Department of Pulmonary and Critical Care Medicine (Dr Bezwada), Yuma Regional Medical Center, Yuma, AZ; and the Department of Pulmonary and Critical Care Medicine (Drs Beamis and Villanueva), Lahey Clinic Medical Center, Burlington, MA.

Correspondence to: Anne V. Gonzalez, MD, MSc, Montreal Chest Institute, McGill University Health Centre, 3650 Saint-Urbain St K1.09, Montreal, QC, Canada H2X 2P4; e-mail: anne.gonzalez@mcgill.ca


Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestpubs.org/site/misc/reprints.xhtml).


© 2010 American College of Chest Physicians


Chest. 2010;137(6):1375-1381. doi:10.1378/chest.09-2020
Text Size: A A A
Published online

Background:  Thoracoscopic talc insufflation (TTI) has been used to obliterate the pleural space and prevent recurrent pleural effusions or pneumothorax. Reports of acute pneumonitis and ARDS after the use of talc raised concern about its safety. Differences in particle size of various talc preparations may explain the variable occurrence of pneumonitis. We sought to determine the incidence of lung injury after TTI over a 13-year period at our institution.

Methods:  Patients who underwent TTI between January 1994 and July 2007 were identified from a prospectively maintained logbook. The talc used was commercially available sterile talc (Sclerosol). The hospital course was reviewed in detail, and all cases of respiratory insufficiency were examined with regard to onset, suspected cause, and outcome. Talc-related lung injury was defined as the presence of new infiltrates on chest radiograph and increased oxygen requirements, with no other identifiable trigger than talc exposure.

Results:  A total of 138 patients underwent 142 TTIs for recurrent pleural effusions or spontaneous pneumothorax. TTI was performed most frequently for malignant pleural effusions (75.5% of effusions). The median dose of talc was 6 g (range, 2-8 g). Dyspnea with increased oxygen requirements developed within 72 h postprocedure for 12 patients. Four patients (2.8%) had talc-related lung injury, and talc exposure may have contributed to the respiratory deterioration in four additional patients.

Conclusions:  We report the occurrence of lung injury after TTI using the only talc approved by the US Food and Drug Administration. These results reinforce previous concerns regarding the talc used for pleurodesis in North America.

Figures in this Article

Pleurodesis is the induction of symphysis between the parietal and visceral pleurae to obliterate the pleural space and prevent the accumulation of fluid or air. The most common indication is malignant pleural effusion. The technique is also used for recurrent pneumothorax and in selected patients with nonmalignant pleural effusions.

Pleurodesis is accomplished by mechanical or chemical means. Chemical pleurodesis can be performed by thoracoscopic talc insufflation (TTI) or by bedside instillation of a sclerosing agent via a chest tube, after complete drainage of the pleural cavity. A range of agents has been used for this purpose, including talc, tetracycline, doxycycline, and bleomycin. Talc is widely considered to be the most effective and least expensive pleurodesis agent.14

Concern has arisen about the use of talc for pleurodesis after reports of respiratory failure.5 Both pneumonitis and ARDS have been described after talc poudrage or administration of talc slurry.69 A large prospective study from Europe recently reported no cases of ARDS after TTI for malignant pleural effusions.10 It has been hypothesized that differences in talc preparations may account for the variable occurrence of respiratory failure.11,12 TTI has been performed at the Lahey Clinic since 1994, using a single, commercially available talc preparation. We sought to determine the incidence of lung injury related to talc in patients who underwent TTI over a 13-year period at our institution.

The technique of medical thoracoscopy has been reviewed elsewhere.13,14 Briefly, after patient positioning, preparation, and draping, lidocaine is instilled at the chosen point of entry (fourth to sixth intercostal space, midaxillary line). After blunt dissection, a trocar is inserted and pleural fluid evacuated using a suction catheter. Air is allowed to enter the pleural space to create a working space while equilibrating pleural pressures. The pleural space is inspected, and parietal pleural biopsies are taken when indicated. TTI is performed using aerosolized sterile talc and inspection confirms even talc distribution. A chest tube connected to a suction device evacuates the air and remaining fluid, maintaining close apposition of the pleural surfaces. The chest tube is removed once drainage decreases to < 150 mL per day. Medical thoracoscopy has been performed at the Lahey Clinic since 1994. A logbook of procedures is maintained prospectively.

Patients who underwent TTI between January 1994 and July 2007 were identified from the thoracoscopy logbook. During this 13-year period, the only talc used for pleurodesis was commercially available sterile talc delivered using single-use pressurized spray canisters (Sclerosol; Bryan Corporation; Woburn, MA). This is the only talc preparation approved by the US Food and Drug Administration (FDA). Each pressurized canister contains 4 g of talc. It is difficult to know with precision how much talc is delivered when less than a full canister is used: If the dose of talc was documented as a range, the higher estimated dose was recorded.

The medical charts were reviewed on all patients after approval of the Lahey Clinic Institutional Review Board. Patient characteristics, comorbidities, and effusion cause were recorded. Details of the procedure performed, including side, dose of talc, and duration of chest tube drainage, were compiled. The length of stay after TTI was calculated in patients whose stay was not prolonged as the result of reasons unrelated to the procedure (eg, first cycle of chemotherapy). Patients were followed until January 1, 2008. Mortality was verified using the Social Security death index (http://ssdi.rootsweb.ancestry.com). The “date last known alive” listing was the date of the patient’s last documented visit to the Lahey Clinic.

The postprocedure hospital course was reviewed, and all cases of respiratory insufficiency were examined with regard to onset, suspected cause, and outcome. Respiratory insufficiency was defined as increasing dyspnea or respiratory distress associated with oxygen desaturation and/or increased oxygen requirements. Onset was defined as < 24 h, 24 to 72 h, and > 72 h postprocedure. The cause of the respiratory deterioration was established based on review of the chart (documented diagnosis and/or differential diagnosis, arterial blood gas, clinical evolution, and outcome) and imaging (chest radiographs and/or CT scans of the thorax). The cause of the respiratory deterioration was agreed upon by consensus from all authors. Lung injury was defined as the presence of new infiltrates on chest radiographs in the context of increased oxygen requirements; if an arterial blood gas result was available, the Pao2 to Fio2 ratio was calculated. When lung injury related to talc was thought to be the culprit for the respiratory deterioration, the case was labeled a “talc reaction.” When a talc reaction was suspected but an alternate diagnosis could not be excluded, details of the presentation and/or differential diagnosis were considered.

The database was constructed using Access 2002 (Microsoft Corporation; Redmond, WA). Categorical variables are presented as the proportion of affected subjects. For continuous variables, either mean ± SD or median and range are shown. The Fisher exact test was used to compare the dose of talc received by patients with talc-related lung injury vs other subjects undergoing TTI. The Kaplan-Meier method was used to estimate time to death in patients with an underlying malignant pleural effusion vs other indications for pleurodesis. Statistical analyses were performed using SPSS (SPSS, Inc; Chicago, IL), and survival time curves were generated with GraphPad Prism (GraphPad Software, Inc; La Jolla, CA).

A total of 138 patients underwent 142 procedures between January 1994 and July 2007. The majority underwent TTI for recurrent pleural effusions; three procedures were performed for pneumothorax. Patient characteristics are detailed in Table 1. The mean age was 67 ± 13 years, and 47% were women. Malignant pleural effusion accounted for 75.5% of pleural effusions. The median talc dose was 6 g, and the mean period of chest tube drainage was 4.3 days.

Table Graphic Jump Location
Table 1 —Patient Characteristics

CAD = coronary artery disease; CHF = congestive heart failure; GU = genitourinary; MPE = malignant pleural effusion.

All patients were followed until death, last visit to the Lahey Clinic, or January 1, 2008. Survival was examined in patients who underwent TTI for malignant pleural effusions: the median and mean survival times were 5.5 months and 9.5 months, respectively. In contrast, patients who underwent TTI for benign pleural effusions or pneumothorax had a mean survival time of over 3 years. The Kaplan-Meier curves for the two groups are shown in Figure 1.

Figure Jump LinkFigure 1. Survival time after TTI. MPE = malignant pleural effusion; TTI = thoracoscopic talc insufflation.Grahic Jump Location

Dyspnea and increased oxygen requirements within 72 h of talc insufflation developed in 12 patients. Talc-related lung injury (talc reaction) occurred in four of 142 procedures (2.8%). Talc exposure may have contributed to the respiratory deterioration in an additional four patients (possible or suspected talc reaction). Two patients presented atypical features: Patient 3 showed only localized radiographic changes, suspicious for a talc-related lung injury, whereas in patient 6, the full radiographic changes were delayed by a few days. In two other patients, the possibility of pulmonary edema (patient 7) or reexpansion pulmonary edema (patient 2) could not be excluded.

Respiratory insufficiency within 72 h of TTI developed in four patients, for reasons unrelated to talc. Respiratory symptoms and radiographic changes at > 72 h postprocedure developed in an additional two patients, and these events were also deemed unrelated to talc. Details of all these cases and selected radiographic images are shown in Table 2 and , Figures 24 respectively.

Table Graphic Jump Location
Table 2 —Review of Patients With Respiratory Deterioration Postprocedure

Talc reactions and suspected talc reactions are listed in bold-faced type. L = left; LLL = left lower lobe; MV = mechanical ventilation; NIV = noninvasive ventilation; NP = nasal prongs; O2 = oxygen; R = right; RLL = right lower lobe; TTI = thoracoscopic talc insufflation.

a 

Arterial blood gas done while on 100% nonrebreathing mask.

Figure Jump LinkFigure 2. Patient 6 underwent TTI for right-sided MPE (A) and developed dyspnea and increased O2 requirements within 24 h (B), followed by extensive right lung consolidation in the following days (C). O2 = oxygen. See Figure 1 for expansion of other abbreviations.Grahic Jump Location
Figure Jump LinkFigure 3. Patient 9 developed dyspnea and increased O2 requirements within 48 h of right-sided TTI for MPE, with CT scan evidence of right lower lobe consolidation and ground-glass opacities. See Figures 1 and 2 for expansion of other abbreviations.Grahic Jump Location
Figure Jump LinkFigure 4. Patient 11 underwent TTI for right-sided MPE and developed dyspnea and increased O2 requirements within 72 h of the procedure. CT scan revealed a new left-sided effusion and bilateral ground-glass opacities. See Figures 1 and 2 for expansion of other abbreviations.Grahic Jump Location

One patient with a talc reaction required noninvasive ventilation; the other three patients received additional oxygen by nasal prongs or mask. In the patients with a suspected talc reaction, two patients required noninvasive ventilation. Patient 2 had advanced underlying malignancy, and the respiratory failure may have been due to reexpansion pulmonary edema vs a talc-related lung injury; he died after a conservative treatment decision was implemented. Three patients who had non-talc-related respiratory symptoms and subsequently died all had advanced malignancy.

The doses of talc received by patients who had a talc reaction (probable or suspected) vs all others who underwent TTI were compared by Fisher exact test. The cutoff used was a talc dose ≥ 6 g. There was no statistically significant association between talc dose and the occurrence of talc-related lung injury.

The use of talc to achieve pleurodesis was initially described by Norman Bethune in 1935.15 Talc can be administered as slurry through a chest tube or insufflated during thoracoscopy. Comparisons of TTI and talc slurry pleurodesis have yielded conflicting results. A 2004 Cochrane review concluded talc was the most efficacious sclerosing agent and TTI was superior to bedside talc instillation.2 The Phase 3 Intergroup Study of TTI vs talc slurry was a prospective, randomized trial comparing the two pleurodesis methods in patients with malignant pleural effusions.16 No significant difference in pleurodesis success was noted, but the subgroup of patients with lung or breast cancer had a higher success rate with TTI.

Controversy about the role of talc as a pleurodesis agent resulted from reports of respiratory failure associated with its use. Rinaldo et al6 reported on three patients who developed ARDS after instillation of 10 g of talc slurry. A case of acute pneumonitis with bilateral pleural effusions after instillation of 2 g of talc was reported by Bouchama and colleagues.7 In a review of 56 patients who received talc slurry in 73 procedures, one case of respiratory failure attributed to talc was recorded.17 Campos et al8 reported four cases of respiratory failure that occurred 24 to 48 h after TTI. The same authors reviewed their 15-year experience with TTI and reported respiratory failure in 1.3% of cases.18 Rehse and colleagues9 reported the highest rate of respiratory complications after talc pleurodesis (33%), with 9% of patients developing ARDS. In a randomized trial of TTI vs talc slurry, respiratory failure was observed in 4% of patients treated with talc slurry and 8% of patients randomized to TTI.16

In contrast, large series of patients undergoing TTI included no cases of respiratory failure. Weissberg and Ben-Zeev19 reported no poudrage-related deaths in 360 patients. In a French series of 360 procedures using Luzenac talc (Luzenac, France), there were no cases of talc-induced respiratory failure.20 In a recent multicenter, prospective, cohort study of 558 patients with malignant pleural effusions who underwent TTI using French-calibrated, large-particle talc, no patients developed ARDS.10 There were no episodes of respiratory failure after pleurodesis in another series of 112 procedures for primary spontaneous pneumothorax using French-graded talc.21

We reviewed the experience with TTI at the Lahey Clinic between January 1994 and July 2007 to determine the incidence of talc-related lung injury. The talc used throughout this period was Sclerosol, which is the only FDA-approved talc for thoracoscopic insufflation. Respiratory deterioration occurred within 72 h of TTI in 12 of 142 procedures (8.5%). Up to eight cases of lung injury may have been talc related. After detailed chart review, an alternate diagnosis could not be excluded in two patients and another two had atypical presentations. In four patients, a more definitive diagnosis of talc reaction could be established. If we only consider patients in whom no alternate diagnosis was considered, the incidence of talc-related lung injury in our series is 2.8%. Importantly, there were no cases of ARDS.

The study suffers from the limitations typical of a retrospective review. Assessment of the post-TTI course was restricted to detailed chart review, and thus limited to information that was recorded for the purpose of clinical care. Interpretation was based on the documented diagnosis or differential diagnosis, clinical evolution, and radiographic images. When more than a single diagnosis was recorded, it was difficult to establish a definitive diagnosis retrospectively. This was true when the possibility of pulmonary edema was raised. Reexpansion pulmonary edema, in particular, is usually unilateral and occurs after the evacuation of a pneumothorax or large pleural effusion. It is a rare condition with a mortality rate of up to 20% and for which treatment is supportive.22 Although we report no cases of ARDS after TTI, the occurrence of lung injury with no other culprit than talc exposure is a significant complication.

The affected patients experienced respiratory symptoms and increased oxygen requirements. The thoracoscopy logbook was maintained prospectively, making the denominator of the incidence calculation reliable. All patients who died after TTI had advanced underlying malignancy. One patient in whom a possible talc reaction was suspected died, but because of diagnostic uncertainty, talc-related lung injury cannot be implicated as the cause of death.

The pathogenesis of talc-induced lung injury remains incompletely understood. An animal study of two doses of talc slurry reported increased extrapleural talc deposition with the higher dose.23 The use of a maximum of 4 to 5 g of talc has been advocated,24 yet ARDS has occurred after both large and small doses of talc. ARDS has also been reported after the administration of talc as slurry or by poudrage. Striking differences in the incidence of respiratory failure and ARDS across centers have led investigators to examine differences in talc preparations.

Particle size distribution was analyzed in eight talc preparations used for pleurodesis, and marked variations were noted.11 The mean particle size of various US talcs ranged from 10 to 20 μm, vs 33 μm for French talc, with a larger proportion of small particles (< 10 μm) in US talcs. Particle size and distribution are highly dependent on the measurement method used. Kuzniar and colleagues25 examined the particle size distribution of Sclerosol using scanning microscopy: the median diameter was 18.2 μm, the 10th and 90th percentiles were 5.3 μm and 34.4 μm, respectively. The authors reported an acute lung injury incidence of 5.9% after operative talc pleurodesis, although two different talc preparations were used in this series.

Large-particle talc, also referred to as “graded” or “calibrated” talc, is talc from which the small particles (< 10 μm) have been mostly removed. The French large-particle talc Steritalc (Novatech; La Ciotat, France) contains 11% of particles < 5 μm, when measured using polarized microscopy; with laser diffraction, the 10th percentile of particle distribution is 5.5 μm.26 The US talc Sclerosol and French talc have been compared with laser diffraction: the 10th percentiles of particle distribution were 3.8 and 5.5 μm for Sclerosol and French talc, respectively. The 20th percentiles were 7.6 μm for Sclerosol and 10.5 μm for French talc. These results indicate that the Sclerosol talc preparation includes a larger proportion of small particles than French-graded talc (Dr Rodriguez-Panadero, personal communication).

The systemic distribution of small talc particles with subsequent inflammation has been proposed as a mechanism for acute pneumonitis and ARDS. The diameter of pleural stomata is approximately 6.2 μm,27 thus allowing the systemic absorption of smaller talc particles. This hypothesis is corroborated by the autopsy finding of talc crystals in the lung, liver, kidney, heart, and skeletal muscle of a patient who died of respiratory failure after TTI.8 The influence of talc particle size on extrapleural dissemination was investigated in rabbits by Ferrer et al28: The intrapleural injection of large-particle talc resulted in less pulmonary and systemic talc particle deposition than nongraded talc. In two small, randomized trials of mixed talc (mean particle size < 15 μm) vs graded talc, mixed talc worsened gas exchange and induced more systemic inflammation.29

In a large, prospective, cohort study of talc poudrage for malignant pleural effusion, the authors reported the appearance of new infiltration after thoracoscopy in seven of 558 patients. In one patient, this was attributed to transient cardiogenic pulmonary edema. We cannot exclude that some form of lung injury may have occurred in a proportion of patients with new lung infiltrates. However, the authors report these events were not associated with respiratory distress (Dr J. Janssen, personal communication). New lung infiltration of unclear cause occurred in 1.1% of patients (6/558), which is less than in the current series, where radiographic changes occurred in association with respiratory symptoms and increased oxygen requirements. Overall, the two recent European prospective studies of TTI using French calibrated talc attest to the safety of large-particle talc preparations.10,21

In conclusion, we report the occurrence of talc-related lung injury after thoracoscopic insufflation. We are aware of no other series reporting on the incidence of lung injury after exclusive use of the only FDA-approved talc for pleurodesis. Based on these findings and the established safety record of graded large-particle talc, we advocate the preferential use of large-particle talc for pleurodesis. Until graded large-particle talc is available in the United States, Sclerosol should be used with the knowledge that it may cause lung injury in a small proportion of patients.

Author contributions:Dr Gonzalez: participated in the study conception, completed the data collection, analyzed data, prepared the manuscript, and reviewed the data and the final manuscript.

Dr Bezwada: participated in the study conception, completed the data collection, and reviewed the data and the final manuscript.

Dr Beamis: participated in the study conception, and reviewed the data and the final manuscript.

Dr Villanueva: participated in the study conception, and reviewed the data and the final manuscript.

Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Other contributions: We acknowledge the assistance of Ms Rebecca Liberman with statistical analyses.

FDA

Food and Drug Administration

TTI

thoracoscopic talc insufflation

Walker-Renard PB, Vaughan LM, Sahn SA. Chemical pleurodesis for malignant pleural effusions. Ann Intern Med. 1994;1201:56-64. [PubMed]
 
Shaw P, Agarwal R. Pleurodesis for malignant pleural effusions. Cochrane Database Syst Rev. 2004;1:CD002916
 
Tan C, Sedrakyan A, Browne J, Swift S, Treasure T. The evidence on the effectiveness of management for malignant pleural effusion: a systematic review. Eur J Cardiothorac Surg. 2006;295:829-838. [CrossRef] [PubMed]
 
Kennedy L, Sahn SA. Talc pleurodesis for the treatment of pneumothorax and pleural effusion. Chest. 1994;1064:1215-1222. [CrossRef] [PubMed]
 
Light RW. Talc should not be used for pleurodesis. Am J Respir Crit Care Med. 2000;1626:2024-2026. [PubMed]
 
Rinaldo JE, Owens GR, Rogers RM. Adult respiratory distress syndrome following intrapleural instillation of talc. J Thorac Cardiovasc Surg. 1983;854:523-526. [PubMed]
 
Bouchama A, Chastre J, Gaudichet A, Soler P, Gibert C. Acute pneumonitis with bilateral pleural effusion after talc pleurodesis. Chest. 1984;865:795-797. [CrossRef] [PubMed]
 
Campos JRM, Werebe EC, Vargas FS, Jatene FB, Light RW. Respiratory failure due to insufflated talc. Lancet. 1997;3499047:251-252. [CrossRef] [PubMed]
 
Rehse DH, Aye RW, Florence MG. Respiratory failure following talc pleurodesis. Am J Surg. 1999;1775:437-440. [CrossRef] [PubMed]
 
Janssen JP, Collier G, Astoul P, et al. Safety of pleurodesis with talc poudrage in malignant pleural effusion: a prospective cohort study. Lancet. 2007;3699572:1535-1539. [CrossRef] [PubMed]
 
Ferrer J, Villarino MA, Tura JM, Traveria A, Light RW. Talc preparations used for pleurodesis vary markedly from one preparation to another. Chest. 2001;1196:1901-1905. [CrossRef] [PubMed]
 
Noppen M. Who’s (still) afraid of talc? Eur Respir J. 2007;294:619-621. [CrossRef] [PubMed]
 
Villanueva AG, Beamis JF.Beamis JF, Mathur PN, Mehta AC. Medical thoracoscopy: diagnosis of pleural pulmonary disorders. Interventional Pulmonary Medicine. 2004; New York, NY Marcel Dekker:431-449
 
Mathur PN, Astoul P, Boutin C. Medical thoracoscopy. Technical details. Clin Chest Med. 1995;163:479-486. [PubMed]
 
Bethune N. Pleural poudrage: new technique for the deliberate production of pleural adhesion as preliminary to lobectomy. J Thorac Surg. 1935;4:251-261
 
Dresler CM, Olak J, Herndon JE II, et al; Cooperative Groups Cancer and Leukemia Group B; Eastern Cooperative Oncology Group; North Central Cooperative Oncology Group; Radiation Therapy Oncology Group Cooperative Groups Cancer and Leukemia Group B; Eastern Cooperative Oncology Group; North Central Cooperative Oncology Group; Radiation Therapy Oncology Group Phase III intergroup study of talc poudrage vs talc slurry sclerosis for malignant pleural effusion. Chest. 2005;1273:909-915. [CrossRef] [PubMed]
 
Kennedy L, Rusch VW, Strange C, Ginsberg RJ, Sahn SA. Pleurodesis using talc slurry. Chest. 1994;1062:342-346. [CrossRef] [PubMed]
 
de Campos JRM, Vargas FS, de Campos Werebe E, et al. Thoracoscopy talc poudrage : a 15-year experience. Chest. 2001;1193:801-806. [CrossRef] [PubMed]
 
Weissberg D, Ben-Zeev I. Talc pleurodesis. Experience with 360 patients. J Thorac Cardiovasc Surg. 1993;1064:689-695. [PubMed]
 
Viallat JR, Rey F, Astoul P, Boutin C. Thoracoscopic talc poudrage pleurodesis for malignant effusions. A review of 360 cases. Chest. 1996;1106:1387-1393. [CrossRef] [PubMed]
 
Györik S, Erni S, Studler U, Hodek-Wuerz R, Tamm M, Chhajed PN. Long-term follow-up of thoracoscopic talc pleurodesis for primary spontaneous pneumothorax. Eur Respir J. 2007;294:757-760. [CrossRef] [PubMed]
 
Mahfood S, Hix WR, Aaron BL, Blaes P, Watson DC. Reexpansion pulmonary edema. Ann Thorac Surg. 1988;453:340-345. [CrossRef] [PubMed]
 
Montes JF, Ferrer J, Villarino MA, Baeza B, Crespo M, Garcia-Valero J. Influence of talc dose on extrapleural talc dissemination after talc pleurodesis. Am J Respir Crit Care Med. 2003;1683:348-355. [CrossRef] [PubMed]
 
American Thoracic SocietyAmerican Thoracic Society Management of malignant pleural effusions. Am J Respir Crit Care Med. 2000;1625:1987-2001. [PubMed]
 
Kuzniar TJ, Blum MG, Kasibowska-Kuzniar K, Mutlu GM. Predictors of acute lung injury and severe hypoxemia in patients undergoing operative talc pleurodesis. Ann Thorac Surg. 2006;826:1976-1981. [CrossRef] [PubMed]
 
Navarro Jiménez C, Gómez Izquierdo L, Sánchez Gutiérrez C, et al. Análisis morfométrico y mineralógico de 14 muestras de talco usado para pleurodesis en distintos países de Europa y América. Neumosur. 2005;173:197-202
 
Li J. Ultrastructural study on the pleural stomata in human. Funct Dev Morphol. 1993;34:277-280. [PubMed]
 
Ferrer J, Montes JF, Villarino MA, Light RW, García-Valero J. Influence of particle size on extrapleural talc dissemination after talc slurry pleurodesis. Chest. 2002;1223:1018-1027. [CrossRef] [PubMed]
 
Maskell NA, Lee YC, Gleeson FV, Hedley EL, Pengelly G, Davies RJ. Randomized trials describing lung inflammation after pleurodesis with talc of varying particle size. Am J Respir Crit Care Med. 2004;1704:377-382. [CrossRef] [PubMed]
 

Figures

Figure Jump LinkFigure 1. Survival time after TTI. MPE = malignant pleural effusion; TTI = thoracoscopic talc insufflation.Grahic Jump Location
Figure Jump LinkFigure 2. Patient 6 underwent TTI for right-sided MPE (A) and developed dyspnea and increased O2 requirements within 24 h (B), followed by extensive right lung consolidation in the following days (C). O2 = oxygen. See Figure 1 for expansion of other abbreviations.Grahic Jump Location
Figure Jump LinkFigure 3. Patient 9 developed dyspnea and increased O2 requirements within 48 h of right-sided TTI for MPE, with CT scan evidence of right lower lobe consolidation and ground-glass opacities. See Figures 1 and 2 for expansion of other abbreviations.Grahic Jump Location
Figure Jump LinkFigure 4. Patient 11 underwent TTI for right-sided MPE and developed dyspnea and increased O2 requirements within 72 h of the procedure. CT scan revealed a new left-sided effusion and bilateral ground-glass opacities. See Figures 1 and 2 for expansion of other abbreviations.Grahic Jump Location

Tables

Table Graphic Jump Location
Table 1 —Patient Characteristics

CAD = coronary artery disease; CHF = congestive heart failure; GU = genitourinary; MPE = malignant pleural effusion.

Table Graphic Jump Location
Table 2 —Review of Patients With Respiratory Deterioration Postprocedure

Talc reactions and suspected talc reactions are listed in bold-faced type. L = left; LLL = left lower lobe; MV = mechanical ventilation; NIV = noninvasive ventilation; NP = nasal prongs; O2 = oxygen; R = right; RLL = right lower lobe; TTI = thoracoscopic talc insufflation.

a 

Arterial blood gas done while on 100% nonrebreathing mask.

References

Walker-Renard PB, Vaughan LM, Sahn SA. Chemical pleurodesis for malignant pleural effusions. Ann Intern Med. 1994;1201:56-64. [PubMed]
 
Shaw P, Agarwal R. Pleurodesis for malignant pleural effusions. Cochrane Database Syst Rev. 2004;1:CD002916
 
Tan C, Sedrakyan A, Browne J, Swift S, Treasure T. The evidence on the effectiveness of management for malignant pleural effusion: a systematic review. Eur J Cardiothorac Surg. 2006;295:829-838. [CrossRef] [PubMed]
 
Kennedy L, Sahn SA. Talc pleurodesis for the treatment of pneumothorax and pleural effusion. Chest. 1994;1064:1215-1222. [CrossRef] [PubMed]
 
Light RW. Talc should not be used for pleurodesis. Am J Respir Crit Care Med. 2000;1626:2024-2026. [PubMed]
 
Rinaldo JE, Owens GR, Rogers RM. Adult respiratory distress syndrome following intrapleural instillation of talc. J Thorac Cardiovasc Surg. 1983;854:523-526. [PubMed]
 
Bouchama A, Chastre J, Gaudichet A, Soler P, Gibert C. Acute pneumonitis with bilateral pleural effusion after talc pleurodesis. Chest. 1984;865:795-797. [CrossRef] [PubMed]
 
Campos JRM, Werebe EC, Vargas FS, Jatene FB, Light RW. Respiratory failure due to insufflated talc. Lancet. 1997;3499047:251-252. [CrossRef] [PubMed]
 
Rehse DH, Aye RW, Florence MG. Respiratory failure following talc pleurodesis. Am J Surg. 1999;1775:437-440. [CrossRef] [PubMed]
 
Janssen JP, Collier G, Astoul P, et al. Safety of pleurodesis with talc poudrage in malignant pleural effusion: a prospective cohort study. Lancet. 2007;3699572:1535-1539. [CrossRef] [PubMed]
 
Ferrer J, Villarino MA, Tura JM, Traveria A, Light RW. Talc preparations used for pleurodesis vary markedly from one preparation to another. Chest. 2001;1196:1901-1905. [CrossRef] [PubMed]
 
Noppen M. Who’s (still) afraid of talc? Eur Respir J. 2007;294:619-621. [CrossRef] [PubMed]
 
Villanueva AG, Beamis JF.Beamis JF, Mathur PN, Mehta AC. Medical thoracoscopy: diagnosis of pleural pulmonary disorders. Interventional Pulmonary Medicine. 2004; New York, NY Marcel Dekker:431-449
 
Mathur PN, Astoul P, Boutin C. Medical thoracoscopy. Technical details. Clin Chest Med. 1995;163:479-486. [PubMed]
 
Bethune N. Pleural poudrage: new technique for the deliberate production of pleural adhesion as preliminary to lobectomy. J Thorac Surg. 1935;4:251-261
 
Dresler CM, Olak J, Herndon JE II, et al; Cooperative Groups Cancer and Leukemia Group B; Eastern Cooperative Oncology Group; North Central Cooperative Oncology Group; Radiation Therapy Oncology Group Cooperative Groups Cancer and Leukemia Group B; Eastern Cooperative Oncology Group; North Central Cooperative Oncology Group; Radiation Therapy Oncology Group Phase III intergroup study of talc poudrage vs talc slurry sclerosis for malignant pleural effusion. Chest. 2005;1273:909-915. [CrossRef] [PubMed]
 
Kennedy L, Rusch VW, Strange C, Ginsberg RJ, Sahn SA. Pleurodesis using talc slurry. Chest. 1994;1062:342-346. [CrossRef] [PubMed]
 
de Campos JRM, Vargas FS, de Campos Werebe E, et al. Thoracoscopy talc poudrage : a 15-year experience. Chest. 2001;1193:801-806. [CrossRef] [PubMed]
 
Weissberg D, Ben-Zeev I. Talc pleurodesis. Experience with 360 patients. J Thorac Cardiovasc Surg. 1993;1064:689-695. [PubMed]
 
Viallat JR, Rey F, Astoul P, Boutin C. Thoracoscopic talc poudrage pleurodesis for malignant effusions. A review of 360 cases. Chest. 1996;1106:1387-1393. [CrossRef] [PubMed]
 
Györik S, Erni S, Studler U, Hodek-Wuerz R, Tamm M, Chhajed PN. Long-term follow-up of thoracoscopic talc pleurodesis for primary spontaneous pneumothorax. Eur Respir J. 2007;294:757-760. [CrossRef] [PubMed]
 
Mahfood S, Hix WR, Aaron BL, Blaes P, Watson DC. Reexpansion pulmonary edema. Ann Thorac Surg. 1988;453:340-345. [CrossRef] [PubMed]
 
Montes JF, Ferrer J, Villarino MA, Baeza B, Crespo M, Garcia-Valero J. Influence of talc dose on extrapleural talc dissemination after talc pleurodesis. Am J Respir Crit Care Med. 2003;1683:348-355. [CrossRef] [PubMed]
 
American Thoracic SocietyAmerican Thoracic Society Management of malignant pleural effusions. Am J Respir Crit Care Med. 2000;1625:1987-2001. [PubMed]
 
Kuzniar TJ, Blum MG, Kasibowska-Kuzniar K, Mutlu GM. Predictors of acute lung injury and severe hypoxemia in patients undergoing operative talc pleurodesis. Ann Thorac Surg. 2006;826:1976-1981. [CrossRef] [PubMed]
 
Navarro Jiménez C, Gómez Izquierdo L, Sánchez Gutiérrez C, et al. Análisis morfométrico y mineralógico de 14 muestras de talco usado para pleurodesis en distintos países de Europa y América. Neumosur. 2005;173:197-202
 
Li J. Ultrastructural study on the pleural stomata in human. Funct Dev Morphol. 1993;34:277-280. [PubMed]
 
Ferrer J, Montes JF, Villarino MA, Light RW, García-Valero J. Influence of particle size on extrapleural talc dissemination after talc slurry pleurodesis. Chest. 2002;1223:1018-1027. [CrossRef] [PubMed]
 
Maskell NA, Lee YC, Gleeson FV, Hedley EL, Pengelly G, Davies RJ. Randomized trials describing lung inflammation after pleurodesis with talc of varying particle size. Am J Respir Crit Care Med. 2004;1704:377-382. [CrossRef] [PubMed]
 
NOTE:
Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s "Cited By" API will populate this tab (http://www.crossref.org/citedby.html).

Some tools below are only available to our subscribers or users with an online account.

Related Content

Customize your page view by dragging & repositioning the boxes below.

CHEST Journal Articles
CHEST Collections
PubMed Articles
  • CHEST Journal
    Print ISSN: 0012-3692
    Online ISSN: 1931-3543