One concern about talc is that its intrapleural administration has been associated with the development of ARDS and death in some patients. The incidence of ARDS has varied markedly from series to series, and most of the reported cases have been from the United States. There were 13 respiratory deaths in the 449 patients (2.9%) in the study by Dresler et al8 discussed previously. Maskell et al13 randomized 20 patients with malignant effusions to receive 20 mg/kg tetracycline or 4 g of mixed talc, with most particles <15 μm. They reported that the patients who received mixed talc had a significantly greater decrease in diethylene triamine pentaacetic acid clearance, a significantly greater decrease in arterial oxygen saturation, and a significantly greater increase in C-reactive protein.12 It appears that acute lung injury depends on the size of the talc used. Maskell et al13 randomized 48 patients to receive mixed talc or graded talc in which most particles <15 μm had been removed. They reported that the patients who received the graded talc had a significantly smaller increase in the alveolar to arterial oxygen gradient, a significantly smaller decrease in PaO2, and a significantly smaller increase in C-reactive protein. Janssen et al,14 in a multicenter, open-label, prospective cohort study of 558 patients who received 4 g calibrated French large-particle-sized talc for malignant effusion, reported that there were no instances of ARDS. However, seven patients did develop pulmonary infiltrates, which they attributed to reexpansion pulmonary edema in two, cardiogenic pulmonary edema in one, and respiratory failure unrelated to talc in one.13 I am not convinced that the pulmonary infiltrates in some of these patients were not related to the talc. In general, if one elects to use talc as a pleurodesing agent, only large-sized talc should be used.