Is Talc Indicated for Pleurodesis?: Con: Talc Should Not be Used for Pleurodesis

Old age and underlying interstitial abnormalities are risk factors for development of ARDS after pleurodesis using limited amount of large particle size talc

BACKGROUND AND OBJECTIVE

Talc pleurodesis is commonly performed to manage refractory pleural effusion or pneumothorax. It is considered as a safe procedure as long as a limited amount of large particle size talc is used. However, acute respiratory distress syndrome (ARDS) is a rare but serious complication after talc pleurodesis. We sought to determine the risk factors for the development of ARDS after pleurodesis using a limited amount of large particle size talc.

METHODS

We retrospectively reviewed patients who underwent pleurodesis with talc or OK-432 at the University of Tokyo Hospital.

RESULTS

Twenty-seven and 35 patients underwent chemical pleurodesis using large particle size talc (4 g or less) or OK-432, respectively. Four of 27 (15%) patients developed ARDS after talc pleurodesis. Patients who developed ARDS were significantly older than those who did not (median 80 vs 66 years, P = 0.02) and had a higher prevalence of underlying interstitial abnormalities on chest computed tomography (CT; 2/4 vs 1/23, P < 0.05). No patient developed ARDS after pleurodesis with OK-432. This is the first case series of ARDS after pleurodesis using a limited amount of large particle size talc.

CONCLUSION

Older age and underlying interstitial abnormalities on chest CT seem to be risk factors for developing ARDS after talc pleurodesis.

Pleurodese

Pleurodesis is a way of inducting an inflammatory process in the pleural surface in order to create the closure of the pleural space. The exact mechanism isn't completely understood and there is still a great deal of controversy concerning pleurodesis. Pleurodesis can be achieved by introduction of a sclerosant agent trough a chest tube into the pleural space, by medical thoracoscopy, by surgical thoracoscopy or by thoracotomy. The principal sclerosant agents are talc and tetracycline. The indications for pleurodesis are malignant recurrent pleural effusion, primary recurrent pneumothorax, secondary pneumothorax and benign pleural effusion resistant to medical treatment. There are, although, some contraindications to performing it. Serious complications of pleurodesis are rare and depend on the technique and agent used. The method of choice for pleurodesis is related to the experience and technical facilities available. The author presents a review about pleurodesis.

Influence of talc dose on extrapleural talc dissemination after talc pleurodesis

This study was designed to ascertain, in a rabbit model, extrapleural talc deposition and the related inflammatory response after talc slurry pleurodesis with two clinical doses, 200 and 50 mg/kg. Histopathologic evaluations revealed that whereas numerous rabbits receiving a high dose had talc in the ipsilateral (70%) and contralateral (55%) lung, mediastinum (90%), pericardium (30%), and liver (25%), a small number of animals treated with a low dose showed talc in the ipsilateral lung (10%) and mediastinum (20%) and none in the contralateral lung, pericardium, or liver. Hematologic and immunocytochemical analyses showed that a systemic inflammatory response develops shortly after pleurodesis with a high talc dose involving massive accumulation of neutrophils and macrophages in lung tissue. Zymography also revealed that the pulmonary expression of matrix metalloproteinases 2 and 9 was up-regulated in both lungs in a dose-dependent manner soon after talc instillation. Furthermore, microscopic examination of lung specimens revealed that the higher the dose of talc, the greater the development of both fibrotic visceral pleural thickening and foreign-body granulomas. These findings show pleurodesis with a high talc dose to be associated with an increased risk of extrapleural talc deposition, which may originate undesirable acute and chronic inflammatory responses.