Chest
Volume 137, Issue 6, June 2010, Pages 1375-1381
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ORIGINAL RESEARCH
PLEURAL DISEASE
Lung Injury Following Thoracoscopic Talc Insufflation: Experience of a Single North American Center

https://doi.org/10.1378/chest.09-2020Get rights and content

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.

Section snippets

Materials and Methods

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

Results

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.

All patients were followed until death, last

Discussion

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

Acknowledgments

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

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