Ann Thorac Surg 2007;84:2136. doi:10.1016/j.athoracsur.2007.06.012
© 2007 The Society of Thoracic Surgeons
Correspondence
Pleurodesis Using Small Talc Particles Results in an Unacceptably High Rate of Acute Lung Injury and Hypoxia
Ryan D. Baron, MRCS,
Richard Milton, FRCS(CTh),
James A.C. Thorpe, FRCS Ed, FRCS Eng
Department of Thoracic Surgery, St. James University Hospital, Beckett St, Leeds, LS9 7TF United Kingdom
(Email: ryan.baron{at}doctors.org.uk).
To the Editor:
We read with interest the article by Kuzniar and colleagues [1]. In a series of 84 patients undergoing video-assisted thoracoscopic surgery (VATS), talc pleurodesis the incidences of acute lung injury (ALI) and severe hypoxemia were 5.9% and 29.8%, respectively. Our experience in a series of 281 procedures is that these incidences are much lower. We report only a solitary case of acute lung injury. We postulate that the difference in incidence between the two series may result from the use of different talc particle sizes.
Kuzniar and colleagues [1] use two preparations of talc that differ significantly in size (ie, mean diameters of 10.7 µm and 18.2 µm). Both preparations fall toward the smaller end of the spectrum of available talc. In contrast, we use Steritalc (Novotech, La Ciotat, France) (mean diameter, 33.6 µm) that falls at the upper end of the size range [2].
The hypothesised mechanism by which intrapleural talc administration induces systemic inflammation is through dissemination of talc through the lymphatic channels [3]. Larger talc particles are disseminated to a lesser degree than smaller particles [3]. Particles less than 10 µm also contribute through a phagocytosis-induced mechanism [4]. Maskell and colleagues [5] demonstrated that smaller talc particles are associated with greater hypoxemia, a greater incidence of pyrexia, and larger increases in C-reactive protein. Furthermore, the use of smaller talc particles has been shown to be sufficient to render a moderately hypoxic preoperative patient, severely hypoxic following the procedure [5].
We recognize the difficulty in comparing talc sizes between studies. However Ferrer and colleagues [2] measured the diameters of eight talc preparations using a laser method and found four talcs manufactured in the United States amongst the smallest, and Steritalc (Novotech) as the largest.
We believe that using talc preparations with smaller particles potentially results in an unacceptably high incidence of hypoxia and acute lung injury, and we would recommend that an alternative preparation comprising talc of a larger size be used in all cases of talc-induced pleurodesis.
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References
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- Kuzniar TJ, Blum MG, Kasibowska-Kuznair K, Mutlu GM. Predictors of acute lung injury and severe hypoxemia in patients undergoing operative talc pleurodesis Ann Thorac Surg 2006;82:1976-1981.[Abstract/Free Full Text]
- Ferrer J, Villarino MA, Tura JM, Traveria A, Light RW. Talc preparations used for pleurodesis vary markedly from one preparation to another Chest 2001;119:1901-1905.[Medline]
- 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;168:348-355.[Abstract/Free Full Text]
- Ferrer J, Montes JF, Villarino MA, Light RW, Garcia-Valero J. Influence of particle size on extrapleural talc dissemination after talc slurry pleurodesis Chest 2002;122:1018-1027.[Medline]
- Maskell NA, Lee G, Gleeson FV, Hedley EL, Pengelly G, Davies RJO. Randomized trials describing lung inflammation after pleurodesis with talc of varying particle size Am J Respir Crit Care Med 2004;170:377-382.[Abstract/Free Full Text]
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