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The safety of talc pleurodesis is under dispute following reports of talc-induced acute respiratory distress syndrome (ARDS) and death. We investigated the safety of large-particle talc for thoracoscopic pleurodesis to prevent recurrence of primary spontaneous pneumothorax (PSP). 418 patients with recurrent PSP were enrolled between 2002 and 2008 in nine centres in Europe and South Africa. The main exclusion criteria were infection, heart disease and coagulation disorders. Serious adverse events (ARDS, death or other) were recorded up to 30 days after the procedure. Oxygen saturation, supplemental oxygen use and temperature were recorded daily at baseline and after thoracoscopic pleurodesis (2 g graded talc). During the 30-day observation period following talc poudrage, no ARDS (95% CI 0.0-0.9%), intensive care unit admission or death were recorded. Seven patients presented with minor complications (1.7%, 95% CI 0.7-3.4%). After pleurodesis, mean body temperature increased by 0.41°C (95% CI 0.33-0.48°C; p<0.001) at day 1 and returned to baseline value at day 5. Pleural drains were removed after day 4 in 80% of patients. Serious adverse events, including ARDS or death, did not occur in this large, multicentre cohort. Thoracoscopic talc poudrage using larger particle talc to prevent recurrence of PSPS can be considered safe.

Background: Talc is the most effective chemical pleurodesis agent for patients with malignant pleural effusion. However, concerns have arisen about the safety of intrapleural application of talc, after reports of development of acute respiratory distress syndrome in 1-9% of treated patients. Our aim was to establish whether use of large-particle-size talc is safe in patients with malignant pleural effusion., Methods: We did a multicentre, open-label, prospective cohort study of 558 patients with malignant pleural effusion who underwent thoracoscopy and talc poudrage with 4 g of calibrated French large-particle talc in 13 European hospitals, and one in South Africa. The primary endpoint was the occurrence of acute respiratory distress syndrome after talc pleurodesis., Findings: No patients developed acute respiratory distress syndrome (frequency 0%, one-sided 95% CI 0-0.54%). 11 (2%) patients died within 30 days. Additionally, seven patients had non-fatal post-thoracoscopy complications (1.2%), including one case of respiratory failure due to unexplained bilateral pneumothorax., Interpretation: Use of large-particle talc for pleurodesis in malignant pleural effusion is safe, and not associated with the development of acute respiratory distress syndrome.

Medical thoracoscopy under local anesthesia with simple talc poudrage is a safe and cost-effective technique to prevent recurrences in the case of primary spontaneous pneumothorax. Pathogenesis of primary spontaneous pneumothorax, i.e. a pneumothorax occurring without any underlying lung disease, remains unclear; there is no proof that the air leak leading to air escape into the visceral pleura is located in blebs or bullae visualized during the procedure. Therefore we do not have any evidence that blebs or small bullae cauterization or resection adds any further benefit to pleurodesis. Pulmonologists doing thoracoscopic talc pleurodesis should learn to better control pain due to thoracoscopic talcage as it has been shown that thoracoscopic talcage is not more painful than a chest tube drainage in patients providing they receive at least some opioids. There is also a debate on the best surgical approach to treat pneumothorax but minithoracotomy with pleurectomy remains the gold standard although more expensive and associated with some morbidity or mortality.

Malignant pleural mesothelioma (MPM) remains a disease of very poor prognosis despite all new therapeutic approaches. We describe here 13 cases with MPM. The main symptoms at presentation were dyspnea (12/13) followed by weight loss (7/13), cough (3/13) and thoracic pain (2/13). On chest X-ray, all patients had pleural effusion associated with pleural thickening in 8/13 cases (62%). A definitive diagnosis was brought by thoracoscopy in 11/12 cases (diagnostic sensitivity 92%). In one patient, thoracoscopy was technically impracticable because of very important obesity. By thoracoscopic talc pleurodesis, we were able to control the pleural effusion in all patients with suppression of dyspnea (11). The mean survival after diagnosis was 6.8 +/- 5.0 months (range 1-16). At the present time, we believe that thoracoscopy is well indicated in any suspicion of MPM not only for diagnosis but also for palliative treatment of this pleural disease. However, there is a need for well controlled studies to improve the outcome of MPM.

Background: Complicated (recurring or persistent) spontaneous pneumothorax requires treatment either by talc pleurodesis with bullae electrocoagulation or, more aggressively, by thoracotomy or video-assisted thoracoscopic surgery. However, the relative merits of bullectomy, pleurectomy, and pleurodesis have not yet been established in the treatment of spontaneous pneumothorax., Methods: The complications, duration of drainage, length of hospital stay, and immediate and long term success rate of treating complicated spontaneous pneumothorax with talc pleurodesis under local anaesthesia supplemented with nitrous oxide were studied., Results: Talc pleurodesis was performed in 93 patients without serious complication (two benign arrhythmias, two subcutaneous emphysema, two pneumonia, one bronchospasm). The procedure was immediately successful in 90 patients (97%) with a median duration of drainage of five days (range 2-40) and a median length of hospital stay of 5.2 days (range 3-40). After a mean follow up duration of 5.1 (range 1-9.4) years in 84 cases the long term success rate was 95%, although six cases developed a small localised recurrence of spontaneous pneumothorax which did not require further surgery. Macroscopic staging at thoracoscopy was only carried out in the last 59 cases of whom 10 (17%) had bullae with a diameter of > 2 cm. In this group of patients the risk of definitive failure requiring surgery was significantly higher than in those patients without such bullae (odds ratio 7; confidence interval 3.7 to 13.3; p = 0.03), although eight of these patients did not require thoracotomy. Total lung capacity was reduced immediately after talc pleurodesis (mean (SD) 75 (23)% predicted at 10 days) but had improved to 95 (14)% predicted at 12 months., Conclusions: This study shows that simple thoracoscopic talc pleurodesis under local anaesthesia is a safe and effective treatment for complicated spontaneous pneumothorax. However, patients with bullae of > 2 cm in diameter have a greater risk of treatment failure.

Chylothorax is a rare complication of lymphoma with a poor prognosis. The treatment is not well established. We report a case of lymphoma complicated by bilateral chylothorax in which, despite optimal chemotherapy and radiotherapy, pleural effusion persisted. Pleuroscopy was performed under local anesthesia, followed by pleural instillation of pure talc. The immediate result was satisfactory and six months later there was no recurrence of chylothorax. Talc pleurodesis appears to be a simple and safe way of treating chylothorax resistant to conventional therapy.