- Marc Noppen, MD
Marc Noppen, MD
- Professor and Head, Interventional Endoscopy Unit
- Universitair Ziekenhuis Brussel
Pleurodesis is a procedure performed to obliterate the pleural space to prevent recurrent pleural effusion or pneumothorax or to a treat persistent pneumothorax. Pleurodesis is commonly accomplished by draining the pleural fluid, when present, followed by either a mechanical procedure (ie, abrasion, or (partial) pleurectomy) or instillation of a chemical irritant into the pleural space, which causes inflammation and fibrosis. Talc pleurodesis is a specific form of chemical pleurodesis. Talc is the most effective sclerosant available for pleurodesis in malignant pleural effusion . As compared to indwelling pleural catheter placement, talc pleurodesis has been shown to be equally effective in relieving dyspnea .
This topic will review the indications, contraindications, patient selection, procedure, and outcomes of talc pleurodesis. Discussions of the management of malignant and refractory nonmalignant pleural effusions and an overview of chemical pleurodesis are provided separately. (See "Management of malignant pleural effusions" and "Management of refractory nonmalignant pleural effusions" and "Chemical pleurodesis".)
WHAT IS TALC
Talc is predominantly hydrated magnesium silicate (Mg3Si4O10(OH)2), and was first used for pleurodesis in 1935 . Varying amounts of calcium, aluminum, and iron may be present, according to the origin of the formulation. Talc may also contain several mineral contaminants (eg, magnesite, dolomite, kaolinite, calcite, chlorite, serpentine, and quartz); medicinal talc is asbestos free .
Particle size — Talc preparations with a high proportion of particles <5 to 10 micron in diameter are associated with more severe local and systemic inflammatory responses [5,6] and with a poorer outcome . However, formal standards for talc production for pleurodesis are lacking, and there is a wide variation in composition and particle size in the various talc preparations used worldwide .
- In the USA, talc pleurodesis approved by the Food and Drug Administration is provided in two forms: sterile talc powder and as a talc aerosol canister with two delivery tubes (4 gm of talc per tube) that use dichlorofluoromethane (CFC-12) as a propellant. The particle size distribution for the FDA approved talc has not been disclosed by the manufacturer.
- In Europe, commercial talc for pleurodesis is manufactured by Novatech (La Ciotat, France), and comes in four forms: Steritalc F2 (2 grams of sterile talc powder in a glass vial), Steritalc F4 (4 grams of sterile talc powder in a glass vial), Steritalc Spray (3 grams in a spray canister with propellant gas), and Steritalc PF4 spray (4 grams in a hand/air-driven pump). The French Novatech talc (not approved for use in the USA) is size-calibrated with a median particle diameter of 31.3 microns.
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- WHAT IS TALC
- Particle size
- Mechanism of action
- INDICATIONS AND EFFICACY
- Recurrent malignant effusion
- Refractory non-malignant effusion
- Recurrent and persistent spontaneous pneumothorax
- PATIENT SELECTION AND OUTCOME PREDICTORS
- PATIENT PREPARATION
- Concomitant medications
- TALC INSUFFLATION OR TALC SLURRY?
- PLEURODESIS PROCEDURE
- Talc insufflation
- - Sedation and analgesia
- - Insufflation
- Talc slurry
- - Slurry preparation
- - Sedation and analgesia
- - Slurry instillation
- COMPLICATIONS AND SAFETY
- Insufflation versus slurry
- Systemic inflammation and respiratory failure
- Long-term adverse effects
- Measures to improve safety
- SUMMARY AND RECOMMENDATIONS