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Eur J Cardiothorac Surg 2007;31:1147-1148. doi:10.1016/j.ejcts.2007.03.012
Copyright © 2007, European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved
Letters to the Editor |
Division of Thoracic Surgery, University of Modena and Reggio Emilia, Policlinico di Modena, Via del Pozzo 71, 41100 Modena, Italy
Received 7 March 2007; accepted 9 March 2007.
* Corresponding author. Tel.: +39 059 4222257; fax: +39 056 360159. (Email: morandi.uliano{at}unimo.it).
Key Words: Pleural effusion • Talc pleurodesis • Talc particles • Granulometry
We thank Dr Molnar and Dr Rami-Porta for their comments and questions [1].
The question about size of talc particles is definitely intriguing. In fact, one can expect that particle size may influence pleural inflammation and extrapleural talc dissemination, affecting efficacy of pleurodesis and accounting for side effects, especially ARDS.
Mean particle size among talcs used in several countries ranges from about 10 to 30 µm [2]. Talc particles instilled into the pleural cavity cause local inflammation and can disseminate in extrapleural organs, leading to tissue damage and acute lung injury [3]. Ferrer et al. [4] compared pleurodesis by instillation of talc usually used for human treatment (mean diameter 8.3 µm) and talc with particles of larger size (mean diameter 12 µm). Normal talc elicited greater lung and extrapulmonary particle spread and more pleural inflammation and thickening than larger talc; however, both talcs were equally effective in obtaining pleurodesis. The authors concluded that, if ARDS is due to talc deposition, it is likely better to use talc with large particles, eliminating particles <10 µm. Maskell et al. [5] compared pleurodesis with ‘mixed talc’ (mean diameter < 15 µm) to pleurodesis with ‘graded talc’ (most particles <10 µm removed). Mixed talc induced more lung and systemic inflammation and worsened gas exchange, thus the use of larger talc would reduce the morbidity of the procedure. Finally, among the talcs used in different countries, the lowest sizes correspond to talcs administrated in United States, where most patients who developed a post-pleurodesis ARDS were reported.
When assessing the particle size, different methods could give different results [2,4,5]: when investigating the granulometry of talc, it should be important to mention the analysis method.
In our study, we used the same talc for both poudrage and slurry procedure, a sterile, asbestos-free, calibrated talc, extracted from a mine in Luzenac (France). Granulometry was assessed by the same method for both preparations: average diameter was 14 µm, with 25% of particles <10 µm in both talcs. Thus, particle size did not represent a variable in our study, and we think that the difference in efficacy between poudrage and slurry remains related to the method of delivery of talc, the former creating an highly homogeneous dispersion of the particles. According to Ferrer et al. [4], the particle diameter of our talc is at low risk for ARDS, a complication that we did not observe.
In 1990s, we began our experience with talc poudrage by using a puffer similar to those used to deliver perfumes. It was effective, but we found the disposable gas propelled atomizer more practical, easier, and faster to use. Moreover, disposable atomizers are easily available on the market and are not expensive.
Throughout the study, we applied a standardized method to prepare and deliver the mixture for talc slurry. Thus, the dispersion of the slurry depended rather on the ability of the patient to change position during the clamping time. We acknowledge that this may be a variable that we did not take into account; however, our group of ‘talc slurry’ patients was to small to further subgrouping.
References
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