Talc has been widely used for over 75 years as a sclerosing agent in patients with recurrent malignant pleural effusion. It is probably more effective than other agents, widely available and cheap with minimal side effects. However, recent concerns about patients developing acute respiratory distress syndrome (ARDS) have led to misgivings about its use. Talc, instilled either by slurry or by thoracoscopy, has been shown to produce more than 90% success in the control of recurrent malignant pleural effusion.

In this open-label, prospective cohort study, which was conducted in 13 European hospitals and one in South Africa, 558 patients with malignant pleural effusion underwent thoracoscopy and talc poudrage with 4 g talc. Large-particle talc produced in France, with a mean particle size of 24.5 μm, was used. It was thought not to be ethical to compare small- with large-particle talc as the evidence suggests that talc particle size is the main cause of side effects.

There were no cases of ARDS reported in this study. Eleven (2%) patients died within 30 days. All deaths were attributed to the diseases rather than the procedure itself. One patient had respiratory failure due to bilateral pneumothoraces; six other patients had non-fatal post-thoracoscopy complications. In general, side effects from thoracoscopic pleurodesis were mild. There was a mild increase in temperature and oxygen use, which might be due to mild systemic and lung inflammation caused by talc.

The authors concluded that use of talc for pleurodesis in malignant pleural effusion is safe, and suggest that fears about ARDS are largely unfounded as long as large-particle talc is used.