Thoracoscopic Talc Poudrage in Malignant Pleural Effusions: Effective Pleurodesis Despite Low Pleural pH

doi:10.1378/chest.113.4.1007

Chest

Volume 113, Issue 4, April 1998, Pages 1007-1012

https://doi.org/10.1378/chest.113.4.1007 Get rights and content

Study objective

To determine the effectiveness of pleurodesis by thoracoscopic talc poudrage (TTP) in patients with low pH malignant pleural effusions.

Design

Review of prospectively collected data on all thoracoscopic procedures performed from 1982 to 1996.

Patients and setting

Twenty-five members in a prepaid, closed-panel health maintenance organization, whose malignant pleural effusion pH was ≤7.30.

Interventions

Pleural fluid pH was measured prior to diagnostic and therapeutic, single puncture, rigid thoracoscopy, under local anesthesia, in an operating room.

Measurements and results

Success of pleurodesis was determined with serial radiographs at 10 days, 30 days, and frequent intervals until death or up to 1 year following the procedure. Failure was indicated by evidence of recurrent fluid or persistence of a space between the visceral and parietal pleura. Morbidity of the procedure, days of chest tube drainage, and days of hospitalization were recorded concurrently during hospitalization and outpatient follow-up. Fifty of the 76 patients found to have a pleural pH measurement had a pleural pH >7.30, averaging 7.37 (7.31 to 7.55). The other 26 patients (34%) with pH ≤7.30 (low pH) are the subjects of this study, of whom 25 were evaluable. Pleurodesis was successful in 22 of 25 (88%), although 4 died prior to 30 days. The three failures all had trapped lung. Chest tube drainage averaged 3.2±1.3 days, which approximated the time of hospitalization (3.3±1.1 days). There were no thoracoscopy-related deaths; significant morbidity occurred only in one patient with trapped lung, who had prolonged chest tube drainage before and after TTP, and eventually developed empyema.

Conclusions

TTP is an effective pleurodesis technique in malignant pleural effusions, even when the pleural pH is low. The short hospital stay and high success rate make this approach a good choice in palliating symptomatic malignant pleural effusions.

Section snippets

MATERIALS AND METHODS

Chart and database review of all patients receiving thoracoscopy by two of us (Y.A. and R.R.K.), in a Kaiser Foundation hospital from 1982 to 1996, revealed 145 patients receiving TTP whose final diagnosis was malignant pleural effusion; of these, a prethoracoscopic pleural pH was found in 76. Twenty-six (34%) of these 76 pH values were found to be ≤7.30. One patient was nonevaluable: he had initially successful pleurodesis, was alive and ambulatory at 30 days, but did not return for follow-up

Characterization of Patients

The range of pleural pH was 7.06 to 7.55 in the 76 patients. Fifty patients with pH >7.30 averaged 7.37 and are not further characterized in this study. The pH in the 25 patients under consideration (“low pH”, Table 1) ranged from 7.06 to 7.30. Median age was 70 years (range, 42 to 83 years). Nineteen patients (76%) were male.

The final diagnoses are listed in the chronological Table 1, including nine primary lung cancers, seven mesotheliomas, six nonpulmonary metastatic pleural adenocarcinomas,

DISCUSSION

This study reveals a high success rate of TTP pleurodesis in patients suffering from recurrent malignant pleural effusions with low pleural pH. Although a minority of patients died within a few weeks and thus could not long benefit from pleurodesis, we believe the median survival of 4.3 months and mean of 7.4 months justify the use of this palliative approach. Successful pleurodesis spared patients the discomfort of pleural effusion and of the need for repeated thoracenteses or more invasive

ACKNOWLEDGMENT

We would like to thank Mrs. Janis Yao for providing statistical support. Drs. Karlmann Wasserman and Herbert H. Webb and Mrs. Yao were very helpful in reviewing the manuscript. Miss Barbara McLaughlin provided clerical assistance.

REFERENCES (15)

SahnSA.
Malignant pleural effusions
Clin Chest Med
(1985)
Rodriguez-PanaderoF et al.
Survival time of patients with pleural metastatic carcinoma predicted by glucose and pH studies
Chest
(1989)
Sanchez-ArmengolA et al.
Survival and talc pleurodesis in metastatic pleural carcinoma, revisited: report of 125 cases
Chest
(1993)
ViallatJR et al.
Thoracoscopic talc poudrage pleurodesis for malignant effusions: a review of 360 cases
Chest
(1996)
HartmanDL et al.
Comparison of insufflated talc under thoracoscopic guidance with standard tetracycline and bleomycin pleurodesis for control of malignant pleural effusions
Cardiovasc Surg
(1993)
KennedyL et al.
Pleurodesis using talc slurry
Chest
(1994)
YimAPC et al.
Thoracoscopic talc insufflation versus talc slurry for symptomatic malignant pleural effusion
Ann Thorac Surg
(1996)

There are more references available in the full text version of this article.

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Citation Excerpt :
These investigators excluded those with trapped lung and those who died within 30 days of the procedure. Another study by Aelony and colleagues49 showed that surgical talc poudrage was successful in 88% of 25 patients with MPEs despite a low pleural pH (<7.30), a factor that has been traditionally thought of as a predictor for failed pleurodesis. Zhang and colleagues50 performed medical thoracoscopic talc poudrage pleurodesis on 27 patients with MPEs and achieved an overall success of pleurodesis of 96.3% (26/27), with an average duration of chest tube of 6.85 days.
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Chest

Clinical Investigations: CancerThoracoscopic Talc Poudrage in Malignant Pleural Effusions: Effective Pleurodesis Despite Low Pleural pH

Study objective

Design

Patients and setting

Interventions

Measurements and results

Conclusions

Section snippets

MATERIALS AND METHODS

Characterization of Patients

DISCUSSION

ACKNOWLEDGMENT

Clin Chest Med

Chest

Chest

Chest

Cardiovasc Surg

Chest

Ann Thorac Surg

Clinical Investigations: Cancer
Thoracoscopic Talc Poudrage in Malignant Pleural Effusions: Effective Pleurodesis Despite Low Pleural pH