Complications of talc poudrage in the United States.

A recent article in CHEST (June 2010) by Gonzalez et al 1 on the complications of talc pleurodesis is important because it may be the largest report on the use of Sclerosol talc (Bryan Corporation; Woburn, Massachusetts), the only proprietary talc sanctioned by the US Food and Drug Administration (FDA). The article would have been enhanced if the authors had shared their 1to 6-month success rates for pleurodesis, because Sclerosol may be more or less effective than other talcs. Conversations with Bryan Corporation representatives suggest that the current talc is different from the original one. One of their goals (to defi ne the incidence of lung injury from talc) cannot be met in this kind of retrospective study because a pathognomonic fi nding for talc lung injury has not been defi ned. Their estimate of a 2.8% incidence is subjective, which they acknowledge (referred to as “consensus” in their article). Radiographic fi ndings may be seen after pleural drainage or thoracoscopy without talc insuffl ation. Two articles were inappropriately referenced as showing complications of talc insuffl ation. Rehse et al 2 found zero cases of respiratory failure after simple talc poudrage but several cases of ARDS when talc was applied following pleural abrasion, a to understand the inner state of the patient, including the internal and external infl uences that impede autonomous choice, rather than simply assuming that statements of choice can be accepted at face value. Clinicians should feel comfortable making best-interest assessments regarding the care of their patients and should make those assessments explicit when necessary. The choices of nonautonomous individuals are not to be respected when one knows that harm will follow. To say that the principle of autonomy rests on the ability of the individual to make autonomous decisions is not a tautology; if a patient is unable to make autonomous decisions, the clinician who relies on the articulated choices of such a patient to determine the course of care will be making a clinical and a moral error.