Treatment proposal and drainage protocol

The earlier in the course of the disease the catheter is inserted, the greater the benefit is to the patient.

International guidelines for malignant pleural effusion and malignant ascites clearly state that tunneled indwelling catheters should be considered for early treatment. The treatment method provides patients with effective symptom relief and saves hospital days. The cost will therefore be lower than for alternative treatment methods. Studies on benign pleural fluid and ascites also show good results.

Treatment options for malignant pleural effusion

Ascites catheter treatment suggestions

The earlier in the course of the disease the patient receives the catheter, the greater the benefit to the patient. A large study³ has chosen to implant the catheter without prior therapeutic paracentesis in patients with newly diagnosed malignant ascites with rapid accumulation, troublesome symptoms and poor quality of life. The reason for this is because repeated paracentesis (Large Volume Paracentesis = LVP) would be uncomfortable for the patient.

Furthermore, repetition of this procedure (LVP, reds anm) leads to frequent hospital visits, which are inconvenient for the patient, entail the use of more healthcare resources, and may lead to delays in drainage resulting in patients becoming progressively symptomatic in the terminal stages of their illnesses. Given that over 80 percent of the patients in this study had poor performance status (an ECOG score of at least 3), in our clinic we used clinical judgement that the PleurX catheter would benefit the patient – rather than a history of therapeutic paracentesis – as another indication for catheter insertion. This was justified by the low rate of catheter removal (4,05%), as mentioned earlier³.

Suggested drainage protocol for pleural fluid

In case of pleurodesis prescription:

  1. Implant the catheter and drain as much as possible.
  2. The patient can go home the same day and drain 500 ml daily (alternatively up to a maximum of 1000 ml if the patient can tolerate it) with ewimed drainage set (bag) or PleurX™ drainage set (vacuum bottle).
  3. If you have less than 100 ml, you can reduce the dosage to every other day.
  4. If less than 50 ml 3 times in a row, the patient probably has pleurodes. Check with ultrasound or X-ray.
  5. In the case of confirmed pleurodesis, the choice of removing the catheter or keeping it may be made, depending on the patient’s preference or what is medically desirable.

For symptom relief:

  1. Drain 2-3 times a week (max 1000 ml) and if necessary with ewimed drainage set (bag) or PleurX™ drainage set (vacuum bottle).
  2. The drainage interval can be spaced out when fluid production is reduced, but rarely more than once a week.
  3. Note that there may be a pleurisy despite sparse drainage intervals, see above.

Sources for drainage protocol pleural fluid see references 1 and 2.

Suggested drainage protocol for ascites

  1. Implant the catheter and try to tap as empty as possible based on the patient’s medical conditions before the patient goes home. Observe national guidelines for ascites sampling regarding possible albumin replacement.
  2. The patient can go home the same day and then drains a maximum of 2000 ml per day with the ewimed drainage set.
  3. To avoid leakage, we recommend more frequent drops in the first few weeks until the cuff of the catheter has grown in.
  4. Drain 2-3 times a week and if necessary with ewimed drainage set 2000 ml.

Sources for drainage protocol ascites see references 3 and 4.

Benefits for you as a treating physician:

  • Saves medical time (no repeated punctures and associated risks)
  • Cost reduction
  • Faster start of therapy, in parallel with medical therapy and/or radiotherapy

Advantages for your patients:

  • Improved quality of life and effective symptom relief
  • No unnecessary punctures
  • Reduction of hospital stays and doctor visits


  1. Wahidi et al., Randomized Trial of Pleural Fluid ­Drainage Frequency in Patients with Malignant ­Pleural Effusions. The ASAP ­Trial. American Journal of Respiratory and Critical Care Medicine. 2017; 195(8):1050-1057.
  2. Chalhoub et al., The Use of the PleurX Catheter in the Management of Non-Malignant Pleural Effusions, Chronic Respiratory Disease; 8(3): 185-191.
  3. Wong BCT et al., Indwelling Peritoneal Catheters for Managing Malignancy-Associated Ascites, Journal of Palliative Care 31:4 / 2015; 243-249.
  4. Nationell riktlinje 2016 på uppdrag av Svensk Gastroenterologisk Förenings styrelse: Ascites och njursvikt vid levercirros – utredning och behandling.
  5. Bhatnagar, Keenan, Morley, et al. Outpatient Talc Administration by Indwelling Pleural Catheter for Malignant Effusion. The New England Journal of Medicine. 2018; 378(14):1313-1322.

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