Fluid build-up around the lungs or abdomen may be drained before mesothelioma is diagnosed or at the same time as the biopsy.

• Pleural tap – In pleural mesothelioma, a pleural tap drains fluid from around the lungs. Your doctor will numb the area with a local anaesthetic and insert a needle between your ribs into the pleural cavity, which is connected to a bag for the fluid to drain into. This may take about 30–60 minutes.
• Peritoneal tap – In peritoneal mesothelioma, a peritoneal tap drains fluid from the abdomen. Your doctor will numb the area with a local anaesthetic into the abdomen and insert a needle through the skin into the peritoneal cavity, which is connected to a bag for the fluid to drain into. It takes a few hours for all the fluid to collect into a drainage bag. 

To prevent fluid building up again in the lining of the lungs, you may have a talc pleurodesis. Pleurodesis means closing the pleural cavity. 

Sterile talcum powder (talc slurry) is inserted into the pleural cavity, which causes an inflammation that helps fuse the two layers of the pleura together and closes the space. A talc pleurodesis is best done during VATS by a cardiothoracic surgeon, but is sometimes done by a respiratory physician.

After a talc pleurodesis, some people experience a burning pain in the chest for 24–48 hours. This pain can be eased with medicine and you will be able to have physiotherapy to improve lung expansion.

VATS with pleurectomy decortication

When fluid is drained and talc pleurodesis is done during VATS, part or all of the outer layer of the pleura (parietal pleura) is removed. This is known as pleurectomy decortication or PD. This may be done when the parietal pleura, which lines the chest wall, has become thick and inelastic.

Open surgery (thoracotomy) with pleurectomy decortication

Even after VATS and talc pleurodesis, the fluid may build-up around the lungs again, causing breathlessness. The surgeon may suggest more extensive surgery called thoracotomy with pleurectomy decortication (PD).

This surgery may also be recommended as a first option if the cancer has grown in a way that makes it difficult to perform VATS successfully. A thoracotomy helps to prevent fluid building up again in most cases. It also makes it easier for the lungs to expand and to transfer oxygen to the blood.

Pain can last longer than after VATS, but the improvement in symptoms may make open surgery a worthwhile option if VATS has been unsuccessful or isn’t possible.

Indwelling pleural catheter

Some people cannot have VATS or open surgery, either because they are too unwell or because the cancer has grown in a way that makes the surgery too difficult. Instead, you may be offered an indwelling pleural catheter (also known as a drain) to remove the fluid and improve your breathing. This can also be used if the pleural fluid builds up again after pleurodesis.

Under local anaesthetic, the specialist inserts a thin tube through the chest wall into the pleural cavity. When the fluid builds up and needs to be drained (usually once or twice a week), the end of the catheter is connected to a bottle.

Sometimes with an indwelling pleural catheter, the pleural cavity may close up over time and stop producing fluid. If this occurs, the drain will be removed.

If fluid keeps building up around the abdomen, a small tube can be inserted to allow fluid to flow into a bottle. This is known as an indwelling peritoneal catheter or drain and is managed similarly to an indwelling pleural catheter.

Heated chemotherapy

To control ascites, your doctor may suggest a single dose of heated chemotherapy directly into the abdomen. This can be given during laparoscopy, and there is some evidence that it can help prevent fluid building up again.

It can be distressing to feel short of breath, but a range of simple strategies and treatments can provide some relief at home.

• Treating other conditions  – other conditions, such as anaemia or a lung infection, may also make you feel short of breath, and these can often be treated.
• Sleep in a chair – use a recliner chair to help you sleep in a more upright position.
• Ask about medicines – talk to your doctor about medicines, such as a low dose of morphine, to ease breathlessness. Make sure your chest pain is well controlled, as pain may stop you breathing deeply. 
• Check if equipment could help – to improve the capacity of your lungs, you can blow into a device called an incentive spirometer. You may be able to use an oxygen concentrator at home to deliver oxygen to your lungs, or a portable oxygen cylinder for outings. If you have a cough or wheeze, you may benefit from a nebuliser, a device that delivers medicine into your lungs.
• Modify your movement – some types of gentle exercise can help but check with your doctor first.
• Relax on a pillow – lean forward on a table with an arm crossed over a pillow to allow your breathing muscles to relax.
• Create a breeze – use a handheld fan to direct a cool stream of air across your face if you experience breathlessness when you are not exerting yourself.
• Find ways to relax – listen to a  relaxation recording or learn other ways to relax. Some people find  breathing exercises, acupuncture and meditation helpful. 

• Pain medicines – Different types and strengths of pain medicines may be used to achieve good pain control. Opioids, such as morphine or oxycodone, are the most common drugs used to control moderate to severe mesothelioma pain. 
• Procedures to manage fluid build-up – Aside from breathlessness, fluid build-up around the lungs or abdomen can cause pain. Various treatments can help drain the fluid and try to prevent it building up again.
• Radiation therapy – This may be used to shrink mesothelioma that is pressing on nerves, bones or major blood vessels and causing pain. Sometimes the mesothelioma can grow through the scar from VATS surgery and produce a lump in the skin. Radiation therapy can reduce the size of the lump and ease any associated pain.
• Chemotherapy –  This can reduce the size of the mesothelioma that is causing the pain.
• Debulking surgery – If you are well enough and it is technically possible, surgery may be used to remove the part of the mesothelioma causing pain and other symptoms. This is known as debulking surgery. Talk to your doctor for more information.

• Try to do some gentle physical activity every day. This will help you sleep better. Talk to a physiotherapist or exercise physiologist, who can tailor an exercise program, and an occupational therapist, who can suggest equipment to help you move safely.
• Limit or cut out the use of alcohol, caffeine, nicotine and spicy food.
• Avoid using technology, such as television, computers or smartphones, before bed, as the light tells your body it’s time to wake up.
• Follow a regular routine before bed and set up a calm sleeping environment. You may find soothing music or a relaxation recording helpful. Ensure the room is dark, quiet and a cool temperature.
• Listen to our Sleep and Cancer podcast episode.

• Have small meals and snacks regularly. A large, full plate may put you off eating – try using a smaller plate with smaller portions. Likewise, drink from a half-full glass.
• Eat moist food such as scrambled eggs. Moist food tends to be easier to eat and will cause less irritation if you have a sore mouth.
• Avoid fatty or sugary foods if these make you feel sick.
• Use lemon juice and herbs to add flavour to bland food.
• Eat more of your favourite foods – follow your cravings.
• If solid food doesn’t appeal, ask a dietitian about protein drinks or other supplements.

• Drink plenty of fluids.
• Eat fresh fruit and vegetables and fibre-rich foods (e.g. prunes), unless your doctor advises otherwise.
• Try to be physically active every day. Talk to your doctor or physiotherapist to find the exercise that is right for you.
• Ask your doctor how to manage constipation. You may be prescribed medicines to help control symptoms.
• Try over-the-counter laxatives, but check the dose with the pharmacist and let your doctor know. 
• Talk to your treatment team about how to manage bowel obstruction. If your stomach is swollen and you are in pain, call 000 as it may be an emergency.