Inhaled Tranexamic Acid for Hemoptysis?

Written by Sam Parnell

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For patients with hemoptysis, inhaled tranexamic acid was associated with significantly reduced expectorated blood volume, hospital length of stay, need for invasive interventions, and hemoptysis recurrence rate at one year. Patients with inhaled tranexamic acid also had higher rate of hemoptysis resolution within 5 days.

Why does this matter?
Hemoptysis, defined as the expectoration of blood, has a broad differential and can range from simple blood streaked sputum to life-threatening massive hemoptysis. Management of hemoptysis consists of interventional procedures to stop hemorrhage along with identifying and treating the specific underlying cause. However, there are few other effective medical therapies for undifferentiated hemoptysis besides supportive care. Intravenous tranexamic acid (TXA) has shown promise at reducing surgical blood loss, decreasing abnormal uterine bleeding, and controlling acute hemorrhage in trauma. Therefore, could inhaled TXA be a potential medical therapy for hemoptysis?

TXA in hemoptysis: The results may take your breath away…
This was a single center, prospective, double-blind, randomized, placebo-controlled trial of 47 adults with hemoptysis comparing nebulized TXA 500 mg/5 ml vs nebulized normal saline 5 ml as the placebo control, given 3 times a day up to 5 days from admission. Patients with massive hemoptysis (expectorated blood > 200 ml/24 hrs), respiratory or hemodynamic compromise, pregnancy, renal or hepatic failure, coagulopathy, or TXA hypersensitivity were excluded.

TXA compared to placebo was associated with an improved rate of hemoptysis resolution within 5 days (96% vs 50%, p<0.0005), reduced length of stay (5.7 vs 7.8 days, p=0.046), reduced rate of invasive procedures such as bronchoscopy or angiographic embolization (0% vs 18.2%, p=0.041), and reduced recurrence of hemoptysis at 1 year (4% vs 22.7%, p=0.0092). No side effects were noted.

This was a small single center study with several limitations and a large proportion of patients excluded that we normally care for in the Emergency Department, including those with massive hemoptysis. However, the results are compelling that nebulized tranexamic acid may be a safe and effective treatment option for patients with hemoptysis. With little downside and few other proven medical therapies for hemoptysis, nebulized TXA could be a useful adjunct to add to your mental tool belt.

Inhaled Tranexamic Acid for Hemoptysis Treatment: A Randomized Controlled Trial. Chest. 2018 Oct 12. pii: S0012-3692(18)32572-8. doi: 10.1016/j.chest.2018.09.026. [Epub ahead of print]

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