Bedside Clinical Question: Can nebulized tranexamic acid (TXA) be used as treatment in a patient presenting with hemoptysis?
Background:
Hemoptysis, the expectoration of blood from the lungs or bronchial tree due to pulmonary or bronchial hemorrhage, is a distressing symptom often seen in the ED. Its severity ranges from moderate to massive, which can lead to asphyxia or shock from blood loss.
ED management of hemoptysis includes treating the underlying cause. Immediate interventions like bronchoscopy, embolization, or surgery may not be needed for all patients depending on the severity of their presentation.
Recent literature supports the use of TXA as a treatment option.
Nebulized TXA, a medication that prevents fibrinolysis to achieve hemostasis, has shown promising results in case reports and series for the management of hemoptysis in the ED setting.
Answer:
A 2018 double-blind, randomized controlled trial assessed nebulized TXA (500 mg TID) versus placebo (normal saline) in 47 patients with hemoptysis of varying causes. The study found that TXA led to higher rates of hemoptysis resolution and a faster reduction in bleeding starting on day two of treatment. There were no adverse effects in either group. Additionally, the TXA group had shorter hospital stays and required fewer interventional procedures to control bleeding.
A 2023 single-center retrospective matched cohort study of 14 patients in the nebulized TXA arm found no reduction in the need for invasive interventions. However, it concluded that nebulized TXA may be a safe, noninvasive bridging therapy for managing hemoptysis when more definitive interventions are not immediately available.
A 2023 pragmatic, open-label, single-center pilot trial compared nebulized TXA (500 mg TID) to IV TXA (500 mg TID) in adults presenting to the ED with hemoptysis. Among 55 patients in each group, hemoptysis cessation at 30 minutes was significantly higher in the nebulized TXA arm. Hemoptysis was also significantly reduced at all time points in the nebulized group. Fewer patients required bronchial artery embolization, and more were discharged directly from the ED.
Conclusion:
While the data on the efficacy and safety of nebulized TXA for hemoptysis is limited, the available evidence is promising, indicating that it could be a valid and potentially beneficial option for the pharmacological management of non-life-threatening hemoptysis, when more definitive interventions are not readily available or indicated.
References:
Gopinath B, Mishra PR, Aggarwal P, et al. Nebulized vs IV Tranexamic Acid for Hemoptysis: A Pilot Randomized Controlled Trial. Chest. 2023;163(5):1176-1184. doi:10.1016/j.chest.2022.11.021
Alkazemi A, Kovacevic M, Dube K, et al. Effectiveness of Nebulized Tranexamic Acid in Patients with Moderate-to-Massive Hemoptysis at a Tertiary Academic Medical Center. J Aerosol Med Pulm Drug Deliv. 2023;36(6):309-315. doi:10.1089/jamp.2022.0038
Wand O, Guber E, Guber A, Epstein Shochet G, Israeli-Shani L, Shitrit D. Inhaled Tranexamic Acid for Hemoptysis Treatment: A Randomized Controlled Trial. Chest. 2018;154(6):1379-1384. doi:10.1016/j.chest.2018.09.026
Written and revised by: Yasmeen Ettrick, PharmD PGY1 Pharmacy Resident and Joanne Routsolias, PharmD, RN, BCPS, Clinical PharmD Specialist