The Role of Inhaled TXA in Hemoptysis.
Background information
The antifibrinolytic medication Tranexamic Acid (TXA) has been gaining more popularity in its use to stop various types of bleeding. By preventing activation of plasmin and clot breakdown, this synthetic derivative’s ability to reduce bleeding has applied to post-partum hemorrhage, intracranial hemorrhage, epistaxis and trauma — each with varying results.[1-4] The application of TXA for upper and lower gastrointestinal bleeding continues to stir debate and has prompted ongoing double-blind randomized control trials (RCT).[5,6] Recent evidence has shown there may be a utility for inhaled TXA in patients with hemoptysis, as the main advantage of nebulized vs. systemic TXA is a more rapid onset of action.
What we know
A large meta review identified 13 papers, two of which were double-blinded RCTs, with the best evidence as to whether TXA stops hemoptysis.
- Following review of these studies the authors concluded that TXA may reduce both duration and volume of bleeding with low-risk for short-term thromboembolic complications in patients with hemoptysis.[7]
- It is important to note that these studies used various routes of TXA administration, ranging from oral and intravenous to endobronchial administration. None however, investigated the inhaled route of TXA administration.
A recent and first of its kind prospective RCT was published looking at the effectiveness of nebulized TXA in patients with non-massive hemoptysis.
- Even though this was a small study, when compared to placebo, inhaled TXA resulted in faster resolution of hemoptysis, shorter hospital length of stay and fewer invasive procedures in patients with non-massive hemoptysis.[8]
- Another important and relevant note is that the resolution of hemoptysis in these patients was days and not minutes or hours. Effects of the treatment may not be as rapid as anticipated and should be considered when administrating nebulized TXA.
Case studies using inhaled TXA have led to the cessation of hemoptysis secondary to malignancy.
- Five cancer patients over two case studies were shown to have their bleeding time reduced when administered nebulized TXA. The only adverse effect was bronchospasm in one of these patients.[9,10]
Pros
- Easy and quick to administer
- Inexpensive medication ($100/dose)
- Faster resolution of hemoptysis
- Shorter hospital length of stay
- Fewer invasive procedures
Cons
- Exact resolution of symptoms unclear
- Limited studies performed in the emergency department
- Role in massive hemoptysis remains limited to case reports
- May increase mortality if given more than three hours to stop bleeding after injury in trauma patients.[2]
How to do it
Take Home Message:
When treating patients with hemoptysis, administration of nebulized TXA is another tool that may result in faster resolution of symptoms, decreased hospital length of stay and reduce the need for invasive procedures. More emergency medicine relevant studies are needed to adapt this as a standard of care.
REFERENCES:
- The WOMAN Trial Collaborators. Effect of Early Tranexamic Acid Administration on Mortality, Hysterectomy, and Other Morbidities in Women With Post-Partum Haemorrhage (WOMAN). Obstet Gynecol Surv. 2017.PMID: 28456509
- CRASH-2 trial collaborators. Effects of tanexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage (CRASH-2): a ransomised placebo-controlled trial. Lancet 2010; 376: 23-32. PMID: 20554319
- Sprigg N et al. Tranexamic Acid for Hyperacute Primary IntraCerebral Haemorrhage (TICH-2): An International Randomised, Placebo-Controlled, Phase 3 Superiority Trial. Lancet 2018. PMID: 29778325
- Zahed R et al. A new and rapid method for epistaxis treatment using injectable form of tranexamic acid topically: a randomized controlled trial. Am J Emerg Med 2013 PMID: 23911102
- Roberts I et al. HALT-IT – tranexamic acid for the treatment of gastrointestinal bleeding: study protocol for a randomised controlled trial. Trials. 2014 PMID: 25409738
- DeWeert D et al. ED CRASH Course: TXA MATTERS! – emDOCs.net – Emergency Medicine Education. 2016. Link Here
- Moen C, et al. Does tranexamic acid stop haemoptysis?. Interact Cardiovasc Thorac Surg. 2013; PMID: 23966576
- Wand O et al. Inhaled Tranexamic Acid for Hemoptysis Treatment: A Randomized Controlled Trial. CHEST 2018. PMID: 30321510
- Segrelles Calvo G et al. Inhaled Tranexamic Acid as an Alternative for Hemoptysis Treatment. Chest. 2016. PMID: 26867844
- Komura S et al. Hemoptysis? Try Inhaled Tranexamic Acid. J Emerg Med. 2018 PMID: 29502864
- Rezaie S. TXA for Everyone: Inhaled TXA for Hemoptysis – REBEL EM – Emergency Medicine Blog 2018. Link Here