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Hemoptysis is a common symptom in the emergency department. It is defined as the expectoration of blood originating from the tracheobronchial tree or lung parenchyma. It is a symptom of diverse respiratory diseases such as lung cancer, infections and vasculitis.
emoptysis is a common symptom in the emergency depart-
ment. It is defined as the expectoration of blood originating
H 1,2
from the tracheobronchial tree or lung parenchyma. It is a symp-
tom of diverse respiratory diseases such as lung cancer, infections
1,3,4 and vasculitis. The severity can vary, ranging from immediate
life-threatening hemorrhage to minimal blood-streaked sputum.3
Treatment options are diverse and mostly based on the under-
ling disease, for example radiotherapy for bronchial carcinoma,
immunosuppressives for vasculitis or antibiotics for infections.
For massive hemoptysis, interventional procedures such as angio-
graphic bronchial artery embolization and various endobronchial
1,3,5 interventions are used.
Tranexamic acid is a cheap, synthetic drug with
anti-fibrinolytic activity based on inhibiting the activation of
plasminogen.3 It is especially used intravenously, orally and
topically to prevent and treat various bleeding complications, but
only a few studies have investigated the effect of tranexamic acid
as an inhalation drug for hemoptysis.2 In this review, the available
literature about aerosolized tranexamic acid for both massive and
non-massive hemoptysis is listed.
Massive hemoptysis is defined as hemoptysis that is more than
200 milliliters in 24-hours or hemoptysis that cause respiratory
or hemodynamic instability.3 Review of the literature about the
use of inhaled tranexamic acid for massive hemoptysis showed
there are only case reports and case series available (Table 1). All
cases except one demonstrated at least improvement and often
cc Copyright 2020 by Leenaerts V. This is an open-access article distributed under Creative Commons Attribution 4.0 International License (CC BY 4.0), which resolution of the bleeding after administration of nebulized
tranexamic acid in patients of very different ages with varying
underlying etiologies of the massive hemoptysis. There were no
2,4-10 adverse events reported.
Non-massive hemoptysis is defined as hemoptysis less than
200 milliliters in 24-hours without respiratory of hemodynamic
instability. Table 2 shows the available literature about nebulized 3,4 11 tranexamic acid in non-massive hemoptysis. Calvo et al showed
in a case series of 4 males with moderate hemoptysis due to lung
cancer or bronchiectasis that bleeding stopped after inhalation of
tranexamic acid. One patient experienced bronchoconstriction
as side effect which easily resolved after administration of a
bronchodilator. In a randomized controlled trial of Wand et al3
47 adults with non-massive hemoptysis of various underlying
etiologies were randomized for getting nebulized tranexamic acid or
nebulized normal saline. In the tranexamic acid group, the bleeding
was stopped more frequently at day 5 and there was a shorter
hospital stay than in the normal saline group. Moreover there was
no need for invasive procedures in the tranexamic acid group while
18.2% of patients required angiography or bronchoscopy in the
normal saline group.
There are some case reports and case series about the use
of nebulized tranexamic acid in massive hemoptysis. Most
showed improvement or even resolution of the bleeding after
2,4-10 administration. Caution is needed since there is a high-risk of
reporting bias as negative results are not often published. For non- Emerg Med Open J. 2020; 6(1): 6-8. doi: 10.17140/EMOJ-6-156
Table 1. Publications Regarding Inhaled Tranexamic for Massive Hemoptysis
Middle aged men and women with massive 5 Case series Solomonov et al hemoptysis due to lung cancer (2), other types of with 6 cases cancer (3) or trombopenia (1)
6 46-years-old man with massive hemoptysis via Hankerson et al Case report tracheostomy tube due to lung cancer
One 75-years-old woman with massive hemoptysis
7 Case series due to bronchiectasis and one 79-years-old man Patel et al with 2 cases with hemoptysis due to thrombocytopenia and
chronic obstructive lung disease
Eleven children aged 0-18-year with pulmonary
8 Case series hemorrhage, mostly due to congenital heart Bernardo et al with 11 cases disease, renal failure, malignancy and liver failure.
but one patient was intubated.
69-years-old woman with massive hemoptysis
Komura et al Case report post-chemotherapy for lung cancer on rivaroxaban. after tranexamic acid. No
No effect of nebulized epinephrine.
30-years-old man with massive hemoptysis due to
Ng et al Case report pulmonary tuberculosis. Bronchoscopy, angiography
and intravenous tranexamic acid had failed.
4 70-years-old woman with massive hemoptysis due Inhaled tranexamic acid (dose not mentioned in Bleeding stopped after first Modi et al Case report to microscopic polyangiitis.
Three 14-66-years-old females with massive
10 Case series hemoptysis due to systemic lupus, vasculitis or Alabdrabalnabi et al with 3 cases anticoagulation.Two of them got intravenous
tranexamic acid without resolution of bleeding.
Table 2. Publications Regarding Inhaled Tranexamic for Non-Massive Hemoptysis
11 250-500 mg nebulized tranexamic Calvo et al Case series hemoptysis due to bronchiectasis (1)
3 Randomized 47 adult patients with non-massive Wand et al tranexamic acid 2x/d No need to interventional procedures in the controlled trial hemoptysis of various etiologies
massive hemoptysis there is 1 randomized controlled trail which
showed beneficial effect of inhalation of tranexamic acid on
bleeding time, need for invasive procedures and length of hospital
stay.3 There is no ideal dosing known for aerosolized tranexamic
acid. Moreover there are no comparative studies between
intravenous, oral and nebulized tranexamic acid for hemoptysis.
Further research with high quality randomized controlled trials
is needed. In the meantime, nebulized tranexamic acid should
be considered for patients with both massive and non-massive
hemoptysis since there is some evidence, it is cheap and there are
little side effects.
There is some evidence for the use of nebulized tranexamic acid in
both massive and non-massive hemoptysis of various underlying
causes. The only reported side effect is bronchoconstriction, easily
resolved with administration of a bronchodilator. Therefore,
aerosolized tranexamic acid must be considered. Further research
500 mg tranexamic acid dissolved in water,
sodium hydroxide or hydrochloric acid In all cases, the bleeding
administered 3-4 x/day via inhalation (4) or via stopped with the first dose of
the bronchoscope (2).The duration of the tranexamic acid.
therapy varied from one single dose up to No adverse events.
3-months
Inhalation of 1000 mg tranexamic acid dissolved Bleeding stopped 15-minutes
in 100 ml normal saline over 30-45-minutes after administration
500 mg nebulized tranexamic acid every 8-hours The bleeding stopped without
for a minimum of 48-hours other interventions.
Improvement of bleeding
Inhalation of 250-500 mg tranexamic acid every after 1 dose in all patients
All 6-12-hours except 1.
No adverse events.
Bleeding stopped 10-minutes Nebulization of 1000 mg tranexamic acid in 20
ml of normal saline recurrence of bleeding.
48-hours of nebulized tranexamic acid (dose not Bleeding stopped after
mentioned in article) 48-hours
article) in combination with pulse steroids dose of tranexamic acid
Improvement in bleeding in Inhaled tranexamic acid 500 mg 3 x/day all cases.
Four males, 58-84y old with moderate Bleeding stopped after 6-48 hours. One patient
had bronchoconstriction as side effect, resolved acid 2-3x/day over 15 minutes or lung cancer (3) after administration of a bronchodilator.
More frequent resolution of hemoptysis within
Intervention: 500 mg nebulized 5 days in the intervention group.
Placebo: nebulized normal saline intervention group.
Shorter hospital stay in the intervention group.
is needed.