Thread by @WellingtonICU

This week's Journal Twitter thread will be on a novel therapy
sciencedirect.com/science/articl…

This Tweetorial was prepared by @jwri7170 and focuses on inhaled tranexamic acid for haemoptysis

Haemoptysis can be a symptom of diverse respiratory conditions. Severity can range from trivial to immediately life threatening. A few hundred mLs of blood can be fatal. Most haemoptysis arises from the high pressure bronchial system

Effective treatment usually involves either angiographic embolization or various endobronchial interventions to control bleeding

No effective medical treatment exists other than addressing the underlying cause e.g. infection

Tranexamic acid (TXA) an antifibrinolytic is commonly used systemically for various causes of acute blood loss. Topical TXA is effective in reducing blood loss in surgery. Nebulised TXA as a treatment for haemoptysis has been reported for in case reports and a small series

This DB PC RCT tested the effectiveness of nebulised TXA in patients without massive haemoptysis (>200mL in 24 hours), cardiorespiratory instability or coagulopathy in a single centre in Israel

The intervention arm received nebulised TXA 500mg/5mL three times a day with placebo group getting saline. Treatment was continued for up to 5 days.
Other treatment was up to the attending clinician

Primary outcome was resolution of haemoptysis during first 5 days and difference in volume of haemoptysis. Secondary measures were need for bronchoscopic intervention, angio, surgery and hospital LOS. Mortality and recurrence at 30 days and 1 year was assessed. Safety also

47 patients were enrolled, 25 getting TXA and 22 placebo. Most were smoking men with a mean age of 66. 2/3 had lung disease and a little over half were using an anticoagulant or antiplatelet drug. No stat significant differences between 2 groups

Main causes of bleeding in both groups were bronchiectasis, malignancy, infection and COPD

Mean blood loss on admission was 51mL vs 35ml ( TXA v Plac). Bleeding resolved in 96% on TXA vs 50% on placebo (p< .0005). Blood loss sig less from day 2 with TXA

18% of placebo group needed interventional procedure for bleeding vs none in TXA group. No surgery was performed in either group. Investigations such as CT and bronchoscopy were the same b/w groups. TXA patients were in hospital about 2 days less

Combined mortality and recurrence were stat sig better at 30 days, though not individually. Mort at one year was the same but recurrence was 22% in placebo vs 4% in TXA (P<0.01)

Nebulised TXA in this study stopped bleeding more frequently and decreased amount of blood loss compared to placebo without any reported adverse effects. There was less intervention and patients were home faster and had less recurrence. Seems like a reasonable intervention?

A 2016 Cochrane review which included 2 trials using systemic TXA for haemoptysis showed that less bleeding time but concluded that the evidence was insufficient for a recommendation
cochranelibrary.com/cdsr/doi/10.10…

Another broader review of TXA use including lower quality evidence also concluded that TXA also worked for haemoptysis though made no firm recommendations
academic.oup.com/icvts/article/…

The use of nebulised TXA is attractive as it may get the drug to the site of bleeding in a faster and more effective way while potentially limiting any systemic adverse effects

Some of the limitations of this trial are the small numbers, a single centre, developed world setting where there are low rates of TB. It also excluded patients with big bleeds, perhaps the ones more relevant to intensive care

A 2016 RCT in patients with sub massive haemoptysis showed IV TXA potentially useful as bridging therapy to definitive intervention
ncbi.nlm.nih.gov/pubmed/27470681

To me it seems there is little to lose in trying nebulised TXA in haemoptysis certainly the non massive variety and it’s conceivable that it may buy important time in those bleeding more briskly. I will consider it next time I’m faced with significant haemoptysis

side note from @DogICUma
1. this is a small, single centre, proof of concept study & such studies should never be used to drive treatment decisions
2. it is impossible to reliably assess the risks and benefits of this treatment based on a sample size of 47 patients

additional side note from @DogICUma
1. the bottom line is that a multicentre study is needed

@threadreaderapp unroll