Side Effects - One
patient developed bronchospasm which was successfully treated with
bronchodilators. No patients had systemic side effects or thromboembolic events.
How to Perform - 500mg
of tranexamic acid IV formulation; placed in a traditional nebulizer; administered
over 15 minutes.
Hankerson et al. 2015
·
We chose to prepare a 10 mg/ml solution by diluting one gram of TXA
intravenous formulation in 100 ml of 0.9% normal saline. The TXA solution was
nebulized and delivered to the patient’s mouth and tracheostomy tube via
facemask. The hemoptysis completely resolved over a period of 15 minutes with
continuous nebulized TXA solution. We delivered the entire one gram of TXA via
continuous nebulizer over the course of 30 to 45 minutes, even though the
bleeding had resolved.
·
One must also consider the possibility of bronchospasm when TXA is
delivered via nebulizer, but thus far this has not been shown to occur.
·
In retrospect, if we used a more concentrated TXA solution similar to
the 500 mg/5 ml preparation used by Solomonov et al., it would have likely been
safe, and we may have reached hemostasis more quickly.
Solomonov et al. 2009
·
For unidentifiable bleeding episodes, we used inhaled tranexamic acid
500 mg/5 ml 3-4 times a day (Hexakapron, TEVA Group, Tel-Aviv, Israel), and for
identifiable bleeding episodes we used boluses of tranexamic acid administered
through the working channel of the flexible bronchoscope.
·
Each ampoule of 5 ml contained 500 mg of tranexamic acid dissolved in
water for injection, sodium hydroxide and hydrochloric acid (for pH
adjustment). A quantitative and qualitative (verbal) evaluation of the symptoms
was made, such as general clinical evaluation, chest X-ray, and blood
tests.
·
The rationale for administrating inhaled TA to pulmonary bleeding was to
enhance the activity of depleted anti-fibrinolytic factors in ongoing bleeding
sites along the bronchial tree.
·
Based on this review, the treatment duration may vary from single dose
to 3 months.
Bafaqih et al. 2015
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Dosing
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Children <25kg
|
250 mg/dose
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Children >25kg
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500 mg/dose
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Concentration
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500 mg/5 mL
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Frequency
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3-4 times daily
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Admini-stration
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Jet nebulizer with a flow rate of 5 L of oxygen per minute
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Remarks
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||
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·
In case of response, n-TXA was
continued for 2-3 doses after bleeding completely stopped.
·
If no or minimal response was seen
after 3 to 4 doses of n-TXA (18 to 24 hours from the first dose of n-TXA) or
if bleeding severity escalated as judged by the treating physician at any
time before that, rFVIIa (Novoseven RT, 1mg lyophilized powder vials, Novo
Nordisk, Denmark) nebulization was added every 4 hours until bleeding
stopped.
·
Before each n-rFVIIa dose a
judgment was made by the treating physician whether evidence of active DAH
still existed or not. If not, n-rFVIIa was stopped and n-TXA continued for
another 2-3 doses.
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*TXA = Tranexamic Acid
*DHA = Diffuse alveolar hemorrhage
References:
1. Hankerson et al. Nebulized
Tranexamic Acid as a Noninvasive Therapy for Cancer-Related Hemoptysis.
Journal of Palliative Medicine:
Vol. 18, No. 12 (2015).
2. Solomonov et al. Pulmonary
hemorrhage: A novel mode of therapy. Respiratory Medicine (2009) 103, 1196-1200
3. Bafaqih H, Chehab
M, Almohaimeed S, Thabet F, Alhejaily A, AlShahrani M et al. Pilot trial
of a novel two-step therapy protocol using nebulized tranexamic acid and
recombinant factor VIIa in children with intractable diffuse alveolar
hemorrhage. Ann Saudi Med 35(3): 231-239.
[All references accessed on 17 Dec 2018]
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