Scientific Letter
Nebulized Tranexamic Acid as a Therapeutic Alternative in Pulmonary Hemorrhage
Ácido tranexámico nebulizado como alternativa de tratamiento en la hemorragia pulmonar
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Alternative in Pulmonary Hemorrhage" "tieneTextoCompleto" => true "saludo" => "Dear Editor," "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "442" "paginaFinal" => "443" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Alejandro González-Castro, Juan Carlos Rodriguez-Borregán, Enrique Chicote, Patricia Escudero, Diego Ferrer" "autores" => array:5 [ 0 => array:4 [ "nombre" => "Alejandro" "apellidos" => "González-Castro" "email" => array:1 [ 0 => "e409@humv.es" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Juan Carlos" "apellidos" => "Rodriguez-Borregán" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "Enrique" "apellidos" => "Chicote" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "Patricia" "apellidos" => "Escudero" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 4 => array:3 [ "nombre" => "Diego" "apellidos" => "Ferrer" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Medicina Intensiva, Hospital Universitario Marqués de Valdecilla, Santander, Cantabria, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Neumología, Hospital Universitario Marqués de Valdecilla, Santander, Cantabria, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Ácido tranexámico nebulizado como alternativa de tratamiento en la hemorragia pulmonar" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1232 "Ancho" => 2175 "Tamanyo" => 112744 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Course of the event, described in terms of hemoglobin levels and the need for transfusion (number of packed red blood cell units) on the left vertical axis of the figure. The right vertical axis shows the course of lung compliance and PaO<span class="elsevierStyleInf">2</span>/FiO<span class="elsevierStyleInf">2</span> until the start of mechanical ventilation weaning maneuvers.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Pulmonary hemorrhage is a potentially life-threatening condition that sometimes requires immediate intervention to stop the bleeding. When the source of the bleeding is not identifiable, for example, in alveolar hemorrhage, therapeutic options are limited and include correction of the coagulation defects, along with life-sustaining treatment as needed.<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">1–3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">In this context, tranexamic acid (TA), a synthetic antifibrinolytic agent, has been approved for the oral or intravenous treatment or prophylaxis of bleeding episodes in patients with coagulation disorders. Based on its effectiveness in the control of local mucosal bleeding (nose, colon, rectum, and mouth), it has been evaluated for use in pulmonary hemorrhage of different etiologies.<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">4–6</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">We report the case of an 18-year-old man, diagnosed with idiopathic pulmonary hemosiderosis, who had received several lines of treatment, and who was currently receiving corticosteroids, hydroxychloroquine, and immunoglobulins.</p><p id="par0020" class="elsevierStylePara elsevierViewall">He was admitted to the ICU with a clinical picture of dyspnea and frank hemoptysis, requiring orotracheal intubation due to global respiratory failure. Chest X-ray showed bilateral infiltrates, and anemia with a 2<span class="elsevierStyleHsp" style=""></span>g/dL decrease in hemoglobin from baseline was detected. Fiberoptic bronchoscopy was performed, showing the bronchial mucosa covered with red blood, surging up from both lower lobes. Antimicrobial treatment began with a wide-spectrum antimicrobial and the corticosteroid dose was increased to 1<span class="elsevierStyleHsp" style=""></span>mg/kg/12<span class="elsevierStyleHsp" style=""></span>h.</p><p id="par0025" class="elsevierStylePara elsevierViewall">The patient's progress in the following hours was poor, and collection of bloody fluid from the orotracheal tube persisted. Anemia developed again with a fall in hemoglobin levels of 1.5<span class="elsevierStyleHsp" style=""></span>g/dL, and ventilation and oxygenation became more difficult, with reduced lung compliance. Chest X-ray showed increased patchy bilateral consolidations. Fiberoptic bronchoscopy was repeated, showing aspiration of fresh blood from both lower lobes.</p><p id="par0030" class="elsevierStylePara elsevierViewall">The patient's clinical status continued to worsen and diffuse alveolar hemorrhage was suspected. Treatment began with nebulized TA on day 3 of admission, and antimicrobial treatment, sedation, and analgesia were maintained. A 22<span class="elsevierStyleHsp" style=""></span>mm Cirrus®2 nebulizer breathing kit was used for nebulization. Using this system and a gas flow of 8<span class="elsevierStyleHsp" style=""></span>L/min, 77% of the output volume contains particles at least 5<span class="elsevierStyleHsp" style=""></span>μm in diameter with a mean mass diameter of 2.7<span class="elsevierStyleHsp" style=""></span>μm.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">7</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">We used a TA dose of 500<span class="elsevierStyleHsp" style=""></span>mg/5<span class="elsevierStyleHsp" style=""></span>mL/12<span class="elsevierStyleHsp" style=""></span>h, during which time the patient remained on mechanical ventilation.</p><p id="par0040" class="elsevierStylePara elsevierViewall">A significant improvement was observed in the following days, with no new episodes of bleeding or anemia, and the patient's respiratory status improved, so sedation could be discontinued. He awakened correctly and was weaned from mechanical ventilation, with extubation on day 9 of hospitalization. <a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a> describes the course of the event, in terms of lung compliance, PaO<span class="elsevierStyleInf">2</span>/FiO<span class="elsevierStyleInf">2</span>, anemia, and need for transfusion during the first 7 days in the ICU, at which time mechanical ventilation weaning maneuvers were initiated.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">Diffuse alveolar hemorrhage, whether idiopathic or associated with hematological disorders is an entity with a mortality rate ranging between 70% and 90%.<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">8,9</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">TA, a synthetic derivative of the amino acid lysine, has anti-fibrinolytic activity, as it binds with plasminogen, thus inhibiting fibrin binding and subsequent plasmin activation.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">4</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">A Cochrane review identifies two clinical trials which evaluate the use of oral and intravenous TA (Anchafibrin<span class="elsevierStyleSup">®</span>).<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">10</span></a> There is insufficient evidence to recommend its use, but some small studies suggest that it may reduce hemorrhage duration. However, a review article<span class="elsevierStyleSup">33</span> of the published series concludes that, while a recommendation with strong evidence cannot be given, TA can reduce both bleeding duration and volume, with a low short-term risk of thromboembolic disease (weak recommendation, 2B).<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">11</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">The recommendation to administer nebulized TA in pulmonary hemorrhage may be based on pathophysiological evidence that it increases the activity of anti-fibrinolytic factors that are depleted in sites of continuous bleeding throughout the bronchial tree. Studies indicate that the drug is more effective when administered locally rather than systemically, suggesting that local administration provides improved, more durable inhibition of fibrinolysis, with less systemic absorption, thus reducing the risk of thrombosis associated with the latter. Indeed, the local application of TA has proven efficacy in the control of bleeding of different etiologies, with no significant adverse effects.<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">12,13</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">The data suggest that administering TA by inhalation is an effective, inexpensive, safe, and easy-to-manage technique, making it a good option for the treatment of pulmonary hemorrhage in emergency rooms or even general hospitalization units.</p><p id="par0070" class="elsevierStylePara elsevierViewall">However, no cause-and-effect relationship can be inferred, as favorable progress may be due to a spontaneous resolution of the case. For this reason, we believe that additional prospective randomized clinical trials are needed to evaluate the use of TA in this syndrome, since treatment duration and dose have not yet been fully clarified.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: González-Castro A, Rodriguez-Borregán JC, Chicote E, Escudero P, Ferrer D. Ácido tranexámico nebulizado como alternativa de tratamiento en la hemorragia pulmonar. Arch Bronconeumol. 2018;54:442–443.</p>" ] ] "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1232 "Ancho" => 2175 "Tamanyo" => 112744 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Course of the event, described in terms of hemoglobin levels and the need for transfusion (number of packed red blood cell units) on the left vertical axis of the figure. The right vertical axis shows the course of lung compliance and PaO<span class="elsevierStyleInf">2</span>/FiO<span class="elsevierStyleInf">2</span> until the start of mechanical ventilation weaning maneuvers.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:13 [ 0 => array:3 [ "identificador" => "bib0070" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Non-infectious pulmonary complications after bone marrow transplantation" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "I. Khurshid" 1 => "L.C. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 18 | 2 | 20 |
| 2024 October | 163 | 46 | 209 |
| 2024 September | 233 | 38 | 271 |
| 2024 August | 190 | 56 | 246 |
| 2024 July | 141 | 30 | 171 |
| 2024 June | 142 | 49 | 191 |
| 2024 May | 139 | 34 | 173 |
| 2024 April | 103 | 35 | 138 |
| 2024 March | 94 | 23 | 117 |
| 2024 February | 62 | 17 | 79 |
| 2023 October | 1 | 0 | 1 |
| 2023 June | 4 | 0 | 4 |
| 2023 March | 26 | 4 | 30 |
| 2023 February | 129 | 28 | 157 |
| 2023 January | 165 | 58 | 223 |
| 2022 December | 163 | 34 | 197 |
| 2022 November | 191 | 30 | 221 |
| 2022 October | 207 | 37 | 244 |
| 2022 September | 173 | 44 | 217 |
| 2022 August | 261 | 58 | 319 |
| 2022 July | 226 | 52 | 278 |
| 2022 June | 226 | 44 | 270 |
| 2022 May | 239 | 47 | 286 |
| 2022 April | 289 | 48 | 337 |
| 2022 March | 202 | 37 | 239 |
| 2022 February | 204 | 34 | 238 |
| 2022 January | 256 | 53 | 309 |
| 2021 December | 206 | 45 | 251 |
| 2021 November | 190 | 50 | 240 |
| 2021 October | 269 | 76 | 345 |
| 2021 September | 162 | 53 | 215 |
| 2021 August | 152 | 49 | 201 |
| 2021 July | 155 | 40 | 195 |
| 2021 June | 198 | 47 | 245 |
| 2021 May | 203 | 79 | 282 |
| 2021 April | 568 | 107 | 675 |
| 2021 March | 403 | 47 | 450 |
| 2021 February | 322 | 50 | 372 |
| 2021 January | 283 | 33 | 316 |
| 2020 December | 255 | 48 | 303 |
| 2020 November | 330 | 45 | 375 |
| 2020 October | 265 | 59 | 324 |
| 2020 September | 324 | 41 | 365 |
| 2020 August | 343 | 44 | 387 |
| 2020 July | 1 | 2 | 3 |
| 2020 March | 338 | 40 | 378 |
| 2020 February | 573 | 49 | 622 |
| 2020 January | 623 | 56 | 679 |
| 2019 December | 623 | 60 | 683 |
| 2019 November | 607 | 79 | 686 |
| 2019 October | 566 | 59 | 625 |
| 2019 September | 436 | 47 | 483 |
| 2019 August | 251 | 54 | 305 |
| 2019 July | 230 | 52 | 282 |
| 2019 June | 168 | 22 | 190 |
| 2019 May | 156 | 37 | 193 |
| 2019 April | 134 | 43 | 177 |
| 2019 March | 96 | 45 | 141 |
| 2019 February | 34 | 28 | 62 |
| 2019 January | 3 | 4 | 7 |
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