Analysis of tranexamic acid in hemoptysis: effectiveness in a noninterventional evaluation (ATHENE)

Hemoptysis is a common reason for respiratory ICU admission and may rapidly become life‑threatening. For patients not requiring immediate bronchial artery embolization (BAE), no pharmacologic standard exists. Despite growing use after encouraging early reports, the real‑world effectiveness of nebulized tranexamic acid (TXA) in ICU practice remains uncertain.

To assess whether nebulized TXA reduces early hemoptysis recurrence in ICU patients not requiring emergent BAE.

Single‑center retrospective cohort (2017-2021) including adults admitted for hemoptysis; exclusions were bleeding >200 mL at admission or BAE within 6 h. Propensity score matching (1:2, with replacement) used admission bleeding volume, etiology, prior hemoptysis, and anticoagulant/antiplatelet therapy, with adequate post‑matching balance. The primary endpoint was 72‑hour recurrence (≥50 mL cumulative bleeding). Secondary endpoints included 30‑day recurrence, acute respiratory failure, BAE, length of stay, and 30‑day mortality. Conditional logistic regression was applied.

Among 228 patients, 75 (33%) received nebulized TXA, with use rising from 0% to 78% over the study period. After matching (75 TXA and 147 control observations), hemoptysis recurrence at 72 h was similar between groups: recurrence occurred in 12.3% of patients in the control group versus 10.7% in the TXA group, with no significant difference between groups (OR 0.93, 95% CI 0.37-2.32). No differences were found in 30‑day recurrence, acute respiratory failure, BAE, or length of stay. Thirty‑day mortality was higher in the TXA group (9.3%vs 1.9%; OR5.9, 95%CI1.2-28.8), driven by few events mostly related to underlying malignancy.

In this real‑world ICU cohort, nebulized TXA did not reduce hemoptysis recurrence at 72 h. Nonetheless, TXA use increased markedly during the study period, reflecting a significant shift in clinical practice. This rapid uptake underscores clinical interest and strengthens the need for adequately powered randomized trials to define the role of inhaled TXA in hemoptysis management.