In patients who undergo a flexible bronchoscopy (FB), no significant difference has been reported between the use of adrenaline vs tranexamic acid (TXA) to control noncatastrophic iatrogenic endobronchial bleeding following cold saline failure, according to study findings published in Chest.
Cold saline and adrenaline are the most commonly used topical hemostatic agents during FB procedures. Investigators sought to evaluate the efficacy and safety of TXA compared with adrenaline for the control of bleeding during FB.
The investigators conducted a cluster-randomized, double-blind, single-center trial (ClinicalTrials.gov identifier: NCT04771923) at a tertiary teaching hospital in Zagreb, Croatia, between February 22, 2021, and February 4, 2022. All patients were randomly assigned to weekly clusters receiving up to 3 applications of TXA (2 mL of a 50 mg/mL solution; a total of 100 mg of TXA per application) or adrenaline (2 mL of 1:10000 solution; a total of 0.2 mg of adrenaline per application) following hemostasis failure subsequent to 3 applications of 5 mL cold saline (4°C). The study permitted crossover for up to 3 further applications prior to proceeding to the use of other interventions. Severity of bleeding was graded by the bronchoscopist via use of a visual analogue scale (VAS; 1=very mild; 10=severe).
A total of 2033 FB procedures were performed. Overall, 130 patients received adrenaline (n=65) or TXA (n=65), with 12 individuals excluded for violation of protocol.
Study results showed that bleeding was stopped in 83.1% of patients in both groups (P =1). Bleeding severity and the number of applications needed to control the bleeding (N) were similar in both groups (adrenaline mean [SD] VAS, 4.9 [1.3]; N=1.8 [0.8] vs TXA mean VAS, 5.3 [1.4]; N=1.8 [0.8]).
Additionally, both adrenaline and TXA were more successful in the control of moderate bleeding (86.7% vs 88.7%, respectively; P =.008) than in the control of severe bleeding (40.0% vs 58.3%, respectively; P =.012). Both adrenaline and TXA required more applications for control of severe bleeding (3.0 [0.0] vs 2.4 [0.5], respectively; P =.006) than for control of moderate bleeding (1.7 [0.8] vs 1.7 [0.8], respectively; P =.002). No drug-associated adverse reactions were reported in either group.
Limitations of the current study include its single-center design; limited generalizability due to the use of investigated drugs in specific doses and concentrations following failure of cold saline; the exclusion of non-iatrogenic bleeding from the protocol because of concerns over patient safety and the inability to provide informed consent for trial participation in emergency situations; and the inclusion of different bronchoscopic techniques with different mechanisms for bleeding.
As the investigators concluded, “We found no significant difference between adrenaline and TXA for controlling noncatastrophic iatrogenic endobronchial bleeding after cold saline failure, adding to the body of evidence that TXA can be used safely and effectively during FB.”
Badovinac S, Glodić G, Sabol I, et al. Tranexamic acid versus adrenaline for controlling iatrogenic bleeding during flexible bronchoscopy (TAVA): a double blind, randomized control trial. Chest. Published online October 20, 2022. doi:10.1016/j.chest.2022.10.013