Disclosure(s): No relevant financial relationship(s) to disclose.
First Author: Mae Leef, D.O. Co-Author: Danielle Gratza, M.D. – Internal Medicine Resident Physician, Advocate Lutheran General Hospital Co-Author: Nikolina Madjer, M.D. – Critical Care Fellow Physician, Advocate Lutheran General Hospital Co-Author: Clayton Johnson, D.O. – Internal Medicine Resident Physician, Advocate Lutheran General Hospital Co-Author: Richard Irving, D.O. – Internal Medicine Resident Physician, Advocate Lutheran General Hospital Co-Author: Daniel Sherlock, M.D. – Internal Medicine Chief Resident, Advocate Lutheran General Hospital Co-Author: Christopher Bentsen, M.D. – Internal Medicine Resident Physician, Advocate Lutheran General Hospital Co-Author: Ronak Patel, D.O. – Internal Medicine Resident Physician, Advocate Lutheran General Hospital Co-Author: Abdul Hamid Alraiyes, M.D. – Interventional Pulmonologist, Advocate Lutheran General Hospital
Introduction: Pulmonary hemorrhage is a known complication of extracorporeal membrane oxygenation (ECMO), often exacerbated by the need for continuous anticoagulation. This case highlights the use of bronchoscopic tranexamic acid (TXA) instillation as a temporizing treatment for pulmonary hemorrhage in a patient supported with both venovenous (VV) ECMO and an Impella device.
Description: A 45-year-old male presented with acute chest pain and was diagnosed with an anterior myocardial infarction. He developed cardiogenic shock with severe pulmonary edema. Emergent coronary intervention was performed, and an Impella device was placed. Despite adequate cardiac support, oxygenation worsened, prompting VV ECMO initiation. Subsequently, he developed significant hemoptysis via his endotracheal tube. Bronchoscopy revealed extensive blood clots in the bronchial tree. After clot removal with a cryoprobe, ongoing oozing was identified in the right middle lobe (RML) and left lower lobe (LLL). A total of 1000 mg of TXA was administered: two 500 mg doses diluted in 9 cc of normal saline (10 cc total per dose). Each dose was bronchoscopically instilled into the RML and LLL respectively, followed by 10 cc of air to ensure delivery. Following this, bleeding and pulmonary clot burden significantly decreased. The patient was gradually weaned off both ECMO and Impella support.
Discussion: Hemoptysis in anticoagulated patients poses a challenging management dilemma. While systemic TXA is commonly used to control bleeding, it carries risks such as pulmonary embolism or stroke—especially concerning in patients with mechanical support devices. In this case, systemic TXA was contraindicated due to clotting risk, and nebulized TXA was ineffective. Bronchoscopic instillation led to decreased bleeding, reduced clot burden, and improved oxygenation. Despite some exploration within Interventional Pulmonology (IP), this approach remains underutilized in both IP and ICU settings. This case supports topical TXA as a viable alternative to systemic administration, offering effective hemorrhage control with fewer systemic side effects.
