This week in Pulmonary

This AudioScholar briefing is generated by artificial intelligence for healthcare professionals and trainees. It is not medical advice.

Welcome to This Week in Pulmonary. This week we're covering 10 notable papers spanning a coordinated push on anti-inflammatory relievers in asthma, new ways to predict who progresses toward chronic lung and vascular disease, and sobering trial and real-world data from critical care and thoracic oncology. Let's dive in.

Asthma reliever therapy is the clearest point of convergence this week, with two major guidance documents arriving at much the same place. In the American Journal of Respiratory and Critical Care Medicine, an American Thoracic Society panel led by Khurana used systematic reviews and GRADE appraisal across six questions spanning NAEPP steps 1 through 5 [1]. For patients at steps 1 and 2, the panel made strong recommendations for as-needed inhaled corticosteroid with either albuterol-type short-acting beta agonist or formoterol over short-acting beta agonist alone, and conditional recommendations over scheduled inhaled steroid with a rescue inhaler. At steps 3 to 5, it strongly recommends maintenance-and-reliever therapy with budesonide-type ICS-formoterol over a scheduled ICS-LABA plus short-acting beta agonist, and conditionally supports an inhaled corticosteroid plus short-acting beta agonist reliever for patients who remain on fixed ICS-LABA. The panel explicitly weighed severe exacerbation prevention against cumulative steroid exposure. Writing in the European Respiratory Journal, Reddel and colleagues summarize the 2026 GINA strategy report, which continues to recommend against short-acting beta agonist-only treatment and keeps low-dose ICS-formoterol, either as-needed only or as maintenance-and-reliever therapy, as its preferred track for adults and adolescents [2]. New this year are expanded anti-inflammatory reliever options for adults and children, revised biologic selection guidance in severe asthma, and substantial updates to acute management. Taken together, the American and global positions are now closely aligned on the reliever question, which narrows the room for regional disagreement that has slowed uptake. On the diagnostic side, a post hoc analysis of the ATLANTIS cohort in ERJ Open Research by Quek and colleagues looked at 518 adults with confirmed asthma [3]. Oscillometry picked up a bronchodilator response in an additional 11 percent of participants missed by spirometry, although spirometry identified more responders overall. Patients responsive only on spirometry had more obstruction and higher exhaled nitric oxide, while those responsive on both tests showed narrower airways and more gas trapping on CT. This is hypothesis-generating phenotyping, supporting oscillometry as complementary rather than a replacement test.

A second thread this week is prediction: identifying who is heading toward overt disease, and whether our measurement tools are fair. In the American Journal of Respiratory and Critical Care Medicine, Çolak and colleagues built a simple pre-COPD score in the Copenhagen General Population Study and validated it in two further cohorts, including COPDGene [4]. Points are given for ten or more pack-years, active smoking, any respiratory symptom, asthma, and a borderline ratio between 0.70 and 0.75, with four points for preserved ratio impaired spirometry. Ten-year incidence of COPD climbed from about one and a half percent in the low-risk group to roughly 42 percent in the very high-risk group, and discrimination was good across all three populations. The score also tracked with exacerbations, and it offers a structured way to define who might enter future prevention trials, though no intervention has yet been tested against it. Also in the American Journal of Respiratory and Critical Care Medicine, Azarbarzin and colleagues analyzed two large sleep cohorts, MESA and the Sleep Heart Health Study [5]. Among Black participants, about a fifth fewer airflow-defined respiratory events met the four percent desaturation criterion than among White participants, consistent with pulse oximetry overestimating saturation in darker skin. Desaturation-based apnea indices were not linked to cardiovascular events or death in Black participants, whereas a heart-rate response measure detected events similarly across groups and was associated with roughly a quarter to a third higher risk of events in both cohorts. The findings raise a real equity question about current scoring rules, though alternative metrics are not yet in scoring guidelines. And in ERJ Open Research, a Danish nationwide cohort from Kølner-Augustson and colleagues followed 197 patients with non-IPF fibrotic interstitial lung disease [6]. Close to six in ten patients met 2022 progressive pulmonary fibrosis criteria within four years, and no baseline variable predicted who would progress. Patients with progression lost about 140 millilitres more vital capacity per year, yet survival did not differ significantly from those without progression, while a higher ILD-GAP stage was independently associated with worse survival. In a modest real-world cohort, that disconnect questions how well the progression label alone captures prognosis.

Pulmonary embolism risk, both short- and long-term, is the focus of two European studies. In the European Respiratory Journal, Becattini and colleagues report from the prospective multicentre COPE study of 5,213 patients with acute PE [7]. Major bleeding within 30 days occurred in about three percent of patients overall, rising to nearly 13 percent among those receiving thrombolysis. Active cancer, prior bleeding, dementia, anemia, syncope and thrombolysis predicted early bleeding, while cancer, prior bleeding and anemia predicted late bleeding. Four clinical phenotypes, from previous VTE or estrogen users through to frail comorbid patients, predicted bleeding about as well as existing scores, suggesting phenotyping is an alternative rather than a better tool. Looking further out, Spychalska and colleagues in ERJ Open Research followed 342 PE survivors for a median of over three years, during which chronic thromboembolic pulmonary hypertension developed in about six percent [8]. A D-dimer to NT-proBNP ratio above 10 identified a low-risk group in whom only 2 of 171 patients developed the condition, a negative predictive value near 99 percent. A ratio of 10 or less combined with an elevated tricuspid gradient defined a group with roughly one in five incidence. This is a single-centre derivation with few events, so the threshold needs external validation before it could guide follow-up imaging.

Finally, two papers from critical care and thoracic oncology temper enthusiasm for promising agents. In Chest, the ADJUST trial by Chen and colleagues randomized adults with sepsis to intravenous ulinastatin, 400,000 units every eight hours, or placebo for up to ten days [9]. Twenty-eight-day mortality was essentially identical, at just under a quarter in each arm, secondary outcomes did not differ, and adverse events were about fourteen points more frequent with ulinastatin. The authors conclude that routine use is not supported, a clear negative result for an agent used in some regions on the strength of earlier signals. In the Journal of Thoracic Oncology, Joshi and colleagues describe 265 patients treated with tarlatamab for small cell lung cancer across 11 United States centres in the ONWARD consortium [10]. Disease control was achieved in about half of evaluable patients, median overall survival was eight months, and activity appeared similar in patients with brain metastases. Cytokine release syndrome followed the first dose in about four in ten patients and neurotoxicity in about one in five, with severe neurotoxicity more common than in trials. A small group of 19 patients given prophylactic tocilizumab had markedly less cytokine release syndrome and shorter hospitalization, an observational signal the authors say needs prospective testing.

If you only have time for one paper this week, make it the American Thoracic Society guideline on as-needed inhaled corticosteroids [1]. It brings a major United States guideline body firmly into line with GINA on retiring short-acting beta agonist-only relief across the full severity spectrum, settling a question that has left many clinicians caught between competing documents.

That's your roundup for This Week in Pulmonary. The full transcript and references are available on the episode page. See you next week.

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