This Week in Pulmonary — Oct 6, 2026

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 chronic airway infection, acute and critical respiratory illness, and the growing population burden of lung disease along with how we screen for and diagnose it. Let's dive in.

We start with chronic mycobacterial and neutrophilic airway disease, where one trial may shift the starting point of treatment. In the American Journal of Respiratory and Critical Care Medicine, Daley and colleagues report ENCORE, a phase 3b double-blind trial of 425 adults with newly diagnosed Mycobacterium avium complex lung disease who had not yet started antibiotics [1]. Patients received azithromycin and ethambutol for 12 months, plus either amikacin liposome inhalation suspension at 590 milligrams daily or placebo. Until now, the inhaled liposomal amikacin had been approved only for refractory disease. On the primary endpoint, a respiratory symptom score, the amikacin group improved by about three points more one month after treatment ended, and the gap widened to roughly five points at three months. The microbiology was more striking. About 82 percent of patients on amikacin converted their cultures by month 13, compared with about 56 percent on placebo, and durable conversion at month 15 was about three quarters versus just under half. No new safety signals emerged. The population was mostly older women, which matches who presents with this disease, and the symptom difference is modest in absolute terms, but the culture data make this the first randomized evidence supporting a three-drug regimen including inhaled amikacin from the very start of therapy. On the bronchiectasis front, ERJ Open Research carries the design of AIRTIVITY, led by Chalmers [2]. This phase 3 trial is randomizing roughly 1,680 adults and 75 adolescents to the oral cathepsin C inhibitor verducatib at 2.5 milligrams or placebo for up to 76 weeks, with annualised exacerbation rate as the primary endpoint. Its notable features are a broad range of causes and, unusually, the inclusion of people with cystic fibrosis bronchiectasis. There are no efficacy results yet; this paper tells us what question will be answered, and how.

Our second theme is acute and critical respiratory illness, where this week brings one informative negative trial, one cautious early signal, and two pieces that refine existing decisions. Also in the American Journal of Respiratory and Critical Care Medicine, Kim and colleagues report SAFER, a multicenter open-label trial at eight South Korean hospitals comparing pulse methylprednisolone at 10 milligrams per kilogram for three days with a nonpulse regimen of 1 milligram per kilogram for seven days in acute exacerbation of idiopathic pulmonary fibrosis [3]. Pulse dosing did not lower mortality. Deaths at 28 days were about 10 percent with pulse versus about 15 percent without, and at 90 days about a quarter versus about 30 percent, differences that were not statistically significant, and secondary outcomes such as intensive care admission and ventilation were also similar. With only 100 patients, the trial cannot rule out a modest difference in either direction, but it offers no support for the widely held belief that higher doses are better, and it is the first randomized evidence to inform a dosing choice that guidelines leave undefined. In Chest, Huang and colleagues tested TISA-818, an anti-inflammatory montelukast-peptide conjugate, in a phase 2 trial of 58 patients with infection-related ARDS, using the 2023 global definition that includes non-intubated patients [4]. The primary endpoint was safety, and the drug was generally tolerated, though treatment-related adverse events were more frequent on active drug. Day 28 mortality was numerically higher in the 12 milligram once-daily arm, about a quarter of patients versus about 5 percent on placebo, an imbalance that did not persist at day 60. In a non-intubated subgroup of just 27 patients, the twice-daily 6 milligram dose numerically favoured about six more respiratory support-free days, without statistical significance. This is hypothesis-generating at most, and the mortality signal deserves attention in any larger trial. Back in the American Journal of Respiratory and Critical Care Medicine, Timsit and colleagues review antibiotic duration in sepsis and severe infection [5]. They summarise randomized evidence showing that courses shorter than seven days are noninferior to longer ones across bacteremia, intra-abdominal infection after source control, and ventilator-associated pneumonia, with procalcitonin algorithms as a possible tool to individualise stopping. They are explicit that evidence remains thin for Staphylococcus aureus bacteremia, non-fermenting Gram-negative organisms, multidrug-resistant pathogens, invasive candidiasis and immunocompromised hosts. Finally in this theme, Fan and colleagues in Chest compared the new 2026 American Heart Association and American College of Cardiology pulmonary embolism categories with the 2019 European Society of Cardiology scheme in 2,251 hospitalized patients at a Chinese tertiary centre [6]. The American categories discriminated 30-day mortality noticeably better, and at the high-risk threshold they picked up about 84 percent of embolism-related deaths, compared with about 59 percent for the European high-risk stratum, at similar specificity. A small group of 37 patients classed as European intermediate risk but in the highest American categories had roughly three quarters dying within 30 days. The advantage shrank when the extreme categories were excluded, and this is retrospective, single-system prognostic work, so it says nothing yet about whether reclassification changes outcomes.

Our third theme is the scale of lung disease in populations, and the tools to find and act on it earlier. In The Lancet Global Health, Duong and colleagues analysed spirometry from 119,252 adults across 25 high, middle and low income countries in the PURE cohort [7]. Airflow obstruction was found in just under one in ten participants, and nearly nine in ten of those people had never been diagnosed with an airway disease, with underdiagnosis more common in younger, less symptomatic people and in lower-income countries. Undiagnosed obstruction was not benign. Compared with normal spirometry, it carried about a fifty percent higher risk of death and roughly doubled the risk of respiratory events, while diagnosed disease roughly doubled mortality. These are observational associations, but they were consistent across income levels, ages and smoking status. A national picture for interstitial disease comes from Thorax, where Massen and colleagues used linked English health records from 2005 to 2022 [8]. Incidence of interstitial lung disease rose by about 30 percent over the period before plateauing from 2018, and age and sex adjusted mortality fell by about 15 percent in idiopathic pulmonary fibrosis but was unchanged for other forms. Median survival across all interstitial disease was 5.4 years, and the authors estimate around 200,000 people in England now live with these conditions, with 60,000 new diagnoses each year. Turning to prevention, JAMA publishes a four-arm trial by Hart and colleagues in 3,259 medically underserved people who smoked and were referred for lung cancer screening at health systems across the United States [9]. Against an ask-advise-refer baseline, free pharmacotherapy added essentially nothing, with sustained abstinence of about 5 percent versus about 4 percent. Adding financial incentives of up to 600 dollars, contingent on biochemically confirmed quitting, roughly doubled abstinence to just under 9 percent, while a mobile health tool on top did not add further benefit. Absolute quit rates remain low, but this is strong randomized evidence that contingent incentives outperform medication access alone in this population. Lastly, in Chest, Bi and colleagues randomized 2,485 patients with subpleural lung lesions in China to biopsy guided by plain ultrasound, contrast-enhanced ultrasound, or CT [10]. Contrast-enhanced ultrasound gave the highest diagnostic yield, about 89 percent versus about 79 percent for CT and 76 percent for plain ultrasound, and the lowest complication rate, under 5 percent compared with about 16 percent for CT. The gains held for both malignant and specific benign diagnoses. The findings apply only to lesions abutting the pleura and depend on local ultrasound expertise, so generalisability outside high-volume centres is still an open question.

If you only have time for one paper this week, make it ENCORE [1]. It is the first randomized trial to ask whether inhaled liposomal amikacin belongs in first-line therapy for Mycobacterium avium complex lung disease, and its large culture conversion gains reopen the question of what standard initial treatment should look like.

Here is what this week's evidence adds up to in Pulmonary. First, adding inhaled liposomal amikacin to a two-drug oral regimen in newly diagnosed avium complex disease improved culture conversion substantially and symptoms modestly in a single well-conducted trial, and guidelines have yet to weigh in. Second, a small randomized trial found no survival advantage for pulse-dose steroids in acute exacerbation of pulmonary fibrosis, which weakens the rationale for high doses without settling the role of steroids themselves. Third, short antibiotic courses are now well supported for several common severe infections, while key exceptions remain under-studied. Fourth, undiagnosed airflow obstruction and interstitial lung disease are far commoner and more consequential than often assumed, based on large observational data. Fifth, for screening-eligible smokers from underserved groups, contingent financial incentives roughly doubled quitting in a large trial, whereas free medication alone did not move the needle.

That's your roundup for This Week in Pulmonary. The full transcript and references are available on the episode page in your AudioScholar library. This is an AI-curated summary — for clinical decisions, always consult primary sources and current guidelines. See you next week.

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