Pulmonology

Low-dose, short-course systemic steroids improve short-term survival in severe pneumonia and ARDS

This systematic review and meta-analysis pooled 20 randomized trials including 3459 adults with severe non-COVID pneumonia or ARDS. Adjunct low-dose corticosteroids for ≤15 days probably reduced short-term mortality in severe pneumonia (RR 0.73; 95% CI 0.57–0.93; moderate certainty). They also probably reduced short-term mortality in ARDS (RR 0.77; 95% CI 0.61–0.99; moderate certainty). In severe pneumonia, steroids may lower secondary shock risk, though certainty was low. 1

Stepped budesonide–formoterol AIR strategy lowers exacerbations in obstructive airways disease

This 52-week open-label cluster randomized trial in Vietnam enrolled 3095 adults with recurrent acute respiratory symptoms and obstructive airways disease suggestive of asthma or COPD. Facilities assigned to the AIR strategy used budesonide–formoterol 160/4.5 μg as-needed, stepped to maintenance plus reliever, with quarterly reviews. AIR participants were less likely to have ≥1 moderate or severe exacerbation than usual care (28.6% vs 36.0%; RR 0.79; 95% CI 0.65–0.97). Respiratory hospitalizations were also lower (17.4% vs 24.1%; RR 0.74; 95% CI 0.54–1.00), with similar all-cause mortality and grade 3–4 adverse events. 2

Eosinophil-guided steroid duration is non-inferior to standard 5-day therapy in hospitalized asthma

This open-label randomized trial assigned 110 adults hospitalized for asthma exacerbations to usual 5-day prednisolone or eosinophil-guided duration based on pre-treatment blood eosinophils. In the eosinophil-guided arm, patients with eosinophils <300 cells/μL received 3 days of prednisolone, while those ≥300 cells/μL received 5 days. Treatment failure was similar (10.9% eosinophil-guided vs 7.3% usual care; absolute difference 3.6%; 95% CI -8.9% to 16.2%), meeting the prespecified non-inferiority margin. Within the eosinophil-guided group, non-eosinophilic exacerbations received lower cumulative steroid doses than eosinophilic ones, without worse outcomes. 3

Driving pressure–guided high PEEP fails to reduce postoperative pulmonary complications

This multicenter randomized trial included 1435 adults at increased pulmonary risk undergoing open abdominal surgery with low tidal volume ventilation. Patients received either driving pressure–guided high PEEP with recruitment maneuvers or standard low PEEP without recruitment. Pulmonary complications within 5 postoperative days occurred similarly (19.8% high PEEP vs 17.4% low PEEP; absolute difference 2.5%; 95% CI -1.5% to 6.4%). High PEEP increased intraoperative hypotension (54.0% vs 45.0%) and vasoactive use, whereas intraoperative desaturation was more frequent with low PEEP. 4