The edition · Pulmonology
Pulse methylprednisolone bought nothing in acute exacerbation of fibrosis
SAFER tests the dose everybody uses, cryospray beats sham on symptom scores, antifibrotic dose reductions look less costly than feared, and two pulmonary embolism classifications disagree about who is high risk.
The edition in brief
SAFER randomised 100 adults with acute exacerbation of idiopathic pulmonary fibrosis at eight South Korean university hospitals to intravenous pulse methylprednisolone 10 mg/kg for three days or a non-pulse regimen of 1 mg/kg for seven days, both followed by protocolised tapering. Mortality at 28 days was 10.0% with pulse against 14.6% without (risk difference -4.6 percentage points, 95% CI -18.8 to 9.1) and at 90 days 24.5% against 29.8% (-5.3, -23.1 to 12.6). Neither difference was demonstrable, and secondary outcomes did not separate. With 100 patients the trial cannot exclude a clinically meaningful benefit, but it removes the assumption that pulse dosing is established. SPRAY-CB randomised 203 patients with chronic obstructive pulmonary disease and chronic bronchitis 2:1 to metered liquid nitrogen cryospray or sham bronchoscopy. St George's Respiratory Questionnaire improved by 5.9 points more with treatment (95% CI -11.6 to -0.2) and the COPD Assessment Test by 3.4 (-5.8 to -1.0). Exacerbation rates overall were similar, severe exacerbations were 21.3% against 26.9%, and periprocedural pneumothorax occurred after 3.6% of treatments. In two US data sources covering 1,572 patients with idiopathic pulmonary fibrosis, around 40% had reduced or stopped antifibrotic therapy, and progression rates did not differ consistently from those on full dose. A Chinese cohort of 2,251 hospitalised patients found the 2026 AHA/ACC pulmonary embolism categories discriminated 30-day mortality better than the 2019 ESC scheme.
Cryospray beat sham bronchoscopy on symptom scores, at a pneumothorax cost
Sham-controlled evidence supports a modest symptom benefit from bronchial cryospray in chronic bronchitis, against a pneumothorax risk of about one in 28 treatments.
Reducing or stopping antifibrotics did not clearly change how fast fibrosis progressed
When antifibrotic tolerability is the problem, a reduced dose is a defensible alternative to stopping; the evidence does not show it costs control.
Two pulmonary embolism classifications, and a group only one of them calls high risk
Treat haemodynamic stability as one input rather than the definition of risk in acute pulmonary embolism; the discordant group had very high early mortality.
A dexamethasone implant supplement, and the eye check your steroid patients are not getting
Record cumulative systemic steroid exposure in your respiratory patients and arrange an eye examination; nobody else in the pathway will.
Watch the patient use the inhaler before changing the drug
Before escalating therapy, watch the patient use their own inhaler through the whole sequence.
SAFER: pulse methylprednisolone did not improve survival in acute exacerbation of fibrosis
Treat a non-pulse corticosteroid regimen as a defensible default in acute exacerbation of idiopathic pulmonary fibrosis, and give pulse dosing a specific reason when you choose it.
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