Is there evidence for the use of inhalers in patients with pulmonary fibrosis?

Inhaled Therapy in Pulmonary Fibrosis: Evidence-Based Recommendations

There is insufficient evidence to support the routine use of inhalers (bronchodilators or inhaled corticosteroids) in patients with pulmonary fibrosis, and emerging data suggests potential harm, particularly with inhaled corticosteroids. 1

Key Evidence Against Routine Inhaler Use

Inhaled Corticosteroids: Potential Harm

• Recent UK population-based cohort data (2025) demonstrates that regular ICS use in IPF patients is associated with increased pneumonia hospitalizations (HR 1.40,95%CI: 1.25-1.55) and increased all-cause mortality (HR 1.19,95%CI: 1.06-1.33). 1
• This represents the most recent and highest-quality evidence directly addressing inhaler use in pulmonary fibrosis patients, showing clear harm rather than benefit. 1
• The increased infection risk is particularly concerning in older patients and those with advanced disease, who comprise the majority of the IPF population. 1

Bronchodilators: Limited Rationale

• Pulmonary fibrosis is fundamentally a restrictive lung disease, not an obstructive airway disease where bronchodilators provide benefit. 2
• Bronchodilators may only be considered if there is documented concurrent reversible airflow obstruction (essentially treating coexisting asthma or COPD, not the fibrosis itself). 3
• Without demonstrated bronchospasm or reversibility on pulmonary function testing, bronchodilators lack a mechanistic rationale in pure fibrotic disease. 2

When Inhalers Might Be Considered (Treating Comorbidities, Not Fibrosis)

Bronchodilators for Concurrent Obstructive Disease

• If spirometry demonstrates reversible airflow obstruction (≥12% and 200mL FEV1 improvement post-bronchodilator), then bronchodilators may be used to treat the obstructive component. 3
• This represents treatment of coexisting COPD or asthma, not treatment of the pulmonary fibrosis itself. 3
• A therapeutic trial with objective monitoring (repeat spirometry) should guide continuation. 3

Specific Clinical Scenarios

• For palliation of breathlessness due to concurrent reversible airflow obstruction only, bronchodilators may be indicated. 3
• Beta-agonists should be administered before any nebulized treatments that carry bronchospasm risk. 3

Evidence-Based Alternatives for Pulmonary Fibrosis

Antifibrotic Therapy (The Actual Treatment)

• Pirfenidone and nintedanib are the only medications with demonstrated efficacy in slowing IPF progression. 4
• These agents target the fibrotic process itself, unlike inhalers which address airway symptoms. 4

Supportive Measures

• Supplemental oxygen for severe resting hypoxemia (PaO2 ≤55 mmHg or SpO2 ≤88%). 3
• Pulmonary rehabilitation for symptomatic patients. 3
• Lung transplantation evaluation for refractory disease. 2

Critical Pitfalls to Avoid

Do Not Prescribe ICS Without Clear Indication

• The default should be to avoid ICS in IPF patients unless there is documented asthma or another specific indication requiring corticosteroid therapy. 1
• The risk-benefit balance is unfavorable given the pneumonia and mortality risks. 1
• Older patients and those with advanced disease face the highest risk from ICS-associated infections. 1

Do Not Assume Dyspnea Equals Bronchospasm

• Breathlessness in pulmonary fibrosis is primarily due to restrictive physiology and impaired gas exchange, not bronchospasm. 2
• Objective testing (spirometry with bronchodilator response) is required before attributing symptoms to reversible airflow obstruction. 3

Recognize Treatment Burden

• If inhalers are prescribed for documented comorbid conditions, consider the cumulative treatment burden in IPF patients who already face complex medication regimens. 5
• Fast delivery devices and simplified regimens improve adherence when inhaled therapy is truly indicated. 5

Clinical Algorithm

Step 1: Confirm pulmonary fibrosis diagnosis and assess for comorbid obstructive lung disease. 2

Step 2: Perform spirometry with bronchodilator response testing if obstructive symptoms are present. 3

Step 3:

• If reversibility demonstrated (≥12% and 200mL FEV1 improvement): Consider bronchodilators for the obstructive component. 3
• If no reversibility: Do not prescribe bronchodilators. 3

Step 4: Avoid routine ICS prescription given pneumonia and mortality risks unless treating documented asthma or other specific indication. 1

Step 5: Focus treatment on antifibrotic agents (pirfenidone or nintedanib) as the primary disease-modifying therapy. 4