OBJECTIVES: Pulmonary involvement is common in systemic lupus erythematosus (SLE), but the relative risk of pulmonary manifestations in SLE versus non-SLE subjects remains unclear. This study aimed to evaluate the risk of pulmonary manifestations in SLE subjects compared with matched controls. METHODS: Using data from the Korean National Health Insurance Service (2009-2017), we identified 6074 individuals aged ≥20 years with newly diagnosed SLE and 60 740 matched controls by age and sex (1:10 ratio) who did not have prior pulmonary manifestations. RESULTS: Over a mean follow-up of 9.3±2.7 years, the incidence of pulmonary manifestations was 15.2 per 1000 person-years in the SLE cohort and 4.5 per 1000 person-years in the matched cohort. The SLE cohort had a significantly higher risk of pulmonary manifestations (adjusted HR (aHR) 3.26
95% CI 2.99 to 3.56). The highest risk was observed for pulmonary hypertension (aHR 14.66
95% CI 9.43 to 22.80), followed by interstitial lung disease (aHR 9.58
95% CI 7.99 to 11.49), pleural disorders (aHR 3.29
95% CI 2.84 to 3.81), pulmonary embolism (aHR 2.66
95% CI 2.06 to 3.43), tuberculosis (aHR 2.35
95% CI 1.88 to 2.93), acute respiratory distress syndrome and haemorrhage (aHR 1.85
95% CI 1.51 to 2.25) and lung cancer (aHR 1.41
95% CI 1.02 to 1.95). CONCLUSIONS: Subjects with SLE have an approximately 3.3-fold higher risk of pulmonary manifestations compared with matched controls. Notably, the risks of pulmonary hypertension and interstitial lung disease are particularly elevated.