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Background An updated comprehensive assessment of the burden of hospitalised viral lower respiratory tract disease (LRTD) is especially salient after the COVID-19 pandemic. Therefore, we aimed to comprehensively describe clinical characteristics and outcomes of US adults hospitalised with viral LRTD between 2015 and 2023.Methods In this retrospective analysis, adults hospitalised between 1 January 2015 and 31 March 2023 were identified using Optum’s deidentified Clinformatics Data Mart Database. Index date was the first International Classification of Diseases, 9th/10th Revision (ICD-9/10) code for viral LRTD hospitalisation. Outcomes included intensive care unit (ICU) admission, non-invasive ventilation (NIV), invasive mechanical ventilation/extracorporeal membrane oxygenation (IMV/ECMO), costs, 30-day mortality and 30-day readmissions. Outcomes were stratified by viral aetiology (ICD-9/10), clinical severity and time period (2015–2019; 2020–2021; 2022–2023). Time-to-event data were assessed using Kaplan-Meier estimates.Results Of 387 449 patients hospitalised for viral LRTD, 38.1% were admitted to ICU within 30 days of index (84.6% of these were admitted on index date); 8.4% and 8.7%, respectively, received NIV and IMV/ECMO within 30 days of index and 30-day mortality was 15.1%. Median (IQR) length of stay and mean (SD) hospitalisation costs were 7 (4–15) days and $42 752 ($44 841), respectively. Admission to ICU, mortality and costs were substantial across all aetiologies but peaked from 2020 to 2021; readmissions and costs remained high even into 2022–2023.Conclusions Severe viral LRTD incurred substantial burden for US healthcare systems across all viral aetiologies, even in non-pandemic years, with frequent ICU admission and ventilation use, and with considerable associated costs. Readmission rates and costs remain high even after the peak of COVID-19.