When do you start steroids for radiation pneumonitis?

Great question on a relevant clinical topic. It's very important to remember that pneumonitis is a diagnosis of exclusion. Sometimes, if the timing is right and the patient's presentation is typical, there is a tendency to move quickly to the conclusion that the symptoms are caused by pneumonitis. Remember, however, that these same patients are at higher risk of developing pneumonia as well (frequently getting adjunctive chemotherapy so counts are low or recovering, may have segmental or lobar a...

I usually start steroids soon, when symptoms develop, if the symptoms are severe. I will give a trial of antibiotics if I think there is possibly an infection. But if there is no fever or colored sputum and no infiltrate on chest X Ray, I go right to steroids. If they are very symptomatic and I am worrying also about infection, I might give only a few days of antibiotics before starting steroids. Certainly I try to think of other causes for the dyspnea and if possible rule them out as well. The ...

I woud start prednisone in any patient with clinical evidence of radiation pneumonopathy where SOB is not atributed to a worsening of their COPD for instance. In the case outlined here, the patient's SOB may be related to underlying lung disease and not radiation effect. If the pulmonologist is unconvinced, a course of steroids would be appropriate to try.