Fibrosis

A submission from a reader: "34 year old, non-smoking African American female presenting with a recurring (for three years now), chronic (lasts for several weeks up to a few months) dry, non productive cough. No other symptoms (though the attached CT report says wheezing). No response to a variety of drug treatments over the years, including steroid shot, Levaquin, OTC Mucinex, OTC Claritin, Tussionex, Nasacort, OTC Prilosec, 6-day regimen of Metrol (4mg), Advair and Albuterol. First pulmonologist (who performed no diagnostic tests) diagnosed asthma and allergies. Nothing indicated on chest x-ray. Internal medicine doctor ordered CT scan (report attached). Second pulmonologist said subpleural cysts exist, which he indicated exist with UIP patients, but he said this was not UIP. Also said it's not tuberculosis or sarcoidosis. Prescribed 20 mg of Prednisone twice a day to get rid of cough, said we will proceed once cough is gone. Said a lung biopsy or thoracic biopsy may be in order.

CT reading:
Helical CT images through the chest were obtained following
intravenous contrast administration.

Within both lungs and involving both the upper and lower lung zones,
there are areas of subpleural macrocystic change with some
associated subpleural interstitial thickening. There are no
particular areas of ground-glass opacity associated with these
findings. No significant nodularity is seen. The central and midlung
zones are spared. No pleural fluid or lymphadenopathy is seen. These
findings can be seen in patients with usual interstitial pneumonia
(UIP) although this would be somewhat atypical in a patient of this
age group. Does the patient have a smoking history? Other
interstitial lung disease in its early stages may give a similar
appearance.

ICS in the hospital

What is your usual practice regarding inhaled steroids when you admit a patient for either status asthmaticus or AECB?
If they are already on an ICS on admission and they will be on a systemic steroid do you continue the ICS?
Conversely, if they are not on an ICS on admission and are now on a systemic steroid, do you start an ICS during the admission or after D/C?

Sepsis and steroids

IS:
This is not a case presentation, but want to take a poll on what people are doing about steroids and sepsis. Do you administer steroids emperically after initial fluid bolus or do you attempt resuscitation per the 6hr bundle first and then administer steroids if still on pressors or hypotensive?