PULMONOLOGY Flashcards
(246 cards)
1
Q
Which of the following is the most common method by which microorganisms gain access to the lower respiratory tract?
a. Aspiration from the oropharynx
b. Contiguous extension from infected pleural/mediastinal space
c. Hematogenous spread from distant sites
d. Overgrowth of normal respiratory flora
A
The correct answer is: Aspiration from the oropharynx
2
Q
Which of the following is TRUE regarding the diagnostic work-up for pneumonia?
a. A sputum sample is considered adequate for culture if it contains >10 neutrophils and <25 squamous epithelial cells per low-power field.
b. Blood cultures have a high diagnostic yield and should be considered routine for all hospitalized CAP patients.
c. Pneumatoceles on the chest X-ray are suggestive of Staphylococcus epidermidis as the etiologic organism.
d. The most frequently isolated pathogen from blood cultures is Streptococcus pneumoniae.
A
The correct answer is: The most frequently isolated pathogen from blood cultures is Streptococcus pneumoniae.
3
Q
Which phase of classic lobar pneumonia is characterized by the presence of a proteinaceous exudate and bacteria in the alveoli?
a. Edema
b. Red hepatization
c. Gray hepatization
d. Resolution
A
The correct answer is: Edema
4
Q
Which of the following criteria should be met 24 hours prior to discharging a patient admitted for community acquired pneumonia?
a. Oxygen saturation of at least 95%
b. Respiratory rate of < 20 cycles/minute
c. Heart rate < 100 beats/minute
d. Able to walk at least 180 meters
A
The correct answer is: Heart rate < 100 beats/minute
5
Q
Which of the following is considered an atypical causative organism for pneumonia?
a. Haemophilus influenzae
b. Klebsiella pneumoniae
c. Mycoplasma pneumoniae
d. Pseudomonas aeruginosa
A
The correct answer is: Mycoplasma pneumoniae
6
Q
A patient with hypertension and diabetes develops community-acquired pneumonia. The CURB-65 score is 0. Which among the following antibiotic regimens is most appropriate?
a. Azithromycin 500 mg PO once, then 250 mg OD
b. Co-Amoxiclav 2 g PO BID
c. Doxycycline 100 mg PO BID
d. Moxifloxacin 400 mg PO OD
A
The correct answer is: Moxifloxacin 400 mg PO OD
7
Q
When advising patients regarding the expected course of recovery after treatment for CAP, chest pain and sputum production should have substantially reduced by which time frame?
a. 1 week
b. 4 weeks
c. 6 weeks
d. 3 months
A
The correct answer is: 4 weeks
8
Q
Which among the organisms below is a multi-drug resistant (MDR) pathogen below is known to cause ventilator-associated pneumonia?
a. Escherichia coli
b. Burkholderia cepacia
c. Proteus spp.
d. Serratia marcescens
A
The correct answer is: Burkholderia cepacia
9
Q
Which of the following is the classic etiologic organism in Lemierre’s syndrome leading to lung abscess from septic embolization?
a. Aspergillus spp.
b. Fusobacterium necrophorum
c. Peptostreptococcus spp.
d. Rhodococcus equi
A
The correct answer is: Fusobacterium necrophorum
10
Q
Which of the following is TRUE regarding lung abscess?
a. Lung abscesses may arise from septic emboli, particularly from mitral valve endocarditis involving Staphylococcus aureus.
b. Primary lung abscesses are more common in the left lung.
c. Pseudomonas aeruginosa and other gram-negative rods are the most common etiologic organisms in primary lung abscesses.
d. Putrid-smelling sputum is considered virtually diagnostic of an anaerobic lung abscess.
A
The correct answer is: Putrid-smelling sputum is considered virtually diagnostic of an anaerobic lung abscess.
11
Q
A size of lung abscess of is less likely to respond to antibiotic therapy and might require surgical resection or percutaneous drainage?
a. 1-2 cm in diameter
b. > 2-4 cm in diameter
c. > 4-6 cm in diameter
d. > 6-8 cm in diameter
A
The correct answer is: > 6-8 cm in diameter
12
Q
Which of the following is part of Virchow’s triad that predisposes to venous thromboembolism (VTE)?
a. Endothelial injury
b. Anemia
c. Platelet deficiency
d. Arterial hypertension
A
The correct answer is: Endothelial injury
13
Q
What are the two most common genetic causes of prothrombotic states?
a. Antithrombin deficiency and hyperhomocysteinemia
b. Factor V Leiden mutation and prothrombin G20210A mutation
c. Protein C and Protein S deficiencies
d. Prothrombin G20210A mutation and antithrombin deficiency
A
The correct answer is: Factor V Leiden mutation and prothrombin G20210A mutation
14
Q
Which of the following are the most common gas exchange abnormalities seen in pulmonary embolism?
a. Arterial hypoxemia and respiratory acidosis
b. Arterial hypoxemia and respiratory alkalosis
c. Increased A-a O2 gradient and arterial hypoxemia
d. Increased A-a O2 gradient and respiratory alkalosis
A
The correct answer is: Increased A-a O2 gradient and arterial hypoxemia
15
Q
Which of the following is the most common symptom of pulmonary embolism?
a. Palpitations
b. Pleuritic chest pain
c. Syncope
d. Unexplained breathlessness
A
The correct answer is: Unexplained breathlessness
16
Q
In patients with PE, which chest CT finding has been found to have an increased likelihood of death within the next 30 days?
a. Filling defects in ≥3 segmental pulmonary arteries
b. Pulmonary infarction
c. Right ventricular enlargement
d. Saddle embolus
A
The correct answer is: Right ventricular enlargement
17
Q
For a definitive diagnosis of pulmonary embolism, which of the following should be visualized on chest CT with IV contrast?
a. Abrupt occlusion of vessels
b. Intraluminal filling defect in more than one projection
c. Prolonged arterial phase with slow filling
d. Segmental oligemia or avascularity
A
The correct answer is: Intraluminal filling defect in more than one projection
18
Q
Which of the following statements regarding anticoagulation for VTE is TRUE?
a. Anticoagulation is considered primary therapy for VTE.
b. For patients with cancer and VTE, the recommended duration of anticoagulation is 6 months.
c. In case of major bleeding, the antidote for rivaroxaban is idarucizumab.
d. Warfarin requires bridging with a parenteral anticoagulant to nullify its early procoagulant effect.
A
The correct answer is: Warfarin requires bridging with a parenteral anticoagulant to nullify its early procoagulant effect.
19
Q
After an initial fluid challenge, which of the following are the first-line inotropic agents for PE-related shock?
a. Dobutamine and epinephrine
b. Dopamine and dobutamine
c. Norepinephrine and dobutamine
d. Norepinephrine and epinephrin
A
The correct answer is: Dopamine and dobutamine
20
Q
What is the treatment of choice for chronic thromboembolic pulmonary hypertension (CTEPH)?
a. Balloon angioplasty of pulmonary arterial webs
b. Bosentan
c. Pulmonary thromboendarterectomy
d. Sildenafil
A
The correct answer is: Pulmonary thromboendarterectomy
21
Q
For ARDS to be classified as severe, PaO2/FiO2 or PF ratio should be:
a. ≤ 50 mmHg
b. ≤ 100 mmHg
c. ≤ 200 mmHg
d. ≤ 300 mmHg
A
The correct answer is: ≤ 100 mmHg
22
Q
Pro-inflammatory cytokines attracting leukocytes (especially neutrophils) into the pulmonary interstitium and alveoli occurs during which phase of ARDS?
a. Exudative
b. Fibrotic
c. Proliferative
d. Recovery
A
The correct answer is: Exudative
23
Q
Which of the following events occurs during the proliferative phase of ARDS?
a. Breakdown of the tight alveolar barrier
b. Formation of hyaline membrane whorls
c. Increase in number of type II pneumocytes
d. Intimal fibroproliferation in the pulmonary microcirculation
A
The correct answer is: Formation of hyaline membrane whorls
24
Q
The most important group of patients who benefit from a trial of non-invasive ventilation are:
a. COPD exacerbations with respiratory acidosis
b. Decompensated heart failure with arterial hypoxemia
c. Decreased sensorium with low minute ventilation
d. Pulmonary embolism with elevated A-a O2 gradient
A
The correct answer is: COPD exacerbations with respiratory acidosis
25
Which of the following is the correct term for what the ventilator senses to initiate an assisted breath?
a. Cycle
b. Limit
c. Mode
d. Trigger
The correct answer is: Trigger
26
In the absence of symptoms, a diagnosis of OSAHS is made if the apnea-hypopnea index (AHI) is greater than:
a. 5 episodes/hour of sleep
b. 15 episodes/hour of sleep
c. 30 episodes/hour of sleep
d. 50 episodes/hour of sleep
The correct answer is: 15 episodes/hour of sleep
27
Which of the following therapies for OSAHS has the highest level of evidence for efficacy?
a. Continuous positive airway pressure
b. Oral appliances
c. Upper airway neurostimulation
d. Uvulopalatopharyngoplasty
The correct answer is: Continuous positive airway pressure
28
What is the imaging of choice to guide thoracentesis?
a. Computed tomography
b. Magnetic resonance imaging
c. Fluoroscopy
d. Ultrasound
The correct answer is: Ultrasound
29
What primarily explains the development of effusion in tuberculosis?
a. Decreased lymphatic drainage from tuberculous fibrosis
b. Direct invasion of the mesothelial cells that line the pleural cavity
c. Granulomatous inflammation of the mediastinal lymph nodes
d. Hypersensitivity reaction to tuberculous protein in the pleural space
The correct answer is: Hypersensitivity reaction to tuberculous protein in the pleural space
30
What is the primary treatment of a patient with hemothorax?
a. Angiographic coil embolization
b. Chest tube insertion
c. Pleurodesis
d. Thoracotomy
The correct answer is: Chest tube insertion
31
Which of the following causes transudative effusion?
a. Asbestos exposure
b. Peritoneal dialysis
c. Rheumatoid pleuritis
d. Viral infection
The correct answer is: Peritoneal dialysis
32
Which of the following explains the development of bronchiectasis from tuberculosis infection?
a. Extrinsic compression of the airway by enlarged granulomatous lymph nodes leads to focal bronchiectasis
b. Deficiency of antiproteases results to uncontrolled damaging effects of neutrophil elastase and impaired bacterial killing
c. Immune-mediated reaction damages the bronchial wall predominantly involving the central airways
d. Lung fibrosis results to dilated airways from parenchymal distortion
The correct answer is: Extrinsic compression of the airway by enlarged granulomatous lymph nodes leads to focal bronchiectasis
33
What organism should be covered in the initial empiric antibiotic treatment of acute exacerbation of bronchiectasis?
a. Acinetobacter baumannii
b. Aspergillus flavus
c. Haemophilus influenzae
d. Mycobacterium avium-intracellulare complex
The correct answer is: Haemophilus influenzae
34
Which of the following chest radiograph pleural findings specifically indicates past exposure to asbestos and not a sign of pulmonary impairment?
a. Effusion
b. Fibrosis
c. Plaque
d. Reticulation
The correct answer is: Plaque
35
What occupational lung disease is seen in high-resolution chest CT scan as profuse miliary infiltration and “crazy paving” or the polygonal shapes produced by diffuse ground glass densities with thickened septa?
a. Asbestosis
b. Chronic beryllium disease
c. Coal worker’s pneumoconiosis
d. Silicosis
The correct answer is: Silicosis
36
What is the most common interstitial lung disease (ILD) of unknown cause?
a. Cryptogenic Organizing Pneumonia
b. Granulomatosis with polyangiitis
c. Idiopathic pulmonary fibrosis
d. Respiratory Bronchiolitis—associated ILD
The correct answer is: Idiopathic pulmonary fibrosis
37
What is the current definitive test for establishing the presence of emphysema and diagnose co-existing interstitial lung disease and bronchiectasis in COPD?
a. Arterial blood gas and oximetry
b. Chest computed tomography scan
c. Bronchoscopy with lung biopsy
d. Pulmonary function test
The correct answer is: Chest computed tomography scan
38
Which is TRUE of the use of systemic glucocorticoids in patients admitted to the hospital for acute COPD exacerbation?
a. Avoided and not beneficial
b. Hastens recovery and reduces relapse
c. Given for at least eight weeks
d. Prolongs hospitalization due to side effects
The correct answer is: Hastens recovery and reduces relapse
39
```
According to the Global Initiative for Chronic Obstructive Lung Disease (GOLD), what is required to make the diagnosis of COPD?
a. Body plethysmography
b. Chest CT scan
c. Peak expiratory flow measurement
d. Spirometry
F
```
The correct answer is: Spirometry
40
Which is TRUE of the physiologic abnormalities in COPD?
a. PaO2 immediately decreases once FEV1 starts to decline
b. PaCO2 immediately increases once FEV1 starts to decline
c. Shunt physiology is the major determinant of elevation in PaCO2
d. V/Q mismatch accounts for all of the reduction in PaO2
The correct answer is: Shunt physiology is the major determinant of elevation in PaCO2
41
What would the development of clubbing in a patient with COPD indicate?
a. Check for cor pulmonale
b. Chronic hypoxemia and respiratory acidosis
c. Consider lung malignancy
d. Very severe disease
The correct answer is: Consider lung malignancy
42
A 65-year-old male, chronic smoker with no previous hospitalizations, consulted for 3 month history of cough with associated dyspnea described as need to stop to rest when walking. Spirometry showed post-bronchodilator FEV1/FVC 0.6, %predicted FEV1 60. What will you recommend?
a. Short-acting beta agonist
b. Long acting muscarinic antagonist
c. Long-acting beta agonist and inhaled corticosteroid
d. Long acting beta agonist, long-acting muscarinic antagonist and inhaled corticosteroid
The correct answer is: Long acting muscarinic antagonist
43
A 62-year-old male COPD patient on inhaled tiotropium started two months ago consulted the clinic because of persistence of breathlessness and exercise limitation. What will you recommend?
a. Add inhaled corticosteroid
b. Add theophylline
c. Shift to LABA/ICS
d. Shift to LABA/LAMA
The correct answer is: Shift to LABA/LAMA
44
Which is the most common allergen to trigger asthma?
a. Cat dander
b. Dust mite
c. Fungal spores
d. Grass pollen
The correct answer is: Dust mite
45
What is the characteristic histopathologic finding of airway remodeling in asthma?
a. Activation of mucosal mast cells
b. Mucosal infiltration of eosinophils and T lymphocytes
c. Subepithelial collagen deposition
d. Vasodilation and increased number of blood vessels
The correct answer is: Subepithelial collagen deposition
46
Which is TRUE of the diagnostic tests used in asthma?
a. Chest x-ray shows hyperinflation only in severe patients.
b. Fractional exhaled nitric oxide is used as an adjunct to rule in or rule out asthma.
c. Serum IgE is specific for asthma and elevated in all asthma phenotypes.
d. Whole body plethysmography is required to document lung volumes and capacities.
Feedback
The correct answer is: Chest x-ray shows hyperinflation only in severe patients.
47
A 25-year-old female, a famous singer, recently diagnosed to have bronchial asthma through spirometry, refuses to comply with prescribed daily inhaler because of fear of the possible side effects on the quality of her voice. She had allergic rhinitis for the past 5 years. She only has occasional twice a month symptoms of shortness of breath relieved by salbutamol tablets. What is recommended in this case?
a. Inhaled salbutamol PRN
b. Inhaled tiotropium daily
c. Oral montelukast daily
d. Oral salbutamol PRN
The correct answer is: Oral montelukast daily
48
What is the primary action of β2 agonists?
a. Inhibition of mast cell mediator release
b. Inhibition of sensory nerve activation
c. Reduction in plasma exudation
d. Relaxation of airway smooth muscle cell
The correct answer is: Relaxation of airway smooth muscle cell
49
A 63/F with heart failure and diabetic kidney disease on chronic hemodialysis was admitted for gradually progressive dyspnea and desaturation. CBC showed mild anemia and leukocytosis. On CXR, there was left lower lobe consolidation and a blunted left costophrenic angle. The Gram stain of the sputum sample shown below should prompt the addition of which antibiotic to the empiric regimen?
a. Azithromycin
b. Gentamicin
c. Levofloxacin
d. Vancomycin
• Gram (+) cocci in clusters: Staph aureus
The correct answer is: Vancomycin
50
Which of the following is the most common method by which microorganisms gain access to the lower respiratory tract?
a. Aspiration from the oropharynx
b. Contiguous extension from infected pleural/mediastinal space
c. Hematogenous spread from distant sites
d. Overgrowth of normal respiratory flora
```
Host Defenses Against Pneumonia
• Mechanical factors
o Hairs and turbinates of the nares
o Branching architecture of the tracheobronchial tree
• Mucociliary clearance
• Local antibacterial factors
• Gag & cough reflexes
• Normal respiratory flora
• Resident alveolar macrophages
The correct answer is: Aspiration from the oropharynx
```
51
Which of the following is TRUE regarding the pathophysiology of pneumonia?
a. Interleukin 1 and tumor necrosis factor stimulate the release of neutrophils and their attraction to the lung.
b. It is the proliferation of microorganisms that triggers the clinical syndrome of pneumonia.
c. Rales on auscultation and the radiographic infiltrate are a consequence of alveolar capillary leak, similar to ARDS.
d. The most likely cause of an altered alveolar microbiota in CAP is previous antibiotic therapy.
* Interleukin 1 and tumor necrosis factor Interleukin 8 & G-CSF stimulate the release of neutrophils and their attraction to the lung. (IL-1 & TNF result in fever.)
* It is the host inflammatory response, rather than the proliferation of microorganisms, that triggers the clinical syndrome of pneumonia.
* The most likely cause of an altered alveolar microbiota in CAP HAP/VAP is previous antibiotic therapy. (For CAP, it is viral URTIs.)
The correct answer is: Rales on auscultation and the radiographic infiltrate are a consequence of alveolar capillary leak, similar to ARDS.
52
Which phase of classic lobar pneumonia is characterized by the presence of a proteinaceous exudate and bacteria in the alveoli?
a. Edema
b. Red hepatization
c. Gray hepatization
d. Resolution
The correct answer is: Edema
53
Which phase of classic lobar pneumonia is characterized by predominance of neutrophils and the disappearance of bacteria from the alveolar space?
a. Edema
b. Red hepatization
c. Gray hepatization
d. Resolution
The correct answer is: Gray hepatization
54
Which of the following is considered an atypical causative organism for pneumonia?
a. Haemophilus influenzae
b. Klebsiella pneumoniae
c. Mycoplasma pneumoniae
d. Pseudomonas aeruginosa
```
Typical
• Streptococcus pneumoniae
• Haemophilus influenzae
• Staphylococcus aureus
• Klebsiella pneumoniae
• Pseudomonas aeruginosa
Usually respond to beta-lactam antibiotics
```
Atypical
• Mycoplasma pneumoniae
• Chlamydia pneumoniae
• Legionella
• Respiratory viruses
Cannot be cultured on standard media or seen on Gram’s stain
Needs a macrolide, fluoroquinolone or tetracycline
The correct answer is: Mycoplasma pneumoniae
55
In influenza infection, which bacterial pathogen typically complicates the patient’s course with pneumonia superinfection or coinfection?
a. Burkholderia cepacia
b. Chlamydia pneumoniae
c. Pseudomonas aeruginosa
d. Staphylococcus aureus
The correct answer is: Staphylococcus aureus
56
Which of the following is TRUE regarding the clinical presentation of pneumonia?
a. A flat percussion note in an area of decreased breath sounds is reflective of underlying consolidated lung.
b. Correcting dehydration can lead to easier sputum expectoration and a more apparent infiltrate on CXR.
c. Due to enhanced inflammation and increased procoagulant activity, most ACS episodes occur beyond one week from the onset of CAP.
d. Gross hemoptysis is suggestive of pneumococcal pneumonia.
* A dull percussion note in an area of decreased breath sounds is reflective of underlying consolidated lung.
* Due to enhanced inflammation and increased procoagulant activity, most ACS episodes occur within the first week after onset of CAP.
* Gross hemoptysis is suggestive of CA-MRSA pneumonia.
The correct answer is: Correcting dehydration can lead to easier sputum expectoration and a more apparent infiltrate on CXR.
57
Pneumococcal resistance to beta-lactam drugs is due solely to which mechanism?
a. Low-affinity penicillin-binding proteins
b. Mutations in genes encoding topoisomerase II & IV
c. Superantigens such as enterotoxins B & C and Panton-Valentine leukocidin
d. Target-site modification caused by ribosomal methylation in 23S rRNA
• Mutations in genes encoding topoisomerase II & IV (resistance to fluoroquinolones)
• Superantigens such as enterotoxins B & C and Panton-Valentine leucocidin (seen in CA-MRSA strains)
• Target-site modification caused by ribosomal methylation in 23S rRNA (resistance to macrolides)
The correct answer is: Low-affinity penicillin-binding proteins
58
A 44/F working as a Disney cruise attendant just returned to the Philippines from a three-week onboard ship quarantine after a crewmate tested swab positive for SARS-CoV-2. Two days after disembarking, she started developing high-grade fever, productive cough, shortness of breath, and myalgias. She has no other co-morbidities. Upon hospital admission, nasopharyngeal swab was negative for SARS-CoV-2. Sputum cultures yielded only normal respiratory flora. Her CXR is shown below. Which diagnostic exam will MOST likely clinch the diagnosis?
a. GenXpert MTB assay of sputum samples
b. Legionella urinary antigen test
c. Repeat NP swab RT-PCR for SARS-CoV-2
d. Sputum fungal cultures
• No growth on cultures raises possibility of atypical etiologic organism. Cruise ship exposure increases index of suspicion for Legionnaire’s disease.
The correct answer is: Legionella urinary antigen test
59
Pseudomonas aeruginosa is a usual suspected pathogen for CAP in patients with the following underlying conditions, EXCEPT:
a. Bronchiectasis
b. COPD
c. Cystic fibrosis
d. Lung abscess
Typical pathogens in lung abscess:
1. CA-MRSA
2. Oral anaerobes
3. Fungi
4. TB
The correct answer is: Lung abscess
60
Which of the following epidemiologic factors is suggestive of Burkholderia cepacia as a possible etiologic microorganism of CAP?
a. Alcoholism
b. Bronchiectasis
c. Dementia
d. Lung abscess
The correct answer is: Bronchiectasis
61
Which of the following is TRUE regarding the diagnostic work-up for pneumonia?
a. A sputum sample is considered adequate for culture if it contains >10 neutrophils and <25 squamous epithelial cells per low-power field.
b. Blood cultures have a high diagnostic yield and should be considered routine for all hospitalized CAP patients.
c. Pneumatoceles on the chest X-ray are suggestive of Staphylococcus epidermidis as the etiologic organism.
d. The most frequently isolated pathogen from blood cultures is Streptococcus pneumoniae.
• A sputum sample is considered adequate for culture if it contains >10 >25 neutrophils and <25 <10 squamous epithelial cells per low-power field.
• Blood cultures have a high low diagnostic yield (only 5-14% are positive) and should be are no longer considered routine for all hospitalized CAP patients.
• Pneumatoceles on the chest X-ray are suggestive of Staphylococcus epidermidis aureus as the etiologic organism.
The correct answer is: The most frequently isolated pathogen from blood cultures is Streptococcus pneumoniae.
62
Which of the following is considered a risk factor for early deterioration in community acquired pneumonia?
a. Anemia
b. Hyponatremia
c. Severe respiratory alkalosis (PCO2 less than 30 mmHg)
d. Tachycardia > 120 beats/min
The correct answer is: Hyponatremia
63
A 62/M with a 30-pack-year smoking history was admitted for fever, productive cough, and right-sided chest pain. Chest X-ray reveals consolidation of the right middle lobe, similar to his films from a previous admission 2 months ago for pneumonia. After getting the necessary cultures and blood tests, which diagnostic test is MOST appropriate at this point?
a. Bronchoscopy with bronchoalveolar lavage
b. Chest CT with IV contrast
c. Endobronchial ultrasound with transbronchial needle aspiration
d. VQ lung scan
• Bronchoscopy with bronchoalveolar lavage (BAL fluid specimens can be cultured and analyzed for cell cytology, but would not be the next best step for this case)
• Chest CT with IV contrast (need to rule out an underlying neoplasm causing recurrent post-obstructive pneumonia in the same lung segment)
• Endobronchial ultrasound with transbronchial needle aspiration (may be the next step to get a histologic diagnosis, if lung mass is visualized on chest CT and is easily accessible from the bronchus)
• VQ lung scan (more appropriate for CTEPH)
The correct answer is: Chest CT with IV contrast
64
The most important risk factor for antibiotic-resistant pneumococcal infection is:
a. Antibiotic use within the previous 3 months
b. Hospitalization within the previous 3 months
c. Immunocompromised state/condition
d. Prolonged, close contact with patient with known MDR infection
The correct answer is: Antibiotic use within the previous 3 months
65
A 70/F was admitted for difficulty of breathing on a 1-week background of productive cough, poor appetite, and increasing disorientation. Her vitals on arrival at the ER were as follows: BP 100/70, HR 116, RR 32, T 38.2 ℃, O2 sat 89%. Her CXR is shown below. What is the appropriate disposition for this patient?
a. Send home and treat as outpatient
b. Admit to observation unit pending lab results and cultures
c. Admit to regular room
d. Admit to ICU
```
CURB-65 CRITERIA:
• Confusion
• Urea >7 mmol/L
• RR ≥30/min
• BP ≤ 90/60 mmHg
• 65 years or older
```
0: outpatient
1-2: inpatient
≥3: ICU
The correct answer is: Admit to ICU
66
A hypertensive, diabetic patient with CAP and a CURB-65 score of 0 should be started on which antibiotic regimen?
a. Azithromycin 500 mg PO once, then 250 mg OD
b. Co-Amoxiclav 2 g PO BID
c. Doxycycline 100 mg PO BID
d. Moxifloxacin 400 mg PO OD
Azithromycin - (only if no comorbidities or previous antibiotic use in past 3 months)
Co-Amoxiclav - (should still have an added macrolide for atypical coverage)
Doxycycline - (only if no comorbidities or previous antibiotic use in past 3 months)
```
CURB-65 CRITERIA:
• Confusion
• Urea >7 mmol/L
• RR ≥30/min
• BP ≤ 90/60 mmHg
• 65 years or older
0: outpatient
1-2: inpatient
≥3: ICU
```
The correct answer is: Moxifloxacin 400 mg PO OD
67
The following beta-lactams are appropriate as empiric therapy against possible Pseudomonas pneumonia, EXCEPT:
a. Cefepime 1-2 g IV q12
b. Ertapenem 1 g IV OD
c. Meropenem 1 g IV q8
d. Piperacillin-tazobactam 4.5 g IV q6
• Ertapenem has no antipseudomonal coverage
The correct answer is: Ertapenem 1 g IV OD
68
The drugs of choice for CAP caused by Enterobacter species are:
a. Fluoroquinolones or carbapenems
b. Linezolid or vancomycin
c. Macrolides or doxycycline
d. Penicillins or cephalosporins
* Linezolid or vancomycin - (MRSA)
* Macrolides or doxycycline - (outpatient empiric therapy for patients with no comorbidities and no previous antibiotics, has atypical coverage)
* Penicillins or cephalosporins - (Enterobacter spp. are typically resistant to cephalosporins.)
The correct answer is: Fluoroquinolones or carbapenems
69
When advising patients regarding the expected course of recovery after treatment for CAP, chest pain and sputum production should have substantially reduced by which time frame?
a. 1 week
b. 4 weeks
c. 6 weeks
d. 3 months
The correct answer is: 4 weeks
70
For CAP with bacteremia involving likely MDR pathogens such as P. aeruginosa and MRSA, the recommended antibiotic treatment duration is:
a. 7-14 days
b. 7-21 days
c. 14-21 days
d. ≥ 28 days
The correct answer is: ≥ 28 days
71
MDR pathogens that cause VAP include the following, EXCEPT:
a. Acinetobacter spp.
b. Burkholderia cepacia
c. Legionella pneumophila
d. Serratia marcescens
The correct answer is: Serratia marcescens
72
The following are recommended prevention strategies for VAP, EXCEPT:
a. Early percutaneous tracheostomy if with abnormal swallowing function
b. Frequent handwashing to minimize cross-contamination
c. More frequent blood transfusions to improve host immunity
d. Sedation holidays to assess readiness for weaning/extubation
The correct answer is: More frequent blood transfusions to improve host immunity
73
In critically ill VAP patients, the most important risk factors for replacement of normal oropharyngeal flora with pathogenic microorganisms include the following, EXCEPT:
a. Antibiotic selection pressure
b. Cross-infection from other patients and contaminated equipment
c. Malnutrition
d. Prolonged duration of ventilation
The correct answer is: Prolonged duration of ventilation
74
The Achilles heel of the quantitative-culture approach to the diagnosis of VAP is:
a. Effect of antibiotic therapy
b. Frequent tracheal colonization of pathogenic bacteria
c. Inconsistency of Gram stain and culture results
d. Possibility of atypical organisms that may not grow on standard culture media
* Effect of antibiotic therapy - (a single antibiotic dose can reduce colony counts below the diagnostic threshold)
* Frequent tracheal colonization of pathogenic bacteria - (the quantitative approach actually aims to circumvent this, by setting diagnostic thresholds for culture colony counts above which true VAP infection is more likely than mere colonization)
The correct answer is: Effect of antibiotic therapy
75
Atypical pathogens have a markedly lower incidence in VAP compared to CAP. Which of the following is the exception to this observation?
a. Chlamydia pneumoniae
b. Legionella spp.
c. Mycoplasma pneumoniae
d. Respiratory syncytial virus
• Legionella can be a nosocomial pathogen, especially with breakdowns in the water treatment systems of hospitals.
The correct answer is: Legionella spp.
76
For non-ventilated patients with HAP, the only pathogen that may be more common in this population (compared to VAP) is:
a. Acinetobacter baumannii
b. Anaerobes
c. MRSA
d. Pseudomonas aeruginosa
• Anaerobes (greater risk of macroaspiration and lower oxygen tensions)
The correct answer is: Anaerobes
77
Which of the following is FALSE regarding non-ventilated HAP vs. VAP?
a. De-escalation of antibiotic therapy is more likely in HAP patients.
b. HAP patients generally have better underlying host immunity.
c. HAP patients have a higher frequency of non-MDR pathogens.
d. The risk of antibiotic failure is lower in HAP.
• De-escalation of antibiotic therapy is more less likely in HAP patients (due to difficulty in obtaining sputum samples appropriate for culture, compared to intubated patients)
The correct answer is: HAP patients have a higher frequency of non-MDR pathogens.
78
Lung abscesses are considered to be primary in the following patients, EXCEPT:
a. 21/M with known HIV infection
b. 36/F with scleroderma and esophageal strictures
c. 42/F with recent seizure episode
d. 64/M who came in with stroke and GCS 6
* Primary lung abscess: usually arise from aspiration, in the absence of an underlying pulmonary or systemic condition
* Secondary lung abscess: arise in the setting of an underlying condition, such as a post-obstructive process or a systemic process
The correct answer is: 21/M with known HIV infection
79
Which of the following is the classic etiologic organism in Lemierre’s syndrome leading to lung abscess from septic embolization?
a. Aspergillus spp.
b. Fusobacterium necrophorum
c. Peptostreptococcus spp.
d. Rhodococcus equi
The correct answer is: Fusobacterium necrophorum
80
Which of the following is the MOST likely pathogen in a primary lung abscess?
a. Legionella pneumophila
b. Nocardia spp.
c. Prevotella spp.
d. Staphylococcus aureus
* Infection begins in the pharynx, classically from Fusobacterium necrophorum
* Spreads to the neck and the carotid sheath
* Thrombophlebitis of the internal jugular vein leads to septic embolization to the lungs
The correct answer is: Prevotella spp.
81
Which of the following is TRUE regarding lung abscess?
a. Lung abscesses may arise from septic emboli, particularly from mitral valve endocarditis involving Staphylococcus aureus.
b. Primary lung abscesses are more common in the left lung.
c. Pseudomonas aeruginosa and other gram-negative rods are the most common etiologic organisms in primary lung abscesses.
d. Putrid-smelling sputum is considered virtually diagnostic of an anaerobic lung abscess.
• Lung abscesses may arise from septic emboli, particularly from mitral tricuspid valve endocarditis involving Staphylococcus aureus.
• Primary lung abscesses are more common in the left right lung.
• Pseudomonas aeruginosa and other gram-negative rods are the most common etiologic organisms in primary secondary lung abscesses.
The correct answer is: Putrid-smelling sputum is considered virtually diagnostic of an anaerobic lung abscess.
82
A 45/M epileptic with increasing frequency of seizures over the past month was admitted for a 1-week history of fever, night sweats, and productive cough. His CXR is shown below. Which drug regimen is MOST appropriate?
a. Clindamycin 600 mg IV q8
b. HRZE 4 tabs OD
c. Metronidazole 500 mg IV q6
d. TMP-SMX 160/800 mg/tab, 2 tabs q6
* Radiograph is of a primary lung abscess with air-fluid levels
* HRZE - PTB
* Metronidazole - covers anaerobes but not microaerophilic streptococci
* TMP-SMX - PCP pneumonia
The correct answer is: Clindamycin 600 mg IV q8
83
A lung abscess of what size is less likely to respond to antibiotic therapy and might need surgical resection or percutaneous drainage?
a. > 2-4 cm in diameter
b. > 4-6 cm in diameter
c. > 6-8 cm in diameter
d. > 8-10 cm in diameter
The correct answer is: > 6-8 cm in diameter
84
The following are part of Virchow’s triad that predisposes to venous thromboembolism (VTE), EXCEPT:
a. Endothelial injury
b. Hypercoagulability
c. Platelet activation
d. Venous stasis
```
Virchow’s triad:
• Endothelial injury
• Hypercoagulability
• Reduced blood flow (stasis)
The correct answer is: Platelet activation
```
85
What are the two most common genetic causes of prothrombotic states?
a. Antithrombin deficiency and hyperhomocysteinemia
b. Factor V Leiden mutation and prothrombin G20210A mutation
c. Protein C and Protein S deficiencies
d. Prothrombin G20210A mutation and antithrombin deficiency
The correct answer is: Factor V Leiden mutation and prothrombin G20210A mutation
86
Which of the following is the most common acquired cause of thrombophilia?
a. Antiphospholipid antibody syndrome
b. Estrogen-containing contraceptives
c. Long-haul air travel
d. Malignancy
The correct answer is: Antiphospholipid antibody syndrome
87
Which of the following are the most common gas exchange abnormalities seen in pulmonary embolism?
a. Arterial hypoxemia and respiratory acidosis
b. Arterial hypoxemia and respiratory alkalosis
c. Increased A-a O2 gradient and arterial hypoxemia
d. Increased A-a O2 gradient and respiratory alkalosis
The correct answer is: Increased A-a O2 gradient and arterial hypoxemia
88
The hallmark signs/symptoms of massive pulmonary embolism include the following, EXCEPT:
a. Chest pain
b. Dyspnea
c. Hypotension
d. Syncope
• Cyanosis (not chest pain) is a hallmark sign of massive pulmonary embolism.
The correct answer is: Chest pain
89
Which of the following is the most common symptom of pulmonary embolism?
a. Palpitations
b. Pleuritic chest pain
c. Syncope
d. Unexplained breathlessness
The correct answer is: Unexplained breathlessness
90
D-dimer levels may be increased in the following conditions, EXCEPT:
a. Cancer
b. First trimester of pregnancy
c. Myocardial infarction
d. Sepsis
• D-dimer levels are increased in the 2nd and 3rd trimester of pregnancy.
The correct answer is: First trimester of pregnancy
91
In patients with PE, which of the following is the most common abnormality on the ECG?
a. New-onset right bundle branch block
b. Sinus tachycardia
c. S1Q3T3 sign (McGinn-White sign)
d. T-wave inversion in leads V1 to V4
The correct answer is: T-wave inversion in leads V1 to V4
92
Which of the following is the primary diagnostic criterion for DVT on ultrasonography?
a. Absence of flow augmentation with distal compression
b. Increased intraluminal echogenicity
c. Loss of color flow on Doppler indicating absent blood flow
d. Loss of vein compressibility under moderate external pressure
The correct answer is: Loss of vein compressibility under moderate external pressure
93
Which of the following refers to the peripheral wedge-shaped density seen in pulmonary embolism?
a. Hampton’s hump
b. McConnell’s sign
c. Palla’s sign
d. Westermark’s sign
* Westermark’s sign: focal oligemia (paucity of pulmonary vascular markings)
* Palla’s sign: enlarged right descending pulmonary artery
* Hampton’s hump: peripheral wedge-shaped density usually located at pleural base (due to infarction of a pulmonary segment)
* McConnell’s sign: hypokinetic RV free wall
The correct answer is: Hampton’s hump
94
In patients with PE, which chest CT finding has been found to have an increased likelihood of death within the next 30 days?
a. Filling defects in ≥3 segmental pulmonary arteries
b. Pulmonary infarction
c. Right ventricular enlargement
d. Saddle embolus
The correct answer is: Right ventricular enlargement
95
A triple rule-out CT is primarily utilized to assess for the following differentials, EXCEPT:
a. Acute aortic syndrome
b. Acute coronary syndrome
c. Pneumothorax
d. Pulmonary embolism
The correct answer is: Pneumothorax
96
For a definitive diagnosis of pulmonary embolism, which of the following should be visualized on chest CT with IV contrast?
a. Abrupt occlusion of vessels
b. Intraluminal filling defect in more than one projection
c. Prolonged arterial phase with slow filling
d. Segmental oligemia or avascularity
The correct answer is: Intraluminal filling defect in more than one projection
97
A 35/F came to your clinic with a swollen left leg. She just came home from the US two days ago. She has no maintenance meds, but takes oral contraceptives. On physical exam, there is calf tenderness and pitting edema in the affected leg. The right leg appears normal. Which diagnostic test is MOST appropriate for this patient?
a. D-dimer
b. Invasive contrast phlebography
c. MR venography with gadolinium contrast
d. Venous duplex ultrasound
The correct answer is: Venous duplex ultrasound
98
Which of the following statements regarding anticoagulation for VTE is TRUE?
a. Anticoagulation is considered primary therapy for VTE.
b. For patients with cancer and VTE, the recommended duration of anticoagulation is 6 months.
c. In case of major bleeding, the antidote for rivaroxaban is idarucizumab.
d. Warfarin requires bridging with a parenteral anticoagulant to nullify its early procoagulant effect.
• Anticoagulation is considered primary therapy secondary prevention for VTE.
• For patients with cancer and VTE, the recommended duration of anticoagulation is 6 months indefinite or until rendered cancer-free/in remission.
• In case of major bleeding, the antidote for rivaroxaban is idarucizumab andexanet. (Idarucizumab is for dabigatran.)
• Warfarin requires bridging with a parenteral anticoagulant to nullify its early procoagulant effect. (at least 5 days)
The correct answer is: Warfarin requires bridging with a parenteral anticoagulant to nullify its early procoagulant effect.
99
A 52/F with ovarian new growth was admitted for gynecologic surgery. At 48 hours post-op, she was referred for sudden-onset tachypnea and desaturation. Vitals were as follows: BP 80/60, HR 114, RR 28, O2 sat. (room air) 85%. Her right lower extremity was more swollen and edematous than the left. A focused bedside echo showed a dilated RV partially compressing the LV. What is the recommended course of action for this patient?
a. Order for CT pulmonary angiogram. If diagnosis confirmed, start enoxaparin and initiate systemic fibrinolysis with alteplase.
b. Order for CT pulmonary angiogram. If diagnosis confirmed, start enoxaparin and refer for possible catheter-directed fibrinolysis or suction thrombectomy.
c. Order for D-dimer. If diagnosis confirmed, start enoxaparin and initiate systemic fibrinolysis with alteplase.
d. Order for D-dimer. If diagnosis confirmed, start enoxaparin and refer for possible catheter-directed fibrinolysis or suction thrombectomy.
• Systemic fibrinolysis relatively contraindicated due to recent surgery
The correct answer is: Order for CT pulmonary angiogram. If diagnosis confirmed, start enoxaparin and refer for possible catheter-directed fibrinolysis or suction thrombectomy.
100
For patients with provoked, isolated calf DVT, what is the recommended minimum duration of anticoagulation?
a. 1 month
b. 3 months
c. 6 months
d. 12 months
• “Provoked” = provoked by surgery, trauma, estrogen, or indwelling central venous catheter or pacemaker
The correct answer is: 3 months
101
After an initial fluid challenge, which of the following are the first-line inotropic agents for PE-related shock?
a. Dobutamine and epinephrine
b. Dopamine and dobutamine
c. Norepinephrine and dobutamine
d. Norepinephrine and epinephrine
The correct answer is: Dopamine and dobutamine
102
What is the treatment of choice for chronic thromboembolic pulmonary hypertension (CTEPH)?
a. Balloon angioplasty of pulmonary arterial webs
b. Bosentan
c. Pulmonary thromboendarterectomy
d. Sildenafil
• For inoperable patients: medical management with pulmonary vasodilators or balloon angioplasty of webs
The correct answer is: Pulmonary thromboendarterectomy
103
Which of the following is the preferred VTE prophylaxis strategy for patients undergoing cancer surgery?
a. Apixaban 2.5 mg PO BID
b. Enoxaparin 40 mg SC OD
c. Fondaparinux 2.5 mg SC OD
d. Unfractionated heparin 5000 units SC TID
• For patients undergoing cancer surgery, including gynecologic cancer surgery – prophylaxis strategy is enoxaparin 40 mg daily; consider 1 month of prophylaxis
The correct answer is: Enoxaparin 40 mg SC OD
104
The following clinical disorders are associated with ARDS and cause direct lung injury, EXCEPT:
a. Aspiration of gastric contents
b. Pneumonia
c. Pulmonary contusion
d. Sepsis
The correct answer is: Sepsis
105
Among trauma patients, the most frequently reported surgical conditions in ARDS include the following, EXCEPT:
a. Chest wall trauma/flail chest
b. Multiple bone fractures
c. Near-drowning
d. Pulmonary contusion
The correct answer is: Near-drowning
106
For ARDS to be classified as severe, PaO2/FiO2 or PF ratio should be:
a. ≤ 50 mmHg
b. ≤ 100 mmHg
c. ≤ 200 mmHg
d. ≤ 300 mmHg
The correct answer is: ≤ 100 mmHg
107
Which of the following is TRUE regarding the Berlin diagnostic criteria for ARDS?
a. Acute onset within 1 month of a clinical insult or new or worsening respiratory symptoms
b. Bilateral opacities on chest radiograph consistent with pulmonary edema
c. Left atrial hypertension must be present
d. Severity classification must be based on a PF ratio obtained while on at least 10 cm H2O of CPAP or PEEP
• Acute onset within 1 month 1 week of a clinical insult or new or worsening respiratory symptoms
• Left atrial hypertension must be present absent
• Severity classification must be based on a PF ratio obtained while on at least 10 5 cm H2O of CPAP or PEEP
The correct answer is: Bilateral opacities on chest radiograph consistent with pulmonary edema
108
Pro-inflammatory cytokines attracting leukocytes (especially neutrophils) into the pulmonary interstitium and alveoli occurs during which phase of ARDS?
a. Exudative
b. Fibrotic
c. Proliferative
d. Recovery
The correct answer is: Exudative
109
Which of the following events occurs during the proliferative phase of ARDS?
a. Breakdown of the tight alveolar barrier
b. Formation of hyaline membrane whorls
c. Increase in number of type II pneumocytes
d. Intimal fibroproliferation in the pulmonary microcirculation
• Breakdown of the tight alveolar barrier - (exudative)
• Formation of hyaline membrane whorls - (exudative)
• Intimal fibroproliferation in the pulmonary microcirculation- (fibrotic)
The correct answer is: Formation of hyaline membrane whorls
110
In terms of clinical correlation, most patients are liberated from mechanical ventilation during which phase of ARDS?
a. Exudative
b. Fibrotic
c. Proliferative
d. Recovery
The correct answer is: Proliferative
111
What is the only ARDS therapy with a grade A level of recommendation?
a. High-frequency ventilation
b. Low tidal volumes ≤ 6 mL/kg predicted body weight
c. PEEP ≥ 8 cm H2O
d. Plateau pressure ≤ 30 cm H2O
The correct answer is: Low tidal volumes ≤ 6 mL/kg predicted body weight
112
The following ARDS therapies have been shown to have some benefit, EXCEPT:
a. Early neuromuscular blockade
b. Extracorporeal membrane oxygenation (ECMO)
c. Prone positioning
d. Surfactant replacement
The correct answer is: Surfactant replacement
113
Which of the following statements regarding prognosis of ARDS patients is FALSE?
a. High levels of required PEEP and longer durations of mechanical ventilation are associated with less recovery of pulmonary function.
b. Mortality risk and recovery of lung function is strongly associated with the extent of lung injury in early ARDS.
c. Patients usually recover maximal lung function within 6 months.
d. Patients with ARDS arising from direct lung injury are nearly twice as likely to die as those with indirect causes of lung injury.
• The major risk factors for ARDS mortality are nonpulmonary, such as advanced age, sepsis, and preexisting organ dysfunction from other chronic medical illnesses.
The correct answer is: Mortality risk and recovery of lung function is strongly associated with the extent of lung injury in early ARDS.
114
The following are contraindications to non-invasive ventilation, EXCEPT:
a. Severe encephalopathy
b. Severe GI bleed
c. Severe renal insufficiency
d. Unstable angina and myocardial infarction
The correct answer is: Severe renal insufficiency
115
The most important group of patients who benefit from a trial of non-invasive ventilation are:
a. COPD exacerbations with respiratory acidosis
b. Decompensated heart failure with arterial hypoxemia
c. Decreased sensorium with low minute ventilation
d. Pulmonary embolism with elevated A-a O2 gradient
• Decompensated heart failure with arterial hypoxemia (intubation and conventional MV remain the ventilatory method of choice for acute hypoxemic respiratory failure)
• Decreased sensorium with low minute ventilation (NIV is contraindicated)
• Pulmonary embolism with elevated A-a O2 gradient (not much benefit since PE is a perfusion problem)
The correct answer is: COPD exacerbations with respiratory acidosis
116
Which of the following is the correct term for what the ventilator senses to initiate an assisted breath?
a. Cycle
b. Limit
c. Mode
d. Trigger
• Cycle (factors that determine the end of inspiration)
• Limit (operator-specified values which are monitored in the ventilatory circuit, and if exceeded, terminate inspiratory flow)
• Mode (manner in which ventilator breaths are triggered, cycled, and limited)
The correct answer is: Trigger
117
General support principles for patients on mechanical ventilation include the following, EXCEPT:
a. Frequent bedturning to prevent decubitus ulcers
b. GI mucosal protectants such as antacids and sucralfate
c. Low molecular weight heparin for VTE prophylaxis
d. Parenteral nutrition preferred over enteral feeding
• Parenteral nutrition only as alternative in those with severe GI pathology that make it difficult to initiate enteral feeding
The correct answer is: Parenteral nutrition preferred over enteral feeding
118
The following conditions indicate a patient’s amenability to weaning from the ventilator, EXCEPT:
a. Adequate gas exchange with low PEEP (<8 cm H2O) and FiO2 (<0.5)
b. Antibiotic course completed for any underlying pulmonary infections
c. Capable of initiating spontaneous breaths
d. Hemodynamically stable and off vasopressor support
The correct answer is: Antibiotic course completed for any underlying pulmonary infections
119
The following are risk factors for OSAHS, EXCEPT:
a. Down syndrome
b. Hyperthyroidism
c. Menopause
d. Micrognathia
• Hypothyroidism (not hyperthyroidism) is a risk factor for OSAHS.
The correct answer is: Hyperthyroidism
120
The most common daytime symptom of OSAHS is:
a. Dry mouth
b. Excessive sleepiness
c. Fatigue
d. Irritability
The correct answer is: Excessive sleepiness
121
Which of the following is TRUE regarding the diagnosis of OSAHS?
a. The absence of a complaint of dyspnea is consistent with the diagnosis.
b. The absence of obesity excludes the diagnosis.
c. The absence of snoring (as reported by a bed partner or household member) excludes the diagnosis.
d. The gold standard for diagnosis is 24-hour BP monitoring.
* The absence of a complaint of dyspnea is consistent with the diagnosis. (The absence of dyspnea distinguishes OSAHS from the PND of heart failure, nocturnal asthma, and GERD with laryngospasm.)
* The absence of obesity excludes the diagnosis. (It is, however, present in 40-60% of cases.)
* The absence of snoring (as reported by a bed partner or household member) excludes the diagnosis. (Pharyngeal collapse may still occur without tissue vibration.)
* The gold standard for diagnosis is 24-hour BP monitoring overnight polysomnogram (PSG). (OSAHS does lead to abnormalities in BP, such as a non-dipping pattern or resistant hypertension.)
The correct answer is: The absence of a complaint of dyspnea is consistent with the diagnosis.
122
In the absence of symptoms, a diagnosis of OSAHS is made if the apnea-hypopnea index (AHI) is greater than:
a. 5 episodes/hour of sleep
b. 15 episodes/hour of sleep
c. 30 episodes/hour of sleep
d. 50 episodes/hour of sleep
• 5 episodes/hour of sleep (use this cut-off if with symptoms)
• 15 episodes/hour of sleep (also cut-off for moderate OSAHS)
• 30 episodes/hour of sleep (cut-off for severe OSAHS)
The correct answer is: 15 episodes/hour of sleep
123
Which of the following therapies for OSAHS has the highest level of evidence for efficacy?
a. Continuous positive airway pressure
b. Oral appliances
c. Upper airway neurostimulation
d. Uvulopalatopharyngoplasty
• Oral appliances (mostly for mild OSAHS who cannot tolerate CPAP)
• Upper airway neurostimulation (promising alternative, but needs more studies)
• Uvulopalatopharyngoplasty (less effective in severe OSAHS and obese patients)
• CPAP controlled studies: beneficial effect on BP, alertness, mood, QOL, and insulin sensitivity
• CPAP uncontrolled studies: favorable effect on CV outcomes, ejection fraction, AF recurrence, and mortality risk
The correct answer is: Continuous positive airway pressure
124
How does hepatic hydrothorax develop?
a. Cirrhosis of the liver causes a direct inflammatory reaction of the parietal pleura
b. Direct movement of peritoneal fluid through the small openings of the diaphragm
c. Increased amount of fluid in the liver interstitial spaces exits across the visceral pleura
d. Obstruction of the thoracic duct by the enlarged liver leading to decreased lymph absorption
The predominant mechanism is the direct movement of peritoneal fluid through small openings in the diaphragm into the pleural space. The effusion is usually right-sided and frequently is large enough to produce severe dyspnea.
The correct answer is: Direct movement of peritoneal fluid through the small openings of the diaphragm
125
What is the underlying pathology in a primary spontaneous pneumothorax?
a. Chronic obstructive pulmonary disease
b. Emphysema
c. Pleural blebs
d. Positive pleural pressure
• Primary spontaneous pneumothoraxes are usually due to rupture of apical pleural blebs, small cystic spaces that lie within or immediately under the visceral pleura.
The correct answer is: Pleural blebs
126
What is the imaging of choice to guide thoracentesis?
a. Computed tomography
b. Magnetic resonance imaging
c. Radiography
d. Ultrasound
• Chest ultrasound has replaced the lateral decubitus x-ray in the evaluation of suspected pleural effusions and as a guide to thoracentesis.
The correct answer is: Ultrasound
127
A 66-year-old male, previously diagnosed with heart failure and a known heavy smoker, was admitted at the emergency room for shortness of breath, non-productive cough and low-grade fever. Chest x-ray showed moderate pleural effusion on the right. Thoracentesis and blood tests were done with the following results:
Pleural Fluid analysis- Total protein: 65 g/L; LDH: 85 u/L; yellow, hazy, RBC–0, WBC –17 x 106/L (neutrophils – 5%, lymphocytes – 95%); acid fast bacilli smear, gram stain, culture studies, cytology – pending results
Serum- Total protein: 35 g/L (NV: 64-82 g/L); LDH: 210 (NV: 100-190 u/L).
What type of pleural effusion does he have?
a. Chylous pleural effusion
b. Exudative pleural effusion
c. Hemorrhagic pleural effusion
d. Transudative pleural effusion
• PF/serum LDH: <0.6 (0.40 in this case)
• PF/serum TP: >0.5 (1.86 in this case)
• PF LDH < 2/3 of upper limit of serum
• Presence of malignant cells
• Q/Q: no empyema, no hemothorax, not milky white/chylous
• Exudative pleural effusions meet at least one of the criteria, whereas transudative pleural effusions meet none.
1. Pleural fluid protein/ serum protein > 0.5
2. Pleural fluid LDH/ serum LDH > 0.6
3. Pleural fluid LDH more than two-thirds the normal upper limit for serum
The correct answer is: Exudative pleural effusion
128
Which of the following causes exudative effusion?
a. Myxedema
b. Pulmonary embolism
c. Nephrotic syndrome
d. Superior vena cava obstruction
The correct answer is: Pulmonary embolism
129
What pleural fluid study is virtually diagnostic of an effusion secondary to congestive heart failure?
a. Adenosine deaminase
b. Interferon γ
c. N-terminal pro-brain natriuretic peptide
d. Triglyceride level
• A pleural fluid N-terminal pro-brain natriuretic peptide (NT-proBNP) >1500 pg/mL is virtually diagnostic that the effusion is secondary to congestive heart failure.
• Adenosine deaminase – tuberculous effusion
• Interferon γ – tuberculous effusion
• Triglyceride level – chylous effusion
The correct answer is: N-terminal pro-brain natriuretic peptide
130
What primarily explains the development of effusion in tuberculosis?
a. Decreased lymphatic drainage from tuberculous fibrosis
b. Direct invasion of the mesothelial cells that line the pleural cavity
c. Granulomatous inflammation of the mediastinal lymph nodes
d. Hypersensitivity reaction to tuberculous protein in the pleural space
• Tuberculous pleural effusions usually are associated with primary TB and are thought to be due primarily to a hypersensitivity reaction to tuberculous protein in the pleural space.
The correct answer is: Hypersensitivity reaction to tuberculous protein in the pleural space
131
A 72-year-old male, 35 pack years smoker and non-compliant to previously given unrecalled inhaled medication, is admitted to the emergency room for sudden onset of chest tightness. He was having an increase in frequency of coughing and sputum production for the past two weeks. On physical examination: intercostal muscle retractions, right chest lag, decreased tactile fremitus and hyper-resonant right lung field, decreased breath sounds on the right and wheezing on the left. What is the likely diagnosis?
a. Asthma exacerbation from pneumonia
b. COPD exacerbation with pneumothorax
c. Pneumonia with pleural effusion
d. Pulmonary embolism from lung malignancy
• Most secondary pneumothoraxes are due to chronic obstructive pulmonary disease.
*right chest lag, decreased fremitus, hyperresonance, decreased breath sounds– pneumothorax
**left wheezing – COPD exacerbation
The correct answer is: COPD exacerbation with pneumothorax
132
A 28-year-old female, diagnosed asthmatic more than 20 years ago and on maintenance inhaled corticosteroids, consulted the emergency room for substernal chest pain radiating to the neck. She had slightly bulging suprasternal notch, with crepitus on palpation, clear breath sounds on all lung fields. Chest x-ray was noted to have curvilinear lucencies of the mediastinum. What is the management plan?
a. analgesic and oxygen
b. anticoagulation and inhaled steroid
c. chest tube insertion
d. needle aspiration
• DIAGNOSIS: Pneumomediastinum
• Symptoms: severe substernal chest pain with or without radiation into the neck and arms
• Signs: subcutaneous emphysema in the suprasternal notch and Hamman’s sign (crunching or clicking noise synchronous with the heartbeat)
• Usually no treatment is required but will be absorbed faster by inspiring high concentrations of oxygen. If mediastinal structures are compressed, the compression can be relieved with needle aspiration.
The correct answer is: analgesic and oxygen
133
A 78-year-old male, known hypertensive with chronic obstructive pulmonary disease, was admitted ofr exacerbation and pneumonia. He was intubated, hooked to a mechanical ventilator and stabilized in the intensive care unit. On the 2nd ICU day, he was referred for sudden onset of respiratory distress and hypotension. He has absent breath sounds on the right and high peak inspiratory pressure. What is the next step in the management?
a. aggressive suctioning and re-intubation if no improvement
b. decrease tidal volume to 6mL/kg and increase PEEP
c. insert needle into right 2nd anterior intercostal space
d. nebulization and shift to broader spectrum antibiotics
• DIAGNOSIS: Tension pneumothorax
• Findings: high peak inspiratory pressures during mechanical ventilation , enlarged hemithorax with no breath sounds, hyperresonance to percussion, and shift of the mediastinum to the contralateral side.
• A large-bore needle should be inserted into the pleural space through the second anterior intercostal space. The needle should be left in place until a thoracostomy tube can be inserted.
The correct answer is: insert needle into right 2nd anterior intercostal space
134
A 58-year-old female, known hypertensive and diabetic, was diagnosed two years ago with congestive heart failure. She is now currently admitted for symptoms of cough, shortness of breath, pleuritic chest pain and fever. Chest x-ray showed bilateral pleural effusion, cardiomegaly and congestive changes. Ultrasound showed homogenous anechoic effusion approximately 300mL on each lung. She was given oxygen support, intravenous antibiotics and diuretics. What will make you recommend thoracentesis?
a. bilateral pleural effusion
b. fever and pleuritic chest pain
c. shortness of breath and cough
d. no indication for thoracentesis
• In patients with heart failure, a diagnostic thoracentesis should be performed if the effusions are not bilateral and comparable in size, if the patient is febrile, or if the patient has pleuritic chest pain to verify that the patient has a transudative effusion.
The correct answer is: fever and pleuritic chest pain
135
A 32-year-old female was sent to the emergency room for shortness of breath. On chest x-ray, there was note of small pleural effusion on the left. Thoracentesis was done and pleural fluid analysis showed:
clear, light yellow, RBC–0, WBC –9 x 106/L (neutrophils 10%, lymphocytes 90%)
exudative by Light’s criteria; Glucose: >60mg/dL (not low)
Gram stain: no polymorphonuclear cells, no organism;
Culture: no growth
AFB smear: negative; Cytology: no atypical cells.
What is the next step in the management?
a. serum antinuclear antibody (ANA) test
b. spiral computed tomography scan
c. repeat thoracentesis and pleural fluid analysis
d. thoracoscopy with pleural biopsy
Pulmonary embolism
• Most overlooked in the differential diagnosis of an undiagnosed pleural effusion
The correct answer is: spiral computed tomography scan
136
What is the primary treatment of a patient with hemothorax?
a. Angiographic coil embolization
b. Chest tube insertion
c. Pleurodesis
d. Thoracotomy
• Most patients with hemothorax should be treated with tube thoracostomy, which allows continuous quantification of bleeding.
* bleeding emanates from a laceration of the pleura - apposition of the two pleural surface
* *bleeding > 200 mL/h – consider angiographic coil embolization, thoracoscopy or thoracotomy
The correct answer is: Chest tube insertion
137
Which of the following causes transudative effusion?
a. Asbestos exposure
b. Peritoneal dialysis
c. Rheumatoid pleuritis
d. Viral infection
The correct answer is: Peritoneal dialysis
138
A 21-year-old male was admitted at the emergency room for dyspnea. On history, he was previously admitted for right pneumothorax managed by oxygen and simple aspiration. For this admission, chest-xray showed moderate right pneumothorax and chest tube was inserted. What will you recommend?
a. Indwelling pigtail catheter
b. Intrapleural injection of octreotide
c. Stapling of blebs and pleural abrasion
d. Start anti-TB medications
* DIAGNOSIS: recurrent pneumothorax
* If the lung does not expand with aspiration or if the patient has a recurrent pneumothorax, thoracoscopy with stapling of blebs and pleural abrasion is indicated.
The correct answer is: Stapling of blebs and pleural abrasion
139
Which of the following explains the development of bronchiectasis from tuberculosis infection?
a. Extrinsic compression of the airway by enlarged granulomatous lymph nodes leads to focal bronchiectasis
b. Deficiency of antiproteases results to uncontrolled damaging effects of neutrophil elastase and impaired bacterial killing
c. Immune-mediated reaction damages the bronchial wall predominantly involving the central airways
d. Lung fibrosis results to dilated airways from parenchymal distortion
Other mechanisms of TB bronchiectasis:
1. intrinsic obstruction as a result of erosion of a calcified lymph node through the airway wall (e.g., broncholithiasis)
2. especially in reactivated tuberculosis, parenchymal destruction from infection can result in areas of more diffuse bronchiectasis.
• Deficiency of antiproteases results to uncontrolled damaging effects of neutrophil elastase and impaired bacterial killing - a1 antitrypsin deficiency
• Immune-mediated reaction damages the bronchial wall predominantly involving the central airways - ABPA / autoimmune diseases
• Lung fibrosis results to dilated airways from parenchymal distortion - traction bronchiectasis, post radiation fibrosis
The correct answer is: Extrinsic compression of the airway by enlarged granulomatous lymph nodes leads to focal bronchiectasis
140
A 32-year-old male, smoker, works as a painter, consulted for chronic cough productive of thick sputum. Physical examination revealed diffuse crackles and wheezing. Chest CT scan showed lack of bronchial tapering, thickened bronchial walls and inspissated secretions in both lung fields. What is the diagnosis?
a. Asbestosis
b. Bronchiectasis
c. Chronic obstructive pulmonary disease
d. Lung abscess
CT findings of bronchiectasis:
• airway dilation (detected as parallel “tram tracks” or as the “signet-ring sign”
• lack of bronchial tapering
• bronchial wall thickening in dilated airways, inspissated secretions (e.g., the “tree-in-bud” pattern)
• cysts emanating from the bronchial wall (especially pronounced in cystic bronchiectasis)
The correct answer is: Bronchiectasis
141
What organism should be covered in the initial empiric antibiotic treatment of acute exacerbation of bronchiectasis?
a. Acinetobacter baumannii
b. Aspergillus flavus
c. Haemophilus influenzae
d. Mycobacterium avium-intracellulare complex
• Antibiotics targeting the causative or presumptive pathogen (with Haemophilus influenzae and P. aeruginosa isolated commonly) should be administered in acute exacerbations, usually for a minimum of 7–10 days and perhaps for as long as 14 days.
The correct answer is: Haemophilus influenzae
142
Which of the following is TRUE of the management of bronchiectasis?
a. Administration of systemic glucocorticoids has no role in the treatment of bronchiectasis of whatever etiology.
b. Inhaled steroids improve lung function, reduce sputum production and decrease frequency of exacerbations.
c. Pulmonary rehabilitation and regular exercise programs did not show any benefit in improving secretion clearance and quality of life.
d. Resection of a focal area of suppuration may be an option for refractory cases.
• Refractory cases - surgery can be considered, with resection of a focal area of suppuration. In advanced cases, lung transplantation can be considered.
• Administration of systemic glucocorticoids is useful in autoimmune, non-infectious bronchiectasis
• No significant benefit with inhaled steroids
• Pulmonary rehabilitation and regular exercise programs are beneficial in improving secretion clearance and quality of life.
The correct answer is: Resection of a focal area of suppuration may be an option for refractory cases.
143
A 62-year-old male, chronic smoker, was diagnosed with bronchiectasis localized on the right middle lobe on chest CT scan. What test or procedure should be recommended?
a. α1 antitrypsin levels
b. bronchoscopy
c. CT-guided percutaneous biopsy
d. HIV screening
• DIAGNOSIS: Focal bronchiectasis
• Evaluation: almost always requires bronchoscopy to exclude airway obstruction by an underlying mass or foreign body.
The correct answer is: bronchoscopy
144
Which of the following chest radiograph pleural findings specifically indicates past exposure to asbestos and not a sign of pulmonary impairment?
a. Effusion
b. Fibrosis
c. Plaque
d. Reticulation
Pleural plaques
• Indicate past exposure to asbestos, characterized by either thickening or calcification along the parietal pleura, particularly along the lower lung fields, the diaphragm, and the cardiac border
• Without additional manifestations, imply only exposure, not pulmonary impairment
The correct answer is: Plaque
145
What occupational lung disease is seen in high-resolution chest CT scan as profuse miliary infiltration and “crazy paving” or the polygonal shapes produced by diffuse ground glass densities with thickened septa?
a. Asbestosis
b. Chronic beryllium disease
c. Coal worker’s pneumoconiosis
d. Silicosis
Silicosis
• Characteristic HRCT pattern: shows multiple small nodules consistent with silicosis but also diffuse ground-glass densities with thickened intralobular and interlobular septa producing polygonal shapes (“crazy paving”)
The correct answer is: Silicosis
146
Which occupational dust is responsible for chest tightness and significant drop in FEV1 toward the end of the first day of the workweek or the “Monday chest tightness”?
a. Coal
b. Cotton
c. Fungal spores
d. Grain
Cotton Dust (Byssinosis)
• Characterized clinically as occasional (early-stage) and then regular (late-stage) chest tightness toward the end of the first day of the workweek (“Monday chest tightness”). Exposed workers may show a significant drop in FEV1 over the course of a Monday workshift.
The correct answer is: Cotton
147
Which of the following is TRUE of occupational lung diseases?
a. Asbestos-related diseases are limited to exposure by directly handling the material.
b. Coal dust causes chronic bronchitis and chronic obstructive pulmonary disease.
c. Grain dust exposure presentation is restrictive lung disease similar to smokers.
d. Silicosis causes alveolar macrophage dysfunction which increases the risk of asthma.
• In addition to coal worker’s pneumoconiosis, coal dust can cause chronic bronchitis and COPD. The effects of coal dust are additive to those of cigarette smoking.
• Asbestos-related diseases is also seen in bystander exposure, community exposure and disturbance of naturally occurring asbestos.
• Grain dust exposure presentation is obstructive airway disease identical to the characteristic findings in cigarette smokers.
• Silicosis causes alveolar macrophage dysfunction which increases the risk of tuberculosis and fungi.
The correct answer is: Coal dust causes chronic bronchitis and chronic obstructive pulmonary disease.
148
Which of the following is TRUE of environmental exposures and lung diseases?
a. Household air pollution from cooking with solid fuels is associated with chronic bronchitis and COPD.
b. Inhaled fine particles from combustion sources tend to remain in the airstream and are exhaled without causing lung injury.
c. Secondhand smoke has been shown to have little effect in the prevalence of respiratory illnesses except cancer.
d. Studies of cities with different levels of air particulate pollution showed similar cardio-pulmonary mortality rates.
• Indoor exposure to household air pollution from cooking or heating with solid fuels (wood, dung, crop residues, charcoal, coal) – associated with both chronic bronchitis and COPD.
The correct answer is: Household air pollution from cooking with solid fuels is associated with chronic bronchitis and COPD.
149
What is the most common interstitial lung disease (ILD) of unknown cause?
a. Cryptogenic Organizing Pneumonia
b. Granulomatosis with polyangiitis
c. Idiopathic pulmonary fibrosis
d. Respiratory Bronchiolitis—associated ILD
The correct answer is: Idiopathic pulmonary fibrosis
150
What is the typical pulmonary function test results of interstitial lung diseases?
FEV1 – forced expiratory volume in 1s; FVC – forced vital capacity;
DLCO – diffusing capacity of the lung for carbon monoxide; TLC – total lung capacity
a. ↓ FEV1/FVC, ↓ DLCO
b. ↑ FEV1/FVC, ↓ DLCO
c. ↓ TLC, ↓FEV1, ↓ FVC
d. ↓ TLC, ↓ FEV1, ↑FVC
* Restrictive deficit is typified by a reduced total lung capacity (TLC), and symmetrically reduced measures of forced expiratory volume in 1 s (FEV1) and forced vital capacity (FVC).
* Reduction in the diffusing capacity of the lung for carbon monoxide (DLCO) is also common
The correct answer is: ↓ TLC, ↓FEV1, ↓ FVC
151
What intervention is proven to slow down the lung function and improve survival of patients with idiopathic pulmonary fibrosis?
a. Anti-fibrotic therapy
b. Immunosuppression
c. Oxygen supplementation
d. Physical therapy
• Antifibrotic therapy (pirfenidone and nintedanib) can slow decline of lung function and may also improve survival.
• Lung transplantation can extend survival and improve the quality of life in a subset of IPF patients who meet criteria to undergo transplant.
• Immunosuppression is associated with increased morbidity and mortality.
The correct answer is: Anti-fibrotic therapy
152
What histopathologic findings in usual interstitial pneumonia (UIP) distinguish it from non-specific interstitial pneumonia (NSIP)?
a. honeycomb changes
b. interstitial inflammation
c. lymphocytic infiltration
d. presence of fibrosis
• UIP - honeycomb changes and fibroblast foci (subepithelial collections of myofibroblasts and collagen), fibrotic changes alternate with areas of preserved normal alveolar architecture consistent with temporal and spatial heterogeneity
• NSIP - honeycomb changes are usually absent and fibroblast foci are rare, varying amounts of interstitial inflammation and fibrosis with a uniform appearance
The correct answer is: honeycomb changes
153
Which of the following is TRUE of interstitial lung diseases (ILD) associated with connective tissue diseases (CTD)?
a. Antifibrotic therapy is proven to improve survival and delay disease progression.
b. Cytotoxic agents like cyclophosphamide may be useful and have shown variable success.
c. Hallmark histopathologic findings is consistent with usual interstitial pneumonia.
d. They are most commonly observed in systemic lupus erythematosus compared to other CTDs
• Cyclophosphamide has a modest benefit in preservation of lung function and is associated with significant toxicity
The correct answer is: Cytotoxic agents like cyclophosphamide may be useful and have shown variable success.
154
Which intervention is NOT show to improve survival of patients with COPD?
a. Inhaled corticosteroids and muscarinic antagonists
b. Lung volume reduction in selected patients with emphysema
c. Oxygen therapy in chronically hypoxemic patients
d. Smoking cessation
• Only three interventions—smoking cessation, oxygen therapy in chronically hypoxemic patients, and lung volume reduction surgery (LVRS) in selected patients with emphysema—have been demonstrated to improve survival of patients with COPD
The correct answer is: Lung volume reduction in selected patients with emphysema
155
What is the current definitive test for establishing the presence of emphysema and diagnose co-existing interstitial lung disease and bronchiectasis in COPD?
a. Arterial blood gas and oximetry
b. Chest computed tomography scan
c. Bronchoscopy with lung biopsy
d. Pulmonary function test
• Chest computed tomography (CT) scan - current definitive test for:
o establishing the presence or absence of emphysema
o pattern of emphysema
o presence of significant disease involving medium and large airways
o also enables the discovery of coexisting interstitial lung disease and bronchiectasis
The correct answer is: Chest computed tomography scan
156
Which is TRUE of the use of systemic glucocorticoids in patients admitted to the hospital for acute COPD exacerbation?
a. Avoided and not beneficial
b. Hastens recovery and reduces relapse
c. Given for at least eight weeks
d. Prolongs hospitalization due to side effects
• In patients admitted to the hospital, the use of systemic glucocorticoids:
o reduces the length of stay
o hastens recovery
o reduces the chance of subsequent exacerbation or relapse
• 2 weeks of glucocorticoid therapy produces benefit indistinguishable from 8 weeks of therapy
The correct answer is: Hastens recovery and reduces relapse
157
According to the Global Initiative for Chronic Obstructive Lung Disease (GOLD), what is required to make the diagnosis of COPD?
a. Body plethysmography
b. Chest CT scan
c. Peak expiratory flow measurement
d. Spirometry
• Spirometry is required to make the diagnosis; presence of a post-bronchodilator FEv1/FVC<0.70 confirms the presence of persistent airflow obstruction.
The correct answer is: Spirometry
158
What is the most typical physiologic abnormality in COPD ?
a. Chronic hypoxemia
b. Decrease in the diffusing capacity of the lung for carbon monoxide
c. Persistent reduction in forced expiratory flow rate
d. Shunting
• Persistent reduction in forced expiratory flow rates is the most typical finding in COPD.
• Can also occur: Increases in the residual volume and the residual volume/total lung capacity ratio, non-uniform distribution of ventilation, and ventilation-perfusion mismatching
The correct answer is: Persistent reduction in forced expiratory flow rate
159
Which is TRUE of the physiologic abnormalities in COPD?
a. PaO2 immediately decreases once FEV1 starts to decline
b. PaCO2 immediately increases once FEV1 starts to decline
c. Shunt physiology is the major determinant of elevation in PaCO2
d. V/Q mismatch accounts for all of the reduction in PaO2
* Ventilation-perfusion mismatching accounts for essentially all of the reduction in Pao2 that occurs in COPD
* PaO2 usually remains near normal until the FEV1 is decreased to ~50% of predicted.
* Elevation of Paco2 is not expected until the FEV1 is <25% of predicted
The correct answer is: Shunt physiology is the major determinant of elevation in PaCO2
160
What would the development of clubbing in a patient with COPD indicate?
a. Check for cor pulmonale
b. Chronic hypoxemia and respiratory acidosis
c. Consider lung malignancy
d. Very severe disease
• Clubbing of the digits is not a sign of COPD, and its presence should alert the clinician to initiate an investigation for causes of clubbing. In this population, the development of lung cancer is the most likely explanation for newly developed clubbing.
The correct answer is: Consider lung malignancy
161
Which is TRUE of the pharmacologic management of stable phase COPD?
a. Chronic use oral glucocorticoids is recommended for very severe COPD or category D patients
b. Long-acting muscarinic agonists (LAMA) reduce exacerbations and mortality rate
c. Long-acting beta agonists (LABA) provide symptomatic relief with no effect on frequency of exacerbations
d. Theophylline can improve airflow and vital capacity but is not considered as first-line therapy option
* Theophylline produces modest improvements in airflow and vital capacity, but is not first-line therapy due to side effects and drug interactions.
* Chronic use of oral glucocorticoids are not recommended because of an unfavorable benefit/risk ratio
* LAMA improve symptoms and reduce exacerbations, but only seen to have trend to reduction of mortality.
* LABA provide symptomatic benefit and reduce exacerbations, though to a lesser extent than a LAMA.
The correct answer is: Theophylline can improve airflow and vital capacity but is not considered as first-line therapy option
162
A 65-year-old male, chronic smoker with no previous hospitalizations, consulted for 3 month history of cough with associated dyspnea described as need to stop to rest when walking. Spirometry showed post-bronchodilator FEV1/FVC 0.6, %predicted FEV1 60. What will you recommend?
a. Short-acting beta agonist
b. Long acting muscarinic antagonist
c. Long-acting beta agonist and inhaled corticosteroid
d. Long acting beta agonist, long-acting muscarinic antagonist and inhaled corticosteroid
* GOLD Stage II, moderate severity
* Category B based on symptoms/ previous hospitalizations – long acting bronchodilator
The correct answer is: Long acting muscarinic antagonist
163
Which factor is against initiating inhaled corticosteroid in combination with long acting bronchodilators in patients with COPD?
a. Concomitant asthma
b. Repeated pneumonia
c. Signs of heart failure
d. Uncontrolled diabetes
• AGAINST USE of ICS: repeated pneumonia events, blood eosinophils <100 cells/uL, history of mycobacterial infection
The correct answer is: Repeated pneumonia
164
A 62-year-old male COPD patient on inhaled tiotropium started two months ago consulted the clinic because of persistence of breathlessness and exercise limitation. What will you recommend?
a. Add inhaled corticosteroid
b. Add theophylline
c. Shift to LABA/ICS
d. Shift to LABA/LAMA
• For patients with persistent breathlessness or exercise limitation on long acting bronchodilator monotherapy, the use of two bronchodilators is recommended.
The correct answer is: Shift to LABA/LAMA
165
A 65-year-old male, newly diagnosed with COPD (FEV1 80% predicted) was prescribed with formoterol/budesonide metered dose inhaler for mild symptoms of breathlessness with strenuous activity. He complains of exercise limitations despite compliance to medications. What will you recommend?
a. Add roflumilast
b. Add theophylline
c. Shift to LABA/LAMA
d. Start oral corticosteroids
• Switching to LABA/LAMA should be considered if the original indication for ICS was inappropriate.
The correct answer is: Shift to LABA/LAMA
166
A 67-year-old male COPD patient on indacaterol/ glycopyrronium for the past 3 months noted a slight increase in shortness of breath and cough. He was previously admitted last year for severe exacerbation. Blood eosinophil count is 450 cells/uL. What is your recommendation?
a. Add inhaled corticosteroid
b. Add roflumilast
c. Shift to salmeterol/fluticasone
d. Shift to tiotropium
• In patients who develop further exacerbations on LABA/LAMA, escalation to LABA/LAMA/ICS.
The correct answer is: Add inhaled corticosteroid
167
A 62-year-old male, chronic smoker, discharged last month for severe dyspnea, was given salbutamol tablets as needed. Spirometry done in the outpatient showed FEV1/FVC 0.6 and FEV1 60% predicted. He claims to have shortness of breath when walking uphill or climbing stairs. What inhalation drug will you recommend to him?
a. Indacaterol
b. Tiotropium
c. Budesonide
d. Salmeterol/fluticasone
* GOLD Stage II, moderate severity
* Category C based on symptoms/previous hospitalizations – LAMA
The correct answer is: Tiotropium
168
A 58-year-old male, recently diagnosed with COPD had one hospital admission for an exacerbation and complains of breathlessness when walking uphill or climbing stairs. What is his COPD severity group?
a. High symptoms, high risk
b. High symptoms, low risk
c. Low symptoms, high risk
d. Low symptoms, low risk
• Category C based on symptoms mMRC 1 and previous hospitalization for an exacerbation
The correct answer is: Low symptoms, high risk
169
A58-year-old male with chronic bronchitis consulted the clinic for breathlessness, increasing cough frequency and sputum production despite being on one month of inhaled formoterol/ budesonide and tiotropium. He is unable to discontinue smoking despite attending a counseling program and was hospitalized the previous year for an exacerbation. Previous spirometry result and lab results: FEV1/FVC 0.6, FEV1 35% predicted, blood eosinophil count 400 cells/uL. What will you recommend?
a. Add azithromycin
b. Add roflumilast
c. Switch to salmeterol/fluticasone and glycopyrronium bromide
d. Withdraw the inhaled corticosteroid and shift to LABA/LAMA
• In patients treated with LABA/LAMA/ICS who still have exacerbations: add roflumilast if FEV1 <50%predicted and with chronic bronchitis.
The correct answer is: Add roflumilast
170
A COPD patient with good symptom control on triple therapy (LABA/LAMA/ICS) consulted for repeated readings of 86% on pulse oximetry for the past month. PaO2 2 weeks ago was 53 mmHg. Recent arterial blood gas requested: PaO2 50 mmHg, PaCo2 40 mmHg, O2sats 84% at room air. What will you recommend?
a. Add roflumilast to current regimen
b. Continuous positive airway pressure
c. Interventional bronchoscopy
d. Long-term oxygen therapy
• Long-term oxygen therapy is indicated for stable patients who have PaO2 below 55mmHg or below 88% SaO2 with or without hypercapnia, confirmed twice over a three-week period.
The correct answer is: Long-term oxygen therapy
171
A 70-year-old male with COPD on tiotropium was admitted to the emergency room because of worsening dyspnea and cyanosis. He was received tachypneic with intercostal muscle retractions. Arterial blood gas: PaO2 50 mmHg, PaCO2 50 mmHg, pH 7.28 on face mask at 10LPM. Which of the following is the appropriate intervention?
a. Bilevel positive airway ventilation
b. High flow nasal cannula
c. Intubation and mechanical ventilation
d. Maintain oxygen therapy and admit to intensive care unit
• Non-invasive mechanical ventilation should be the first mode of ventilation used in COPD patients with acute respiratory failure who have no absolute contraindications.
The correct answer is: Bilevel positive airway ventilation
172
A 65-year-old female with COPD on glycopyrronium bromide inhaler was admitted to the emergency room because of worsening dyspnea. She was received tachypneic RR 30, with intercostal muscle retractions. Which of the following is the appropriate management of her inhaled drug/s?
a. Add inhaled corticosteroid and continue glycopyrronium bromide
b. Add inhaled salbutamol and continue glycopyrronium bromide
c. Start budesonide nebulization
d. Start salbutamol/ipratropium bromide nebulization
• Short-acting inhaled beta-agonists, with or without short-acting anticholinergics, are recommended as the initial bronchodilator to treat an acute exacerbation.
The correct answer is: Start salbutamol/ipratropium bromide nebulization
173
Which of the following is TRUE of smoking cessation strategies?
a. E-cigarette as a smoking cessation aid is effective and safe alternative to nicotine replacement products.
b. Self-initiated strategies are better that physician counseling.
c. Intensifying counseling intensity by increasing duration and number of sessions improves cessation success rates.
d. Pharmacologic interventions such as buproprion can be used as sole intervention for smoking cessation.
• There is a relationship between counseling intensity and cessation success.
• E-cigarette as a smoking cessation aid is uncertain at present.
• Counseling by physician increases quit rates over self-initiated strategies.
• Pharmacologic interventions should always be used as component of supportive intervention program.
The correct answer is: Pharmacologic interventions such as buproprion can be used as sole intervention for smoking cessation.
174
Which of the following is the major risk factor for asthma?
a. Airway hyperresponsiveness
b. Atopy
c. Early viral infections
d. Indoor allergens
* Atopy is the major risk factor for asthma, and non-atopic individuals have a very low risk of developing asthma.
* Patients with asthma commonly suffer from other atopic diseases: allergic rhinitis (>80% of asthmatic patients), and atopic dermatitis (eczema).
The correct answer is: Atopy
175
Which is the most common allergen to trigger asthma?
a. Cat dander
b. Dust mite
c. Fungal spores
d. Grass pollen
Dermatophagoides species
• Dust mite
• Most common allergens to trigger asthma
• Leads to low-grade chronic symptoms that are perennial
The correct answer is: Dust mite
176
What is the mechanism by which exercise triggers asthma?
a. Hyperventilation increases cholinergic bronchoconstriction
b. Hyperventilation triggers mast cell mediator release
c. Increase in airway inflammation with increased numbers of eosinophils during exercise
d. Inhibition of breakdown of kinins during exercise leads to bronchoconstriction
Hyperventilation during exercise
• Results in increased osmolality in airway lining fluid and triggers mast cell mediator release, resulting in bronchoconstriction
Mechanisms of the triggers of asthma
•Stress-induced bronchoconstriction through cholinergic reflex pathways
•Viral infection increase airway inflammation, increased number of neutrophils
•Inhaled allergens activate mast cells with bound IgE directly leading to the immediate release of bronchoconstrictor mediators
•Beta-blockers increase cholinergic bronchoconstriction
The correct answer is: Hyperventilation triggers mast cell mediator release
177
What is the characteristic histopathologic finding of airway remodeling in asthma?
a. Activation of mucosal mast cells
b. Mucosal infiltration of eosinophils and T lymphocytes
c. Subepithelial collagen deposition
d. Vasodilation and increased number of blood vessels
Airway remodeling in asthma
• Structural changes in the airways
• Characteristic finding: thickening of the basement membrane due to subepithelial collagen deposition
secondary to subepithelial collagen deposition
- deposition of types III and V collagen below the true basement membrane
- associated with eosinophil infiltration, presumably through the release of profibrotic mediators such as transforming growth factor-β
The correct answer is: Subepithelial collagen deposition
178
Which group of inflammatory mediators is primarily responsible for bronchoconstriction in asthma?
a. Chemokines
b. Cytokines
c. Mast cell-derived
d. Transcription factors
• Limitation of airflow is due mainly to bronchoconstriction (from mast cell mediators), but airway edema, vascular congestion, and luminal occlusion with exudate may contribute.
Mast cell-derived mediators
• Histamine, prostaglandin D2, and cysteinyl-leukotrienes
• Contract airway smooth muscle, increase microvascular leakage, increase airway mucus secretion, and attract other inflammatory cells
The correct answer is: Mast cell-derived
179
Which is TRUE of the physiologic changes in asthma?
a. Increased in FEV1/FVC due to hyperinflation or air trapping
b. Increases in arterial PCO2 is common leading to ventilatory failure
c. Reduction in FEV1 and peak expiratory flow from bronchoconstriction
d. Residual volume is decreased during exacerbations because of early closure of peripheral airways
* Reduction in forced expiratory volume in 1 second (FEV1), FEV1/ forced vital capacity (FVC) ratio, and peak expiratory flow (PEF)
* Increase in airway resistance
* Lung hyperinflation (air trapping) and increased RV, during acute exacerbations and in severe persistent asthma
* Reduced ventilation and increased pulmonary blood flow result in V/Q mismatch (in more severe asthma)
* Ventilatory failure is very uncommon, even in patients with severe asthma, arterial PCO2 tends to be low due to increased ventilation
The correct answer is: Reduction in FEV1 and peak expiratory flow from bronchoconstriction
180
Which is TRUE of the diagnostic tests used in asthma?
a. Chest x-ray shows hyperinflation only in severe patients.
b. Fractional exhaled nitric oxide is used as an adjunct to rule in or rule out asthma.
c. Serum IgE is specific for asthma and elevated in all asthma phenotypes.
d. Whole body plethysmography is required to document lung volumes and capacities.
• Chest roentgenography is usually normal but in more severe patients may show hyperinflated lungs. In exacerbations, there may be evidence of a pneumothorax.
• Fractional exhaled nitric oxide is used as a noninvasive test to measure eosinophilic airway inflammation
• Serum IgE indicates atopic status but not specific for asthma
• Whole body plethysmography shows increased airway resistance, increased total lung capacity and residual volume but rarely necessary
The correct answer is: Chest x-ray shows hyperinflation only in severe patients.
181
What is the most common reason for poor control of asthma?
a. Concurrent allergic rhinosinusitis
b. Continuous exposure to ambient levels of allergens
c. Poor compliance to inhaled corticosteroid
d. Wrong inhaler technique
Most common reason for poor control of asthma: poor adherence with medication, particularly ICS
• Patients do not feel any immediate clinical benefit or may be concerned about side effects
• Difficult to monitor as there are no useful plasma measurements that can be made but measuring FENO may identify the problem
• Compliance may be improved by giving the ICS as a combination with a LABA that gives symptom relief
Other factors that can make asthma difficult to control
• Exposure to high, ambient levels of allergens or unidentified occupational agents
• Severe rhinosinusitis
• Drugs such as beta-adrenergic blockers, aspirin, and other cyclooxygenase (COX) inhibitors
• Premenstrual worsening in women
• Hyper- and hypothyroidism
The correct answer is: Poor compliance to inhaled corticosteroid
182
Which is TRUE of asthma in pregnancy?
a. Most patients will have worsening of asthma control during pregnancy.
b. Inhaled corticosteroid is under FDA Category D – with evidence of human risk, but potential benefits of use outweigh the risk.
c. If oral steroid is needed, prednisone is preferred to protect the fetus from its systemic effects.
d. Corticosteroids and short-acting beta-agonists are contraindicated during breastfeeding.
• If an OCS is needed - better to use prednisone rather than prednisolone as it cannot be converted to the active prednisolone by the fetal liver, thus protecting the fetus from systemic effects of the corticosteroid.
The correct answer is: If oral steroid is needed, prednisone is preferred to protect the fetus from its systemic effects.
183
What is the most effective treatment of a worsening type 2 brittle asthma?
a. Continuous infusion of beta-agonist
b. Intravenous steroid
c. Omalizumab
d. Subcutaneous epinephrine
• Type 1 brittle asthma – OCS or continuous infusion of β2-agonists
• Type 2 brittle asthma – subcutaneous epinephrine (suggests that the worsening is likely to be a localized airway anaphylactic reaction with edema)
The correct answer is: Subcutaneous epinephrine
184
A 27-year-old male, non-smoker, consulted your clinic for occasional shortness of breath once/month for the past three months. On PE, he had clear breath sounds. Chest x-ray was unremarkable and spirometry showed more than 15% improvement post-bronchodilator in FEV1 and FEV1%. What is the best inhaled medication regimen for him?
a. Salbutamol PRN
b. Low dose budesonide/formoterol PRN
c. Low dose budesonide daily + salbutamol PRN
d. Low dose budesonide/formoterol daily + salbutamol PRN
• The preferred STEP 1 controller for adults is low dose combination ICS-formoterol taken as needed for relief of symptoms. This is for patients with symptoms less than twice a month and no exacerbation risk factors.
The correct answer is: Low dose budesonide/formoterol PRN
185
A 20-year-old female consulted the clinic for intermittent shortness of breath. On history, she was prescribed with salbutamol tablets during acute episodes of dyspnea when she was 7 years old. She then became asymptomatic until 2 months ago when she recurrence of symptoms and was again advised to nebulize with salbutamol. Thereafter, she noted to have at least 3 episodes of dyspnea per week usually during exercise that requires nebulization, but no limitations in daily activities and no night time symptoms. What will you advise her?
a. Perform spirometry with reversibility test to support asthma diagnosis and then start daily low dose budesonide inhalation with salbutamol as reliever.
b. Perform spirometry with reversibility test to support asthma diagnosis and then start daily low dose fluticasone/salmeterol inhalation with salbutamol as reliever.
c. Start daily low dose budesonide inhalation with as needed salbutamol and follow up after 1 month for monitoring.
d. Start daily low dose fluticasone/salmeterol inhalation with as needed salbutamol and follow up after 1 month for monitoring.
• Confirm first the diagnosis of asthma before starting controller medications then initiate appropriate medication (STEP 2 – low dose ICS + SABA reliever)
The correct answer is: Perform spirometry with reversibility test to support asthma diagnosis and then start daily low dose budesonide inhalation with salbutamol as reliever.
186
A 42-year-old male, non-smoker, on daily fluticasone/formoterol 50/5mcg 2 puffs twice a day, consulted for occasional breathlessness on long walks and climbing uphill despite good compliance for the past 6 months. On history, he was diagnosed with bronchial asthma by their health center doctor based on his intermittent symptoms of shortness of breath and normal chest x-ray. Recent spirometry showed normal lung function. What will you recommend?
a. Asthma diagnosis should be confirmed by discontinuing inhaled drug and observing if lung function declines.
b. Asthma diagnosis should be confirmed by repeating spirometry after withholding inhaler for at least 12 hours.
c. No need to confirm diagnosis. Discontinue current drug and consider alternative diagnoses.
d. No need to confirm diagnosis. Increase dose of inhaled drug and re-assess response.
• Confirm the diagnosis of asthma even in patients already taking controller medications.
The correct answer is: Asthma diagnosis should be confirmed by repeating spirometry after withholding inhaler for at least 12 hours.
187
A 19-year-old male consulted the clinic for episodes of chest tightness. He was diagnosed with bronchial asthma by spirometry and given inhaled albuterol during exacerbations. He reported that he would only have less than 1/week need for the inhaler and no limitations in daily activities. What worries him is his once a week episodes of waking up with shortness of breath for the past two months. What can you add to his current reliever therapy?
a. As needed low dose budesonide
b. As needed low dose budesonide/formoterol
c. Daily low dose budesonide
d. Daily low dose budesonide/formoterol
• Patient is on SABA only treatment since diagnosis which is no longer recommended. (STEP 3)
The correct answer is: Daily low dose budesonide/formoterol
188
A 24-year-old male on daily low dose budesonide/formoterol and albuterol as needed, consulted for the recurrence of his asthma attacks that would wake him up once a week. He was compliant to his medications with proper inhaler technique. Which is NOT an option?
a. Add montelukast
b. Add oral prednisone
c. Add tiotropium
d. Increase dose of the budesonide
• Addition of low dose oral corticosteroids may be an option for adults with severe asthma (STEP 5). This should only be considered if with poor symptom control and/or frequent exacerbations with STEP 4 treatment.
The correct answer is: Add oral prednisone
189
A 34-year-old female, diagnosed with bronchial asthma and maintained on daily low dose budesonide, had no symptoms nor need for albuterol as reliever for the past 6 months. Latest FEV1 is 80%. She is asking about the possibility of not having maintenance inhalational drug out of convenience, financial considerations and worry about long-term side effects. What will you advise her?
a. Continue the current regimen and reassure her that it is free of any side effects
b. Discontinue daily budesonide and continue reliever therapy as needed
c. Shift to a long acting beta agonist as reliever therapy
d. Switch to low dose budesonide/formoterol as needed
• Stepping down treatment may be done when asthma is well controlled for at least 3 months and with good lung function.
The correct answer is: Switch to low dose budesonide/formoterol as needed
190
A 20-year-old female, diagnosed asthmatic on low dose budesonide/formoterol twice a day and as needed salbutamol inhalation, came to the ambulatory unit of the hospital because of persistent dyspnea not relieved by an increase in dose of her controller and reliever drugs. After 1 hour of every 20 minutes salbutamol and one dose of oral prednisone 50mg, her symptoms resolved and PEF improved. Which is the appropriate advice on her inhaled drugs upon discharge until follow up?
a. Continue with previous dose of budesonide/formoterol and increase salbutamol to three times a day
b. Continue with previous dose of budesonide/formoterol and resume as-needed salbutamol
c. Increase dose of budesonide/formoterol and increase salbutamol to three times a day
d. Increase dose of budesonide/formoterol and resume as-needed salbutamol
• Step up controller therapy for 1-2 weeks and reduce reliever to as-needed.
The correct answer is: Increase dose of budesonide/formoterol and resume as-needed salbutamol
191
A 32-year-old female, diagnosed asthmatic on as needed salbutamol inhalation, consulted your clinic for advice after she was rushed that same morning to the local health center for shortness of breath not relieved by an increase in frequency of her inhaler. She improved after several doses of salbutamol nebulization and single dose of oral prednisone. She was sent home with oral prednisone and was advised to immediately consult an internist or pulmonologist. How will you manage her corticosteroid and inhaled medication?
a. Continue prednisone for 5 days and increase salbutamol to three times a day.
b. Continue prednisone for 5 days, as-needed salbutamol and start low dose inhaled corticosteroid.
c. Discontinue prednisone, continue as-needed salbutamol and start low dose inhaled corticosteroid.
d. Discontinue prednisone, increase salbutamol to three times a day.
• Initiate regular ICS-containing controller therapy, reduce reliever to as-needed and continue oral steroid for 5-7 days.
The correct answer is: Continue prednisone for 5 days, as-needed salbutamol and start low dose inhaled corticosteroid.
192
A 38-year-old female, diagnosed asthmatic compliant with her low dose fluticasone/ salmeterol, was rushed to the emergency room because of worsening dyspnea despite an increase in dose of her as-needed salbutamol and oral prednisone for the past three days. She is agitated, talks in words, RR 34, HR 122, O2 saturation 88% and PEF 45%. Which of the following is an appropriate intervention in the ER?
a. Consider giving intravenous magnesium if with deterioration despite adequate initial treatment.
b. Defer giving of systemic corticosteroids since patient was already on oral prednisone and did not confer any benefit.
c. Give diazepam 5mg IV for the agitation to help in asthma control.
d. Start bilevel positive airway pressure if oxygen desaturation persists after initial intervention.
• Intravenous magnesium sulfate may be considered for those who fails to respond to initial treatment and have persistent hypoxemia.
The correct answer is: Consider giving intravenous magnesium if with deterioration despite adequate initial treatment.
193
A 28-year-old female, diagnosed asthmatic on medium dose fluticasone/salmeterol and as-needed salbutamol inhalation, is being prepared for discharge after being intubated and staying in the ICU for severe asthma exacerbation. She is currently asymptomatic with normal lung function. Which of the following is an appropriate plan for her until her follow up within a week?
a. Continue oral steroids, increase dose of fluticasone/ salmeterol, continue as-needed salbutamol
b. Continue oral steroids, maintain previous dose of fluticasone/ salmeterol, increase salbutamol to every 6 hours and add ipratropium inhaler to the regimen
c. Discontinue oral steroids, increase dose of fluticasone/ salmeterol, continue as-needed salbutamol
d. Discontinue oral steroids, maintain previous dose of fluticasone/ salmeterol, increase salbutamol to every 6 hours and add ipratropium inhaler to the regimen
• Discharge management planning until next follow-up within a week: continue OCS, increase dose of ICS, continue reliever therapy as-needed.
The correct answer is: Continue oral steroids, increase dose of fluticasone/ salmeterol, continue as-needed salbutamol
194
A 32-year-old female, diagnosed asthmatic on maintenance fluticasone/ salmeterol and as-needed salbutamol, observed increasing need for her reliever therapy. Which of the following is NOT an acceptable short-term self-management treatment modification?
a. Add oral prednisone if severe or not responding
b. Add montelukast or tiotropium
c. Increase frequency of salbutamol
d. Increase dose of inhaled fluticasone/salmeterol
• The written action plan helps patients to recognize and respond appropriately to worsening asthma. It should include specific instructions for the patient about changes to reliever and controller medications, how to use oral corticosteroids if needed and when and how to access medical care.
The correct answer is: Add montelukast or tiotropium
195
A 19-year-old female, non-smoker, consulted the OPD for chest tightness and dyspnea 2-3x/week usually during exercise or long walks for the past two months. She has not experienced night time symptoms. On PE, her breath sounds were clear. Chest x-ray was normal and pulmonary function test showed 18% improvement post-bronchodilator in FEV1 and FEV1%. What is an appropriate treatment option for her?
a. Low dose budesonide daily + salbutamol PRN
b. Low dose budesonide/formoterol daily + salbutamol PRN
c. Formoterol/glycopyrronium daily + salbutamol PRN
d. Tiotropium daily + salbutamol PRN
• The preferred STEP 2 controller for adults is low dose ICS controller and plus as-needed SABA or as-needed low dose ICS-formoterol. This is for patients with symptoms more than twice a month but less than daily.
The correct answer is: Low dose budesonide daily + salbutamol PRN
196
A 25-year-old female, a famous singer, recently diagnosed to have bronchial asthma through spirometry, refuses to comply with prescribed daily inhaler because of fear of the possible side effects on the quality of her voice. She had allergic rhinitis for the past 5 years. She only has occasional twice a month symptoms of shortness of breath relieved by salbutamol tablets. What can you recommend her?
a. Inhaled salbutamol PRN
b. Inhaled tiotropium daily
c. Oral montelukast daily
d. Oral salbutamol PRN
• Leukotriene receptor antagonists (LTRA) may be used as initial controller treatment for some patients who are unable or unwilling to use ICS, for patients who experience intolerable side-effects from ICS or for patients with concomitant allergic rhinitis.
The correct answer is: Oral montelukast daily
197
Which is TRUE of bronchodilators in the treatment of asthma?
a. Concomitant administration of inhaled corticosteroids prevents tolerance of mast cells of β2 agonists.
b. In acute severe asthma, anticholinergics should be given before β2-agonists, as they have faster onset and are more effective in bronchodilation.
c. Inflammatory cells also express β2 receptors, β2-agonist use will also decrease the number of these cells in the airway causing a reduction in airway hyperresponsiveness.
d. The mechanism of action of theophylline is the prevention of cholinergic nerve-induced bronchoconstriction and mucus secretion.
• Tolerance is a potential problem with any agonist given chronically. Mast cells become rapidly tolerant, but their tolerance may be prevented by concomitant administration of ICS. Corticosteroids also activate anti-inflammatory genes such as mitogen-activated protein (MAP) kinase phosphatase-1 and increase the expression of β2-receptors.
The correct answer is: Concomitant administration of inhaled corticosteroids prevents tolerance of mast cells of β2 agonists.
198
What is the primary action of β2 agonists?
a. Inhibition of mast cell mediator release
b. Inhibition of sensory nerve activation
c. Reduction in plasma exudation
d. Relaxation of airway smooth muscle cells
• Primary action of β2-agonists: relax airway smooth-muscle cells of all airways, where they act as functional antagonists, reversing and preventing contraction of airway smooth-muscle cells by all known bronchoconstrictors
The correct answer is: Relaxation of airway smooth muscle cells
199
A 63/F with heart failure and diabetic kidney disease on chronic hemodialysis was admitted for progressive dyspnea and desaturation. CBC showed mild anemia and leukocytosis. Chest Xray showed left lower lobe consolidation. The Gram stain of the sputum sample shown should prompt the addition of which antibiotic to the empiric regimen?
a. Azithromycin
b. Gentamicin
c. Levofloxacin
d. Vancomycin
The correct answer is: Vancomycin
200
What is considered as adequate sputum sample?
a. PMN >25 and squamous epithelial cells <10 per HPF
b. PMN <25 and squamous epithelial cells >10 per HPF
c. PMN >25 and squamous epithelial cells <10 per LPF
d. PMN <25 and squamous epithelial cells >10 per LPF
The correct answer is: PMN >25 and squamous epithelial cells <10 per LPF
201
Which of the following is TRUE regarding the pathophysiology of pneumonia?
a. Interleukin 1 and tumor necrosis factor stimulate the release of neutrophils and their attraction to the lung.
b. It is the proliferation of microorganisms that triggers the clinical syndrome of pneumonia.
c. Rales on auscultation and the radiographic infiltrate are a consequence of alveolar capillary leak, similar to ARDS.
d. The most likely cause of an altered alveolar microbiota in CAP is previous antibiotic therapy.
The correct answer is: Rales on auscultation and the radiographic infiltrate are a consequence of alveolar capillary leak, similar to ARDS.
202
Which phase of classic lobar pneumonia is characterized by predominance of neutrophils and the disappearance of bacteria from the alveolar space?
a. Edema
b. Red hepatization
c. Gray hepatization
d. Resolution
The correct answer is: Gray hepatization
203
Which of the following is TRUE regarding the clinical presentation of pneumonia?
a. A flat percussion note in an area of decreased breath sounds is reflective of underlying consolidated lung.
b. Correcting dehydration can lead to easier sputum expectoration and a more apparent infiltrate on CXR.
c. Due to enhanced inflammation and increased procoagulant activity, most acute coronary syndrome episodes occur beyond one week from the onset of CAP.
d. Gross hemoptysis is suggestive of pneumococcal pneumonia.
The correct answer is: Correcting dehydration can lead to easier sputum expectoration and a more apparent infiltrate on CXR.
204
Which of the following epidemiologic factors is suggestive of Burkholderia cepacia as a possible etiologic microorganism of CAP?
a. Alcoholism
b. Bronchiectasis
c. Dementia
d. Lung abscess
The correct answer is: Bronchiectasis
205
Which of the following is considered a risk factor for early deterioration in community acquired pneumonia?
a. Anemia
b. Hyponatremia
c. Severe respiratory alkalosis
d. Tachycardia > 120 beats/min
The correct answer is: Hyponatremia
206
The most important risk factor for antibiotic-resistant pneumococcal infection is:
a. Antibiotic use within the previous 3 months
b. Hospitalization within the previous 3 months
c. Immunocompromised state/condition
d. Prolonged, close contact with patient with known multi-drug resistant infection
The correct answer is: Antibiotic use within the previous 3 months
207
A 65 year-old patient is seen at the ER for fever and cough. A diagnosis of community-acquired pneumonia is made. On physical examination, he had a blood pressure of 90/60 mm Hg and respiratory rate of 30 cycles/minute. Which among the following antibiotic regimens is most appropriate?
a. Azithromycin 500 mg PO once, then 250 mg OD
b. Co-Amoxiclav 2 g PO BID
c. Doxycycline 100 mg PO BID
d. Levofloxacin 750 mg PO OD
The correct answer is: Levofloxacin 750 mg PO OD
208
The drugs of choice for community-acquired pneumonia caused by Enterobacter species are:
a. Fluoroquinolones or carbapenems
b. Linezolid or vancomycin
c. Macrolides or doxycycline
d. Penicillins or cephalosporins
The correct answer is: Fluoroquinolones or carbapenems
209
For CAP with bacteremia involving likely MDR pathogens such as P. aeruginosa and MRSA, the recommended antibiotic treatment duration is:
a. 7-14 days
b. 7-21 days
c. 14-21 days
d. ≥ 28 days
The correct answer is: ≥ 28 days
210
For non-ventilated patients with hospital-acquired pneumonia, the only pathogen that may be more common in this population (compared to ventilator-associated pneunmonia) is:
a. Acinetobacter baumannii
b. Anaerobes
c. MRSA
d. Pseudomonas aeruginosa
The correct answer is: Anaerobes
211
Which of the following is the MOST likely pathogen in a primary lung abscess?
a. Legionella pneumophila
b. Nocardia spp.
c. Prevotella spp.
d. Staphylococcus aureus
The correct answer is: Prevotella spp.
212
Which of the following is the most common genetic cause of prothrombotic states?
a. Antithrombin deficiency
b. Factor V Leiden mutation
c. Protein C deficiencies
d. Hyperhomocysteinemia
The correct answer is: Factor V Leiden mutation
213
Which of the following is the most common acquired cause of thrombophilia?
a. Antiphospholipid antibody syndrome
b. Estrogen-containing contraceptives
c. Long-haul air travel
d. Malignancy
The correct answer is: Antiphospholipid antibody syndrome
214
Which of the following is the hallmark sign of massive pulmonary embolism?
a. Chest pain
b. Cyanosis
c. Tachycardia
d. Tachypnea
The correct answer is: Cyanosis
215
Which of the following is the primary diagnostic criterion for DVT on ultrasonography?
a. Absence of flow augmentation with distal compression
b. Increased intraluminal echogenicity
c. Loss of color flow on Doppler indicating absent blood flow
d. Loss of vein compressibility under moderate external pressure
The correct answer is: Loss of vein compressibility under moderate external pressure
216
Which of the following refers to the peripheral wedge-shaped density seen in pulmonary embolism?
a. Hampton’s hump
b. McConnell’s sign
c. Palla’s sign
d. Westermark’s sign
The correct answer is: Hampton’s hump
217
A 35/F came to your clinic with a swollen left leg. She just came home from the US two days ago. She has no maintenance meds, but takes oral contraceptives. On physical exam, there is calf tenderness and pitting edema in the affected leg. The right leg appears normal. Which diagnostic test is MOST appropriate for this patient?
a. D-dimer
b. Invasive contrast phlebography
c. MR venography with gadolinium contrast
d. Venous duplex ultrasound
The correct answer is: Venous duplex ultrasound
218
For patients with provoked, isolated calf DVT, what is the recommended minimum duration of anticoagulation?
a. 1 month
b. 3 months
c. 6 months
d. 12 months
The correct answer is: 3 months
219
Which of the following is the preferred VTE prophylaxis strategy for patients undergoing cancer surgery?
a. Apixaban 2.5 mg PO BID
b. Enoxaparin 40 mg SC OD
c. Fondaparinux 2.5 mg SC OD
d. Unfractionated heparin 5000 units SC TID
The correct answer is: Enoxaparin 40 mg SC OD
220
Which of the following is TRUE regarding the Berlin diagnostic criteria for ARDS?
a. Acute onset within 1 month of a clinical insult or new or worsening respiratory symptoms
b. Bilateral opacities on chest radiograph consistent with pulmonary edema
c. Left atrial hypertension must be present
d. Severity classification must be based on a PF ratio obtained while on at least 10 cm H2O of CPAP or PEEP
The correct answer is: Bilateral opacities on chest radiograph consistent with pulmonary edema
221
In terms of clinical correlation, most patients are liberated from mechanical ventilation during which phase of ARDS?
a. Exudative
b. Fibrotic
c. Proliferative
d. Recovery
The correct answer is: Proliferative
222
What is the only ARDS therapy with a grade A level of recommendation?
a. High-frequency ventilation
b. Low tidal volumes ≤ 6 mL/kg predicted body weight
c. PEEP ≥ 8 cm H2O
d. Plateau pressure ≤ 30 cm H2O
The correct answer is: Low tidal volumes ≤ 6 mL/kg predicted body weight
223
The most common daytime symptom of OSAHS is:
a. Dry mouth
b. Excessive sleepiness
c. Fatigue
d. Irritability
The correct answer is: Excessive sleepiness
224
Which of the following is TRUE regarding the diagnosis of OSAHS?
a. The absence of a complaint of dyspnea is consistent with the diagnosis.
b. The absence of obesity excludes the diagnosis.
c. The absence of snoring (as reported by a bed partner or household member) excludes the diagnosis.
d. The gold standard for diagnosis is 24-hour BP monitoring.
The correct answer is: The absence of a complaint of dyspnea is consistent with the diagnosis.
225
How does hepatic hydrothorax develop?
a. Cirrhosis of the liver causes a direct inflammatory reaction of the parietal pleura
b. Direct movement of peritoneal fluid through the small openings of the diaphragm
c. Increased amount of fluid in the liver interstitial spaces exits across the visceral pleura
d. Obstruction of the thoracic duct by the enlarged liver leading to decreased lymph absorption
The correct answer is: Direct movement of peritoneal fluid through the small openings of the diaphragm
226
What is the underlying pathology in a primary spontaneous pneumothorax?
a. Chronic obstructive pulmonary disease
b. Emphysema
c. Pleural blebs
d. Positive pleural pressure
The correct answer is: Pleural blebs
227
Which of the following causes exudative effusion?
a. Myxedema
b. Pulmonary embolism
c. Nephrotic syndromea
d. Superior vena cava obstruction
The correct answer is: Pulmonary embolism
228
What pleural fluid study is virtually diagnostic of an effusion secondary to congestive heart failure?
a. Adenosine deaminase
b. Interferon γ
c. N-terminal pro-brain natriuretic peptide
d. Triglyceride level
The correct answer is: N-terminal pro-brain natriuretic peptide
229
A 28-year-old female with bronchial asthma went to the emergency room for substernal chest pain radiating to the neck. She had slightly bulging suprasternal notch, with crepitus on palpation, clear breath sounds on all lung fields. Chest x-ray was noted to have curvilinear lucencies of the mediastinum. What is the most appropriate management plan?
a. analgesic and oxygen
b. anticoagulation and inhaled steroid
c. chest tube insertion
d. needle aspiration
The correct answer is: analgesic and oxygen
230
Which of the following is TRUE of the management of bronchiectasis?
a. Administration of systemic glucocorticoids has no role in the treatment of bronchiectasis of whatever etiology.
b. Inhaled steroids improve lung function, reduce sputum production and decrease frequency of exacerbations.
c. Pulmonary rehabilitation and regular exercise programs did not show any benefit in improving secretion clearance and quality of life.
d. Resection of a focal area of suppuration may be an option for refractory cases.
The correct answer is: Resection of a focal area of suppuration may be an option for refractory cases.
231
A 62-year-old male, chronic smoker, was diagnosed with bronchiectasis localized on the right middle lobe on chest CT scan. What test or procedure should be recommended?
a. α1 antitrypsin levels
b. bronchoscopy
c. CT-guided percutaneous biopsy
d. HIV screening
The correct is: bronchoscopy
232
Which occupational dust is responsible for chest tightness and significant drop in FEV1 toward the end of the first day of the workweek or the “Monday chest tightness”?
a. Coal
b. Cotton
c. Fungal spores
d. Grain
The correct answer is: Cotton
233
Which of the following is TRUE of occupational lung diseases?
a. Asbestos-related diseases are limited to exposure by directly handling the material.
b. Coal dust causes chronic bronchitis and chronic obstructive pulmonary disease.
c. Grain dust exposure presentation is restrictive lung disease similar to smokers.
d. Silicosis causes alveolar macrophage dysfunction which increases the risk of asthma.
The correct answer is: Coal dust causes chronic bronchitis and chronic obstructive pulmonary disease.
234
Which of the following is TRUE of environmental exposures and lung diseases?
a. Household air pollution from cooking with solid fuels is associated with chronic bronchitis and COPD.
b. Inhaled fine particles from combustion sources tend to remain in the airstream and are exhaled without causing lung injury.
c. Secondhand smoke has been shown to have little effect in the prevalence of respiratory illnesses except cancer.
d. Studies of cities with different levels of air particulate pollution showed similar cardio-pulmonary mortality rates.
The correct answer is: Household air pollution from cooking with solid fuels is associated with chronic bronchitis and COPD.
235
What intervention is proven to slow down the lung function and improve survival of patients with idiopathic pulmonary fibrosis?
a. Anti-fibrotic therapy
b. Immunosuppression
c. Oxygen supplementation
d. Physical therapy
The correct answer is: Anti-fibrotic therapy
236
What is the most typical physiologic abnormality in COPD ?
a. Chronic hypoxemia
b. Decrease in the diffusing capacity of the lung for carbon monoxide
c. Persistent reduction in forced expiratory flow rate
d. Shunting
The correct answer is: Persistent reduction in forced expiratory flow rate
237
Which is TRUE of the pharmacologic management of stable phase COPD?
a. Chronic use oral glucocorticoids is recommended for very severe COPD or category D patients
b. Long-acting muscarinic agonists (LAMA) reduce exacerbations and mortality rate
c. Long-acting beta agonists (LABA) provide symptomatic relief with no effect on frequency of exacerbations
d. Theophylline can improve airflow and vital capacity but is not considered as first-line therapy option
The correct answer is: Theophylline can improve airflow and vital capacity but is not considered as first-line therapy option
238
Which factor is against initiating inhaled corticosteroid in combination with long acting bronchodilators in patients with COPD?
a. Concomitant asthma
b. Repeated pneumonia
c. Signs of heart failure
d. Uncontrolled diabetes
The correct answer is: Repeated pneumonia
239
A 65-year-old male, newly diagnosed with COPD (FEV1 80% predicted) was prescribed with formoterol/budesonide metered dose inhaler for mild symptoms of breathlessness with strenuous activity. He complains of exercise limitations despite compliance to medications. What will you recommend?
a. Add roflumilast
b. Add theophylline
c. Shift to LABA/LAMA
d. Start oral corticosteroids
The correct answer is: Shift to LABA/LAMA
240
A 58-year-old male, recently diagnosed with COPD had one hospital admission for an exacerbation and complains of breathlessness when walking uphill or climbing stairs. What is his COPD severity group?
a. High symptoms, high risk
b. High symptoms, low risk
c. Low symptoms, high risk
d. Low symptoms, low risk
The correct answer is: Low symptoms, high risk
241
Which of the following is TRUE of smoking cessation strategies?
a. E-cigarette as a smoking cessation aid is effective and safe alternative to nicotine replacement products.
b. Self-initiated strategies are better that physician counseling.
c. Intensifying counseling intensity by increasing duration and number of sessions improves cessation success rates.
d. Pharmacologic interventions such as buproprion can be used as sole intervention for smoking cessation.
The correct answer is: Pharmacologic interventions such as buproprion can be used as sole intervention for smoking cessation.
242
Which of the following is the major risk factor for asthma?
a. Airway hyperresponsiveness
b. Atopy
c. Early viral infections
d. Indoor allergens
The correct answer is: Atopy
243
What is the mechanism by which exercise triggers asthma?
a. Hyperventilation increases cholinergic bronchoconstriction
b. Hyperventilation triggers mast cell mediator release
c. Increase in airway inflammation with increased numbers of eosinophils during exercise
d. Inhibition of breakdown of kinins during exercise leads to bronchoconstriction
The correct answer is: Hyperventilation triggers mast cell mediator release
244
What is the most common reason for poor control of asthma?
a. Concurrent allergic rhinosinusitis
b. Continuous exposure to ambient levels of allergens
c. Poor compliance to inhaled corticosteroid
d. Wrong inhaler technique
The correct answer is: Poor compliance to inhaled corticosteroid
245
Which is TRUE of asthma in pregnancy?
a. Most patients will have worsening of asthma control during pregnancy.
b. Inhaled corticosteroid is under FDA Category D – with evidence of human risk, but potential benefits of use outweigh the risk.
c. If oral steroid is needed, prednisone is preferred to protect the fetus from its systemic effects.
d. Corticosteroids and short-acting beta-agonists are contraindicated during breastfeeding.
The correct answer is: If oral steroid is needed, prednisone is preferred to protect the fetus from its systemic effects.
246
Which is TRUE of bronchodilators in the treatment of asthma?
a. Concomitant administration of inhaled corticosteroids prevents tolerance of mast cells of β2 agonists.
b. In acute severe asthma, anticholinergics should be given before β2-agonists, as they have faster onset and are more effective in bronchodilation.
c. Inflammatory cells also express β2 receptors, β2-agonist use will also decrease the number of these cells in the airway causing a reduction in airway hyperresponsiveness.
d. The mechanism of action of theophylline is the prevention of cholinergic nerve-induced bronchoconstriction and mucus secretion.
The correct answer is: Concomitant administration of inhaled corticosteroids prevents tolerance of mast cells of β2 agonists.
