Respiratory

Question 1

What is the mechanism of action of Riocoguat?
What types of pulmonary hypertension is it used for?
What trial confirmed the two uses?

Answer 1

Agonist of guanylate cyclase leading to vessel relaxation
Type 1 and type 4 (CTEPH)
REPLACE trial

Question 2

What is Kartagener syndrome?
What is its inheritance?
Classic features?

Answer 2

Primary ciliary dyskinesia
Autosomal recessive
Situs invertus, chronic sinusitis, bronchiectasis, infertility

Question 3

What type of emphysema is endobronchial valve treatment recommended?
What trial proved this?

Answer 3

Heterogenous emphysema without collateral ventilation
TRANSFORM trial

Question 4

What are the advantages of systemic thrombolysis versus catheter-directed thrombolysis for large pulmonary embolism?
What is the major disadvantage?
What two studies support catheter over systemic thrombolysis?

Answer 4

Advantages: decreased death, improved quality of life, reduced right heart strain, less long term pulmonary hypertension
Disadvantage: major haemorrhage
Studies: PERFECT and SEATTLE II

Question 5

What type of lung cancer has the best prognosis?
What is its 5 year survival average?

Answer 5

Carcinoid
Typical = 85-90%
Atypical = 50-70%

Question 6

What is the 5 year survival of stage 1 small cell lung cancer?
What about stage 1 non-small cell lung cancer?

Answer 6

Small cell = 45-50%
Non-small cell = 30%

Question 7

When is PET scanning most useful in assessing lung cancer (3 situations)?
What size lesion is PET not useful for?

Answer 7

1) Solitary pulmonary nodules – distinguishes benign vs malignant. – sens 96%, spec 78%.
2) Carcinoma staging
3) Surveillance

Not useful when lesion is <1cm.

Question 8

What did the MIST2 study prove in regards to pleural drainage?

Answer 8

Alteplase and Dornase are effective in preventing surgical intervention in chest drains for parapneumonic effusions

Question 9

What is the action of Alteplase?
What is the action of Dornase?

Answer 9

Alteplase converts plasminogen to the proteolytic enzyme plasmin, which lyses fibrin as well as fibrinogen.
Dornase alfa is a recombinant human deoxyribonuclease I (rhDNase) that cleaves down extracellular long-chain DNA in the sputum

Question 10

What is the Bohr effect?

Answer 10

Describes when acidosis shifts the oxyhemoglobin dissociation curve to the RIGHT. A decrease in pH reduces hemoglobin’s affinity for oxygen, enhancing oxygen release to the tissues.

Question 11

What causes flow-volume curves to show normal expiration but the flow limitation during inspiration produces an “inspiratory plateau”?
Why?

Answer 11

Vocal cord paralysis.
during expiratory the cords are blown open but during inspiration the weak cord is drawn inward, causing flow restriction

Question 12

In stage II and III NSCLC, after surgery what chemo if offered?

Answer 12

Cisplatin and Vinorelbine

Question 13

What is the mechanism of action of Erlotinib?

Answer 13

Erlotinib is a tyrosine kinase inhibitor that targets the epidermal growth factor receptor (EGFR). It has been shown to improve survival in certain types of cancer, particularly non-small cell lung cancer (NSCLC)

Question 14

What does it mean if FeNO increases >10ppm or >60% over baseline?

Answer 14

An increase of more than 10 ppb or more than 60% over baseline threshold means that there is ongoing eosinophilic inflammation and therefore would suggest the need for steroids.

Question 15

What is the mechanism of action of Nintendanib?
What are the three growth factor cells it acts upon?
What part of PFTs does it slow the decline?

Answer 15

Intracellular tyrosine kinase inhibitor
Acts on Fibrogenic, Platelet and Vascular endothelial cells
Slows the decline in FVC

Question 16

What does DLCO measure?
What does a reduced DLCO indicate?
What diseases common have low DLCO?

Answer 16

Measures the efficiency of gas transfer from the alveoli into the blood.
Reduced DLCO can indicate issues in alveolar surface area, membrane thickness or capillary blood volume.
Diseases = pulmonary fibrosis, emphysema, pulmonary vascular disorders

Question 17

What type of lung cancer is Lambert-Eaton myasthenia syndrome associated with?
Where does is act on the neuromuscular junction?

Answer 17

Small cell lung cancer
Autoimmune antibodies acting on pre-synaptic calcium channels

Question 18

What type of electrolyte abnormality occurs in squamous cell lung cancer?
How does it occur?

Answer 18

Hypercalcaemia
Caused by ectopic production of parathyroid hormone-related peptide (PTHrP)

Question 19

What is first line treatment for PJP?
Back up options?

Answer 19

Trimethoprim-sulfamethoxazole
Clindamycin or Pentamidine

Question 20

What is the pathophysiology of emphysema?
What phase of the respiratory cycle does it lead to air flow obstruction?

Answer 20

Chronic lung disease that is characterised by destruction of alveoli and loss of lung elasticity
Flow obstruction in expiration

Question 21

What are the 5 causes of hypoxemia ?

Answer 21

Hypoventilation
V/Q mismatch
Right to left shunt
Diffusion limitation
Reduced inspired oxygen tension

Question 22

What are some pharmacological treatments for restless legs syndrome?
What is a simple oral supplement that can be used?

Answer 22

Levodopa, Pramipexole
Iron supplement

Question 23

What are the hallmark symptoms of narcolepsy?

Answer 23

Excessive daytime sleepiness
Cataplexy
Sleep paralysis
Hypnagogic hallucinations

Question 24

What 3 letter acronym (an enzyme) is elevated in small cell lung cancer?

Answer 24

NSE = neuron-specific enolase

Question 25

What stage of lung cancer is Durvalumab used? What is its mechanism of action? What trial supported its use pre and post surgery?

Answer 25

Resectable stage II to IIIb It’s action is a PD-L1 inhibitor AEGEAN

Question 26

How is bronchiolitis obliterans syndrome defined in post-transplant patients ?

Answer 26

Decline in FEV1, FEV1/FVC <70%, no restrictive deficits and no fibrotic-like opacities

Question 27

Criteria for lung transplant in ILD patients:

Answer 27

Pulmonary fibrosis with FVC <80% predicted or DLCO <40% predicted Decline in FVC or DLCO >10% within 6 months Supplemental oxygen requirement at rest or exertion Pulmonary hypertension Inflammatory ILD - progressive decline in function & radiographically despite treatment

Question 28

What is Samter’s triad? What is it also known as?

Answer 28

Asthma + nasal polyps + aspirin/NSAID hypersensitivity Also known as Aspirin-exacerbated respiratory disease (AERD)

Question 29

What type of pathogen is a galactomannan assay used for?

Answer 29

Invasive aspergillosis

Question 30

What is the most, second most and third most common bacteria causing infection in COPD patients?

Answer 30

Haemophilus influenzae Streptococcus pneumoniae Moxaxella pneumoniae

Question 31

What trials supported the use of long term oxygen therapy ? How many hours a day minimum is required for benefit?

Answer 31

Trials = NOTT (nocturnal oxygen therapy trial) and MRC (medical research council) Minimum 15hrs per day

Question 32

What trials supported the use of long term oxygen therapy ? How many hours a day minimum is required for benefit?

Answer 32

Trials = NOTT (nocturnal oxygen therapy trial) and MRC (medical research council) Minimum 15hrs per day

Question 33

What is the equation to calculate the alveolar partial pressure?

Answer 33

PA02 = (Fi02 x (Patm - PH20) is (PaC02 / Resp Quotient)

Question 34

How do you diagnose eosinophilic bronchitis ? Treatment? Is atopy more, less or the same as general population?

Answer 34

Diagnosis = >2.5% eosinophils in sputum, absence of airway hyperresponsiveness Treatment = steroids Atopy = same/slightly higher

Question 35

What type of inhaler is tiotropium? What receptor does tiotropium act upon?

Answer 35

It is a long-acting, anti-muscarinic bronchodilator (LAMA) Acts of M3 receptor

Question 36

What is the mechanism of action of Omalizumab? How do asthmatic patients qualify?

Answer 36

Monoclonal antibody against IgE Binds to free IgE and IgE bound to receptors, reducing the amount available to trigger allergic cascade Qualify = mod-severe asthma, positive skin test to perennial aeroallergen (pollen) and symptoms inadequately controlled with inhaled corticosteroids

Question 37

What is the strongest predictive sign of malignancy for solitary pulmonary nodules on CT? What size is considered higher risk?

Answer 37

Spiculated, irregular border Size >5mm

Question 38

What level of chloride is required on sweat testing for CF? On how many occasions ? What is tested on a newborn screening for CF?

Answer 38

>60mmol/L on two separate occasions Newborn screen = elevated immune reaction to trypsinogen (IRT)

Question 39

What type of diuretic is contraindicated in sarcoidosis? Why?

Answer 39

Thiazide Risk of worsening hypercalcaemia

Question 40

what cell is elevated in COPD with type 2 inflammation? What monoclonal antibody is used to treat this?

Answer 40

Eosinophils Dupilumab

Question 41

What are the 3 types of lung aspergillosis infections? Describe each

Answer 41

Allergic Bronchopulmonary Aspergillosis (ABPA): An allergic reaction in the lungs, usually affecting people with asthma or cystic fibrosis. Aspergilloma (Fungal Ball): A mass of fungal hyphae, mucus, and debris forming in pre-existing lung cavities. Chronic Pulmonary Aspergillosis: A long-term condition where Aspergillus causes lung damage over months or years.

Question 42

What are the two most common anti-TB drugs that TB becomes resistant to? What are their mechanism of action?

Answer 42

Rifampicin and Isoniazid Rifampin: bactericidal, inhibiting DNA-dependent RNA polymerase (RNAP). Isoniazid: inhibit bacterial cell wall synthesis by activation of enzyme KatG

Question 43

What is better for MRSA; Linezolid or Meropenam?

Answer 43

Linezolid

Question 44

Age of onset for COP? Males vs females? Symptoms for 2 weeks, 2 months or 6 months? Imaging findings? Treatment?

Answer 44

Disease onset is typically in the fifth or sixth decades of life Males and females affected equally Symptomatic for less than two months clinical presentation = mimics pneumonia Imaging features = multiple ground-glass or consolidative opacities that tend to be at the lung periphery Treatment = steroids

Question 45

What does high ACE levels indicate?

Answer 45

Sarcoid

Question 46

What gene is implicated in Alpha-1-antitrypsin disease? What is the best genotype? What is the worst?

Answer 46

SERPINA1 Best = MM Worst = ZZ

Question 47

All of the following drugs could be used in the treatment of multi-drug resistant tuberculosis (MDR-TB) except? What chronic lung condition can it be used for? And which one of the other options does it increase risk of toxicity? Clarithromycin Moxifloxacin Amikacin Capreomycin Linezolid

Answer 47

Clarithromycin Chronic condition = Mycobacterium avium complex Toxicity = Linezolid