Pulmonology Practice Questions

Q: Type 1 respiratory failure is characterized by which of the following?

Low PaO2 and normal PCO2. Respiratory failure is clinically defined as the inability of the respiratory system to maintain adequate gas exchange [1]. It is categorized into two primary types based on arterial blood gas (ABG) patterns: **1. Why Option A is Correct:** **Type 1 Respiratory Failure (Hypoxemic)** is characterized by **Hypoxemia (PaO2 < 60 mmHg)** with a **normal or low PaCO2 (normocapnia or hypocapnia)** [1]. The primary pathophysiology involves a failure of oxygenation, usually due to **V/Q mismatch** (the most common cause) or **intrapulmonary shunting** [2]. Because CO2 is 20 times more diffusible than oxygen, the patient can initially compensate for hypoxia by increasing minute ventilation (hyperventilation), which keeps the PCO2 normal or even low [2]. Common causes include pneumonia, pulmonary edema, ARDS, and pulmonary embolism. **2. Why the Other Options are Incorrect:** * **Option B (Low PaO2 and high PCO2):** This describes **Type 2 Respiratory Failure (Hypercapnic/Ventilatory failure)**. This occurs when alveolar ventilation is inadequate to excrete the CO2 produced by the body [1]. Common causes include COPD, neuromuscular disorders (e.g., Guillain-Barré), and CNS depression. * **Option C & D:** These do not fit the clinical definition of respiratory failure. Respiratory failure, by definition, requires the presence of hypoxemia (PaO2 < 60 mmHg) while breathing room air [1]. **High-Yield Clinical Pearls for NEET-PG:** * **Type 3 Respiratory Failure:** Perioperative respiratory failure (due to atelectasis). * **Type 4 Respiratory Failure:** Associated with shock (hypoperfusion of respiratory muscles). * **The A-a Gradient:** In Type 1 failure due to intrinsic lung disease, the Alveolar-arterial (A-a) gradient is **increased**. In Type 2 failure due to extrapulmonary causes (like opioid overdose), the A-a gradient remains **normal**.

Q: A 75-year-old lady with severe chronic obstructive pulmonary disease (COPD) presents with acute breathlessness. The chest X-ray shows no focal consolidation. She is afebrile, but D-dimers are markedly elevated. Which of the following is the best investigation to diagnose this condition?

CT pulmonary angiography. **Explanation:** The clinical presentation of acute breathlessness, a clear chest X-ray (no consolidation), and markedly elevated D-dimers in an elderly patient strongly suggests **Acute Pulmonary Embolism (PE)**. **1. Why CT Pulmonary Angiography (CTPA) is the Correct Answer:** CTPA is currently the **gold standard and investigation of choice** for diagnosing pulmonary embolism. It allows direct visualization of emboli as filling defects within the pulmonary arteries. In this patient, the absence of focal consolidation on X-ray helps rule out pneumonia, making a vascular event more likely. CTPA is preferred due to its high sensitivity, specificity, and ability to provide alternative diagnoses if PE is absent. **2. Why Other Options are Incorrect:** * **MRI (A):** While it can detect PE, it is not the first-line investigation due to long acquisition times, lower resolution for peripheral vessels, and difficulty in monitoring unstable patients. * **Ventilation-Perfusion (V/Q) Scan (B):** Although used when CTPA is contraindicated (e.g., renal failure), it is **unreliable in COPD patients**. Underlying lung disease causes pre-existing ventilation defects, leading to "indeterminate" or "non-diagnostic" results. * **High-Resolution CT (HRCT) Thorax (C):** HRCT is used to evaluate interstitial lung disease and parenchyma (e.g., bronchiectasis, fibrosis). It is not designed to evaluate the pulmonary vasculature for clots. **Clinical Pearls for NEET-PG:** * **Gold Standard for PE:** CT Pulmonary Angiography. * **Best Initial Test for PE:** Chest X-ray (usually normal; done to rule out other causes). * **Westermark Sign:** Focal oligemia (hyperlucency) distal to an embolus on CXR. * **Hampton’s Hump:** Wedge-shaped opacity representing pulmonary infarction. * **Investigation of choice in Pregnancy/Renal Failure:** V/Q scan or Doppler Ultrasound of leg veins (to avoid radiation/contrast).

Q: Which interstitial lung disease is characterized by granulomas on lung biopsy?

Sarcoidosis. **Explanation:** **Sarcoidosis** is the correct answer because it is a multisystem inflammatory disease defined histologically by the presence of **non-caseating granulomas**. These granulomas are organized collections of epithelioid histiocytes, multinucleated giant cells (often containing **Schumann bodies** or **Asteroid bodies**), and a rim of lymphocytes. In the lungs, these typically follow a lymphangitic distribution along the pleura and bronchovascular bundles. **Analysis of Incorrect Options:** * **Usual Interstitial Pneumonitis (UIP):** This is the hallmark pattern of Idiopathic Pulmonary Fibrosis (IPF). It is characterized by **spatial and temporal heterogeneity**, fibroblastic foci, and "honeycombing," but lacks granulomas. * **Diffuse Alveolar Damage (DAD):** This is the histological correlate of **ARDS**. It is characterized by the formation of **hyaline membranes** lining the alveolar spaces, not granulomatous inflammation. * **Desquamative Interstitial Pneumonia (DIP):** This is a smoking-related ILD characterized by the diffuse accumulation of **intra-alveolar macrophages** (pigmented "smoker's macrophages") rather than organized granulomas. **High-Yield NEET-PG Pearls:** * **Differential for Lung Granulomas:** Always distinguish between **Non-caseating** (Sarcoidosis, Hypersensitivity Pneumonitis, Berylliosis) and **Caseating** (Tuberculosis, Fungal infections). * **Kveim-Siltzbach Test:** A historical skin test for Sarcoidosis (rarely used now). * **Radiology:** Look for bilateral hilar lymphadenopathy (Stage I) and the "Galaxy Sign" on HRCT. * **Lab Marker:** Elevated Serum **ACE (Angiotensin-Converting Enzyme)** levels and hypercalciuria/hypercalcemia due to 1-alpha hydroxylase activity in macrophages.

Q: Which of the following is NOT true about Kartagener's syndrome?

Mental retardation. Explanation: **Kartagener’s Syndrome** is a subset of **Primary Ciliary Dyskinesia (PCD)**, an autosomal recessive disorder characterized by the structural and functional impairment of cilia. The syndrome is classically defined by a clinical triad: **Situs Inversus (including Dextrocardia), Chronic Sinusitis, and Bronchiectasis.** [1] **Why Mental Retardation is the Correct Answer:** Mental retardation is **not** a feature of Kartagener’s syndrome. The pathology is strictly related to the dysfunction of dynein arms in cilia (most commonly a defect in the DNAH5 or DNAH11 genes). Since cognitive development does not rely on ciliary motility, intelligence and neurological functions remain normal. **Analysis of Incorrect Options:** * **A. Dextrocardia:** In PCD, the lack of ciliary motion during embryonic development leads to the random rotation of internal organs. In 50% of cases, this results in *Situs Inversus Totalis*, where the heart is on the right side (Dextrocardia). * **B. Infertility:** Ciliary action is essential for the motility of sperm tails (flagella) and the movement of ova through the fallopian tubes. Therefore, both males and females with this syndrome often face infertility. * **C. Bronchiectasis:** Impaired mucociliary clearance leads to recurrent pulmonary infections, chronic inflammation, and permanent dilation of the bronchi (bronchiectasis), typically involving the lower lobes. [1] **High-Yield Clinical Pearls for NEET-PG:** * **The Triad:** Bronchiectasis + Sinusitis + Situs Inversus. [1] * **Diagnosis:** The screening test of choice is **Nasal Nitric Oxide (nNO)** levels (which are low). The gold standard for diagnosis is **Electron Microscopy** (showing absent dynein arms) or genetic testing. * **Associated Condition:** Young’s Syndrome (Bronchiectasis + Obstructive Azoospermia) is a common differential but lacks the ciliary structural defects seen in Kartagener’s. [1]

Q: In the management of pulmonary emboli, what is the recommended infusion time for alteplase?

1-3 hours. **Explanation:** In the management of hemodynamically unstable (massive) pulmonary embolism (PE), thrombolytic therapy is indicated to rapidly dissolve the clot and reduce right ventricular strain [1]. **Alteplase (rt-PA)** is the preferred thrombolytic agent [2]. **1. Why Option A is Correct:** The standard FDA-approved regimen for alteplase in acute PE is **100 mg administered as a continuous intravenous infusion over 2 hours**. This rapid infusion (1-3 hour window) is preferred over older, prolonged regimens because it achieves faster clot lysis and hemodynamic improvement without a significant increase in major bleeding complications. In extreme cases of cardiac arrest, a "bolus" dose may be considered, but the 2-hour infusion remains the gold standard for massive PE. **2. Why Other Options are Incorrect:** * **Options B, C, and D:** These timeframes (4-12 hours) represent outdated protocols. Historically, first-generation thrombolytics like Streptokinase were administered over 12–24 hours [2]. However, for Alteplase, prolonged infusions do not offer additional efficacy and significantly increase the risk of bleeding, particularly intracranial hemorrhage [1]. **3. Clinical Pearls for NEET-PG:** * **Indication:** Thrombolysis is reserved for **Massive PE** (defined by hypotension: SBP <90 mmHg) or select cases of Submassive PE with evidence of severe RV dysfunction [1]. * **Drug of Choice:** Alteplase (100 mg over 2 hours). * **Alternative:** Tenecteplase (TNK-tPA) is often used in MI but is currently being studied for PE (not yet the primary standard over Alteplase in all guidelines). * **Contraindication:** Always screen for absolute contraindications like recent intracranial hemorrhage, active internal bleeding, or recent ischemic stroke (within 3 months) [1]. * **Post-Thrombolysis:** Heparin therapy should be initiated/resumed once the aPTT falls below twice the upper limit of normal.

Q: Thermoplasty is used in which condition?

Asthma. **Explanation:** **Bronchial Thermoplasty (BT)** is an innovative, FDA-approved bronchoscopic procedure specifically designed for the management of **severe, persistent asthma** that remains uncontrolled despite optimal medical therapy (high-dose inhaled corticosteroids and long-acting beta-agonists) [1]. **Why Asthma is the Correct Answer:** The pathophysiology of asthma involves hypertrophy and hyperplasia of the **bronchial smooth muscle (BSM)**, leading to airway hyperresponsiveness and narrowing. Bronchial thermoplasty uses controlled **radiofrequency energy** (thermal energy) delivered via a catheter to the airways. This heat selectively reduces the mass of the smooth muscle, thereby decreasing the lung's ability to constrict during an asthma attack. It typically involves three separate sessions targeting different lobes of the lungs. **Why Other Options are Incorrect:** * **COPD:** While COPD involves airway obstruction, the primary pathology is alveolar destruction (emphysema) and chronic inflammation/mucus production (bronchitis), rather than reversible smooth muscle constriction. * **Bronchiectasis:** This is characterized by permanent, abnormal dilation of the bronchi due to chronic infection and inflammation. Treatment focuses on airway clearance and antibiotics, not smooth muscle reduction. * **Carcinoma Lung:** Treatment modalities for lung cancer include surgery, chemotherapy, radiotherapy, or endobronchial interventions like stenting or laser ablation, but not thermoplasty. **High-Yield Clinical Pearls for NEET-PG:** * **Indication:** Severe persistent asthma in patients ≥18 years old [1]. * **Mechanism:** Reduction of airway smooth muscle (ASM) mass. * **Contraindication:** Patients with pacemakers, internal defibrillators, or those experiencing an active asthma exacerbation. * **Common Side Effect:** Transient worsening of respiratory symptoms (cough, wheeze) immediately following the procedure.

Question 1

Type 1 respiratory failure is characterized by which of the following?

Accepted Answer

Low PaO2 and normal PCO2

Answer

Low PaO2 and high PCO2

Answer

Normal PaO2 and high PCO2

Answer

High PaO2 and high PCO2

Question 2

A 75-year-old lady with severe chronic obstructive pulmonary disease (COPD) presents with acute breathlessness. The chest X-ray shows no focal consolidation. She is afebrile, but D-dimers are markedly elevated. Which of the following is the best investigation to diagnose this condition?

Accepted Answer

CT pulmonary angiography

Answer

MRI

Answer

Ventilation-perfusion (V/Q) scan

Answer

High-resolution CT thorax

Question 3

A 30-year-old paraplegic male with a history of recurrent UTIs secondary to an indwelling Foley catheter presents with fever and hypotension requiring hospitalization, fluid therapy, and intravenous antibiotics. He improves initially, but over one week, he develops increasing shortness of breath and tachypnea. He has frothy sputum and diffuse alveolar infiltrates. There is no fever, jugular venous distension, S3 gallop, or peripheral or sacral edema. What is the best prognostic indicator?

Accepted Answer

Pulmonary capillary wedge pressure

Answer

Blood cultures

Answer

CT scan of the chest

Answer

Ventilation-perfusion scan

Question 4

Which interstitial lung disease is characterized by granulomas on lung biopsy?

Accepted Answer

Sarcoidosis

Answer

Usual interstitial pneumonitis

Answer

Diffuse alveolar damage

Answer

Desquamative interstitial pneumonia

Question 5

Which of the following is NOT true about Kartagener's syndrome?

Accepted Answer

Mental retardation

Answer

Dextrocardia

Answer

Infertility

Answer

Bronchiectasis

Question 6

In the management of pulmonary emboli, what is the recommended infusion time for alteplase?

Accepted Answer

1-3 hours

Answer

4-6 hours

Answer

7-9 hours

Answer

10-12 hours

Question 7

A 30-year-old man presents with coughing up blood and sputum. There is no associated dyspnea, fever, or pleuritic chest pain. His past medical history is significant for recurrent pneumonias and a chronic cough productive of foul-smelling purulent sputum. The sputum production is usually worse when lying down and in the morning. He quit smoking 5 years ago and started when he was 18 years old. On physical examination, he appears chronically ill with clubbing of the fingers. Wet inspiratory crackles are heard at the lung bases posteriorly. Chest imaging reveals scarring in the right lower lobe, identified as airway dilatation, bronchial wall thickening, and grapelike cysts. Which of the following is the most likely diagnosis?

Accepted Answer

Bronchiectasis

Answer

Chronic bronchitis

Answer

Disseminated pulmonary tuberculosis

Answer

Pulmonary neoplasm

Question 8

Thermoplasty is used in which condition?

Accepted Answer

Asthma

Answer

COPD

Answer

Bronchiectasis

Answer

Carcinoma lung

Question 9

A 80-year-old male presented with a lung abscess in the left upper zone. What is the best initial treatment modality?

Accepted Answer

Antibiotics guided by identified organisms

Answer

Surgical drainage

Answer

Tube thoracostomy

Answer

Observation (wait and watch)

Question 10

Clinical manifestations of bronchogenic carcinoma include the following except?

Accepted Answer

Gastroparesis due to vagal involvement

Answer

Hoarseness of voice due to involvement of left recurrent laryngeal nerve

Answer

Horner's syndrome

Answer

Diaphragmatic palsy due to infiltration of phrenic nerve

Pulmonology — MCQs

Pulmonology — MCQs

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