Pulmonology Practice Questions

Q: Peri-operative respiratory failure is an example of

Type III respiratory failure. ***Type III respiratory failure*** - This is often termed **peri-operative respiratory failure**, characterized by **atelectasis**, **reduced functional residual capacity**, and abnormal gas exchange post-surgery. - It results from the effects of anesthesia, surgery, and pain on respiratory mechanics, leading to **poor lung expansion** and hypoxemia. *Type II respiratory failure* - Characterized by **hypercapnia (high PCO2)** and **hypoxemia (low PO2)**, indicating inadequate alveolar ventilation. - Common causes include conditions like **COPD exacerbations** or **neuromuscular disorders** impacting the respiratory pump. *Type I respiratory failure* - Defined by **hypoxemia (low PO2)** with normal or low PCO2, indicating a primary problem with oxygenation. - Examples include **pulmonary edema** or **pneumonia**, where gas exchange is impaired at the alveolar-capillary membrane. *Type IV respiratory failure* - This categorization refers to **shock-related respiratory failure**, where inadequate oxygen delivery to respiratory muscles leads to their failure. - It is typically seen in states of **severe circulatory collapse**, such as septic or cardiogenic shock, and is not directly related to the peri-operative period in the way Type III is.

Q: Which of the following conditions are contraindications for noninvasive positive-pressure ventilation in patients with respiratory failure? I. Craniofacial abnormalities II. Significant burns III. Respiratory failure with PaCO_2 of 60 mm Hg IV. Cardiovascular instability Select the correct answer using the code given below :

I, II and IV. ***I, II and IV*** - **Craniofacial abnormalities** (I) can prevent a proper mask seal, leading to air leaks and ineffective ventilation. - **Significant burns** (II), especially on the face, can make mask application impossible due to pain, skin integrity issues, and infection risk. - **Cardiovascular instability** (IV), such as severe hypotension or active myocardial ischemia, can be worsened by the positive intrathoracic pressure applied by NPPV, which can decrease venous return and cardiac output. *I, III and IV* - While **craniofacial abnormalities** (I) and **cardiovascular instability** (IV) are contraindications, NPPV can be beneficial for **respiratory failure with a PaCO2 of 60 mm Hg** (III) as it helps reduce CO2 levels and avoids intubation. - Therefore, including III as a contraindication makes this option incorrect. *II, III and IV* - **Significant burns** (II) and **cardiovascular instability** (IV) are clear contraindications. However, **respiratory failure with a PaCO2 of 60 mm Hg** (III) is often an indication for NPPV, not a contraindication. - This option incorrectly identifies a key indication as a contraindication. *I, II and III* - **Craniofacial abnormalities** (I) and **significant burns** (II) are valid contraindications for NPPV. - However, **respiratory failure with a PaCO2 of 60 mm Hg** (III) is a common indication for NPPV, especially in conditions like COPD exacerbations, as it helps improve ventilation and reduce hypercapnia.

Q: A 62-year old male chronic smoker has been diagnosed with Chronic Obstructive Pulmonary Disease (COPD). On pulmonary function testing, the ratio of Forced Expiratory Volume in 1 second (FEV1) to Forced Vital Capacity (FVC) was 0.6 and FEV1 was 70 % of predicted. What is the severity of airflow obstruction in this patient as per GOLD criteria?

Stage II - Moderate. **Stage II - Moderate** - According to GOLD criteria, an FEV1/FVC ratio of less than 0.70 confirms airflow obstruction [1]. In this case, the ratio is 0.6. - A predicted FEV1 between 50% and 79% (inclusive) indicates **moderate COPD**, which aligns with the patient's FEV1 of 70% predicted [1]. *Stage III - Severe* - This stage is characterized by a **post-bronchodilator FEV1** between 30% and 49% of predicted [1]. - The patient's FEV1 of 70% predicted is too high for Stage III, indicating less severe obstruction. *Stage IV - Very severe* - This is the most severe stage, defined by a **post-bronchodilator FEV1** less than 30% of predicted, or FEV1 less than 50% predicted with signs of respiratory failure [1]. - The patient's FEV1 of 70% predicted is significantly higher than the threshold for very severe COPD. *Stage I - Mild* - Stage I is diagnosed when the **post-bronchodilator FEV1** is 80% or greater than predicted [1]. - The patient's FEV1 of 70% predicted falls below this criterion, indicating a more significant obstruction than mild.

Q: Under the Stepwise Approach to the management of Bronchial Asthma, which one of the following is the correct initial treatment at Step 1 for a patient diagnosed with Asthma?

Low dose inhaled corticosteroid only. ***Low dose inhaled corticosteroid only*** - For newly diagnosed asthma patients requiring daily controller therapy (Step 1 or 2 as per GINA 2021+), a **low-dose inhaled corticosteroid (ICS)** is the recommended initial monotherapy [1]. - ICS addresses the underlying inflammation in asthma, which is crucial even in mild persistent cases. *Low dose inhaled corticosteroid plus leukotriene antagonist* - This combination is typically considered at **higher steps** (e.g., Step 3 or 4) if control is not achieved with low-dose ICS alone or if there are specific indications like **aspirin-exacerbated respiratory disease** [1]. - Initiating with two controller medications at Step 1 is generally not recommended as per guideline. *Low dose inhaled corticosteroid plus long acting anti-muscarinic agents* - **Long-acting muscarinic antagonists (LAMAs)** are primarily used in **severe asthma** that remains uncontrolled despite ICS/LABA therapy, usually at Step 4 or 5. - They are not considered a first-line addition to ICS at Step 1. *Low dose inhaled corticosteroid plus oral corticosteroid* - **Oral corticosteroids** are reserved for asthma **exacerbations** or very severe, uncontrolled asthma, used for short periods due to significant systemic side effects [1]. - They are never used as initial daily maintenance therapy at Step 1 due to their high side effect profile.

Q: Consider the following pleural fluid analysis : pH-7.6 Pleural fluid protein -0.5 g / dL Serum total protein -6.5 g / dL Pleural fluid LDH - 100 U / L Serum LDH - 300 U / L What is the most likely diagnosis?

Myxedema. ***Myxedema*** - The pleural fluid analysis shows a **transudative effusion** (pleural fluid protein/serum protein ratio < 0.5 and pleural fluid LDH/serum LDH ratio < 0.6), a characteristic of myxedema (hypothyroidism) [1]. - While other causes of transudates exist, a **high pH** in a transudate, as seen here (pH 7.6), is suggestive of myxedema or a parapneumonic effusion that is not infected, but the latter would likely be an exudate [1]. *Sarcoidosis* - Sarcoidosis typically causes an **exudative pleural effusion**, characterized by higher protein and LDH levels in the pleural fluid. - The pleural fluid pH in sarcoidosis is usually normal to slightly low, but not as high as 7.6 in an exudative process. *Rheumatoid arthritis* - Pleural effusions due to rheumatoid arthritis are typically **exudative**, with low glucose and very low pH (often <7.0 to 7.1) [1]. - The given pleural fluid composition does not match the typical findings of a rheumatoid effusion. *Pancreatitis* - Pancreatitis can cause an **exudative pleural effusion**, particularly on the left side, with very high amylase levels. - The protein and LDH ratios in this case are consistent with a transudate, not an exudate as seen in pancreatitis.

Q: Which organ is PRIMARILY involved in cystic fibrosis?

Lungs. Lungs - The lungs are **primarily affected** in cystic fibrosis due to the dysfunction of the **CFTR protein**, leading to the production of thick, sticky mucus [1]. - This thick mucus obstructs the airways, causing **recurrent infections**, inflammation, and progressive lung damage, which is the leading cause of morbidity and mortality [1], [2]. *Pancreas* - The pancreas is also significantly affected in cystic fibrosis, leading to **exocrine pancreatic insufficiency** and malabsorption. - However, while pancreatic issues are prominent, the **pulmonary complications** are typically the primary cause of severe illness and death [2]. *Kidney* - The kidneys are generally **not directly affected** by the primary pathology of cystic fibrosis. - Renal complications are usually secondary to treatments or long-term systemic effects of the disease. *Liver* - The liver can be affected in cystic fibrosis, leading to **focal biliary cirrhosis** and other hepatobiliary issues. - However, severe liver disease is less common than pulmonary or pancreatic manifestations and usually does not represent the primary organ involved in the acute or chronic progression of the disease.

Q: Consider the following statements: The clinical features of tension pneumothorax include 1. tracheal shift to contralateral side 2. absent breath sounds on the affected side 3. low output circulatory failure 4. peripheral cyanosis Which of the statements given above is/are correct?

1, 2 and 3. ***1, 2 and 3*** - **Tracheal deviation to the contralateral side** is a hallmark sign of tension pneumothorax [1], caused by the increasing pressure in the affected hemithorax pushing mediastinal structures away. - **Absent breath sounds on the affected side** result from the complete collapse of the lung and inability of air to enter the pleural space with inspiration [1]. **Low output circulatory failure** occurs due to increased intrathoracic pressure compressing the heart and great vessels, impairing venous return and cardiac output [2]. *1 and 3 only* - While **tracheal shift to the contralateral side** and **low output circulatory failure** [2] are indeed features, this option incorrectly excludes **absent breath sounds on the affected side**, which is a critical clinical finding in tension pneumothorax. - The absence of breath sounds directly reflects the collapsed lung, a primary mechanical consequence of the condition. *2 and 4* - **Absent breath sounds on the affected side** is correct, but **peripheral cyanosis** is not a *primary* or *early* distinguishing feature of tension pneumothorax. While hypoxemia can lead to cyanosis, it's often a late and less specific sign. - This option misses the crucial finding of **tracheal deviation** and the systemic impact of **circulatory failure** [2], which are more direct indicators of the severity and mechanism of tension pneumothorax. *1 and 4* - **Tracheal shift to the contralateral side** is a correct feature. However, **peripheral cyanosis** is a less specific and often later sign compared to the direct mechanical and circulatory effects. - This option incorrectly omits **absent breath sounds on the affected side** and **low output circulatory failure**, both of which are more consistently present and diagnostically important in tension pneumothorax.

Q: Smoking is associated with all the following diseases except:

Sarcoidosis. ***Sarcoidosis*** - **Smoking** has been found to have a protective or null effect on the development of **sarcoidosis**, and it is generally *not* considered a risk factor. - The etiology of sarcoidosis is unknown, but it is thought to involve a combination of genetic predisposition and environmental triggers, none of which strongly implicate smoking. *Emphysema* - **Smoking** is the leading cause of **emphysema**, a type of **COPD**, by causing chronic inflammation and destruction of alveolar walls. - Toxins and irritants in smoke activate inflammatory cells and enzymes, leading to the breakdown of elastic fibers in the lungs. *Cardiovascular disease* - **Smoking** is a major risk factor for various **cardiovascular diseases**, including **atherosclerosis**, **coronary artery disease**, and stroke. - It damages blood vessel walls, increases **blood pressure**, and promotes clot formation, significantly increasing the risk of cardiovascular events. *Lung cancer* - **Smoking** is the primary cause of the vast majority of **lung cancer** cases, with dose-dependent effects on risk [1]. - Carcinogens in tobacco smoke directly damage DNA in lung cells, leading to uncontrolled cell growth and tumor formation [1].

Q: A 50 year old male presented with pain along the left arm and ptosis. His chest X-ray showed soft tissue opacity at the apex of the left lung along with the erosion of the adjacent rib. The probable diagnosis is:

Pancoast lung. ***Pancoast lung*** - A **Pancoast tumor** (superior sulcus tumor) is a **non-small cell lung cancer** located at the apex of the lung, typically invading adjacent structures. - This invasion can lead to **Pancoast syndrome**, characterized by **shoulder and arm pain** (due to brachial plexus involvement) and **Horner's syndrome** (ptosis, miosis, anhidrosis due to sympathetic chain involvement), often accompanied by rib erosion [1]. *Bronchial carcinoma* - While a Pancoast tumor is a type of **bronchial carcinoma** (lung cancer), this option is too general and doesn't specify the unique apical location and associated neurological symptoms [1]. - Bronchial carcinomas can present with a wide range of symptoms, including cough, hemoptysis, and weight loss, but the specific triad of symptoms described points to a particular subtype. *Lung abscess* - A **lung abscess** is a pus-filled cavity in the lung, usually caused by bacterial infection, and typically presents with fever, cough with purulent sputum, and sometimes pleuritic chest pain. - It does not typically cause **arm pain**, **ptosis**, or **rib erosion** unless there is direct extension from the abscess, which is uncommon and not the primary presentation. *Adenocarcinoma of lung* - **Adenocarcinoma** is a subtype of **non-small cell lung cancer**, but it is generally located in the periphery of the lung and is less likely to present with the classic **Pancoast syndrome** symptoms [1]. - While it can be found in the apex, the specific clinical presentation (arm pain, ptosis, rib erosion) points more strongly to the syndrome that results from apical tumor location rather than just the histological type.

Q: A 45-year-old male presents to the emergency department following a motor vehicle accident. He complains of severe chest pain and difficulty breathing. On examination, he appears distressed, with a respiratory rate of 28 breaths per minute. His oxygen saturation is 88% on room air. There is visible bruising on the chest, X-ray is done which is shown below. Which of the following is seen in this patient?

Bronchial breathing. ***Bronchial breathing*** - The provided image is a chest X-ray. The question describes a patient with severe chest pain, difficulty breathing, hypoxemia, and visible chest bruising after a motor vehicle accident, which suggests **pulmonary contusion** or **pneumonia**. - In such conditions, **bronchial breathing** might be heard on auscultation due to consolidation or compression of lung tissue. The X-ray shows diffuse infiltrates or opacities indicative of lung injury, making bronchial breathing a plausible physical exam finding. *Kussmaul breathing* - This is a pattern of **deep and labored breathing** associated with severe **metabolic acidosis**, particularly diabetic ketoacidosis. - While the patient is in distress, the chest X-ray and accident history point to acute respiratory injury rather than metabolic acidosis as the primary cause. *Paradisical breathing* - This term is **not a recognized medical breathing pattern**. It appears to be a distracter. - Medical terminology for breathing patterns includes terms like Kussmaul, Cheyne-Stokes, Biot's, etc. *Apneustic breathing* - Characterized by **prolonged inspiratory pauses** followed by short exhalations, indicating severe damage to the **pons (brainstem)**. - This breathing pattern is typically seen with neurological insults like stroke or severe head injury, which is not directly indicated by the information given, although a head injury could theoretically occur in a MVC, it's not the primary finding for the presented complaints and X-ray.

Question 1

Peri-operative respiratory failure is an example of

Accepted Answer

Type III respiratory failure

Answer

Type II respiratory failure

Answer

Type I respiratory failure

Answer

Type IV respiratory failure

Question 2

Which of the following conditions are contraindications for noninvasive positive-pressure ventilation in patients with respiratory failure?
I. Craniofacial abnormalities
II. Significant burns
III. Respiratory failure with PaCO_2 of 60 mm Hg
IV. Cardiovascular instability

Select the correct answer using the code given below :

Accepted Answer

I, II and IV

Answer

I, III and IV

Answer

II, III and IV

Answer

I, II and III

Question 3

A 62-year old male chronic smoker has been diagnosed with Chronic Obstructive Pulmonary Disease (COPD). On pulmonary function testing, the ratio of Forced Expiratory Volume in 1 second (FEV1) to Forced Vital Capacity (FVC) was 0.6 and FEV1 was 70 % of predicted. What is the severity of airflow obstruction in this patient as per GOLD criteria?

Accepted Answer

Stage II - Moderate

Answer

Stage III - Severe

Answer

Stage IV - Very severe

Answer

Stage I - Mild

Question 4

Under the Stepwise Approach to the management of Bronchial Asthma, which one of the following is the correct initial treatment at Step 1 for a patient diagnosed with Asthma?

Accepted Answer

Low dose inhaled corticosteroid only

Answer

Low dose inhaled corticosteroid plus leukotriene antagonist

Answer

Low dose inhaled corticosteroid plus long acting anti-muscarinic agents

Answer

Low dose inhaled corticosteroid plus oral corticosteroid

Question 5

Consider the following pleural fluid analysis :
pH-7.6
Pleural fluid protein -0.5 g / dL
Serum total protein -6.5 g / dL
Pleural fluid LDH - 100 U / L
Serum LDH - 300 U / L

What is the most likely diagnosis?

Accepted Answer

Myxedema

Answer

Sarcoidosis

Answer

Rheumatoid arthritis

Answer

Pancreatitis

Question 6

Which organ is PRIMARILY involved in cystic fibrosis?

Accepted Answer

Lungs

Answer

Pancreas

Answer

Kidney

Answer

Liver

Question 7

Consider the following statements: The clinical features of tension pneumothorax include

1. tracheal shift to contralateral side 
2. absent breath sounds on the affected side 
3. low output circulatory failure 
4. peripheral cyanosis Which of the statements given above is/are correct?

Accepted Answer

1, 2 and 3

Answer

1 and 3 only

Answer

2 and 4

Answer

1 and 4

Question 8

Smoking is associated with all the following diseases except:

Accepted Answer

Sarcoidosis

Answer

Emphysema

Answer

Cardiovascular disease

Answer

Lung cancer

Question 9

A 50 year old male presented with pain along the left arm and ptosis. His chest X-ray showed soft tissue opacity at the apex of the left lung along with the erosion of the adjacent rib. The probable diagnosis is:

Accepted Answer

Pancoast lung

Answer

Bronchial carcinoma

Answer

Lung abscess

Answer

Adenocarcinoma of lung

Question 10

A 45-year-old male presents to the emergency department following a motor vehicle accident. He complains of severe chest pain and difficulty breathing. On examination, he appears distressed, with a respiratory rate of 28 breaths per minute. His oxygen saturation is 88% on room air. There is visible bruising on the chest, X-ray is done which is shown below. Which of the following is seen in this patient?

Accepted Answer

Bronchial breathing

Answer

Kussmaul breathing

Answer

Paradisical breathing

Answer

Apneustic breathing

Pulmonology — MCQs

Pulmonology — MCQs

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