Pulmonology Practice Questions

Q: What is the most common cause of death in a patient with chronic bronchiectasis?

Infection. ***Infection*** - Chronic bronchiectasis creates a favorable environment for **bacterial colonization** and recurrent infections due to impaired mucociliary clearance and dilated, damaged airways. [1] - These infections, often by **Pseudomonas aeruginosa** or **Haemophilus influenzae**, can lead to acute exacerbations, progressive lung damage, and ultimately **respiratory failure** or overwhelming sepsis, which are common causes of death. [1], [2] *Right-sided heart failure* - **Cor pulmonale**, or right-sided heart failure, can develop as a complication of severe bronchiectasis due to **pulmonary hypertension** from chronic hypoxemia and vascular remodeling. - While it contributes to morbidity and mortality, it is not the most common direct cause of death; the underlying lung disease and subsequent infections are usually the primary drivers. *Hemoptysis* - **Severe hemoptysis** can occur in bronchiectasis due to erosion of inflamed bronchial arteries, which can be life-threatening if massive. [2], [3] - Although it is a serious complication and can be fatal, it is not the most frequent cause of death compared to the cumulative effect of chronic infections and progressive respiratory decline. *Carcinoma* - While patients with chronic lung conditions, including bronchiectasis, may have an **increased risk of lung cancer**, it is not the most common cause of death directly attributable to bronchiectasis itself. [3] - The direct and immediate threats to life in bronchiectasis are typically related to **exacerbations, infections, and respiratory failure**.

Q: In an ICU setting, patients suffering from which respiratory pathology are at risk of CO2 narcosis?

Emphysema. ***Emphysema*** - Patients with **emphysema** often have chronic **CO2 retention** due to impaired gas exchange and reduced expiratory airflow, making them susceptible to CO2 narcosis with supplemental oxygen [4]. - Their **respiratory drive** is primarily cued by hypoxic stimulation, and increasing oxygen can suppress this drive, leading to further CO2 accumulation [1], [4]. *Pneumonia* - While pneumonia can cause respiratory distress, it typically leads to **hypoxemia** rather than hypercapnia in early stages, as ventilation-perfusion mismatch is the primary issue [3]. - Patients with pneumonia are not inherently predisposed to **CO2 narcosis** unless there is severe underlying lung disease or muscle fatigue. *Asthma* - Acute asthma exacerbations mainly cause **bronchoconstriction** and **air trapping**, leading to hypoxemia. Hypercapnia only occurs in severe, life-threatening asthma with significant respiratory muscle fatigue or impending respiratory failure [2]. - Patients with asthma are generally not at chronic risk of **CO2 narcosis** unless in an acute, severe episode and over-oxygenated. *Bronchiectasis* - Bronchiectasis involves **permanent dilation of bronchi** due to chronic infection and inflammation, leading to impaired mucociliary clearance and recurrent infections. - While it can cause chronic respiratory symptoms and hypoxemia, it typically does not directly lead to **CO2 retention** to the extent seen in advanced COPD, unless there is significant co-existing lung parenchymal damage.

Q: Pink puffers are typically associated with which condition?

Emphysema. ***Emphysema*** - Patients with **emphysema** are often referred to as "pink puffers" because they maintain relatively normal arterial oxygen tension (pink) by **pursing their lips** and using accessory muscles to forcefully exhale (puffing) [1]. - This effort to maintain adequate oxygenation and ventilation, despite severe airflow obstruction, differentiates them from "blue bloaters" [1]. - In emphysema, the loss of alveolar walls leaves small airways unsupported, which contributes to air trapping and increased expiratory effort [2]. *Chronic bronchitis* - Patients with **chronic bronchitis** are classically described as "blue bloaters" due to **hypoxemia** (causing cyanosis or "blueness") and often present with **edema** from right heart failure (bloating) [1]. - They typically have a prominent cough with **sputum production** and less respiratory distress at rest compared to emphysema patients [1]. *Pneumonia* - **Pneumonia** is an acute infection of the lung parenchyma characterized by **fever**, cough, and **dyspnea**, and does not fit the long-term clinical phenotype of "pink puffer." - It typically causes an **influx of inflammatory cells** and fluid into the alveoli, leading to impaired gas exchange. *Bronchiectasis* - **Bronchiectasis** is characterized by **permanent dilation of the bronchi** and is often associated with chronic productive cough and recurrent infections. - While it can cause chronic respiratory symptoms, it does not typically present with the "pink puffer" phenotype associated with the specific compensatory mechanisms seen in emphysema.

Q: In allergic bronchopulmonary aspergillosis, where are the lesions primarily located?

Bronchi and bronchioles. In allergic bronchopulmonary aspergillosis, where are the lesions primarily located? ***Bronchi and bronchioles*** - Allergic bronchopulmonary aspergillosis primarily affects the **airways**, particularly the **bronchi and bronchioles**, due to the hypersensitivity reaction to the Aspergillus species. - It leads to **mucous plugging** and inflammatory changes in these structures, resulting in symptoms like **cough** and **wheeze**. *All of the above* - This option is incorrect as lesions are not typically found in all structures; ABPA specifically targets the **airways**. - The disease's hallmark features are localized to the **bronchi and bronchioles**, making this option misleading. *Pleura* - While pleural involvement can occur in other pulmonary diseases, it is not characteristic of **allergic bronchopulmonary aspergillosis**. - ABPA does not typically cause **pleural effusions** or lesions in the pleura, focusing instead on airway pathology. *Alveoli* - In ABPA, the primary lesions do not occur in the **alveoli**, but rather in the **airway passages**. - While lung inflammation can affect the alveoli in other contexts, it is not a specific feature of this condition.

Q: Which of the following is least likely to cause a cavity in the lungs?

Sarcoidosis. ***Sarcoidosis*** - Sarcoidosis typically leads to **granuloma formation** in the lungs rather than cavitary lesions [1]. - It usually presents with **bilateral hilar lymphadenopathy** and interstitial lung disease, not lung cavities [1]. *Wegeners* - Wegeners (now called Granulomatosis with Polyangiitis) can cause lung cavities due to **vascular inflammation** [1]. - It typically presents with **pulmonary nodules** that may cavitate and is associated with **renal involvement** [1]. *Hydatid* - Hydatid disease is caused by **Echinococcus** species and can result in cyst formation in the lungs that may become infected and develop cavities. - The cavitary lesions are often due to secondary infections of the cysts. *Staphylococcus* - Staphylococcus can lead to lung abscesses which may cavitate, particularly in cases of **pneumonia** or **aspiration**. - It is commonly associated with **necrotizing pneumonia** and empyema, resulting in cavitary lesions.

Q: Treatment of choice in acute sarcoidosis is

Prednisolone. ***Prednisolone*** - **Corticosteroids** like prednisolone are the first-line treatment for acute sarcoidosis due to their potent **anti-inflammatory** and **immunosuppressive** effects. - They effectively reduce granuloma formation and inflammation, alleviating symptoms and preventing organ damage [1]. *Cyclosporin* - Cyclosporine is an **immunosuppressant** used in some autoimmune diseases and organ transplantation but is not the primary treatment for acute sarcoidosis. - It carries significant side effects, including **nephrotoxicity** and increased infection risk. *Infliximab* - Infliximab is a **TNF-alpha inhibitor** used for chronic, refractory sarcoidosis or in cases where steroids are contraindicated or ineffective. - It is considered a second-line or third-line agent, not the treatment of choice for acute presentation. *IV immunoglobulins* - IV immunoglobulins (IVIG) are used for various **immune deficiencies** and certain autoimmune disorders. - They are not indicated for the initial management of acute sarcoidosis.

Q: Which of the following conditions is primarily associated with alveolar hypoventilation?

Kyphoscoliosis. ***Kyphoscoliosis*** - **Severe kyphoscoliosis** can restrict lung expansion and thoracic cage movement, leading to **reduced tidal volume** and respiratory muscle fatigue, resulting in **alveolar hypoventilation**. [1] - The abnormal curvature of the spine mechanically impedes efficient ventilation, primarily impacting the ability to take deep breaths and clear CO2. *COPD* - While patients with **severe COPD** can develop hypoventilation, it is primarily characterized by **airway obstruction** and **ventilation-perfusion mismatch** rather than being a primary cause of hypoventilation like restrictive disorders. [1] - Initial stages often involve hyperinflation and increased work of breathing, but not necessarily alveolar hypoventilation as the primary feature. *Lobar pneumonia* - **Lobar pneumonia** causes **consolidation** of lung tissue, leading to V/Q mismatch and hypoxemia. [2] - It typically results in *hyperventilation* due to hypoxaemia and inflammation, rather than alveolar hypoventilation. [2] *Bulbar poliomyelitis* - **Bulbar poliomyelitis** affects the motor neurons of the brainstem, leading to weakness of the muscles involved in swallowing and breathing. - While it can cause respiratory failure, its primary association is with direct paralysis of respiratory muscles rather than a structural respiratory compromise like kyphoscoliosis. *Central sleep apnea* - **Central sleep apnea** involves a temporary cessation of breathing efforts due to a lack of neural output from the brainstem. - It is a disorder of respiratory control during sleep and not primarily associated with daytime alveolar hypoventilation due to a structural chest wall defect.

Q: Which of the following is the most characteristic laboratory finding in sarcoidosis?

Elevated level of angiotensin converting enzyme (ACE). ***Elevated level of angiotensin converting enzyme (ACE)*** - **Elevated ACE levels** are a classic laboratory finding in active sarcoidosis, reflecting the increased activity of **macrophages** and **epithelioid cells** within the granulomas. - While not diagnostic on its own, it is a highly **characteristic marker** that correlates with disease activity in many patients. *Pleural effusion is common in sarcoidosis* - **Pleural effusions** are **uncommon** in sarcoidosis, occurring in less than 5% of cases. - When present, they are often small and lymphocytic but not a typical or common feature. *Facial nerve palsy is the most common neurological manifestation* - While **facial nerve palsy** can occur in sarcoidosis (neurosarcoidosis), it is **not the most common neurological manifestation**. - **Cranial neuropathies** (especially facial nerve palsy) are notable features, but other neurological presentations like **meningitis**, **seizures**, or **peripheral neuropathy** are also seen. *Bilateral parotid enlargement is the most common presentation* - **Parotid gland enlargement** can occur in sarcoidosis, particularly as part of **Heerfordt's syndrome** (uveoparotid fever), but it is **not the most common presentation** of the disease. - The most common initial presentation of sarcoidosis is usually **pulmonary involvement**, often detected incidentally on chest X-ray or presenting with respiratory symptoms.

Q: An Adult with asthma presents with asthma symptoms every day and wakes up in the night approximately 2 to 3 days in a week. He can be classified as having :

Moderate Persistent Asthma. ***Moderate Persistent Asthma*** - This classification is characterized by **daily asthma symptoms** [1] and **nighttime awakenings occurring 3-4 times per week**. The patient's symptoms fit this description. - The patient's presentation of daily symptoms and 2-3 nighttime awakenings per week indicates a level of severity that surpasses mild persistent asthma but does not meet the criteria for severe persistent asthma [1]. *Intermittent Asthma* - This classification involves symptoms less than **twice a week** and nighttime awakenings less than **twice a month**. - The patient's symptoms are daily, which exceeds the criteria for intermittent asthma. *Mild Persistent Asthma* - This type features symptoms more than **twice a week** but less than **daily**, and nighttime awakenings occurring 3-4 times per month [1]. - The patient experiences daily symptoms, which is more frequent than what is seen in mild persistent asthma. *Severe Persistent Asthma* - This classification involves symptoms throughout the **day** and nighttime awakenings **every night** or multiple times a week (7 nights/week). Also, the patient has a very limited activity level. - While the patient has daily symptoms, the frequency of nighttime awakenings is not severe enough to be classified as severe persistent asthma.

Question 1

What is the most common cause of death in a patient with chronic bronchiectasis?

Accepted Answer

Infection

Answer

Hemoptysis

Answer

Carcinoma

Answer

Right-sided heart failure

Question 2

In an ICU setting, patients suffering from which respiratory pathology are at risk of CO2 narcosis?

Accepted Answer

Emphysema

Answer

Pneumonia

Answer

Asthma

Answer

Bronchiectasis

Question 3

Which of the following is a common cause of respiratory failure in the immediate post-operative period?

Accepted Answer

Kyphoscoliosis causing Type 2 respiratory failure due to restrictive lung disease and hypoventilation

Answer

Post-operative atelectasis causing Type 1 respiratory failure due to ventilation-perfusion mismatch

Answer

Pulmonary fibrosis causing Type 1 respiratory failure due to impaired gas diffusion

Answer

Flail chest causing Type 1 respiratory failure due to chest wall instability and ventilation-perfusion mismatch

Question 4

Pink puffers are typically associated with which condition?

Accepted Answer

Emphysema

Answer

Chronic bronchitis

Answer

Pneumonia

Answer

Bronchiectasis

Question 5

In allergic bronchopulmonary aspergillosis, where are the lesions primarily located?

Accepted Answer

Bronchi and bronchioles

Answer

None of the options

Answer

Pleura

Answer

Alveoli

Question 6

Which of the following is least likely to cause a cavity in the lungs?

Accepted Answer

Sarcoidosis

Answer

Granulomatosis with Polyangiitis (GPA)

Answer

Tuberculosis

Answer

Staphylococcus aureus pneumonia

Question 7

Treatment of choice in acute sarcoidosis is

Accepted Answer

Prednisolone

Answer

Cyclosporin

Answer

Infliximab

Answer

IV immunoglobulins

Question 8

Which of the following conditions is primarily associated with alveolar hypoventilation?

Accepted Answer

Kyphoscoliosis

Answer

COPD

Answer

Lobar pneumonia

Answer

Bulbar poliomyelitis

Answer

Bulbar poliomyelitis

Answer

Central sleep apnea

Question 9

Which of the following is the most characteristic laboratory finding in sarcoidosis?

Accepted Answer

Elevated level of angiotensin converting enzyme (ACE)

Answer

Pleural effusion is common in sarcoidosis

Answer

Facial nerve palsy is the most common neurological manifestation

Answer

Bilateral parotid enlargement is the most common presentation

Question 10

An Adult with asthma presents with asthma symptoms every day and wakes up in the night approximately 2 to 3 days in a week. He can be classified as having :

Accepted Answer

Moderate Persistent Asthma

Answer

Intermittent Asthma

Answer

Mild Persistent Asthma

Answer

Severe Persistent Asthma

Pulmonology — MCQs

Pulmonology — MCQs

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