Respiratory Module 1

In the management of obstructive sleep apnea (OSA), Continuous Positive Airway Pressure (CPAP) therapy is often employed.

Which of the following lung volumes is primarily increased as a result of CPAP use?

Functional residual capacity

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Tidal volume

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Expiratory reserve volume

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Inspiratory reserve volume

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Residual volume

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A 65-year-old man presents with symptoms of paroxysmal nocturnal dyspnea on a background of known ischaemic heart disease. He had an echocardiogram performed last month which revealed a left ventricular ejection fraction of 25%. The respiratory parameters from a polysomnographic sleep study are shown below:

What is the most likely explanation for the change?

Cheyne-Stoke respiration

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Obstructive sleep apnea

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Periodic leg movement disorder

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Upper airway resistance syndrome

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Obesity hypoventilation syndrome

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In patients with moderate to severe obstructive sleep apnea, treatment with CPAP is unlikely to achieve the following outcome:

Improved nocturnal snoring

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Improved daytime somnolence

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Improved mood

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Reduction in risk of cardiovascular mortality.

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A 45 year old man is diagnosed with obstructive sleep apnea. His AHI is 50 events/ hour on an overnight sleep study. He has had a trial of CPAP at home which reduced his AHI to less than 5 events/hr, but found CPAP intolerable. Since he stopped using it, his daytime somnolence had become worse.

What other alternative does he have?

mandibular splint advancement

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breath right nasal strips

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high flow nasal insufflation

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modafinil

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uvulopalatopharyngoplasty

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A 67 year old man with a BMI of 40 has been diagnosed with bulbar motor neuron disease for the last two years. He sees you in clinic complaining of having excess daytime sleepiness and had an Epsworth sleepiness score of 16/24.

He then proceed to have a level III sleep study (Embletta system) which revealed the following information:

Overall AHI 39.9
Oxygen saturation average 95.1%
Frequent Hypopnoea and Obstructive Apnoea occurred during the sleep period with an average duration of 19.2 seconds
Average Oxygen desaturation to below 90% in 5.3% of the recording time.

His spirometry shows an FEV1 of 2.82 (78% predicted), FVC 3.81 (74% predicted), Ratio 0.78.

Apart from commencing a trial of CPAP, which of the following is the most appropriate next step in management?

Request for measurements of Mean Inspiratory Pressure (MIP), maximal sniff nasal inspiratory pressure (SNIP) and Mean Expiratory Pressure (MEP).

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Advise on immediate weight loss.

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Request for a formal lung function test including DLCO.

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Request for an urgent echocardiogram to look for evidence of pulmonary hypertension

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Refer for a barium swallow to assess risk of aspiration.

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A patient with a mutation in the PHOX2B gene will most likely benefit from the following intervention:

Positive pressure ventilation

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Pneumonectomy

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A combination of Elexacaftor, tezacaftor and ivacaftor taken twice daily.

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Heart and lung transplantation

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During diving, there is a change in external pressure as the depth of the dive changes.

According to Boyle’s Law, what actually occurs as a free diver rises to the surface?

Volume of the air in the diver’s lungs increases

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Volume of the air in the diver’s lungs decreases

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Partial pressure of O2 in the diver’s lungs decreases

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Partial pressure of CO2 in the diver’s lungs decreases

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No change in pressure or gas solubility occurs

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Selexipag is a selective prostacyclin-receptor agonist with a recognized role in the treatment of pulmonary arterial hypertension.

What is the most common side effect associated with this medication?

Headache

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Diarrhea

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Dyspnea

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Myalgia

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Nausea

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Riociguat is a soluble guanylate cyclase stimulator that is most useful in which condition?

Pulmonary hypertension related to chronic thromboembolism

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Pulmonary arterial hypertension related to fibrosing mediastinitis

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Pulmonary hypertension related to LV systolic dysfunction

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Pulmonary hypertension related to COPD

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Pulmonary hypertension related to LV diastolic dysfunction

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A 60 year old man undergoes a right heart catheter study and his results are as follows:

mPAP 23 mmHg
PAWP 10 mmHg
PVR 3 WU

Based on the above haemodynamic profile, where is the most likely anatomical location for this man’s pulmonary hypertension?

Pre-capillary pulmonary hypertension

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Isolated post-capillary pulmonary hypertension

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Combined pre and post-capillary pulmonary hypertension

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He does not have pulmonary hypertension

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In the treatment of pulmonary hypertension, vasodilator therapy should be avoided in which of the following patient group?

Pulmonary hypertension secondary to left heart disease.

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Idiopathic pulmonary arterial hypertension.

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Pulmonary hypertension secondary to scleroderma

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Pulmonary hypertension secondary to HIV

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Inhaled Treprostinil have shown promising results in the treatment of which group of pulmonary hypertension?

Pulmonary hypertension due to Interstitial lung disease

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Pulmonary hypertension due to COPD

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Pulmonary hypertension due to chronic thromboembolism

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Pulmonary hypertension due to left heart disease

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If an average 70kg man has a respiratory rate of about 18 breaths per minute and a tidal volume of 600 mL. What would his pulmonary ventilation be?

10.8L/min

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15.5L/min

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12.0L/min

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8.5L/min

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10.0L/min

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A 40 year old man complains of increasing dyspnea, worsening cough with increased sputum production and recurrent lower respiratory tract infection. He is infertile and has had a previous sinus surgery for recurrent nasal polyps and recurrent sinusitis. He has signs of situs inversus on examination.

Which of the following would provide the least useful information in establishing a diagnosis for this man?

Lung function test

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Bronchoscopy

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Nasal biopsy

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Molecular testing for mutations in DNAI1 and DNAH5

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Digital high speed video imaging (DHSV) of ciliary beat pattern

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Which of the following intervention has NOT been proven to improve survival in patients with chronic obstructive pulmonary disease (COPD)?

Long-acting beta-agonists and inhaled corticosteroids

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Long term oxygen therapy

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Smoking cessation

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Lung volume reduction surgery

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Lung transplantation

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You are seeing a 65 year old man with severe COPD in clinic . His FEV1 is 28% predicted. However his disease has been stable on 3 bronchodilators (tiotropium,salmeterol and fluticasone) and had only one admission in the last four years following an infective exacerbation of his COPD. Given the stability of his condition, you decide to slowly withdraw his inhaled dose of fluticasone over a 3 month period.

What could potentially happen to him in the next 12 months following the withdrawal of his inhaled corticosteroid?

Moderate decrease in the absolute FEV1

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Moderate increase in the absolute FEV1

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Increased risk of future exacerbations

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Reduced risk of pneumonia

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Reduced risk of esophageal candidiasis

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A 70-year-old man with a history of severe chronic obstructive pulmonary disease (COPD) presents to your clinic for a routine review. He has been diagnosed with an FEV1 of 30% indicating severe obstruction. His symptom burden is high with a COPD Assessment Test (CAT) score of 20, and he experiences significant dyspnea as reflected by a Modified Medical Research Council (MMRC) dyspnea scale score of 3.

Over the past year, he has been hospitalized twice due to infective exacerbations of his COPD.

His current medication regimen includes Salmeterol/Fluticasone inhaled twice daily and Salbutamol as needed for acute symptom relief. Considering his frequent exacerbations and current symptom burden, you consider optimizing his inhaler therapy.

Which of the following inhaler changes would be most beneficial in preventing future COPD exacerbations for this man?

Indacaterol-Glycopyrronium plus Fluticasone

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Indacaterol-Glycopyrronium

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Salmeterol

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Glycopyrronium

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Fluticasone

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The use of high flow nasal oxygen is increasingly recognized as an important treatment modality for patients with acute hypoxemic respiratory failure.

The following are benefits of such therapy compared to non-invasive ventilation, except?

reduced length of ICU stay

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large reduction in all cause mortality

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modest reduction in hospital acquired pneumonia

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modest reduction in intubation

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increase patient comfort

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Which of the following statement regarding Preserved Ratio Impaired Spirometry (PRISm) is incorrect?

Patients with PRISm are at a higher risk of developing COPD over time.

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Increased risk of frailty progression

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Early initiation of a long-acting bronchodilator is recommended.

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Both high and low BMI are associated with increased risk of PRISm

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A 56 year old man with a background of moderate COPD (FEV1 60% predicted) presents to your clinic for a review. He is an ex-smoker of 30 pack years. On your clinical assessment, he has a CAT score of 12 and mMRC of 2. His resting oxygen saturation is 90 percent on air. Over the last 12 months, he has presented twice to the emergency department with COPD exacerbations requiring antibiotic and steroid therapy. He is currently taking umeclidinium bromide 62.5mcg inhaled once daily and uses Salbutamol as required.

All of the following treatment advice would be appropriate for this man except?

Request for long term oxygen therapy (LTOT)

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Switch to a LAMA/LABA combination

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Add on an inhaled corticosteroid if serum eosinophil is ≥ 300 cells/µL

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Refer for pulmonary rehabilitation.

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Recommend annual influenza vaccination.

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The upper respiratory tract consists of the nasal cavity, pharynx and larynx. The lower respiratory tract consists of the trachea, bronchi and lungs.

If a person accidentally inhales a foreign object, for example a peanut, where in the respiratory tract is it most likely to lodge?

Right main bronchus

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Left main bronchus

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The carina

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Larynx

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Pharynx

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Which of the following patient group would most likely benefit from endobronchial valve placement?

Heterogenous emphysema without collateral ventilation

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Severe bronchiectasis

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Severe paraseptal emphysema

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Emphysema with extensive fibrosis

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Severe emphysema with a suspicious lung nodule

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A D-dimer with a threshold of 500 mcg/L has been shown to be a highly sensitive test with a correspondingly high negative predictive value among patients with low pretest probability for PE. However, the Ddimer level tends to increase with age.

If so, what would be an optimal D-dimer cutoff value for a 63 year old?

630

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700

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590

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850

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560

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Rivaroxaban is a direct oral anti-coagulant that is indicated for the treatment of DVT and PE.

Which of the following scenario could potentially determine its preference over oral Dabigatran?

A history of dyspepsia

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Elevated blood pressure

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High alcohol intake

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Previous stroke

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Hepatic dysfunction

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A 52-year-old previously healthy man from Queensland presents to the emergency department with acute onset of dyspnea. He is visibly in severe respiratory distress, with a respiratory rate of 40 breaths per minute, a pulse rate of 120 beats per minute, and blood pressure measuring 100/60 mmHg. His oxygen saturation is 85% on room air.

A bedside echocardiogram reveals signs of right ventricular strain, suggestive of acute pulmonary hypertension.

The initial ECG demonstrates an incomplete right bundle branch block. Laboratory investigations reveal a troponin level of 120 ng/L and a pro-BNP level of 1500 pg/mL, indicating cardiac strain.

An urgent CT Pulmonary Angiography (CTPA) is performed, confirming a large saddle embolus obstructing the right main pulmonary artery, a critical finding that necessitates immediate intervention.

Given the severity of the presentation and the imaging findings, systemic thrombolysis would typically be considered. However, due to specific patient factors or potential contraindications to systemic thrombolysis, the decision is made to proceed with catheter-directed thrombolysis (CDT) in the catheterization laboratory.

What is the major advantage of catheter-directed thrombolysis (CDT) over systemic thrombolysis in the management of a large pulmonary embolism as described in this patient?

Reduction in risk of major hemorrhage

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Improvement in 30 day mortality rate

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Less risk of in-hospital mortality

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Marked improvement in functional outcome

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Improvement in quality of life.

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A 70 year old man with a background of severe COPD with an FEV1 of 20% is being discharged from the ward today following a week long admission with severe infective exacerbation of COPD requiring a period of non-invasive ventilation.

Which of the following index will best predict his hospital readmission in the next 3 months?

CODEX

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BODE

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BODEX

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ADO

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DOSE

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A 70 year old woman with known COPD is admitted to hospital with a two day history of worsening reathlessness, cough and sputum production. Clinically she is tachypneic with a RR of 40 and saturating 89% on 2L/min of oxygen. Her arterial blood gas shows acute respiratory acidosis with a pH of 7.20 and a pCO2 of 100.

Which of the following intervention will most likely reduce her risk of needing invasive intubation and ventilation?

Non-invasive ventilation

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Antibiotics

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Continuous positive airway pressure

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Nebulized bronchodilators

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Oxygen supplementation aiming Sats above 92 percent

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In the management of community acquired pneumonia, which of the following clinical tool has the highest accuracy of predicting patients who will require intensive respiratory and ventilatory support (IRVS)?

SMART COP

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CURB-65

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PSI

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MY COPS

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APACHE

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What is the antibiotic of choice for severe community acquired pneumonia in patients living in a non-tropical region in Australia?

IV ceftriaxone and azithromycin

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Oral roxithromycin

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IV Augmentin

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IV Penicillin

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IV Flucloxacillin

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Which of the following primary lung cancer has the most favourable prognosis?

Carcinoid

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Bronchoalveolar(Adenocarcinoma)

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Large cell

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Small cell

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Squamous cell

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Glycopyrronium bromide is an inhaled long-acting muscarinic antagonist (LAMA) that is used as a maintenance bronchodilator treatment to relieve symptoms in adults with chronic obstructive pulmonary disease (COPD).

What is the most common side effect of this medication?

dry mouth

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nasopharyngitis

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headache

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insomnia

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sinusitis

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With regards to Positron Emission Tomography (PET) scanning, which of the following statement below is incorrect?

PET scan is useful in differentiating between thoracic malignant lesions and tuberculosis.

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tumors less than 5mm in size may not be detected by PET scan

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PET scan is more sensitive than CT in detecting recurrence of non small cell lung cancer previously treated with radiotherapy

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hyperglycemia can reduce intracellular uptake of the radioactive substrate FDG

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false negative results can occur with carcinoid tumors

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In individuals with persistent symptoms of asthma, treatment with an inhaled corticosteroid will improve the following except?

reduces the risk of oral thrush

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reduces symptoms

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reduces use of rescue medications

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decrease exacerbation rates

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reduces hospital admissions

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Which of the following malignancies has the highest mortality rate in Australia?

Lung cancer

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Bowel cancer

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Prostate cancer

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Breast cancer

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Pancreatic cancer

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A 35-year-old man presents with fever, malaise, a red indurated rash on his lower leg and marked painful swelling of both ankles. His chest X-ray is shown below:

What is the most likely diagnosis?

sarcoidosis.

Correct Incorrect Correct answer

tuberculosis

Correct Incorrect Correct answer

lymphoma.

Correct Incorrect Correct answer

Reiter's syndrome.

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systemic lupus erythematosus

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A 37 year old man from Wellington, previously fit and well, presents with two months history of general unwellness with increased lethargy, abdominal pain and headache. He is a current smoker of 10 pack years. Examination is unremarkable. His serum sodium, potassium and creatinine are all within normal limits.

However he does have a raised serum corrected calcium of 3.5mmol/L and a suppressed serum PTH of 0.6 pmol/L. His chest X-ray shows prominent bilateral hilar lymphadenopathy.

What is the most likely explanation for his hypercalcemia?

High serum calcitriol concentrations

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Excessive PTHrP Secretion

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Increased Bone Resorption

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Reduced Renal Clearance

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Minerolcorticoid deficiency

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A 66-year-old man with a 50-pack-year smoking history presents for assessment of disabling dyspnoea and reduced exercise tolerance. Physical examination reveals poor chest expansion with increased percussion note and vesicular but globally reduced breath sounds. There is no evidence of cardiac failure.

His pulmonary function tests show a forced expiratory volume in 1 second (FEV1) of 0.89 L (predicted 2.95 L) and a forced vital capacity (FVC) of 2.10 L (predicted 3.65 L). After bronchodilator, FEV1 increased to 1.1 L and FVC to 3.0 L. Residual volume was 185% predicted, carbon monoxide diffusing capacity was 50% predicted and his resting SaO2 was 95% on room air.

You decide to refer him to the pulmonary rehabilitation program.

Which one of the following is least likely to improve after completion of a pulmonary rehabilitation program?

Lung function

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Exercise tolerance

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Exertional dyspnoea

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Overall quality of life.

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Emotional function

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The following are potential biomarkers for a guarded prognosis from COVID-19 pneumonia except?

Serum lymphocyte of 1.4 x 10*9 (normal range 1.0- 4.0)

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Serum ferritin 1000 (normal range 20-400)

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Serum LDH 500 (normal range 120-250)

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D-dimer 3500 (normal range 500 ug/L)

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Serum troponin T 100 (normal range <15ng/L)

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The following vaccines are recommended for all patients with stable COPD except?

Respiratory Syncytial Virus vaccine

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Influenzae vaccine

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Pneumococcal vaccine

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SARS-COV-2 vaccination

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Respiratory Module 1

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