Respiratory Module 4

A 55-year-old woman presents with a 2-year history of cough and dyspnea. Imaging studies reveal a 3-cm mass in the right lung. Fine-needle aspiration biopsy is performed, and the pathology report suggests a neuroendocrine tumor. Immunohistochemical staining is ordered to confirm the diagnosis.

Which of the following biomarkers is most specific for neuroendocrine tumors, including carcinoid tumors, and is likely to be positive in this patient’s tumor?

INSM1 (Insulinoma-associated protein 1)

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Chromogranin A

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Synaptophysin

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TTF-1 (Thyroid transcription factor

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p63

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A 65-year-old male presents to the emergency department with progressive breathlessness over the past two weeks. He has a history of chronic heart failure and type 2 diabetes mellitus.

On examination, he is tachypneic with a respiratory rate of 24 breaths per minute, oxygen saturation of 89% on room air, and decreased breath sounds with dullness to percussion at the right lung base.

A chest X-ray confirms a large right-sided pleural effusion.

Which of the following best explains the pathophysiology of breathlessness in this patient?

Decreased respiratory system compliance due to mechanical restriction and increased pleural pressure

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Impaired gas exchange due to atelectasis and reduced perfusion in the compressed lung

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Altered diaphragmatic movement leading to inefficient ventilation

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Increased intrapleural pressure causing reduced venous return and decreased cardiac output

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Compensatory hyperventilation to correct for hypoxemia leading to respiratory alkalosis

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A 62-year-old male ex-heavy smoker of 40 pack years, presents to the clinic with worsening shortness of breath, chronic cough, and frequent exacerbations of COPD.

His FEV1 is measured at 18% of predicted, and his BODE index is calculated to be 8.

He has experienced two episodes of hypercapnic respiratory failure in the past year. On arterial blood gas analysis, his PCO2 is 53 mmHg, and his PO2 is 58 mmHg.

He has just been recently diagnosed with bowel cancer and is currently awaiting an oncology appointment.

Based on the above clinical scenario, which of the following criteria would exclude him from being considered for lung transplant?

Recent diagnosis of bowel cancer

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Forced expiratory volume in one second of 18 percent predicted.

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Body-mass, airflow obstruction, dyspnea and exercise (BODE) index of 8.

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Chronic Type 2 respiratory failure with PCO2 >50 mmHg and/or PO2 <60 mmHg.

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Recurrent exacerbations of hypoxic respiratory failure

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Which of the following is not a criterion for lung transplant in Interstitial Lung Disease (ILD)?

Decline in FVC of > 5% or decline in DLCO > 5% within the prior 6 months

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Any form of pulmonary fibrosis with forced vital capacity (FVC) of <80% predicted or diffusing capacity of the lungs for carbon monoxide (DLCO) <40% predicted

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Development of pulmonary hypertension demonstrated by ECHO or right-heart catheter

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Desaturation to < 88% on 6-minute walk test or >50 m decline in 6-minute walk test distance in the past 6 months

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Inflammatory ILD where there is progressive decline of pulmonary function with radiographic progression despite treatment

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A 55-year-old male patient with end-stage idiopathic pulmonary fibrosis underwent bilateral lung transplantation 18 months ago. He has been closely monitored post-transplant and has been compliant with his immunosuppressive medications.

Recently, he presents to the transplant clinic for his routine follow-up visit complaining of increasing dyspnea on exertion and a persistent dry cough.

Physical examination reveals decreased breath sounds at the lung bases bilaterally. Pulmonary function tests show a significant decline in forced expiratory volume in one second (FEV1) compared to baseline measurements taken three months ago. The patient’s FEV1 is now 65% of the baseline value.

Which of the following would be most characteristic of chronic allograft lung dysfunction (CLAD) in this patient?

Presence of bronchiolitis obliterans syndrome (BOS) on lung biopsy.

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Acute onset within the first year post-transplant

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Improvement in pulmonary function tests over time

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Presence of restrictive lung physiology

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Transient decline in lung function after the first year post-transplant

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A 55-year-old patient with end-stage renal failure on peritoneal dialysis (PD) presents with recurrent shortness of breath. Chest X-ray shows a large pleural effusion on the right side. The patient has had multiple episodes of pleural effusion in the past, which have been treated with thoracentesis. Pleural fluid analysis from the latest thoracentesis reveals:

Glucose: 300 mg/dL (normal pleural fluid glucose: 50-80 mg/dL)
Protein: 0.5 g/dL (normal pleural fluid protein: 2-4 g/dL)
LDH50 U/L (normal pleural fluid LDH: 100-200 U/L)
pH: 7.4 (normal pleural fluid pH: 7.35-7.45)
Cell count: 100 cells/μL (normal pleural fluid cell count: <1000 cells/μL), predominantly mononuclear cells.

Which of the following is the most likely cause of the recurrent pleural effusion in this patient?

Dialysate leakage from peritoneal dialysis

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Heart failure

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Malignancy

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Pulmonary embolism

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Tuberculosis

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Treatment with an inhaled corticosteroid (ICS) should be considered for patients with any of the following except?

stable COPD patient with no previous exacerbation in the last 12 months.

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exacerbations of asthma in the last two years

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asthma symptoms three times a week or more

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waking at least one night per week due to asthma symptoms

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asthma symptoms once a week.

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A 50 year old male with previous lung transplant develops a persistent cough with increasing shortness of breath for the last 3 days. Early inspiratory crackles are heard on lung auscultation.

Pulmonary function test demonstrates irreversible airflow obstruction with decreased FEV1:FVC ratio and a low DLCO

His chest radiograph shows normal lungs. However the HRCT shows air trapping by the expiratory view with a mosaic pattern, bronchiolectasis and small airway wall thickening.

What is the most likely diagnosis?

Constrictive Bronchiolitis Obliterans

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Hypersensitivity pneumonitis

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Sarcoidosis

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Severe asthma

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Chronic obstructive pulmonary disease

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A 17 year old male is referred with poorly controlled asthma. He has been taking inhaled Budesonide 400mcg 1 puff twice daily for the past 5 months but continues to have daily wheeze and cough requiring up to 6 additional puffs of inhaled corticosteroid each day.

His inhaler technique is satisfactory and all other treatable traits have been considered.

His chest X ray shows hyperinflation but otherwise unremarkable. His lung function test shows moderate obstructive pattern with 93% increase in FEV1 after bronchodilator therapy.

What is the most appropriate next step?

add inhaled salmeterol 50mcg twice daily

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add 10mg prednisone on alternate days

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add oral montelukast 5mg once daily

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increase budesonide dose to 800mcg twice daily

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replace budesonide with fluticasone 125mcg 2 puffs twice daily

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A 30 year old female with a history of asthma and chronic sinusitis develops worsening shortness of breath and wheezing after ingesting aspirin. She responded to treatment with salbutamol, oral corticosteroids, inhaled fluticasone and montelukast.

What other clinical feature would this patient have?

nasal polyps

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aortic regurgitation

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palmar erythema

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subcutaneous nodules

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finger clubbing

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A patient is on long term inhaled corticosteroid for her asthma.

Which complication is most likely to occur?

hoarse voice

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oral candidiasis

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cataracts

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skin thinning

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osteoporosis

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What is the antibiotic of choice for treating community acquired pneumonia?

penicillin plus doxycycline

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penicillin alone

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penicillin plus gentamicin

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ciprofloxacin

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Vancomycin

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What is the most common fungal infection in transplant patient?

Candida

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Aspergillus

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Zygomycetes

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Scedosporium

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Cryptococcus

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In immunosuppressed patients, the use of galactomannan assay is useful in the diagnosis of which type of infection?

Invasive aspergillosis

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Staph aureus septicemia

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Gram negative septicemia

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Candida albican

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Meningococcal septicemia

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What is the most common bacteria isolated in acute exacerbation of COPD?

Haemophilus influenzae

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Pseudomonas spp.

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Streptococcus spp.

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Moraxella catarrhalis

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Klebsiella pneumoniae

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In a 65 year old male with COPD, which of the following carries the greatest risk of death over the next 12 months?

Hospitalisation for an acute exarcerbation of the disease

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FEV1 of 60% predicted

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BMI of <20kg/m2.

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PaO2 of 58mmHg

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PaCO2 of 47mmHg

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The BODE index is a useful clinical tool in predicting the risk of death in patients with COPD.

Which of the following parameter is not part of the BODE index?

Age

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FEV1(% of predicted)

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Distance walked in 6 minutes

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Dyspnea scale

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Body mass index

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In patients with COPD, which of the following intervention has the greatest impact on mortality?

Smoking cessation

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Short acting beta agonist

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Flu vaccination

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Long acting beta agonist

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Pulmonary rehabilitation

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An 80-year-old male with advanced COPD presents with 6 months history of progressive breathlessness along with orthopnea and PND. Clinically, he is hypoxic at rest with a resting oxygen saturation of 86 percent. There is globally reduced air entry on both lungs with fine inspiratory crackles at the lung bases. His JVP is elevated at 3cm. He has abdominal ascites and pitting edema up to both knees.His arterial blood gas shows a PO2 of 56mmHg with normal PCO2 and normal pH.

His chest x-ray shows hyper-inflated lung fields with some interstitial edema.

What is the best treatment to improve his long-term survival?

long term oxygen therapy

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frusemide infusion

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periodic paracentesis for his ascites.

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short term oxygen therapy

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triple inhaler therapy.

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Calculate the A-a gradient of this patient based on the following ABG:

Ph 7.49
pCO2 48 mmHg
PO2 54 mmHg
HCO3 33 mmHg

(Assume the atmospheric pressure at sea level is 760 mmHg., the respiratory quotient is 0.8 and the water vapour pressure is 47 mmHg.Fi02 is 0.21.)

35mmHg

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25mmHg

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30mmHg

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40mmHg

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45mmHg

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Which one of the following is a contraindication to surgical resection in lung cancer?

Vocal cord paralysis

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Hemoptysis

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FEV 1.9L

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Histology showing squamous cell cancer

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Calcium of 2.84mmol/L

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Which of the following feature is not consistent with the diagnosis of eosinophilic bronchitis?

the condition is not steroid responsive

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presence of >2.5% eosinophils in induced sputum

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absent of airway hyperesponsiveness

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A cause of chronic cough

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Atopy at the same frequency as general population.

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In COPD patients with moderate symptom burden and frequent exacerbation, the combination of inhaled corticosteroids and LABA is likely to a have a positive impact on the following features, except?

Improved mortality

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Quality of life

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Reduced frequency of exacerbation

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Improved symptom

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Delays exacerbations

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The use of Tiotropium in COPD patients improves all of the following except?

Reduces rate of loss lung function

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Frequency of exacerbations

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FEV1

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Symptom score

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Quality of life

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Which of the following monoclonal antibodies is beneficial in the treatment of asthma in young adults?

Omalizumab

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Natalizumab

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Infliximab

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Interferon alpha

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Tocilizumab

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Which of the following is not an indication for a bronchoscopy in patients with bronchiectasis?

routine bronchoscopic sampling of the lower respiratory tract

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to exclude proximal obstruction in a localized disease.

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high-resolution CT (HRCT) suggests atypical mycobacterial infection but negative sputum culture

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failure of responding to treatment.

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when bronchiectasis affects a single lobe in children.

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Which of the following lung cancer is most associated with smoking?

Small cell

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Adenocarcinoma

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Large cell

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Neuroendocrine

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Squamous cell

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A 50 year old smoker is found to have an asymptomatic solitary pulmonary nodule on chest CT.

Which of the following features would be the strongest predictor of malignancy?

Irregular with spiculated margins

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Size of less than 3mm

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Doubling time greater than 500 days

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Increased radiological density (>170 Hounsfield units)

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Smooth, discreet border

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Vital capacity is the sum of:

Tidal volume, inspiratory reserve volume and expiratory reserve volume

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Tidal volume and expiratory reserve volume

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Tidal volume and inspiratory reserve volume

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Tidal Volume and residual volume

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Inspiratory reserve volume and expiratory reserve volume

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The following are all suitable criteria for diagnosing a patient with cystic fibrosis except?

Elevated sweat chloride on two occasions

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Positive newborn screening test

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A sibling with Cystic Fibrosis

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Genotype consistent with CF

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Abnormalities in ion transport across airway or nasal epithelium

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Increasing the activity of defective cystic fibrosis transmembrane conductance regulator (CFTR) protein is a potential treatment for cystic fibrosis. A recent randomized controlled trial have demonstrated the efficacy of combination treatment with CFTR modulators elexacaftor, tezacaftor and ivacaftor.

Which group of CF patients will most likely benefit from this combination therapy?

F508del mutation

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R117H Missense

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W1282X mutation

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R553X mutation

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Which of the following is the highest risk factor for developing lung cancer?

Smoking

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Radiation

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Asbestos exposure

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Heavy metals

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Radon

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What is becoming the most common histological finding in lung cancer especially in females?

Adenocarcinoma

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Large cell carcinoma

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Squamous cell carcinoma

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Small cell carcinoma

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Oat cell carcinoma

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A 60 year old lady is referred to your respiratory clinic for advise on further management of her COPD. She is an ex-smoker with a 10 pack year smoking history. She has been complaining of worsening dyspnea over a period of 6 months. This is despite being on maximal medical therapy and following completion of 6 weeks pulmonary rehab program.

Her latest lung function test is shown below:

FEV1 of 1.8L, 82% predicted.
FVC of 2.74L, 96% predicted.
FEV1/FVC ratio of 0.6
TLC of >110% predicted, RV of >250 percent predicted.
DLCO of 50% predicted.

These are the coronal and sagittal views of her chest CT:

Which of the following factors would make her a less favorable candidate for a bullectomy?

HRCT appearance demonstrating homogeneous, diffuse emphysema without a single large bulla

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Having a TLC above 100 percent and RV of more than 200 percent predicted.

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A previous ex-smoker

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Age 60 years old

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Having progressive dyspnea despite being on maximal inhaler therapy.

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Amivantamab may have a role in the treatment of which type of lung cancer?

Metastatic NSCLC with EGFR exon 20 insertions.

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Metastatic NSCLC with ALK mutation

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Metastatic NSCLC with wild type EGFR mutation

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Metastatic NSCLC with EGFR T790M resistance mutation.

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Respiratory Module 4

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