Mock Respiratory Module 1

In the management of obstructive sleep apnoea (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 paroxysmal nocturnal dyspnoea on a background of ischaemic heart disease.

An echocardiogram performed last month revealed a left ventricular ejection fraction of 25 percent.

The respiratory parameters from a polysomnographic sleep study demonstrate a crescendo-decrescendo pattern of ventilation with central apnoeas at the nadir.

What is the most likely explanation for the sleep study finding?

Cheyne-Stoke respiration

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Obstructive sleep apnoea

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Periodic limb 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 apnoea, treatment with CPAP is least likely to achieve which of the following outcomes?

Reduced nocturnal snoring

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Reduced daytime somnolence

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Improved mood

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Reduction in risk of cardiovascular mortality.

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Improved health-related quality of life

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A 45-year-old man is diagnosed with obstructive sleep apnoea with an apnoea-hypopnoea index of 50 events per hour. A home trial of CPAP reduced his index to fewer than 5 events per hour but he found CPAP intolerable. Since stopping, his daytime somnolence has worsened.

Which of the following is the most appropriate alternative therapy?

Mandibular advancement splint

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Nasal dilator 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 body mass index of 40 kg/m² has had bulbar-onset motor neurone disease for two years. He reports excessive daytime sleepiness with an Epworth Sleepiness Scale score of 16 out of 24.

A level III sleep study revealed an apnoea-hypopnoea index of 39.9, an average oxygen saturation of 95.1 percent, frequent hypopnoeas and obstructive apnoeas with an average duration of 19.2 seconds, and oxygen desaturation below 90 percent for 5.3 percent of recording time.

Spirometry shows an FEV1 of 2.82 L (78 percent predicted), FVC of 3.81 L (74 percent predicted), and a ratio of 0.78.

Apart from a trial of positive airway pressure therapy, which of the following is the most appropriate next step?

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 formal lung function testing including DLCO

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Request an urgent echocardiogram to assess for pulmonary hypertension

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Refer for a barium swallow to assess aspiration risk

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A patient with a mutation in the PHOX2B gene will most likely benefit from which of the following interventions?

Nocturnal positive pressure ventilation

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Overnight continuous positive airway pressure (CPAP)

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The combination of elexacaftor, tezacaftor and ivacaftor

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Long-term supplemental oxygen therapy

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A respiratory stimulant such as acetazolamide

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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?

The volume of air in the diver's lungs increases

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The volume of air in the diver's lungs decreases

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The partial pressure of carbon dioxide in the diver's lungs decreases

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The partial pressure of oxygen in the diver's lungs decreases

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No change in pressure or gas solubility occurs

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A 60-year-old man undergoes right heart catheterisation with the following results:

mean pulmonary arterial pressure (mPAP) = 23 mmHg
pulmonary arterial wedge pressure (PAWP) = 10 mmHg
pulmonary vascular resistance (PVR) = 3 Wood units.

Based on this haemodynamic profile, which of the following best describes his 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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Exercise-induced pulmonary hypertension

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

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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Pulmonary arterial hypertension secondary to congenital heart disease

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Selexipag is a selective prostacyclin receptor agonist used in pulmonary arterial hypertension.

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

Headache

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Diarrhoea

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Dyspnoea

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Myalgia

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Nausea

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Inhaled treprostinil has 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 thromboembolic disease

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Pulmonary hypertension due to left heart disease

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Pulmonary hypertension due to sleep-disordered breathing

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

Pulmonary hypertension related to chronic thromboembolic disease

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Pulmonary arterial hypertension related to fibrosing mediastinitis

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Pulmonary hypertension related to left ventricular systolic dysfunction

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Pulmonary hypertension related to COPD

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Pulmonary hypertension related to left ventricular diastolic dysfunction

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An average 70 kg man has a respiratory rate of 18 breaths per minute and a tidal volume of 600 mL.

What is his minute (pulmonary) ventilation?

10.8L/min

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15.5L/min

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12.0L/min

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8.1L/min

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10.0L/min

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A 40-year-old man complains of increasing dyspnoea, worsening productive cough and recurrent lower respiratory tract infections. He is infertile and has undergone previous sinus surgery for recurrent nasal polyps and sinusitis. Examination reveals situs inversus.

Which of the following investigations would provide the least useful information in establishing his diagnosis?

Spirometry

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Nasal brush biopsy with electron microscopy

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Nasal nitric oxide measurement

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Genetic testing for mutations in DNAI1 and DNAH5

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High-speed video microscopy of ciliary beat pattern

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A 56-year-old man with moderate COPD (FEV1 60 percent predicted) is an ex-smoker of 30 pack-years. He has a COPD Assessment Test score of 12 and a Modified Medical Research Council dyspnoea score of 2.

His resting oxygen saturation is 90 percent on room air.

Over the past 12 months he has attended the emergency department twice with exacerbations requiring antibiotics and corticosteroids.

He currently takes umeclidinium 62.5 micrograms once daily and salbutamol as required.

Which of the following would be least appropriate?

Prescribe long-term oxygen therapy

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Switch to a long-acting muscarinic antagonist plus long-acting beta-agonist combination

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Add an inhaled corticosteroid if the blood eosinophil count is at or above 300 cells per microlitre

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Refer for pulmonary rehabilitation.

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Recommend annual influenza vaccination.

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Which of the following is the single most effective intervention for improving survival in patients with chronic obstructive pulmonary disease?

Triple inhaler therapy (long-acting muscarinic antagonist, long-acting beta-agonist and inhaled corticosteroid)

Correct Incorrect Correct answer

Long-term oxygen therapy in patients with severe resting hypoxaemia

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Smoking cessation

Correct Incorrect Correct answer

Lung volume reduction surgery in selected patients

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Lung transplantation in selected patients

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A 65-year-old man with severe COPD (FEV1 28 percent predicted) has been stable on triple therapy (tiotropium, salmeterol and fluticasone) with only one exacerbation requiring admission in the past four years.

Concerned about the long-term risks of inhaled corticosteroids, you are considering gradually withdrawing his fluticasone over a three-month period.

But before doing so, you review his blood count, which shows a peripheral blood eosinophil count of 0.45 x 10⁹/L (450 cells per microlitre).

Which of the following statements best guides your management?

A blood eosinophil count at or above 300 cells per microlitre identifies a higher risk of exacerbation following withdrawal, favouring continuation of the inhaled corticosteroid

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A blood eosinophil count is not a useful predictor of outcome after inhaled corticosteroid withdrawal

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The inhaled corticosteroid should be withdrawn regardless of the eosinophil count, as withdrawal is uniformly safe

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A high blood eosinophil count indicates that inhaled corticosteroid withdrawal will reduce his pneumonia risk without any increase in exacerbations

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The eosinophil count should only be checked after withdrawal if he subsequently exacerbates

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A 70-year-old man with severe COPD (FEV1 30 percent predicted) has a COPD Assessment Test score of 20 and a Modified Medical Research Council dyspnoea score of 3. He does not have a history of asthma.

Over the past 12 months he has been hospitalised twice for infective exacerbations.

He currently uses salmeterol-fluticasone (an inhaled corticosteroid–long-acting beta-agonist combination) twice daily with correct technique and good adherence, and salbutamol as required.

His blood eosinophil count is 0.34 x 10⁹/L (340 cells per microlitre).

Which of the following changes would be most appropriate to reduce his risk of future exacerbations?

Escalate to single-inhaler triple therapy (inhaled corticosteroid, long-acting muscarinic antagonist and long-acting beta-agonist)

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Indacaterol-glycopyrronium (dual bronchodilation) alone

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Salmeterol alone

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Glycopyrronium alone

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Add dupilumab, a monoclonal antibody targeting the interleukin-4 receptor alpha subunit

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High-flow nasal oxygen is increasingly used in acute hypoxaemic respiratory failure.

Which of the following is not a demonstrated benefit of high-flow nasal oxygen compared with conventional or alternative respiratory support?

Reduced length of intensive care stay

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A large reduction in all-cause mortality

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A modest reduction in hospital-acquired pneumonia

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A modest reduction in the need for intubation

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Increased patient comfort

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Which of the following statements regarding Preserved Ratio Impaired Spirometry is incorrect?

Patients with this pattern are at higher risk of developing COPD over time

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It is associated with an 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 body mass index are associated with an increased risk of this pattern

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It is associated with increased cardiovascular and all-cause mortality

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Which of the following vaccines is not currently recommended for all patients with stable COPD?

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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Tdap (pertussis-containing) vaccine where not previously received in adulthood

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A 66-year-old man with a 50 pack-year smoking history presents with disabling dyspnoea and reduced exercise tolerance.

Examination reveals poor chest expansion, hyper-resonant percussion, and globally reduced breath sounds without features of cardiac failure.

Spirometry shows an FEV1 of 0.89 L (predicted 2.95 L) and an FVC of 2.10 L (predicted 3.65 L); post-bronchodilator FEV1 rose to 1.1 L and FVC to 3.0 L.

Residual volume is 185 percent predicted, carbon monoxide diffusing capacity is 50 percent predicted, and resting SaO2 is 95 percent on room air.

He is referred to pulmonary rehabilitation.

Which of the following is least likely to improve after completing the programme?

Lung function (spirometry)

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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 wellbeing

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If an adult accidentally inhales a foreign object such as 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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Carina

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Larynx

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Pharynx

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Which of the following patient groups is most likely to benefit from endobronchial valve placement?

Heterogenous emphysema without collateral ventilation

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Severe bronchiectasis

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Severe paraseptal emphysema with active infection

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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 threshold of 500 micrograms per litre has high sensitivity and negative predictive value for excluding pulmonary embolism in patients with low pretest probability, but D-dimer rises with age.

What is the optimal age-adjusted D-dimer cut-off for a 63-year-old patient?

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 anticoagulant indicated for the treatment of deep vein thrombosis and pulmonary embolism.

Which of the following scenarios could favour its use over dabigatran?

A history of dyspepsia

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Elevated blood pressure

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High alcohol intake

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A previous stroke

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Hepatic dysfunction

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A 52-year-old previously healthy man from Tauranga 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?

A reduction in the risk of major haemorrhage

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An improvement in 30-day mortality

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A reduction in in-hospital mortality

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A marked improvement in functional outcome

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An improvement in quality of life

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A 70-year-old woman with known COPD is admitted with a two-day history of worsening breathlessness, cough and sputum production.

She is tachypnoeic with a respiratory rate of 40 breaths per minute and oxygen saturation of 89 percent on 2 L/min of oxygen.

Her arterial blood gas shows acute respiratory acidosis with a pH of 7.20 and a PaCO2 of 100 mmHg.

Which intervention is most likely to reduce her risk of requiring invasive intubation and ventilation?

Non-invasive ventilation (bilevel positive airway pressure)

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Antibiotics

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Continuous positive airway pressure

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Nebulised bronchodilators

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Controlled oxygen therapy targeting saturation above 92 percent

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What is the recommended empirical antibiotic regimen for severe community-acquired pneumonia in a patient living in a non-tropical region of Australia?

Intravenous ceftriaxone plus azithromycin

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Oral roxithromycin

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Intravenous amoxicillin-clavulanate

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Intravenous benzylpenicillin

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Intravenous flucloxacillin

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

Typical carcinoid tumour

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Adenocarcinoma

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Large cell carcinoma

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Small cell carcinoma

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Squamous cell carcinoma

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Regarding positron emission tomography scanning, which of the following statements is incorrect?

PET reliably differentiates thoracic malignancy from tuberculosis

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Tumours smaller than approximately 8 to 10 mm may not be reliably detected by PET

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

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Hyperglycaemia can reduce intracellular uptake of the radiotracer fluorodeoxyglucose

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False-negative results can occur with carcinoid tumours

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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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In individuals with persistent asthma, regular treatment with an inhaled corticosteroid improves all of the following outcomes except?

Reduced risk of dysphonia and oral candidiasis

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Reduced risk of asthma-related death

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Improved asthma symptom control

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Reduced decline in lung function over time

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Reduced frequency of severe exacerbations

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A 35-year-old man presents with fever, malaise, a tender red indurated rash on his shins, and painful swelling of both ankles. His chest radiograph shows bilateral hilar lymphadenopathy.

What is the most likely diagnosis?

Sarcoidosis

Correct Incorrect Correct answer

Reactive arthritis

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Systemic lupus erythematosus

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Tuberculosis

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Lymphoma

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A 37-year-old man from Queenstown, previously well, presents with two months of malaise, lethargy, abdominal pain and headache. He is a current smoker with a 10 pack-year history. Examination is unremarkable.

Serum sodium, potassium and creatinine are normal. His corrected serum calcium is 3.5 mmol/L (reference 2.10 to 2.60 mmol/L) with a suppressed parathyroid hormone of 0.6 pmol/L (reference 1.6 to 6.9 pmol/L).

His chest radiograph shows prominent bilateral hilar lymphadenopathy.

What is the most likely mechanism of his hypercalcaemia?

Elevated serum calcitriol concentrations

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Excessive parathyroid hormone-related peptide secretion

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Increased osteoclastic bone resorption

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Reduced renal calcium clearance

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Mineralocorticoid deficiency

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Mock Respiratory Module 1

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