Respiratory Module 4

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?

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

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?

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?

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

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?

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?

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?

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

Which complication is most likely to occur?

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

What is the most common fungal infection in transplant patient?

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

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

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

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?

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

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 survival?

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.)

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

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

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?

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

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

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

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

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?

Vital capacity is the sum of:

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

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?

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

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

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?

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