Respiratory Module 5

Which of the following best explains how tirzepatide can be beneficial in the treatment of OSA?

Tirzepatide facilitates significant weight loss, which in turn reduces the fat deposits around the neck and improves airway patency.

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Tirzepatide directly stimulates the upper airway muscles, preventing airway collapse during sleep.

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Tirzepatide primarily reduces the inflammatory response in the upper airway, thereby improving airflow.

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Tirzepatide enhances the activity of diaphragm muscles, leading to more effective breathing during sleep.

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Tirzepatide increases the production of surfactant in the lungs, improving overall lung compliance and function.

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A 32-year-old man is referred to the general medical outpatient clinic. He and his wife had been referred by his GP to the infertility clinic for consideration for assisted conception. He is generally fit and well and works as a central heating engineer. He has been referred because he has a chronic productive cough and a history of recurrent chest infections since childhood in addition to recurrent sinusitis.

Investigations show:

Sodium sweat test: Normal
Immunoglobulins (IgG, IgM, IgA): Normal

What is the most likely diagnosis?

Primary ciliary dyskinesia

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Chediak-Higashi syndrome

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Cystic fibrosis

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Situs inversus

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Bronchiectasis

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A 57 year old male, ex-smoker presents with symptoms of headache and dyspnea for the last 3 months including unexplained weight loss.

Clinically, he has marked facial edema with distended veins in both his chest and neck. His face appears flushed. Resting oxygen saturation is 92 percent on air.

What is the most appropriate step?

CT chest

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Check morning cortisol level

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Polysomnography

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Measure IGF-1 level

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Full liver function test

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A 62 year old female patient is thought to be a good candidate for surgical resection of her primary lung cancer in the right upper lobe.

However, based on her recent CT report, the physician is concerned about the possibility of distant metastases.

What would be the best investigation for this?

PET CT

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Whole body MRI

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Nuclear Medicine Bone Scan

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Tumour markers

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Sputum cytology

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Which of the following interstitial lung disease carries the poorest prognosis?

acute interstitial pneumonitis

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usual interstitial pneumonitis

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nonspecific interstitial pneumonia

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desquamative interstitial pneumonia

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lymphocytic interstitial pneumonia

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Which of the following type of interstitial lung disease resolves with smoking cessation?

Respiratory bronchiolitis associated interstitial lung disease (RBILD)

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Acute interstitial pneumonitis (AIP)

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Lymphocytic intersitial pneumonia (LIP)

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Usual interstitial pneumonitis (UIP)

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Non specific intersitial pneumonitis (NSIP)

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Which of the following types of ILD is associated with sjogren’s disease?

Lymphocytic interstitial pneumonitis

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Non-specific interstitial pneumonia

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Usual Interstitial Pneumonia

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Respiratory Bronchiolitis- ILD

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Desquamative Interstitial Pneumonia

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Which of the following feature on radiology would strongly suggest the presence of usual interstitial pneumonia (UIP) as opposed to non specific interstitial pneumonia (NSIP)?

presence of honeycombing

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traction bronchiectasis

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bronchial dilatation

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architectural distortion

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areas of irregular linear opacity

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A 60 year old patient with a long history of COPD presents with increasing shortness of breath and clear sputum production.

Which of the following intervention is most likely to reduce risk of hospitalization?

Oral steroids

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Oral antibiotics

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Inhaled steroids

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IV theophylline

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IV Magnesium

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Which of the following is the strongest indication for thrombolysis in a patient with pulmonary embolism?

Hypotension (systolic blood pressure <90mmHg).

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Pre-existing history of pulmonary hypertension

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Tachycardia (pulse >120/minute).

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Right ventricular enlargement on echocardiogram.

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Large area of embolism on ventilation perfusion lung scan.

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A 30 year old female at 33 weeks gestation presents with acute dyspnea and pleuritic chest pain. She has a sinus tachycardia of 110 bpm and a swollen right leg. Her chest was clear on auscultation.

ECG revealed sinus tachycardia with rate of 110/min and a CXR was normal.

What is the next most appropriate step in management?

Doppler ultrasound scan of lower limbs

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D-dimer

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CT pulmonary angiography

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Ventilation perfusion scan

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Empiric treatment with LMWH for 6 months

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Which of the following condition carries the strongest risk factor for development of a spontaneous pneumothorax?

Having an FEV1/FVC ratio of <40%

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Idiopathic pulmonary fibrosis

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Infrequent episodic asthma

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Pulmonary sarcoidosis

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Rheumatoid arthritis

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A 20 year old male non-smoker, usually fit and well presents with acute onset of left sided chest pain while playing soccer.

His admission chest x-ray shows a moderate sized left sided pneumothorax. His vital signs are otherwise stable.He denies being short of breath and current pain score is 2/10.

What would be the recommended acute management for this patient?

Continued observation

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Chest tube insertion

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High flow nasal oxygen

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Immediate surgical pleurodesis

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Non-invasive ventilation therapy has been shown to provide a short term mortality benefit in which of the following situations?

60 year old man with hypercapneic respiratory failure secondary to COPD

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20 year old woman with status asthmaticus

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40 year old morbidly obese man with sleep apnea

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70 year old man with acute pulmonary edema

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80 year old woman with bronchiectasis and hypoxic respiratory failure

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Which of the following feature is highly suggestive of nicotine dependence?

Smoking within 10 minutes of waking up

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A history of a smoking related illness

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A family history of cigarette smoking

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Absence of previous quit attempts

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Smoking 20 cigarettes per day

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A 50 year old woman with limited scleroderma presents with worsening shortness of breath on exertion. Examination reveals raised JVP and loud P2.

Her ECHO shows normal LV and moderately dilated and hypokinetic right ventricle. Her estimated right ventricular systolic pressure is 65mmHg.

Right heart catheter study confirms elevated right heart pressures with no change to inhaled nitric oxide.

What is the most effective therapy to improve her symptoms in the next 3 months?

Bosentan

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Exercise training program

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Frusemide

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Nifepine

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Supplemental home oxygen

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In a patient with idiopathic pulmonary fibrosis, which of the following treatment will most likely result in the greatest survival benefit?

lung transplantation

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prednisone

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pirfenidone

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nintedanib

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supplemental oxygen

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Which of the following is the best predictor of mortality in patients with idiopathic pulmonary fibrosis?

DLCO and FVC

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FVC only

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FEV1

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FEV1/FVC

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TLC

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What is the DLCO cut-off for transplant referral in patients with idiopathic pulmonary fibrosis?

Below 40%

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Below 50%

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Below 60%

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Below 70%

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Below 80%

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In a critically ill patient who is hemodynamically unstable, which of the following finding would be highly suggestive of an underlying pulmonary embolism?

Right ventricular dysfunction on ECHO

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Widened mediastinum on CXR

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Positive D-dimer

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Positive leg USS for proximal DVT

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Raised JVP

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A 67 year old male presents with acute dyspnea and right sided pleuritic chest pain. He had just underwent a laparotomy with bowel resection 2 weeks ago for bowel cancer.

He is now critically ill and has become hemodynamically unstable.

CTPA confirms the presence of a large saddle embolus in the right main pulmonary artery.

What is the best management?

Percutaneous mechanical thrombectomy

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Commence warfarin

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Immediate thrombolysis

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Commence Low molecular weight heparin

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Give Aspirin

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A patients with severe COPD presents to the emergency department with an acute exacerbation of COPD. As part of the treatment, oral Prednisone 40mg once daily was started on admission. What is the optimum duration of oral glucocorticoid therapy?

Five days total

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Fourteen days total

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Wean off by 10mg per week for total of 4 weeks duration.

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Wean off by 5mg per week for a total of 4 weeks duration.

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Wean off by 10mg per week for a total of 6 weeks duration.

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Which of the following radiological feature is an independent predictor of mortality in patients with interstitial pulmonary fibrosis (IPF)?

Extent of reticulation and honeycombing

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Presence of micronodules

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Extent of traction bronchiectasis

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Extensive ground glass attenuation

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Extensive mediastinal adenopathy

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Which of the following bronchial challenge test causes a direct constriction of the airway smooth muscles?

Methacholine

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Mannitol

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Hypertonic saline

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Exercise challenge

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Adenosine monophosphate

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A 64 year old man with a background of moderate COPD (FEV1 of 55%) has been newly diagnosed with metastatic lung squamous cell carcinoma. Apart from referring him to the medical oncologist for consideration of systemic chemotherapy,which of the following is the most appropriate next step in management?

Early palliative care referral

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Optimize bronchodilators

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Arrange an urgent lung function test with DLCO.

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Optimize his nutritional status prior to chemotherapy

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Referral to pulmonary rehabilitation

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A 37 year old man has been recently diagnosed with sarcoidosis associated with mild hypercalcemia of 2.6 mmol/L and has been recently commenced on oral prednisone for his sarcoidosis. Last week, he visited his GP and was started on an oral thiazide diuretic for blood pressure control. He has been informed that he is at high risk of developing kidney stones so have been somewhat compliant with a restricted calcium and oxalate diet. However, he now presents to ED with increased confusion and is found to have severe hypercalcemia of 5 mmol/L.

What is the most likely cause for his worsening hypercalcemia?

Thiazide diuretic

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Inadequate restriction of dietary calcium

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Inadequate restriction of dietary oxalate

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Prednisone use

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Underlying malignancy causing excess PTHrP secretion.

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Dupilumab has been recently shown to be effective in the treatment of moderate to severe uncontrolled asthma.

Which pro-inflammatory signal does it block?

Interleukin-4 and interleukin-13.

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Interleukin-5.

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Interleukin-17 and interleukin-23.

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Interleukin-4 and interleukin-17.

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Interleukin-5 and interleukin-13.

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Which of the following cytotoxic drug carries the highest risk of interstitial pneumonia and lung injury?

Bleomycin

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Paclitaxel

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Peplomycin

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Vinorelbine

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Pemitrexed

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Pulmonary function test has an essential role in monitoring the progression of interstitial lung disease. When used for monitoring disease progression, which parameter could be regarded as significant?

10% change in FVC OR 15% change in DCLO from baseline

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10% change in FEV1 AND 15% change in DLCO from baseline

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15% change in FVC OR 10% change in DLCO from baseline

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15% change in FEV1 OR 15% change in DLCO from baseline

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10% change in FVC OR 10% change in DLCO from baseline

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Which of the following condition has a predominantly lymphocytic cellular pattern on bronchoalveolar lavage (BAL)?

Sarcoidosis

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Eosinophilic pneumonias

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Idiopathic pulmonary fibrosis

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Diffuse alveolar damage

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Asbestosis

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A 75 year old man presents with several months history of dry cough and progressive breathlessness on exertion. On examination, he has finger clubbing, reduced chest expansion and on chest auscultation, fine velcro inspiratory crackles can be heard bi-basally. His current oxygen saturation is 88 percent on air.

A HRCT performed demonstrates areas of subpleural honeycombing with moderate to severe traction bronchiectasis bibasally along with extensive reticulation in the right lower lobe.

You suspect that this patient has some form of interstitial lung disease but which of the following investigation should be avoided as part of your diagnostic work up?

Surgical lung biopsy

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Bronchoalveolar lavage

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Discussion at the multi-disciplinary meeting.

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Pulmonary function test

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Serologic testing

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Which of the following treatment should be avoided in patients with idiopathic pulmonary fibrosis?

Combination of prednisone, azathioprine and N-acetylcysteine

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Pirfenidone

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Nintedanib

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Omeprazole

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Domiciliary oxygen

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Mepolizumab is a humanized monoclonal antibody that has been recently recognized as being effective in the treatment of severe chronic eosinophilic asthma.

What is the target receptor for this medication?

Interleukin-5

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Immunoglobin E (IgE)

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Interleukin-4

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Thymic stromal lymphopoietin (TSLP)

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Interleukin-13

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You are more likely to improve severe asthma control by blocking the actions of the following pro-inflammatory cytokines except?

Interleukin-23

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Interleukin-5

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Interleukin-33

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Thymic stromal lymphopoetin (TSLP)

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Interleukin-4

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In COPD patients with Type 2 inflammation, the blocking of which pro-inflammatory cytokine/s can likely lead to fewer exacerbations?

Interleukin 4 and Interleukin 13

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Interleukin 5

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Thymic stromal lymphoprotein (TSL)

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Interleukin 4 and 5

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Interleukin 23

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The following statements are all part of the Asthma Control Questionnaire-5 (ACQ-5) except?

asthma symptoms upon waking up in the morning.

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nocturnal asthma symptoms.

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limitation in activities due to asthma.

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confidence in leaving home due to asthma.

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Gefapixant is a P2X3 receptor antagonist that has shown promising results for the treatment of refractory and unexplained chronic cough.

What is the most common side effect of this medication?

Taste disturbance

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Severe nausea

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Autoimmune Encephalitis

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Hallucinations

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Postural hypotension

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What is recommended for treating pneumothorax with persistent air leak in adults who are not fit for surgery?

Tube drainage

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Chemical pleurodesis

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Autologous blood pleurodesis

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Repeated needle aspirations

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Respiratory Module 5

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