Pulmo Flashcards by J Z

A 55/M chronic smoker, former miner in Benguet, with hypertension and kyphoscoliosis presented with persistent exercise limitation despite smoking cessation and adherence to his anti-hypertensive medications. Chest x-ray revealed hyperinflated lungs and flattened hemidiaphragm while pulmonary function tests reveal obstructive ventilatory defect and reduced peak flow. Which of the following is the MOST likely etiology of his symptoms?

a.COPD
b.Left heart failure
c. Kyphoscoliosis
d.Interstitial lung disease

A. COPD

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A 65/ M with COPD is consulting for dyspnea. He is compliant to his inhaler therapy but reports that he needs to stop to rest when walking at his own pace on level ground. What is the grade of his dyspnea using the Modified Medical Research Council Dyspnea Scale?

a. Grade 1
b. Grade 2
c. Grade 3
d. Grade 4

Grade 2

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Which of the following is the procedure of choice to control massive hemoptysis?

a. Bronchial artery embolization
b. Surgical resection
c.Bronchoscopy with balloon catheter insertion
d.Rigid bronchoscopy with photocoagulation

Bronchial artery embolization

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Which of the following causes of hypoxia may be corrected by inspiring 100% O2 for several minutes?

a. Hypoventilation
b. Eisenmenger’s syndrome
c. Pulmonary atelectasis
d. Pulmonary AV malformation

Hypoventilation

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Which of the following is the most common mechanism of entry of bacteria to the lower respiratory tract?

a. Aspiration from the oropharynx
b. Hematogenous spread
c. Contiguous extension from an infected pleural or mediastinal space
d. Inhalation of pathogenic bacteria

Aspiration from the oropharynx

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Which of the following is a known risk factor for community-acquired methicillin-resistant Staphylococcus aureus (MRSA)?

a. Congestive heart failure
b. Gastric acid suppression
c. Chronic hemodialysis in previous 30 days
d. Gross hemoptysis

Gross hemoptysis

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A 64/M with type 2 diabetes mellitus, hypertension and dyslipidemia presented at the ER for a 5-day history of productive sputum, exertional dyspnea and low-grade fever. Examination showed BP 120/65, HR 100, RR 24, T 37.8°C, O2 saturation 95% at room air, GCS 15 and coarse crackles at the right lung base. Pertinent labs showed elevated procalcitonin, BUN 5 mmol/L, eGFR 78 mL/min/1.73 m2, Hb 120 and WBC 12. Imaging showed reticulonodular infiltrates on the right lung base. What is the CURB-65 score of the patient?

a. 0
b. 1
c. 2
d. 3

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A 62/F on chronic hemodialysis was brought to the ER for dyspnea, productive cough and increased sleeping time. She self-medicated with multiple antibiotics with no resolution of symptoms. She was eventually intubated for respiratory distress and was admitted at the ICU. Which of the following is an appropriate empiric antibiotic regimen for the patient?

a. Cefepime 2 g IV every 8 hours + Levofloxacin 750 mg IV every 24 hours + Linezolid 600 mg IV every 12 hours
b. Piperacillin tazobactam 4.5 g IV every 6 hours
c. Piperacillin tazobactam 4.5 g IV every 6 hours + Cefepime 2 g IV every 8 hours
d. Cefepime 2 g IV every 8 hours + Levofloxacin 750 mg IV every 24 hours

Cefepime 2 g IV every 8 hours + Levofloxacin 750 mg IV every 24 hours + Linezolid 600 mg IV every 12 hours

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In patients with ventilator-associated pneumonia (VAP) or hospital-acquired pneumonia (HAP), what is the recommended duration of antibiotic therapy according to the Infectious Diseases Society of America (IDSA)?

a.7 days
b.5 days
c.14 days
d.21 days

7 days

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Which of the following pathogens may be more common in the non-VAP population with hospital-acquired pneumonia? (HPIM20 C121 P918)

a.Gram-positive organisms
b. Gram-negative organisms
c.Anaerobes
d. Atypical pathogens

Anaerobes

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For a sputum sample to be adequate for culture, the following criteria should be met on Gram stain:

a. >25 neutrophils and <10 squamous epithelial cells per low-power field
b. >25 neutrophils and <10 squamous epithelial cells per high-power field
c.<25 neutrophils and >10 squamous epithelial cells per low-power field
d.<25 neutrophils and >10 squamous epithelial cells per high-power field

> 25 neutrophils and <10 squamous epithelial cells per low-power field

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A 33/M post-stroke patient consulted for a 1-month history of on/off fever, productive cough with putrid smelling sputum and pleuritic chest pain. Chest X-ray showed a solitary thick-walled cavity measuring 5 cm with air-fluid level found at the middle posterior lobe of the right lung. Which of the following is the most appropriate empiric therapy?

a. Clindamycin
b. Ceftriaxone + Azithromycin
c. Metronidazole
d. Vancomycin

Clindamycin

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Which of the following pathophysiologic processes explain the occurrence of crackles?

a.Obstruction of medium-sized airways
b.Alveolar filling
c.Fibrosis of the interstitium
d.Consolidation of lung parenchyma

b.Alveolar filling

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Which of the following describes exercise-induced asthma?

a. Best prevented by regular treatment with inhaled corticosteroids (ICS)
b. Typically begins before, during, or after exercise has ended
c. Does not resolve spontaneously
d. Worse in hot, humid conditions

Best prevented by regular treatment with inhaled corticosteroids (ICS)

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Which of the following is the characteristic physiologic abnormality in asthma?

a. Airway hyperresponsiveness
b.Airway remodeling
c.Reversibility of airflow limitation
d.Eosinophil infiltration and mast cell activation

Airway hyperresponsiveness

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A 22/M with known asthma and maintained on PRN albuterol consulted your clinic for increased inhaler use to 3x/week. He reports nocturnal awakening once a week but denies limitation of activities and daytime symptoms. Which of the following is the next step in the management of this patient?

a. Add inhaled corticosteroids to his current medications
b. Continue short-acting beta-agonist inhaler
c. Start long-acting beta-agonist on top of his current medication
d. Start intravenous corticosteroids to control his symptoms

Add inhaled corticosteroids to his current medications

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A 37/M consulted for shortness of breath, chest tightness and wheezing. He underwent spirometry with reduced FEV1 and reduced FEV1/FVC. He has been having troublesome daily symptoms and night-time awakening most days of the week. What initial treatment is recommended for the patient?

a. As needed low dose inhaled corticosteroid (ICS)-formoterol
b. As needed short-acting β2-agonist
c. Low dose maintenance ICS-formoterol
d. Medium dose maintenance ICS-formoterol

Medium dose maintenance ICS-formoterol

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Which of the following pathologic types of emphysema is associated with cigarette smoking?

a. Centrilobular
b. Panlobular
c. Paraseptal
d. Panseptal

Centrilobular

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A 65/M consulted for persistent dyspnea. He presents with a 5-year history of cough and chronic sputum production. He was previously diagnosed with COPD but was non-compliant to his inhaler therapy. Currently, he complains of breathlessness when walking briskly on level ground or at his own pace. He also has a history of one hospital admission six months prior due to exacerbation. What is his COPD Group Severity Classification?

a. A
b. B
c. C
d. D

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Which of the following interventions is the only pharmacologic therapy demonstrated to unequivocally decrease mortality rates in patients with COPD?

a. Long-acting beta-2 agonists (LABA)
b. Inhaled corticosteroids (ICS) + LABA
c. Oxygen therapy
d. Long-acting muscarinic antagonists (LAMA)

Oxygen therapy

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Which of the following interstitial lung diseases (ILD) is strongly associated with smoking?

a. Respiratory bronchiolitis-associated ILD
b. Idiopathic pulmonary fibrosis (IPF)
c. Nonspecific interstitial pneumonitis (NSIP)
d. Sarcoidosis

Respiratory bronchiolitis-associated ILD

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Which of the following is now considered to be the standard of care in the initial evaluation of a patient with suspected interstitial lung disease?

a. Bronchoscopy
b. Chest radiograph
c. High resolution chest CT
d. Lung biopsy

HRCT

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A boilermaker in a shipyard consulted for chronic cough and progressive dyspnea. Considering his occupational exposure, what is the expected chest radiographic hallmark of his condition?

a.Irregular or linear opacities that usually are first noted in the lower lung fields
b.Profuse military infiltration
c. Small rounded opacities in the upper lobes
d. Nodules generally confined to the upper half of the lungs

Irregular or linear opacities that usually are first noted in the lower lung fields

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Which of the following interstitial lung diseases presents with non-caseating granulomas on histopathology?

a. TB-associated ILD
b. Systemic sclerosis-associated ILD
c. Sarcoidosis
d. Acute interstitial pneumonia

Sarcoidosis

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Which of the following is the most common cancer associated with asbestos exposure? a. Mesothelioma b. Lung cancer c. Breast cancer d. Lymphoma

Lung cancer

Which of the following laboratory parameters can differentiate an effusion from malignancy versus heart failure? a. Lactate dehydrogenase b. Glucose c. Differential count d. pH

Lactate dehydrogenase

A 28/M with critical COVID-19 was intubated for respiratory distress and desaturation as low as 48% on room air. He had no recurrence of desaturation while on mechanical ventilation until the 4th hospital day when the patient was referred for O2 saturation as low as 82% while on ACVC FiO2 100% and PEEP 14. Recruitment maneuver was done by increasing PEEP to 30 for 30 seconds. After 5 minutes, he was noted to have hypotension and persistent desaturation. PE showed absent breath sounds on the right, hyperresonant right hemithorax on percussion and tracheal deviation to the left. What is the definitive management? a.Chest tube insertion b. Needling c. Mechanical ventilation with FiO2 100% and lower pressure support d. Refer to Pulmonology

Chest tube insertion

A 45/F with breast cancer was admitted for fever, dyspnea and weight loss. She immediately underwent thoracentesis for left-sided pleural effusion. Further work-up revealed loculated pleural effusion, gross pus in the pleural space, pleural fluid glucose 40 mg/dL and presence of gram-negative organism on Gram stain. Which of the following patient factors most importantly indicates a need for a more invasive procedure than a thoracentesis? a. Loculated pleural effusion b. Gross pus in the pleural space c. Pleural fluid glucose 40 mg/dL d. Gram-negative organism on Gram stain

Loculated pleural effusion

Which of the following compartments of the mediastinum is commonly affected by masses of vascular origin? a. Anterior b. Middle c. Posterior d. Lateral

Middle

A 34/M former varsity athlete was playing basketball when he developed sudden onset dyspnea. Upon assessment at the ER, he had stable vital signs and absent breath sounds on the left with no tracheal deviation. What is the diagnosis? a. Primary spontaneous pneumothorax b. Secondary spontaneous pneumothorax c. Tension pneumothorax d. Traumatic pneumothorax

Primary spontaneous pneumothorax

A 50/M was brought to the ER due to dyspnea and was found to have massive pleural effusion. Thoracentesis showed milky fluid which was found to have triglyceride 150 mg/dL. What is the treatment of choice for his condition? a. Insertion of a chest tube and administration of octreotide b. Ligation of the thoracic duct c. Percutaneous transabdominal thoracic duct blockage d. Prolonged thoracostomy with chest tube drainage

Insertion of a chest tube and administration of octreotide

A 50/F was admitted for mastectomy for breast cancer stage 3. She remained bedridden for a week, then developed fever, sudden onset dyspnea and refractory desaturation. Examination showed HR 120, BP 90/50, O2 saturation 88%, with pitting edema and tenderness over the right leg. What is the likelihood of pulmonary embolism (PE) in this case? a. Low b. Moderate c. High d. Unlikely

High

Which of the following patients with pulmonary embolism can be managed with anticoagulation alone? a. 58/F with known metastatic breast cancer, BP 90/60, with right ventricular wall hypokinesia on echocardiography b. 50/M smoker with documented deep vein thrombosis on venous duplex scan, BP 70/40 despite administration of dopamine and dobutamine c. 25/F with COVID-19, moderate pneumonia, BP 90/60, HR 120, with normal right and left ventricular wall motion and contractility on echocardiography d. 45/M with COPD in exacerbation, with persistent desaturation despite intubation and mechanical ventilation, clubbing and cyanosis noted in the fingernails, BP 80/50 on dopamine, with perfusion defect in the presence of normal ventilation on lung scan

25/F with COVID-19, moderate pneumonia, BP 90/60, HR 120, with normal right and left ventricular wall motion and contractility on echocardiography

A 60/M was admitted due to deterioration of sensorium. He is on palliative therapy for stage 4 colon cancer, and warfarin for documented deep venous thrombosis. PE findings showed GCS 7 with preferential movement of right upper and lower extremities, BP 160/100, HR 54. Plain cranial CT showed a bleed on the left basal ganglia with surrounding edema. INR is 4. Which of the following is the best treatment for the patient? a. Prothrombin complex concentrate b. Protamine Sulfate c. Platelet concentrate d. Parenteral Vitamin K

Prothrombin complex concentrate

At what level of apnea-hypopnea index can you make a diagnosis of obstructive sleep apnea/hypopnea syndrome in the absence of symptoms? a. Apnea-hypopnea index > 20 episodes/hour b. Apnea-hypopnea index > 15 episodes/hour c. Apnea-hypopnea index > 10 episodes/hour d. Apnea-hypopnea index > 5 episodes/hou

Apnea-hypopnea index > 15 episodes/hour

A 55/M with diabetes and hypertension was referred for evaluation of gasping and snoring during sleep. He reported having trouble concentrating and suddenly dozing off at work. His BMI is 32 kg/m2. On work-up, his apnea-hypopnea index is 32 events/hour. What is the best management for this patient? a. Continuous positive airway pressure b. Oral appliances c. Upper airway surgery d. Upper airway neuro-stimulation

Continuous positive airway pressure

Which of the following interventions must be done in a 26/M obese patient on CPAP and complaining of aerophagia? a. Administer antacids b. Change mask interface c. Provide bilevel positive airway pressure d. Provide heated humidification

Administer antacids

A 53/M with known hypertension and diabetes came into the ER due to difficulty breathing. He has been experiencing progressive exertional dyspnea over the past few days, associated with orthopnea, intermittent chest discomfort and occasional undocumented febrile episodes. His home medications include dapagliflozin, losartan and furosemide. PE findings showed BP 80/60; HR 120s; RR 30s; T 38°C; distended neck veins; coarse bibasal crackles; soft heart sounds; and cold, clammy extremities. What was the most likely cause of his hypotension? a. Adrenal insufficiency b. Cardiogenic shock c. Hypovolemic shock d. Septic shock

Cardiogenic shock

In the natural history of ARDS, what phase is characterized by injury to the alveolar capillary endothelial cells with loss of normally tight alveolar barrier to fluid leading to accumulation of edema fluid in the interstitial and alveolar spaces? a. Exudative b. Proliferative c. Fibrotic d. Resolution

Exudative

A 28/M with COVID-19 was sent to the ER for a 1-week history of progressive dyspnea and febrile episodes. At the ER, he was intubated for respiratory distress and was immediately admitted at the ICU. Chest radiograph showed bilateral opacities and normal-sized heart. Post intubation ABG showed pH 7.3, HCO3 9, pCO2 25, PaO2 200 at FiO2 100%. What is the ARDS severity? a. Moderate b. Mild c. Severe d. Critical

Moderate

Which of the following is NOT a Class B recommendation for the treatment of ARDS? a. Low tidal volume b. Minimized left atrial pressures c. High PEEP d. Prone position

Low tidal volume

A 45/F with preexisting barotrauma was intubated for respiratory distress. Which of the following is the preferred mode of ventilation for this patient? a. Pressure-control ventilation b. Inverse-ratio ventilation c. Intermittent mandatory ventilation d.Airway pressure release ventilation (APVR)

Pressure-control ventilation

In the treatment of bronchiectasis with acute exacerbations, antibiotics should be administered to target which common isolates or presumptive pathogens? a. Anaerobes and Pseudomonas aeruginosa b. Streptococcus pneumoniae and Staphylococcus aureus c. Haemophilus influenzae and Pseudomonas aeruginosa d. Mycobacteria and Legionella spp.

Haemophilus influenzae and Pseudomonas aeruginosa

A 45/M with critical COVID -19 was hooked to high-flow nasal cannula (40 LPM, FiO2 90%) at the ER. After two hours, findings showed RR 30, O2 saturation was 90% at FiO2 90%, with the rest of the vital signs stable. What is the Rox Index? a. 3.3 b. 0.33 c. 0.37 d. 3.7

3.3

Which of the following criteria may aid in distinguishing transudative from exudative effusion outside of the Light’s criteria? a. Pleural fluid protein/serum protein >0.5 b. Pleural fluid LDH/serum LDH >0.6 c. Pleural fluid LDH more than two-thirds the normal upper limit for serum d. Gradient between serum and pleural fluid protein levels >31 g/L

Gradient between serum and pleural fluid protein levels >31 g/L

Which of the following is not a component in the calculation of the sepsis-related organ failure assessment (SOFA) score? a. PaO2/FiO2 b. WBC count c. Bilirubin count d. Urine output

WBC count

Which of the following laboratory tests may be performed to measure eosinophilic airway inflammation and may be used as a test of compliance with therapy? a. Exhaled NO b. Radioallergosorbent test c. Metacholine challenge test d. Measurement of PEF twice daily

Exhaled NO

Which of the following diagnostics is often necessary to differentiate community-acquired pneumonia from other conditions? (HPIM C121 P911) a. Sputum studies b. Chest radiograph c. Chest CT scan d. Arterial blood gas

Chest radiograph

A 52/M was admitted twice for fever, cough and dyspnea. On his second admission, a sputum culture revealed heavy growth of community-acquired methicillin-resistant Staphylococcus aureus (MRSA). Which of the following is a risk factor for pathogen resistance to usual therapy for pneumonia caused by this organism? (HPIM C121 P909 T121-1) a. Hospitalization for ≥2 days in the previous 90 days b. Congestive heart failure c. Concurrent influenza d. Gastric acid suppression

Concurrent influenza

A 58/M was brought to the outpatient clinic for fever, cough and difficulty of breathing. PE revealed a disoriented patient with RR 30, BP 100/70, HR 112, temperature 38.5°C. The results from a prior consult showed BUN 12 mmol/L and creatinine 1.8 mg/dL. Based on the CURB-65 criteria, what is the recommended management for the patient? (HPIM C121 P912) a. Outpatient management can be done b. Admit to the wards c. Admit to the ICU d. Refer to a neurologist for evaluation

Admit to the ICU

A 60/F was admitted due to productive cough and mild dyspnea. She has stable vital signs but has poor oral intake. She was admitted to the ward for intravenous antibiotics. She mentioned a previous allergy to penicillin. What is a suitable alternative to ß-lactams in her case? (HPIM C121 P913 T121-5) a. Clindamycin b. Macrolides c. Respiratory fluoroquinolones d. Aminoglycosides

Respiratory fluoroquinolones

Which of the following is a risk factor for early deterioration in community-acquired pneumonia? (HPIM C121 P912 T121-4) a. Bibasal infiltrates b. Severe tachycardia (>120 bpm) c. Hyperglycemia d. Thrombocytopenia

Thrombocytopenia

A 39/M had recovered from pneumonia last July 2022. He consults about an upcoming pre-employment chest x-ray screening scheduled in January 2023 and asks if the prior infection will show on the new x-ray. How long does it usually take for chest x-ray abnormalities to resolve? (HPIM C121 P914) a. 1-2 weeks b. 2-4 weeks c. 4-12 weeks d. 12-20 weeks

4-12 weeks

Which of the microbiologic causes of ventilator-associated pneumonia is NOT considered a multidrug resistant pathogen? (HPIM C121 P915 T121-6) a. Methicillin-sensitive S. aureus b. Legionella pneumophila c. ESBL-positive Enterobacteriaceae d. Acinetobacter spp.

Methicillin-sensitive S. aureus

A 62/M was admitted for cough, difficulty of breathing and increased sleeping time. He was eventually intubated for ventilatory support. A week before admission, he was prescribed azithromycin 500 mg OD which he completed for 5 days. Which of the following is an appropriate empirical antibiotic treatment for him? (HPIM C121 P917 T121-8) a. Piperacillin-Tazobactam 4.5 g IV q6h b. Piperacillin-Tazobactam 4.5 g IV q6h + Cefepime 2 g IV q8h c. Levofloxacin 750 mg IV q24h + Linezolid 600 mg IV q12h d. Cefepime 2 g IV q8h + Levofloxacin 750 mg IV q24h + Linezolid 600 mg IV q12h

Cefepime 2 g IV q8h + Levofloxacin 750 mg IV q24h + Linezolid 600 mg IV q12h

In cases of ventilator-associated pneumonia, clinical improvement, if it occurs, is usually evident within how many hours of the initiation of antibiotic treatment? (HPIM C121 P918) a. 12-24 hours b. 24-48 hours c. 48-72 hours d. >72 hours

48-72 hours

In community-acquired pneumonia, response to therapy is expected within hours to days of initiating treatment. Failure to improve within what timeframe is an indication to repeat the chest radiograph? (PSMID PCCP CPG Diagnosis, Empiric Management and Prevention of CAP in Immunocompetent Adults 2016 Update P14) a. After 24 hours b. After 36 hours c. After 48 hours d. After 72 hours

After 72 hours

A 68/M was brought to the ER for cough, progressive dyspnea and increased sleeping time. He had not been eating well in the last week despite forced feeding. Initial findings showed RR 35, HR 130, afebrile, with O2 saturation 95% on room air. What is an appropriate antibiotic regimen for his CAP? (PSMID PCCP CPG Diagnosis, Empiric Management and Prevention of CAP in Immunocompetent Adults 2016 Update P4-5 T1) a. Ceftriaxone + Azithromycin b. Ampicillin-sulbactam + Moxifloxacin c. Clindamycin d. Ceftriaxone + Levofloxacin

Ampicillin-sulbactam + Moxifloxacin

In the treatment of community-acquired pneumonia, which of the following patient parameters is an indication to streamline your antibiotic therapy from a previous empiric regimen? (PSMID PCCP CPG Diagnosis, Empiric Management and Prevention of CAP in Immunocompetent Adults 2016 Update P15 T2) a. Resolution of fever for >12 hours b. RR 20 with less coughing c. Culture results yielding heavy growth of Staphylococcus aureus d. Patient denies dyspnea and is off oxygen support

RR 20 with less coughing

After discharge, a repeat chest radiograph is recommended to establish a new radiographic baseline and to exclude the possibility of malignancy associated with CAP. You will advise your patient to do it after how many weeks? (PSMID PCCP CPG Diagnosis, Empiric Management and Prevention of CAP in Immunocompetent Adults 2016 Update P20) a. 1-2 weeks b. 2-4 weeks c. 4-6 weeks d. 6-8 weeks

4-6 weeks

Which of the following chest radiographic findings specifically indicate past exposure to asbestos? (HPIM C283 P1978) a. Pleural plaques b. Irregular opacities on lung bases c. Calcification of hilar nodes d. Rounded opacities on upper lung fields

Pleural plaques

A boilermaker in a shipyard consulted you for chronic cough and progressive dyspnea. If you are entertaining an occupational exposure, what is the expected chest radiographic hallmark of his condition? (HPIM C283 P1977-1978) a. Irregular or linear opacities that usually are first noted in the lower lung fields b. Profuse military infiltration c. Small rounded opacities in the upper lobes d. Nodules generally confined to the upper half of the lungs

Irregular or linear opacities that usually are first noted in the lower lung fields

A stonecutter who worked with a quarrying company for ~15 years was referred to you for evaluation due to possible occupational exposure causing chronic cough. Which is FALSE regarding his condition? (HPIM C283 P1978-1979) a. Clinical and pathologic features of the acute form of this disease are similar to those of diffuse interstitial fibrosis b. The chest radiograph of the acute form may show profuse miliary infiltration and consolidation c. With long-term, less intense exposure, small rounded opacities in the upper lobes may appear d. Whole-lung lavage may provide symptomatic relief and slow the progression

Clinical and pathologic features of the acute form of this disease are similar to those of diffuse interstitial fibrosis

A coal miner for >20 years was referred for occupational exposure evaluation. What is the expected chest radiographic finding in his case? (HPIM C283 P1979) a. Irregular or linear opacities that usually are first noted in the lower lung fields b. Profuse military infiltration c. Calcification of hilar nodules or eggshell pattern d. Nodules generally confined to the upper half of the lung

Nodules generally confined to the upper half of the lung

Which of the following diagnostic tests is used as an initial assessment tool for respiratory impairment rating in occupational lung diseases? (HPIM C283 P1982) a. Chest radiograph b. Chest CT scan c. Arterial Blood Gas d. Spirometry

Spirometry

Which of the following tests is most suited for the work-up of focal bronchiectasis and its likely etiology? (HPIM C284 P1983-1984 T284-1) a. Chest CT Scan b. Genetic testing c. Spirometry d. Sputum gram’s stain

Chest CT Scan

A 58/M patient consults for persistent chronic productive cough with ongoing production of thick tenacious sputum. No fever is reported. Physical examination revealed crackles and wheezing as well as mild clubbing of the digits. What is the imaging modality of choice for confirming the diagnosis? (HPIM C284 P1984) a. Chest CT Scan b. Chest radiograph c. Chest MRI d. Bronchoscopy

Chest CT Scan

In the treatment of bronchiectasis with acute exacerbations, antibiotics should be administered to target which common isolates or presumptive pathogens? (HPIM C284 P1985) a. Anaerobes and Pseudomonas aeruginosa b. Streptococcus pneumoniae and Staphylococcus aureus c. Haemophilus influenzae and Pseudomonas aeruginosa d. Mycobacteria and Legionella spp.

Haemophilus influenzae and Pseudomonas aeruginosa

Which of the following interstitial lung diseases (ILD) presents with non-caseating granulomas on histopathology? (HPIM C287 P1999, 2001 T287-1) a. TB-associated ILD b. Systemic sclerosis-associated ILD c. Sarcoidosis d. Acute interstitial pneumonia

Sarcoidosis

Which of the following is now considered to be the standard of care in the initial evaluation of a patient with suspected interstitial lung disease? (HPIM C287 P2001) a. Bronchoscopy b. Chest radiograph c. High resolution chest CT d. Lung biopsy

High resolution chest CT

Which of the following statements does NOT describe the pathologic changes in airways of patients with COPD? (HPIM C286 P1991-1992) a. Eosinophilic infiltration with predominance of mast cells b. Goblet cell metaplasia with mucus-secreting cells replacing surfactant producing cells c. Squamous cell metaplasia of the bronchi with decreased mucociliary clearance d. Destruction of alveolar walls with impaired gas exchange

Eosinophilic infiltration with predominance of mast cells

Which of the following statements is TRUE regarding the pathophysiology of COPD? (HPIM C286 P1992) a. Ventilation-perfusion mismatch causes decreased in PaO2 that is not responsive to oxygen supplementation b. Airflow obstruction with increased FEV1/FVC c. Air trapping with decreased residual lung volume d. Hyperinflation resulting to flattened diaphragm with difficulty generating inspiratory pressures

Hyperinflation resulting to flattened diaphragm with difficulty generating inspiratory pressures

Which of the following statements is FALSE regarding COPD? (HPIM C286 P1992) a. PaO2 remains near normal until FEV1 is decreased to <50% of predicted b. PaO2 remains near normal until FEV1 is decreased to <25% of predicted c. Elevation of PaCO2 is not detected until FEV1 is < 25% of predicted d. Pulmonary hypertension typically occurs in marked decreases in FEV1 and chronic hypoxemia of PaO2 < 55mmHg

PaO2 remains near normal until FEV1 is decreased to <25% of predicted

A 50/M patient consulted for difficulty breathing. Two years prior to consultation, he started having occasional cough with scant sputum production noted when during his commute to work. He also noted difficulty in breathing while doing his usual weekend exercises such as jogging and stretching. Symptoms persisted until 6 months prior to consultation when he started feeling breathless upon walking more than one block. He also reported increased frequency of coughing bouts and sputum production, resolved by rest for 5-15 minutes. He also noted weight loss. He had a 50-pack year smoking history, with some unsuccessful attempts in quitting in the past. PE findings showed BMI 19 kg/m2, bitemporal wasting, increased AP diameter of the chest, expiratory wheezes and unremarkable cardiac PE. Post-bronchodilator FEV1/FVC is 50% of predicted with FEV1 of 50% of predicted. What is the patient’s GOLD 2021 classification? (Global Initiative for Chronic Obstructive Lung Disease 2021 F2.4, HPIM C286 P1996 F286-5) a. GOLD 1 Group A b. GOLD 2 Group B c. GOLD 3 Group C d. GOLD 4 Group D

GOLD 2 Group B

Which of the following signs is an independent poor prognostic factor in COPD? (HPIM C286 P1995) a. Exertional dyspnea b. Chronic hyperinflation c. Bitemporal wasting d. Hypoxemia

Bitemporal wasting

Which of the following spirometry findings best describe airflow obstruction due to emphysema? (HPIM C279 P1949 F279-6) a. FEV1 < 50% of predicted b. Total lung capacity (TLC) 60% of predicted c. Residual volume (RV) of 60% predicted d. DLco 120% of predicted

FEV1 < 50% of predicted

A 55/M diagnosed with COPD and maintained on inhaled formoterol, presented at the ER for difficulty of breathing. Two days prior to consult, he experienced fever and cough with increasing sputum production. He self-medicated with paracetamol and increased the frequency of inhaled formoterol but without relief. On the day of admission, the patient was noted to be gasping and disoriented. Findings at the ER showed BP 80/50mmHg, O2 saturation 79%, GCS 7 (E2V3M2), and crackles and rhonchi on both lung fields. Which of the following is the next best step in managing this patient? (HPIM C286 P1998) a. Invasive mechanical ventilation via an endotracheal tube b. Administer non-invasive positive pressure ventilation for respiratory failure c. Treat with IV antibiotics and systemic glucocorticoids d. Bronchodilator via metered-dose inhaler with theophylline

Invasive mechanical ventilation via an endotracheal tube

Which of the following options reduces exacerbations in patients with stable COPD? (Global Initiative for Chronic Obstructive Lung Disease 2021) a. Tiotropium b. Prednisone c. Salbutamol d. Pneumococcal vaccine

Tiotropium

A 75/M came in due to difficulty breathing. He was diagnosed with COPD 5 years ago, maintained on an inhaled bronchodilator but was unable to follow-up. He presented at the out-patient clinic with worsening exertional dyspnea over the past year associated with marked weight loss and occasional hemoptysis. No other symptoms were elicited. On PE, there was clubbing of the fingernails. What would be the next best step in the management of this patient? (HPIM C286 P1995) a. Order a chest CT-scan b. Obtain a sputum sample c. Do a chest ultrasound d. Get arterial blood gas

Order a chest CT-scan

Which of the following is the definitive test to detect the presence of emphysema in patients with COPD? (HPIM C286 P1995) a. Spirometry b. Lung Scan c. Chest CT Scan d. Chest Radiograph

Chest CT Scan

Which of the following statements is true of the deep venous thrombosis (DVT)? (HPIM C273 P1910) a. The triad of venous stasis, Raynaud's Phenomenon and thrombophlebitis underlies the occurrence of venous thrombosis b.Prothrombin gene mutation causes dysfunction in the prothrombin making it easily degraded by protein C c.Factor V Leiden is the most common acquired cause of thrombophilia d. DVT causes postthrombotic syndrome which, in severe cases, can lead to stasis ulcer

DVT causes postthrombotic syndrome which, in severe cases, can lead to stasis ulcer

Which of the following is the longest vein in the body? (HPIM C276 P1930) a. Common femoral vein b. Common iliac vein c.Great saphenous vein d. Inferior vena cava

Great saphenous vein

58/F patient with varicose veins was instructed to lie down and elevate the legs. A tourniquet was then placed on the proximal thigh and the patient was instructed to stand. There was note of filling of the varicose veins in 20 seconds, hence, a diagnosis of deep venous insufficiency was made. This maneuver to determine whether the varicose veins are from a deep venous insufficiency is called? (HPIM C276 P1931) a. Brodie-Trendelenburg test b. Perthes test c. Tap test d. Compression test

Brodie-Trendelenburg test

A 58/M is consulting for right leg swelling of 1-year duration. The swelling is usually noted in the afternoon and causes occasional cramping and dull ache over the right calf area. There is also discoloration of the right shin area becoming more brown compared to the contralateral leg. He has no chest pain, dyspnea, easy fatigability or fever. There is no change in the size of his footwear. He is a non-smoker and works as a company messenger/delivery boy. PE shows hyperpigmentation of the right leg, non-pitting edema on the right ankle, and superficial varicose veins over the right calf. Brodie-Trendelenburg Test shows immediate filling of the varicose veins on removal of tourniquet; Perthes test is negative. Right leg circumference is more than 2 cm compared to the left. What is the most likely diagnosis of the patient? (HPIM C276 P1931) a. Deep venous thrombosis b. Secondary varicose veins c. Chronic venous insufficiency d. Lymphedema

Chronic venous insufficiency

Which of the following is the most common symptom of deep venous thrombosis? (HPIM C273 P1911) a. Diffusely edematous lower extremity b. Cramp in the calf that intensifies over several days c. Sudden sharp pain in the calf region d. Claudication or pain that intensifies while walking

Cramp in the calf that intensifies over several days

Which of the following statements is true regarding pulmonary embolism (PE)? (HPIM C273 P1910-1911) a. Massive PE is characterized by thrombosis of at least half of the pulmonary vasculature b. Dyspnea, syncope, hypotension, and cyanosis are hallmarks of submassive PE c. Acute respiratory failure is the usual cause of death in patients with massive PE d. Submassive PE accounts for majority of the cases and has an excellent prognosis

Massive PE is characterized by thrombosis of at least half of the pulmonary vasculature

Which of the following is the most common symptom of pulmonary embolism? (HPIM C273 P1911) a. Piercing chest pain b. Unexplained breathlessness c. Intermittent palpitations d. Worsening cramps

Unexplained breathlessness

A 50/F was admitted for mastectomy for breast cancer stage III. She remained bedridden for a week, then developed fever, sudden onset dyspnea and refractory desaturation. Examination showed HR 120, BP 90/50, O2 saturation 88%, with pitting edema and tenderness over the right leg. What is the likelihood of pulmonary embolism (PE) in this case? (HPIM C273 P1911 T273-1) a. Low b. Moderate c. High d. PE is unlikely

High

Which of the following statements best describes plasma D-dimer in the diagnosis of deep venous thrombosis (DVT)/pulmonary embolism (PE)? (HPIM C273 P1912) a. D-dimer is both sensitive and specific and is a good “rule out” test b. Increased D-dimer signifies fibrin breakdown products and effective thrombolysis c. D-dimer is specific but not sensitive in detecting DVT hence, it is not used in patients with low likelihood of DVT d. D-dimer increases in myocardial infarction, sepsis, cancer and pregnancy

D-dimer is specific but not sensitive in detecting DVT hence, it is not used in patients with low likelihood of DVT

Which of the following imaging modalities is correctly matched to its expected finding for pulmonary embolism? (HPIM C273 P1912-1913) a. Lung scan: 2 or more segmental perfusion defect in the presence of abnormal ventilation b. CT scan with contrast: intraluminal filling defect in one or more projections c. Echocardiography: Palla’s sign d. Chest radiograph: Hampton’s hump

Chest radiograph: Hampton’s hump

Which of the following parenteral anticoagulants can be given in patients with venous thromboembolism (VTE) but with suspected heparin-induced thrombocytopenia? (HPIM C273 P1914 T273-3) a. Enoxaparin b. Rivaroxaban c. Tinzaparin d. Bivalirudin

Bivalirudin

Which of the following is true regarding the use of unfractionated heparin in patients with pulmonary embolism? (HPIM C273 P1914) a. Monitor INR and treat to a target of 2-3 b. Monitor activated partial thromboplastin time (aPTT) with target patient value of 30-50 seconds c. Initial intravenous bolus of 50 units/kg followed by infusion of 12 units/kg/hour d. Initial intravenous bolus of 80 units/kg followed by infusion of 18 units/kg/hour

Initial intravenous bolus of 80 units/kg followed by infusion of 18 units/kg/hour

A 60 year old male was admitted due to decrease in sensorium. He is on palliative therapy for stage 4 colon cancer, and warfarin for documented deep venous thrombosis. Physical findings showed GCS 7 with preferential movement of right upper and lower extremities, BP 160/100, HR 54. Plain cranial CT showed bleed on the left basal ganglia with surrounding edema. INR is 4. Which of the following is the best management for this patient to prevent pulmonary embolism? (HPIM C273 P1915) a. Shift warfarin to Rivaroxaban for lesser risk of bleeding b. Pharmacomechanical catheter-directed thrombolysis c. Insertion of inferior vena cava (IVC) filter d. Graduated compression stockings with 30-40 mmHg

Insertion of inferior vena cava (IVC) filter

Which of the following management strategies is recommended for massive pulmonary embolism and hypotension? (HPIM C273 P1915) a. Aggressive volume repletion with 1L of normal saline b. Restriction of fluid infusion upon diagnosis due to exacerbation of right ventricular wall stress c. Dobutamine and dopamine as first-line inotropic agents d. Avoidance of norepinephrine

Dobutamine and dopamine as first-line inotropic agents

A 24-year-old woman is seen for a complaint of shortness of breath and wheezing. She notes the symptoms to be worse when she has exercised outdoors and is around cats. She has had allergic rhinitis in the spring and summer for many years and suffered from eczema as a child. On physical examination, she is noted to have expiratory wheezing. Her pulmonary function tests demonstrate an FEV1 of 2.67 (79% predicted), FVC of 3.81 L (97% predicted), and an FEV1/FVC ratio of 70% (86% predicted). After administration of albuterol, the FEV1 increases to 3.0 L (12.4%). Which of the following statements regarding the patient’s disease process is true? a. Confirmation of the diagnosis will require methacholine challenge testing. b. Mortality due to the disease has been increasing over the past decade. c. The most common risk factor in individuals with the disorder is genetic predisposition. d. The prevalence of the disorder has not changed in the past several decades. e. The severity of the disease does not vary significantly within a given patient with the disease.

e. The severity of the disease does not vary significantly within a given patient with the disease.

A 38-year-old woman is brought to the emergency department for status asthmaticus. She rapidly deteriorates and dies of her disease. All of the following pathologic findings would likely be seen in this individual EXCEPT: a. Infiltration of the airway mucosa with eosinophils and activated T lymphocytes b. Infiltration of the alveolar spaces with eosinophils and neutrophils c. Occlusion of the airway lumen by mucous plugs d. Thickening and edema of the airway wall e. Thickening of the basement membrane of the airways with subepithelial collagen deposition

b. Infiltration of the alveolar spaces with eosinophils and neutrophils

A 24-year-old woman was diagnosed with asthma 4 months ago and was treated with inhaled albuterol as needed. Since her last visit, she feels generally well and typically requires using her inhaler approximately four to seven times a week when around pollen or cats or when exercising in cold air. The inhaled albuterol generally helps, and she only requires a repeat round of inhalations approximately two times a week. She is on no other medications and is a nonsmoker, and her only pet is a goldfish named Puffer. Based on this information, you advise which of the following? a. Add inhaled beclomethasone b. Add inhaled salmeterol twice a day c. Add inhaled tiotropium d. Continue present therapy e. Think of a new name for the goldfish

a. Add inhaled beclomethasone

A 28-year-old woman with longstanding mild persistent asthma comes to see you because she just found out that she is pregnant. Her only medications are inhaled beclomethasone twice a day and albuterol as needed. She typically uses her albuterol less than twice per week. She wants to know what to expect regarding her asthma severity and whether any medication changes should be made at this time. Which of the following statements is correct? a. She should continue her current therapy and follow symptoms. b. She should switch from inhaled albuterol as needed to inhaled tiotropium as needed. c. She should switch from inhaled beclomethasone to a inhaled salmeterol. d. There is a greater than 70% chance that her asthma symptoms will become less severe during pregnancy. e. There is a greater than 70% chance that her asthma symptoms will become more severe during pregnancy.

a. She should continue her current therapy and follow symptoms.

A 69-year-old man with COPD has been admitted to the hospital three times over the past year for COPD exacerbations. He has daily cough with sputum production and an FEV1 of 45% predicted. He previously smoked a pack of cigarettes daily for 50 years, quitting 1 year ago. His oxygen saturation on room air is 91%. Which of the following treatments is most likely to decrease the frequency of his exacerbations? a. Azithromycin 250 mg three times weekly b. Continuous oxygen at 2 L/min c. Nocturnal bilevel positive airway pressure with an inspiratory pressure of 18 cm H2O and expiratory pressure of 12 cm H2O d. Roflumilast 500 μg daily e. Theophylline 300 mg daily

d. Roflumilast 500 μg daily

A 70-year-old man with known COPD is seen for follow-up. He has been clinically stable without an exacerbation for the past 6 months. However, he generally feels in poor health and is limited in what he can do. He reports dyspnea with usual activities. He is currently being managed with albuterol MDI twice daily and as needed. He has a 50-pack-year history of smoking and quit 5 years previously. His other medical problems include peripheral vascular disease, hypertension, and benign prostatic hyperplasia. He is managed with aspirin, lisinopril, hydrochlorothiazide, and tamsulosin. On examination, the patient has a resting oxygen saturation of 93% on room air. He is hyperinflated to percussion with decreased breath sounds at the apices and faint expiratory wheezing. His pulmonary function tests demonstrate an FEV1 of 55% predicted, FVC of 80% predicted, and FEV1/FVC ratio of 50%. What is the next best step in the management of this patient? a. Initiate a trial of oral glucocorticoids for a period of 4 weeks and initiate inhaled fluticasone if there is a significant improvement in pulmonary function. b. Initiate treatment with inhaled fluticasone 110 μg/puff twice daily. c. Initiate treatment with inhaled fluticasone 250 μg/puff in combination with inhaled salmeterol 50 mg/puff twice daily. d. Initiate treatment with inhaled tiotropium 18 μg/daily. e. Perform exercise and nocturnal oximetry and initiate oxygen therapy if these demonstrate significant hypoxemia.

d. Initiate treatment with inhaled tiotropium 18 μg/daily.

A 56-year-old woman is admitted to the ICU with a 4-day history of increasing shortness of breath and cough with copious sputum production. She has known severe COPD with an FEV1 of 42% predicted. On presentation, she has a room air blood gas with a pH of 7.26, PaCO2 of 78 mmHg, and PaO2 of 50 mmHg. She is in obvious respiratory distress with use of accessory muscles and retractions. Breath sounds are quiet with diffuse expiratory wheezing and rhonchi. No infiltrates are present on chest radiograph. Which of the following therapies has been demonstrated to have the greatest reduction in mortality rate for this patient? a. Administration of inhaled bronchodilators b. Administration of IV glucocorticoids c. Early administration of broad-spectrum antibiotics with coverage of P aeruginosa d. Early intubation with mechanical ventilation e. Use of noninvasive positive-pressure ventilation

e. Use of noninvasive positive-pressure ventilation

A 63-year-old man with a long history of cigarette smoking comes to see you for a 4-month history of progressive shortness of breath and dyspnea on exertion. The symptoms have been indolent, with no recent worsening. He denies fever, chest pain, or hemoptysis. He has a daily cough of 3 to 6 tablespoons of yellow phlegm. The patient says he has not seen a physician for over 10 years. Physical examination is notable for normal vital signs, a prolonged expiratory phase, scattered rhonchi, elevated jugular venous pulsation, and moderate pedal edema. Hematocrit is 49%. Which of the following therapies is most likely to prolong his survival? a. Atenolol b. Enalapril c. Oxygen d. Prednisone e. Theophylline

Oxygen

A 53-year-old man is admitted with fevers and right pleuritic chest pain for 5 days. He has a history of alcohol dependence. On presentation, his temperature is 39.2°C, heart rate is 112 bpm, blood pressure is 102/62 mmHg, respiratory rate is 24 breaths/min, and SaO2 is 92% on room air. He has absent breath sounds in the right lower chest with dullness to percussion and decreased tactile fremitus. Chest radiograph confirms a right lower lobe consolidation with associated effusion. The effusion is not free flowing. Initial thoracentesis demonstrates gross pus in the pleural space, and the Gram stain is positive for gram-positive cocci in pairs and chains. A large-bore chest tube is placed. Which of the following treatments should also be recommended in this patient to improved resolution of the empyema in this individual? a. Immediate referral for decortication b. Intrapleural instillation of alteplase 10 mg twice daily for 3 days c. Intrapleural instillation of alteplase 10 mg plus deoxyribonuclease 5 mg twice daily for 3 days d. Intrapleural instillation of deoxyribonuclease 5 mg twice daily for 3 days e. Intrapleural instillation of streptokinase 250,000 IU

c. Intrapleural instillation of alteplase 10 mg plus deoxyribonuclease 5 mg twice daily for 3 days

A 44-year-old woman with acquired immunodeficiency syndrome (AIDS) has acute hypoxemic respiratory failure due to Pneumocystis jiroveci. She is intubated and mechanically ventilated with the following settings: assist-control, tidal volume 350 mL (6 mL/kg ideal body weight), FiO2 1.0, respiratory rate 28 breaths/min, and PEEP 12 cmH2O. Her arterial blood gas values on these settings are as follows: pH 7.28, PaO2 68 mmHg, and PaCO2 64 mmHg. Her inspiratory plateau pressure is 26 cmH2O. You are called acutely to the bedside when her blood pressure abruptly drops to 70/40 mmHg. At the same time, the high-pressure alarms on the ventilator begin to alarm with peak airway pressures now registering at 55 cmH2O. Breath sounds are inaudible on the right side and are clear on the left. What is the best course of action at this time? a. Administer a fluid bolus to improve venous return. b. Disconnect the patient from the ventilator to allow a full exhalation. c. Place a large-bore needle into the right second anterior intercostal space to alleviate a tension pneumothorax. d. Sedate the patient to achieve ventilator synchrony. e. Suction the patient to remove obstructing mucus plugs.

c. Place a large-bore needle into the right second anterior intercostal space to alleviate a tension pneumothorax.

A 62-year-old woman is admitted to the hospital with a community-acquired pneumonia with a 4-day history of fever, cough, and right-sided pleuritic chest pain. The admission chest x-ray identifies a right lower and middle lobe infiltrate with an associated effusion. All of the following characteristics of the pleural effusion indicate a complicated effusion that may require tube thoracostomy EXCEPT: a. Loculated fluid b. Pleural fluid pH <7.20 c. Pleural fluid glucose <60 mg/dL d. Positive Gram stain or culture of the pleural fluid e. Recurrence of fluid following the initial thoracentesis

e. Recurrence of fluid following the initial thoracentesis

A 28-year-old man presents to the emergency department with acute-onset shortness of breath and pleuritic chest pain on the right that began 2 hours previously. He is generally healthy and has no medical history. He has smoked one pack of cigarettes daily since the age of 18. On physical examination, he is tall and thin, with a body mass index of 19.2 kg/m2. He has a respiratory rate of 24 breaths/min with an oxygen saturation of 95% on room air. He has slightly decreased breath sounds at the right lung apex. A chest x-ray demonstrates a 20% pneumothorax on the right. Which of the following statements is true regarding pneumothorax in this patient? a. A CT scan is likely to show emphysematous changes. b. If the patient were to develop recurrent pneumothoraces, thoracoscopy with pleural abrasion has a success rate of near 100% for prevention of recurrence. c. Most patients with this presentation require tube thoracostomy to resolve the pneumothorax. d. The likelihood of recurrent pneumothorax is about 25%. e. The primary risk factor for the development of spontaneous pneumothorax is a tall and thin body habitus.

b. If the patient were to develop recurrent pneumothoraces, thoracoscopy with pleural abrasion has a success rate of near 100% for prevention of recurrence.

A 52-year-old woman is admitted to the hospital with lethargy and marked symptoms of volume overload. She has a past medical history of morbid obesity with a body mass index of 52 kg/m2, severe obstructive sleep apnea, hypertension, and type 1 diabetes mellitus. She is in generally poor health and has been noncompliant with her insulin as well as with continuous positive airway pressure (CPAP) as she reports claustrophobia. She cannot recall when she last used CPAP therapy. On physical examination, the patient is somnolent but arousable. Her vital signs are as follows: blood pressure 168/92 mmHg, heart rate 92 bpm, respiratory rate 14 breaths/min, afebrile, and SaO2 82% on room air. Her SaO2 increases to 92% on 6 L/min by nasal cannula, but her mental status becomes more lethargic. She has distant heart and lung sounds without crackles. There is 4+ edema bilaterally to the thighs and onto the abdominal wall. Chest x-ray shows low lung volumes. Initial arterial blood gas values on 6 L/min nasal oxygen are pH 7.22, PaCO2 88 mmHg, and PaO2 72 mmHg. Which of the following statements is true regarding the patient’s condition? a. Abnormalities of the PHOX2b gene are associated with this condition. b. CPAP therapy alone is adequate for treatment of this patient. c. Initial treatment of the condition should include intubation and mechanical ventilation given the patient’s known intolerance of CPAP therapy. d. Obstructive sleep apnea coexists with the diagnosis in about 75% of cases. e. Weight loss will lead to improvements in PaCO2 over time.

e. Weight loss will lead to improvements in PaCO2 over time.

A 48-year-old man has recently been diagnosed with obstructive sleep apnea with an apnea- hypopnea index of 21.2/hr. He presents to the clinic for follow-up because he tried CPAP in the sleep laboratory and felt uncomfortable with it. He asks what the potential risks would be to his health if he chose to forego treatment. What advice do you give him? a. Untreated obstructive sleep apnea has an increased risk of mortality due to cardiovascular events including myocardial infarction and stroke. b. Untreated obstructive sleep apnea has an increased risk of depression. c. Untreated obstructive sleep apnea is associated with a sevenfold increased risk of automobile accidents. d. Untreated obstructive sleep apnea raises nocturnal blood pressure, and treatment with CPAP leads to a 2- to 4-mmHg drop in blood pressure. e. All of the above is good advice to give to the patient.

e. All of the above is good advice to give to the patient.

A 48-year-old man with a body mass index of 28.9 kg/m2 is diagnosed with obstructive sleep apnea with an apnea-hypopnea index of 42/hr and a minimum oxygen saturation of 78%. What is the most appropriate initial therapy for this patient? a. CPAP b. Oral appliance therapy c. Oxygen therapy d. Uvulopalatopharyngoplasty e. Weight loss

a. CPAP

A 42-year-old man is admitted to the ICU after an automobile accident. He suffered a compound fracture of the femur and also had internal bleeding from a ruptured spleen and liver hematoma. He has undergone splenectomy and fixation of the femur fracture. He is intubated and sedated following surgery. His hemoglobin after surgery is 5.2 g/dL. His oxygen saturation is 92%, and his PaO2 is 72 mmHg on FiO2 of 0.6. A pulmonary artery catheter was placed during surgery. His cardiac output is 7.8 L/min. A lactate level is 4.8 mmol/L. Which of the following is the least important factor affecting oxygen delivery in this patient? a. Cardiac output b. Hemoglobin concentration c. PaO2 d. SaO2

c. PaO2

A 67-year-old woman was admitted to the ICU with multilobar pneumonia due to Streptococcus pneumoniae and COPD. She requires intubation and mechanical ventilation. All of the following are appropriate interventions to prevent complications in the ICU EXCEPT: a. Administration of enoxaparin 40 mg daily b. Administration of omeprazole 20 mg daily c. Aggressive blood glucose control d. Early mobilization and physical therapy while mechanically ventilated E. Use of a standard care bundle for insertion of central lines

c. Aggressive blood glucose control

A 68-year-old man is admitted to the ICU with fevers, hypotension, and hypoxemia. He has felt ill for the past 2 to 3 days with progressive dyspnea at home. He has a history of COPD, coronary artery disease requiring three-vessel coronary artery bypass surgery, and type 2 diabetes mellitus. He continues to smoke a pack of cigarettes daily and also drinks a six-pack of beer daily. On presentation, his room air oxygen saturation is 79%. With a non-rebreather mask, his oxygen saturation remains at 87%. His blood pressure is 74/40 mmHg, and heart rate is 124 bpm. After fluid bolus, his blood pressure remains low at 86/53 mmHg. His chest radiograph is shown in Figure VI- 64. Within 12 hours after admission, blood cultures are positive for S pneumoniae. He received his first dose of antibiotics in the emergency department and remains on treatment with ceftriaxone and moxifloxacin. He is intubated, sedated, and currently on vasopressor support. His blood gas after intubation is pH 7.28, PaCO2 52 mmHg, and PaO2 64 mmHg on FiO2 0.8. Which of the following best identifies the patient’s diagnosis? a. Acute interstitial pneumonia b. Mild acute respiratory distress syndrome c. Moderate acute respiratory distress syndrome d. Multilobar community acquired pneumonia e. Severe acute respiratory distress syndrome

e. Severe acute respiratory distress syndrome

117. If a lung biopsy were to be taken 4 days after admission in the patient described in Question VI- 64, which statement correctly identifies the expected findings? a. Diffuse alveolar damage with hyaline membranes and protein-rich edema fluid in alveoli b. Extensive eosinophil-rich infiltrate with protein-rich edema fluid c. Extensive fibrosis of the alveolar ducts with development of bullae d. Homogeneous infiltrate of neutrophils and leukocytes affecting all alveolar spaces e. Proliferation of type II pneumocytes and presence of a lymphocyte-rich pulmonary infiltrate

a. Diffuse alveolar damage with hyaline membranes and protein-rich edema fluid in alveoli

118. A 48-year-old woman is admitted to the surgical ICU following a motor vehicle accident. She has suffered a concussion, fractures of ribs 4 through 8 on the left with a hemopneumothorax, and a lacerated spleen that required splenectomy. During the surgery to remove her spleen, she required transfusion of 6 units of packed red blood cells, 6 units of platelets, and 4 units of fresh frozen plasma. Upon admission to the ICU after surgery, she remains intubated and sedated. A chest tube is in place on the left. Her chest radiograph shows diffuse bilateral infiltrates. The left lung has dense infiltrates, and there are also extensive infiltrates on the right. She is diagnosed with a left lung contusion and acute respiratory distress syndrome. She weighs 90 kg. She is 66 inches in height. Her ideal body weight is 59 kg. Her oxygen saturation on FiO2 1.0 is 92% with an arterial blood gas showing pH of 7.28, PaCO2 of 48 mmHg, and PaO2 of 68 mmHg. What is the best initial tidal volume in this patient? a. 236 mL b. 354 mL c. 472 mL d. 540 mL e. 590 mL

b. 354 mL

You are managing a patient admitted to the medical ICU for severe acute respiratory distress syndrome due to necrotizing pancreatitis. The patient has an ideal body weight of 70 kg. The patient’s ventilator is set on a volume control with a respiratory rate of 28 bpm, tidal volume of 420 mL, FiO2 of 0.7, and PEEP of 8 cmH2O. The patient is hypoxemic with an SaO2 of 86% on these settings. You review the static pressure-volume curve for the respiratory system. The lower inflection point is at 12 cmH2O. The upper inflection point is at 30 cmH2O. Measured pressure with an inspiratory hold is 26 cmH2O. Which of the following is the best choice to improve oxygenation in this patient? a. Administer a paralytic agent b. Decrease tidal volume to 350 mL c. Increase FiO2 to 0.8 d. Increase PEEP to 12 cmH2O e. Increase tidal volume to 560 mL

d. Increase PEEP to 12 cmH2O

120. A 75-year-old man is admitted to the ICU for sepsis in the setting of neutropenia due to chemotherapy for gastric cancer. He has severe acute respiratory distress syndrome and requires intubation. During the first 48 hours of his ICU stay, his volume status is positive 6 L. Which of the following statements regarding fluid management in acute respiratory distress syndrome is true? a. Aggressive diuresis to maintain a low left atrial filling pressure is associated with increased risk of acute kidney injury requiring hemodialysis. b. Maintaining a low left atrial filling pressure through diuresis improves lung compliance and improves oxygenation. c. Maintaining a low left atrial filling pressure through diuresis shortens ICU stay and decreases mortality in the medical intensive care unit, but not the surgical ICU. d. Placement of a pulmonary arterial catheter for accurate measurement of left atrial filling pressure improves diagnostic accuracy and provides added benefit in determining fluid management strategy.

b. Maintaining a low left atrial filling pressure through diuresis improves lung compliance and improves oxygenation.

Which of the following is the most common sleep disorder in the population? A. Delayed sleep phase syndrome B. Insomnia C. Obstructive sleep apnea D. Narcolepsy E. Restless legs syndrome

B. Insomnia

From which stage of sleep are the parasomnias somnambulism and night terrors most likely to occur? A. Stage 1 B. Stage 2 C. Slow-wave sleep D. Rapid eye movement (REM) sleep

C. Slow-wave sleep

All of the following statements regarding the organization of a normal night’s sleep in a healthy young adult are true EXCEPT: A. REM sleep comprises 20%–25% of total sleep. B. Sleep deprivation increases the amount of slow-wave sleep. C. Sleep organization varies substantially from night to night. D. Slow-wave (N3) non-REM (NREM) sleep progressively declines with age.

C. Sleep organization varies substantially from night to night.

Match each of the following pulmonary function test results to the respiratory disorder in which it is most likely to be found. Myasthenia gravis A. Increased total lung capacity (TLC), decreased vital capacity (VC), decreased FEV1/FVC ratio B. Decreased TLC, decreased VC, decreased residual volume (RV), increased FEV1/FVC ratio, normal maximum inspiratory pressure (MIP) C. Decreased TLC, increased RV, normal FEV1/FVC ratio, decreased MIP D. Normal TLC, normal RV, normal FEV1/FVC ratio, normal MIP

C. Decreased TLC, increased RV, normal FEV1/FVC ratio, decreased MIP

Match each of the following pulmonary function test results to the respiratory disorder in which it is most likely to be found. Idiopathic pulmonary fibrosis A. Increased total lung capacity (TLC), decreased vital capacity (VC), decreased FEV1/FVC ratio B. Decreased TLC, decreased VC, decreased residual volume (RV), increased FEV1/FVC ratio, normal maximum inspiratory pressure (MIP) C. Decreased TLC, increased RV, normal FEV1/FVC ratio, decreased MIP D. Normal TLC, normal RV, normal FEV1/FVC ratio, normal MIP

B. Decreased TLC, decreased VC, decreased residual volume (RV), increased FEV1/FVC ratio, normal maximum inspiratory pressure (MIP)

Match each of the following pulmonary function test results to the respiratory disorder in which it is most likely to be found. Familial pulmonary hypertension A. Increased total lung capacity (TLC), decreased vital capacity (VC), decreased FEV1/FVC ratio B. Decreased TLC, decreased VC, decreased residual volume (RV), increased FEV1/FVC ratio, normal maximum inspiratory pressure (MIP) C. Decreased TLC, increased RV, normal FEV1/FVC ratio, decreased MIP D. Normal TLC, normal RV, normal FEV1/FVC ratio, normal MIP

D. Normal TLC, normal RV, normal FEV1/FVC ratio, normal MIP

Match each of the following pulmonary function test results to the respiratory disorder in which it is most likely to be found. COPD

Match each of the following pulmonary function test results to the respiratory disorder in which it is most likely to be found. COPD A. Increased total lung capacity (TLC), decreased vital capacity (VC), decreased FEV1/FVC ratio B. Decreased TLC, decreased VC, decreased residual volume (RV), increased FEV1/FVC ratio, normal maximum inspiratory pressure (MIP) C. Decreased TLC, increased RV, normal FEV1/FVC ratio, decreased MIP D. Normal TLC, normal RV, normal FEV1/FVC ratio, normal MIP

A. Increased total lung capacity (TLC), decreased vital capacity (VC), decreased FEV1/FVC ratio

Which of the following is the major risk factor for asthma? A. Air pollution B. Atopy C. Diet D. Maternal cigarette smoking E. Upper respiratory viral infections

B. Atopy

A 24-year-old woman is seen for a complaint of shortness of breath and wheezing. She notes the symptoms to be worse when she has exercised outdoors and is around cats. She has had allergic rhinitis in the spring and summer for many years and suffered from eczema as a child. On physical examination, she is noted to have expiratory wheezing. Her pulmonary function tests demonstrate an FEV1 of 2.67 (79% predicted), FVC of 3.81 L (97% predicted), and an FEV1/FVC ratio of 70% (86% predicted). After administration of albuterol, the FEV1 increases to 3.0 L (12.4%). Which of the following statements regarding the patient’s disease process is true? A. Confirmation of the diagnosis will require methacholine challenge testing. B. Mortality due to the disease has been increasing over the past decade. C. The most common risk factor in individuals with the disorder is genetic predisposition. D. The prevalence of the disorder has not changed in the past several decades. E. The severity of the disease does not vary significantly within a given patient with the disease.

E. The severity of the disease does not vary significantly within a given patient with the disease.

A 38-year-old woman is brought to the emergency department for status asthmaticus. She rapidly deteriorates and dies of her disease. All of the following pathologic findings would likely be seen in this individual EXCEPT: A. Infiltration of the airway mucosa with eosinophils and activated T lymphocytes B. Infiltration of the alveolar spaces with eosinophils and neutrophils C. Occlusion of the airway lumen by mucous plugs D. Thickening and edema of the airway wall E. Thickening of the basement membrane of the airways with subepithelial collagen deposition

B. Infiltration of the alveolar spaces with eosinophils and neutrophils

Which of the following patients is appropriately diagnosed with asthma? A. A 24-year-old woman treated with inhaled corticosteroids for cough and wheezing that has persisted for 6 weeks following a viral upper respiratory infection B. A 26-year-old man who coughs and occasionally wheezes following exercise in cold weather C. A 34-year-old woman evaluated for chronic cough with an FEV1/FVC ratio of 68% with an FEV1 that increases from 1.68 L (52% predicted) to 1.98 L (61% predicted) after albuterol (18% change in FEV1) D. A 44-year-old man who works as a technician caring for the mice in a medical research laboratory and complains of wheezing, shortness of breath, and cough that are most severe at the end of the week E. A 60-year-old man who has smoked two packs of cigarettes per day for 40 years who has dyspnea and cough and who has airway hyperreactivity in response to methacholine

A 24-year-old woman was diagnosed with asthma 4 months ago and was treated with inhaled albuterol as needed. Since her last visit, she feels generally well and typically requires using her inhaler approximately four to seven times a week when around pollen or cats or when exercising in cold air. The inhaled albuterol generally helps, and she only requires a repeat round of inhalations approximately two times a week. She is on no other medications and is a nonsmoker, and her only pet is a goldfish named Puffer. Based on this information, you advise which of the following? A. Add inhaled beclomethasone B. Add inhaled salmeterol twice a day C. Add inhaled tiotropium D. Continue present therapy E. Think of a new name for the goldfish

A. Add inhaled beclomethasone

A 28-year-old woman with longstanding mild persistent asthma comes to see you because she just found out that she is pregnant. Her only medications are inhaled beclomethasone twice a day and albuterol as needed. She typically uses her albuterol less than twice per week. She wants to know what to expect regarding her asthma severity and whether any medication changes should be made at this time. Which of the following statements is correct? A. She should continue her current therapy and follow symptoms. B. She should switch from inhaled albuterol as needed to inhaled tiotropium as needed. C. She should switch from inhaled beclomethasone to a inhaled salmeterol. D. There is a greater than 70% chance that her asthma symptoms will become less severe during pregnancy. E. There is a greater than 70% chance that her asthma symptoms will become more severe during pregnancy.

A. She should continue her current therapy and follow symptoms.

A 69-year-old man with COPD has been admitted to the hospital three times over the past year for COPD exacerbations. He has daily cough with sputum production and an FEV1 of 45% predicted. He previously smoked a pack of cigarettes daily for 50 years, quitting 1 year ago. His oxygen saturation on room air is 91%. Which of the following treatments is most likely to decrease the frequency of his exacerbations? A. Azithromycin 250 mg three times weekly B. Continuous oxygen at 2 L/min C. Nocturnal bilevel positive airway pressure with an inspiratory pressure of 18 cm H2O and expiratory pressure of 12 cm H2O D. Roflumilast 500 μg daily E. Theophylline 300 mg daily

D. Roflumilast 500 μg daily

All of the following are risk factors for COPD EXCEPT: A. Airway hyperresponsiveness B. Coal dust exposure C. Passive cigarette smoke exposure D. Recurrent respiratory infections E. Use of biomass fuels in poorly ventilated areas

D. Recurrent respiratory infections

A 65-year-old woman is evaluated for dyspnea on exertion and chronic cough. She has a long history of tobacco use, smoking 1.5 packs of cigarettes daily since the age of 20. She is a thin woman in no obvious distress. Her oxygen saturation on room air is 93% with a respiratory rate of 22 breaths/min. The lungs are hyperexpanded on percussion with decreased breath sounds in the upper lung fields. You suspect COPD. What are the expected findings on pulmonary function testing? FEV1 | FVC | FEV1/FVC ratio | TLC | DLCO A. Decreased, Normal/decreased, Decreased, Decreased, Decreased B. Decreased, Normal/decreased, Decreased, Increased, Decreased C. Decreased, Decreased, Normal, Decreased, Decreased D. Decreased, Normal/decreased, Decreased, Increased, Increased

B. Decreased, Normal/decreased, Decreased, Increased, Decreased

A 70-year-old man with known COPD is seen for follow-up. He has been clinically stable without an exacerbation for the past 6 months. However, he generally feels in poor health and is limited in what he can do. He reports dyspnea with usual activities. He is currently being managed with albuterol MDI twice daily and as needed. He has a 50-pack-year history of smoking and quit 5 years previously. His other medical problems include peripheral vascular disease, hypertension, and benign prostatic hyperplasia. He is managed with aspirin, lisinopril, hydrochlorothiazide, and tamsulosin. On examination, the patient has a resting oxygen saturation of 93% on room air. He is hyperinflated to percussion with decreased breath sounds at the apices and faint expiratory wheezing. His pulmonary function tests demonstrate an FEV1 of 55% predicted, FVC of 80% predicted, and FEV1/FVC ratio of 50%. What is the next best step in the management of this patient? A. Initiate a trial of oral glucocorticoids for a period of 4 weeks and initiate inhaled fluticasone if there is a significant improvement in pulmonary function. B. Initiate treatment with inhaled fluticasone 110 μg/puff twice daily. C. Initiate treatment with inhaled fluticasone 250 μg/puff in combination with inhaled salmeterol 50 mg/puff twice daily. D. Initiate treatment with inhaled tiotropium 18 μg/daily. E. Perform exercise and nocturnal oximetry and initiate oxygen therapy if these demonstrate significant hypoxemia.

D. Initiate treatment with inhaled tiotropium 18 μg/daily.

A 56-year-old woman is admitted to the ICU with a 4-day history of increasing shortness of breath and cough with copious sputum production. She has known severe COPD with an FEV1 of 42% predicted. On presentation, she has a room air blood gas with a pH of 7.26, PaCO2 of 78 mmHg, and PaO2 of 50 mmHg. She is in obvious respiratory distress with use of accessory muscles and retractions. Breath sounds are quiet with diffuse expiratory wheezing and rhonchi. No infiltrates are present on chest radiograph. Which of the following therapies has been demonstrated to have the greatest reduction in mortality rate for this patient? A. Administration of inhaled bronchodilators B. Administration of IV glucocorticoids C. Early administration of broad-spectrum antibiotics with coverage of P aeruginosa D. Early intubation with mechanical ventilation E. Use of noninvasive positive-pressure ventilation

E. Use of noninvasive positive-pressure ventilation

A 63-year-old man with a long history of cigarette smoking comes to see you for a 4-month history of progressive shortness of breath and dyspnea on exertion. The symptoms have been indolent, with no recent worsening. He denies fever, chest pain, or hemoptysis. He has a daily cough of 3 to 6 tablespoons of yellow phlegm. The patient says he has not seen a physician for over 10 years. Physical examination is notable for normal vital signs, a prolonged expiratory phase, scattered rhonchi, elevated jugular venous pulsation, and moderate pedal edema. Hematocrit is 49%. Which of the following therapies is most likely to prolong his survival? A. Atenolol B. Enalapril C. Oxygen D. Prednisone E. Theophylline

C. Oxygen

A 53-year-old man is admitted with fevers and right pleuritic chest pain for 5 days. He has a history of alcohol dependence. On presentation, his temperature is 39.2°C, heart rate is 112 bpm, blood pressure is 102/62 mmHg, respiratory rate is 24 breaths/min, and SaO2 is 92% on room air. He has absent breath sounds in the right lower chest with dullness to percussion and decreased tactile fremitus. Chest radiograph confirms a right lower lobe consolidation with associated effusion. The effusion is not free flowing. Initial thoracentesis demonstrates gross pus in the pleural space, and the Gram stain is positive for gram-positive cocci in pairs and chains. A large-bore chest tube is placed. Which of the following treatments should also be recommended in this patient to improved resolution of the empyema in this individual? A. Immediate referral for decortication B. Intrapleural instillation of alteplase 10 mg twice daily for 3 days C. Intrapleural instillation of alteplase 10 mg plus deoxyribonuclease 5 mg twice daily for 3 days D. Intrapleural instillation of deoxyribonuclease 5 mg twice daily for 3 days E. Intrapleural instillation of streptokinase 250,000 IU

C. Intrapleural instillation of alteplase 10 mg plus deoxyribonuclease 5 mg twice daily for 3 days

A 44-year-old woman with acquired immunodeficiency syndrome (AIDS) has acute hypoxemic respiratory failure due to Pneumocystis jiroveci. She is intubated and mechanically ventilated with the following settings: assist-control, tidal volume 350 mL (6 mL/kg ideal body weight), FiO2 1.0, respiratory rate 28 breaths/min, and PEEP 12 cmH2O. Her arterial blood gas values on these settings are as follows: pH 7.28, PaO2 68 mmHg, and PaCO2 64 mmHg. Her inspiratory plateau pressure is 26 cmH2O. You are called acutely to the bedside when her blood pressure abruptly drops to 70/40 mmHg. At the same time, the high-pressure alarms on the ventilator begin to alarm with peak airway pressures now registering at 55 cmH2O. Breath sounds are inaudible on the right side and are clear on the left. What is the best course of action at this time? A. Administer a fluid bolus to improve venous return. B. Disconnect the patient from the ventilator to allow a full exhalation. C. Place a large-bore needle into the right second anterior intercostal space to alleviate a tension pneumothorax. D. Sedate the patient to achieve ventilator synchrony. E. Suction the patient to remove obstructing mucus plugs.

C. Place a large-bore needle into the right second anterior intercostal space to alleviate a tension pneumothorax.

A 62-year-old woman is admitted to the hospital with a community-acquired pneumonia with a 4-day history of fever, cough, and right-sided pleuritic chest pain. The admission chest x-ray identifies a right lower and middle lobe infiltrate with an associated effusion. All of the following characteristics of the pleural effusion indicate a complicated effusion that may require tube thoracostomy EXCEPT: A. Loculated fluid B. Pleural fluid pH <7.20 C. Pleural fluid glucose <60 mg/dL D. Positive Gram stain or culture of the pleural fluid E. Recurrence of fluid following the initial thoracentesis

E. Recurrence of fluid following the initial thoracentesis

A 58-year-old man is evaluated for dyspnea and found to have a moderate right-sided pleural effusion. He undergoes thoracentesis with the following characteristics. The following are possible causes, EXCEPT: A. Cirrhosis B. Lung cancer C. Mesothelioma D. Pulmonary embolism E. Tuberculosis

A. Cirrhosis

A 28-year-old man presents to the emergency department with acute-onset shortness of breath and pleuritic chest pain on the right that began 2 hours previously. He is generally healthy and has no medical history. He has smoked one pack of cigarettes daily since the age of 18. On physical examination, he is tall and thin, with a body mass index of 19.2 kg/m2. He has a respiratory rate of 24 breaths/min with an oxygen saturation of 95% on room air. He has slightly decreased breath sounds at the right lung apex. A chest x-ray demonstrates a 20% pneumothorax on the right. Which of the following statements is true regarding pneumothorax in this patient? A. A CT scan is likely to show emphysematous changes. B. If the patient were to develop recurrent pneumothoraces, thoracoscopy with pleural abrasion has a success rate of near 100% for prevention of recurrence. C. Most patients with this presentation require tube thoracostomy to resolve the pneumothorax. D. The likelihood of recurrent pneumothorax is about 25%. E. The primary risk factor for the development of spontaneous pneumothorax is a tall and thin body habitus.

B. If the patient were to develop recurrent pneumothoraces, thoracoscopy with pleural abrasion has a success rate of near 100% for prevention of recurrence.

A 52-year-old woman is admitted to the hospital with lethargy and marked symptoms of volume overload. She has a past medical history of morbid obesity with a body mass index of 52 kg/m2, severe obstructive sleep apnea, hypertension, and type 1 diabetes mellitus. She is in generally poor health and has been noncompliant with her insulin as well as with continuous positive airway pressure (CPAP) as she reports claustrophobia. She cannot recall when she last used CPAP therapy. On physical examination, the patient is somnolent but arousable. Her vital signs are as follows: blood pressure 168/92 mmHg, heart rate 92 bpm, respiratory rate 14 breaths/min, afebrile, and SaO2 82% on room air. Her SaO2 increases to 92% on 6 L/min by nasal cannula, but her mental status becomes more lethargic. She has distant heart and lung sounds without crackles. There is 4+ edema bilaterally to the thighs and onto the abdominal wall. Chest x-ray shows low lung volumes. Initial arterial blood gas values on 6 L/min nasal oxygen are pH 7.22, PaCO2 88 mmHg, and PaO2 72 mmHg. Which of the following statements is true regarding the patient’s condition? A. Abnormalities of the PHOX2b gene are associated with this condition. B. CPAP therapy alone is adequate for treatment of this patient. C. Initial treatment of the condition should include intubation and mechanical ventilation given the patient’s known intolerance of CPAP therapy. D. Obstructive sleep apnea coexists with the diagnosis in about 75% of cases. E. Weight loss will lead to improvements in PaCO2 over time

E. Weight loss will lead to improvements in PaCO2 over time

A 48-year-old man has recently been diagnosed with obstructive sleep apnea with an apnea- hypopnea index of 21.2/hr. He presents to the clinic for follow-up because he tried CPAP in the sleep laboratory and felt uncomfortable with it. He asks what the potential risks would be to his health if he chose to forego treatment. What advice do you give him? A. Untreated obstructive sleep apnea has an increased risk of mortality due to cardiovascular events including myocardial infarction and stroke. B. Untreated obstructive sleep apnea has an increased risk of depression. C. Untreated obstructive sleep apnea is associated with a sevenfold increased risk of automobile accidents. D. Untreated obstructive sleep apnea raises nocturnal blood pressure, and treatment with CPAP leads to a 2- to 4-mmHg drop in blood pressure. E. All of the above is good advice to give to the patient.

E. All of the above is good advice to give to the patient.

A 48-year-old man with a body mass index of 28.9 kg/m2 is diagnosed with obstructive sleep apnea with an apnea-hypopnea index of 42/hr and a minimum oxygen saturation of 78%. What is the most appropriate initial therapy for this patient? A. CPAP B. Oral appliance therapy C. Oxygen therapy D. Uvulopalatopharyngoplasty E. Weight loss

A. CPAP

A 42-year-old man is admitted to the ICU after an automobile accident. He suffered a compound fracture of the femur and also had internal bleeding from a ruptured spleen and liver hematoma. He has undergone splenectomy and fixation of the femur fracture. He is intubated and sedated following surgery. His hemoglobin after surgery is 5.2 g/dL. His oxygen saturation is 92%, and his PaO2 is 72 mmHg on FiO2 of 0.6. A pulmonary artery catheter was placed during surgery. His cardiac output is 7.8 L/min. A lactate level is 4.8 mmol/L. Which of the following is the least important factor affecting oxygen delivery in this patient? A. Cardiac output B. Hemoglobin concentration C. PaO2 D. SaO2

C. PaO2

A 67-year-old woman was admitted to the ICU with multilobar pneumonia due to Streptococcus pneumoniae and COPD. She requires intubation and mechanical ventilation. All of the following are appropriate interventions to prevent complications in the ICU EXCEPT: A. Administration of enoxaparin 40 mg daily B. Administration of omeprazole 20 mg daily C. Aggressive blood glucose control D. Early mobilization and physical therapy while mechanically ventilated E. Use of a standard care bundle for insertion of central lines

C. Aggressive blood glucose control

A 68-year-old man is admitted to the ICU with fevers, hypotension, and hypoxemia. He has felt ill for the past 2 to 3 days with progressive dyspnea at home. He has a history of COPD, coronary artery disease requiring three-vessel coronary artery bypass surgery, and type 2 diabetes mellitus. He continues to smoke a pack of cigarettes daily and also drinks a six-pack of beer daily. On presentation, his room air oxygen saturation is 79%. With a non-rebreather mask, his oxygen saturation remains at 87%. His blood pressure is 74/40 mmHg, and heart rate is 124 bpm. After fluid bolus, his blood pressure remains low at 86/53 mmHg. His chest radiograph is shown in Figure VI- 64. Within 12 hours after admission, blood cultures are positive for S pneumoniae. He received his first dose of antibiotics in the emergency department and remains on treatment with ceftriaxone and moxifloxacin. He is intubated, sedated, and currently on vasopressor support. His blood gas after intubation is pH 7.28, PaCO2 52 mmHg, and PaO2 64 mmHg on FiO2 0.8. Which of the following best identifies the patient’s diagnosis? A. Acute interstitial pneumonia B. Mild acute respiratory distress syndrome C. Moderate acute respiratory distress syndrome D. Multilobar community acquired pneumonia E. Severe acute respiratory distress syndrome

E. Severe acute respiratory distress syndrome

If a lung biopsy were to be taken 4 days after admission in the patient described in Question VI- 64, which statement correctly identifies the expected findings? A. Diffuse alveolar damage with hyaline membranes and protein-rich edema fluid in alveoli B. Extensive eosinophil-rich infiltrate with protein-rich edema fluid C. Extensive fibrosis of the alveolar ducts with development of bullae D. Homogeneous infiltrate of neutrophils and leukocytes affecting all alveolar spaces E. Proliferation of type II pneumocytes and presence of a lymphocyte-rich pulmonary infiltrate

A. Diffuse alveolar damage with hyaline membranes and protein-rich edema fluid in alveoli

A 48-year-old woman is admitted to the surgical ICU following a motor vehicle accident. She has suffered a concussion, fractures of ribs 4 through 8 on the left with a hemopneumothorax, and a lacerated spleen that required splenectomy. During the surgery to remove her spleen, she required transfusion of 6 units of packed red blood cells, 6 units of platelets, and 4 units of fresh frozen plasma. Upon admission to the ICU after surgery, she remains intubated and sedated. A chest tube is in place on the left. Her chest radiograph shows diffuse bilateral infiltrates. The left lung has dense infiltrates, and there are also extensive infiltrates on the right. She is diagnosed with a left lung contusion and acute respiratory distress syndrome. She weighs 90 kg. She is 66 inches in height. Her ideal body weight is 59 kg. Her oxygen saturation on FiO2 1.0 is 92% with an arterial blood gas showing pH of 7.28, PaCO2 of 48 mmHg, and PaO2 of 68 mmHg. What is the best initial tidal volume in this patient? A. 236 mL B. 354 mL C. 472 mL D. 540 mL E. 590 mL

B. 354 mL

You are managing a patient admitted to the medical ICU for severe acute respiratory distress syndrome due to necrotizing pancreatitis. The patient has an ideal body weight of 70 kg. The patient’s ventilator is set on a volume control with a respiratory rate of 28 bpm, tidal volume of 420 mL, FiO2 of 0.7, and PEEP of 8 cmH2O. The patient is hypoxemic with an SaO2 of 86% on these settings. You review the static pressure-volume curve for the respiratory system. The lower inflection point is at 12 cmH2O. The upper inflection point is at 30 cmH2O. Measured pressure with an inspiratory hold is 26 cmH2O. Which of the following is the best choice to improve oxygenation in this patient? A. Administer a paralytic agent B. Decrease tidal volume to 350 mL C. Increase FiO2 to 0.8 D. Increase PEEP to 12 cmH2O E. Increase tidal volume to 560 mL

D. Increase PEEP to 12 cmH2O

A 75-year-old man is admitted to the ICU for sepsis in the setting of neutropenia due to chemotherapy for gastric cancer. He has severe acute respiratory distress syndrome and requires intubation. During the first 48 hours of his ICU stay, his volume status is positive 6 L. Which of the following statements regarding fluid management in acute respiratory distress syndrome is true? A. Aggressive diuresis to maintain a low left atrial filling pressure is associated with increased risk of acute kidney injury requiring hemodialysis. B. Maintaining a low left atrial filling pressure through diuresis improves lung compliance and improves oxygenation. C. Maintaining a low left atrial filling pressure through diuresis shortens ICU stay and decreases mortality in the medical intensive care unit, but not the surgical ICU. D. Placement of a pulmonary arterial catheter for accurate measurement of left atrial filling pressure improves diagnostic accuracy and provides added benefit in determining fluid management strategy.

B. Maintaining a low left atrial filling pressure through diuresis improves lung compliance and improves oxygenation.

Match the mode of ventilation with its description. Assist-control ventilation Intermittent mandatory ventilation Pressure control ventilation Pressure support ventilation A. This mode of ventilation is time triggered and time cycle and pressure limited. The tidal volume and inspiratory flow rate are dependent upon lung compliance. B. This mode of ventilation provides a set minute ventilation based on respiratory rate and tidal volume. Spontaneous breaths above the set respiratory rate may be supported in a pressure mode. C. This mode of ventilation is the most common mode of mechanical ventilation. Each breath, whether triggered by the patient or the ventilator, provides a prespecified tidal volume. D. This mode of ventilation is patient trigged, flow cycled, and pressure limited. Use of this mode of ventilation requires a patient to be spontaneously breathing.

Assist-control ventilation C Intermittent mandatory ventilation B Pressure control ventilation A Pressure support ventilation D

A 62-year-old woman was intubated for community-acquired pneumonia and sepsis. Upon admission to the ICU, she was hypotensive and required vasopressor treatment. She was sedated with propofol to achieve comfort on the ventilator. The ICU has a daily protocol for sedation interruption. She currently has been intubated for 8 days. Which of the following is a contraindication to a spontaneous breathing trial in this patient? A. B. C. D. E. B. Improving infiltrates on chest radiograph C. FiO2 of 0.45 D. Ongoing need for vasopressor support E. Patient is breathing over the set respiratory rate by 8 breaths/min F. PEEP of 8 cmH2O

D. Ongoing need for vasopressor support

All of the following statements regarding the epidemiology of sepsis and septic shock are true EXCEPT: A. Gram-positive bacteria are the most commonly isolated causative organisms in sepsis syndromes. B. In individuals with septic shock, blood cultures are positive in 40%–70% of cases. C. Most cases of sepsis occur in individuals with significant underlying illness. D. Respiratory infections are the most common cause of sepsis syndromes. E. The annual incidence of severe sepsis has increased over the past 30 years with a current incidence of approximately 3 per 1000 population.

A. Gram-positive bacteria are the most commonly isolated causative organisms in sepsis syndromes.

A 62-year-old woman presents to the emergency department for evaluation of fevers and respiratory symptoms. She began to feel ill about 2 days ago, and her symptoms have been progressively worse since that time. She has a past medical history of rheumatoid arthritis and takes adalimumab 40 mg every other week. On presentation in the emergency department, the patient appears acutely ill and dyspneic. Her oxygen saturation is 84% on room air with a respiratory rate of 25 breaths/min. Initial blood pressure is 82/44 mmHg, heart rate is 132 bpm, and temperature is 101.9°F. She has crackles over the entire lower half of her right lung. Her chest radiograph shows consolidation of the right lower and middle lobes without a pleural effusion. Blood and sputum cultures are drawn. The patient is begun on IV hydration and treatment with ceftriaxone and moxifloxacin. After 2 hours, the patient has received 2 L of normal saline. Her blood pressure is 98/70 mmHg with a heart rate of 125 bpm. She is requiring 50% oxygen by nasal mask to maintain her SaO2 at 92%–94%. Since presentation to the emergency department, she has produced 100 mL of urine. A blood gas is performed with a pH of 7.46, PaCO2 of 32 mmHg, and PaO2 of 76 mmHg. How would this patient’s presentation be classified? A. Refractory septic shock B. Septic shock C. Sepsis D. Signs of possibly harmful systemic response E. Systemic inflammatory response syndrome

C. Sepsis