Pulmonary & Critical Care

Question 1

Patients with asthma exacerbations who have signs that indicate a severe attack should be?

Answer 1

Hospitalized

Question 2

Treatment of aspirin-exacerbated respiratory disease (AKA Samter’s triad) consists of symptom treatment with?

Answer 2

Glucocorticoids and removal of the exposure to NSAIDs/aspirin; treatment can also include a leukotriene receptor antagonist.

Question 3

In patients with severe COPD associated with chronic bronchitis & a history of recurrent exacerbations, what medication can reduce risk and frequency of exacerbations?

Answer 3

Roflumilast, a selective phosphodiesterase-4 inhibitor

Note: Contraindicated in patients with liver impairment & has significant drug interactions.

Question 4

in a patient with a high probability of obstructive sleep apnea without underlying cardiopulmonary or neuromuscular disease, what is the next test?

Answer 4

Home sleep testing is the first test indicated

Note: Polysomnography performed in a sleep laboratory is the preferred diagnostic test for OSA in patients with underlying cardiopulmonary or neuromuscular disease who might require advanced positive airway pressure modes (such as bilevel positive airway pressure) or supplemental oxygen but would not be indicated for this patient who has no evidence of such comorbidities.

Question 5

Subsolid (e.g. ground-glass) lung nodules 6-8 mm in size should be initially followed up at?

Answer 5

6-12 months and then every 2 years for 5 years because of the slow rate of growth if such masses are malignant.

Question 6

In a patient with IPF on Pirfenidone, an abrupt worsening during a few days to weeks in the absence of another cause for dyspnea such as infection, heart failure, or pulmonary embolism and is notable for new bilateral ground-glass opacities superimposed on findings consistent with usual interstitial pneumonia on CT scan?

Answer 6

An acute exacerbation of idiopathic pulmonary fibrosis

Question 7

This diagnosis is suggested by mid-chest tightness* with exposure to particular triggers such as strong irritants or emotions; difficulty breathing in; and symptoms that only *partially respond to asthma medications?

Answer 7

Vocal cord dysfunction

Question 8

Used to prevent and treat delirium in critically ill patients?

Answer 8

Early mobilization with physical and occupational therapy and interruption of sedation

Question 9

This is the best way to prevent deaths and complications from lung cancer and other diseases?

Answer 9

Smoking cessation

Question 10

In patients who cannot maintain a patent airway or protect the airway against aspiration, what should be done?

Answer 10

A secure airway should be established with intubation

Question 11

Patients with mild persistent asthma uncontrolled with a short-acting β₂-agonist should be stepped up to?

Answer 11

Low-dose inhaled glucocorticoids & SABA PRN

or

Low dose inhaled glucocorticoid-LABA combination & SABA PRN.

Question 12

Typically occurs in older individuals with nonproductive cough and progressive dyspnea on exertion; the diagnosis is supported by findings of usual interstitial pneumonitis (B/L peripheral & basal predominant septal line thickening with honeycombing at the bases) on a high-resolution CT scan of the chest?

Answer 12

Idiopathic pulmonary fibrosis

Question 13

The most appropriate method to evaluate volume status remains the

Answer 13

Physical examination; several technologies can help confirm the assessment.

Question 14

Typical imaging findings in this type of lung cancer include a large mediastinal mass and hyponatremia due to ectopic production of antidiuretic hormone?

Answer 14

Small cell lung cancer

Other paraneoplastic syndromes includes: Ectopic ACTH production, Lambert-Eaton syndrome & SVC syndrome

Question 15

The first steps in managing a patient with a presumed COPD exacerbation are to:

Answer 15

Confirm the diagnosis and to evaluate other causes of the acute presentation such as with an ECG.

Question 16

What is the strongest indication for treatment of obstructive sleep apnea, atrial fibrillation, diabetes, excessive daytime sleepiness or HTN?

Answer 16

Excessive daytime sleepiness

Question 17

This intervention is indicated for patients with obesity hypoventilation syndrome and hypercapnic respiratory failure who do not improve with noninvasive positive pressure ventilation?

Answer 17

Early intubation

Question 18

This test is indicated for patients experiencing symptoms of COPD and who are younger than 45 years of age or have a strong family history of COPD?

Answer 18

Measurement of α₁-antitrypsin level

Question 19

What is a simple intervention to mitigate mucosal irritation in positive airway pressure therapy in OSA patients?

Answer 19

In-line heated humidification

Question 20

What is the treatment in patients with moderate to severe uncontrolled asthma with the eosinophilic phenotype

Answer 20

Mepolizumab can reduce emergency department visits, hospitalizations, and requirements for inhaled and oral glucocorticoids

Question 21

Treatment for severe carbon monoxide poisoning?

Answer 21

Hyperbaric oxygen therapy

Indications for hyperbaric oxygen therapy are: loss of consciousness, ischemic cardiac changes, neurological deficits, significant metabolic acidosis, or carboxyhemoglobin level >25%.

Question 22

This test is recommended for patients with a severe exacerbation of COPD to assess for hypercapnia and hypoxemia?

Answer 22

ABG

Question 23

can estimate pulmonary artery pressures and is the preferred initial test if pulmonary hypertension is suspected in a patient with a widened spilt S2 ?

Answer 23

Transthoracic echo

Question 24

In patients with obesity-related asthma, this intervention improves asthma control, lung function, and quality of life; reduces asthma medication use; and should be considered an essential part of the treatment plan?

Answer 24

Weight loss

Question 25

Initial treatment of central sleep apnea should target modifiable risk factors; for example in a patient with heart failure demonstrating signs of volume overload, treat with?

Answer 25

Furosemide, which has been shown to improve central sleep apnea and Cheyne-Stokes breathing and should precede other therapies for sleep apnea.

Question 26

Patients with a history of asthma-COPD overlap syndrome should not be prescribed a

Answer 26

A long-acting β_<u>2</u>-agonist without concurrent therapy with an inhaled glucocorticoid because of the increased risk of mortality in patients with asthma who are prescribed long-acting β₂-agonist monotherapy.

Question 27

During air travel, ______________ is most likely to occur at cruising altitude in patients with bullous lung disease, particularly those with a recent exacerbation of airways disease who are, therefore, more prone to air trapping.

Answer 27

Pneumothorax

Question 28

What is the most appropriate management for patients with upper-lobe predominant emphysema and significant exercise limitations?

Answer 28

Lung volume reduction surgery, improves quality of life and survival

Question 29

How do you diagnosed COPD?

Answer 29

Spirometry.

A postbronchodilator FEV₁/FVC of <0.70 is diagnostic of airflow obstruction & is consistent with the diagnosis of COPD.

Question 30

For individuals with idiopathic pulmonary fibrosis who develop severe respiratory distress that has no underlying reversible cause, supportive mechanical ventilation is of little long-term benefit; in these circumstances, the focus should be?

Answer 30

Palliative care

Question 31

Patients with diffuse cutaneous systemic sclerosis are at high risk for the development of diffuse parenchymal lung disease, which is the leading cause of death in these patients and as such should have what test?

Answer 31

High-resolution chest CT scan

Question 32

Cough-variant asthma refers to asthma in which the predominant manifestation is cough, and without other typical asthma symptoms; the diagnosis is supported by

Answer 32

Abnormal spirometry or methacholine challenge testing if spirometry is normal

Question 33

Are the preferred method for rapid intravenous administration of large amounts of fluids?

Answer 33

Peripheral wide-bore venous catheters

Question 34

Patients who are not responding to typical therapy for COPD exacerbations should be carefully evaluated for

Answer 34

Heart failure, pneumonia, and pulmonary embolism with CT pulmonary angiography

Question 35

Patients with a solid indeterminate lung nodule larger than 8 mm and high probability of malignancy should be staged using a PET/CT scan followed by

Answer 35

Definitive management with surgical wedge resection

Question 36

Parietal plaques are the most common radiologic finding in patients with?

Answer 36

Asbestosis

Question 37

Treat a patient for an acute asthma exacerbation with persistent symptoms with?

Answer 37

Intravenous magnesium sulfate reduces hospital admissions and improves lung function in adults with acute asthma who have not responded sufficiently to oxygen, nebulized short-acting β₂-agonists, and intravenous glucocorticoids.

Question 38

Treat septic shock that persists after adequate fluid resuscitation & vasopressors using?

Answer 38

Glucocorticoids e.g Hydrocortisone are indicated in patients with sepsis who have not achieved hemodynamic stability from intravenous fluid administration and vasopressor therapies.

Question 39

Patients with asbestos exposure most commonly present with symptoms of chest pain and a slowly enlarging pleural effusion, what’s the diagnosis?

Answer 39

Malignant pleural mesothelioma

Question 40

Patients whose symptoms and spirometry are consistent with mild COPD can begin treatment with

Answer 40

A short-acting bronchodilator as needed

Question 41

Treat a patient with chronic hypoventilation due to neuromuscular disease such as amyotrophic lateral sclerosis (ALS)?

Answer 41

Non-invasive ventilation with bilevel positive airway pressure

Question 42

Patients with a primary spontaneous pneumothorax should be encouraged to stop?

Answer 42

Smoking to prevent recurrence

Question 43

Adults include chronic asthma-like symptoms, chronic sinusitis, nasal polyposis, recurrent pancreatitis, infertility, and bronchiectasis?

Answer 43

Cystic Fibrosis

Question 44

An exacerbation of COPD is defined as a sustained worsening of symptoms, typically cough, dyspnea, and sputum production; standard treatment of moderate to severe exacerbations includes?

Answer 44

Antibiotics and oral glucocorticoids

Question 45

Patients with pulmonary hypertension secondary to lung disease and associated hypoxemia should be treated with?

Answer 45

Supplemental oxygen

Question 46

Right heart catheterization demonstrates a mean pulmonary arterial pressure of 36 mm Hg, with no change with inhaled nitric oxide, what is the treatment of pulmonary arterial hypertension?

Answer 46

The most appropriate treatment is Bosentan, not calcium channel blocker

Question 47

When an occupational lung disease is being considered, clinicians should request a

Answer 47

Material Safety Data Sheet detailing chemical properties and known health risks associated with substances within the workplace

Question 48

Evaluate a patient with an anterior mediastinal mass and symptoms of myasthenia gravis with?

Answer 48

Acetylcholine receptor antibody

Question 49

Secondary respiratory infections are common in patients with inhalational injuries, especially from Staphylococcus and Pseudomonas species, and are a major cause of morbidity and mortality. Treatment should include

Answer 49

IV Antibiotics

Question 50

Treatment for a patient at risk for alcohol withdrawal who has overdosed on benzodiazepines?

Answer 50

Is supportive with assurance of adequate ventilation; flumazenil is generally not recommended for benzodiazepine overdose as it can precipitate seizures in chronic users and its short half-life makes it difficult to sustain reversal of long-acting benzodiazepines.

Question 51

Treat hypersensitivity pneumonitis?

Answer 51

Removal of the offending antigen is the most appropriate treatment of acute hypersensitivity pneumonitis.

Question 52

In patients with severe COPD and frequent exacerbations, what is the most appropriate treatment to reduce exacerbations?

Answer 52

Chronic macrolide therapy

Question 53

Treat a patient with acute hypoxemic respiratory failure & ARDS with?

Answer 53

Intubation & mechanical ventilation

Question 54

in a patient with limited cutaneous systemic sclerosis and CREST syndrome, what is the associated pulmonary disease?

Answer 54

Pulmonary arterial hypertension

Question 55

Patients with hypoperfusion due to sepsis should be managed with aggressive

Answer 55

Crystalloid fluid resuscitation using an initial bolus of 30 mL/kg of body weight.

Question 56

Treat secondary spontaneous pneumothorax, which has a high likelihood of recurrence with?

Answer 56

Pleurodesis

Question 57

Identify risk factors of acute exacerbations of COPD?

Answer 57

Patients with COPD who have had two or more acute exacerbations within the last year, who have an FEV₁ of less than 50% of predicted, or who have ever been hospitalized for an acute exacerbation are considered to be at high risk for recurrent acute exacerbations.

Question 58

Treat a patient with neurologic disease and hypercapnic respiratory failure with?

Answer 58

Noninvasive ventilation with bilevel positive airway pressure, which improves survival and quality of life in patients with neuromuscular disease.

Question 59

For adults with a hypertensive emergency and without a compelling condition (such as aortic dissection) systolic blood pressure should be reduced by?

Answer 59

no more than 25% within the first hour; then, if stable, to 160 mm Hg within the next 2 to 6 hours; and then cautiously to normal during the following 24 to 48 hours

Question 60

Treat a patient for cyanide poisoning as a coexposure to carbon monoxide poisoning after a house fire?

Answer 60

Hydroxocobalamin effectively removes cyanide from the mitochondrial respiration system and is the preferred antidote for cyanide poisoning.

Question 61

Manage a patient with clinical signs of cystic fibrosis and a negative sweat chloride test?

Answer 61

Repeat sweat chloride testing, as Negative sweat chloride testing does not exclude the diagnosis of cystic fibrosis in patients with high pretest probability of disease.

Question 62

When should you screen for lung cancer?

Answer 62

Aged 50 to 80 years with a greater than 20-pack-year history of tobacco use within the previous 15 years.

Question 63

Manage oversedation in a patient in the ICU by doing?

Answer 63

Daily sedation & analgesics vacations/interruptions, have been shown to decrease the incidence of delirium, the need for diagnostic testing, and the amount of time spent on mechanical ventilation and in the ICU.

Question 64

Patients with nonexertional heat stroke should be treated with?

Answer 64

• *Evaporative cooling (i.e**
• *Sprayed water and cooling fans)** to lower their core temperature to a safe level

Question 65

Initial treatment of septic or distributive shock should focus on aggressive

Answer 65

Fluid resuscitation with crystalloids within the first 3 hours of presentation.

Question 66

Treat a patient in cardiac arrest due to accidental hypothermia with?

Answer 66

Continued CPR & and active internal rewarming.

Question 67

Treat high-altitude cerebral edema with?

Answer 67

Dexamethasone, although the most important treatment of high-altitude cerebral edema is descent to lower elevation, dexamethasone should be administered immediately upon recognition of high-altitude cerebral edema.

Question 68

Treat a critically ill patient who has acute pain with?

Answer 68

IV opioids are the first-line drug class of choice to treat nonneuropathic pain in critically ill patients; all intravenously administered opioids have equi-analgesic efficacy and are associated with similar clinical outcomes when titrated to similar pain intensity end points.

Question 69

Manage an asymptomatic patient with stage I pulmonary sarcoidosis?

Answer 69

Treatment of pulmonary sarcoidosis should be based on symptoms rather than radiographic findings.

Question 70

To prevent of ventilator-associated lung injury and a reduction in mortality related to ARDS?

Answer 70

Use of low tidal volume ventilation and positive end-expiratory pressure

Question 71

In the early sepsis management, a central venous catheter should be recognized as a source of sepsis and should be managed how?

Answer 71

Remove the central venous catheter

Question 72

The initial step in the evaluation of the patient with excessive daytime sleepiness is to ensure adequate quantities of sleep on a regular basis using either:

Answer 72

Actigraphy or a sleep diary

Question 73

Effusions associated with a pH less than 7.2 or pleural fluid glucose level less than 60 mg/dL (3.3 mmol/L) require thoracostomy drainage in addition to antibiotics?

Answer 73

Complicated parapneumonic effusion

Question 74

Provide recommended vaccinations for patients with COPD?

Answer 74

Annual influenza vaccination and the pneumococcal polysaccharide vaccine (PPSV23) are recommended for all patients with chronic lung disease (COPD, emphysema, asthma).

Question 75

Treat a patient with chronic thromboembolic pulmonary hypertension (CTEPH)?

Answer 75

Pulmonary thromboendarterectomy

two diagnostic criteria for CTEPH: (1) mean pulmonary artery pressure of 25 mm Hg or higher by right heart catheterization in the absence of left heart pressure overload & (2) compatible imaging evidence of chronic thromboembolism.

Question 76

Evaluate readiness to liberate from mechanical ventilation in a patient with COPD with?

Answer 76

30-minutes spontaneous breathing trial

Question 77

Treat a patient with empyema?

Answer 77

Instillation of intrapleural tissue plasminogen activator-deoxyribonuclease has been shown to decrease the radiographic pleural opacity, lower the rate of surgical referral, and decrease hospital stay of patients with empyema.

Question 78

_______________________ is the most appropriate test to perform next for this patient with persistent cough following a presumed viral upper respiratory tract infection. These symptoms can be the initial presentation of asthma, which is common in patients older than 65 years.

Answer 78

Methacholine challenge testing

Question 79

Treat a patient who has anaphylaxis with?

Answer 79

Epinephrine

Question 80

Patients with severe acute respiratory distress syndrome have a demonstrated mortality benefit from:

Answer 80

Low tidal volume ventilation in the prone position

Question 81

Chest CT is the definitive diagnostic study & typical findings are airway dilatation with lack of tapering, bronchial wall thickening, and cysts.

Answer 81

Bronchiectasis

Question 82

Patients who work in industries that expose them to silica dust are at risk for?

Answer 82

Silicosis

Question 83

Diagnose ICU-acquired weakness in a critically ill patient using the?

Answer 83

Medical Research Council muscle scale

Question 84

Includes cough, fever, and malaise for 6 to 8 weeks that does not respond to antibiotics; patchy opacities on chest radiograph; and ground-glass opacities on CT scan that are peripherally distributed; glucocorticoids are first-line therapy

Answer 84

Cryptogenic organizing pneumonia

Question 85

Treat a patient with a hemodynamically unstable pulmonary embolism using?

Answer 85

Thrombolytic therapy

Question 86

Should be started as soon as possible for severely malnourished patients or those at high risk of malnutrition for whom enteral nutrition is not possible?

Answer 86

Parenteral nutrition

Question 87

Is found in active smokers who have chest CT scan findings of centrilobular micronodules?

Answer 87

Respiratory bronchiolitis–associated interstitial lung disease

Note: Pulmonary Langerhans cell histiocytosis is characterized by middle & upper zone thin-walled cysts* w/ accompanying nodules & is *often associated with pHTN. Patients tend to be young adults with cough and dyspnea.

Question 88

Should be strongly considered when a patient with silicosis* develops constitutional symptoms, worsening respiratory impairment, *hemoptysis, or changes in the chest radiograph, particularly cavities.

Answer 88

Tuberculosis, sputum sample for acid-fast bacillus

Question 89

Flattening of both the inspiratory and expiratory curve of the flow-volume loop suggests a

Answer 89

Fixed upper airway obstruction; direct examination of the airways is indicated to confirm the finding and identify the cause.

Question 90

How should you treat asthma during pregnancy?

Answer 90

Treatment of asthma during pregnancy is similar to treatment in nonpregnant patients.

Question 91

Evaluate a patient with diffuse parenchymal lung disease using?

Answer 91

High-resolution chest CT scan

Question 92

For patients with negative cytology in whom malignancy is suspected, what is the next step in management?

Answer 92

Thoracoscopy with pleural biopsy allows for direct visualization of the pleural surface and has a diagnostic sensitivity for malignant disease of greater than 90%.

Question 93

He has symptoms of progressive dyspnea on exertion, inspiratory crackles, restrictive pulmonary function tests, and a chest radiograph demonstrating diffuse parenchymal lung disease. This constellation of findings suggests interstitial lung disease, how do you diagnosed?

Answer 93

High-resolution CT scan of the chest

Question 94

Treat disruptive snoring in an obese patients with?

Answer 94

Weight-loss

Question 95

For patients with a malignant pleural effusion and rapid reaccumulation of fluid, management should include

Answer 95

Indwelling pleural catheters provide significant symptom relief, and 50% to 70% of patients achieve spontaneous pleurodesis after 2 to 6 weeks.

Question 96

Include hyperthermia, tremor, hyperreflexia and clonus; treatment is mainly supportive, using benzodiazepines as needed to keep the patient calm and to control blood pressure and heart rate. Patient is usually taking a SSRI or SNRI

Answer 96

Serotonin Syndrome

Question 97

In patients with hemorrhagic shock, initial management includes:

Answer 97

Volume resuscitation with blood products to stabilize the patient

Question 98

Patients with isopropyl alcohol poisoning can be treated effectively using

Answer 98

Supportive care

Question 99

Is the procedure of choice for diagnosing and staging mediastinal and hilar lymphadenopathy in patients with suspected thoracic malignancy?

Answer 99

Endobronchial ultrasound-guided transbronchial needle aspiration

Question 100

In the treatment of opioid overdose the antidote effects of naloxone will usually wear off before the opioid effects are gone?

Answer 100

observation and repeated dosing are often necessary

Question 101

The most common causes of hypoxemic respiratory failure are conditions that lead to ventilation-perfusion mismatch or shunt; hypoxemia due to ventilation-perfusion mismatch with shunting does not improve with supplemental oxygen. A likely diagnosis is?

Answer 101

Pulmonary embolism

Question 102

Is characterized by daytime hypercapnia, defined as an arterial PCO₂ greater than 45 mm Hg that is thought to be a consequence of diminished ventilatory drive and capacity related to extreme obesity?

Answer 102

Obesity hypoventilation syndrome

Question 103

If previous data on bronchiectasis exacerbations are not available, a _____________ should be started to ensure Pseudomonas coverage until the sputum culture is completed.

Answer 103

fluoroquinolone