Respiratory

Question 1

A 23-year-old patient comes into clinic for asthma follow-up. Which of the following would be concerning about the patient’s use of albuterol HFA MDI?
A. She uses 2 canisters of albuterol in 1 month.
B. She primes her inhaler prior to the initial use.
C. She uses 2 inhalations prior to beginning exercise.
D. She waits 30 seconds between each inhalation.

Answer 1

. Answer: A

Option A: Correct. Using 2 canisters of albuterol in 1 month is concerning. This means that the patient is using 200 doses of albuterol in 1 month. Using albuterol more than twice in 1 week indicates poor asthma control if the patient is using the inhaler correctly.

Question 2

A 35-year-old man has all of his asthma medications with him today. Which of the following is duplication of therapy?
A. Budesonide/formoterol and tiotropium
B. Montelukast and budesonide/formoterol
C. Albuterol and prednisone
D. Budesonide/formoterol and salmeterol

Answer 2

Option D: Correct. Budesonide is an inhaled corticosteroid, formoterol is a long-acting β2-agonist (LABA), and salmeterol is also a LABA. Using a LABA alone is contraindicated for asthma patients and increases the risk for death. Using formoterol and salmeterol together will increase side effects, including cardiovascular risks.

Question 3

Which one of the following medications treats both asthma and allergic rhinitis?
A. Tiotropium
B. Montelukast
C. Albuterol
D. Salmeterol

Answer 3

Option B: Correct. Montelukast is indicated for both asthma and allergic rhinitis and is often prescribed for asthma patients presenting with both diseases.

Question 4

Which of the following is a common side effect of inhaled corticosteroids?
A. Dyspnea
B. Tremor
C. Oral candidiasis
D. Urinary retention

Answer 4

Option C: Correct. Oral candidiasis occurs when patients do not rinse and spit after use. The corticosteroid changes the normal oral flora if the medication settles on the inside of the mouth. Ciclesonide is an ICS that does not cause this side effect. Using a spacer for ICS in the MDI formulation also helps.

Question 5

A 6-year-old girl presents with an asthma exacerbation. She weighs 40 pounds and is able to swallow tablets well. The recommended prednisone dose is 1 to 2 mg/kg/day orally in 2 divided doses (maximum of 60 mg/day). Which of the following is the correct dose for this patient?
A. 10 mg orally twice daily
B. 40 mg orally daily
C. 36 mg orally twice daily
D. 5 mg orally twice daily

Answer 5

Option A: Correct. Converting 40 pounds to kilogram by dividing 40 by 2.2 is 18.2 kg. The dose is 1 to 2 mg/kg/day so multiplying 18.2 × 2 gives a total daily dose range of 18.2 to 36.4 mg/day. Dividing the dose into two daily doses helps decrease stomach upset and may also decrease adrenal suppression. Prednisone is available as 1, 2.5, 5, 10, 20, and 50 mg tablets. So dosing of 10 mg twice daily (20 mg/day) is in the range of 18.2 to 36.4 mg/day.

Question 6

Which of the following is an appropriate technique with a dry powder inhaler?
A. Shaking the inhaler
B. Exhaling into the inhaler
C. Using a quick, deep inhalation
D. Cleaning the inhaler with water

Answer 6

Option C: Correct. Using a quick, deep breath is needed to pull the dry powder out of the inhaler and into the lungs.

Question 7

For which of the following patients with asthma is a valve-holding chamber with a mask appropriate?
A. A 2-year-old using albuterol as needed for wheezing
B. A 70-year-old with asthma and arthritis in her hands
C. A 7-year-old with asthma using albuterol before physical education
D. A 40-year-old using ICS who gets oral candidiasis frequently

Answer 7

Option A: Correct. A 2-year-old is not able to use the correct inhalation technique with an MDI and mouthpiece of inhaling a slow steady breath after a spray of medication is released into the valve-holding chamber (VHC). Using a mask with VHD allows the child to breathe normally with the mask over the nose and mouth to deliver the medication to the lungs.

Question 8

A 4-year-old patient with asthma has parents that both smoke cigarettes. Which of the following parental actions is appropriate to help improve the child’s asthma?
A. Smoking outside the home and car
B. Using an air purifier
C. Quitting smoking together by getting counseling and using medication
D. Switching to electronic cigarettes or cigars

Answer 8

Option C: Correct. Using medication and counseling doubles the tobacco abstinence rates at 1 year. If both parents quit together, it will help each of them be successful working as a team to help their child

Question 9

A 32-year-old man with asthma is using a tiotropium SMI. Which of the following would be an inappropriate usage technique?
A. Twisting the base of the inhaler until he hears a “click”
B. Opening the mouthpiece and he hears a “click”
C. Pressing the actuation button and breathing in slowly
D. Replacing the inhaler every 6 months

Answer 9

Option D: Correct. The inhaler has 30 days of medication and should be replaced on a monthly basis or within 3 months after puncturing the canister, whichever comes first.

Question 10

What method is used to determine if an inhaler without a counter is empty?
A. Shake the inhaler
B. Use the inhaler until there are no more sprays
C. Submerge the canister in a cup of water, and it is empty if it floats
D. Tally the use of medication used each day until the total number of actuations is reached

Answer 10

Option D: Correct. There are only a few MDIs left that do not have a counter, Proventil (albuterol) and Xopenex (levalbuterol). Keeping track of how many actuations are used each day up to 200 actuations is recommended.

Question 11

A 71-year-old woman with asthma is confused about all of her medications. Which of the following issues needs to be addressed with the patient today?
A. Mometasone/formoterol 100/5 mcg, 2 inhalations twice daily (120 actuations). The inhaler counter reads “10” and the inhaler was last filled 4 months ago.
B. Albuterol 90 mcg, 2 inhalations every 6 hours as needed for shortness of breath. The counter reads “170”. The inhaler was last filled 1 month ago.
C. Tiotropium Respimat 1.25 mcg, 2 inhalations daily. Dose counter “0”. Last filled 30 days ago.
D. Prednisone 20 mg tablets 40 mg orally for 3 days. Last filled one year ago. #4 tablets remaining.

Answer 11

Option A: Correct. Mometasone/formoterol is a controller medication containing both ICS and LABA. If the patient were using it twice daily every day, her inhaler would be empty in 1 month. Adherence to ICS/LABA decreases the need for albuterol, decreases exacerbations, and prevents hospitalizations. Counseling about the mechanism of action and perhaps changing inhalers may help adherence.

Question 12

A 51-year-old woman with severe persistent asthma has been taking fluticasone/vilanterol 200/5 mcg, 1 inhalation daily; montelukast 10 mg orally daily; tiotropium 2.5 mcg inhalation 2 inhalations daily; and prednisone 10 mg orally daily for the past 30 days. She has had multiple exacerbations, especially when prednisone is tapered off. Which laboratory test may help determine if mepolizumab is a good treatment option to help this patient discontinue prednisone?
A. IgE
B. CBC with differential
C. RAST
D. Pulmonary function tests

Answer 12

Option B: Correct. Mepolizumab is an IL-5 antagonist useful in patients with eosinophilic asthma. Checking a CBC with differential will assess if the absolute eosinophil count is elevated.

Question 13

Which of the following statements is using motivational interviewing to increase adherence to ICS?
A. It is important to take this medication every day as directed to prevent asthma symptoms.
B. Inflammation is the key factor making the airways tight. This medication will keep the inflammation away.
C. How did the doctor tell you to take this medication?
D. What is it that you dislike about this medication? What medications have helped your asthma in the past?

Answer 13

Option D: Correct. Asking the patient what they dislike about their current regimen will help identify misconceptions or alternative regimens that the patient may be willing to use.

Question 14

A 45-year-old man has moderate persistent asthma and COPD GOLD grade 2, class B. He has an ACT of 15 today. He takes albuterol less than twice a week and does not find albuterol to be helpful. He is not able to walk to the store like he previously did 1 year ago. He continues to smoke ½ ppd. His renal function is normal. He is taking fluticasone MDI 110 mcg, 2 inhalations twice daily. What is the best approach to his current management?
A. Initiate varenicline starter pack 0.5/1 mg twice daily
B. Initiate tiotropium 2.5 mcg, 2 inhalations daily
C. Increase fluticasone MDI 220 mcg, 2 inhalations twice daily
D. Change to fluticasone/salmeterol 250/50 mcg, 1 inhalation twice daily

Answer 14

Option A: Correct. Treating the patient with tobacco dependence will decrease the decline in lung function and improve all-cause mortality. Lower doses of ICS will be able to be used to treat asthma when he quits smoking.

Question 15

A 5-year-old girl with asthma and allergic rhinitis is taking montelukast 4 mg chew tablet every evening and budesonide Respules 0.5 mg via jet nebulizer once daily. She has not had an asthma exacerbation in over 1 year. Today in clinic her ACT is 24. She has not used albuterol in the past month. How can her asthma regimen be stepped down?
A. Discontinue albuterol MDI
B. Discontinue budesonide Respules
C. Discontinue montelukast
D. Decrease the dose of budesonide to 0.25 mg/day

Answer 15

Option B: Correct. Although ICS outperformed LTRA in clinical trials for preventing asthma exacerbations, this patient is well controlled and on the lowest dose of budesonide for her age. A trial of 4 weeks without the ICS and close monitoring is recommended. Continuing the LTRA montelukast will help with both asthma and allergic rhinitis and has a better safety profile than the ICS.

Question 16

Which of the following is an adverse effect of indacaterol?
A. Hypokalemia
B. Bradycardia
C. Urinary retention
D. Seizures

Answer 16

Option A: Correct. hypokalemia has been associated with LABA therapy via a shift of potassium intracellularly.

Question 17

An 81-year-old woman presents to the emergency department complaining of symptoms consistent with a COPD exacerbation. She tells you that she takes only tiotropium daily at home and is supposed to be on one other medication but has not had it refilled in the last 6 months. She also has a past medical history significant for depression, hypertension, and osteoporosis. Which of the following would be the most appropriate medication to aid in treating her acute COPD exacerbation?
A. Budesonide
B. Aminophylline
C. Roflumilast
D. Levalbuterol

Answer 17

Option D: Correct. A SABA is the most important medication for a patient during a COPD exacerbation..

Question 18

LABAs and/or LAMAs may improve all of the following parameters in a COPD patient with an FEV1 of 55% predicted except:
A. Symptom frequency
B. Lung function
C. Exacerbation rates
D. Mortality rates

Answer 18

Option D: Correct. No medication (including LABA and LAMA) has shown a beneficial effect on mortality rates.

Question 19

A 58-year-old man with COPD was started on an inhaled corticosteroid 2 months ago. Which of the following parameters would be best for evaluating the effectiveness of the inhaled corticosteroid and determining if continued use is needed?
A. Arterial blood gases
B. Serum glucose levels
C. Symptom improvement
D. FEV1/FVC ratio

Answer 19

Option C: Correct. Inhaled corticosteroids can improve symptoms in certain COPD patients and therapy may continue if improvement is noted.

Question 20

Which of the following plays a major role in inflammation of COPD?
A. Neutrophils
B. Eosinophils
C. Mast cells
D. Immunoglobulin E

Answer 20

Option A: Correct. The primary inflammatory cells involved in COPD pathophysiology are neutrophils, macrophages, and CD8+ T lymphocytes.

Question 21

Where in the lungs is the primary site of obstruction in COPD?
A. Large bronchi
B. Large bronchioles
C. Mucus glands
D. Small bronchi and bronchioles

Answer 21

Option D: Correct. Small bronchi and bronchioles are the major site of airflow obstruction due to fibrosis, increased mucus, and accumulation of inflammatory debris.

Question 22

A 59-year-old man presents with cough, sputum production, and dyspnea with exertion that began 6 months ago. He is a nonsmoker, but he has worked as a bartender four nights a week for the last 32 years. Lung examination reveals significant wheezing bilaterally. Which one of the following confirms the suspected diagnosis of COPD?
A. PaCO2 55 mm Hg (7.3 kPa) on arterial blood gas
B. Exposure to secondhand smoke
C. Postbronchodilator FEV1/FVC ratio of 60% (0.60)
D. Postbronchodilator FEV1 75%

Answer 22

Option C: Correct. Postbronchodilator FEV1/FVC ratio of less than 70% (0.70) confirms the diagnosis of COPD.

Question 23

All of the following are appropriate patient education points for COPD except:
A. Smoking cessation counseling
B. Role of regular exercise
C. Signs and symptoms of an exacerbation
D. When to quit taking medications as symptoms improve

Answer 23

Option D: Correct. Patients should be advised on the importance of medication adherence even when symptoms are controlled. Adherence helps maintain control and reduce risk of exacerbations. Once effective medications are started, they are generally continued for the long-term.

Question 24

Which of the following would be the most appropriate initial regimen for a patient with a CAT score of 14 and a history of one COPD exacerbation in the past year treated as an outpatient?
A. Tiotropium once a day
B. Monotherapy with as-needed albuterol
C. Fluticasone/salmeterol twice a day
D. Umeclidinium/vilanterol once a day

Answer 24

Option A: Correct. LAMA is indicated due to more symptoms (CAT score > 10) and low exacerbation risk (high exacerbation risk is 2 or more outpatient-treated exacerbations in 12 months or history of exacerbation requiring hospitalization).

Question 25

Which of the following clinical presentations are suggestive of COPD?
A. Sudden onset of cough and large volumes of purulent sputum
B. Chronic cough, sputum production, shortness of breath with activity; symptoms have gradually worsened over the last year
C. Wheezing and chest tightness that occurs when exposed to strong fumes; symptom onset in childhood
D. Cough, sputum production, shortness of breath, and fever; symptoms started 1 week ago

Answer 25

Option B: Correct. Chronic cough, sputum production, and dyspnea on exertion are the usual presenting symptoms of COPD.

Question 26

A 66-year-old man was admitted to the hospital 4 days ago for an acute COPD exacerbation. During this hospitalization, he has been treated with albuterol 2.5 mg via nebulizer every 4 hours, prednisone 40 mg orally once daily, and azithromycin 500 mg once daily, as well as tiotropium 18 mcg inhaled once daily and theophylline 200 mg orally twice daily. Today he complains of white patches on his tongue and the inside of his mouth. Which of the following is the most likely cause of this adverse effect?
A. Prednisone
B. Albuterol
C. Tiotropium
D. Theophylline

Answer 26

Option A: Correct. The patient is complaining of oral thrush, which is a known adverse effect of prednisone (systemic corticosteroid) use.

Question 27

A 65-year-old woman with emphysema is seen in clinic today for a checkup. Her current COPD pharmacotherapy includes tiotropium 18 mcg once daily and albuterol MDI every 4 hours as needed. She is adherent with medications and uses her inhalers correctly. She reports increasing albuterol use over the last 3 months due to increased breathlessness; she denies any recent changes in sputum purulence or volume. Her CAT score today is 23 (compared to 18 three months ago) and she has not had any exacerbations in the last 3 years. Which of the following is the most appropriate change to her current treatment regimen?
A. Add roflumilast 500 mcg orally every 24 hours
B. Add methylprednisolone 60 mg intravenously every 6 hours
C. Add fluticasone/salmeterol 500 mcg/50 mcg, one inhalation every 12 hours
D. Discontinue tiotropium and start umeclidinium/vilanterol 62.5 mcg/25 mcg, one inhalation daily

Answer 27

Option D: Correct. Combination LABA/LAMA is the recommended controller therapy, and patients should receive combination inhalers when possible to minimize inhaler burden.

Question 28

A 75-year-old man with severe COPD currently treated with tiotropium, formoterol/budesonide, and an albuterol MDI as needed presents to the clinic complaining of a more frequent cough, increased sputum production, and change in sputum color. The last time he had symptoms like these was 6 months ago, and at that time he was hospitalized for 3 days. After being diagnosed with a COPD exacerbation and continuing his current maintenance therapies, which of the following is the most appropriate initial treatment recommendation?
A. Mometasone 220 mcg inhalation every 12 hours
B. Doxycycline 100 mg orally every 12 hours
C. Ipratropium two inhalations every 6 hours
D. Theophylline 300 mg orally every 12 hours

Answer 28

Option B: Correct. The patient is complaining of signs and symptoms of a COPD exacerbation and warrants appropriate antibiotic therapy due to increased sputum production and change in sputum color.

Question 29

A 67-year-old man with COPD, hypertension, dyslipidemia, coronary artery disease, and osteoarthritis presents to clinic for routine follow-up. He is currently treated with tiotropium, albuterol as needed, lisinopril, metoprolol, atorvastatin, aspirin, and acetaminophen. He reports no changes in his respiratory symptoms over the last 3 months and his CAT score today is 9. He went to an urgent care facility twice in the past 10 months (last visit 4 months ago) for worsening COPD symptoms and was started on tiotropium at his last visit. Additionally, he was treated with antibiotics and prednisone at both urgent care visits. Which of the following is the most appropriate pharmacotherapeutic recommendation to make today?
A. No changes are needed because the patient’s symptoms are stable
B. Add budesonide/formoterol inhaler
C. Add roflumilast
D. Discontinue metoprolol

Answer 29

Option A: Correct. The patient has limited symptoms and had no change in symptoms since the tiotropium was appropriately added to his regimen3 months ago.

Question 30

A 63-year-old man presents to clinic complaining of chronic cough and sputum production and shortness of breath with activity. PFTs completed prior to his visit show an FEV1/FVC ratio of 68% (0.68) and FEV1 65% of predicted. His CAT score is 12. He has not had any exacerbations. Which of the following would be most appropriate as the initial regimen for COPD?
A. Budesonide/formoterol twice a day
B. Ipratropium/albuterol four times a day
C. Umeclidinium once a day
D. Albuterol as needed

Answer 30

Option C: Correct. LAMAs are indicated in patients with more symptoms as indicated by this CAT score greater than 10.

Question 31

Which symptom is least typical of allergic rhinitis?
A. Sneezing
B. Rhinorrhea
C. Ocular itching
D. Wheezing

Answer 31

Option D: Correct. Wheezing is not a symptom specific to allergic rhinitis, it may be noted in patients with asthma and allergic rhinitis, but this is not a manifestation of allergic rhinitis alone.

Question 32

At what age are allergies least likely to cause rhinitis symptoms and thus most likely need additional evaluation for further for other causes of rhinitis?
A. 18 months
B. 24 months
C. 18 years
D. 65 years

Answer 32

Option A: Correct. Younger children with allergies are likely present with other symptoms such as sneezing and itching

Question 33

Which medication is most effective for most symptoms of AR?
A. Azelastine nasal spray
B. Cromolyn intranasal spray
C. Fluticasone propionate nasal spray
D. Loratadine tablet

Answer 33

Option C: Correct. INCs are the most effective therapy and considered first line agents for AR as per current guidelines.

Question 34

Rhinitis medicamentosa or rebound congestion is a possible effect from overuse of which medication type?
A. Intranasal antihistamine
B. Intranasal corticosteroid
C. Intranasal decongestant
D. Intranasal saline spray

Answer 34

Option C: Correct. Continuous use of intranasal decongestants can cause a paradoxical rebound phenomenon of persistent nasal congestion, called rhinitis medicamentosa.

Question 35

Which oral antihistamine is the least sedating?
A. Diphenhydramine
B. Chlorpheniramine
C. Cetirizine
D. Fexofenadine

Answer 35

Option D: Correct. Fexofenadine virtually has no sedative effects even at doses higher than recommended.

Question 36

Which intranasal corticosteroid has the least systemic absorption?
A. Beclomethasone
B. Budesonide
C. Ciclesonide
D. Flunisolide

Answer 36

Option C: Correct. The older INCSs (beclomethasone, flunisolide, and budesonide) have significant absorption, whereas, among the newer products, fluticasone, ciclesonide, and mometasone have bioavailability of less than 1% to 2%.

Question 37

Which intranasal medication has the greatest potential to cause sedation?
A. Azelastine
B. Cromolyn
C. Fluticasone
D. Oxymetazoline

Answer 37

Option A: Correct. There is enough systemic absorption to cause sedation in some patients using azelastine (about 10%).

Question 38

Which medication may be most helpful for patient with vasomotor (idiopathic, autonomic) rhinitis or mixed etiology of AR?
A. Loratadine
B. Cetirizine
C. Fluticasone nasal spray
D. Ipratropium nasal spray

Answer 38

Option D: Correct. Antimuscarinic agents, such as ipratropium, may be particularly
helpful for patients who have vasomotor (idiopathic, autonomic) rhinitis, or those who may have a mixed etiology.

Question 39

Which grass allergen SLIT is FDA-approved for children age 5 years and older?
A. Oralair
B. Grastek
C. Ragwitek
D. Odactra

Answer 39

Option B: Correct. Grastek contains only Timothy grass pollen and is approved for ages 5 years and older.

Question 40

Which medication is most likely to cause paradoxical CNS stimulation in young children?
A. Cetirizine
B. Diphenhydramine
C. Fluticasone
D. Montelukast

Answer 40

Option B: Correct. First-generation H1 antihistamines, such as diphenhydramine may cause paradoxical CNS stimulation in the very young (< 2 years old).

Question 41

Which is the most appropriate recommendation for a 25-year-old man who complains of runny nose, sneezing, and ocular tearing and itch, when episodically exposed to his girlfriend’s dog, as an OTC agent he could use for pre-exposure?
A. Cetirizine
B. Diphenhydramine
C. Intranasal cromolyn
D. Intranasal fluticasone

Answer 41

Option C: Correct. Cromolyn can be used effectively on an as needed basis for episodic exposures to allergens, such as in this scenario. Additionally, the use of this agent would address his symptoms of rhinorrhea, sneezing, and ocular tearing and itch.

Question 42

AB is a 62-year-old male patient with symptomatic benign prostatic hyperplasia/hypertrophy (BPH), poorly controlled hypertension, diabetes, and persistent rhinorrhea due to a mixed vasomotor and allergic rhinitis. He has not had good response to oral fexofenadine and intranasal fluticasone propionate + azelastine. Which is the most appropriate added treatment for him at this time?
A. Cetirizine
B. Prednisone
C. Pseudoephedrine
D. Intranasal ipratropium

Answer 42

Option D: Correct. Antimuscarinic agents, such as ipratropium, may be particularly
helpful for patients who have vasomotor (idiopathic, autonomic) rhinitis, or those who may have a mixed etiology.

Question 43

JD is a 15-year-old man with concurrent moderate persistent asthma and allergic rhinitis. His medications include fluticasone propionate/salmeterol 230 mcg/21 mcg 2 puff inhaled twice a day, montelukast 10 mg daily, fluticasone nasal spray, and azelastine nasal spray. Which additional tests would be needed to evaluate if omalizumab is appropriate for his asthma and AR?
A. Complete blood count (CBC) with differential assessing total eosinophils
B. Flow cytometry to assess T helper phenotypes
C. Serum immunoglobulin (IgE)
D. Basophil histamine release assay

Answer 43

Option C: Correct. Omalizumab is a monoclonal antibody that binds to IgE and thus evaluation of baseline serum IgE would be appropriate to evaluate to determine if the patient is a candidate for the medication.

Question 44

24-year-old woman, who is known to be 8 weeks pregnant, has been on saline nasal rinses, oral montelukast, and oral loratadine for moderate allergic rhinitis. Her symptoms of nasal congestion, rhinorrhea, sneezing, and ocular itching are still poorly controlled, despite good adherence. Which is the most appropriate to recommend as an additional and/or replacement medication.
A. Diphenhydramine
B. Intranasal cromolyn
C. Intranasal triamcinolone
D. Oral phenylephrine

Answer 44

Option B: Correct. Cromolyn is also FDA pregnancy category B and is considered
safe.

Question 45

JK is a 10-year-old boy being treated for his AR with the following: cetirizine, intranasal fluticasone, intranasal azelastine, and montelukast. His mother comes to you with a question about drug-related issues with sleep. He has not been sleeping well and become more withdrawn. Which medication is most likely causing these new symptoms?
A. Azelastine
B. Cetirizine
C. Fluticasone
D. Montelukast

Answer 45

Option D: Correct. There are postmarketing reports of neuropsychiatric events,
including sleep disturbances, depression and suicidal ideation with montelukast use.