ITE Pulmonary and Critical Care — Questions and Answers

Question 1: A 58-year-old man with COPD presents with acute hypercapnic respiratory failure. ABG shows pH 7.28, PaCO2 72 mmHg, PaO2 58 mmHg on room air. Which intervention is MOST appropriate as first-line therapy?

Immediate endotracheal intubation
Non-invasive positive pressure ventilation (NIPPV) (Correct answer)
High-flow nasal cannula at 40 L/min
Heliox administration

Correct answer: Non-invasive positive pressure ventilation (NIPPV)

NIPPV (BiPAP) is the first-line intervention for acute hypercapnic respiratory failure in COPD, reducing intubation rates, mortality, and hospital length of stay.

Question 2: A 45-year-old woman develops acute respiratory distress syndrome (ARDS) after septic shock. P/F ratio is 95. Which ventilator strategy has the strongest mortality benefit?

High tidal volume ventilation at 10 mL/kg IBW
Low tidal volume ventilation at 6 mL/kg IBW with plateau pressure <30 cmH2O (Correct answer)
Pressure-controlled ventilation targeting RR <12 breaths/min
High PEEP strategy with FiO2 titration only

Correct answer: Low tidal volume ventilation at 6 mL/kg IBW with plateau pressure <30 cmH2O

The ARDSNet trial demonstrated that low tidal volume ventilation (6 mL/kg IBW) with plateau pressure <30 cmH2O reduces mortality by 22% compared to higher tidal volumes.

Question 3: A 62-year-old woman with known pulmonary arterial hypertension presents with worsening dyspnea and right heart failure. Echocardiogram shows RV dilation and septal bowing. Which hemodynamic finding on right heart catheterization confirms WHO Group 1 PAH?

Mean PAP >20 mmHg with PCWP >15 mmHg
Mean PAP >20 mmHg with PCWP ≤15 mmHg and PVR ≥3 Wood units (Correct answer)
Systolic PAP >50 mmHg with normal PVR
Mean PAP >25 mmHg with elevated cardiac output

Correct answer: Mean PAP >20 mmHg with PCWP ≤15 mmHg and PVR ≥3 Wood units

Updated 2022 ESC/ERS guidelines define PAH (Group 1) as mean PAP >20 mmHg with PCWP ≤15 mmHg and PVR ≥3 Wood units on right heart catheterization.

Question 4: A 70-year-old man on mechanical ventilation develops sudden hemodynamic instability with decreased breath sounds on the left, tracheal deviation to the right, and rising peak airway pressures. What is the immediate management?

Chest X-ray to confirm diagnosis
Needle decompression of the left hemithorax (Correct answer)
Increase PEEP to recruit atelectatic lung
Bronchoscopy to assess for mucus plugging

Correct answer: Needle decompression of the left hemithorax

Tension pneumothorax is a clinical diagnosis requiring immediate needle decompression at the 2nd intercostal space midclavicular line before imaging.

Question 5: A 55-year-old man with idiopathic pulmonary fibrosis (IPF) has FVC 65% predicted and DLCO 48% predicted. Honeycombing is present on HRCT. Which medication has been shown to slow FVC decline in IPF?

Prednisone 60 mg/day
Nintedanib 150 mg twice daily (Correct answer)
N-acetylcysteine 600 mg three times daily
Azathioprine 150 mg/day

Correct answer: Nintedanib 150 mg twice daily

Nintedanib (and pirfenidone) are the only FDA-approved antifibrotic agents that slow FVC decline in IPF; corticosteroids and azathioprine increase mortality in IPF.

Question 6: A 48-year-old woman with obesity (BMI 38) presents with daytime somnolence, morning headaches, and an AHI of 42 events/hour with SpO2 nadir of 78% on polysomnography. What is the MOST appropriate first-line treatment?

Supplemental oxygen via nasal cannula at night
Continuous positive airway pressure (CPAP) (Correct answer)
Bilevel positive airway pressure (BiPAP)
Uvulopalatopharyngoplasty (UPPP)

Correct answer: Continuous positive airway pressure (CPAP)

CPAP is the first-line treatment for moderate-to-severe obstructive sleep apnea, effectively eliminating apneic events and improving symptoms.

Question 7: A 35-year-old African American woman presents with bilateral hilar lymphadenopathy, erythema nodosum, and polyarthritis. Serum ACE is elevated. Bronchoscopy with BAL shows lymphocytosis with CD4:CD8 ratio of 5:1. What is the MOST likely diagnosis?

Lymphoma with pulmonary involvement
Sarcoidosis (Correct answer)
Hypersensitivity pneumonitis
Berylliosis

Correct answer: Sarcoidosis

Löfgren syndrome (bilateral hilar adenopathy, erythema nodosum, and arthritis) combined with elevated ACE and high BAL CD4:CD8 ratio is pathognomonic for sarcoidosis.

Question 8: A 67-year-old man with Stage IIIA non-small cell lung cancer (NSCLC) and ECOG performance status 1 has a PD-L1 expression of 85%. He has no driver mutations (EGFR/ALK negative). Which treatment approach is MOST appropriate?

Cisplatin/pemetrexed chemotherapy alone
Pembrolizumab monotherapy
Concurrent chemoradiation followed by durvalumab (Correct answer)
EGFR-targeted therapy with osimertinib

Correct answer: Concurrent chemoradiation followed by durvalumab

For unresectable Stage III NSCLC, concurrent chemoradiation followed by consolidation durvalumab (PACIFIC trial) is the standard of care regardless of PD-L1 expression.

Question 9: A 52-year-old woman with massive hemoptysis (>600 mL in 24 hours) from a left lower lobe cavitary lesion is hemodynamically stable. What is the MOST appropriate immediate management?

Emergent left pneumonectomy
Bronchial artery embolization
Rigid bronchoscopy with Fogarty balloon tamponade
Position patient with left side down and consult interventional radiology (Correct answer)

Correct answer: Position patient with left side down and consult interventional radiology

In massive hemoptysis, positioning the bleeding lung in the dependent (down) position protects the unaffected lung and is the immediate stabilizing maneuver before definitive treatment.

Question 10: A patient in the ICU on mechanical ventilation has the following ABG: pH 7.50, PaCO2 30 mmHg, PaO2 95 mmHg, HCO3 23 mEq/L. Current settings: TV 500 mL, RR 18, PEEP 5, FiO2 0.40. What is the MOST appropriate ventilator adjustment?

Increase PEEP to improve oxygenation
Decrease respiratory rate to correct respiratory alkalosis (Correct answer)
Increase tidal volume to increase minute ventilation
Decrease FiO2 to 0.21

Correct answer: Decrease respiratory rate to correct respiratory alkalosis

The ABG shows respiratory alkalosis (low PaCO2, elevated pH) with adequate oxygenation; decreasing respiratory rate reduces minute ventilation and corrects hypocapnia.

Question 11: A 60-year-old man undergoes right heart catheterization. Results: RA pressure 18 mmHg, RV 55/20 mmHg, PA 55/28 mmHg (mean 38), PCWP 24 mmHg, cardiac output 3.8 L/min. What is the MOST likely diagnosis?

Idiopathic pulmonary arterial hypertension
Pulmonary hypertension due to left heart disease (Group 2) (Correct answer)
Chronic thromboembolic pulmonary hypertension (CTEPH)
Pulmonary hypertension due to lung disease (Group 3)

Correct answer: Pulmonary hypertension due to left heart disease (Group 2)

Elevated PCWP (>15 mmHg) with elevated mean PAP indicates post-capillary (Group 2) pulmonary hypertension due to left heart disease, not pre-capillary PAH.

Question 12: A 44-year-old nonsmoking woman presents with progressive dyspnea and diffuse cystic lung disease on CT. She also has recurrent pneumothoraces and chylothorax. Serum VEGF-D is markedly elevated. What is the MOST likely diagnosis?

Pulmonary Langerhans cell histiocytosis
Lymphangioleiomyomatosis (LAM) (Correct answer)
Birt-Hogg-Dubé syndrome
Pulmonary emphysema

Correct answer: Lymphangioleiomyomatosis (LAM)

LAM presents in women of childbearing age with diffuse thin-walled cysts, chylothorax, recurrent pneumothorax, and markedly elevated serum VEGF-D (>800 pg/mL is diagnostic).

Question 13: A 75-year-old man with COPD (FEV1 38% predicted) and hypoxemia at rest (PaO2 55 mmHg) has been started on long-term oxygen therapy. What is the minimum daily duration of supplemental oxygen recommended to improve survival?

8 hours per day
12 hours per day
15 hours per day (Correct answer)
24 hours per day

Correct answer: 15 hours per day

The NOTT trial established that continuous oxygen (>15 hours/day) improves survival in COPD with severe resting hypoxemia, with the greatest benefit at 24 hours.

Question 14: A 38-year-old woman presents with pleuritic chest pain, dyspnea, and hemoptysis 2 weeks after a total knee replacement. CT pulmonary angiography confirms bilateral pulmonary emboli without RV dysfunction. She has no contraindications to anticoagulation. What is the MOST appropriate treatment?

Systemic thrombolysis with IV alteplase
Catheter-directed thrombolysis
Anticoagulation with rivaroxaban or apixaban (Correct answer)
Surgical embolectomy

Correct answer: Anticoagulation with rivaroxaban or apixaban

Submassive PE without hemodynamic compromise or severe RV dysfunction is treated with anticoagulation alone; DOACs (rivaroxaban or apixaban) are preferred for low-risk PE.

Question 15: A 29-year-old man with known cystic fibrosis (CF) has FEV1 that has declined to 25% predicted despite maximal inhaled therapy. He is listed for lung transplantation. His most recent sputum grows Burkholderia cepacia complex. How does this organism affect transplant candidacy?

It is not a contraindication to transplantation
It is a relative contraindication requiring additional workup
It is an absolute contraindication at most transplant centers (Correct answer)
It requires pre-transplant eradication with IV antibiotics before listing

Correct answer: It is an absolute contraindication at most transplant centers

Burkholderia cepacia complex (especially genomovar III/cenocepacia) is considered an absolute contraindication to lung transplantation at most centers due to dramatically increased post-transplant mortality.

Question 16: An ICU patient develops ventilator-associated pneumonia (VAP) on day 8. Endotracheal cultures grow Pseudomonas aeruginosa. Which antibiotic combination should be used empirically given concern for multidrug-resistant (MDR) Pseudomonas?

Piperacillin-tazobactam monotherapy
Cefepime plus tobramycin (Correct answer)
Ceftazidime-avibactam plus colistin
Meropenem plus ceftolozane-tazobactam

Correct answer: Cefepime plus tobramycin

For MDR Pseudomonas VAP, combination therapy with an antipseudomonal beta-lactam plus an aminoglycoside (e.g., cefepime plus tobramycin) is recommended pending susceptibilities.

Question 17: A 50-year-old woman with rheumatoid arthritis on methotrexate presents with new onset dyspnea and bilateral ground-glass opacities on CT chest. BAL shows eosinophilia. Lung biopsy reveals organizing pneumonia pattern. Which statement about this drug-induced lung injury is TRUE?

Methotrexate must be permanently discontinued and can never be restarted
The organizing pneumonia pattern from methotrexate typically responds to corticosteroids (Correct answer)
High-dose cyclophosphamide is the treatment of choice
Methotrexate-induced lung disease carries a >50% mortality rate

Correct answer: The organizing pneumonia pattern from methotrexate typically responds to corticosteroids

Methotrexate-induced organizing pneumonia typically responds well to discontinuation of methotrexate and systemic corticosteroids, with most patients recovering fully.

Question 18: A 65-year-old man with severe COPD (FEV1/FVC 0.52, FEV1 32% predicted) has symptoms despite maximal bronchodilator therapy. CT shows heterogeneous emphysema predominantly in the upper lobes with low exercise capacity. Which intervention has demonstrated mortality benefit in this population?

Bronchoscopic lung volume reduction with endobronchial valves
Lung volume reduction surgery (LVRS) (Correct answer)
Inhaled triple therapy (LABA/LAMA/ICS)
Azithromycin prophylaxis 250 mg daily

Correct answer: Lung volume reduction surgery (LVRS)

The NETT trial demonstrated that LVRS reduces mortality and improves exercise capacity in COPD patients with upper-lobe predominant emphysema and low baseline exercise capacity.

Question 19: A 55-year-old woman with recently diagnosed hypersensitivity pneumonitis (HP) is found to have a pet cockatiel at home. After antigen avoidance, symptoms persist and DLCO is 52% predicted. Which finding on surgical lung biopsy would indicate chronic fibrotic HP rather than subacute HP?

Non-caseating granulomas with giant cells
Peribronchiolar fibrosis with architectural distortion and honeycombing (Correct answer)
Diffuse alveolar damage with hyaline membranes
Eosinophilic infiltrates with mucous plugging

Correct answer: Peribronchiolar fibrosis with architectural distortion and honeycombing

Chronic fibrotic HP is characterized by peribronchiolar fibrosis, bronchiolocentricity, and architectural distortion (including honeycombing), distinguishing it from subacute HP which shows granulomas without fibrosis.

Question 20: A 32-year-old woman presents to the ICU with status asthmaticus unresponsive to nebulized bronchodilators, systemic corticosteroids, and magnesium sulfate. She is becoming fatigued. ABG: pH 7.32, PaCO2 50 mmHg. What does the rising PaCO2 indicate in this context?

Adequate compensation for metabolic acidosis
Impending respiratory failure requiring preparation for intubation (Correct answer)
Successful bronchodilation reducing dynamic hyperinflation
Hyperventilation-induced hypocapnia returning to baseline

Correct answer: Impending respiratory failure requiring preparation for intubation

In an asthmatic who was initially hyperventilating (low PaCO2), normalization or rising PaCO2 indicates muscle fatigue and impending respiratory failure requiring intubation preparation.

Question 21: A mechanically ventilated patient with ARDS has refractory hypoxemia (P/F ratio 65) despite optimized ventilator settings and prone positioning for 18 hours. Which rescue therapy should be considered next?

High-frequency oscillatory ventilation (HFOV)
Inhaled nitric oxide
Venovenous extracorporeal membrane oxygenation (VV-ECMO) (Correct answer)
Partial liquid ventilation with perfluorocarbon

Correct answer: Venovenous extracorporeal membrane oxygenation (VV-ECMO)

VV-ECMO is the rescue therapy for severe refractory ARDS when conventional strategies including prone positioning have failed, as supported by the CESAR and EOLIA trials.

ITE Pulmonary and Critical Care

A 58-year-old man with COPD presents with acute hypercapnic respiratory failure.
ABG shows pH 7.28, PaCO2 72 mmHg, PaO2 58 mmHg on room air.
Which intervention is MOST appropriate as first-line therapy?

🃏 ITE Flashcards — Study This Quiz as Flip Cards →

📚 Want to go deeper? Read the Full ITE Study Guide →

What Practice Test Geeks adds beyond an AI chat for ITE

An AI chatbot can quiz you, but it can't reproduce the exam conditions or keep your record. Here you get:

A timed, full-length ITE mock exam — 300 questions in 360 minutes with a 60% pass mark, modeled on the official exam's question count and time limit, followed by a score report broken down by exam domain.
A fixed ITE question bank: the same test every attempt, so your score is comparable from one try to the next instead of changing with every regenerated quiz.
Progress saved on your device: completed tests, scores and missed questions stay in My Progress, so you can retake only what you got wrong.
A printable ITE cheat sheet you can print or save as a PDF.
ITE flashcards built from the same question bank.

Start the Timed ITE Mock Exam →

These practice questions were written with AI tools. They are not real exam questions. Exam facts are checked against the official sources listed below. Not reviewed by a subject-matter expert. Editorial policy

Sources & references

Exam facts on this page (fees, format, dates, passing scores) are checked against these official sources; the date is our last check. Editorial policy

acponline.org — Test delivery, eligibility, retake policy, time limit, fees, passing score, exam information · verified Nov 2026