ITE Pulmonary and Critical Care 3 — Questions and Answers
Question 1: 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 2: 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 3: 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 4: 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 5: 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 6: 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 7: 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.
ITE Pulmonary and Critical Care 3
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?