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