ITE Pulmonary and Critical Care 5 — Questions and Answers
Question 1: A 48-year-old man presents with massive pleural effusion. Thoracentesis reveals exudative fluid (LDH 380 U/L, protein 4.2 g/dL, pH 7.15, glucose 42 mg/dL). Gram stain is negative, but culture grows Streptococcus milleri. What is the MOST appropriate next management step?
- IV antibiotics alone with repeat thoracentesis in 48 hours
- Chest tube drainage plus IV antibiotics (Correct answer)
- Thoracoscopy with decortication
- Intrapleural tPA plus DNase
Correct answer: Chest tube drainage plus IV antibiotics
A complicated parapneumonic effusion with pH <7.20 and glucose <60 mg/dL with positive culture (empyema) requires chest tube drainage combined with IV antibiotics.
Question 2: A 40-year-old man is admitted to the ICU with septic shock from pneumonia. After 6 hours of resuscitation with 4 L of crystalloid, he remains hypotensive with MAP 58 mmHg. He is on norepinephrine 0.18 mcg/kg/min. Point-of-care echo shows hyperdynamic LV function with IVC collapsibility >50%. What intervention is MOST appropriate?
- Add vasopressin 0.03 units/min to norepinephrine
- Administer an additional 2 L of IV fluid bolus (Correct answer)
- Start dobutamine for cardiogenic shock
- Begin hydrocortisone 200 mg/day for refractory septic shock
Correct answer: Administer an additional 2 L of IV fluid bolus
IVC collapsibility >50% indicates volume responsiveness; additional fluid resuscitation is appropriate when dynamic indices suggest ongoing hypovolemia in distributive shock.
Question 3: A 68-year-old former shipyard worker presents with progressive dyspnea and pleural plaques on chest CT. Pulmonary function testing shows FVC 68%, FEV1 70%, FEV1/FVC 0.82, DLCO 55% predicted. What type of pattern is present and what is the MOST likely diagnosis?
- Obstructive pattern due to asbestos-related COPD
- Restrictive pattern due to asbestosis (Correct answer)
- Mixed pattern due to mesothelioma
- Normal spirometry with isolated DLCO reduction from pulmonary vascular disease
Correct answer: Restrictive pattern due to asbestosis
A reduced FVC with preserved FEV1/FVC ratio (restrictive pattern) combined with reduced DLCO and occupational asbestos exposure indicates asbestosis (interstitial fibrosis from asbestos).
Question 4: A 72-year-old woman has a 2.4 cm solid pulmonary nodule discovered incidentally on CT. She has a 40 pack-year smoking history and stopped 5 years ago. PET scan shows SUV of 4.8 in the nodule. CT-guided biopsy shows adenocarcinoma. Staging workup reveals no metastatic disease. What is the preferred management for Stage IA NSCLC in a patient with FEV1 70% predicted?
- Stereotactic body radiation therapy (SBRT)
- Surgical resection with anatomic lobectomy (Correct answer)
- Wedge resection due to borderline lung function
- Concurrent chemoradiation
Correct answer: Surgical resection with anatomic lobectomy
Anatomic lobectomy is the standard of care for resectable Stage I NSCLC in operable patients; FEV1 70% predicted is sufficient for lobectomy, making surgery preferable to SBRT.
Question 5: A 55-year-old man is being weaned from mechanical ventilation after 10 days for ARDS. He passes a spontaneous breathing trial (SBT) using PSV 5/PEEP 5 for 30 minutes with stable vitals and adequate oxygenation. What is the NEXT most important assessment before extubation?
- Repeat ABG to confirm PaO2 >80 mmHg
- Assessment of airway patency, cough strength, and secretion management (Correct answer)
- Echocardiogram to rule out cardiac dysfunction
- 24-hour sedation holiday before attempting extubation
Correct answer: Assessment of airway patency, cough strength, and secretion management
After a successful SBT, the primary determinant of extubation success is the ability to protect and maintain the airway, including adequate cough strength and secretion clearance.
Question 6: A 35-year-old woman with systemic lupus erythematosus (SLE) presents with acute dyspnea and hemoptysis. Chest X-ray shows bilateral alveolar infiltrates. Bronchoscopy with BAL returns progressively bloodier returns from all lobes. ANA titer is 1:640. Anti-dsDNA is markedly elevated. Urinalysis shows RBC casts. What is the MOST likely diagnosis?
- Granulomatosis with polyangiitis (GPA)
- Diffuse alveolar hemorrhage (DAH) from SLE (Correct answer)
- Goodpasture syndrome (anti-GBM disease)
- Microscopic polyangiitis (MPA)
Correct answer: Diffuse alveolar hemorrhage (DAH) from SLE
Diffuse alveolar hemorrhage in the setting of active SLE (elevated anti-dsDNA, lupus nephritis with RBC casts) is most consistent with SLE-associated DAH, a life-threatening complication.
Question 7: A 63-year-old man with Stage IV NSCLC (adenocarcinoma) is found to have an EGFR exon 19 deletion on molecular testing. He has good performance status and no brain metastases. Which first-line treatment provides the longest progression-free survival?
- Carboplatin/pemetrexed plus pembrolizumab
- Erlotinib 150 mg daily
- Osimertinib 80 mg daily (Correct answer)
- Gefitinib 250 mg daily
Correct answer: Osimertinib 80 mg daily
Osimertinib (3rd generation EGFR TKI) demonstrated superior PFS and OS over 1st generation TKIs in the FLAURA trial and is the preferred first-line agent for EGFR-mutated NSCLC.
ITE Pulmonary and Critical Care 5
A 48-year-old man presents with massive pleural effusion.
Thoracentesis reveals exudative fluid (LDH 380 U/L, protein 4.2 g/dL, pH 7.15, glucose 42 mg/dL).
Gram stain is negative, but culture grows Streptococcus milleri.
What is the MOST appropriate next management step?