MD Pulmonary Disease Management 2 — Questions and Answers
Question 1: A 58-year-old with COPD has an FEV1/FVC ratio of 0.62 and FEV1 of 48% predicted. He remains symptomatic on LABA monotherapy. What is the most appropriate next step?
- Add inhaled corticosteroid (ICS)
- Add long-acting muscarinic antagonist (LAMA) (Correct answer)
- Start oral theophylline
- Initiate roflumilast
Correct answer: Add long-acting muscarinic antagonist (LAMA)
GOLD guidelines recommend dual bronchodilation (LABA + LAMA) for COPD patients symptomatic on monotherapy before adding ICS.
Question 2: A patient with idiopathic pulmonary fibrosis (IPF) shows progressive decline in FVC. Which medication has been shown to slow disease progression?
- Prednisone
- Azathioprine
- Nintedanib (Correct answer)
- N-acetylcysteine
Correct answer: Nintedanib
Nintedanib and pirfenidone are the only antifibrotic agents proven to slow FVC decline in IPF; prednisone and azathioprine are no longer recommended.
Question 3: Which ventilator setting change is most appropriate for a patient with ARDS who develops worsening hypoxemia despite FiO2 of 0.6 and PEEP of 10 cmH2O?
- Increase tidal volume to 10 mL/kg IBW
- Increase PEEP to 14-16 cmH2O (Correct answer)
- Switch to pressure control ventilation
- Administer inhaled nitric oxide as first-line rescue
Correct answer: Increase PEEP to 14-16 cmH2O
Increasing PEEP improves oxygenation in ARDS by recruiting atelectatic alveoli while maintaining lung-protective tidal volumes of 4-6 mL/kg IBW.
Question 4: A 35-year-old woman develops progressive dyspnea and bilateral hilar lymphadenopathy on chest X-ray. Biopsy shows noncaseating granulomas. Which finding would most strongly indicate need for systemic corticosteroid treatment?
- Asymptomatic bilateral hilar adenopathy
- Erythema nodosum with arthralgia
- Hypercalcemia with renal involvement (Correct answer)
- Löfgren syndrome presentation
Correct answer: Hypercalcemia with renal involvement
Hypercalcemia with renal involvement in sarcoidosis requires systemic corticosteroids to prevent nephrocalcinosis and renal failure.
Question 5: A 70-year-old smoker presents with new-onset hemoptysis. CT shows a 3.5 cm spiculated right upper lobe mass. PET scan shows no distant metastases. Mediastinoscopy shows no lymph node involvement. What is the preferred treatment?
- Definitive chemoradiation
- Lobectomy (Correct answer)
- Wedge resection
- Stereotactic body radiation therapy (SBRT)
Correct answer: Lobectomy
Lobectomy is the preferred surgical approach for stage I-II non-small cell lung cancer in patients with adequate pulmonary reserve.
Question 6: Which pulmonary function pattern is most consistent with a diagnosis of hypersensitivity pneumonitis?
- Obstructive pattern with air trapping
- Restrictive pattern with reduced DLCO (Correct answer)
- Mixed obstructive-restrictive with normal DLCO
- Normal spirometry with elevated TLC
Correct answer: Restrictive pattern with reduced DLCO
Hypersensitivity pneumonitis typically produces a restrictive pattern with reduced DLCO due to interstitial inflammation and fibrosis.
Question 7: A 45-year-old with HIV (CD4 count 85 cells/μL) presents with progressive dyspnea, dry cough, and bilateral ground-glass opacities. LDH is elevated. What is the first-line treatment?
- Trimethoprim-sulfamethoxazole plus prednisone (Correct answer)
- Fluconazole
- Liposomal amphotericin B
- Ganciclovir
Correct answer: Trimethoprim-sulfamethoxazole plus prednisone
TMP-SMX is first-line for Pneumocystis jirovecii pneumonia (PCP), and adjunctive corticosteroids are indicated when PaO2 <70 mmHg or A-a gradient >35 mmHg.
MD Pulmonary Disease Management 2
A 58-year-old with COPD has an FEV1/FVC ratio of 0.62 and FEV1 of 48% predicted.
He remains symptomatic on LABA monotherapy.
What is the most appropriate next step?