ITE Pulmonary and Critical Care 2 — 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.
ITE Pulmonary and Critical Care 2
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?