Free Pulmonology mock test

Pulmonology sample questions with answers

10 more original exam-style Pulmonology questions, worked in full. They are not real or recalled exam questions, and none of them is in the mock above or on the bank page, so sit the mock first if you have not.

1. Question 1 · Interstitial and Inflammatory (Diffuse Parenchymal) Lung Disease

   A 47-year-old man has a spontaneous pneumothorax. CT shows a modest number of thin-walled, oval and lentiform cysts clustered in the basal, perihilar and paramediastinal regions, some abutting vessels. He has small white papules on the face and neck, and his mother had a renal tumour. Which is the most likely diagnosis?

   1. ABirt-Hogg-Dube syndrome
   2. BPulmonary Langerhans cell histiocytosis
   3. CLymphangioleiomyomatosis
   4. DEmphysema due to alpha-1 antitrypsin deficiency
   Show answer and explanation

   Correct answer: A. Birt-Hogg-Dube syndrome

   Birt-Hogg-Dube syndrome, caused by germline folliculin (FLCN) mutations, produces basal, perihilar and paramediastinal lentiform cysts often abutting vessels, recurrent pneumothorax, cutaneous fibrofolliculomas and a familial risk of renal tumours such as chromophobe and hybrid oncocytic carcinoma. PLCH occurs in smokers with upper-zone nodules and bizarre cysts that spare the costophrenic angles, and LAM affects women with uniform round cysts throughout all zones. Alpha-1 antitrypsin deficiency causes basal emphysema without discrete walled cysts and without skin or renal features.

   Reference: Gupta N et al, Diffuse Cystic Lung Disease, Am J Respir Crit Care Med, 2015; ERS Monograph on Orphan Lung Diseases, 2023

2. Question 2 · Sleep Medicine and Sleep-Disordered Breathing

   Which statement best explains why central apnoeas may appear at sleep onset and during unstable NREM sleep in an otherwise healthy adult?

   1. AThe hypoxic ventilatory drive is abolished in NREM sleep, removing the principal stimulus to breathe
   2. BPaCO2 falls by 8-10 mmHg on falling asleep because alveolar ventilation increases
   3. CThe wakefulness drive to breathe is lost, so ventilation ceases whenever PaCO2 falls below the apnoeic threshold, which lies only a few mmHg below the eupnoeic PaCO2
   4. DMetabolic CO2 production rises at sleep onset, widening the CO2 reserve
   Show answer and explanation

   Correct answer: C. The wakefulness drive to breathe is lost, so ventilation ceases whenever PaCO2 falls below the apnoeic threshold, which lies only a few mmHg below the eupnoeic PaCO2

   During wakefulness a non-chemical 'wakefulness drive' maintains breathing even when PaCO2 is low; this drive disappears in NREM sleep, so ventilation becomes critically dependent on PaCO2 remaining above the apnoeic threshold, which sits only about 2-6 mmHg below eupnoeic PaCO2 (a narrow CO2 reserve). PaCO2 actually rises by roughly 2-8 mmHg in sleep because alveolar ventilation falls, so option B is wrong. Hypoxic drive is blunted rather than abolished, and metabolic rate falls in sleep, narrowing rather than widening the CO2 reserve.

   Reference: Dempsey JA et al., Physiol Rev (2010), Pathophysiology of sleep apnea; Murray & Nadel's Textbook of Respiratory Medicine, 7th ed (2022)

3. Question 3 · Patient Safety, Professionalism, Ethics and Communication

   A cluster of Pseudomonas aeruginosa isolates with an identical antibiogram is recovered from bronchoalveolar lavage samples of five patients bronchoscoped over two weeks, and none has clinical infection. Which failure of bronchoscope reprocessing is the most likely explanation and the most important to correct?

   1. AFailure to sterilise the bronchoscope by steam autoclaving after each patient
   2. BFailure to use a new sterile bite block for every procedure
   3. CInadequate manual cleaning with brushing and flushing of all channels before high-level disinfection, with incomplete drying and storage
   4. DFailure to send every bronchoscope for ethylene oxide sterilisation weekly
   Show answer and explanation

   Correct answer: C. Inadequate manual cleaning with brushing and flushing of all channels before high-level disinfection, with incomplete drying and storage

   Pseudo-outbreaks and true outbreaks linked to flexible bronchoscopes are most often traced to inadequate manual cleaning and channel brushing before high-level disinfection, together with residual moisture that permits biofilm formation during storage, so thorough cleaning, drying and hanging vertically are the critical steps. Flexible bronchoscopes are heat-labile semicritical devices that cannot be steam autoclaved, and routine ethylene oxide sterilisation is neither standard nor a substitute for correct cleaning. Bite blocks do not contact the sampling channel and would not produce identical channel-derived isolates.

   Reference: ESGE-ESGENA Guideline: Reprocessing of Flexible Endoscopes (Endoscopy, 2018); CDC/HICPAC Guideline for Disinfection and Sterilization in Healthcare Facilities (2008, updated); BTS Guideline for Diagnostic Flexible Bronchoscopy in Adults (Thorax, 2013)

4. Question 4 · Pleural Diseases

   A 74-year-old former shipyard worker has a small right exudative effusion with focal nodular parietal pleural thickening measuring 12 mm on CT. He has severe COPD (FEV1 28% predicted) and would tolerate single-lung ventilation and pneumothorax induction poorly. Which is the most appropriate way to obtain tissue?

   1. AImage-guided (CT or ultrasound) cutting-needle biopsy of the thickened pleura
   2. BBlind Abrams closed needle biopsy of the posterior chest wall
   3. CVATS pleural biopsy under general anaesthesia
   4. DRepeat therapeutic aspiration with cell-block cytology only
   Show answer and explanation

   Correct answer: A. Image-guided (CT or ultrasound) cutting-needle biopsy of the thickened pleura

   When there is a visible pleural target, image-guided cutting-needle biopsy achieves a sensitivity for malignancy of around 85% and avoids the pneumothorax induction and single-lung ventilation that his respiratory reserve will not tolerate. Blind Abrams biopsy is significantly less sensitive than image-guided biopsy for malignant disease because the lesions are patchy. VATS carries unacceptable anaesthetic risk here, and further cytology alone has already been shown to be low-yield for mesothelioma in particular.

   Reference: Maskell NA et al., Lancet (2003), CT-guided versus Abrams pleural biopsy; BTS Pleural Disease Guideline (Thorax, 2023)

5. Question 5 · Congenital, Neuromuscular, Chest Wall and Airway Structural Disorders

   A 58-year-old man reports severe orthopnoea developing within seconds of lying flat and breathlessness on immersion to the waist. Seated FVC is 2.4 L and supine FVC is 1.5 L. Fluoroscopic sniff testing is reported as showing no paradoxical motion of either hemidiaphragm. Which investigation is most likely to establish the diagnosis?

   1. ARepeat fluoroscopic sniff testing in the lateral decubitus position
   2. BB-mode diaphragm ultrasound with measurement of thickening fraction at the zone of apposition bilaterally
   3. CHigh-resolution CT of the chest with expiratory sequences
   4. DCardiopulmonary exercise testing with measurement of the ventilatory equivalent for CO2
   Show answer and explanation

   Correct answer: B. B-mode diaphragm ultrasound with measurement of thickening fraction at the zone of apposition bilaterally

   Orthopnoea with a supine fall in FVC of more than 25-30% strongly suggests bilateral diaphragm paralysis, and the sniff test is unreliable in bilateral disease because accessory and abdominal muscle recruitment can move both hemidiaphragms passively downwards, producing a false-negative result. Diaphragm ultrasound showing absent or minimal thickening fraction at the zone of apposition on both sides is the most useful bedside confirmatory test, supported by low sniff nasal inspiratory pressure and, where available, phrenic nerve conduction studies. CT and exercise testing characterise other causes of dyspnoea but do not assess diaphragm function.

   Reference: ERS Statement on Respiratory Muscle Testing at Rest and During Exercise (Laveneziana P et al., Eur Respir J 2019); ATS/ERS Statement on Respiratory Muscle Testing, Am J Respir Crit Care Med 2002

6. Question 6 · Respiratory Physiology, Pulmonary Function Testing and Thoracic Imaging

   An FDG PET-CT is requested to characterise an 18 mm solid lung nodule in a 62-year-old man from a region with a high burden of tuberculosis. Which statement about the limitations of PET-CT in this setting is correct?

   1. APET-CT reliably distinguishes malignant from infective nodules because granulomas are not FDG-avid
   2. BGranulomatous disease such as tuberculosis and sarcoidosis causes false-positive FDG uptake, while carcinoid tumours, well-differentiated adenocarcinoma in situ and lesions under about 8 mm cause false negatives
   3. CPET-CT has near-perfect sensitivity for lesions of any size, so a negative scan excludes malignancy regardless of nodule diameter
   4. DPET-CT is contraindicated in diabetes because hyperglycaemia increases FDG uptake in tumour
   Show answer and explanation

   Correct answer: B. Granulomatous disease such as tuberculosis and sarcoidosis causes false-positive FDG uptake, while carcinoid tumours, well-differentiated adenocarcinoma in situ and lesions under about 8 mm cause false negatives

   FDG uptake reflects glucose metabolism rather than malignancy specifically, so active granulomatous and other inflammatory processes - very relevant where tuberculosis is endemic - produce false positives, while slowly metabolising lesions such as carcinoid tumours and subsolid adenocarcinoma in situ, together with nodules below roughly 8 mm which fall under scanner resolution and suffer partial volume effects, produce false negatives. Sensitivity is therefore size- and histology-dependent, and hyperglycaemia reduces rather than increases tumour FDG uptake by competitive inhibition, which is why glucose control before scanning is advised rather than the test being contraindicated.

   Reference: MacMahon H et al. Guidelines for Management of Incidental Pulmonary Nodules Detected on CT Images: From the Fleischner Society 2017. Radiology 2017;284:228-243; Gould MK et al. Evaluation of Individuals With Pulmonary Nodules: ACCP Evidence-Based Clinical Practice Guidelines. Chest 2013;143(5 Suppl):e93S-e120S

7. Question 7 · Obstructive Lung Disease

   A 48-year-old man treated for 'refractory asthma' had a prolonged intubation and tracheostomy after a road traffic accident three years ago. Spirometry shows FEV1 1.9 L, FVC 3.6 L, FEV1/FVC 0.53, and the flow-volume loop demonstrates plateauing of both the inspiratory and expiratory limbs with a FEF50/FIF50 ratio of approximately 1.0. What does this pattern indicate?

   1. AVariable intrathoracic obstruction such as tracheomalacia
   2. BVariable extrathoracic obstruction such as vocal cord paralysis
   3. CFixed upper airway obstruction such as post-tracheostomy tracheal stenosis
   4. DSmall airways obstruction due to severe asthma
   Show answer and explanation

   Correct answer: C. Fixed upper airway obstruction such as post-tracheostomy tracheal stenosis

   Plateauing of both limbs of the flow-volume loop with an FEF50/FIF50 ratio near 1.0 is the signature of a fixed upper airway obstruction, which in this history is almost certainly a post-tracheostomy or post-intubation tracheal stenosis requiring CT of the neck and chest and bronchoscopic assessment. Variable intrathoracic lesions flatten the expiratory limb only, variable extrathoracic lesions flatten the inspiratory limb only, and diffuse small airways disease produces a concave (scooped) expiratory limb rather than a plateau.

   Reference: ATS/ERS Technical Standard on Interpretive Strategies for Routine Lung Function Tests, 2022

8. Question 8 · Respiratory Infections and Tuberculosis

   In a patient with a primary lung abscess treated with appropriate intravenous antibiotics, which of the following represents the strongest indication to proceed to percutaneous or bronchoscopic drainage?

   1. AAny cavity larger than 3 cm on the initial CT scan
   2. BThe presence of an air-fluid level within the cavity
   3. CFoul-smelling sputum at presentation
   4. DA large abscess with persistent sepsis and lack of clinical improvement after 7 or more days of appropriate antibiotic therapy
   Show answer and explanation

   Correct answer: D. A large abscess with persistent sepsis and lack of clinical improvement after 7 or more days of appropriate antibiotic therapy

   Drainage is indicated when medical therapy fails, typically signalled by persistent fever and sepsis beyond about 7 to 10 days, and is more often needed with very large cavities (commonly cited as greater than 6 to 8 cm), impending rupture, or an underlying obstructing lesion. Cavity size alone at presentation, an air-fluid level and putrid sputum are expected features of an anaerobic lung abscess and do not by themselves mandate intervention.

   Reference: Murray and Nadel's Textbook of Respiratory Medicine, 7th edition, 2022, chapter on anaerobic infections and lung abscess

9. Question 9 · Pulmonary Vascular Disorders

   A 52-year-old woman with newly diagnosed PR3-ANCA granulomatosis with polyangiitis presents with diffuse alveolar haemorrhage, hypoxaemic respiratory failure and a creatinine that has risen from 90 to 320 micromol/L over 5 days. She has completed her family and wishes to preserve fertility. In addition to high-dose glucocorticoids, which remission-induction agent is most appropriate?

   1. AMethotrexate 25 mg weekly
   2. BRituximab
   3. CAzathioprine 2 mg/kg daily
   4. DMycophenolate mofetil 2 g daily
   Show answer and explanation

   Correct answer: B. Rituximab

   Severe, organ-threatening ANCA-associated vasculitis requires induction with glucocorticoids plus either rituximab or cyclophosphamide; the RAVE trial showed rituximab to be non-inferior to cyclophosphamide (and superior in relapsing disease) while avoiding gonadal toxicity and bladder cancer risk, making it preferable in this patient. Methotrexate is reserved for non-severe disease and is contraindicated with significant renal impairment. Azathioprine and mycophenolate are maintenance agents and are not adequate for induction in life-threatening disease.

   Reference: Stone et al., RAVE trial, N Engl J Med 2010; 2021 ACR/Vasculitis Foundation Guideline for the Management of ANCA-Associated Vasculitis

10. Question 10 · Thoracic Neoplasms and Lung Cancer

    A 71-year-old man with COPD has a right lower lobe non-small cell lung cancer and is being assessed for right lower lobectomy. His preoperative FEV1 is 60% predicted. Using the anatomical segment-counting method (19 total segments, 5 in the right lower lobe), what is his predicted postoperative FEV1?

    1. AApproximately 30% predicted
    2. BApproximately 38% predicted
    3. CApproximately 44% predicted
    4. DApproximately 55% predicted
    Show answer and explanation

    Correct answer: C. Approximately 44% predicted

    Predicted postoperative FEV1 equals the preoperative value multiplied by (19 minus the number of segments to be removed) divided by 19, so 60 x 14/19 gives approximately 44% predicted. Values above 30% predicted for both ppoFEV1 and ppoDLCO generally indicate acceptable risk, while values below 30% mandate cardiopulmonary exercise testing with peak VO2 measurement. Segment counting overestimates loss when the resected lobe is poorly perfused, in which case quantitative perfusion scanning is more accurate.

    Reference: ERS/ESTS Clinical Guidelines on Fitness for Radical Therapy in Lung Cancer Patients, Eur Respir J 2009; ACCP Physiologic Evaluation of the Patient With Lung Cancer, Chest 2013