Pulmonology Prometric exam questions

The Pulmonology exam in every GCC country

From each regulator's own exam pages; anything a regulator does not publish says so. Assessment mode also depends on your licence title, so confirm your route on your eligibility notice.

12 worked Pulmonology practice questions

Original exam-style questions from the bank, spread across the blueprint domains. They are not real or recalled exam questions. Try each one, then open the answer for the rationale and reference. None of them appear in the free mock exam, so reading them will not spoil it.

1. Question 1 · Obstructive Lung Disease

   A 61-year-old man who continues to smoke 15 cigarettes daily has severe COPD with a chronic bronchitis phenotype (daily productive cough), post-bronchodilator FEV1 33% predicted, blood eosinophils 110 cells/microlitre, and three exacerbations in the last year despite optimal inhaled triple therapy. Which additional oral pharmacotherapy is most appropriate?

   1. ALong-term azithromycin 250 mg daily
   2. BMaintenance oral prednisolone 10 mg daily
   3. CLong-term oral doxycycline
   4. DRoflumilast 500 micrograms daily
   Show answer and explanation

   Correct answer: D. Roflumilast 500 micrograms daily

   Roflumilast is specifically recommended for patients with chronic bronchitis, FEV1 below 50% predicted and continuing exacerbations on optimised inhaled therapy, and its benefit is independent of smoking status. Long-term azithromycin is an alternative in this setting but the evidence of benefit was seen chiefly in former smokers and is attenuated in current smokers, maintenance systemic corticosteroid is harmful in stable COPD, and continuous tetracycline prophylaxis is not a guideline-supported strategy.

   Reference: GOLD Report 2024/2025; Calverley et al., Lancet, 2009 (M2-124/M2-125); Albert et al., New England Journal of Medicine, 2011 (MACRO)

2. Question 2 · Respiratory Infections and Tuberculosis

   A 49-year-old man with poorly controlled type 2 diabetes is admitted in diabetic ketoacidosis. He develops fever, pleuritic pain and haemoptysis. CT shows a rapidly enlarging consolidation with a reversed halo sign and evidence of vascular invasion, and biopsy shows broad, ribbon-like, aseptate hyphae branching at wide angles. Which management is most appropriate?

   1. AVoriconazole alone
   2. BCaspofungin alone
   3. COral itraconazole with clinical observation
   4. DLiposomal amphotericin B with urgent surgical debridement and aggressive correction of hyperglycaemia and acidosis
   Show answer and explanation

   Correct answer: D. Liposomal amphotericin B with urgent surgical debridement and aggressive correction of hyperglycaemia and acidosis

   The histology of broad aseptate wide-angle branching hyphae with angioinvasion in a ketoacidotic diabetic indicates mucormycosis, which requires prompt high-dose liposomal amphotericin B, early surgical debridement of necrotic tissue, and reversal of the predisposing metabolic state. Voriconazole and echinocandins have no reliable activity against Mucorales (voriconazole prophylaxis is in fact a recognised risk factor for breakthrough mucormycosis), and itraconazole with observation would be fatal in this rapidly progressive angioinvasive infection.

   Reference: ECMM/MSGERC Global Guideline for the Diagnosis and Management of Mucormycosis, Lancet Infectious Diseases 2019

3. Question 3 · Pulmonary Vascular Disorders

   A 31-year-old woman with suspected pulmonary veno-occlusive disease and a biallelic EIF2AK4 mutation is started on intravenous epoprostenol. Within hours she becomes acutely dyspnoeic and hypoxaemic, with new diffuse alveolar and interstitial infiltrates but no fever and a normal left ventricular filling pressure. What is the most likely explanation and the most appropriate definitive plan?

   1. AAnaphylaxis to epoprostenol; switch to an endothelin receptor antagonist and continue medical therapy
   2. BDrug-induced acute pulmonary oedema from increased pre-capillary flow across fixed post-capillary obstruction; titrate vasodilators cautiously in an expert centre and refer urgently for lung transplantation
   3. CAcute pulmonary embolism; start therapeutic anticoagulation and repeat CTPA
   4. DFluid overload from the epoprostenol diluent; give a loop diuretic and increase the epoprostenol dose
   Show answer and explanation

   Correct answer: B. Drug-induced acute pulmonary oedema from increased pre-capillary flow across fixed post-capillary obstruction; titrate vasodilators cautiously in an expert centre and refer urgently for lung transplantation

   In pulmonary veno-occlusive disease the obstruction lies in the post-capillary venules, so pulmonary vasodilators increase pre-capillary flow into a fixed downstream obstruction and precipitate acute, sometimes fatal, pulmonary oedema; this is the classic clue to the diagnosis. Because no medical therapy is effective and the disease progresses rapidly, urgent lung transplantation referral is the definitive plan, with any cautious vasodilator use confined to expert centres with close monitoring. Anaphylaxis would present with rash, bronchospasm and circulatory collapse. There is nothing to suggest thromboembolism, and increasing the epoprostenol dose would worsen the oedema.

   Reference: Montani et al., Pulmonary veno-occlusive disease, Eur Respir J 2016; 2022 ESC/ERS Pulmonary Hypertension Guidelines

4. Question 4 · Thoracic Neoplasms and Lung Cancer

   A 55-year-old woman with EGFR exon 19 deletion adenocarcinoma has had an excellent response to osimertinib for 20 months. She now develops rapidly enlarging liver metastases and a rising LDH. Rebiopsy of a liver lesion shows small cell carcinoma morphology with retention of the original EGFR exon 19 deletion. What is the most appropriate next treatment?

   1. AIncrease the osimertinib dose and continue
   2. BSwitch to erlotinib plus bevacizumab
   3. CPlatinum-etoposide chemotherapy
   4. DSingle-agent pembrolizumab
   Show answer and explanation

   Correct answer: C. Platinum-etoposide chemotherapy

   Histological transformation to small cell carcinoma occurs in roughly 3-10% of EGFR-mutant tumours progressing on EGFR tyrosine kinase inhibitors, is suggested by rapid clinical deterioration with a rising LDH, and requires rebiopsy to confirm; the retained founder EGFR mutation confirms clonal origin. Treatment follows small cell principles with platinum-etoposide chemotherapy. Escalating or switching EGFR inhibitors is ineffective once transformation has occurred, and single-agent checkpoint blockade performs poorly in EGFR-mutant disease.

   Reference: ESMO Clinical Practice Guidelines for Metastatic Non-Small-Cell Lung Cancer, Ann Oncol 2023; Sequist LV et al., Sci Transl Med 2011

5. Question 5 · Occupational and Environmental Lung Disease

   A 64-year-old woman with severe COPD (FEV1 34% predicted) plans a 9-hour flight. Her resting room-air SpO2 in clinic is 93%. She undergoes a hypoxic challenge test breathing 15% oxygen, during which her PaO2 falls to 6.1 kPa (46 mmHg). What is the most appropriate recommendation?

   1. AShe should not fly under any circumstances
   2. BShe may fly without any assessment because her resting saturation exceeds 92%
   3. CIn-flight supplemental oxygen should be arranged, typically starting at 2 L/min via nasal cannula
   4. DShe should take prophylactic acetazolamide instead of oxygen
   Show answer and explanation

   Correct answer: C. In-flight supplemental oxygen should be arranged, typically starting at 2 L/min via nasal cannula

   Cabin pressurisation to an equivalent altitude of about 1,500-2,500 m gives an inspired oxygen fraction equivalent to roughly 15%, and a hypoxic challenge result with PaO2 below about 6.6 kPa (50 mmHg) or SpO2 below 85% indicates a need for in-flight oxygen, conventionally 2 L/min by nasal cannula. A resting saturation of 92-95% with a risk factor such as severe COPD is precisely the group in whom hypoxic challenge testing is indicated rather than an indication to fly unassessed, air travel is not absolutely contraindicated once oxygen is provided, and acetazolamide is not a substitute for supplemental oxygen.

   Reference: British Thoracic Society Clinical Statement on Air Travel for Passengers with Respiratory Disease (2022)

6. Question 6 · Critical Care Medicine and Respiratory Failure

   Five minutes after intubation for near-fatal asthma, a patient's blood pressure falls from 110/70 to 60/35 mmHg. Peak airway pressure is 58 cmH2O but plateau pressure is 24 cmH2O, breath sounds are symmetrical though very quiet, and the flow-time trace shows expiratory flow persisting until the next breath. What is the most appropriate immediate action?

   1. ABriefly disconnect the patient from the ventilator to allow full exhalation, give a fluid bolus, then resume ventilation with a lower rate and longer expiratory time
   2. BPerform immediate bilateral needle decompression for presumed tension pneumothoraces
   3. CIncrease the respiratory rate and minute ventilation to correct the hypercapnia
   4. DAdd PEEP of 15 cmH2O to stent open the small airways
   Show answer and explanation

   Correct answer: A. Briefly disconnect the patient from the ventilator to allow full exhalation, give a fluid bolus, then resume ventilation with a lower rate and longer expiratory time

   The combination of a very high peak with a near-normal plateau pressure, quiet symmetrical breath sounds and truncated expiratory flow points to dynamic hyperinflation with auto-PEEP impeding venous return, not pneumothorax; disconnection with gentle chest compression allows the trapped gas to escape and blood pressure typically recovers within seconds. A pneumothorax would raise the plateau pressure and produce asymmetrical findings, so blind bilateral needle decompression is not the first response. Increasing the rate shortens expiration and worsens trapping, and high external PEEP in this passive patient adds further hyperinflation.

   Reference: Leatherman J, Mechanical ventilation for severe asthma, Chest 2015; Tuxen DV & Lane S, Am Rev Respir Dis 1987

7. Question 7 · Interventional Pulmonology, Bronchoscopy and Lung Transplantation

   A 64-year-old ex-smoker with heterogeneous upper-lobe-predominant emphysema has FEV1 28% predicted, residual volume 230% predicted, and 6-minute walk distance 280 m despite optimal therapy and pulmonary rehabilitation. Which factor is the single most important determinant of whether endobronchial valve placement will produce lobar volume reduction?

   1. AAbsence of interlobar collateral ventilation, shown by an intact fissure on CT or a negative Chartis assessment
   2. BA DLCO above 50% predicted
   3. CA body mass index below 25 kg/m2
   4. DThe presence of at least three exacerbations in the preceding year
   Show answer and explanation

   Correct answer: A. Absence of interlobar collateral ventilation, shown by an intact fissure on CT or a negative Chartis assessment

   Endobronchial valves work by producing lobar atelectasis, which only occurs if air cannot enter the target lobe through collateral channels; fissure integrity on quantitative CT or a negative Chartis measurement is therefore the decisive selection criterion, alongside hyperinflation with residual volume above roughly 175-200% predicted and a suitable FEV1 range. DLCO and BMI influence overall candidacy and are typically bounded by trial criteria, and exacerbation frequency is not a determinant of the physiological response to valves.

   Reference: Klooster et al., STELVIO trial (N Engl J Med, 2015); Criner et al., LIBERATE trial (Am J Respir Crit Care Med, 2018); GOLD Report (2024)

8. Question 8 · Interstitial and Inflammatory (Diffuse Parenchymal) Lung Disease

   A 66-year-old woman has HRCT showing mid- and upper-zone predominant reticulation with traction bronchiectasis, plus mosaic attenuation and air trapping in three or more lobes in at least two lobules. She has no clear exposure history. Compared with idiopathic pulmonary fibrosis, which feature most strongly favours fibrotic hypersensitivity pneumonitis in this case?

   1. APresence of traction bronchiectasis
   2. BAge over 65 years
   3. CBasal predominance of reticulation
   4. DUpper/mid-zone predominance with widespread lobular air trapping
   Show answer and explanation

   Correct answer: D. Upper/mid-zone predominance with widespread lobular air trapping

   Fibrotic HP characteristically shows upper- or mid-zone predominant or diffuse fibrosis together with signs of small airways disease, namely mosaic attenuation and expiratory air trapping in multiple lobules and lobes, whereas IPF is basal and subpleural predominant with minimal air trapping. Traction bronchiectasis occurs in any fibrotic ILD and does not discriminate. Age over 65 is if anything more typical of IPF, and basal predominance also favours IPF, so neither helps distinguish HP.

   Reference: ATS/JRS/ALAT Clinical Practice Guideline: Diagnosis of Hypersensitivity Pneumonitis in Adults, Am J Respir Crit Care Med, 2020

9. Question 9 · Sleep Medicine and Sleep-Disordered Breathing

   A 29-year-old woman is referred for a multiple sleep latency test to investigate hypersomnolence. She works rotating shifts, sleeps about 5 hours on work nights, and takes venlafaxine for depression. What must be done before the test to avoid a misleading result?

   1. ANothing; the multiple sleep latency test is unaffected by medication or prior sleep
   2. BPerform the multiple sleep latency test on the same day as a home sleep apnoea test
   3. CSimply advise a single night of extended sleep before the test
   4. DWithdraw REM-suppressing medication for at least two weeks (or five half-lives of the drug and its metabolites) and document at least two weeks of adequate, regular sleep by diary and actigraphy, with overnight polysomnography demonstrating at least 6 hours of sleep immediately beforehand
   Show answer and explanation

   Correct answer: D. Withdraw REM-suppressing medication for at least two weeks (or five half-lives of the drug and its metabolites) and document at least two weeks of adequate, regular sleep by diary and actigraphy, with overnight polysomnography demonstrating at least 6 hours of sleep immediately beforehand

   Chronic insufficient sleep, circadian misalignment from shift work and REM-suppressing drugs such as serotonergic and noradrenergic antidepressants all shorten sleep latency or suppress sleep-onset REM periods, producing false-positive or false-negative results. Standards therefore require drug withdrawal for at least two weeks or five half-lives, two weeks of sleep diary and actigraphy showing adequate sleep, and an immediately preceding polysomnogram with at least 6 hours of sleep that excludes other sleep disorders. A single night of recovery sleep is insufficient, and a home apnoea test cannot substitute for the required attended polysomnogram.

   Reference: Krahn LE et al., AASM Recommended Protocols for the MSLT and MWT, J Clin Sleep Med (2021); ICSD-3-TR (AASM, 2023)

10. Question 10 · Patient Safety, Professionalism, Ethics and Communication

    You have written a manuscript reporting outcomes of endobronchial valve therapy. Your department head, who had no role in the design, conduct, analysis or drafting of the study, instructs you to list him as senior author because the work came from his unit and he will not otherwise approve submission. What is the most appropriate response?

    1. AAdd him as senior author, since departmental leadership confers responsibility for all research output
    2. BAdd him as first author to preserve the working relationship and note your own contribution in the acknowledgements
    3. CSubmit the manuscript to a different journal without informing him or naming him at all
    4. DDecline to list him as an author, explain the ICMJE authorship criteria, offer an acknowledgement if appropriate, and escalate through the institution's research integrity route if he persists
    Show answer and explanation

    Correct answer: D. Decline to list him as an author, explain the ICMJE authorship criteria, offer an acknowledgement if appropriate, and escalate through the institution's research integrity route if he persists

    The ICMJE criteria require substantial contribution to conception or analysis, drafting or critical revision, final approval, and accountability for the work, so conferring authorship on the basis of position alone is gift or honorary authorship and constitutes research misconduct. Individuals who provided only general supervision or facilities may be acknowledged rather than listed as authors. Circumventing the problem by covertly submitting elsewhere does not resolve the integrity issue and creates further governance and institutional-approval problems.

    Reference: ICMJE. Recommendations for the Conduct, Reporting, Editing and Publication of Scholarly Work in Medical Journals (updated 2023); COPE guidance on authorship disputes

11. Question 11 · Pleural Diseases

    A 63-year-old man with severe bullous emphysema is referred with a suspected large left pneumothorax on chest radiograph. He is breathless but haemodynamically stable, and the radiograph shows a large lucent area in the left upper zone whose inferior margin is concave towards the lateral chest wall. What should be done before pleural intervention?

    1. AInsert a chest drain immediately in the triangle of safety, as delay risks tension
    2. BObtain a CT of the thorax to distinguish a giant bulla from a pneumothorax
    3. CPerform needle aspiration in the second intercostal space mid-clavicular line as a diagnostic test
    4. DRepeat the chest radiograph in full expiration to confirm the lung edge
    Show answer and explanation

    Correct answer: B. Obtain a CT of the thorax to distinguish a giant bulla from a pneumothorax

    A large lucency with a margin concave to the chest wall is characteristic of a giant bulla rather than a pneumothorax, whose lung edge is convex to the chest wall; draining a bulla creates an iatrogenic bronchopleural fistula with a persistent air leak. CT reliably distinguishes the two and is recommended when the diagnosis is uncertain in a stable patient. Immediate drainage or blind needle aspiration risks this exact complication, and expiratory films add little diagnostic value and are no longer recommended.

    Reference: BTS Pleural Disease Guideline (Thorax, 2023); Murray & Nadel's Textbook of Respiratory Medicine, 7th ed. (2022)

12. Question 12 · Occupational and Environmental Lung Disease

    A 26-year-old man requests a fitness-to-dive assessment. Three years ago he had a primary spontaneous pneumothorax treated with an intercostal drain alone; CT shows apical blebs bilaterally. He is asymptomatic with normal spirometry. What advice is correct?

    1. ADiving is safe as long as he ascends more slowly than 9 metres per minute
    2. BA history of spontaneous pneumothorax with residual blebs is a contraindication to compressed-gas diving unless definitive surgical management (such as pleurectomy) has been performed and reassessment is satisfactory
    3. CNormal spirometry excludes any risk and no restriction is needed
    4. DHe may dive to a maximum depth of 10 metres without further assessment
    Show answer and explanation

    Correct answer: B. A history of spontaneous pneumothorax with residual blebs is a contraindication to compressed-gas diving unless definitive surgical management (such as pleurectomy) has been performed and reassessment is satisfactory

    Air trapping in blebs or bullae allows gas expansion during ascent (Boyle's law), risking pulmonary barotrauma, tension pneumothorax and arterial gas embolism, so a previous spontaneous pneumothorax with residual bullous disease is regarded as a contraindication to compressed-gas diving unless definitive surgical treatment such as pleurectomy has been undertaken, with specialist reassessment thereafter. Spirometry is insensitive to focal bullous disease, and depth or ascent-rate limits do not abolish the expansion risk since the greatest relative volume change occurs in the final metres of ascent.

    Reference: British Thoracic Society guidelines on respiratory aspects of fitness for diving (Thorax); UK Sport Diving Medical Committee guidance

Pulmonology reference books and guidelines

Every question in this bank names the textbook or guideline its answer rests on. These are the sources our Pulmonology questions cite most often - the reading list to revise from alongside the bank.

Where your regulator publishes a reading list, use the editions it names. Exam questions are not taken from any one book.