Pulmonology Prometric exam questions with answers

1. Question 1Obstructive Lung Diseaseeasy

   A 58-year-old woman with a 35 pack-year smoking history has chronic exertional dyspnoea and cough. Which spirometric finding is required to confirm COPD?

   1. APre-bronchodilator FEV1 below 80% predicted
   2. BPost-bronchodilator FEV1/FVC ratio below 0.70
   3. CAn FEV1 increase of less than 200 mL after bronchodilator
   4. DReduced DLCO with normal spirometry
   Show answer and explanation▾

   Answer: B. Post-bronchodilator FEV1/FVC ratio below 0.70

   GOLD requires persistent airflow obstruction, defined as a post-bronchodilator FEV1/FVC ratio below 0.70, in a patient with compatible symptoms and exposures to diagnose COPD. FEV1 percent predicted grades severity but does not establish obstruction, and pre-bronchodilator values may overdiagnose it. Lack of bronchodilator reversibility is neither required nor sufficient, and an isolated low DLCO does not meet the spirometric criterion.

2. Question 2Obstructive Lung Diseasemedium

   A 64-year-old man with newly confirmed COPD (post-bronchodilator FEV1 52% predicted) had two exacerbations requiring oral corticosteroids in the past year. His CAT score is 18 and blood eosinophil count 350 cells/microlitre. He uses no maintenance inhalers. Following GOLD, which initial maintenance therapy is most appropriate?

   1. ALong-acting muscarinic antagonist alone
   2. BInhaled corticosteroid with long-acting beta-agonist
   3. CLong-acting beta-agonist alone
   4. DLABA plus LAMA plus inhaled corticosteroid
   Show answer and explanation▾

   Answer: D. LABA plus LAMA plus inhaled corticosteroid

   Two or more moderate exacerbations in a year places him in GOLD group E, where LABA plus LAMA is the default initial therapy, and adding an inhaled corticosteroid as single-inhaler triple therapy is recommended when blood eosinophils are 300 cells/microlitre or more. ICS-LABA without a LAMA is no longer recommended in COPD. Long-acting bronchodilator monotherapy is insufficient for a patient with frequent exacerbations and raised eosinophils.

3. Question 3Interstitial and Inflammatory (Diffuse Parenchymal) Lung Diseaseeasy

   A 71-year-old man is diagnosed with idiopathic pulmonary fibrosis after multidisciplinary discussion. FVC is 72% predicted and DLCO 48% predicted. He asks about drug treatment to slow disease progression. Which is most appropriate?

   1. ANintedanib or pirfenidone
   2. BPrednisolone, azathioprine and N-acetylcysteine
   3. CHigh-dose oral prednisolone alone
   4. DMycophenolate mofetil
   Show answer and explanation▾

   Answer: A. Nintedanib or pirfenidone

   The antifibrotic drugs nintedanib and pirfenidone slow the annual decline in FVC in idiopathic pulmonary fibrosis and are recommended for patients with confirmed disease. Combination prednisolone, azathioprine and N-acetylcysteine increased mortality and hospitalisation in the PANTHER-IPF trial, and corticosteroid monotherapy is not recommended. Immunosuppressants such as mycophenolate are used in connective tissue disease-associated ILD, not in IPF.

4. Question 4Interstitial and Inflammatory (Diffuse Parenchymal) Lung Diseasehard

   A 59-year-old woman with fibrotic hypersensitivity pneumonitis has avoided her bird exposure and taken mycophenolate for 18 months. Over the past year her dyspnoea has worsened, FVC has fallen by 7% predicted (absolute) and HRCT shows increased reticulation and traction bronchiectasis. Which treatment is recommended in current ATS/ERS/JRS/ALAT guidance?

   1. APirfenidone in place of mycophenolate
   2. BIntravenous cyclophosphamide pulses
   3. CAddition of nintedanib
   4. DHigh-dose oral prednisolone for 6 months
   Show answer and explanation▾

   Answer: C. Addition of nintedanib

   She meets the 2022 definition of progressive pulmonary fibrosis: at least two of worsening symptoms, physiological decline (an absolute FVC fall of 5% predicted or more, or a DLCO fall of 10% or more, within a year) and radiological progression, despite management of the underlying ILD. The guideline conditionally recommends nintedanib for progressive pulmonary fibrosis, based mainly on the INBUILD trial, whereas further research was recommended before advising pirfenidone. High-dose steroids and cyclophosphamide have no proven benefit for progressive fibrotic hypersensitivity pneumonitis.

5. Question 5Respiratory Infections and Tuberculosismedium

   A 42-year-old man with smear-positive pulmonary tuberculosis is in week 4 of rifampicin, isoniazid, pyrazinamide and ethambutol. He is asymptomatic, but his ALT has risen from normal to 6 times the upper limit of normal; bilirubin is normal. What is the most appropriate management?

   1. AContinue all drugs and repeat liver tests in 2 weeks
   2. BStop the hepatotoxic drugs and reintroduce them sequentially once ALT improves
   3. CStop isoniazid permanently and continue the other three drugs
   4. DHalve the doses of all four drugs
   Show answer and explanation▾

   Answer: B. Stop the hepatotoxic drugs and reintroduce them sequentially once ALT improves

   Hepatotoxic antituberculous drugs should be stopped when ALT exceeds 5 times the upper limit of normal without symptoms, or 3 times with symptoms or jaundice. Rifampicin, isoniazid and pyrazinamide are withheld, a non-hepatotoxic interim regimen is considered for infectious or severe disease, and the drugs are reintroduced one at a time with liver test monitoring once ALT falls below about twice the upper limit. Continuing all drugs risks fulminant hepatitis, and dose reduction leads to inadequate treatment and resistance.

6. Question 6Sleep Medicine and Sleep-Disordered Breathingmedium

   A 50-year-old woman with a BMI of 44 kg/m2 has daytime sleepiness and ankle oedema. Daytime arterial PaCO2 is 6.8 kPa (51 mmHg) with no lung or neuromuscular disease, and polysomnography shows an AHI of 62/h. She is clinically stable. Which initial positive airway pressure therapy is recommended?

   1. AContinuous positive airway pressure
   2. BBilevel non-invasive ventilation with a backup rate
   3. CNocturnal oxygen alone
   4. DDaytime high-flow nasal oxygen
   Show answer and explanation▾

   Answer: A. Continuous positive airway pressure

   She has obesity hypoventilation syndrome (BMI of 30 kg/m2 or more with daytime PaCO2 of 6 kPa (45 mmHg) or more, after excluding other causes). In stable ambulatory patients with OHS and coexisting severe OSA, ATS guidance suggests CPAP as initial therapy rather than non-invasive ventilation, reserving NIV for those who fail CPAP or remain hypercapnic. Oxygen alone can worsen hypercapnia and does not treat upper airway obstruction, and weight-loss interventions should also be offered.

7. Question 7Pulmonary Vascular Disordershard

   A 56-year-old man completed 3 months of anticoagulation for an unprovoked pulmonary embolism but has persistent exertional dyspnoea. Echocardiography shows an intermediate probability of pulmonary hypertension. Which is the preferred imaging test to screen for chronic thromboembolic pulmonary hypertension?

   1. ACT pulmonary angiography
   2. BCardiac MRI
   3. CLower-limb compression ultrasound
   4. DVentilation-perfusion scintigraphy
   Show answer and explanation▾

   Answer: D. Ventilation-perfusion scintigraphy

   V/Q scintigraphy is the preferred screening test for CTEPH because it is more sensitive than CT pulmonary angiography for chronic thromboembolic disease, and a normal scan effectively excludes it. If mismatched perfusion defects are present, right heart catheterisation and pulmonary angiography confirm the diagnosis and assess operability at an expert centre. CTPA can miss chronic distal or web-like lesions, and limb ultrasound does not assess the pulmonary circulation.

8. Question 8Thoracic Neoplasms and Lung Cancermedium

   A 63-year-old smoker has 3 months of proximal leg weakness, dry mouth and erectile dysfunction. Reflexes are reduced but increase after brief maximal voluntary contraction, and grip strength transiently improves with repeated effort. Which antibody and associated tumour are most likely?

   1. AAnti-acetylcholine receptor antibody and thymoma
   2. BAnti-Hu antibody and squamous cell carcinoma
   3. CAnti-P/Q-type calcium channel antibody and small cell lung cancer
   4. DAnti-NMDA receptor antibody and ovarian teratoma
   Show answer and explanation▾

   Answer: C. Anti-P/Q-type calcium channel antibody and small cell lung cancer

   Proximal weakness, autonomic features and reflexes that facilitate after exercise characterise Lambert-Eaton myasthenic syndrome, caused by antibodies against presynaptic P/Q-type voltage-gated calcium channels; about half of cases are paraneoplastic, almost always with small cell lung cancer. Nerve conduction studies show a large increment in compound muscle action potential after brief exercise. Myasthenia gravis causes fatigable weakness that worsens with effort and is associated with thymoma, and anti-Hu is linked to small cell rather than squamous carcinoma.

9. Question 9Pleural Diseaseseasy

   A 48-year-old man with right lower lobe pneumonia has a moderate pleural effusion on ultrasound. Diagnostic aspiration yields cloudy but non-purulent fluid with a pH of 7.05 and a negative Gram stain. What is the most appropriate management?

   1. AInsert a chest drain in addition to antibiotics
   2. BContinue antibiotics and repeat ultrasound in 1 week
   3. CTherapeutic aspiration to dryness only
   4. DRefer for immediate decortication
   Show answer and explanation▾

   Answer: A. Insert a chest drain in addition to antibiotics

   A parapneumonic effusion with pH below 7.2 indicates a complicated parapneumonic effusion that is unlikely to resolve with antibiotics alone, so chest drain insertion is indicated alongside antibiotics, as it is for frank pus or a positive Gram stain or culture. Repeated aspiration is less reliable than tube drainage. Intrapleural fibrinolytic and DNase therapy or surgery are considered if drainage fails, rather than immediate decortication.

10. Question 10Occupational and Environmental Lung Diseasemedium

    A 45-year-old man who has machined copper alloys for the aerospace industry for 12 years has dyspnoea, bilateral hilar lymphadenopathy and perilymphatic nodules on HRCT. Transbronchial biopsy shows non-caseating granulomas. Which test best distinguishes his likely occupational disease from sarcoidosis?

    1. ASerum angiotensin-converting enzyme level
    2. BBronchoalveolar lavage CD4:CD8 ratio
    3. CGallium-67 scintigraphy
    4. DBeryllium lymphocyte proliferation test
    Show answer and explanation▾

    Answer: D. Beryllium lymphocyte proliferation test

    Chronic beryllium disease is clinically, radiologically and histologically very similar to sarcoidosis, and beryllium is used in copper alloys in the aerospace, electronics and dental industries. The beryllium lymphocyte proliferation test on blood or lavage lymphocytes demonstrates beryllium sensitisation and, with granulomas, establishes the diagnosis. Raised serum ACE, a high CD4:CD8 ratio and gallium uptake occur in both conditions and do not discriminate.

11. Question 11Congenital, Neuromuscular, Chest Wall and Airway Structural Disordersmedium

    A 19-year-old woman with cystic fibrosis is compound heterozygous for F508del and a minimal-function nonsense mutation. Her FEV1 is 64% predicted. She asks about CFTR modulator therapy. Which option is most appropriate?

    1. AIvacaftor monotherapy
    2. BLumacaftor-ivacaftor
    3. CElexacaftor-tezacaftor-ivacaftor
    4. DNo modulator is suitable for her genotype
    Show answer and explanation▾

    Answer: C. Elexacaftor-tezacaftor-ivacaftor

    Elexacaftor-tezacaftor-ivacaftor is approved for people with at least one F508del allele, including F508del with a minimal-function mutation, and produces substantial improvements in FEV1, sweat chloride, exacerbation rate and quality of life. Lumacaftor-ivacaftor is effective only in F508del homozygotes and is much less potent. Ivacaftor monotherapy works for gating and certain residual-function mutations, not for F508del with a minimal-function allele.

12. Question 12Critical Care Medicine and Respiratory Failureeasy

    A 69-year-old man with COPD is admitted with an exacerbation. After 1 hour of nebulised bronchodilators, systemic steroids and controlled oxygen targeting SpO2 88 to 92%, arterial blood gas shows pH 7.27, PaCO2 9.2 kPa (69 mmHg) and PaO2 8.1 kPa (61 mmHg). He is alert and cooperative. What is the most appropriate next step?

    1. AIncrease oxygen to achieve SpO2 above 96%
    2. BStart bilevel non-invasive ventilation
    3. CGive intravenous aminophylline and repeat the gas in 4 hours
    4. DImmediate intubation and invasive ventilation
    Show answer and explanation▾

    Answer: B. Start bilevel non-invasive ventilation

    Acute hypercapnic respiratory failure with pH below 7.35 and PaCO2 above 6.5 kPa persisting despite optimal medical therapy is the key indication for bilevel NIV in COPD exacerbations, which reduces intubation and mortality. Raising the oxygen saturation target worsens hypercapnia. Intubation is indicated when NIV fails or is contraindicated, for example with reduced consciousness or inability to protect the airway, and aminophylline is not recommended routinely.

13. Question 13Critical Care Medicine and Respiratory Failuremedium

    A 52-year-old man with pneumonia-related ARDS is ventilated with a tidal volume of 6 mL/kg predicted body weight, PEEP of 14 cmH2O and a plateau pressure of 28 cmH2O. After 12 hours of optimisation, PaO2/FiO2 is 95 mmHg on FiO2 0.8. What is the most appropriate next intervention?

    1. AProne positioning for at least 12 to 16 hours per day
    2. BIncrease tidal volume to 10 mL/kg to improve oxygenation
    3. CRoutine high-frequency oscillatory ventilation
    4. DHigh-dose intravenous methylprednisolone for 3 days
    Show answer and explanation▾

    Answer: A. Prone positioning for at least 12 to 16 hours per day

    For moderate-to-severe ARDS with PaO2/FiO2 below 150 mmHg despite lung-protective ventilation, prolonged prone positioning reduced mortality in the PROSEVA trial and is strongly recommended for more than 12 hours daily. Increasing tidal volume raises ventilator-induced lung injury and mortality. Routine high-frequency oscillatory ventilation increased mortality in OSCILLATE and is not recommended, and pulsed steroids are not a rescue therapy for refractory hypoxaemia.

14. Question 14Respiratory Physiology, Pulmonary Function Testing and Thoracic Imaginghard

    A 38-year-old woman with systemic lupus erythematosus develops new bilateral alveolar opacities and haemoptysis, with a fall in haemoglobin from 118 to 92 g/L over 2 days. Pulmonary function testing shows a DLCO corrected for haemoglobin of 135% predicted. Which explanation best accounts for the raised DLCO?

    1. AThickening of the alveolar-capillary membrane
    2. BLoss of the pulmonary capillary bed
    3. CReduced alveolar volume from consolidation
    4. DExtravascular red cells in the alveoli binding carbon monoxide
    Show answer and explanation▾

    Answer: D. Extravascular red cells in the alveoli binding carbon monoxide

    Diffuse alveolar haemorrhage raises DLCO because extravascular red cells within the alveoli take up inhaled carbon monoxide, and a rising DLCO can help detect fresh bleeding. Interstitial thickening, loss of capillary bed and reduced alveolar volume all lower DLCO. Other causes of a raised DLCO include polycythaemia, left-to-right intracardiac shunts, asthma and obesity.

15. Question 15Interventional Pulmonology, Bronchoscopy and Lung Transplantationhard

    Two years after bilateral lung transplantation, a 50-year-old woman has a persistent fall in FEV1 to 72% of her post-transplant baseline (the mean of her two best values) on repeated testing over 3 months. CT shows air trapping without new opacities, and infection, acute rejection and anastomotic stenosis have been excluded. What is the most appropriate initial treatment?

    1. APulsed intravenous methylprednisolone
    2. BStopping tacrolimus and switching to sirolimus monotherapy
    3. CA trial of long-term azithromycin
    4. DImmediate listing for retransplantation
    Show answer and explanation▾

    Answer: C. A trial of long-term azithromycin

    A persistent decline in FEV1 of 20% or more from baseline after excluding other causes defines chronic lung allograft dysfunction, and air trapping without opacities suggests the bronchiolitis obliterans syndrome phenotype. A trial of azithromycin is recommended first-line because a proportion of patients stabilise or improve their FEV1. Pulsed steroids are ineffective for established BOS, and retransplantation is considered only for carefully selected patients with progressive disease.

Last reviewed September 2026. Questions are original and written to the published exam blueprint; they are not taken from any real paper.