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HERMES Adult Respiratory Medicine study materials
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HERMES Adult Respiratory Medicine practice questions

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Question 1Airway diseases

A 24-year-old with mild intermittent asthma uses a salbutamol inhaler twice weekly and has no night symptoms. According to standard asthma control assessment, how should this be classified?

  1. Well controlled asthma Correct answer.
  2. Uncontrolled asthma
  3. Partly controlled asthma
  4. Severe persistent asthma

Explanation

All four control domains are satisfied: daytime symptoms twice weekly or less, no night waking, reliever use twice weekly or less, and no activity limitation. Any single unmet domain would move the patient to partly controlled rather than well controlled.

Question 2Airway diseases

Which spirometric finding is most characteristic of a diagnosis of asthma in a symptomatic adult?

  1. A restrictive pattern with reduced total lung capacity
  2. A reduced transfer factor with a normal FEV1/FVC ratio
  3. An increase in FEV1 of more than 12% and more than 200 mL after a bronchodilator Correct answer.
  4. A post-bronchodilator FEV1/FVC ratio below 0.70 that does not change after bronchodilator

Explanation

Demonstrating variable airflow limitation is central to confirming asthma, and significant reversibility is defined as an FEV1 gain exceeding 12% and 200 mL. This objective finding distinguishes asthma from fixed obstruction.

Question 3Airway diseases

A patient with COPD has an FEV1 of 45% predicted and reports breathlessness on walking uphill. Which GOLD ABE group does this correspond to?

  1. Group B Correct answer.
  2. Group E
  3. Group A
  4. Group C

Explanation

GOLD ABE grouping uses symptoms and exacerbation history, not spirometry alone. This patient has significant symptoms (mMRC 2) but no reported exacerbations, which places them in group B.

Question 4Airway diseases

Which inhaled therapy regimen improves survival in COPD when added to long-acting bronchodilation in patients with frequent exacerbations and raised blood eosinophils?

  1. Short-acting beta2-agonist as required only
  2. Inhaled corticosteroid combined with a long-acting beta2-agonist and long-acting muscarinic antagonist Correct answer.
  3. Oral theophylline
  4. Long-acting muscarinic antagonist monotherapy

Explanation

Triple therapy with an inhaled corticosteroid, LABA and LAMA reduces mortality and exacerbations in selected patients with COPD and a history of frequent exacerbations. The benefit is greatest in those with elevated blood eosinophil counts.

Question 5Airway diseases

A 30-year-old presents with episodic wheeze, chest tightness and cough that occur mainly at night and after exercise. Which single investigation is most useful to confirm the diagnosis?

  1. Serial peak expiratory flow monitoring showing diurnal variability Correct answer.
  2. Sputum culture
  3. Arterial blood gas analysis
  4. Chest radiograph

Explanation

Demonstrating variable expiratory airflow limitation is key to diagnosing asthma, and serial peak flow monitoring can reveal the characteristic diurnal variability. Symptoms alone are insufficient for a confident diagnosis.

Question 6Airway diseases

A patient with asthma reports using a short-acting beta2-agonist inhaler four times daily and wakes most nights with cough. What is the most appropriate next step?

  1. Continue the current reliever-only regimen
  2. Add oral theophylline
  3. Arrange immediate hospital admission
  4. Step up to regular low-dose inhaled corticosteroid-containing controller therapy Correct answer.

Explanation

Frequent reliever use and night waking indicate poor control, and reliever-only treatment is no longer appropriate. The priority is to start or step up inhaled corticosteroid-containing controller therapy to reduce risk.

Question 7Airway diseases

Which finding on history most strongly suggests a diagnosis of COPD rather than asthma?

  1. Symptoms beginning in childhood
  2. Symptoms that vary from day to day
  3. A long smoking history with progressive breathlessness after age 40 Correct answer.
  4. Widespread wheeze on auscultation

Explanation

COPD typically presents with progressive breathlessness in middle or later life in people with significant exposure history such as tobacco smoke. Childhood onset and marked day-to-day variability favour asthma.

Question 8Airway diseases

A patient with COPD and a history of two moderate exacerbations in the past year has a blood eosinophil count of 350 cells/µL. Which treatment approach is best supported?

  1. Short-acting bronchodilator as required
  2. Long-acting beta2-agonist plus inhaled corticosteroid Correct answer.
  3. Long-acting muscarinic antagonist alone
  4. Oral corticosteroid maintenance

Explanation

In COPD with frequent exacerbations and an eosinophil count of 300 cells/µL or higher, an inhaled corticosteroid combined with a long-acting bronchodilator reduces exacerbation frequency. The eosinophil level is a recognised biomarker for corticosteroid responsiveness.

Question 9Airway diseases

Which feature best distinguishes an acute exacerbation of COPD from worsening asthma?

  1. Increased sputum purulence with increased breathlessness in a person with a long smoking history Correct answer.
  2. Raised blood eosinophils
  3. Presence of atopy
  4. Diurnal variation in peak flow

Explanation

An exacerbation of COPD is defined by acute worsening of respiratory symptoms, often with increased sputum volume or purulence, in a person with established COPD. This presentation differs from the variable airflow limitation of asthma.

Question 10Airway diseases

Which is the recommended first-line controller for a child or adult with persistent asthma?

  1. Short-acting muscarinic antagonist
  2. Long-acting beta2-agonist monotherapy
  3. Regular oral corticosteroid
  4. Regular low-dose inhaled corticosteroid Correct answer.

Explanation

Inhaled corticosteroids are the cornerstone of persistent asthma treatment because they suppress airway inflammation and reduce exacerbations and mortality. They remain the preferred initial controller at all ages.

Question 11Airway diseases

A patient with asthma has an acute attack with a peak expiratory flow of 45% of best, heart rate 115 beats per minute and normal speech. How should this be graded?

  1. Life-threatening
  2. Mild
  3. Severe
  4. Moderate Correct answer.

Explanation

A peak flow of 33 to 50% of best with a heart rate of 110 to 120 and preserved speech indicates a moderate acute asthma attack. Severe attacks are associated with peak flow below 33% and inability to complete sentences.

Question 12Airway diseases

Which medication should be given promptly to a patient with an acute severe asthma attack in addition to inhaled bronchodilators?

  1. Intravenous diuretic
  2. Systemic corticosteroid Correct answer.
  3. Inhaled long-acting beta2-agonist
  4. Oral antibiotic

Explanation

Systemic corticosteroids reduce inflammation and the risk of relapse and should be given early in acute severe asthma. They complement repeated inhaled bronchodilator therapy.

Question 13Airway diseases

Which statement about smoking cessation in COPD is correct?

  1. It is the only intervention shown to slow the decline in lung function Correct answer.
  2. It has no effect once airflow obstruction is established
  3. It is only effective if combined with inhaled corticosteroids
  4. It should be deferred until after pulmonary rehabilitation

Explanation

Smoking cessation is the single most effective intervention to slow the accelerated decline in lung function in COPD. It also reduces symptoms and exacerbation frequency independent of other therapies.

Question 14Airway diseases

Which feature on history most strongly supports a diagnosis of asthma rather than COPD in a 50-year-old?

  1. A 40 pack-year smoking history
  2. Progressive breathlessness over 20 years
  3. Chronic productive cough every morning
  4. Symptoms that improve with a bronchodilator and vary over time Correct answer.

Explanation

Variable symptoms that respond to bronchodilators are typical of the reversible airflow limitation of asthma. COPD is characterised by persistent, progressive symptoms in a person with significant exposure history.

Question 15Airway diseases

What is the main purpose of pulmonary rehabilitation in COPD?

  1. To prevent all future exacerbations
  2. To improve exercise capacity and reduce breathlessness-related disability Correct answer.
  3. To reverse airflow obstruction on spirometry
  4. To eliminate the need for inhaled bronchodilators

Explanation

Pulmonary rehabilitation combines exercise training and education to improve exercise tolerance, reduce dyspnoea and improve quality of life. It does not change the underlying airflow obstruction.

Question 16Airway diseases

Which finding is a recognised feature of life-threatening asthma?

  1. Heart rate of 95 beats per minute
  2. Ability to speak in full sentences
  3. A silent chest on auscultation Correct answer.
  4. Peak expiratory flow above 75% of best

Explanation

A silent chest indicates such severe airflow limitation that little air movement is audible, a hallmark of life-threatening asthma. Other life-threatening features include exhaustion, cyanosis and altered consciousness.

Question 17Airway diseases

A patient with COPD remains breathless despite dual long-acting bronchodilator therapy and has had no exacerbations. Which add-on is most appropriate?

  1. Regular short-acting beta2-agonist alone
  2. Inhaled corticosteroid Correct answer.
  3. Oral corticosteroid maintenance
  4. Long-term oxygen therapy

Explanation

In patients with persistent breathlessness despite dual bronchodilation, adding an inhaled corticosteroid is a recognised step. The decision should be guided by exacerbation history and eosinophil count.

Question 18Airway diseases

Which of the following best defines severe airflow limitation on spirometry in COPD?

  1. FEV1 between 50% and 79% predicted
  2. FEV1 of 80% predicted or more
  3. FEV1 between 30% and 49% predicted Correct answer.
  4. FEV1 below 30% predicted

Explanation

The GOLD spirometric grades define severe obstruction as an FEV1 between 30% and 49% predicted in a patient with an FEV1/FVC ratio below 0.70. Very severe disease corresponds to an FEV1 below 30% predicted.

Question 19Airway diseases

Which is the most appropriate action when a patient with asthma uses a short-acting beta2-agonist inhaler three times a day despite low-dose inhaled corticosteroid therapy?

  1. Continue the same dose and review in six months
  2. Stop the inhaled corticosteroid
  3. Step up to a higher dose of inhaled corticosteroid or add a long-acting beta2-agonist Correct answer.
  4. Switch to a short-acting muscarinic antagonist alone

Explanation

Frequent reliever use indicates inadequate control, so controller therapy should be intensified. This may involve increasing the inhaled corticosteroid dose or adding a long-acting beta2-agonist.

Question 20Airway diseases

Which statement about the role of spirometry in COPD is correct?

  1. A normal ratio excludes symptomatic COPD in all cases
  2. Spirometry is used only to monitor treatment response
  3. Spirometry cannot be performed in patients with COPD
  4. A post-bronchodilator FEV1/FVC ratio below 0.70 confirms persistent airflow limitation Correct answer.

Explanation

The diagnosis of COPD requires a post-bronchodilator FEV1/FVC ratio below 0.70, which demonstrates persistent airflow limitation. Spirometry is therefore central to both diagnosis and severity grading.

Question 21Airway diseases

A patient with COPD has an oxygen saturation of 88% at rest and a history of cor pulmonale. Which intervention has been shown to improve survival?

  1. Oral theophylline
  2. Intermittent oxygen only during exercise
  3. Long-term oxygen therapy for at least 15 hours per day Correct answer.
  4. Short-acting bronchodilator as required

Explanation

Long-term oxygen therapy improves survival in patients with chronic severe hypoxaemia, particularly when used for at least 15 hours per day. It is indicated in patients with resting hypoxaemia and evidence of end-organ effects.

Question 22Airway diseases

Which statement best describes the role of a written asthma action plan?

  1. It replaces the need for inhaled corticosteroid therapy
  2. It is only useful for patients with severe asthma
  3. It should be provided only after hospital admission
  4. It helps patients recognise worsening control and adjust treatment early Correct answer.

Explanation

A written action plan teaches patients to recognise deterioration and to adjust reliever and controller therapy promptly, which reduces exacerbations and hospital attendance. It complements rather than replaces pharmacological therapy.

Question 23Airway diseases

A patient with COPD and an exacerbation has increased sputum purulence and volume. Which treatment is indicated in addition to bronchodilators?

  1. Antibiotics and a short course of oral corticosteroid Correct answer.
  2. Long-term oral corticosteroid
  3. Inhaled corticosteroid monotherapy
  4. Nebulised saline alone

Explanation

An exacerbation with increased sputum purulence and volume suggests bacterial infection, so antibiotics are appropriate alongside a short course of oral corticosteroid. Systemic corticosteroids shorten recovery and reduce relapse.

Question 24Airway diseases

Which feature on history is most consistent with a diagnosis of asthma in a young adult?

  1. Daily productive cough for many years
  2. Symptoms that vary seasonally and are triggered by allergens Correct answer.
  3. Symptoms that are constant and progressive
  4. Clubbing of the fingers

Explanation

Asthma symptoms are characteristically variable and often triggered by allergens, exercise or cold air. This variability reflects the reversible nature of airflow limitation in asthma.

Question 25Airway diseases

Which of the following is a recognised trigger for an acute exacerbation of COPD?

  1. Pulmonary rehabilitation sessions
  2. Regular use of inhaled bronchodilators
  3. Use of a written action plan
  4. Respiratory infection Correct answer.

Explanation

Respiratory infections, particularly viral and bacterial, are the most common triggers of COPD exacerbations. Other triggers include air pollution and poor adherence to therapy.

Question 26Interstitial lung disease

In the classification of idiopathic interstitial pneumonias, usual interstitial pneumonia (UIP) is the histopathological and radiological pattern that defines which disease?

  1. Respiratory bronchiolitis-interstitial lung disease
  2. Idiopathic pulmonary fibrosis Correct answer.
  3. Desquamative interstitial pneumonia
  4. Cryptogenic organising pneumonia

Explanation

UIP is the hallmark morphologic pattern of idiopathic pulmonary fibrosis, showing patchy temporally heterogeneous fibrosis with fibroblast foci and honeycomb change. The other entities show different dominant patterns such as organising pneumonia or uniform macrophage accumulation.

Question 27Interstitial lung disease

Which high-resolution CT feature is most characteristic of a definite usual interstitial pneumonia pattern?

  1. Diffuse ground-glass opacity with relative peripheral sparing
  2. Subpleural basal predominant honeycombing with traction bronchiectasis Correct answer.
  3. Centrilobular nodules with air trapping on expiratory imaging
  4. Upper lobe predominant consolidation with reverse halo sign

Explanation

A definite UIP pattern on HRCT requires subpleural, basal-predominant reticulation, honeycombing and traction bronchiectasis with minimal ground glass. This distribution and honeycombing reflect the underlying heterogeneous fibrosis.

Question 28Interstitial lung disease

A patient with newly diagnosed idiopathic pulmonary fibrosis asks about prognosis and treatment. Which statement best reflects current standard practice?

  1. High-dose corticosteroids combined with cyclophosphamide are first-line therapy
  2. Lung transplantation is contraindicated once antifibrotic therapy is started
  3. Azathioprine plus prednisone improves survival and should be started early
  4. Antifibrotic therapy with pirfenidone or nintedanib slows functional decline but does not cure the disease Correct answer.

Explanation

Antifibrotic agents slow the rate of forced vital capacity decline but are not curative, and lung transplantation remains an option for eligible patients. Immunosuppressive regimens such as prednisone with azathioprine or cyclophosphamide have been associated with harm in IPF.

Question 29Interstitial lung disease

Which exposure is most strongly associated with the development of hypersensitivity pneumonitis?

  1. Intravenous drug use with talc filler
  2. Inhalation of avian proteins and thermophilic actinomycetes Correct answer.
  3. Silica dust from sandblasting
  4. Occupational asbestos fibre inhalation

Explanation

Hypersensitivity pneumonitis is an immune-mediated response to inhaled organic antigens such as bird proteins and thermophilic actinomycetes from mouldy hay or humidifiers. Inorganic dusts and talc produce different pneumoconiotic or granulomatous patterns.

Question 30Interstitial lung disease

Which serologic finding is most characteristic of systemic sclerosis-associated interstitial lung disease?

  1. Anti-glomerular basement membrane antibodies
  2. Anti-topoisomerase I (anti-Scl-70) antibodies Correct answer.
  3. Anti-double-stranded DNA antibodies
  4. Anti-Jo-1 antibodies

Explanation

Anti-topoisomerase I antibodies are associated with diffuse systemic sclerosis and a higher risk of progressive interstitial lung disease. Anti-Jo-1 relates to antisynthetase syndrome and anti-dsDNA to systemic lupus erythematosus.

Question 31Interstitial lung disease

Which finding on bronchoalveolar lavage most strongly supports a diagnosis of pulmonary alveolar proteinosis?

  1. Eosinophils comprising more than 25 percent of cells
  2. Marked lymphocytosis with a CD4:CD8 ratio above 4
  3. Milky effluent with Periodic acid-Schiff-positive lipoproteinaceous material Correct answer.
  4. Numerous haemosiderin-laden macrophages

Explanation

Pulmonary alveolar proteinosis yields a milky lavage fluid containing PAS-positive lipoproteinaceous material derived from surfactant accumulation. Lymphocytosis, haemosiderin macrophages and eosinophilia point to other interstitial or alveolar processes.

Question 32Interstitial lung disease

Which physical examination finding is typical in advanced idiopathic pulmonary fibrosis?

  1. Unilateral wheeze with tracheal deviation
  2. Pulsus paradoxus with elevated jugular venous pressure
  3. Bibasilar fine inspiratory crackles with digital clubbing Correct answer.
  4. Pleural friction rub with dullness to percussion

Explanation

Advanced IPF classically produces bibasilar fine velcro-like inspiratory crackles and digital clubbing from chronic hypoxaemia. Unilateral wheeze, friction rub or pulsus paradoxus suggest other diagnoses.

Question 33Interstitial lung disease

Which interstitial lung disease is most strongly associated with cigarette smoking?

  1. Lymphangioleiomyomatosis
  2. Pulmonary Langerhans cell histiocytosis in non-smokers
  3. Respiratory bronchiolitis-interstitial lung disease Correct answer.
  4. Idiopathic pulmonary haemosiderosis

Explanation

RB-ILD occurs almost exclusively in current or former smokers and shows bronchiolocentric macrophage accumulation. Lymphangioleiomyomatosis and idiopathic pulmonary haemosiderosis are not smoking-related.

Question 34Interstitial lung disease

A 62-year-old man with idiopathic pulmonary fibrosis has resting hypoxaemia. Which intervention has the best evidence for improving exercise capacity in this setting?

  1. Inhaled corticosteroids
  2. Oral N-acetylcysteine monotherapy
  3. Prophylactic azithromycin
  4. Ambulatory oxygen therapy during exertion Correct answer.

Explanation

Supplemental oxygen improves exercise tolerance and reduces dyspnoea in hypoxaemic patients with IPF. Azithromycin, inhaled corticosteroids and N-acetylcysteine monotherapy have not shown reliable benefit for exercise capacity in this population.

Question 35Interstitial lung disease

A 55-year-old woman with rheumatoid arthritis develops progressive dyspnoea. HRCT shows subpleural reticulation with honeycombing and she has no prior exposure history. What is the most likely diagnosis?

  1. Amyloidosis of the lung
  2. Rheumatoid nodule with cavitation
  3. Rheumatoid arthritis-associated usual interstitial pneumonia Correct answer.
  4. Rheumatoid arthritis-associated organising pneumonia

Explanation

Rheumatoid arthritis is the connective tissue disease most often associated with a UIP pattern, and HRCT showing subpleural honeycombing fits this. Organising pneumonia would show patchy consolidation rather than honeycombing.

Question 36Interstitial lung disease

A patient with suspected hypersensitivity pneumonitis has serum precipitins to pigeon antigen and HRCT showing poorly defined centrilobular nodules with air trapping. What is the most appropriate next step in management?

  1. Start long-term azathioprine regardless of exposure
  2. Proceed directly to lung transplantation assessment
  3. Begin empiric antituberculous therapy
  4. Identify and remove the antigen source, with corticosteroids considered for significant symptoms Correct answer.

Explanation

Antigen avoidance is the cornerstone of hypersensitivity pneumonitis management, with corticosteroids reserved for symptomatic or progressive disease. Immunosuppression, transplantation and antituberculous therapy are not first steps here.

Question 37Interstitial lung disease

Which pulmonary function test pattern is most typical of interstitial lung disease?

  1. Restrictive pattern with reduced diffusing capacity Correct answer.
  2. Normal spirometry with isolated reduced diffusing capacity only
  3. Obstructive pattern with increased residual volume
  4. Obstructive pattern reversible with bronchodilator

Explanation

ILD typically produces a restrictive defect with reduced total lung capacity and a reduced diffusing capacity for carbon monoxide. Obstruction with air trapping is more typical of airway disease.

Question 38Interstitial lung disease

Which feature on HRCT most strongly suggests a diagnosis of lymphangioleiomyomatosis rather than pulmonary Langerhans cell histiocytosis?

  1. Uniform thin-walled cysts distributed diffusely including the costophrenic angles Correct answer.
  2. Bilateral hilar lymphadenopathy with eggshell calcification
  3. Centrilobular emphysema with antithyroid antibody positivity
  4. Nodules and cysts predominantly in the upper and mid zones with costophrenic sparing

Explanation

LAM produces uniform thin-walled cysts distributed diffusely, including the lung bases and costophrenic angles. PLCH tends to spare the costophrenic angles and shows nodules with upper and mid zone predominance.

Question 39Interstitial lung disease

A patient with systemic sclerosis develops rapidly progressive ILD with a ground-glass and organising pneumonia pattern. Which immunosuppressive agent is commonly used as first-line therapy in this setting?

  1. Pirfenidone monotherapy
  2. Cyclophosphamide or mycophenolate mofetil Correct answer.
  3. Colchicine
  4. Rituximab as sole first-line agent in all cases

Explanation

Cyclophosphamide and mycophenolate mofetil are established first-line immunosuppressive options for systemic sclerosis-associated ILD with active inflammation. Antifibrotics are used for progressive fibrosis but are not the initial immunosuppressive choice.

Question 40Interstitial lung disease

Which finding on surgical lung biopsy is characteristic of organising pneumonia?

  1. Intra-alveolar buds of granulation tissue (Masson bodies) Correct answer.
  2. Sarcoidal non-caseating granulomas along lymphatics
  3. Diffuse alveolar macrophage accumulation
  4. Hyaline membranes lining alveoli

Explanation

Organising pneumonia is defined by plugs of loose connective tissue (Masson bodies) filling alveoli and bronchioles. Diffuse macrophage accumulation indicates DIP, hyaline membranes indicate diffuse alveolar damage, and lymphatic granulomas indicate sarcoidosis.

Question 41Interstitial lung disease

A patient with idiopathic pulmonary fibrosis has a forced vital capacity decline of 12 percent over 6 months with worsening symptoms. What is the most appropriate management step?

  1. Reassure and repeat spirometry in 12 months
  2. Initiate or continue antifibrotic therapy and assess for lung transplantation candidacy Correct answer.
  3. Prescribe only inhaled bronchodilators
  4. Start high-dose prednisone and azathioprine

Explanation

Progressive FVC decline in IPF warrants antifibrotic therapy and timely transplant assessment. Immunosuppression with prednisone and azathioprine is harmful in IPF, and watchful waiting is inappropriate.

Question 42Interstitial lung disease

Which serologic test is most useful in evaluating a patient with suspected antisynthetase syndrome-associated ILD?

  1. Anti-Jo-1 antibody Correct answer.
  2. Anti-centromere antibody
  3. Anti-mitochondrial antibody
  4. Anti-Scl-70 antibody

Explanation

Anti-Jo-1 is the most common antisynthetase antibody and supports the diagnosis of antisynthetase syndrome with associated ILD. Anti-centromere and anti-Scl-70 relate to systemic sclerosis, and anti-mitochondrial antibody to primary biliary cholangitis.

Question 43Interstitial lung disease

Which HRCT feature best distinguishes fibrotic hypersensitivity pneumonitis from usual interstitial pneumonia?

  1. Traction bronchiectasis within honeycombing
  2. Dense honeycombing confined to the lung bases
  3. Extensive ground-glass opacity, air trapping and relative basal sparing Correct answer.
  4. Subpleural reticulation with minimal ground glass

Explanation

Fibrotic hypersensitivity pneumonitis often shows ground-glass opacity, air trapping and relative sparing of the lung bases, unlike the basal-predominant honeycombing of UIP. These features can guide the diagnostic pathway.

Question 44Interstitial lung disease

A patient with pulmonary alveolar proteinosis due to GM-CSF neutralising antibodies develops worsening hypoxaemia. Which treatment is most appropriate?

  1. Whole lung lavage Correct answer.
  2. Antifibrotic therapy with nintedanib
  3. Systemic corticosteroids
  4. Empiric broad-spectrum antibiotics

Explanation

Whole lung lavage is the standard treatment for symptomatic pulmonary alveolar proteinosis, with GM-CSF therapy as an alternative. Corticosteroids, antifibrotics and antibiotics are not effective for this condition.

Question 45Interstitial lung disease

Which histopathologic feature differentiates desquamative interstitial pneumonia from respiratory bronchiolitis-interstitial lung disease?

  1. Diffuse and uniform alveolar macrophage accumulation versus bronchiolocentric distribution Correct answer.
  2. Presence of fibroblast foci
  3. Necrotising granulomas
  4. Hyaline membrane formation

Explanation

DIP shows diffuse, uniform filling of alveoli by macrophages, whereas RB-ILD has a patchy, bronchiolocentric macrophage accumulation. Both are smoking-related but differ in distribution.

Question 46Interstitial lung disease

A patient with idiopathic pulmonary fibrosis and a new right-sided pneumothorax is most at risk of which complication?

  1. Immediate development of pulmonary embolism from air embolism
  2. Spontaneous resolution without intervention
  3. Persistent air leak and bronchopleural fistula due to underlying fibrotic lung Correct answer.
  4. Conversion to organising pneumonia

Explanation

Patients with fibrotic lung disease and pneumothorax are prone to persistent air leak and bronchopleural fistula because of stiff, non-compliant lung tissue. This often requires more aggressive management such as pleurodesis or surgery.

Question 47Interstitial lung disease

In a patient with suspected hypersensitivity pneumonitis, which combination of findings on bronchoalveolar lavage best supports the diagnosis?

  1. Neutrophilia with elevated CD4:CD8 ratio
  2. Eosinophilia above 25 percent
  3. Presence of malignant cells
  4. Marked lymphocytosis with reduced CD4:CD8 ratio Correct answer.

Explanation

Hypersensitivity pneumonitis typically produces marked BAL lymphocytosis, often with a reduced CD4:CD8 ratio. Neutrophilia, marked eosinophilia or malignant cells point to other diagnoses.

Question 48Interstitial lung disease

Which statement best explains why antifibrotic therapy is used in progressive fibrosing interstitial lung diseases beyond idiopathic pulmonary fibrosis?

  1. All fibrotic ILDs share an identical histologic pattern
  2. Shared profibrotic pathways such as TGF-beta signalling drive progression across fibrotic ILD phenotypes Correct answer.
  3. Antifibrotics reverse established honeycombing
  4. Corticosteroids are contraindicated in every fibrotic ILD

Explanation

Progressive fibrosing ILDs of differing aetiologies share profibrotic mechanisms, which underlies the benefit of antifibrotics in progressive pulmonary fibrosis. These agents slow decline but do not reverse established honeycombing.

Question 49Interstitial lung disease

Which feature distinguishes lymphangioleiomyomatosis from Birt-Hogg-Dube syndrome on HRCT?

  1. Cysts distributed diffusely throughout the lungs with renal angiomyolipomas Correct answer.
  2. Cysts predominantly in the lower lobes with renal cell carcinoma
  3. Unilateral cysts with mediastinal lymphadenopathy
  4. Cysts confined to the upper lobes with skin fibrofolliculomas

Explanation

LAM causes diffuse thin-walled cysts and is associated with renal angiomyolipomas, whereas Birt-Hogg-Dube syndrome causes lower-lobe predominant cysts with renal cell carcinoma and skin fibrofolliculomas. The distribution and associated tumours differ.

Question 50Interstitial lung disease

A patient with idiopathic pulmonary fibrosis develops acute worsening of dyspnoea with new bilateral ground-glass opacities on CT. Which diagnosis should be considered first?

  1. Lymphangioleiomyomatosis
  2. Pulmonary alveolar proteinosis
  3. Acute exacerbation of idiopathic pulmonary fibrosis Correct answer.
  4. Pulmonary Langerhans cell histiocytosis

Explanation

Acute exacerbation of IPF presents as rapid respiratory deterioration with new bilateral ground-glass opacities or consolidation superimposed on a background UIP pattern. The other entities have different chronic imaging features.