Pulmonary Disease Certification Examination: Clinical Reasoning Guide Study Guide

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An adult's FEV1 increases from 2.00 L to 2.30 L after bronchodilator. The increase is 300 mL and 15% of baseline, meeting the adult reversibility criterion and supporting asthma when the symptom history is compatible.

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A peak-flow diary averages 14% daily variability over two weeks despite normal office spirometry. This provides objective support for variable airflow limitation in an adult with compatible episodic symptoms.

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A patient prescribed an inhaled corticosteroid–long-acting bronchodilator reports daily symptoms. Watching an inhalation reveals failure to load the device. Teach the technique and reassess control before labeling the asthma severe.

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An adult using an appropriate corticosteroid–formoterol maintenance regimen asks which inhaler to use for breakthrough symptoms. Review whether the prescribed plan is maintenance-and-reliever therapy and demonstrate its symptom-driven instructions.

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A patient with recurrent exacerbations has elevated eosinophils but inconsistent controller use. First optimize adherence and inhaler delivery; then reassess persistent disease and inflammatory phenotype before selecting a targeted treatment pathway.

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A runner develops inspiratory noise at peak exertion and recovers rapidly after stopping. Arrange continuous laryngoscopy during exercise rather than relying on a normal resting laryngeal examination.

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A previously agitated patient with severe asthma becomes drowsy and has barely audible breath sounds despite ongoing treatment. Treat this as impending respiratory failure and obtain immediate advanced airway and critical care support.

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Repeated stable room-air PaO2 of 53 mm Hg supports oxygen for at least 15 hours daily. Resting SpO2 of 95% with reproducible walking desaturation to 86% instead prompts an individualized ambulatory oxygen assessment.

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A patient remains breathless on correctly used LAMA monotherapy. Consider LABA/LAMA treatment, assess other contributors to limitation, and reassess symptoms and activity after the change.

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A patient has recurrent treated exacerbations despite correctly used LABA/LAMA. Consider triple therapy after confirming adherence and inhaler technique, reviewing prior pneumonia and the exacerbation pattern, and discussing the expected reduction in exacerbations against the increased pneumonia risk.

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During a COPD exacerbation, a patient becomes increasingly tachypneic with prolonged expiration and rising PaCO2. Recognize worsening ventilatory mechanics, assess respiratory acidosis, and evaluate suitability for closely monitored bilevel noninvasive ventilation support.

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A patient with predicted body weight of 60 kg and actual weight of 110 kg develops ARDS. A starting tidal volume near 360 mL follows the 6 mL/kg predicted-weight approach; 660 mL would use the wrong denominator.

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An intubated patient has peak pressure of 42 cm H2O but plateau pressure of 25 cm H2O. Investigate increased airway resistance, including secretions or bronchospasm, rather than equating peak pressure directly with alveolar distending pressure.

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A patient with severe ARDS remains markedly hypoxemic despite lung-protective ventilation. Mobilize a trained team for prolonged prone positioning while maintaining appropriate tidal volume, pressure monitoring, and secure airway and line management.

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After a PEEP increase, oxygenation improves but blood pressure falls and signs of right ventricular strain appear. Reassess the net physiologic effect rather than continuing escalation solely because the saturation is higher.

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An alert patient with a COPD exacerbation has pH 7.28, PaCO2 68 mm Hg, and persistent tachypnea after initial therapy. Begin closely monitored bilevel noninvasive ventilation if airway protection and other clinical conditions permit.

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After initiation of bilevel ventilation for COPD, a patient becomes somnolent, develops weaker respiratory effort, and has a falling pH. Escalate airway management rather than repeatedly adjusting the mask while deterioration continues.

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A hypertensive, alert patient develops acute pulmonary edema with severe respiratory distress. Add appropriate noninvasive positive-pressure support while treating the cardiac precipitant and monitoring for changes in perfusion and respiratory status.

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A patient receiving norepinephrine has adequate arterial pressure but persistent poor perfusion. Echocardiography shows depressed cardiac function. Assess output and consider inotropic support rather than assuming that additional vasoconstriction or fluid will correct the problem.

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An ARDS patient has SpO2 of 96% while receiving a large tidal volume and plateau pressure above the protective target. Reduce excessive mechanical stress and reassess gas exchange rather than accepting the settings because oxygenation looks normal.

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An older adult has progressive exertional dyspnea and basal crackles. CT shows subpleural basal reticulation, traction bronchiectasis, and honeycombing. Identify a UIP pattern, then investigate whether the clinical setting supports idiopathic pulmonary fibrosis.

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A patient with UIP-pattern fibrosis also reports inflammatory joint symptoms and longstanding Raynaud phenomenon. Investigate a systemic inflammatory cause before assigning idiopathic pulmonary fibrosis, because the imaging pattern does not settle the underlying diagnosis.

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A frail patient has characteristic UIP imaging and no identified alternative cause after evaluation. Discuss the case multidisciplinary rather than ordering surgical biopsy automatically; weigh whether any likely tissue result would alter the decision.

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A patient with fibrotic lung disease has positive bird-specific IgG but no clear exposure history. Investigate household, occupational, and indirect bird-related exposures while reviewing imaging; do not diagnose hypersensitivity pneumonitis from the antibody alone.

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A bird keeper has fibrosis, expiratory air trapping, and lavage lymphocytosis. Combine these findings with the exposure history to assess diagnostic confidence; the same CT finding without the supporting context would be less conclusive.

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A patient referred for fibrotic ILD reports difficulty rising from a chair and new hand changes. Expand the history, examination, and targeted systemic evaluation rather than accepting an idiopathic label based only on chest imaging.

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An otherwise uncomplicated adult has habitual loud snoring, witnessed apneas, and prominent daytime sleepiness. After a comprehensive evaluation, a technically adequate home sleep apnea test can be an appropriate diagnostic option.

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A sleepy adult with witnessed apneas has a negative home study but reports being awake for much of the recording. Arrange laboratory polysomnography to resolve the discrepancy.

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An adult with progressive neuromuscular weakness reports morning headaches and disrupted sleep. Select laboratory polysomnography rather than routine home apnea testing because respiratory muscle impairment raises concern for sleep-related hypoventilation.

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An adult with marked obesity and sleep apnea has daytime PaCO2 of 51 mm Hg. Review medications and evaluate alternative ventilatory disorders before concluding that the combination represents obesity hypoventilation syndrome.

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An obese adult with sleep-disordered breathing has bicarbonate of 30 mmol/L. Obtain an arterial blood gas to assess awake hypercapnia, while reviewing diuretic use and other explanations for an elevated bicarbonate concentration.

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A sleepy adult with confirmed uncomplicated OSA starts APAP. At early follow-up, review hours of use, residual events, symptoms, and mask difficulties before declaring treatment ineffective.

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Among 100 people with disease, a test identifies 90; among 900 without disease, 90 test positive. Sensitivity is 90%, but positive predictive value is 90 divided by 180, or 50%.

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A patient has cough, an abnormal radiograph, and a positive IGRA. Obtain appropriate respiratory testing for active tuberculosis rather than treating the immune assay as proof of latent infection.

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An immunocompromised patient has weight loss, compatible imaging, and tuberculosis exposure, but sputum smear and initial NAAT are negative. Pursue additional appropriate specimens and cultures rather than closing the diagnostic evaluation.

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An immunocompetent adult with pneumonia, new confusion, respiratory rate 34/min, and multilobar infiltrates meets three minor criteria and needs assessment for higher-intensity monitoring and treatment. Vasopressor-dependent septic shock independently meets a major criterion. A leukocyte count of 3,000/µL caused by chemotherapy must not be counted as infection-related leukopenia.

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A mildly symptomatic sputum-producing patient has one MAC isolate and noncavitary nodular bronchiectatic changes. Obtain additional cultures before treatment or bronchoscopy; if criteria are later met, separately assess whether treatment or monitored observation is preferable.

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A hospitalized adult without resistant-pathogen risk factors can receive ceftriaxone plus azithromycin after assessment of allergies and contraindications. New microbiologic information may support narrowing or revising the regimen.

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A patient improving rapidly after witnessed gastric aspiration may need supportive care. Persistent infection with an abscess changes the antimicrobial decision and requires assessment of a suppurative complication.

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A febrile patient has a loculated parapneumonic effusion with pleural pH 7.08, but culture remains negative after prior antibiotics. Treat the biochemical and imaging evidence as significant and arrange appropriate drainage.

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A patient with apparently localized lung cancer has one PET-avid mediastinal node and a history of granulomatous infection. Obtain appropriate nodal tissue before excluding a potentially curative strategy based on metabolic imaging alone.

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A patient has a lung mass and an enlarged accessible mediastinal node. Consider ultrasound-guided nodal sampling that could establish malignancy and nodal involvement together, rather than choosing a primary-mass biopsy that answers only diagnosis.

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Imaging shows a lung mass and a safely accessible suspicious distant lesion. Discuss whether sampling that lesion could establish both tumor identity and metastatic involvement before selecting a more invasive biopsy of the primary mass.

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A patient has localized lung cancer but severe exercise limitation and major cardiopulmonary disease. Assess physiologic fitness for the proposed resection while discussing other definitive options, rather than equating early stage with automatic surgical suitability.

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A patient with metastatic lung adenocarcinoma has high PD-L1 expression and an EGFR exon 19 deletion. The EGFR result identifies an EGFR-directed treatment pathway; high PD-L1 alone should not lead directly to immunotherapy selection. Coordinate adequate molecular and PD-L1 testing before committing to the initial systemic regimen.

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A patient with small-cell lung cancer develops confusion, low serum osmolality, and concentrated urine without clinical volume depletion. Evaluate inappropriate antidiuretic hormone activity while excluding other causes of hypotonic hyponatremia and addressing symptom severity.

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A patient with pneumonia has an accessible pleural collection, persistent fever, and nonpurulent fluid with pH 7.10. Arrange drainage with antibiotics rather than waiting for frank pus or a positive culture to appear.

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A patient feels less breathless after malignant effusion drainage, but imaging shows substantial persistent non-expansion. Discuss an indwelling pleural catheter because repeated attempts at pleurodesis may fail without adequate contact between the pleural surfaces.

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A patient with an elevated hemidiaphragm and a small effusion is referred for thoracentesis. Use ultrasound in the intended procedural position to determine whether a safe fluid pocket exists before introducing a needle.

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After a wrong-side pleural procedure, a team reconstructs consent, imaging review, site marking, and time-out failures. It redesigns the verification process and measures compliance rather than simply reminding clinicians to be more careful.

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Before launching a new bronchoscopy sedation workflow, a team maps medication selection, labeling, monitoring, and rescue steps. It identifies high-risk failure points and installs safeguards before the first patient undergoes the revised process.

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A patient using home oxygen says a family member smokes beside the concentrator. Explain the oxygen-enriched fire hazard, establish a smoke-free use environment, and review household ignition sources with the patient and caregiver.

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The two best postoperative FEV1 values are 3.0 and 3.2 L, measured more than three weeks apart. Baseline is 3.1 L; FEV1 at or below 2.48 L meets the 20% decline threshold. Serial measurements and evaluation determine possible, probable, or confirmed CLAD.

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A patient has progressive dyspnea after pulmonary embolism and echocardiographic evidence suggesting pulmonary hypertension. Obtain V/Q scanning; a suggestive result warrants specialist vascular imaging and hemodynamic assessment.

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A patient with low clinical probability and a negative high-sensitivity D-dimer can avoid CT imaging. A patient with high probability should proceed to appropriate imaging rather than using the same exclusion strategy.

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A normotensive patient with PE and RV strain receives anticoagulation and monitored care. New hypotension or evidence of worsening perfusion triggers urgent reassessment for reperfusion rather than routine continuation of the original plan.

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A patient with accessible proximal obstruction and acceptable operative risk should undergo evaluation for endarterectomy. A patient with technically inoperable distal lesions may be considered for balloon pulmonary angioplasty and medical therapy. Persistent symptomatic pulmonary hypertension after surgery warrants reassessment for residual treatable obstruction and consideration of riociguat; anticoagulation continues throughout these pathways.

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A patient with extensive air-space filling remains markedly hypoxemic despite a large increase in inspired oxygen. Consider a substantial intrapulmonary shunt component rather than assuming the oxygen delivery device alone explains the poor response.

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A patient has FVC below the lower limit of normal and a preserved ratio, but normal TLC with increased residual volume. Interpret the reduced FVC in relation to air trapping rather than diagnosing restriction.

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An engineered-stone worker develops weight loss, cough, and nodular lung abnormalities. Investigate silica-related disease and tuberculosis in parallel rather than assuming the occupational explanation makes infection unnecessary to consider in the diagnostic workup.