Pulmonary Disorders II

Answer: C

The patient presents with a CF exacerbation, probably

caused by an infection. The most likely causative organ-

ism of her infection is P. aeruginosa; therefore, therapy

must be directed to P. aeruginosa (Answer B is incor-

rect). In addition, antibiotic treatment should include the

empiric selection of two antibacterial agents, ideally a

β-lactam and an aminoglycoside, dosed to effectively

treat the infection (Answers A and D are incorrect). The

ideal regimen should include a β-lactam dosed to treat

P. aeruginosa – in this case, piperacillin/tazobactam at

the recommended dose – and an aminoglycoside dosed

once daily (Answer C is correct).

According to the STOP2 trial, patients who improve

within 7 days of antimicrobial therapy can complete 10

days of antimicrobials. These patients’ clinical outcomes

are noninferior to those of patients who continue antimi-

crobials for 14 days (Answer B is correct). Answer A is

incorrect; 7 days is too short for an exacerbation of CF.

Answer C is incorrect, given the results of the STOP2

trial. Answer D is incorrect because microbiological

cure is neither expected nor likely for patients with CF.

Answer: D

This patient has signs of right heart failure and rapid

progression of symptoms, which place him in the high-

risk category for mortality within 1 year (greater than

20%) (Answers A, B, and C are incorrect). In addition,

he has symptoms at rest, which place him in WHO FC

IV (Answer D is correct).

Answer: A

The patient’s symptoms and physical findings place

him in WHO FC IV. His unfavorable response to the

vasodilator challenge makes CCBs an undesirable

class of medications for him (Answer B is incorrect).

Epoprostenol continuous infusion is indicated for

patients with PAH presenting with WHO FC IV to

improve symptoms, exercise capacity, and hemodynam-

ics. In addition, it is the only treatment shown to reduce

mortality in PAH (Answer A is correct). Macitentan and

sildenafil could be considered in this patient; however,

his elevated liver enzymes do not make macitentan

an ideal agent (Answer C is incorrect). Intravenous

sildenafil is also not ideal because of the hypotension

associated with the intravenous formulation (Answer D

is incorrect).

Answer: C

Risk factors for increased mortality in patients with

asthma include (1) history of near-fatal asthma (e.g.,

requiring mechanical ventilation); (2) hospitalization

or ED visit for asthma in the past year; (3) active use

of oral corticosteroids or completion of recent course

for asthma; (4) not currently using inhaled corticoste-

roids; (5) use of more than one canister of SABAs per

month; (6) poor adherence to inhaled corticosteroid

containing asthma medications and/or poor adherence

to asthma action plan; (7) social history that includes

major psychosocial problems or psychiatric illness; (8)

food allergies; (9) comorbidities including pneumonia,

diabetes, and arrhythmias. Two of the patient’s listed

characteristics are risk factors (Answer C is correct).

Other answers include one risk factor or none (Answers

A, B, and D are incorrect).

Answer: C

For life-threatening asthma exacerbations, SABAs , short-

acting antimuscarinics, and intravenous corticosteroids

are recommended (Answers A and B are incorrect).

The recommended dose of intravenous corticosteroids

is methylprednisolone 40 mg (equivalent to prednisone

50 mg) intravenously per day administered early in the

course of the exacerbation (Answer C is correct; Answer

D is incorrect).

Answer: D

The latest GOLD guidelines recommend systemic cor-

ticosteroids to shorten recovery time, improve FEV1,

and improve hypoxemia. The recommended dose is

prednisone 40 mg orally once daily (or equivalent) for 5

days. Although recent data identified that some patients

may have worse outcomes with fixed prednisone 40-mg

doses, the data suggest prednisone 60 mg is adequate to

balance the benefit of steroids with the risks of adverse

effects (Answers A and C are incorrect). Adding inhaled

SABAs (nebulized or MDI) with or without a short-

acting anticholinergic is the preferred treatment in an

ECOPD. Antibiotic treatment for 5–7 days is also indi-

cated because the patient has signs of bacterial infection