RESPIRATORY MEDICINE EXAM 2026 UPDATE
WITH COMPLETE SOLUTIONS.
SECTION 1: OBSTRUCTIVE LUNG DISEASE
1. A 65-year-old man with a 40 pack-year smoking history presents with
progressive dyspnea and chronic cough with sputum production. Spirometry
shows FEV1/FVC ratio of 0.62 and FEV1 of 55% predicted. What is the most likely
diagnosis?
• A) Asthma
• B) COPD
• C) Idiopathic pulmonary fibrosis
• D) Bronchiectasis
Correct Answer: B
*Rationale: COPD is defined by a post-bronchodilator FEV1/FVC ratio < 0.70. Risk
factors include smoking history and chronic productive cough. The FEV1 of 55%
predicted indicates GOLD Stage 2 (moderate) COPD. Asthma typically shows
reversibility (> 12% improvement in FEV1).*
2. A patient with COPD has an FEV1 of 35% predicted and develops worsening
dyspnea, confusion, and peripheral edema. What is the most appropriate
oxygen therapy target?
• A) SpO₂ 100%
• B) SpO₂ 88-92%
• C) SpO₂ 94-98%
, • D) SpO₂ 90-95%
Correct Answer: B
*Rationale: In COPD patients, the target SpO₂ is 88-92% to avoid suppressing the
hypoxic drive and causing hypercapnic respiratory failure. Over-oxygenation can
lead to CO₂ retention and respiratory acidosis.*
3. Which of the following is a key feature distinguishing asthma from COPD?
• A) Fixed airflow obstruction
• B) Reversibility of airflow obstruction
• C) Progressive decline in lung function
• D) Chronic cough and sputum production
Correct Answer: B
Rationale: Asthma is characterized by reversible airflow obstruction (≥ 12%
improvement in FEV1 after bronchodilator). COPD has fixed, less reversible
obstruction with progressive decline. Both can cause cough and sputum, but
reversibility is the key distinguishing feature.
4. A patient with COPD exacerbation is started on non-invasive ventilation (NIV).
Which is the most appropriate setting for this patient?
• A) CPAP 10 cmH₂O
• B) BiPAP with IPAP 10 cmH₂O, EPAP 5 cmH₂O
• C) BiPAP with IPAP 20 cmH₂O, EPAP 10 cmH₂O
• D) Pressure support ventilation only
Correct Answer: B
*Rationale: BiPAP (bilevel positive airway pressure) with IPAP 10-20 cmH₂O and
EPAP 4-6 cmH₂O is standard for COPD exacerbations. CPAP is less effective. Higher
,pressures may be needed but should be titrated. IPAP is inspiratory support; EPAP
maintains airway patency.*
5. The most common bacterial pathogen responsible for acute exacerbations of
COPD is:
• A) Pseudomonas aeruginosa
• B) Streptococcus pneumoniae
• C) Haemophilus influenzae
• D) Staphylococcus aureus
Correct Answer: C
Rationale: Haemophilus influenzae, Streptococcus pneumoniae, and Moraxella
catarrhalis are the most common bacterial pathogens in COPD exacerbations.
Pseudomonas is more common in patients with advanced COPD or frequent
antibiotic use.
6. A patient with COPD and severe hypercapnia is being considered for long-
term oxygen therapy (LTOT). Which criteria support LTOT?
• A) PaO₂ < 55 mmHg or SpO₂ < 88% at rest
• B) PaO₂ < 60 mmHg with signs of right heart failure
• C) Both A and B
• D) PaCO₂ > 50 mmHg
Correct Answer: C
*Rationale: LTOT is indicated for: (1) PaO₂ ≤ 55 mmHg or SpO₂ ≤ 88% at rest, or (2)
PaO₂ 56-59 mmHg with signs of right heart failure, polycythemia, or pulmonary
hypertension. LTOT should be used for ≥ 15 hours/day to improve survival.*
, 7. A 40-year-old woman presents with episodic wheezing, chest tightness, and
shortness of breath after exposure to cats. What is the most appropriate initial
diagnostic test?
• A) Chest X-ray
• B) Spirometry with bronchodilator reversibility
• C) Methacholine challenge
• D) Skin prick testing
Correct Answer: B
Rationale: Spirometry with bronchodilator reversibility is the initial test for
asthma. It should be performed at initial presentation and after treatment to
assess response. Methacholine challenge is used when spirometry is normal but
asthma is suspected.
8. Which medication is the most effective controller therapy for persistent
asthma?
• A) Montelukast
• B) Inhaled corticosteroids (ICS)
• C) Long-acting beta-agonists (LABA)
• D) Theophylline
Correct Answer: B
Rationale: Inhaled corticosteroids are the most effective controller therapy for
persistent asthma. They reduce airway inflammation and exacerbations. LABA
should never be used as monotherapy in asthma; they must be combined with ICS.
9. A patient with asthma on high-dose ICS + LABA presents with worsening
symptoms and an FeNO of 50 ppb. What is the most appropriate next step?
WITH COMPLETE SOLUTIONS.
SECTION 1: OBSTRUCTIVE LUNG DISEASE
1. A 65-year-old man with a 40 pack-year smoking history presents with
progressive dyspnea and chronic cough with sputum production. Spirometry
shows FEV1/FVC ratio of 0.62 and FEV1 of 55% predicted. What is the most likely
diagnosis?
• A) Asthma
• B) COPD
• C) Idiopathic pulmonary fibrosis
• D) Bronchiectasis
Correct Answer: B
*Rationale: COPD is defined by a post-bronchodilator FEV1/FVC ratio < 0.70. Risk
factors include smoking history and chronic productive cough. The FEV1 of 55%
predicted indicates GOLD Stage 2 (moderate) COPD. Asthma typically shows
reversibility (> 12% improvement in FEV1).*
2. A patient with COPD has an FEV1 of 35% predicted and develops worsening
dyspnea, confusion, and peripheral edema. What is the most appropriate
oxygen therapy target?
• A) SpO₂ 100%
• B) SpO₂ 88-92%
• C) SpO₂ 94-98%
, • D) SpO₂ 90-95%
Correct Answer: B
*Rationale: In COPD patients, the target SpO₂ is 88-92% to avoid suppressing the
hypoxic drive and causing hypercapnic respiratory failure. Over-oxygenation can
lead to CO₂ retention and respiratory acidosis.*
3. Which of the following is a key feature distinguishing asthma from COPD?
• A) Fixed airflow obstruction
• B) Reversibility of airflow obstruction
• C) Progressive decline in lung function
• D) Chronic cough and sputum production
Correct Answer: B
Rationale: Asthma is characterized by reversible airflow obstruction (≥ 12%
improvement in FEV1 after bronchodilator). COPD has fixed, less reversible
obstruction with progressive decline. Both can cause cough and sputum, but
reversibility is the key distinguishing feature.
4. A patient with COPD exacerbation is started on non-invasive ventilation (NIV).
Which is the most appropriate setting for this patient?
• A) CPAP 10 cmH₂O
• B) BiPAP with IPAP 10 cmH₂O, EPAP 5 cmH₂O
• C) BiPAP with IPAP 20 cmH₂O, EPAP 10 cmH₂O
• D) Pressure support ventilation only
Correct Answer: B
*Rationale: BiPAP (bilevel positive airway pressure) with IPAP 10-20 cmH₂O and
EPAP 4-6 cmH₂O is standard for COPD exacerbations. CPAP is less effective. Higher
,pressures may be needed but should be titrated. IPAP is inspiratory support; EPAP
maintains airway patency.*
5. The most common bacterial pathogen responsible for acute exacerbations of
COPD is:
• A) Pseudomonas aeruginosa
• B) Streptococcus pneumoniae
• C) Haemophilus influenzae
• D) Staphylococcus aureus
Correct Answer: C
Rationale: Haemophilus influenzae, Streptococcus pneumoniae, and Moraxella
catarrhalis are the most common bacterial pathogens in COPD exacerbations.
Pseudomonas is more common in patients with advanced COPD or frequent
antibiotic use.
6. A patient with COPD and severe hypercapnia is being considered for long-
term oxygen therapy (LTOT). Which criteria support LTOT?
• A) PaO₂ < 55 mmHg or SpO₂ < 88% at rest
• B) PaO₂ < 60 mmHg with signs of right heart failure
• C) Both A and B
• D) PaCO₂ > 50 mmHg
Correct Answer: C
*Rationale: LTOT is indicated for: (1) PaO₂ ≤ 55 mmHg or SpO₂ ≤ 88% at rest, or (2)
PaO₂ 56-59 mmHg with signs of right heart failure, polycythemia, or pulmonary
hypertension. LTOT should be used for ≥ 15 hours/day to improve survival.*
, 7. A 40-year-old woman presents with episodic wheezing, chest tightness, and
shortness of breath after exposure to cats. What is the most appropriate initial
diagnostic test?
• A) Chest X-ray
• B) Spirometry with bronchodilator reversibility
• C) Methacholine challenge
• D) Skin prick testing
Correct Answer: B
Rationale: Spirometry with bronchodilator reversibility is the initial test for
asthma. It should be performed at initial presentation and after treatment to
assess response. Methacholine challenge is used when spirometry is normal but
asthma is suspected.
8. Which medication is the most effective controller therapy for persistent
asthma?
• A) Montelukast
• B) Inhaled corticosteroids (ICS)
• C) Long-acting beta-agonists (LABA)
• D) Theophylline
Correct Answer: B
Rationale: Inhaled corticosteroids are the most effective controller therapy for
persistent asthma. They reduce airway inflammation and exacerbations. LABA
should never be used as monotherapy in asthma; they must be combined with ICS.
9. A patient with asthma on high-dose ICS + LABA presents with worsening
symptoms and an FeNO of 50 ppb. What is the most appropriate next step?
