Q1. Which spirometry result indicates an OBSTRUCTIVE pattern? A. FEV₁/FVC < 0.70 B. FEV₁/FVC > 0.80 with reduced FVC C. Normal FEV₁ and FVC D. Raised total lung capacity alone ANSWER: A — FEV₁/FVC < 0.70. Why: obstruction impairs getting air OUT, so FEV₁ falls more than FVC and the ratio drops. B: a preserved or raised ratio with low volumes suggests RESTRICTION. LEARNING POINT: the ratio distinguishes obstruction from restriction before you consider any diagnosis.

Q2. Which feature most suggests ASTHMA rather than COPD? A. Progressive daily breathlessness over years B. Symptom-free intervals with nocturnal wheeze C. Heavy smoking history D. Minimal bronchodilator reversibility ANSWER: B — symptom-free intervals with nocturnal wheeze. Why: variability is the hallmark of asthma. COPD is persistent and progressive. A, C, D: all point towards COPD. LEARNING POINT: variability IS the diagnosis in asthma.

Q3. A 22-year-old with acute asthma becomes quieter on auscultation and drowsy. Gas: pCO₂ 5.8 kPa (was 3.1). This indicates: A. Clinical improvement B. Near-fatal asthma with exhaustion C. Successful bronchodilator response D. Hyperventilation syndrome ANSWER: B — near-fatal asthma. Why: an acutely distressed asthmatic should be hypocapnic. A rising pCO₂ toward normal means they can no longer sustain the work of breathing. A quiet chest means insufficient airflow to generate a wheeze. A, C: the dangerous misreading this question targets. LEARNING POINT: both "improvements" here are deterioration. Escalate to critical care.

Q4. A 55-year-old woman who has never smoked has fixed airflow obstruction and 30 years of cooking on an indoor wood fire. The most likely diagnosis is: A. Asthma B. COPD from biomass smoke exposure C. Pulmonary fibrosis D. Bronchiectasis only ANSWER: B — COPD from biomass exposure. Why: fixed obstruction with poor reversibility is COPD physiologically. Indoor biomass smoke is a major cause in South Asia and predominantly affects women. A: asthma would show reversibility. C: fibrosis gives a RESTRICTIVE pattern. LEARNING POINT: a smoking-only history misses these patients.

Q5. A patient with COPD has SpO₂ 78% during an exacerbation. The correct action is: A. Withhold oxygen because of CO₂ retention risk B. Give controlled oxygen targeting 88–92% and check a blood gas C. Give high-flow oxygen targeting 99% D. Give oxygen only if the patient becomes unconscious ANSWER: B — controlled oxygen, targeting 88–92%. Why: hypoxia at this level causes rapid organ injury, while CO₂ retention develops more slowly and is manageable. The answer is controlled oxygen with gas monitoring. A, D: withholding oxygen from a severely hypoxic patient is the more dangerous error. C: uncontrolled high-flow risks worsening hypercapnia. LEARNING POINT: neither withhold nor flood — titrate.

Q6. A 30-year-old asthmatic with nasal polyps develops severe bronchospasm after taking ibuprofen. The mechanism is: A. IgE-mediated anaphylaxis to ibuprofen B. COX inhibition shunting arachidonic acid toward leukotrienes C. Direct beta-2 receptor blockade D. Histamine release from mast cells ANSWER: B — COX inhibition shifting metabolism toward leukotrienes. Why: in aspirin-exacerbated respiratory disease, inhibiting cyclo-oxygenase diverts arachidonic acid down the lipoxygenase pathway, increasing bronchoconstrictor leukotrienes. The triad of asthma, nasal polyps and NSAID sensitivity is characteristic. C: that is the beta-blocker mechanism. LEARNING POINT: it is pharmacological, not allergic — so it will recur with any NSAID, not just this one.

Q7. A patient with asthma uses her reliever inhaler daily and wakes at night twice weekly, taking her preventer "when tight". The best FIRST step is: A. Add a long-acting beta agonist alone B. Check inhaler technique and adherence, and explain that the preventer is taken daily C. Prescribe a stronger reliever D. Start oral steroids long term ANSWER: B — technique and adherence first. Why: frequent reliever use and night waking indicate uncontrolled inflammation, and the preventer is not being taken as a preventer. Escalating before checking this treats a problem that does not exist. A: a long-acting beta agonist must never be given without an inhaled corticosteroid. LEARNING POINT: most "uncontrolled asthma" is untaken or badly taken medication.