handbook Self-Assessment in Respiratory Medicine Editors Konrad E Bloch with Thomas Brack and Anita K Simonds PUBLISHED BY THE EUROPEAN RESPIRATORY SOCIETY EDITORS Konrad E Bloch with Thomas Brack and Anita K Simonds AUTHORS AND REVIEWERS Ferran Barbé Thomas Brack Dragos Bumbacea Richard Costello Mina Gaga Ildikó Horváth Kostas Kostikas Christian M Lo Cascio Winfried Randerath Anita K Simonds Frank Smeenk Robert Thurnheer Silvia Ulrich Somaini Eleftherios Zervas ERS STAFF Alice Bartlett, Matt Broadhead, May Elphinstone, Jonathan Hansen, Catherine Pumphrey, David Sadler © 2015 European Respiratory Society Design by Claire Turner, Lee Dodd and Ben Watson, ERS Typeset in India by TechSet Composition Ltd Printed in the UK by Latimer Trend and Company Ltd All material is copyright to the European Respiratory Society It may not be reproduced in any way including electronically without the express permission of the society CONTACT, PERMISSIONS AND SALES REQUESTS: European Respiratory Society, 442 Glossop Road, Sheffield, S10 2PX, UK Tel: 44 114 2672860 Fax: 44 114 2665064 e-mail: info@ersj.org.uk ISBN 978-1-84984-07-4 Table of contents Contributors ii Introduction iv How to use this book vi List of abbreviations vii Multiple Choice Questions with explanations Index: the HERMES Syllabus in Respiratory Medicine 545 Blueprint of HERMES examination 547 Contributors Editors Konrad E Bloch Vice Director Pulmonary Division and Sleep Disorders Centre University Hospital Zurich Zurich, Switzerland konrad.bloch@usz.ch Thomas Brack Dept of Internal Medicine and Pulmonary Medicine Kantonsspital Glarus, Switzerland thomas.brack@ksgl.ch Anita K Simonds NIHR Respiratory Disease Biomedical Research Unit Royal Brompton and Hareeld NHS Foundation Trust London, UK a.simonds@rbht.nhs.uk Authors and reviewers Ferran Barbe Respiratory Department, IRBlleida Lleida, Spain CIBERES, Instituto Salud Carlos III Madrid, Spain febarbe.lleida.ics@gencat.cat Konrad E Bloch Pulmonary Division and Sleep Disorders Centre University Hospital Zurich Zurich, Switzerland konrad.bloch@usz.ch Thomas Brack Dept of Internal Medicine and Pulmonary Medicine Kantonsspital Glarus, Switzerland thomas.brack@ksgl.ch Dragos Bumbacea Department of Pulmonology Elias Emergency University Hospital & “Carol Davila” University of Medicine and Pharmacy Bucharest, Romania d.bumbacea@gmail.com ii Richard Costello Dept of Medicine Royal College of Surgeons in Ireland Dublin, Ireland rcostello@rcsi.ie Mina Gaga 7th Respiratory Medical Dept and Asthma Centre Athens Chest Hospital Athens, Greece mgaga@med.uoa.gr Ildikó Horváth National Koranyi Institute for TB and Pulmonology Budapest, Hungary ildiko.horvath@koranyi.hu Kostas Kostikas University of Athens Medical School Attikon Hospital Athens, Greece ktkostikas@gmail.com Christian M Lo Cascio Columbia University Medical Center New York, NY, USA cml2213@columbia.edn Winfried Randerath Clinic of Pneumology and Allergology Center for Sleep Medicine and Respiratory Care Bethanien Hospital Solingen, Germany randerath@klinik-bethanien.de Anita K Simonds NIHR Respiratory Disease Biomedical Research Unit Royal Brompton and Hareeld NHS Foundation Trust London, UK a.simonds@rbht.nhs.uk Frank Smeenk Dept of Pulmonology Catharina Hospital Eindhoven, The Netherlands frank.smeenk@catharinaziekenhuis.nl Robert Thurnheer Ambulante Medizinische Diagnostik Kantonsspital Münsterlingen, Switzerland robert.thurnheer@stgag.ch Silvia Ulrich Clinic of Pneumology University Hospital Zurich Zurich, Switzerland silvia.ulrich@usz.ch Eleftherios Zervas 7th Respiratory Medical Dept Athens Chest Hospital Athens, Greece lefzervas@yahoo.gr iii Introduction In recognition of the increasing demand for education and revalidation in respiratory medicine, the European Respiratory Society (ERS) has initiated the Harmonised Education in Respiratory Medicine for European Specialists (HERMES) project The aim is to promote the highest possible standards of practice in the specialty and to improve harmonisation of training across European countries The HERMES project has been implemented by ERS Education through a task force coordinating inputs from representatives of more than 52 countries After describing the knowledge and skills a European Respiratory Specialist should have (see the index to this book)1 and delineating requirements for the core training curriculum2,3, the further phases of the project include assessments and accreditation of training centres4,5 The European Examination in Adult Respiratory Medicine is one of the assessments developed within the HERMES project4,5 It is a knowledge-based test evaluating topics outlined in the European syllabus The examination consists of 90 multiple-choice questions (MCQs) to be solved within a 3-h examination session Practising respiratory specialists holding a national accreditation and aiming to receive a European Diploma are eligible to take the examination An increasing number of trainees undergoing specialist education, as well as postgraduates who wish to evaluate their knowledge, have now taken the examination All participants receive a detailed analysis of their performance in different areas of the eld, but the Diploma is reserved for nationally accredited practising specialists in respiratory medicine The MCQs selected for the HERMES examination are created by a panel of authors from various countries and settings, i.e from academic centres, community hospitals and specialist practice The authors undergo special training in order to produce valid questions The HERMES examination committee evaluates each new question during workshops and selects those meeting high standards in terms of clinical relevance, unambiguous scientic accuracy and formal aspects Only questions passing this evaluation are subsequently incorporated into examinations Questions are further assessed for their difficulty, selectivity and formal suitability The pass/fail limit of each year’s HERMES examination is set according to predened rules They incorporate difficulty scores given by committee members for each question reecting the likelihood of a minimally qualied examinee answering any particular question correctly (Angoff method); a calibration is also performed by comparison of performance in a set of previously used questions (Rasch equating) Thus, rather than targeting any particular pass rate, the pass limit is set at a level that assures that successful candidates demonstrate a high level of knowledge In response to requests from candidates preparing for the HERMES examination as well as from practising respiratory physicians, the ERS Education Council has prepared this handbook It is a collection of MCQs with answers and comments intended to be a selfassessment companion to the ERS Handbook of Respiratory Medicine5,6, which contains a systematic discussion of topics relevant for the specialist in adult respiratory medicine We are fully aware that many respiratory professionals at all levels from senior specialists to junior trainees wish to test their knowledge personally without necessarily embarking on the HERMES examination The MCQ handbook meets that need in a constructive didactic way The broad range of topics is selected from the syllabus and the relative representation reects the weights attributed by the examination committee to the different topics, iv according to clinical relevance and importance in specialist education as listed in the ‘blueprint’ (see appendix) The current, second edition of the ERS handbook Self-Assessment in Respiratory Medicine contains a completely revised and considerably expanded selection of questions that have been prepared by experienced authors and have undergone a rigorous evaluation according to the principles outlined above The majority of questions are introduced by a case vignette describing a clinical problem to be solved The purpose is not merely to test the knowledge of facts (which could be looked up in a text book or in the Internet) but rather to evaluate the ability of a candidate to apply knowledge and critically weigh different options in a clinical context Accordingly, the choice of answers often contains more than one reasonable alternative, from which the candidate has to select the most appropriate one As a welcome change, other, short questions without vignette are interspersed to test specic knowledge in selected areas In the comments to each question, evidence in favour and against the various answers is discussed and literature references are provided for further reading We hope that all readers of this handbook will enjoy solving the problems presented in the case vignettes and questions, and benet from assessing and refreshing their knowledge in respiratory medicine Konrad E Bloch Thomas Brack Anita K Simonds ERS Educational Council, ERS HERMES Examination ERS Educational Council, Assessments Director Committee, Member Past Chair References Loddenkemper R, et al HERMES: a European core syllabus in respiratory medicine Breathe 2006; 3: 59–69 Loddenkemper R, et al European curriculum recommendations for training in adult respiratory medicine: crossing boundaries with HERMES Eur Respir J 2008; 32: 538–540 Loddenkemper R, et al European curriculum recommendations for training in adult respiratory medicine Breathe 2008; 5: 80–120 Loddenkemper R, et al Adult HERMES: criteria for accreditation of ERS European training centres in adult respiratory medicine Breathe 2010; 7: 171–188 Loddenkemper R, et al Multiple choice and the only answer: the HERMES examination Breathe 2008; 4: 244–246 Palange P, et al eds ERS Handbook of Respiratory Medicine 2nd Edn Sheffield, European Respiratory Society, 2013 v How to use this book This handbook may be used in several ways: for self-assessment; to identify areas of strengths and weaknesses as a guide for further studies; and to refresh and update your knowledge in respiratory medicine Those who wish to experience how it feels to undergo the HERMES examination may set themselves the challenge of solving 90 of the multiplechoice questions (MCQs) collected in this book within h The answers should be recorded on a separate sheet of paper without looking up the comments on the back of each question page Another way of using the book is to solve the MCQs step by step, reading the comments at your convenience The literature references listed with the comments on the reverse of each MCQ allow further reading to obtain more in-depth information Still another approach is to use the index to locate and solve MCQs according to a particular syllabus topic of interest in order to test and consolidate knowledge in a specic area The MCQs in this handbook are presented according to two different formats: in the single-choice MCQ, the reader is asked to select the only correct answer, or the most appropriate answer, from ve options (alternatively, in negatively formulated questions, the only exception or incorrect statement, or the least appropriate of ve answers has to be selected) In the HERMES examination, a correct answer to this type of MCQ is awarded point If more than one answer is marked on the answer sheet, points are given In the second format of MCQ, four answers or statements are listed and the reader must decide whether each one is correct (true) or incorrect (false) In the HERMES examination, four correct true/false decisions are awarded with point, three correct true/false decisions are awarded with 0.5 points and fewer than three with points vi List of abbreviations AHI apnoea–hypopnoea index BMI body mass index COPD chronic obstructive pulmonary disease CPAP continuous positive airway pressure CT computed tomography ECG electrocardiography FEV1 forced expiratory volume in s FVC forced vital capacity HRCT high-resolution computed tomography Hb haemoglobin KCO transfer coefficient of the lung for carbon monoxide MRI magnetic resonance imaging NIV noninvasive ventilation OSA(S) obstructive sleep apnoea (syndrome) PaCO2 arterial carbon dioxide tension PaO2 arterial oxygen tension PtcCO2 transcutaneous carbon dioxide tension SaO2 arterial oxygen saturation SpO2 arterial oxygen saturation measured by pulse oximetry TLC total lung capacity TLCO transfer factor of the lung for carbon monoxide V' E minute ventilation vii Question 258 A 72-year-old man presents because of extreme exertional dyspnoea and fatigue that have progressed over the last 3 years COPD was diagnosed 3 years ago and oxygen (1 L⋅min−1) was prescribed for arterial hypoxaemia (PaO2 7.0 kPa (52 mmHg)) He smoked two packs of cigarettes daily for 20 years but had stopped 30 years ago On physical examination, he appears ill His neck veins are distended to the angle of the mandible while sitting up Cardiac examination reveals a grade 3/6 pansystolic murmur along the left sternal border Peripheral oedema is also present The results of pulmonary function and arterial blood gas studies are shown below FVC L (% predicted) 4.2 (98) FEV1 L (% predicted) 3.6 (87) PaO2 kPa (mmHg) 7.4 (56) PaCO2 kPa (mmHg) 4.2 (32) pH 7.41 Chest radiography shows large pulmonary arteries but no other abnormalities ECG shows Q-waves in II, III and aVF Echocardiography shows enlargement of the right atrium and right ventricle as well as severe pulmonary hypertension with an estimated systolic pulmonary artery pressure of 78 mmHg There is no evidence of mitral stenosis or an atrial septal defect The left ventricle appears normal Which of the following is the most appropriate next step? a b c d e Nebulised bronchodilators Nifedipine titrated to the maximally tolerated dose A sleep study Spiroergometry Right-sided cardiac catheterisation Self-Assessment in Respiratory Medicine 535 Correct answer e Right-sided cardiac catheterisation This patient’s medical history and symptoms are consistent with acutely decompensated right heart failure The typical presentation of right-heart failure includes fatigue, peripheral oedema, ascites, abdominal tenderness and oliguria Myocardial infarction is one of the potential causes, according to the ECG abnormalities pointing towards the involvement of the right ventricle Spirometric values and the chest radiograph not suggest a lung disease that would explain the hypoxaemia and pulmonary hypertension A sleep study might show sleep apnoea but this sleep-related breathing disorder would not explain the major elevation of pulmonary artery pressure Although spiroergometry might show impaired exercise performance due to cardiovascular limitation, it would not further clarify the differential diagnosis Current evidence shows and the European Society of Cardiology/European Respiratory Society guideline states that right heart catheterisation is required to confirm the diagnosis of pulmonary hypertension, to assess the severity of the haemodynamic impairment and to test the vasoreactivity of the pulmonary circulation The diagnosis is not yet established and there is no indication to urgently use any of the listed treatment options References Galiè N, et al Guidelines for the diagnosis and treatment of pulmonary hypertension: the Task Force for the Diagnosis and Treatment of Pulmonary Hypertension of the European Society of Cardiology (ESC) and the European Respiratory Society (ERS), endorsed by the International Society of Heart and Lung Transplantation (ISHLT) Eur Heart J 2009; 30: 2493–2537 Global Initiative for Chronic Obstructive Lung Disease Global strategy for diagnosis, management, and prevention of COPD www.goldcopd.org/uploads/users/files/GOLD_Report_2015_ Apr2.pdf Date last updated: April 2, 2015 Konstantinides SV, et al 2014 ESC Guidelines on the diagnosis and management of acute pulmonary embolism Eur Heart J 2014; 35: 3033–3080 HERMES Syllabus link: 14 Pulmonary vascular diseases Angoff rating: 58% 536 Self-Assessment in Respiratory Medicine Question 259 A 61-year-old woman who has severe COPD seeks advice about taking an international flight Spirometry yields the following values: FVC 2.8 L (78% predicted); FEV1 0.7 L (29% predicted); arter­ ial blood gases breathing air at sea level are PaO2 6.50 kPa (49 mmHg), SaO2 85%, PaCO2 6.10 kPa (46 mmHg), and pH 7.38 These values are very similar to those of 6 and 12 months ago You should advise the patient: a b c d e Not to travel on a commercial airliner That she will maintain satisfactory oxygenation during the flight since she will hyperventilate To use on-board oxygen carried by commercial airlines if shortness of breath develops To make advance arrangements with the airline for physician-prescribed in-flight oxygen Additional oxygen is not warranted since commercial airline cabins are pressurised to sea level Self-Assessment in Respiratory Medicine 537 Correct answer d To make advance arrangements with the airline for physician-prescribed in-flight oxygen Air travel is almost always feasible with appropriate medical support, but this may involve considerable costs The patient will become more hypoxaemic during the flight as hyperventilation will only partially compensate for the reduced barometric pressure in the cabin In this woman, oxygen should be recommended at a flow rate of 2–4 L ⋅ min−1 via nasal cannula during the flight even if she is not short of breath as she is already hypoxaemic at sea level Arrangements for in-flight oxygen have to be made with the airline in advance A hypoxaemic challenge test with an inspiratory oxygen fraction of   0.15 may aid decision-making on the supplemental oxygen flow rate required, but the relevance of these observations has not been validated by clinical outcomes The British Thoracic Society has issued guidelines on managing passengers with stable respira­ tory disease planning air travel These recommendations are summarised in the figure and table Yes Does the patient have any contraindictions to air travel? (as defined in the table) Advise against air travel No Is the patient in a high-risk group? (as defined in the table) Yes Yes Is the patient receiving LTOT? No No Is the sea level oxygen saturation 50 mmHg) or SpO2≥85%? No In-flight oxygen required at 2L·min-1 via nasal cannulae In-flight oxygen not required Optimise usual care Advise based on disease specific recommendations and VTE risk (LTOT patients: double usual flow rate) Physician judgement on advice to fly FIGURE  Algorithm for managing adult passengers with stable respiratory disease planning air travel LTOT: long-term oxygen therapy; VTE: venous thromboembolism Reproduced from Josephs et al (2013) with permission from the publisher 538 Self-Assessment in Respiratory Medicine Table  Recommendations for adults Contraindications to travel   Infectious tuberculosis   Ongoing pneumothorax with persistent air leak   Major haemoptysis  Patients on LTOT whose usual oxygen requirements exceed 4 L ⋅ min−1 at sea level (because commercial airlines are unable to deliver double this rate, which would be the usual recommendation at altitude) High-risk patients requiring further evaluation (see figure)   Patients with previous significant respiratory symptoms associated with air travel  Severe COPD (FEV1