IM 3B

PULMONOLOGY
FINALS
SLEEP BREATHING
DISORDERS
FINALS RATIO
REM
1. Which of the following best
distinguishes Tonic from Phasic stages of
REM sleep?
A. Desynchronized EEG
B. Rapid eye movements in all directions
C. Characteristic swings in BP, HR, RR
D. Frequently occur in early morning hours
RATIO:
STAGES OF REM Sleep
Tonic Stage
Desynchronized EEG
Hypotonia and atonia of major muscle groups
Phasic Stage
REM in all directions
Phasic swing in BP HR RR
Freq early morning
2. Which of the following statements is
NOT TRUE regarding Rapid Eye
Movement (REM) sleep:
A. Characterized by behavioral quiescence with residual
muscle tone and very regular, deep breathing
B. Stage during which dreaming occurs
C. Recognized by body twitches, and irregularity in rate and
depth of respiration
D. Generalized muscle atonia as a result of postsynaptic
inhibition of spinal motor neurons
REFERENCE: Dr. Esguerras ppt
NREM
Characterized by behavioral quiescence with residual muscle tone
and very regular, deep breathing
Has 4 stages (Stages 1-4)
Characterized by INCR. parasympathetic tone
Slower and more regular heartbeat
Slow and more regular respiration, but the normal compensatory
mechanisms remain unchanged other than a moderate reduction
in sensitivity to CO2 & O2
Normal thermoregulatory mechanism such as panting, shivering
and appropriate vascular changes
Tone in the upper airway muscles is diminished
INCR. upper airway resistance compared to wakefulness
REM
Stage during which dreaming occurs
Recognized by body twitches, REM, and irregularity in rate & depth of respiration
EMG recordings showed generalized muscle atonia, the result of postsynaptic
inhibition of spinal motor neurons
Excitatory barrages briefly overcome this inhibition leading to the muscle twitches
Characterized by marked suppression of hypothalamic regulation of homeostasis
Local and brainstem reflexes may still be operational but the hypothalamus is not
Tone in upper airway muscles is virtually absent INCR. upper airway resistance
DEC. Ventilator responses to hypercapnea
INCR. Arousal threshold
INCR. sensitivity of baroreceptor reflex INCR. BP
Occupies a larger portion of sleep
DEC. at birth (as much as 90%) and to ~25% of total sleep time as wakefulness
increases with maturity
3. Which of the following best
distinguishes Tonic from Phasic stages of
REM sleep?
A. Desynchronized EEG
B. Rapid eye movements in all directions
C. Characteristic swings in BP, HR, RR
D. Frequently occur in early morning hours
REFERENCE: Mra trans
NREM
4. NOT TRUE regarding NREM SLEEP
A. Characterized by increased parasympathetic tone
B. Slower and more regular heartbeat
C. Slower and more regular RR but the normal
compensatory mechanism remain unchanged
D. Marked suppression of hypothalamic regulation of
homeostasis
5. K complexes are mostly observed
during which stage of sleep?
a. NREM I
b. NREM II
c. NREM III
d. REM
6. Which of these stages is characterized by
delta waves occuring >50% of an epoch?
a. NREM I
b. NREM II
c. NREM III
d. NREM IV
 % of sleep Characteristic EMG activity
NON-REM 75-80% Behavior quiescence with residual muscle tone and very
regular, deep breathin
STG 1 2-5% Lightest Alpha rhythm dec <50% in an
epoch (one screen)
Theta rhythm & beta waves
appear
Dec EMG activity
STG 2 45-55% Intermediate Delta waves <20%
Begins after 10 Wave phenomenon
12 min of Stage o Sleep spindles sudden inc in
1 wave frequency
Lasts 30 60 o K complexes sudden inc in
min wave amplitude
STG 3 15-20% Deep Delta waves 20% of epoch
 % of sleep Characteristic EMG activity
STG 4 No real division Delta waves > 50%
btwn III & IV
REM 20-25% Onset marked by EEG fast rhythms and delta
sudden and waves sawtooth
dramatic loss of appearance
muscle tone 60
90 min after
NREM onset
Tone stage Desynchronized EEG
Hypotonia and atonia of major muscle groups
Phasic REM in all directions
stage Phasic swing in BP, HR, RR
Frequently in the morning
7. Which of the following is an
epoch of stage III NREM sleep?
A. K component
B. Delta waves > 20%
C. Delta waves < 20%
D. Alpha wave <50%
RATIO: (PPT from Dept.)
STAGES OF Non-REM Sleep
Stage I NREM
2-5% of sleep time; lightest stage of sleep
alpha rhythm < 50% in an epoch
theta rhythm & beta waves appear
EMG activity slightly
Stage II NREM
45-55% of sleep time; intermediate sleep
begins after 10-12 minutes of Stage I NREM
Delta waves < 20%
lasts 30-60 mins
Wave Phenomena:
Sleep Spindles sudden increase in wave frequency
K Complexes sudden increase in wave amplitude
Stage III NREM
15-20% of sleep time; deep sleep
delta waves 20% of the epoch
Stage IV NREM
no real division between stage III and IV except that waves
are > 50% delta waves
8. True of non-REM sleep
A. Onset is marked by sudden and dramatic loss of
muscle tone (REM)
B. Saw tooth appearance REM
C. Characterized by behavioral quiescence with
residual muscle tone and very regular, deep
breathing
D. Consists of a tonic stage and a phasic stage (REM)
9. Which of the following statements is
NOT TRUE regarding NREM sleep:

A. Characterized by increased parasympathetic tone

B. Slower and more regular heartbeat
C. Slow and more regular respiration but the normal compensatory
mechanisms remain unchanged
D. Characterized by marked suppression of hypothalamic regulation
of homostasis
NREM
Characterized by behavioral quiescence with
residual muscle tone and very regular, deep
breathing
Has 4 stages (Stages 1-4)
Characterized by INCR. parasympathetic
tone
Slower and more regular heartbeat
Slow and more regular respiration, but the
normal compensatory mechanisms remain
unchanged other than a moderate reduction
in sensitivity to CO2 & O2
Normal thermoregulatory mechanism such
as panting, shivering and appropriate
vascular changes
Tone in the upper airway muscles is
diminished
INCR. upper airway resistance compared to
wakefulness
REM
Stage during which dreaming occurs
Recognized by body twitches, REM, and irregularity in rate
& depth of respiration
EMG recordings showed generalized muscle atonia, the
result of postsynaptic inhibition of spinal motor neurons
Excitatory barrages briefly overcome this inhibition leading
to the muscle twitches
Characterized by marked suppression of hypothalamic
regulation of homeostasis
Local and brainstem reflexes may still be operational but the
hypothalamus is not
Tone in upper airway muscles is virtually absent INCR.
upper airway resistance
DEC. Ventilator responses to hypercapnea
INCR. Arousal threshold
INCR. sensitivity of baroreceptor reflex INCR. BP
Occupies a larger portion of sleep
DEC. at birth (as much as 90%) and to ~25% of total sleep
time as wakefulness increases with maturity
10. Which of the following is observed in
an epoch of stage III NREM sleep?
a. K complexes
b. Delta waves >20%
c. Delta waves <20%
d. Alpha waves <50%
Answer: B. Delta waves >20%
Non-REM
Non-rapid eye movement
75-80% of sleep time in adult humans
Characterized by behavioral quiescence with residual
muscle tone and very regular, deep breathing
Stage I NREM
2-5% of sleep time; lightest
stage of sleep
alpha rhythm < 50% in an
epoch
theta rhythm & beta waves
appear
EMG activity slightly
Stage II NREM
45-55% of sleep time;
intermediate sleep
begins after 10-12 minutes of
Stage I NREM
Delta waves < 20%
lasts 30-60 mins
Wave Phenomena:
Sleep Spindles sudden
increase in wave frequency
K Complexes sudden
increase in wave
amplitude
Stage III NREM Stage IV NREM
15-20% of sleep time; deep no real division between stage
sleep III and IV except that waves are
delta waves 20% of the > 50% delta waves
epoch
 11. TRUE regarding Sleep
A. Alpha waves are associated with day to day wakefulness
B. Delta sleep is the deepest sleep where sleep talking and
walking mostly occurs.
C. Sleep spindles and K complexes is seen in stage III non Rem
sleep
D. REM cover 75% of sleep time and marked by sudden loss of
muscle tone
E. AOTA
BETA WAVES ALPHA WAVES THETA WAVES DELTA WAVES
Slowest and
Associated with highest
day to day amplitude brain
uring periods of waves
wakefullness
relaxation, still
Highest in awake Slower in frequency, Delta sleep is the
frequency, greater in deepest sleep
Waves are amplitude than
lowest in Most difficult
slower, increase alpha waves
amplitude stage of sleep to
in amplitude
More wake from
More
desynchronous When sleep
synchronous
than other talking and
waves walking mostly
occur
STAGE I STAGE II STAGE III STAGE IV
45-55% of sleep time; No real division
2-5% of sleep intermediate sleep 15-20% of between stage III
time; lightest begins after 10-12 sleep time; and IV except
stage of sleep minutes of Stage I deep sleep that waves are >
NREM 50% delta waves
alpha rhythm delta waves
< 50% in an Delta waves < 20% 20% of the
epoch lasts 30-60 mins epoch
theta rhythm & Sleep Spindles -sudden
beta waves increase in wave
appear frequency
EMG ac2vity K Complexes sudden
slightly increase in wave
amplitude
NON-NREM
Non-rapid eye movement
75-80% of sleep time in adult humans
Characterized by behavioral quiescence with residual
muscle tone and very regular, deep breathing

REM
Rapid Eye Movement
20-25% of sleep time
onset marked by sudden and dramatic loss of muscle tone
1st REM noted 60-90mins after onset of NREM sleep
POLYSOMNOGRAPHY
12. A 49 year old male, was brought to the clinic due to
excessive daytime sleepiness. Patient is hypertensive,
diabetic with BMI = 32kg/m2. He complains of having
fragmented night sleep and morning headaches. He stated
falling asleep while reading, watching TV and at times
whiles sitting and talking to someone. Diagnostic tool of
choice will be:

A. Epworth Sleepiness Scale Questionnaire

B. Polysomnography
C. Fiberoptic Endoscopy
D. CT/MRI of the upper airways
E. Pulmonary Function Test
POLYSOMNOGRAPHY
Method of identifying and evaluating sleep-state and
several physiologic variable during sleep .
A multi-parametric test that is used to study/record in
detail all the biophysiological changes that occur in the
human body when the person is asleep.

The gold standard for diagnosis of OSAHS is an

overnight polysomnogram (PSG). (HPIM, 19 th

edition)
13. TRUE regarding polysomnography
EXCEPT
14.. A 25 year old male with excessive
daytime sleepiness underwent an Epworth
Sleepiness Screening. His score was 12.
What do you plan to do next?
A. Determine predominant brain waves with an awake
EEG
B. Suggest patient to take a leave from work for 2 weeks
C. Recommend sleep polysomnography
D. Draw blood for TSH, Cortisol
EPWORTH SLEEPINESS SCALE
Questionnaire used to screen sleep disorders for
OSA
Score >11 needs further work-up
POLYSOMNOGRAPHY
Method of identifying and evaluating sleep-state and
several physiologic variable during sleep .
A multi-parametric test that is used to study/record in
detail all the biophysiological changes that occur in the
human body when the person is asleep.

The gold standard for diagnosis of OSAHS is an

overnight polysomnogram (PSG). (HPIM, 19 th

edition)
Indications for Polysomnography
Polysomnography is routinely indicated for the diagnosis
of sleep related breathing disorders. (Standard)
Polysomnography is indicated for positive airway pressure
(PAP) titration in patients with sleep related breathing
disorders. (Standard)
A preoperative clinical evaluation for the presence of
obstructive sleep apnea in patients before they undergo
upper airway surgery for snoring or obstructive sleep
apnea. (Standard)
15. A 25 y/o male with excessive daytime
sleepiness underwent an Epworth Sleepiness
Scale Screening. His score was 12. what do
you plan to do next?
a. Determine predominant brain waves with an awake EEG
b. Suggest patient to take a leave from work for 2 weeks to get
enough sleep
c. Recommend sleep polysomnography
d. Drew blood for TSH, Cortisol
Scores of >11 needs further work up
Polysomnography
diagnosis of several disorders such as sleep apnea, narcolepsy,
and periodic limb movement disorder.
allows measurement of sleep stages, respiratory effort and
airflow, oxygen saturation, limb movements, heart rhythm,
and additional parameters.
Single most important laboratory technique for the
assessment of sleep and its disorder
16. This is a multi-parametric test that is
used to study/record in detail all the
biophysical changes that occur in the
human body hen the person is asleep?
A. Oxygen saturation in studies in the awake state
B. Polysomnography
C. Oculomyography
D. Electroencephalography
RATIO:
Polysomnography
Single most important laboratory technique for assessment
of sleep and its disorders
Method of id and eval of sleep-state and several physiologic
variables during sleep
Multi-parametric test used to study/record in detail all the
biophysiological changes that occur in a human body in sleep

Reference: MRA Trans

17. Which of the following is monitored
during a polysomnography?
A. Leg electromyogram
B. Bladder function
C. Nocturnal erections
D. frequency of vivid dreams
RATIO:
Polysomnography
Single most important laboratory technique for assessment
of sleep and its disorders
Method of id and eval of sleep-state and several physiologic
variables during sleep
Multi-parametric test used to study/record in detail all the
biophysiological changes that occur in a human body in sleep
Polysomnography

Measures
Multiple physiological characteristics or pathologic events
simultaneously during sleep at night.
Sleep stages & wakefulness, respiration, cardio-circulatory
functions and body movements.
Polysomnography
Components
EEG, EOG, EMG, ECG
Nasal/oral airflow
Breathing effort (chest & abdomen)
Oximetry
Leg EMG
Body position
Snoring sensors
Continuous audio/video monitoring and behavior
observation
18. Which of these conditions merit an assessment of
cardiopulmonary sleep condition thru sleep
polysomnography (PSG)?

a. Patients with disturbances of respiratory control

whose awake PaO2 > 45mmHg
b. Systematic hypertension with tachyarrthymia on
exercise
c. COPD patients with awake PaO2 >55mmHg but with
cor pulmonale
d. A and B C
 Indications for Cardiopulmonary Sleep Studies
Patients with disturbances of respiratory control whose awake PaO2 > 45mmHg or
with complications (choice A)
Snoring and obesity
Patients with excessive daytime sleepiness
Patients with nocturnal cyclic bradytachy-arrhythmia, nocturnal abnormalities of
atrioventricular conduction and ventricular ectopy during sleep
COPD patients with awake PaO2 > 55mmHg but with cor pulmonale (choice C)
Patients with restrictive ventilatory impairment secondary to chest wall and
neuromuscular disturbances and complicated by chronic hypoventilation,
polycythemia, pulmonary hypertension, disturbed sleep, daytime somnolence and
fatigue
19. This is a multi-parametric test that is
used to study/record in detail ALL the
biophysiological changes that occur in
the human body when the person is
asleep.
a. Oxygen saturation studies in the awake state
b. Polysomnography
c. Occulomyography
d. electroencephalography
Answer: B. Polysomnography
POLYSOMNOGRAPHY
Method of identifying and evaluating sleep-state and
several physiologic variable during sleep

A multi-parametric test that is used to study/record in detail

all the biophysiological changes that occur in the human
body when the person is asleep
 What is monitored in PSG?
Electroencephalogram (EEG)
Electrooculogram (EOG)
Chin electromyogram (EMG)
Electrocardiogram (ECG)
Nasal and/or oral airflow
Breathing effort (chest and
abdomen)
Oximetry
Leg electromyogram (EMG)
Body position
Snoring sensors
Continuous audio/video monitoring
& behavior observation
Indications for Polysomnography
Polysomnography is routinely indicated for the diagnosis of
sleep related breathing disorders. (Standard)
Polysomnography is indicated for positive airway pressure
(PAP) titration in patients with sleep related breathing
disorders. (Standard)
A preoperative clinical evaluation for the presence of
obstructive sleep apnea in patients before they undergo
upper airway surgery for snoring or obstructive sleep
apnea. (Standard)
20. A 49 year old male was brought to the clinic due to
excessive daytime sleepiness. Patient is hypertensive, diabetic
with a BMI of 32. He complains of having fragmented sleep at
night and morning headaches. Diagnostic tool of choice is:
A. Epworth Sleepiness Scale Questionnaire
B. Polysomnography
C. Fiberoptic Endoscopy
D. CT/MRI of the upper airways
E. Pulmonary Function Test
Other Laboratory Findings:
Various imaging studies, including
cephalometric radiography, MRI, CT, and
fiberoptic endoscopy, can be used to
identify anatomic risk factors for OSAHS.
Source: HPIM19th edition
Source: MRA Trans
 21. True regarding polysomnography,
except.
A. Indicated for diagnosis of sleep related breathing disorders and
pre-operative clinical evaluation prior to upper airway surgery in
patients with OSA.
B. Apnea is defined as absence of or >90% decrease in airflow
compared to baseline for more than 10 seconds.
C. Hypopnea is defined as reduction in airflow by >50% of pre-
event baseline lasting for more than 10 seconds.
D. Hypopnea is defined as reduction in airflow by >30% (but <50%)
associated with >4% oxygen desaturation
E. None of the above
OBSTRUCTIVE SLEEP
APNEA
22.. Which of the following is the main
trigger of myocardial ischemia in OSA?
A. Decreased myocardial blood flow
B. Increased heart rate
C. Increased oxygen demand
D. Decreased oxygen saturation
Mechanisms of MI in OSA
Obstructive apnea can lead to myocardial ischemia even in the absence
of hypoxia
Main trigger of ischemia was an increase in oxygen demand rather
than oxygen desaturation
Increased sympathetic activity may contribute to myocardial ischemia
and coronary plague disruption
Chronically elevated catecholamine levels may injure the myocardium
Hypoxia triggers a generalized inflammatory response causing systemic
release of inflammatory mediators
23. Which of these pro-inflammatory
cytokines are released during cyclic
hypoxia in OSA?

A.IL2
B.IL4
C.IL6
D.IL8
OSAHS AND IMPAIRED GLUCOSE-
INSULIN METABOLISM
Cyclical hypoxia could lead to glucose intolerance and
insulin resistance by promoting release of pro-
inflammatory cytokines (IL-6 and TNF alpha)
Sleep fragmentation increases levels of plasma
cortisol glucose levels and insulin concentration
and increased insulin secretion
Sympathetic hyperactivity
Central obesity leads to insulin resistance via
lipolysis and fatty acid availability
24. Which is/are (a) probable site(s) of
obstruction causing snoring in patients?
A. Retropalatal region
B. Retroglossal region
C. Hypopharyngeal region
D. All of the above
 RATIO:
Respiratory Events in OSA
Narrowing at one or more sites along upper airway (retropalatal, retroglossal
or hypopharyngeal region) - snoring
Pharyngeal collapse - apneas and hypopneas
Effort of breathing - lead to arousals and fragmented sleep
Termination of apnea/hypopnea w/arousals

Reference: MRA Trans

25. Which of the following
characterizes Obstructive Apnea?
A. Cessation of airflow, usually for more than 10
seconds
B. With abdominal and/or thoracic effort
C. Usually terminated by an arousal and/or
associated with a desaturation
D. All of the above
 Obstructive Sleep Apnea
Cessation of airflow thru nose or mouth with persistence of
diaphragmatic and intercostal muscle activities
Usu for more than 10 sec
With abdl and/or thoracic effort
Usu terminated by arousal and/or desaturation
Present when Respiratory Disturbance Index (RDA) is >15 events
per hr of sleep and pt has both daytime and nighttime sx
Can coexist with 3 other syndromes (OHSA, CSA, UARS =
Syndrome Z) or can occur independently
 26. Which of the following accurately
defines the term Obstructive Sleep
Apnea?
a. This is characterized by sleep fragmentation in a patient with
Chronic Obstructive Lung Dse Insomnia due to a medical condition
b. This is conditioned marked by intermittent episodes of complete
and partial pharyngeal obstruction during sleep
c. This refers to daytime sensorial disturbance in a patient with CNS
pathologies such as those seen in extensive cerebrovascular
accidents Sleepiness due to a medical condition
d. It may be characterized by daytime sleepiness in individuals with
fragmented sleep including those with an apparent lack of sleep
time - Narcolepsy
Reference taken from Harrisons, 19th edition, Sleep Disorders, pp. 188-191
 27. Chronic cardiovascular morbidity
associated with OSA is:
A. Myocardial Infarction - ACUTE
B. Pulmonary hypertension
C. Cardiac arrhythmia - ACUTE
D. Cerberovascular disease - ACUTE
Acute Chronic
Myocardial infarction Arterial hypertension
Cerebrovascular disease (stroke) Pulmonary hypertension
Cardiac arrhythmia Congestive heart failure

Ref: MRA
28. OSA and Hypertension (parang ganitong question
ata to.. not sure) or effect of treatment.. (pls read nalng
about dito)

A. OSA has a direct and disproportionate effect on systolic BP that

is difficult to control with pharmacologic agents (something ganito
ata ang sagot)
B. Both systolic and diastolic BP are increased with OSA only
systolic BP
C. Each additional episode of apnea/hypopnea per hour of sleep
was associated with a five-fold increase in systolic BP two-fold
increase
RATIO:

Only systolic BP increased with OSA, CPAP significantly attenuated

increase in systolic BP nad no effect on Diastolic BP
OSA has a direct and disproportionate effect on systolic BP that is
difficult to control w/ pharma agents

HPN refractory to max medical tx, 8% had OSA

Ref: Pulmo - Obstructive Sleep Apnea trans by MRA, p.6

29. OSA and impaired glucose insulin
metabolism:

Ref: Pulmo - Obstructive Sleep Apnea trans by MRA, p.7

A. Increase sympathetic activity that increases lipolysis and fatty acid metabolism
central obesity leads to insulin resistance via increase lipolyisis and fatty acid
availability
B. Sleep fragmentation increases levels of plasma cortisol leading to increased
glucose levels and insulin concentration and increased insulin secretion
C. Cyclical hypoxia lead to insulin sensitivity - cyclic hypoxia leads to glucose
intolerance and insulin resitance
D. Overt clinical manifestation of underlying disease occurs before early
metabolic dysfunction - early metabolic dysfunction occurs with OSA before
overt clinical manifestation of underlying disease
RATIO:
Sleep fragmentation increased plasma cortisol increased glucose levels
and insulin conc. and increase insulin secretion
30. Risk factors for CVD in OSA
patients EXCEPT
A. Main trigger of ischemia was a decreased on oxygen
supply rather than increase in oxygen demand
B. Increased leptin levels promoting platelet aggregation
C. Increased C reactive protein associated with blunted
endothelium-dependent vasodilation
D. Increased homocysteine levels causing endothelial
dysfunction and increased oxidative stress
E. None of the above
31. The first line and treatment of choice for mild to
moderate Obstructive Sleep Apnea (OSA), operates by
providing a pneumatic splint for the airway, thereby
preventing collapse during sleep:
a. Uvulopalatopharyngoplasty (UPPP)
b. Laser-assisted uvulopalatoplasty (LAUP)
c. Continuous Positive Airway Pressure (CPAP)
d. Linguaplasty
Answer: C. Continuous Positive
Airway Pressure (CPAP)
Continuous Positive Airway Pressure (CPAP)
Treatment of choice
provides a pneumatic splint that opens the airway during
sleep, usually with pressures of 5 20 mm Hg
RCTs show improvement in breathing during sleep, sleep
quality, sleepiness, BP, vigilance, cognition, driving ability,
mood and QOL
32. Risk factors for CVD in OSA in
patients except:
A. Increased leptin levels promoting platelet aggregation
B. Increased C reactive protein associated with blunted
endothelium-dependent vasodilation
C. Increased homocysteine levels causing endothelial
dysfunction and oxidative stress
D. Main trigger of ischemia was a decreased on oxygen supply
rather than an increase of of oxygen demand
E. None of the above
33. Mechanism of OSA except:
A. Chronic hypoxemia produces pulmonary vasoconstriction and
remodeling of the pulmonary vascular bed predisposing to pulmonary
hypertension
B. Due to thrombolytic coagulation abnormalities provided by recurrent
episodes of hypoxemia predisposes to venous thromboembolism
C. Clinical hypoxia could lead to glucose intolerance and insulin
resistance by promoting release of pro-inflammatory cytokines(IL 6 and
TNF-a)
D.70% of nocturnal growth hormone pulses are associated with slow
wave sleep which are decreased due to sleep fragmentation
E. None of the above
SLEEP DISORDERS
OHS, CENTRAL APNEA, HYPOPNEA , MIXED
34. The diagnosis of obesity
hypoventilation syndrome (OHS)
requires the following except:
A. Body mass index (BMI) 30kg/m2
B. Sleep-disordered breathing
C. Chronic daytime alveolar hypoventilation, defined as
PaCO2 45mmHg, and PaO2 <70mmHg in the absence
of other known causes of hypercapnia
D. All of the above
E. None of the above
 Obesity Hypoventilation Syndrome
(OHS)
aka Pickwickian Syndrome
Abnormal Ventilatory Drive + Obesity

DIAGNOSIS:
body mass index (BMI) - 30 kg/m2
sleep-disordered breathing
chronic daytime alveolar hypoventilation
PaCO2 45 mmHg, and PaO2 < 70 mmHg in the absence of other known
causes of hypercapnia
35. Sleep related apnea wherein there is initial
cessation of airflow with no respiratory effort
followed by periods of cessation of airflow through
the nose or mouth with persistence of
diaphragmatic and intercostal muscle activity

A. Central Apnea
B. Obstructive Sleep Apnea
C. Mixed Apnea
 OBSTRUCTIVE CENTRAL APNEA MIXED APNEA
APNEA
cessation of airflow, cessation of airflow, cessation of airflow,
usually for more than 10 usually for more than usually for more than
seconds 10 seconds 10 seconds with
respiratory effort
WITH abdominal and/or WITHOUT abdominal Contains both central &
thoracic effort and/or thoracic effort obstructive
components, with each
component lasting at
least one normal
respiratory cycle
36. Management of OSAHS except
A. General measures such as weight reduction and
avoidance of alcohol and sedatives
B. Mandibular Repositioning Splint is the treatment of
choice for OSAHS
C. Continuous Positive Airway Pressure (CPAP) provides a
pneumatic splint that opens the airways during sleep
D. Surgical options includes bariatric surgery, tonsillectomy
and jaw advancement surgery
OSAHS Management
1. General Avoid alcohol, sedatives
Measures Weight reduction
2. Pharmacologic Protriptyline, Acetazolamide
3. CPAP TREATMENT OF CHOICE
4. Mandibular works by holding the lower jaw and the tongue
Repositioning forward, thereby widening the pharyngeal
Splint (MRS) airway
5. Surgery Bariatric surgery Tracheostomy
Tonsillectomy Jaw Advancement
Surgery
Uvulopalatopharyngoplasty
37. Repeated episodes of apnea in the
absence of respiratory muscle effort
associated with daytime sleepiness
secondary to fragmented sleep from the
apneic episode

CENTRAL SLEEP APNEA

 OBSTRUCTIVE CENTRAL APNEA MIXED APNEA
APNEA
cessation of airflow, cessation of airflow, cessation of airflow,
usually for more than usually for more than usually for more than
10 seconds 10 seconds 10 seconds with
respiratory effort
WITH abdominal WITHOUT abdominal Contains both central
and/or thoracic effort and/or thoracic effort & obstructive
components, with
each component
lasting at least one
normal respiratory
cycle
38. Obesity with chronic hypoventilation
and daytime hypercapnea, arterial
hypoxemia during wakefulness,
hypersomnolence, pulmonary
hypertension with chronic RSHF and
nocturnal hypoventilation
OBESITY HYPOVENTILATION
SYNDROME (OHS)
Obesity Hypoventilation Syndrome (OHS)
aka Pickwickian Syndrome
Abnormal Ventilatory Drive + Obesity

DIAGNOSIS:
body mass index (BMI) - 30 kg/m2
sleep-disordered breathing
chronic daytime alveolar hypoventilation
PaCO2 45 mmHg, and PaO2 < 70 mmHg in the absence of other known
causes of hypercapnia
CASE: A 48 year old female was brought to the clinic
due to fever. Patient has been complaining of cough
productive with white to yellowish phlegm 2 weeks
prior to consult. She has easy fatigability and
shortness of breath on exertion with occasional
right sided chest pain. There was decreased breath
sound on the right with dullness on percussion.
Chest X-ray was done and revealed pleural effusion
on the right. Chest ultrasound showed 650mL fluid
on the right hemithorax.
39. Which of the following events
distinguished obstructive from central
apnea?
A. Cessation of periodic leg movements
B. Event lasts for 10 seconds, terminated by an
arousal
C. Observations occur more than 5 times per hour
of sleep
D. Persistence of diaphragmatic activities
 OBSTRUCTIVE CENTRAL APNEA MIXED APNEA
APNEA
cessation of airflow, cessation of airflow, cessation of airflow,
usually for more than usually for more than usually for more than
10 seconds 10 seconds 10 seconds with
respiratory effort
WITH abdominal WITHOUT abdominal Contains both central
and/or thoracic effort and/or thoracic effort & obstructive
components, with
each component
lasting at least one
normal respiratory
cycle
40. Negative intrathoracic pressures
generated during an obstructive apnea
event impacts which cardiovascular
response?
A. Blood pressure increases
B. Cardiac output decreases
C. Left ventricular after load increases
D. Myocardial oxygen delivery decreases
 PROPOSED PATHOPHYSIOLOGICAL EFFECTS OF
OBSTRUCTIVE APNEA ON THE CARDIOVASCULAR SYSTEM
41. Which hormone increases with
weight gain and promotes platelet
aggregation?
A. Cortisol
B. Growth Hormone
C. Ghrelin
D. Leptin
LEPTIN
Adipose-derived hormone
Protein that regulates energy intake and
expenditure
increased levels associated with weight
gain
42. Which of the following hormones is
released in a pulsatile manner with a circadial
rhythm?
a. Cortisol
b. Ghrelin
c. Growth hormone
d. TSH
43. Which of these hormones
regulate human sleep?
a. Cortisol
b. Growth hormone
c. Leptin
d. Melatonin
Melatonin
The pineal hormone melatonin is secreted predominantly at
night in both day- and night-active species, reflecting the
direct modulation of pineal activity by a circuitous neural
pathway that links the SCN to the sympathetic nervous
system, which innervates the pineal gland.
Melatonin secretion does not require sleep, but melatonin
secretion is inhibited by ambient light, an effect mediated by
the neural connection from the retina to the pineal gland via
the SCN. Sleep efficiency is highest when the sleep episode
coincides with endogenous melatonin secretion.
44. Which of the following brain waves is the
lowest in and more desynchronous than
other waves?
a. Alpha
b. Beta
c. Delta
d. Theta
45. Which of these brain waves
represent deepest sleep?
a. Alpha
b. Beta
c. Delta
d. Theta
 Beta waves Alpha waves Theta waves Delta waves

Associated with day During periods of Slower in Slowest and highest in

to day wakefulness relaxation, still frequency, amplitude
awake greater in
amplitude
Highest in frequency Waves are Deepest sleep
lowest in amplitude slower, increase
in amplitude

More More Most difficult stage to

desynchronous, synchronous wake from
than other waves
When sleep talking and
walking occur
46. Which of the following best
describes a hypopnea event?
a. Flow reduces by 10% for 20 seconds accompanied by a 1% drop in
SaO2
b. Flow reduces by 15% for 15 seconds accompanied by a 2% drop in
SaO2
c. Flow reduces by 20% for 10 seconds accompanied by a 3% drop in
SaO2
d. Flow reduces by 25% for 5 seconds accompanied by a 1% drop in
SaO2
AASM Guidelines
Peak signal excursions drop by 30% of pre-event baseline
using nasal pressure (diagnostic study), PAP device flow
(titration study) or an alternative hypopnea sensor (diagnostic
study)
Duration of 30% drop in signal excursion is 10 seconds
3% oxygen desaturation from pre-event baseline or event is
associated w/ an arousal
47. Which of these is an identified
risk factor for OSAHS?
a. Age >35
b. BMI >25 kg/m2
c. Female sex
d. Neck circumference >17 inches
Risk factors for OSAHS
Obesity Menopausal women
BMI 30 kg/m2 Increasing age 40 yo
Neck circumference
(+) family history
Men >17 in
Women >16 in Alcohol, smoking, increasing
drug use
Male gender
48. Which of these conditions of sleep
disordered breathing presents with
cataplexy?
a. Idiopathic hyper somnolence
b. Narcolepsy
c. Obstructive sleep apnea hypoventilation syndrome
d. Shift work
49. Which anthropometric
measurements put an individual at risk of
OSAHS?
A. Neck circumference > 15 in men
B. BMI 30 kg/m2
C. Neck circumference
D. BMI 25 kg/m2
 50. This is a multi-parametric test that is used to
study /record in detail all the biophysical changes
that occur in the human body hen the person is
asleep?
A. Oxygen saturation in studies in the awake state
B. Polysomnography
C. Oculomyography
D. Electroencephalography
51. Which of the following is/are
indication(s) of a sleep laboratory
evaluation
A. Serious excessive sleepiness with no known
medical cause and not relieved by 2 weeks of
significant increase of time in bed
B. Snoring with interrupted breathing or periodic limb
movement
C. Nocturnal seizures
D. All of the above
RATIO:
When is Sleep Lab Eval in Order?
1. Serious excessive daytime sleepiness w/no known medical
cause & not relieved by 2 weeks of sig increase of time in bed
2. Snoring with interrupted breathing or periodic limb
movements
3. Nocturnal seizures

Reference: MRA Trans

52. Which of the following is/are an
indication(s) of a cardiopulmonary sleep
study?
A. Pulmonary hypertension
B. Polycythemia
C. Daytime somnolence
D. All of the above
RATIO:
Cardiopulmonary Sleep Studies
Indications
Awake PaO2 >55 mmHg but
w/cor pulmonale
Restrictive ventilator impairment
2 to chest wall and neuromuscular
disturbances and complicated by
chronic hypoventilation,
polycythemia, pulmonary
hypertension, disturbed sleep,
daytime somnolence and fatigue
Disturbance of respiratory
control w/awake PAO2 >45mmHg
or w/complications
Snoring and obesity
Excessive daytime sleepiness
Nocturnal cyclic
bradytachyarrhthymia, nocturnal
abn of AV conduction and
ventricular ectopy during sleep
HPN refractory

Reference: MRA Trans

53. Which of the following diagnostic procedure(s) is
are/helpful in locating the site of upper airway
obstruction in patients with sleep disordered
breathing?
A. Cephalometry
B. MRI of the upper airways
C. Fiberoptic endoscopy
D. All of the above
 RATIO:
LABORATORY ASSESSMENT OF OSAHS
Polysomnography
Cardiopulmonary Sleep Studies
Fiberoptic Endoscopy
CT/MRI of Upper Airways
Cephalometry
Other Tests include:
Thyroid Function Test
Pulmonary Function Test
Reference: MRA Trans
54. Which of the following defines
Sleep Related Apnea?
A. Cessation of breathing for 5 seconds occurring x 5 times
per hour of sleep
B. Cessation of breathing for 10 seconds x 5 times per hour
of sleep
C. Cessation of breathing for 5 seconds occurring x 2 times
per hour of sleep
D. Cessation of breathing for 10 seconds occurring once out
of the total sleep time (TST)
 RATIO:

Central Apnea
cessation of airflow with no respiratory effort
Obstructive sleep Apnea
cessation of airflow through the nose or mouth with persistence of
diaphragmatic & intercostal muscle activities
Mixed Apnea
initial cessation of airflow with no respiratory effort followed by periods of
upper airway OSA
55. Which of the following distinguishes
Central Apnea from Obstructive Apnea?
A. Cessation of airflow, usually for more than 10 seconds
B. Without abdominal and/or thoracic effort
C. May be terminated by an arousal and/or associated with a
desaturation
D. All of the above
RATIO:
Central Apnea
Cessation of airflow, usu for more than 10 sec
With no respiratory effort, i.e., w/o abdl and/or thoracic
effort
May be terminated by an arousal and/or associated with a
desaturation
Very different type of syndrome than OSA; chemo-receptor
irregularities

Reference: MRA Trans

56. Which of the following distinguishes
Mixed Apnea from Obstructive Apnea?
A. Cessation of airflow, usually for more than 10
seconds
B. Without abdominal and/or thoracic effort
C. May be terminated by an arousal and/or associated
with a desaturation
D. Linked with chemo-receptor irregularities
RATIO:
Mixed
Cessation of airflow >10 s (in adults) with respiratory effort
Contains both central and obstructive components, with each
component lasting at least one normal respiratory cycle
Typically leads to a desaturation and an arousal
Is really just a type of obstructive event with the same consequences

D. Linked with chemo-receptor irregularities Is associated ONLY with

Central Apnea (Since MIXED contains both central and obstructive
components, therefore, this is their difference.)
57. Which of the following is TRUE as
regard the cycle of sleep?
a. REM stage episodes decrease in duration increase
b. Slow-wave sleep appears and increase after the
second cycle - disappears
c. With old age, stage 3 diminished or disappears
d. REM counts to about 69% of total sleep time 25%
58. Which of the following is a
recognized risk factor for OSAHS?
a. BMI >25kg/m2 - >30 kg/m2
b. Neck circumference >17 inches for males
c. Female gender male
d. Age >30 years old - 40 years old
Risk Factors for OSAHS
Obesity 70% of patients
BMI 30 kg/m2
Neck Circumference
Men > 17 inches
Women > 16 inches
Male gender
Menopausal women
Increasing age - 40 years old
(+) Family History - risk 2-4x
Alcohol
Smoking
Increasing drug use
59. Which of the following are
considered to be a daytime symptom of
OSAHS?
a. Esophageal reflux nocturnal symptom
b. Diaphoresis nocturnal symptom
c. Decreased libido
d. Drooling nocturnal symptom
Symptoms of OSAHS
NOCTURNAL SYMPTOMS DAYTIME SYMPTOMS
Snoring Sleepiness
Witnessed apnea Fatigue
Choking Morning headache
Dyspnea
Poor concentration
Restlessness
Decreased libido or impotence
Diaphoresis
Decreased attention
Esophageal reflux
Drooling Depression
Dry mouth Personality changes
60. This has diminished respiratory drive and
increased lung resistive load
A. Sleep disorder breathing
B. Pulmonary embolus
C. Myasthenia ata iba..
D. Kyphoscoliosis
Type II respiratory failure is a consequence of alveolar
hypoventilation and results from the inability to
eliminate carbon dioxide effectively.
Mechanisms are categorized by impaired central
nervous system (CNS) drive to breathe, impaired
strength with failure of neuromuscular function in the
respiratory system, and increased load(s) on the
respiratory system
Reasons for diminished CNS drive to breathe include
drug overdose, brainstem injury, sleep-disordered
breathing, and severe hypothyroidism
61. True about Obesity
Hypoventilation Syndrome (OHS)
A. Abnormal ventilator drive and obesity
B. BMI > 35 kg/m
C. Chronic night time alveolar hypoventilation
D. Results from abnormalities in the gene encoding
PHOX2b
E. Absent respiratory response to hypoxia or
hypercapnea
* Obesity Hypoventilation Syndrome diagnosis requires:
BMI > 30kg/m
Sleep disordered breathing
Chronic daytime alveolar hypoventilation defined as PaCO2 > 45
mmHg, and PaO2 < 70mmHg in the absence of other known
causes of hypercapnea

*Abnormalities in the gene encoding

PHOX2b, a transcription factor with a role in neuronal
development, have been implicated in the pathogenesis of
congenital central hypoventilation syndrome.
62. True of Alpha wave
A. Associated with day to day wakefulness (beta
waves)
B. Brain waves that is seen during periods of
relaxation and awake status
C. Deepest sleep (delta waves)
D. Desynchronous (beta waves)
63. True of sleep spindles
A. Sudden increase in wave amplitude (k spindles)
B. Sudden increase in wave frequency
C. Seen during Stage 1 of Non-REM
D. Seen during deep sleep
Sleep spindles: sudden increases in wave frequency seen during
Stage II of NonREM (intermediate sleep)
K complexes: sudden increases in wave amplitude seen during
Stage II of NonREM (intermediate sleep)
Deep sleep Stage III
64. Hypopnea is AASM Guidelines:
a. The peak signal excursion drop by <20% (>/=30%)of pre
event baseline using PAP device flow (not sure of the
statement)
B. The duration of the > 50% (>/=30%)drop in signal excursion
is > 10 sec
C. There is a > 3% oxygen desaturation from prevent baseline
of the event associated with arousal

Ref: L trans
AASM Guideline: (all must be present)

a. The peak signal excursions drop by 30% of pre-event

baseline using nasal pressure (diagnostic study), PAP device
flow (titration study) or an alternative hypopnea sensor
(diagnostic study).
b) The duration of the 30 percent drop in signal excursion
is 10 seconds.
c) There is a 3% oxygen desaturation from pre-event
baseline or the event is associated with an arousal
64. Mechanism of obstruction in OSA

A. Airway close on expiration (inspiration) during sleep

B. Patients have already narrow airways during sleep (wakefulness) with
airway dilating muscles having increased activity
C. Upper airway dilating muscle relax with fall in muscle tone.
D. Expansion (narrowing) at one or more sites along the upper airway

Ref: L trans
Mechanism of obstruction
Airways close on inspiration during sleep
Patients with OSA already have narrow upper airways during
wakefulness (because of the weight of the upper airway) with
airway dilating muscles having increased activity
Upper airway dilating muscles relax with fall in muscle tone
Respiratory events in OSA
Narrowing at one or more sites along the upper airway
(retropalatal,retroglossal or hypopharyngeal region) snoring
65. Epsworth Sleeping Scale score that needs
further workup
A. <10
B. >10 Ratio:
Not all pxs who complain of snoring should be
C. >10.5 evaluated with sleep studies. The Epworth
D. >11 Sleepiness Scale is used to screen sleep disorders or
OSA. At the end of that, you tally your pxs score, and
if it goes more than 11, further workup is necessary
and would require a sleep study. So it is important to
give these pxs rest of around 2 weeks of vacation. If
he does not improve, then it might be OSA

Ref: L
 66. When is sleep laboratory
evaluation in order?
A. Change of shift
B. Difficulty of sleeping
C. Nocturnal seizure
D. Snoring
When is Sleep Laboratory Evaluation in order?
Serious excessive daytime sleepiness with no known medical cause and
not relieved by 2 weeks of significant increase of time in bed
Snoring with interrupted breathing or periodic limb movements
Nocturnal seizures. Hauri et al. Sleep Disorders, 1992
Ref: L trans
67. Leptin is associated with
A. Induces cell adhesion molecules C-reactive protein
B. Weight loss in sleep is associated with increased leptin levels
weight gain
C. Promoter of platelet aggregation
D. Promotes vascular smooth muscle growth homocysteine

Ref: MRA
Inc. Leptin Promote platelet aggregation
Inc. C-reactive Blunted endothelium-depenent vasodilation
protein Increase in cell adhesion molecules correlates with
severity of sleep apnea
Inc. Endothelial dysfunction
homocystein Increased oxidative stress
level Promotes vascular smooth muscle growth
Insulin Sleep apnea higher fasting glucose
resistance IGT -> severity in oxygen desaturation during SA
syndrome
68. Among these statements, which
best describe mixed apnea
a. Cessation of airflow >20 secs with respiratory efforts
b. Contains both central and obstructive component with
each component a one normal respiratory cycle
c. Apneic episodes terminates with tachyarrthmias
d. A and b
Mixed apnea
Cessation of airflow >10 s (in adults) with respiratory effort
Contains both central and obstructive components, with
each component lasting at least one normal respiratory cycle
Typically leads to a desaturation and an arousal
Is really just a type of obstructive event with the same
consequences
69. Sleep related apnea wherein there is
cessation of airflow through the nose or
mouth with persistence of diaphragmatic
and intercostal muscle activity
A. Central apnea
B. Obstructive sleep apnea
C. Mixed apnea
Central Apnea Obstructive Sleep Apnea Mixed
Cessation of airflow, usu Cessation of airflow thru nose or Cessation of airflow
>10 sec mouth with persistence of >10sec (in adults) with
With NO respiratory diaphragmatic and intercostal respiratory effort
effort, (i.e. w/o abdl muscle activities Contains both central
and/or thoracic effort Usu for more than 10 sec and obstructive
May be terminated by With abdl and/or thoracic effort components, with
an arousal and/or Usu terminated by arousal and/or each component
associated with a desaturation lasting at least one
desaturation Present when Respiratory normal respiratory
Very different type of Disturbance Index (RDA) is >15 cycle
syndrome than OSA; events per hr of sleep and pt has Typically leads to a
chemoreceptor both daytime and nighttime sx desaturation and an
irregularities Can coexist with 3 other syndromes arousal
(OHSA, CSA, UARS = Syndrome Z) Is really just a type of
or can occur independently obstructive event with
the same
consequences
70. Management of OSAHS EXCEPT:
A. General measures such as weight reduction and avoidance of
alcohol and sedatives
B. Continuous Positive Airway Pressure (CPAP) provides a
pneumatic splint that opens the airways during sleep
C. Mandibular Repositioning Splint is the treatment of choice for
OSAHS
(CPAP is the standard medical therapy)
D. Surgical options includes bariatric surgery, tonsillectomy and jaw
advancement surgery
E. None of the above
REFERENCE: Doc Esguerra ppt
MANAGEMENT
Medical treatment: 1st line treatment for OSA
A. General measures
Avoidance of alcohol, sedatives, hypnotics
Weight loss
Other (less effective) measures
Pharmacologic agents
Oxygen therapy
Nasal dilators
B. Specific measures
Position therapy
Positive airway pressure
CPAP
Current treatment of choice for OSA
Non-invasive advantage
In OSA px, it:
Reduces number of apneic & hypoxic episodes during sleep
Reduces daytime sleepiness
Improves neuropsychiatic fxn
Provides pneumatic splint for the airway prevents collapse
during sleep when upper airway dilator muscle activity is low
BiPAP
Oral appliances (intraoral devices)
Effective noninvasive alternative to CPAP in patients with mild to
moderate OSA
Most common & best studied appliances are the Mandibular
advancing devices, particularly useful in retrognathia and
micrognathia
For effective results, these devices must be advanced to 50-75%
of maximal forward protrusion of the jaw
Dental appliance: lessens but doesnt abolish OSA and snoring
Currently for mild to moderate OSA with RDI of 15-40
events/hr
C. SURGERY
Nasal surgery (septoplasty, sinus surgery, )
Tonsillectomy adenoidectomy
Uvulopalatopharyngoplasty (UPPP)
Laser-assisted uvulopalayoplasty (LAUP)
Linguaplasty
Genioglossus advancement with myoid myotomy
Sliding genioplasty
Maxillomandibular advancement osteotomy
Tracheostomy
REFERENCE: Harrisons 19th
A comprehensive approach to the management of OSAHS is needed to
reduce risk factors and comorbidities. The clinician should seek to identify
and address lifestyle and behavioral factors as well as comorbidities that
may be exacerbating OSAHS.
As appropriate, treatment should aim to
reduce weight;
optimize sleep duration (79 hours);
regulate sleep schedules (with similar bedtimes and wake times across the week);
encourage the patient to avoid sleeping in the supine position;
treat nasal allergies;
increase physical activity;
eliminate alcohol ingestion within 3 h of bedtime; and
minimize use of sedating medications.
Patients should be counseled to avoid drowsy driving.
CPAP is the standard medical therapy with the highest level of
evidence for efficacy. Delivered through a nasal or nasal-oral mask,
CPAP works as a mechanical splint to hold the airway open, thus
maintaining airway patency during sleep. An overnight CPAP titration
study, performed either in a laboratory or with a home autotitrating
device, is required to determine the optimal pressure setting that
reduces the number of apneas/hypopneas during sleep, improves gas
exchange, and reduces arousals. Rates of adherence to CPAP
treatment are highly variable (average, 5080%) and may be improved
with support by a skilled health care team who can address side
effects (Table 319-3).
Despite the limitations of CPAP, controlled studies have demonstrated
its beneficial effect on blood pressure, alertness, mood, and insulin
sensitivity. Uncontrolled studies also indicate a favorable effect on
cardiovascular outcomes, cardiac ejection fraction, atrial fibrillation
recurrence, and mortality risk.
Oral appliances for OSAHS work by advancing the mandible, thus
opening the airway by repositioning the lower jaw and pulling the
tongue forward. These devices generally work better when
customized for patient use; maximal adaptation can take several
weeks.
Efficacy studies show that these devices can reduce the AHI by 50%
in two-thirds of individuals, although these data are based largely on
patients with mild OSAHS. Side effects of oral appliances include
temporomandibular joint pain and tooth movement.
Oral appliances are most often used for treating patients with mild
OSAHS or patients who do not tolerate CPAP.
However, since adherence to the use of oral appliances sometimes
exceeds CPAP adherence, these devices are under investigation for
treatment of more severe disease.
 Upper airway surgery for OSAHS is less effective than CPAP and is mostly
reserved for the treatment of patients who snore, have mild OSAHS, and
cannot tolerate CPAP.
Uvulopalatopharyngoplasty (removal of the uvula and the margin of the soft
palate) is the most common surgery and, although results vary greatly, has a
success rate similar to or slightly lower than treatment with oral appliances.
Upper airway surgery is less effective in severe OSAHS and in obese patients.
Success rates may be higher for multilevel surgery (involving more than one
site/structure) performed by an experienced surgeon, but the selection of
patients is an important factor and relies on careful targeting of culprit areas
for surgical resection.
Bariatric surgery is an option for obese patients with OSAHS and can improve
not only OSAHS but also other obesity-associated health conditions. Other
procedures that can decrease snoring but have minimal effects on OSAHS
include injection of the soft palate (resulting in stiffening), radiofrequency
ablation, laser-assisted uvulopalatoplasty, and palatal implants.
Supplemental oxygen can improve oxygen saturation, but there is little
71. Characterized by repeated episodes
of apnea during sleep that occur in the
absence of respiratory muscle effort
associated with daytime sleepiness
secondary to sleep fragmentation from
the apneic events:
a. Obstructive sleep apnea (OSA)
b. Central sleep apnea (CSA)
c. Mixed Type Apnea
d. Obesity hypoventilation syndrome (OHS)
Answer: B. Central Sleep Apnea
Central Sleep Apnea
Cessation of airflow, usually for more than 10 seconds
Without abdominal and/or thoracic effort
May be terminated by an arousal and/or associated with a
desaturation
Very different type syndrome than OSA; chemo-receptor
irregularities
Obstructive sleep Apnea
cessation of airflow through the nose or mouth with
persistence of diaphragmatic & intercostal muscle activities
Mixed Apnea
Cessation of airflow >10 s (in adults) with respiratory effort
Contains both central and obstructive components, with
each component lasting at least one normal respiratory
cycle
Typically leads to a desaturation and an arousal
Is really just a type of obstructive event with the same
consequences
Obesity Hypoventilation Syndrome (OHS)

Pickwickian Syndrome
Abnormal ventilatory drive + obesity
90% of patients with OHS has OSA
Other causes of hypoventilation should be ruled out
72. Which anthropometric
measurements put an individual at risk of
OSAHS?
a. Neck circumference >15 in men
b. BMI 30 kg/m2
c. Neck circumference >14 in women
d. BMI 25 kg/m2
Answer: B. BMI 30 kg/m2
Risk Factors for OSAHS Increasing age - 40
Obesity 70% of patients years old
BMI 30 kg/m2 (+) Family History - risk
Neck Circumference 2-4x
Men > 17 inches Alcohol
Women > 16 inches Smoking
Male gender Increasing drug use
Menopausal women
 73. Which is/are a probable site(s) of
obstruction causing snoring in patients
with OSA/OSAHS?
a. Retropalatal region
b. Retroglossal region
c. Hypopharyngeal region
d. All of the above
Respiratory events in OSA
Narrowing at one or more sites along the upper airway
(retropalatal,retroglossal or hypopharyngeal region) snoring
74. Consists of obesity with chronic hypoventilation
and daytime hypercapnia as well as arterial hypoxemia
during wakefulness, hypersomnolence, pulmonary
hypertension with chronic right heart failure and
nocturnal hypoventilation:
a. Obstructive sleep apnea (OSA)
b. Central sleep apnea (CSA)
c. Upper airway resistance syndrome (UARS)
d. Obesity hypoventilation syndrome (OHS)
 Answer: D. Obesity hypoventilation
syndrome (OHS)

Obesity Hypoventilation Syndrome (OHS)

Pickwickian Syndrome
Abnormal ventilatory drive + obesity
90% of patients with OHS has OSA
Other causes of hypoventilation should be ruled out
Diagnosis requires
body mass index (BMI) - 30 kg/m2
sleep-disordered breathing
chronic daytime alveolar hypoventilation
PaCO2 45 mmHg, and PaO2 < 70 mmHg in the absence of other known
causes of hypercapnia
Obstructive Sleep Apnea (OSA)
Characterized by intermittent episodes of complete or
partial pharyngeal obstruction during sleep

Central Apnea
Cessation of airflow, usually for more than 10 seconds
Without abdominal and/or thoracic effort
May be terminated by an arousal and/or associated with a
desaturation
Very different type syndrome than OSA; chemo-receptor
irregularities
MATCHING TYPE(75-77)
A. Obstructive Sleep Apnea Hypopnea syndrome
B. Narcolepsy
C. Idiopathic Hyper somnolence
D. Central Hypoventilation Syndrome
75. A 25 year old female complains of long night sleep and
occasional snoring. she stated having morning drunkenness with
prolonged naps usually in the morning.
C. IDIOPATHIC HYPPERSOMNOLENCE
76. A 56 year old male, hypertensive, diabetic, BMI: 30kg/m2,
came in the clinic with his wife, due to loud snoring during sleep.
He has few less than an hour daytime naps usually in the
afternoon.
A. OBSTRUCTIVE SLEEP APNEA HYPOPNEA SYNDROME
77. A 22 year old male was brought to the clinic due to brief
attack of deep sleep occurring with loss of muscle tone. He has
normal night sleep with frequent daytime naps.
B. Narcolepsy
78.Sleep related apnea where in there is initial
cessation of airflow with no respiratory effort followed
by periods of cessation of airflow thorugh the nose or
mouthwith persistence of diaphgramatic & intercostal
muscle activity

A. Central Apnea
B. Obstructive Sleep Apnea
C. Mixed Apnea
79. Management of OSAHS, except:
A. General measures such as weight reduction and avoidance
of alcohol and sedatives
B. Continuous Positive Airway Pressure (CPAP) provides a
pneumatic splint that opens the airways during sleep
C. Mandibular repositioning splint is the treatment of choice
D. Surgical options include bariatric surgery, tonsillectomy and
jaw advancement surgery
E. None of the above
HYPOVENTILATION/
HYPERVENTILATION
 1. DISEASE OF HYPOVENTILATION
except:
A. Diseases that reduce minute ventilation or increase dead space fall
into four major categories: parenchymal lung and chesll wall disease,
sleep disordered breathing, neuromusclular disease, and respiratory
drive disorders.
B. Hallmark of all alveolar hypoventilation syndromes is a decrease
in alveolar PO2 (PA02) and, therefore in PaO2
C. The resulting respiratory acidosis eventually leads to a
compensatory increase in plasma bicarbonate concentration.
D. The combination of chronic hypoxemia and hypercapnia may also
induce pulmonary vasoconstriction, leading eventually to pulmonary
hypertension, right ventricular hypertrophy, and right heart failure.
Answer: B
It should be:
The hallmark of all alveolar hypoventilation
syndromes is an increase in alveolar Pco2
(PAco2) and therefore in Paco2.
2.Laboratory assessment used to monitor
for respiratory muscle involvement in
diseases with progressive muscle
weakness
A.Polysomnography
B.Fiberoptic Endoscopy
C.CT/MRI of the upper airways
D.PFT Maximal Inspiratory and expiratory pressure
or FVC
E.Cephalometry
Di ko mahanap sa mga trans yung sagot
pero ito na yung sabi ni Harrisons
Elevated plasma bicarbonate in the absence of volume depletion is
suggestive of hypoventilation.
An arterial blood gas demonstrating elevated Paco2 with a normal pH
confirms chronic alveolar hypoventilation.
The subsequent evaluation to identify an etiology should initially focus
on whether the patient has lung disease or chest wall abnormalities.
Physical examination, imaging studies (chest x-ray and/or computed
tomography [CT] scan), and pulmonary function tests are sufficient
to identify most lung/chest wall disorders leading to hypercapnia.
 3. TRUE ABOUT THE CONTROL OF
RESPIRATION
A. Spontaneous cycle of inspiration and expiration is automatically
generated in the brainstem
B. Dorsal respiratory group (DRG) generates the respiratory rhythm
C. Ventral Respiratory Column (VRC) acts as the initial integration site
for the afferent nerves relaying information about the partial pressure of
arterial oxygen (Pa02). PaCO2 pH and blood pressure from the carotid
and aortic chemoreceptors and baroreceptors to the central nervous
system (CNS)
D. Parafacial respiratory group (pFRG) is responsible for the
generation of various forms of inspiratory activity, and lesion leads to
the complete cessation of breathing.
E. All of the above.
 A. Spontaneous cycle of inspiration and expiration is automatically
generated in the brainstem
B. Dorsal respiratory group (DRG) (s/b VRC) generates the
respiratory rhythm
C. Ventral Respiratory Column (VRC) (s/b DRG and pFRG) acts as the
initial integration site for the afferent nerves relaying information
about the partial pressure of arterial oxygen (Pa02). PaCO2 pH and
blood pressure from the carotid and aortic chemoreceptors and
baroreceptors to the central nervous system (CNS)
D. Parafacial respiratory group (pFRG) (s/b pre Botzinger complex)
is responsible for the generation of various forms of inspiratory
activity, and lesion leads to the complete cessation of breathing.
4. Disease of Hypoventilation EXCEPT
A. Diseases that reduce minute ventilation or increase dead space fall
into four major categories: parenchymal lung and chest wall disease,
sleep disordered breathing, neuromuscular disease and respiratory
drive disorders.
B. Hall mark of all alveolar hypoventilation syndromes is a decrease in
alveolar PO2(PAO2) and, therefore in PaO2
C. The resulting respiratory acidosis eventually leads to a compensatory
increase in plasma bicarbonate concentration.
D. If severe, the hypoxemia manifests clinically as cyanosis and can
stimulate erythropoiesis, thereby inducing secondary erythrocytosis
E. The combination of chronic hypoxemia and hypercapnia may also
induce pulmonary vasoconstriction leading to pulmonary
hypertension, right ventricular hypertrophy and right heart failure.
HYPOVENTILATION
CLINICAL FEATURES:
Diseases that reduce minute ventilation or increase dead space fall
into four major categories: parenchymal lung and chest wall disease,
sleep- disordered breathing, neuromuscular disease, and respiratory
drive disorders
Regardless of cause, the hallmark of all alveolar hypoventilation
syndromes is an increase in alveolar PCO2 (PACO2) and therefore in
PaCO2.
The resulting respiratory acidosis eventually leads to a
compensatory increase in plasma bicar- bonate concentration.
The increase in PACO2 results in an obligatory decrease in PAO2,
often resulting in hypoxemia.
CLINICAL FEATURES:
If severe, the hypoxemia manifests clinically as cyanosis and can stimulate
erythropoiesis and thus induce secondary erythrocytosis.
The combination of chronic hypoxemia and hypercapnia may also induce
pulmonary vasoconstriction, leading eventually to pulmonary hypertension,
right ventricular hypertrophy, and right heart failure.
SIGNS AND SYMPTOMS:
Dyspnea during activities of daily living
Orthopnea in diseases affecting diaphragm function
Poor quality sleep
Daytime hypersomnolence
Early morning headaches
Anxiety
Impaired cough in neuromuscular disease

SRC: HPIM 19TH ED P1720-1721

5. Laboratory assessment used to monitor for
respiratory muscle involvement in diseases with
progressive muscle weakness
A. Polysomnography
B. Fiberoptic Endoscopy
C. PFT- Maximal inspiratory and expiratory pressure or
FVC
D. CT/MRI of the upper airways
E. Cephalometry
DIAGNOSIS OF HYPOVENTILATION
Elevated plasma bicarbonate in the absence of volume depletion is
suggestive of hypoventilation.
CHRONIC HYPOVENTILATION= An arterial blood gas demonstrating elevated
PaCO2
POLYSOMONOGRAPHY= often reveals central apneas, hypopneas, or hypoventilation.
Hypoventilation is more marked during sleep in patients with respiratory drive defects,
CT SCAN AND MRI= can sometimes identify structural abnormalities in the pons or
medulla that result in hypoventilation.
MAXIMUM INSPIRATORY AND EXPIRATORY PRESSURES OR FORCED VITAL CAPACITY (FVC)
=can be used to monitor for respiratory muscle involvement in diseases with progressive
muscle weakness. Respiratory muscle weakness has to be profound before lung vol-
umes are compromised and hypercapnia develops. Typically physical examination reveals
decreased strength in major muscle groups prior to the development of hypercapnia.

SRC: HPIM 19TH ED P. 1722

6. A 28 year old female was brought to the emergency room due to
breathlessness. No other associated symptoms such as cough,
fever, or easy fatiguability. BP: 110/60mmhg, CR: 110bpm, RR:
30cpm, Temp: 36.8C, ABG: pH-7.47, pCO2-26, pO2-102, HCO3-22,
O2 sat-99%. Which of the following is NOT TRUE regarding
hyperventilation?
A. Hyperventilation is defined as ventilation in excess of metabolic requirements (CO2
production) leading to reduction in PaCO2
B. If normal respiratory muscle strength is coupled with excessive respiratory drive,
alveolar hyperventilation ensues and leads to hypercapnia.
C. Anxiety can be both an initiating and sustaining factor in the pathogenesis of chronic
hyperventilation
D. Identifying and eliminating habits that perpetuate hypocapnia, such as frequent
yawning or sigh breathing can be helpful in the treatment of hyperventilation.
E. NOTA
 HYPERVENTILATION
CLINICAL FEATURES
Hyperventilation is defined as ventilation in excess of metabolic
requirements (CO2 production) leading to a reduction in PaCO2.
Symptoms can include dyspnea, paresthesias, tetany, headache, dizziness,
visual disturbances, and atypical chest pain.
It is important to note that anxiety disorders and panic attacks are not
synonymous with hyperventilation.
Anxiety disorders can be both an initiating and sustaining factor in the
pathogenesis of chronic hyperventilation, but these are not necessary for
the development of chronic hypocapnia.
Alternatively, if normal respiratory muscle strength is coupled with excessive
respiratory drive, then alveolar hyperventilation ensues and leads to
hypocapnia
HYPERVENTILATION
DIAGNOSIS
Respiratory symptoms associated with acute
hyperventilation can be the initial manifestation of
systemic illnesses such as diabetic ketoacidosis.
Arterial blood gas sampling that demonstrates a
compensated respiratory alkalosis with a near normal pH,
low PaCO2, and low calculated bicarbonate is necessary to
confirm chronic hyperventilation.
 HYPERVENTILATION
TREATMENT:
Clinicians often spend considerable time identifying initiating
factors, excluding alternative diagnoses, and discussing the
patients concerns and fears.
In some patients, reassurance and frank discussion about
hyperventilation can be liberating.
Identifying and eliminating habits that perpetuate hypocapnia,
such as frequent yawning or sigh breathing, can be helpful.
Some evidence suggests that breathing exercises and
diaphragmatic retraining may be beneficial for some patients.
Beta blockers may be helpful in patients with sympathetically
mediated symptoms such as palpitations and tremors.

SRC: HPIM 19TH ED. P. 1722-1723

7. Which is the predominant mechanism of
hypothermia in patients severe
kyphoscoliosis?
a. Hypoventilation
b. Impaired diffusion
c. Shunt
d. Ventilation-perfusion mismatch
8. Which of the following results to a reduced
respiratory muscle strength due to a
diminished respiratory drive?
a. Amyotrophic lateral sclerosis
b. Interstitial lung disease
c. Primary alveolar hypoventilation
d. Phrenic nerve injury
9. Which of the following best exemplifies an increased
load imposed on the respiratory due to an increased
lung elastic load?

a. Hypothyroidism
b. Kyphoscoliosis
c. Obesity
d. Pulmonary embolism
10. Which aspect of the respiratory
system does malnutrition affect?
a. Chest wall elastic load
b. Muscle strength
c. Neuromuscular transmission
d. Respiratory drive
11. A 50 y/o male was brought to your care due to
difficulty in breathing. His chest radiograph showed that
his entire left lung has collapsed. Which of the following
can be ___ of his lung condition?
a. Chest wall elastic load is increased
b. Lung elastic load is increased
c. Neuromuscular transmission is impaired
d. Respiratory drive diminished

The patient has atelectasis

Reduced muscle strength d/t
diminished respiratory drive
Sleep disordered breathing
Narcotic/sedative use
Brainstem stroke
Hypothyroidism
Primary alveolar hypoventilation
Reduced muscle strength d/t impaired
neuromuscular transmission
Amyotrophic lateral sclerosis
Myasthenia gravis
Phrenic nerve injury
Spinal cord lesion
Reduced muscle strength d/t muscle
weakness
Myopathy
Malnutrition
Fatigue
Increase load due to chest wall
disease
Kyphoscoliosis
Obesity
Abdominal distention (ascites)
Increase load due to sleep
disordered breathing
Upper airway obstruction
Intermittent hypoxemia
Increase load due to lung disease
Interstitial lung disease
Airflow obstruction
Atelectasis
Pulmonary embolism
LUNG CARCINOMA
PATHOLOGY OF LUNG
CANCER
1. The histologic type of lung cancer with the
worst prognosis (5-year survival) but sensitive
to platinum-based chemotherapy

A. Small cell CA
B. Squamous cell CA
C. Adenocarcinoma
D. Large cell CA
TREATMENT OF SMALL CELL LUNG CANCER (Harrisons Principles of Internal Medicine,
19th Edition, page 522)
CHEMOTHERAPY
Chemotherapy significantly prolongs survival in patients with SCLC. Four to six cycles
of platinum-based chemotherapy with either cisplatin or carboplatin plus either
etoposide or irinotecan has been the mainstay of treatment for nearly three decades
and is recommended over other chemotherapy regimens irrespective of initial stage.
Cyclophosphamide, doxorubicin (Adriamycin), and vincristine (CAV) may be an
alternative for patients who are unable to tolerate a platinum-based regimen. Despite
response rates to first-line therapy as high as 80%, the median survival ranges from 12
to 20 months for patients with LD and from 7 to 11 months for patients with ED.
Regardless of disease extent, the majority of patients relapse and develop
chemotherapy-resistant disease. Only 612% of patients with LD-SCLC and 2% of
patients with ED-SCLC live beyond 5 years. The prognosis is especially poor for
patients who relapse within the first 3 months of therapy; these patients are said to
have chemotherapy-resistant disease. Patients are said to have sensitive disease if they
relapse more than 3 months after their initial therapy and are thought to have a
somewhat better overall survival.
2. Which is not a characteristic of
Small Cell Carcinoma?
A. Poorly differentiated neuroendocrine tumor
B. It is strongly associated with smoking
C. Presents frequently as central masses with endobronchial growth
D. Cells with scant cytoplasm, small hyperchromatic nuclei with fine (sat
and pepper) chromatin pattern and prominent nuclei
E. Extensive disease is managed by chemotherapy with radiotherapy
Answer: E
Small Cell Carcinoma
poorly differentiated neuroendocrine tumor
presents as central masses w/ endobronchial growth
strongly associated with smoking
Cells with scant cytoplasm, small hyperchromatic nuclei with fine (salt
and pepper) chromatin pattern and prominent nuclei
Tumors arranged in diffuse sheets of cells or may show
neuuroendocrine patterns such as rosettes, trabeculae, or peripheral
palisading of cells at the periphery of nests
Often with widespread cellular necrosis
Managed by chemotherapy with or without radiotheraphy
 Small Cell Carcinoma Staging
Limited disease (LD)
=Limited to one hemithorax
-supraclavicular and mediastinal
lymphadenopathy
Extensive disease (ED)
=Any disease outside of the
hemithorax

Chemotherapy + radiotherapy Chemotherapy

3.True about small cell carcinoma:
A. This may produce specific peptide hormones such as ACTH, AVP, ANF, GRP.

Ref: Pulmo Lung Ca trans by MRA, p. 2

B. Associated with history of smoking Squamous cell carcinoma
C. Have mucinous form, which may be multicentric, and nonmucinous form,
which tends to be solitary adenocarcinoma
D. Occurs peripherally large cell carcinoma and adenocarcinoma

RATIO:
May produce specific peptide hormones
o ACTH, AVP, ANP, GRP
4. Scanty cytoplasm, small
hyperchromatic nuclei and indistinct
nucleoli.

A. Squamous cell CA
B. Small cell CA
C. Adenocarcinoma
D. Large cell CA
SMALL CELL LUNG CARCINOMA
Scanty cytoplasm
Small hyperchromatic nuclei
Fine (salt and pepper) chromatin pattern
Prominent nuclei
Arrangement
o Diffuse sheets of cells or
o Rosettes, trabeculae, peripheral palisading at periphery
of nests (neuroendocrine patterns)
Often with widespread cellular necrosis

Reference: MRA Trans

5. Which of the following histological types is
strongly associated with release of Gastrin-
releasing Peptide? (GRP)?

A. Small Cell Carcinoma

B. Adenocarcinoma
C. Squamous Cell Carcinoma
D. Large Cell Carcinoma
SMALL CELL CARCINOMA
May produce specific peptide hormones
ACTH (Adrenocorticotropic Hormone)
AVP (Argenine Vasopressin)
ANP (Atrial Natriuretic Peptide)
GRP (Gastrin-Releasing Peptide)
Produce distinct Paraneoplastic syndromes

Source: MRA Lung Ca page 2

6. This lung cancer has the highest 5-
year survival rate.

A. Small cell CA
B. Squamous cell CA
C. Large cell CA
D. Bronchoalveolar sub-type
Harrisons Principles of Internal Medicine, 19th Edition, page 508
Another significant modification to the WHO classification system is
the discontinuation of the terms bronchioloalveolar carcinoma and
mixed-subtype adenocarcinoma. The term bronchioloalveolar
carcinoma was dropped due to its inconsistent use and because it
caused confusion in routine clinical care and research. As formerly
used, the termn encompassed at least five different entities with
diverse clinical and molecular properties. The terms adenocarcinoma in
situ and minimally invasive adenocarcinoma are now recommended for
small solitary adenocarcinomas (3 cm) with either pure lepidic growth
(term used to describe single-layered growth of atypical cuboidal cells
coating the alveolar walls) or predominant lepidic growth with 5 mm
invasion. Individuals with these entities experience 100% or near
100% 5-year disease-free survival with complete tumor resection.
7. Ground glass opacities on radiologic
imaging of he lungs
A. Adenocarcinoma
B. Small Cell Carcinoma
C. Bronchoalveolar CA
D. Squamous Cell Carcinoma
8.Which of the following may present as
ground-glass opacities on radiologic
imaging of the lungs?
A. Adenocarcinoma
B. Small Cell Carcinoma
C. Bronchoalveolar Carcinoma
D. Squamous Cell Carcinoma
C. Bronchoalveolar Carcinoma
Bronchioloalveolar ca (BAC) rare subtype(Adenocarcinoma)
that grows along alveoli w/o invasion, single mass on radio,
diffuse multinodular lesion, fluffy infiltrate; CT: ground glass
opacity
Mucinous form multicentric
Nonmucinous solitary

(sya lang ang may radiologic imaging. Subtype ng adenocarcinoma.

Kaya siguro pag wala ang BAC sa choices baka pwede ang
adenocarcinoma.)
Source MRA Lung Ca page 2
9. Strongly associated with release of
gastrin releasing peptides (also ACTH, AVP,
ANP, GRP)

A. Small Cell CA
B. Adenocarcinoma
C. Squamous cell CA
D. Large cell CA
 SMALL CELL CARCINOMA
poorly differentiated neuroendocrine tumor
strongly associated with SMOKING
cells with scant cytoplasm, small hyperchromatic nuclei with fine
(salt and pepper) chromatin pattern and prominent nuclei
produce distinct PARANEOPLASTIC SYNDROMES
May produce specific peptide hormones more than NSCCa:
Adrenocorticotrophic hormone (ACTH)
Arginine vasopressin (AVP)
Atrial Natriuretic Peptide (ANP)
Gastrin-releasing Peptide (GRP)
10. A tissue was submitted to the laboratory after
biopsy of the lung mass was done. Histological
staining was done showing a positive result for
keratin. What is the most possible diagnosis?
A. Adenocarcinoma
B. Small Cell Carcinoma
C. Large Cell Carcinoma
D. Squamous Cell Carcinoma
11. Positive result for KERATIN on
histochemistry staining
A. Adenocarcinoma
B. Small Cell Carcinoma
C. Large Cell Carcinoma
D. Squamous Cell CA
Squamous Cell Carcinoma
Most common pattern infiltrating nest of tumor cells that lack
intercellular bridges
Keratin can usually be seen

Adenocarcinoma
May contain glands, papillary structure, bronchioloalveolar patter,
cellular mucin or solid pattern if poorly differentiated

Large Cell Carcinoma

WITHOUT evidence of squamous, glandular differentiation or features
of SCC by light microscopy
Arranged in syncytial groups and single cells
12. True of squamous cell carcinoma
A. This has scant cytoplasm, small hyperchromatin nuclei with a fine chromatin
pattern and prominent nuclei. small cell carcinoma, the salt and pepper like
chromatin

Ref: Pulmo Lung Ca trans by MRA, p. 1

B. Ground-glass opacity (GGO) adenocarcinoma
C. Include Basaloid carcinoma, which may present as an endobronchial lesion and
may resemble high-grade neuroendocrine tumor and lymphoepithelioma like
carcinoma large cell carcinoma
D. Most common pattern is that of an infiltrating nest of tumor cells that lack
intercellular bridges Keratin can usually be seen when present.
RATIO:
Most common pattern infiltrating nest of tumor cells that lack intercellular
bridges. Keratin can usually be seen
 13. A 50 year old male was referred to you due
to a finding of a right middle lobe pulmonary
mass with central cavitation on chest CT scan.
Which of the following is the most possible
diagnosis

A. Adenocarcinoma
B. Squamous Cell Carcinoma
C. Small Cell Carcinoma
D. Bronchoalveolar Carcinoma
14. Cavitating mass is common in
this type of lung CA
A. Small cell CA
B. Bronchoalveolar cell CA
C. Anaplastic CA
D. Squamous cell CA
Histology ito. Hindi ko Makita sa mga
trans yung mismong ratio. Pero kung
mapapansin nyo na central at cavitary
ang Squamous Cell Ca. yung isang may
cavitary e Large Cell pero peripheral
sya. Yan lang naisip ko na medyo tugma
sa sagot.

Source: Lung Ca Esguerra 2011

(walang name ng gumawa)
15. A variant of this histologic type is
associated with Epstein Bar Virus.

A. Squamous Cell Carcinoma

B. Large Cell Carcinoma
C. Small Cell Carcinoma
D. Adenocarcinoma
15. Associated with EBV
(Lymphoepithelioma like CA)

A. Small Cell Carcinoma

B. Large cell Carcinoma
C. Squamous Cell Carcinoma
D. Adenocarcinoma
LARGE CELL CARCINOMA
Tend to occur peripherally
Defined as poorly differentiated
carcinomas composed of large malignant cells
without evidence of squamous, glandular
differentiation, or features of small cell
carcinoma
Variants:
Basaloid carcinoma (resembles NE tumor)
Lymphoepithelioma-like carcinoma (EBV)
 LARGE CELL CARCINOMA Variants
Basaloid - ~endobronchial, resembling high-grade
neuroendocrine tumor
Lymphoepithelioma-like carcinoma similar to other sites, EBV
related

(Ang sagot dito LCC. Pag may choice na Lymphoepithelioma-like

carcinoma, yun siguro ang isasagot. Hehe)
16. Post obstructive pneumonia is a
usual manifestation of
A. Central or endobronchial growth of primary
tumor
B. Peripheral growth of primary tumor
C. Pancoasts syndrome
D. Small cell CA
 A. Central or endobronchial growth of primary tumor
Central or endobronchial growth Peripheral growth of primary
of primary tumor may cause: tumor may cause:
1. Cough 1. Pain from pleural or chest
wall involvement (malignant
2. Hemoptysis
pleural effusion)
3. Wheeze and stridor
2. Cough
4. Dyspnea
3. Dyspnea
5. Post-obstructive pneumonitis
4. Sx of lung abscess resulting
(fever and productive cough)
from tumor cavitation
17. Peripheral growth of the primary tumor:

a. Stridor CENTRAL
b. Pleural or chest wall involvement
c. Post obstructive pneumonitis -
CENTRAL
d. Hemoptyisis - CENTRAL
18. Regional spread of tumor in the thorax
EXCEPT:

a. Tracheal obstruction
b. Esophageal compression with dysphagia
c. Obstructive pneumonitis - CENTRAL
d. Phrenic nerve paralysis with elevation of the
hemidiaphragm
CENTRAL/ PERIPHERAL
ENDOBRONCHIAL
Cough Pain (pleural or chest
Hemoptysis wall involvement)
Wheeze Dyspnea on a
Stridor restrictive basis
Dyspnea Symptoms of a lung
Post-obstructive abscess resulting from
pneumonitis tumor cavitation
19. Other problems of regional
spread include:
a. Superior vena cava syndrome from vascular
obstruction
b. Pericardial and cardiac extension with
resultant tamponade, arrhythmia, or cardiac
failure
c. Lymphatic obstruction with resultant pleural
effusion
d. All of the above
Other problems of regional spread include:
Superior vena cava syndrome from vascular obstruction
Pericardial and cardiac extension with resultant cardiac
tamponade, arrhythmia, or cardiac failure
Lymphatic obstruction with resultant pleural effusion
Lymphangitic spread through the lungs with hypoxemia
and dyspnea
Transbronchial lung cancer spread Constitutional
symptoms

Tumor growth along multiple alveolar Anoreixa

surfaces Weight loss
Impaired gas exchange Weakness
Respiratory insufficiency Fever
Dyspnea Night sweats

Ref: HPIM 19th Ed. Pg: 510-511

Hypoxemia
Sputum production
 20. Most common life-threatening
metabolic complication of malignancy:
a. Hypocalcemia
b. Hypercalcemia
c. Hypoinsulinemia
d. Hypernatremia
HYPERCALCEMIA resulting Clinical symptoms:
from ectopic production of Nausea
parathyroid hormone, or Vomiting
more commonly, PTH-related Abdominal pain
peptide, is the most common Constipation
life threatening metabolic Polyuria
complication of pregnancy, Thirst
primarily occuring with Altered mental status
squamous cell carciomas of
the lungs.
 21. Which of the following statements on
Non Small Cell Carcinoma is TRUE?
A. Usually Present as central masses with endobronchial
growth at the time of diagnosis Small Cell Ca
B. Generally responds well to chemotherapy Small Cell Ca
C. 90% are smokers or former smokers
D. Pleural involvement is infrequent ADENOCARCINOMA
ASSOCIATED WITH PLEURAL EFFUSION RICH IN
HYALURODINASE LEVELS
Source: MRA Lung Ca
22. Most common pattern of
Squamous cell carcinoma
A. Infiltrating nest of tumor cells that lack intercellular
bridge
B. Tumors are arranged in diffuse sheets of ells or in patterns
such as rosettes, trabeculae, or peripheral palisading of
cells at the periphery nests (SMALL CELL)
C. May contain glands, papillary structure, cellular mucin or
solid pattern if poorly differentiated (ADENO)
D. Poorly differentiated carcinomas composed of large
malignant cells without glandular differentiation (ADENO)
you have to memorize this table
23. Pancoasts Syndrome
A. Usually results from local extension of SQUAMOUS cell
carcinoma
B. Involves C8, T1-2 nerves
C. Presents with shoulder pain radiating to the ULNAR
DISTRIBUTION OF ARM
D. Often with radiologic destruction of the 1st and 2nd rib
 Pancoasts (superior sulcus tumor)
syndrome
Results from local extension of a tumor (usually Squamous cell CA)
growing in the apex of the lung
Involve 8th cervical, 1st & 2nd thoracic nerves (Horners)
Shoulder pain that radiates in ulnar distribution of the arm
Often w/ radiologic destruction of the 1st & 2nd ribs
Other problems of regional spread:
o SVC syndrome from vascular obstruction
o Precordial & cardiac extension w/ tamponade
o Arrhythmia or cardiac failure
o Lymphatic obstruction with pleural effusion
o Lymphangitic spread through the lungs with hypoxemia and dyspnea
24. Cells with scant cytoplasm, small hyperchromic nuclei with fine (salt
and pepper chromatin pattern) and prominent nucleit is a characteristic
of

A. Squamous or epidermoid carcinoma

B. Small cell carcinoma
C. Adenocarcinoma
D. Large cell carcinoma
35. Treatment of choice for Small cell
Lung CA with contralateral hilar nodes
A. Surgical resection (Non small cell types are responsive to
surgery)
B. Surgical + chemotherapy
C. Chemotherapy (small cell responds well to chemotherapy
better than the other types of Lung CA)
D. Chemotherapy + radiation
36. Most common pattern of
Squamous cell carcinoma
A. Infiltrating nest of tumor cells that lack intercellular
bridge
B. Tumors are arranged in diffuse sheets of ells or in patterns
such as rosettes, trabeculae, or peripheral palisading of
cells at the periphery nests (SMALL CELL)
C. May contain glands, papillary structure, cellular mucin or
solid pattern if poorly differentiated (ADENO)
D. Poorly differentiated carcinomas composed of large
malignant cells without glandular differentiation (ADENO)
you have to memorize this table
37. Pancoasts Syndrome
A. Usually results from local extension of SQUAMOUS
cell carcinoma
B. Involves C8, T1-2 nerves
C. Presents with shoulder pain radiating to the ULNAR
DISTRIBUTION OF ARM
D. Often with radiologic destruction of the 1st and 2nd
rib
 Pancoasts (superior sulcus tumor)
syndrome
Results from local extension of a tumor (usually Squamous cell CA)
growing in the apex of the lung
Involve 8th cervical, 1st & 2nd thoracic nerves (Horners)
Shoulder pain that radiates in ulnar distribution of the arm
Often w/ radiologic destruction of the 1st & 2nd ribs
Other problems of regional spread:
o SVC syndrome from vascular obstruction
o Precordial & cardiac extension w/ tamponade
o Arrhythmia or cardiac failure
o Lymphatic obstruction with pleural effusion
o Lymphangitic spread through the lungs with hypoxemia and dyspnea
38. Prophylactic irradiation is
indicated in:
A. Squamous cell CA
B. Small cell CA
C. Adenocarcinoma
D. Large cell CA
TREATMENT OF SMALL CELL LUNG CANCER (Harrisons Principles of Internal
Medicine, 19th Edition, page 522)
PROPHYLACTIC CRANIAL IRRADIATION
Prophylactic cranial irradiation (PCI) should be considered in all
patients with either LD-SCLC or ED-SCLC who have responded well to
initial therapy. A meta-analysis including seven trials and 987 patients
with LD-SCLC who had achieved a complete remission after upfront
chemotherapy yielded a 5.4% improvement in overall survival for
patients treated with PCI. In patients with ED-SCLC who have
responded to first-line chemotherapy, a prospective randomized
phase III trial showed that PCI reduced the occurrence of symptomatic
brain metastases and prolonged disease-free and overall survival
compared to no radiation therapy. Long-term toxicities, including
deficits in cognition, have been reported after PCI but are difficult to
sort out from the effects of chemotherapy or normal aging.
Harrisons Principles of Internal Medicine, 19th Edition, page 515
SMALL CELL CA SQUAMOUS ADENOCARCINOMA LARGE CELL CA
CELL CA
PRODUCE SPECIFIC *BRONCHIOALVEOLAR CA- *BASALOID
PEPTIDE RARE SUBTYPE THAT *LYMPHOEPITHELIA
HORMONES GROWS ALONG ALVEOLI L-LIKE CARCINOMA
WITHOUT INVASION
*PARANEOPLASTIC (GROUND GLASS OPACITY
SYNDROMES IN CT SCAN)

CHEMOTHERAPY W/ OR SURGERY OR RADIOTHERAPHY

W/OUT *DO NOT RESPOND WELL TO CHEMOTHERAPY AS SMALL CELL CA
RADIOTHERAPHY
*SURGERY UNLIKELY TO
BE CURATIVE
*MORE SENSITIVE TO
CHEMOTHERAPHY
THAN NON-SMALL CELL
BIOLOGY OF LUNG
CANCER
39. Which of the following events
take place in tumor suppression?
A. activation of dominant oncogene
B. Activation of tumor suppressor gene
C. Chromosomal gain of 3p
D. Deletion of a large chromosomal DNA segment of one
allele
Tumor Suppression
2 events
Deletion of a large chromosomal DNA segment of one allele
Smaller mutation or epigenetic inactivation of the other allele

Tumor Suppressor Gene

Genes whose reduced fnc can lead to neoplastic
40. Which of the following is involved in
the DNA methylation alteration.

A. Cytosine-Guanosine (CpG) dinucleotide

B. P53 Tumor Suppressor Gene
C. Ubiquitin E3 ligase
D. p16INK4A
E. Transforming Growth Factor-B
Answer: A
Hallmarks of Human Cancer Cell Genesis
1. Chromosomal alterations
2. Chromosomal instability
3. Tumor suppressors - Tumor Suppressor Gene
4. Alterations in DNA methylation-
Cytosine-Guanosine (CpG) dinucleotide
 41. Which of the following is involved in
the DNA methylation alteration in Lung
CA
A. Cytosine-Guanosine (CpG) dinucleotide
B. P53 Tumor suppressor gene
C. Ubiquitin E3 ligase: ONCOGENE
D. P16:NK4A- (Tumor supressor activity)
E. Transforming Growth Factor- B- inhibits cell
proliferation of normal epithelial cells
 A. Cytosine-Guanosine (CpG) dinucleotide

Hallmarks of Human Cancer 4. Alterations in DNA Methylation

Cell Genesis CytosineGuanosine (CpG) dinucleotide
1. Chromosomal alterations Contained in promoter regions
2. Chromosomal instability Protected from methylation in normal cells
3. Tumor suppressors Methylation associated with loss of
expression of the
4. Alterations in DNA particular gene; alternative mechanism for
methylation loss of tumor
suppressor gene function
9p21, 13q14, 17p13
42. Correlated with poor
prognosis
A. Cytosine-Guanosine (CpG) dinucleotide
B. P53 Tumor suppressor gene
C. Ubiquitin E3 ligase
D. P16:NK4A
E. Transforming Growth Factor- B
B. P53 Tumor supressor gene
P53 Tumor Suppressor Gene
Guardian of the genome; safeguard against genetic instability
Activated p53 may participate directly in DNA repair via induction of
p53R2
Activated p53 transactivates genes that may impose cell cycle arrest in
G1 and G2
Smoking induces p53 mutations
Correlates with poor prognosis after surgical treatment of lung
cancers, especially in stage I cancers.
 43. Which of the following is not true
regarding Knudson hypothesis
A. An individual with an inherited predisposition to cancer inherits one
normal and one mutant tumor suppressor gene (TRUE)
B. A non-predisposed individual must acquire somatic mutations in
BOTH the maternal AND paternal supressor gene alleles to initiate
tumor formation
C. 1st degree relatives of lung cancer have 2-3 fold excess risk of lung
cancer
D. Individuals with inherited mutations in RB (patients with
retinoblastoma living to adulthood) and p53 (Li_-Fraumeni syndrome)
genes may develop lung cance
*C and D are under Inherited Predisposition to Lung CA
Inherited Predispositions
1st degree relatives have 2-3 fold excess risk of lung ca
Indvls with inherited mutations in RB (pts with
retinoblastoma living to adulthood) and p53 (Li-Fraumenia)
may develop lung cancer
Knudson Hypothesis
An individual with an inherited predisposition to cancer
inherits 1 normal & 1 mutant tumor suppressor gene
A non-predisposed indvl must acquire somatic mutations in
both the maternal and paternal suppressor gene alleles to
initiate tumor formation
44. Which of the following statements is
consistent with the Knudson Hypothesis?
A. An individual with an inherited predisposition to cancer inherits
one mutant tumor suppressor gene from each parent
B. A non predisposed individual with an inherited predisposition to
cancer inherits one normal and one mutant tumor suppressor gene
C. A non predisposed individual must acquire somatic mutations in
both the maternal and paternal suppressor gene alleles to initiate
tumor formation
D. A predisposed individual must acquire somatic mutations in both
the maternal and paternal suppressor gene alleles to initiate tumor
formation
Knudson hypothesis:
An individual with an inherited predisposition
to cancer inherits 1 normal and 1 mutant tumor
Suppressor gene.
A non predisposed individual must acquire
somatic mutations in both the maternal And
paternal suppressor gene alleles to initiate
tumor formation.
45. Which of the following is an oncogene
that is equated to a favorable prognosis?

A. P14ARF
B. Ubiquitin E3 ligase
C. P53 gene mutation
D. Cytosine guanosine dinucleotide
p14ARF Ubiquitin E3 ligase P53 Tumor Suppressor Gene
(under MDM2);
Exerts growth an oncogene, Guardian of the genome; safeguard
inhibition by interacts with p53 against genetic instability
inhibiting and targets the p53 Activated p53 may participate
ubiquitin E3 ligase protein for directly in DNA repair via induction
activity of MDM2 Degradation. of p53R2
Deletion may Paradoxically in Activated p53 transactivates genes
promote tumor association with a that may impose cell cycle arrest in
promoting activity FAVORABLE G1 and G2
of oncogenes PROGNOSIS Smoking induces p53 mutations
Correlates with poor prognosis after
surgical treatment of lung cancers,
especially in stage 1 cancers.
 46. Which of the following is found to inhibit cell
proliferation even in normal epithelial cells, but
most especially on bronchial and peripheral lung
epithelial cells?
A. Transforming growth factor B
B. Retinoblastoma gene
C. P53 tumor suppressor gene
D. MDM2
Transforming Growth factor B
Inhibits cell proliferation of normal epithelial cells, including
bronchial and peripheral lung epithelial cells, thru inductions
of CDK inhibitors
EPIDEMIOLOGY OF
LUNG CA
 47. Most common type of lung cancer

Ref: Harrison's Principles of Internal Medicine 19th ed., p.507

occurring in never smoker
A. Squamous cell carcinoma
B. Adenocarcinoma young and women
C. Small cell carcinoma
D. Large cell carcinoma
RATIO:Adenocarcinoma has become the most frequent histologic
subtype of lung cancer in the United States as both squamous
carcinoma and small-cell carcinoma are on the decline. In lifetime never
smokers or former light smokers (<10 pack-year history), women, and
younger adults (<60 years), adenocarcinoma tends to be the most
common form of lung cancer.
 48. Which of the following statements
regarding the epidemiology of lung
cancer is TRUE?
A. Relative risk of developing lung CA is increased two fold by active
smoking and four fold by long term passive smoking
B. Lung CA death rate is related to the total cigarette pack years with
risk rising to 60 to 70 times for smoking 2 packs/day for 20 years
compared to non smoker
C. Risk of developing lung cancer decreases with cessation of smoking,
returning to nonsmoker level after several years
D. Men have higher relative risk per given exposure than women (with
risk up to 1.5 times higher) likely due to their higher susceptibility to
tobacco carcinogens.
A. Relative risk of developing lung CA is increased two fold (s/b 13x)
by active smoking and four fold (s/b 1.5x) by long term passive
smoking
B. Lung CA death rate is related to the total cigarette pack years with
risk rising to 60 to 70 times for smoking 2 packs/day for 20 yrs
compared to non smoker
C. Risk of developing lung cancer decreases with cessation of smoking,
returning to nonsmoker level after several years (NEVER return to
nonsmoker level)
D. Men have higher relative risk per given exposure than women
(Women > Men) (with risk up to 1.5 times higher) likely due to their
higher susceptibility to tobacco carcinogens.
 49. Which of the following is TRUE regarding
the association of race and ethnicity to the
epidemiology of lung cancer?
A. Rates of lung cancer occurrence are greater among
African American and white women
B. Lung Cancer rates are 50% higher among African
American men than among white men
C. Mortality rates are greater for African Americans
than Asians
D. Rates of lung cancer occurrence tend to be greater
in South America than in North America
A. Rates of lung cancer occurrence are greater (s/b SIMILAR)
among African American and white women
B. Lung Cancer rates are 50% higher among African American
men than among white men
C. Mortality rates are greater (Asians > Africans) for African
Americans than Asians
D. Rates of lung cancer occurrence tend to be greater (North
> South) in South America than in North America
 RACE AND ETHINICITY
AFRICAN AMERICAN WOMEN = WHITE WOMEN
AFRICAN AMERICAN MEN 50% > WHITE MEN
MORTALITY RATES:
HIGHER= HISPANICS, NATIVE AMERICANS, ASIANS/
PACIFIC ISLANDERS > AFRICAN AMERICANS AND NON-
HISPANICS
 50. Which of the following statements
regarding smoking and the risk for lung
cancer is TRUE?
A. Doubling the number of cigarettes smoked per day was estimated to
triple the risk, doubling the duration of smoking was estimated to increase
the risk 10x
B. Compared to never smokers, smokers have two fold increase in lung
cancer risk
C. Risk for lung cancer increases with duration of smoking and number
of cigarettes smoked per day
D. Stronger effect of amount of cigarettes smoked per day rather
than duration of smoking
Answer: C
A. Doubling (s/b Tripling) the number of cigarettes smoked
per day was estimated to triple the risk, doubling the
duration of smoking was estimated to increase the risk 10x
(100x)
B. Compared to never smokers, smokers have two fold
(20 folds) increase in lung cancer risk
C. Risk for lung cancer increases with duration of smoking
and number of cigarettes smoked per day
D. Stronger effect of amount (Duration) of cigarettes
smoked per day rather than duration (Amount) of smoking
51. Which vitamin is found to have protective
association against lung cancer?
A. Vitamin A
B. Vitamin C
C. Vitamin E
D. Vitamin B

Vitamin A Studies yield null findings

B Carotene Increased risk
Tomatoes, cruciferous vegetables Reduces risk
ETIOLOGY OF LUNG
CANCER
52. Proven occupational
carcinogen for Lung CA
A. Beryllium
B. Vinyl chloride
C. Silica
D. Asbestos
 D. Asbestos
Human Arsenic, Asbestos, Chromates, Chloromethyl
Occupational ethers, Nickel, Polycyclic Aromatic
Causes hydrocarbons,
Radon progeny
Outdoor Air Combustion-related carcinogens
Pollutants
Indoor Air Asbestos, Radon, Cigarette smoke, Fumes
Pollutants from
cooking stoves
 53. Proven cause of occupational
carcinogen of lung cancer:
a. Mustard gas
b. Nickel
c. Silica
d. Iron Ore
e. A and B

Ref: HPIM 19th Ed. Pg: 506 and MRA

trans
54. The relative risk of lung malignancy
in active smoker (40 pack years) is about:
A. 80-90 fold
B. 60-70 fold
C. 40-50 fold
D. 10-20 fold
Cigarette Smoking
Most Lung CA are c/b carcinogens and tumor promoters ingested via
cigarette smoking
Relative risk of lung CA is
o 13x by active smoking
o 1.5x by long term passive smoking
o In women assoc with rise in cigarette smoking
Women have a higher relative risk per given exposure than men
(1.5 x)
Likely due to higher susceptibility to tobacco carcinogens in
women
Lung CA death rate is related to the total cigarette pack years
o Risk is 60-70x for smoking 2 packs/day for 20 yrs compared to non
smoker
Reference: MRA Trans
55. First line treatment for nicotine
dependence:

Harrison's Principles of Internal Medicine 19th ed., p.507

A. Clonidine 2nd line
B. Varenicline
C. Nortriptyline 2nd line
RATIO:
Therapy with an antidepressant (e.g., bupropion) and nicotine replacement
therapy (varenicline, a 42 nicotinic acetylcholine receptor partial agonist)
are approved by the U.S. Food and Drug Administration (FDA) as first-line
treatments for nicotine dependence. However, both drugs have been reported
to increase suicidal ideation and must be used with caution.
Second-line: Clonidine , Nortriptyline
BRONCHOGENIC
CARCINOMA
56. Most common presenting symptoms of lung
cancer:
A. Cough (8-75%)
B. Weight loss (0-68%)
C. Dyspnea (3-60%)
D. Chest pain (20-49%)
57. What is the most common presenting
symptoms of bronchogenic carcinoma?
a. Hemoptysis
b. Weight loss
c. Cough
d. Hoarseness
e. Dyspnea
 Clinical manifestations of
bronchogenic carcinoma
Symptoms Percentage of patients
Cough 45-75%
Weight loss 8-68%
Dyspnea 37-58%
Hemoptysis 27-57%
Chest pain 27-49%
Hoarsness 2-18%
58. Clinical findings suggestive of metastatic
disease EXCEPT:

A. Hepatomegaly >13cm span

B. Elevated alkaline phosphatase, GGT, SGOT, and
calcium levels
C. Fever of unknown origin
D. Hematocrit <40% in men and <35% in women
59. What among the symptoms of lung cancer
may indicate advance presentation and poor
outcome
a. Dyspnea
b. Weight loss
c. Clubbing of fingers
d. Bone pains
e. Hoarseness
Weight loss greater than 10% of total body
weight is considered a bad prognostic sign.
 60. Sign of cancer in a smoker.
a. Hemoptysis
b. Weight loss
c. Cough
d. Hoarseness
e. Dyspnea
(Hey, sorry I cant find the explanation of this on the trans and Harrisons. But, this is what is stated on Harrisons
regarding clinical manifestations of Lung CA.)
The prototypical lung cancer patient is a current or former smoker of
either sex, usually in the seventh decade of life. A history of chronic cough
with or without hemoptysis in a current or former smoker with chronic
obstructive pulmonary disease (COPD) age 40 years or older should
prompt a thorough investigation for lung cancer even in the face of a
normal CXR.
61. Imaging of choice for superior sulcus
tumor, brachial plexus and vertebral invasion
a. CT scan
b. MRI
c. PET scan
d. Chest x-ray
e. Bone scan
 Pancoast (or superior sulcus tumor) syndromes result from
local extension of a tumor growing in the apex of the lung with
involve- ment of the eighth cervical and first and second
thoracic nerves, and present with shoulder pain that
characteristically radiates in the ulnar distribution of the arm,
often with radiologic destruction of the first and second ribs.
Magnetic resonance imaging of the thoracic inlet is always
recommended to define the exact extent of tumor invasion
within the thoracic inlet before surgical intervention.

-Journal of Thoracic Disease

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3791502/
62. Common metastatic site of lung
cancer except:
a. Bones
b. Brain Main sites of metastasis of lung cancer:
Adrenal gland, bone, brain, and liver.
c. Liver
d. Adrenals http://www.cancer.gov/about-cancer/what-is-
cancer/metastatic-fact-sheet
e. stomach
63. Gold standard in imaging
mediastinum
a. Mediastinoscopy
b. Endoscopic untrasound
c. Bronchoscopy
d. Transthoracic needle aspirator
*A definite diagnosis can be obtained with
mediastinoscopy or anterior mediastinotomy in many
patients with masses in the anterior or middle
mediastinal compartments.
 64. True regarding clinical
manifestations of Lung CA except:
A. Peripheral growth of primary tumor may cause pain from pleural or
chest wall involvement, cough, dyspnea, and post-obstructive
pneumonitis
B. Central or endobronchial growth of primary tumor may cause cough,
hemoptysis, wheeze and stridor
C. Pancoasts Syndrome may resent with shoulder pain that radiates in
the ulnar distribution of the arm
D. Small Cell CA may be associated with Cushings syndrome, SIADH and
Myasthenia
E. None of the above
 Answer: A
Peripheral growth of the primary tumor
may cause pain from pleural or chest wall involvement,
dyspnea on a restrictive basis, and symptoms of a lung
abscess resulting from tumor cavitation.
Patients with central or endobronchial growth of the
primary tumor
may present with cough, hemoptysis, wheeze, stridor,
dyspnea, or postobstructive pneumonitis.
 Pancoast (or superior sulcus tumor)
syndromes
result from local extension of a tumor growing in the apex
of the lung with involvement of the eighth cervical and first
and second thoracic nerves, and present with shoulder
pain that characteristically radiates in the ulnar distribution
of the arm, often with radiologic destruction of the first
and second ribs.
65. Pancoasts Syndrome
A. Usually results from local extension of small
cell carcinoma
B. Involves C8, T1-2 nerves
C. Presents with shoulder pain radiating to the
..
D. Often with radiologic destruction of the
vertebral spine
 PANCOASTS SYNDROME
(SUPERIOR SULCUS TUMOR)
Results from local extension of a tumor (usually
Squamous cell CA) growing in the apex of the lung
Involve the 8th cervical, 1st and 2nd thoracic nerves
(C8, T1, T2)
Present with shoulder pain that radiates in the ulnar
distribution of the arm
Often with radiologic destruction of the 1st and 2nd
ribs
Small Cell CA may be associated with Cushings
syndrome, SIADH and Myasthenia
66. True regarding Paraneoplastic
syndromes in Lung CA:
A. Cushing syndrome, SIADH, and peripheral
neuropathies are associated with Squamous cell CA
B. Hypercalcemia is associated with Small cell CA
C. Clubbing & hypertrophic pulmonary
osteoarthropathy is associated with Large cell CA
D. All of the above
Answer: C
67. True regarding paraneoplastic
syndromes in Lung CA
A. Cushing syndrome, SIADH and peripheral
neuropathies are associated with Small cell CA
ONLY
B. Hypercalcemia is associated with Squamous cell CA
C. Clubbing & Hypertrophic pulmonary
osteoarthropathy is associated with Large cell CA
D. AOTA
68.Commonly associated with
hypercalcemia due to production of PTHr
substance:

A. Small cell CA
B. Squamous cell CA
C. Adenocarcinoma
D. Large cell CA
 RATIO:

Reference: MRA Trans

69. Most commonly associated with
SVC and Eaton-Lambert syndrome

A. Small cell CA
B. Squamous cell CA
C. Adenocarcinoma
D. Large cell CA
 RATIO:

Reference: MRA Trans

STAGING &
TREATMENT OF LUNG
CANCER
 PLEASE MEMORIZE!!!

Step 1: Determine first if its a small

cell or non-small cell carcinoma. Its
important to know that only NSLC are
stageable. Small cell CA aka OAT cell
carcinoma cannot be stageable
because its simply small and
cannot be measured in terms of size.

Step 2: Check the size of the tumor

and its invasion (must know!!)

P.S., These steps are based on my understanding..

Its up to you if you will follow. Print these tables
for easy reference
Step 3:
Check the lymph node
involvement
Step 4:
Check if theres metastasis
(which would automatically
yield Stage IV if positive)
Step 5:
Determine the stage:
*If you get N2, think Stage III,
then check the size(T) to
determine if its A or B.

ex. An NSLC with a T size

7cm invading the diaphragm.
LN involves contralateral
mediastinal nodes. No
metastasis

T3, N3, M0 = Stage IIIB

Step 6: Select Treatment modalities for NSLC(MUST KNOW!!!)
Select Treatment modalities for SMALL CELL CARCINOMA (OAT CELL CA)
Directions for #70-74

EXTENDED MATCHING TYPE.

For numbers 70-74: match Column A (Case) with Column B
(Stage).

For numbers 75-79: match Column A & B with Column C

(Treatment modalities)

____70. _____ 75.
A 50 year old female, smoker for 30
pack years, with previous history of
Acute myocardial infarction 6 months
ago, consulted because of exertional
dyspnea, 2-pillow orthopnea and
chronic non-productive cough. Chest CT
scan showed a 4 cm mass in the right
middle lobe, enlarged Right mediastinal,
hilar and subcarinal lymph nodes.
Thoracentesis was done and pleural
fluid was transudative and negative for
malignant cells. Biopsy of lung mass
revealed Adenocarcinoma.
Column B (Stage of Lung Cancer)
A. Stage IIB
B. Stage IIIA
C. Stage IIIB
D. Stage IV
E. None of the above
Column C (Management of Lung Cancer)
A. Pre-operative radiotherapy followed by en bloc
resection of involved chest wall and
consideration of post-operative radiotherapy
B. Chemotherapy
C. Radiotherapy for symptomatic sites and
chemotherapy for ambulatory patients
D. Neoadjuvant chemotherapy and surgical
resection
E. Pneumonectomy with tracheal sleeve resection
with direct reanastomosis to contralateral
bronchus
Answer: B. Stage IIIA, D. Neoadjuvant chemotherapy and surgical
resection

Step 1: Adenocarcinoma.
Step 2: Check the size of the tumor and invasion.
4 cm mass in the right middle lobe = T2a
Step 3: Check the lymph node involvement
enlarged Right mediastinal, hilar and subcarinal lymph nodes. = N2
Step 4: Check if theres metastasis
Thoracentesis was done and pleural fluid was transudative and negative for
malignant cells = M0
Step 5: Determine the stage:
T2a, N2, M0 = Stage IIIA
Step 6: Treatment modalities: (Stage IIIA with advanced N2 involvement)
Neoadjuvant chemotherapy and surgical resection

____71. _____ 76.
A 65 year old male, smoker for 40 pack
years, with on and off productive cough
with blood streaked phlegm, weight loss
of 5 kg in a month. Chest x-ray showed
atelectasis of right upper and middle
lobes. Fiberoptic bronchoscopy revealed a
5 cm endobronchial mass in the right
main bronchus 4 cm from the carina.
Chest CT scan also revealed enlarged
ipsilateral hilar and scalene lymph nodes
and contra lateral supraclavicular lymph
node. Biopsy of lung mass revealed Oat
cell lung Carcinoma. Positive for liver
metastasis.
Column B (Stage of Lung Cancer)
A. Stage IIB
B. Stage IIIA
C. Stage IIIB
D. Stage IV
E. None of the above
Column C (Management of Lung Cancer)
A. Pre-operative radiotherapy followed by en bloc
resection of involved chest wall and
consideration of post-operative radiotherapy
B. Chemotherapy
C. Radiotherapy for symptomatic sites and
chemotherapy for ambulatory patients
D. Neoadjuvant chemotherapy and surgical
resection
E. Pneumonectomy with tracheal sleeve resection
with direct reanastomosis to contralateral
bronchus
Answer: E. None of the above, B. Chemotherapy

Step 1: OAT Cell Carcinoma (SMALL CELL CA)

Step 2: Check the size of the tumor and invasion.
Not Applicable (N/A)
Step 3: Check the lymph node involvement
(N/A)
Step 4: Check if theres metastasis
(N/A)
Step 5: Determine the stage:
(N/A)
Step 6: Treatment modalities: (EXTENSIVE disease)
Chemotherapy

_____72. ______ 77. A 65 year old
male, previous 30 pack-year smoker
with on and off non productive cough
and easy fatigability. Chest CT scan
revealed multiple pulmonary nodules in
the right middle and right lower love,
the biggest of which measures 6 cm
encasing the Right pulmonary artery;
enlarged mediastinal and paratracheal
lymph nodes. There were no distant
metastasis. CT scan guided lung biopsy
revealed Squamous cell Carcinoma.
Column B (Stage of Lung Cancer)
A. Stage IIB
B. Stage IIIA
C. Stage IIIB
D. Stage IV
E. None of the above
Column C (Management of Lung Cancer)
A. Pre-operative radiotherapy followed by en bloc
resection of involved chest wall and
consideration of post-operative radiotherapy
B. Chemotherapy
C. Radiotherapy for symptomatic sites and
chemotherapy for ambulatory patients
D. Neoadjuvant chemotherapy and surgical
resection
E. Pneumonectomy with tracheal sleeve resection
with direct reanastomosis to contralateral
bronchus
Answer: C. Stage IIIB, C. Radiotherapy for symptomatic sites and
chemotherapy for ambulatory patients
Step 1: Squamous cell Carcinoma.
Step 2: Check the size of the tumor and invasion.
revealed multiple pulmonary nodules in the right middle and right lower lobe,
the biggest of which measures 6 cm encasing the Right pulmonary artery = T4
Step 3: Check the lymph node involvement
enlarged mediastinal and paratracheal lymph nodes = N2
Step 4: Check if theres metastasis
There were no distant metastasis. = M0
Step 5: Determine the stage:
T4, N2, M0 = Stage IIIB
Step 6: Treatment modalities: (more advance stage IIIB disease)
Radiotherapy for symptomatic sites and chemotherapy for ambulatory
patients

_____ 73. ______78.
A 60 year old male, smoke for 40
pack years came in because of
blood streaked sputum and weight
loss. Chest X-ray and chest CT scan
revealed 6 cm mass on the left
upper lobe with invasion of
adjacent chest wall, and enlarged
mediastinal and sub carinal lymph
nodes. There were no distant
metastasis. Biopsy of lung mass
revealed. Non-small cell Carcinoma.
Column B (Stage of Lung Cancer)
A. Stage IIB
B. Stage IIIA
C. Stage IIIB
D. Stage IV
E. None of the above
Column C (Management of Lung Cancer)
A. Pre-operative radiotherapy followed by en bloc
resection of involved chest wall and
consideration of post-operative radiotherapy
B. Chemotherapy
C. Radiotherapy for symptomatic sites and
chemotherapy for ambulatory patients
D. Neoadjuvant chemotherapy and surgical
resection
E. Pneumonectomy with tracheal sleeve resection
with direct reanastomosis to contralateral
bronchus
Answer: B. Stage IIIA, A. Pre-operative radiotherapy followed by en
bloc resection of involved chest wall and consideration of post-
operative radiotherapy
Step 1: Non-small cell Carcinoma
Step 2: Check the size of the tumor and invasion.
6 cm mass on the left upper lobe with invasion of adjacent chest wall = T3
Step 3: Check the lymph node involvement
enlarged mediastinal and sub carinal lymph nodes = N2
Step 4: Check if theres metastasis
There were no distant metastasis. = M0
Step 5: Determine the stage:
T3, N2, M0 = Stage IIIA
Step 6: Treatment modalities: (Stage IIIA with selected types of stage T3 tumors)
Pre-operative radiotherapy followed by en bloc resection of involved chest wall
and consideration of post-operative radiotherapy

_____ 74. ______79.
A 58 year old male, 30 pack year
smoker, presenting with chronic
non-productive cough and
exertional dyspnea. Chest CT scan
revealed pulmonary mass, 7 cm in
the right middle lobe, 3 cm mass in
the left upper lobe. There were
enlarged right mediastinal, hilar and
supraclavicular lymphadenopathies.
Lung biopsy showed Squamous cell
Carcinoma.
Column B (Stage of Lung Cancer)
A. Stage IIB
B. Stage IIIA
C. Stage IIIB
D. Stage IV
E. None of the above
Column C (Management of Lung Cancer)
A. Pre-operative radiotherapy followed by en bloc
resection of involved chest wall and
consideration of post-operative radiotherapy
B. Chemotherapy
C. Radiotherapy for symptomatic sites and
chemotherapy for ambulatory patients
D. Neoadjuvant chemotherapy and surgical
resection
E. Pneumonectomy with tracheal sleeve resection
with direct reanastomosis to contralateral
bronchus
Answer: D. Stage IV, C. Radiotherapy for symptomatic sites and
chemotherapy for ambulatory patients
Step 1: Squamous cell Carcinoma.
Step 2: Check the size of the tumor and invasion.
Chest CT scan revealed pulmonary mass, 7 cm in the right middle lobe, 3 cm mass in
the left upper lobe = T4
Step 3: Check the lymph node involvement
There were enlarged right mediastinal, hilar and supraclavicular lymphadenopathies
= N2
Step 4: Check if theres metastasis
lymphadenopathies= M1
Step 5: Determine the stage:
T4, N2, M1 = Stage IV
Step 6: Treatment modalities: (Stage IV)
Radiotherapy for symptomatic sites and chemotherapy for ambulatory patients
For the succeeding slides memorize
80. Tumor with pleural nodules or
malignant pleural dissemination
A.M0
B.M1a
C. M1b
D.M1c
81. In the TNM staging, tumor in the
main bronchus <2cm distal to the carina
is considered
A. T1
B. T2
C. T3
D. T4
82. Tumors associated with atelectasis or
obstructive pneumonitis of the entire
lung
A.T1
B. T2
C. T3
D.T4
83. Metastasis to ipsilateral mediastinal
and/or subcarinal lymph node
A. N0
B. N1
C. N2
D. N3
84. Presence of malignant pleural or
pericardial effusion
a. Stage 1
b. Stage 2
c. Stage 3
d. Stage 4
85. Tumors seen invading the
mediastinum, heart, and great vessels
a. T1
b. T2
c. T3
d. T4
86.Involvement of para-aortic,
pretracheal or pulmonary ligament node
is:

A. No
B. N1
C. N2
RATIO:

Reference: MRA Trans

 87. Tumor invading the chest wall and
diaphragm
a. T1
b. T2
c. T3
d. T4
88. Satellite pulmonary nodules within
the same lobe as the primary tumor is:
A. T1
B. T2
C. T3
D. T4
89. Tumor at the apex or atelectasis
of the entire 1 lung is:

A. T1
B. T2
C. T3
D. T4
90. 63 year old female came in due to cough
and weight loss. 4.2cm spiculated mass on
the right middle lobe. No lymph node
involvement or any metastasis. Patient is
classified as:
A. Stage IA
B. Stage IB
C. Stage IIA
D. Stage IIB
T2A, N0, M0
91. Treatment of choice for above
patient
A. Surgical resection of the tumor
B. Surgical resection with neoadjuvant
chemotherapy
C. Chemotherapy + Radiotherapy
D. Chemotherapy ONLY
 MANAGEMENT FOR
NON-SMALL CELL LUNG CA
EARLY STAGE STAGE I and II Surgery
LOCALLY STAGE IIIA and Chemotherapy
ADVANCED B + Radiotherapy
METASTATIC STAGE IV Chemotherapy
92. 72 years old male complains of dyspnea
came in for second opinion. Chest CT scan
... (not readable) the left upper lobe with
invasion of the carina. There were also
involved lymph nodes; (+) malignant
pleural effusion. Patient is classified as:
A. Stage IIB
B. Stage IIIA
C. Stage IIIB
D. Stage IV
93. Appropriate treatment for
patient (#92)
A. Surgical resection of tumor
B. Surgical resection with neoadjuvant
chemotherapy
C. Chemotherapy + Radiotherapy
D. Chemotherapy
 MANAGEMENT FOR
NON-SMALL CELL LUNG CA
EARLY STAGE STAGE I and II Surgery
LOCALLY STAGE IIIA and Chemotherapy
ADVANCED B + Radiotherapy
METASTATIC STAGE IV Chemotherapy
94. An extended cervical mediastinoscopy can be
done to access enlarged lymph nodes in patient
worked up for mediastinal masses. Which of these
nodal group can be accessed by this procedure?

a. aorto-pulmonary (station 5)
b. Para-aortic (station 6)
c. Subcarinal (station 7)
d. A and B
Surgical exploration of subaortic and para-aortic lymph nodes has
traditionally required the combination of standard cervical
mediastinoscopy and left anterior mediastinotomy. Video-assisted
thoracoscopic surgery is another technique that allows the
exploration of these nodal stations. Extended cervical
mediastinoscopy is a useful and safe technique for the
assessment of para-aortic and subaortic nodal stations through
the same incision of the standard cervical mediastinoscopy.

-Multi-media manual of cardio-thoracic surgery

http://mmcts.oxfordjournals.org/content/2012/mms018.abstract
95. Which of these is a poor prognosis
indicator in patients with seminoma
a. Alpha feto protein
b. Beta HCG
c. Age > 25
d. fever
96. Stage 1 lung cancer but patient
refuses surgery. What is the best option?
a. Chemotherapy
b. Primary radiotherapy
c. Segmentectomy
d. Wedge resection
e. lobectomy
SOLITARY
PULMONARY
NODULE
97. A 48 year old male was seen in the clinic for
evaluation of 2 cm pulmonary nodule on annual chest
radiographic exam. He is a 15 pack/year smoker up to
present. He denies cough, colds, difficulty of breathing
or weight loss but stated having usual clearing of throat.
Patients risk of having cancer is

A. Low
B. Intermediate
C. High
Answer: B
98. This type of calcification in a solitary
pulmonary nodule (SPN) suggests
benignity
A. Popcorn calcification **
B. Bulls eye calcification **
C. Stippled calcification
D. Diffuse calcification

ANSWER: A and B
Radiographic criteria
Which reliably predict a benign nature of solitary pulmonary nodule
1. Lack of growth over a period of > 2 yrs
2. Characteristic patterns of calcification:
a. Dense nidus
b. Multiple punctate foci
c. Bulls-eye calcification- (granuloma)
d. Popcorn ball calcification- (hamartoma)
Serial annual CT Scan to watch the nodule, if it doubles, best toexcise and send
for histiopath

Reference: MRA Trans

99. Characteristic of solitary pulmonary
nodule with benign nature
A. Cigarette smoking (at risk for malignancy)
B. 35 years old, relatively large lesion (at risk for
malignancy)
C. Lack of growth over a period of >2 years
D. Popcorn ball pattern on chest radiograph
D. Popcorn ball appearance
Solitary Pulmonary Nodule
An X-ray density completely surrounded by normal aerated lung, with
circumscribed margins of any shape, usually 1-6 cm in greatest dm
~35% in adults are malignant (primary lung CA)
<1% are malignant in non-smokers under 35 years old
Risk factors in favor of malignancy
1. History of cigarette smoking
2. Age 35 yrs, relatively large lesion
3. Lack of calcification
4. Chest symptoms- assoc w/atelectasis, pneumonitis, or adenopathy
5. Growth of the lesion revealed by comparison with old CXR
 Radiographic criteria
Which reliably predict a benign nature of
solitary pulmonary nodule
1. Lack of growth over a period of > 2 yrs
2. Characteristic patterns of calcification:
a. Dense nidus
b. Multiple punctate foci
c. Bulls-eye calcification- (granuloma)
d. Popcorn ball calcification- (hamartoma)
*Serial annual CT Scan to watch the nodule, if it doubles, best
to excise and send for histopath
100. A 65 year old was seen in the clinic for evaluation of 2cm
pulmonary nodule seen on annual chest radiographic exam. He
is a 25 pack year smoker up to present. He denies cough, colds,
difficulty of breathing or weight loss but stated usual clearing of
throat. Patients risks of having cancer
A. Low
B. Intermediate
C. High
THANK YOU!
ALDRIN MAGHIRANG MEG ALAS
PJ CANERO SHARMAINE MEDEL
MARY JANE FALCON ISSA ABELITA
NIKKO MARQUEZ JERICHO GUIRIBA
CHARINA EVANGELISTA RENAISSA YU
HANNAH LACAR KASSANDRA VILORIA
JOHN MIRASOL IAN MARTINEZ
LHEEZA MITIAM ML ZAMORA
JEFF SAZON CLARISSE CAYETANO
DAVID SANTOS