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MRCP PART 1 · RESPIRATORY MEDICINE

Respiratory medicine questions
for MRCP Part 1.

Clinora has 327 respiratory medicine single best answer questions covering 301 topics. Every question explains all five options, separates the key clue from what it means and what to do next, and links to its source. Try the 5 sample questions below, then practise more for free.

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FREE SAMPLE QUESTIONS

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Question 1Asthma diagnosisMedium

A 29-year-old non-smoker has episodic wheeze, cough and chest tightness. Examination and baseline spirometry are normal. Blood eosinophils are not raised. Which objective finding would support a diagnosis of asthma in this adult under current BTS/NICE/SIGN guidance?

  1. AFeNO 52 ppb
  2. BFeNO 42 ppb with eosinophils within the laboratory reference range
  3. CFEV1 increase of 10% and 180 mL after bronchodilator
  4. DPeak expiratory flow amplitude-percentage-mean variability of 16%
  5. EFEV1 increase of 8% of predicted normal after bronchodilator
Show answer and explanation

Answer: A FeNO 52 ppb

The 2024 joint BTS/NICE/SIGN guideline (NICE NG245) asks for objective evidence before diagnosing asthma, because symptoms alone are non-specific. In adults, the usual first test is a raised blood eosinophil count or FeNO. FeNO of 50 ppb or more confirms type 2 airway inflammation and supports the diagnosis, so 52 ppb is enough. If FeNO is 40–49 ppb, an eosinophil count above the laboratory reference range can support asthma instead. If neither is diagnostic, look for variable airflow obstruction: bronchodilator reversibility with an FEV1 increase of 12% or more and 200 mL or more from baseline, or an increase of 10% or more of predicted normal FEV1; or peak flow variability of 20% or more over 2 weeks. If doubt remains, refer for bronchial challenge testing. Normal baseline spirometry between episodes does not exclude asthma.

Key clue
Variable respiratory symptoms with normal baseline spirometry
What it means
Seek objective evidence of variable airflow obstruction or type 2 inflammation
What to do
FeNO 52 ppb exceeds the adult threshold and supports asthma

Why the other options are less appropriate

  • B 42 ppb is below 50, and an eosinophil count within the normal range does not meet the alternative criterion. Neither supports the diagnosis.
  • C Both thresholds are missed: the route needs 12% or more and 200 mL or more, and 10% with 180 mL meets neither.
  • D Peak flow variability must be 20% or more; 16% is below the threshold.
  • E The alternative bronchodilator route needs an FEV1 rise of 10% or more of predicted normal; 8% is not enough.

Source: NICE NG245: Asthma—diagnosis, monitoring and chronic asthma management

Question 2Asthma diagnosisMedium

An adult has a history suggestive of asthma, but blood eosinophils and FeNO are not diagnostic. Spirometry is unavailable for several weeks. Which next test best assesses variable airflow limitation in routine practice?

  1. ASingle peak expiratory flow measurement
  2. BBronchodilator reversibility when spirometry becomes available
  3. CTwice-daily peak expiratory flow for 2 weeks
  4. DHome overnight oximetry
  5. EImmediate specialist bronchial challenge testing
Show answer and explanation

Answer: C Twice-daily peak expiratory flow for 2 weeks

The history suggests asthma, but neither the blood eosinophil count nor FeNO has confirmed it, and spirometry will not be available for weeks. NICE NG245, the joint BTS, NICE and SIGN guideline, uses a stepwise sequence of objective tests. In adults it starts with eosinophils or FeNO. If these are not diagnostic, the next step is spirometry with bronchodilator reversibility. When spirometry cannot be done promptly, the patient should record peak expiratory flow twice daily for 2 weeks. Variability of 20% or more supports asthma in someone with a suggestive history. A single reading cannot show variability, and one normal value does not exclude asthma, because airflow limitation in asthma comes and goes. Show the patient good technique and use the same meter throughout. If asthma is still suspected after these tests are negative, refer for bronchial challenge testing, such as methacholine or mannitol. Where possible, make the diagnosis before starting inhaled corticosteroids, because treatment can reduce variability and make later tests less informative.

Key clue
Suggestive history with spirometry unavailable or delayed
What it means
Use an available objective test of day-to-day variability
What to do
Use twice-daily PEF monitoring for 2 weeks

Why the other options are less appropriate

  • A One peak flow value cannot show change over time. Asthma is supported by variability across repeated readings, not a single result.
  • B Reversibility testing is the usual next step, but waiting several weeks delays diagnosis when a peak flow diary can start now.
  • D Overnight oximetry looks for sleep-related desaturation, such as in obstructive sleep apnoea. It does not measure airflow limitation.
  • E Bronchial challenge is reserved for when earlier objective tests are negative but asthma is still suspected. It is not the next step here.

Source: NICE NG245: Asthma—diagnosis, monitoring and chronic asthma management

Question 3Asthma initial treatmentMedium

A 38-year-old with newly confirmed asthma wakes with symptoms four nights each week but is currently stable and does not require admission. What is the recommended initial inhaled strategy?

  1. ALow-dose MART with ICS/formoterol
  2. BAs-needed low-dose ICS/formoterol AIR therapy
  3. CRegular low-dose ICS with a SABA reliever
  4. DModerate-dose MART from the outset
  5. EAn LTRA with a SABA reliever
Show answer and explanation

Answer: A Low-dose MART with ICS/formoterol

Waking at night with asthma four nights a week means his asthma is highly symptomatic. NICE NG245 (the joint BTS, NICE and SIGN guideline) changes the initial treatment for that reason. For most people aged 12 and over with newly diagnosed asthma, NG245 recommends as-needed low-dose ICS/formoterol, known as anti-inflammatory reliever (AIR) therapy. When the person is highly symptomatic at presentation, for example waking at night regularly, or presents with a severe exacerbation, NG245 recommends starting low-dose maintenance and reliever therapy (MART) with ICS/formoterol instead. Any acute symptoms are treated at the same time. One inhaler does both jobs: it is taken regularly, and extra doses are used for symptoms. Every reliever dose also contains a corticosteroid. SABA alone is no longer used. If asthma is not controlled on low-dose MART, check adherence and inhaler technique, then measure FeNO or the blood eosinophil count, and move up to moderate-dose MART. Refer if asthma is still not controlled on moderate-dose MART.

Key clue
New diagnosis plus frequent nocturnal waking
What it means
Highly symptomatic asthma needs maintenance anti-inflammatory treatment
What to do
Start low-dose ICS/formoterol MART

Why the other options are less appropriate

  • B AIR therapy is the starting treatment for less symptomatic asthma. Frequent night waking calls for regular maintenance from the start.
  • C Regular ICS with a SABA reliever is the older approach. NG245 now prefers ICS/formoterol-based treatment.
  • D Moderate-dose MART is the next step if low-dose MART does not give control. It is not where treatment starts.
  • E An LTRA is an add-on option later in treatment. It is not the preferred first controller for highly symptomatic adult asthma.

Source: NICE NG245: Medicines for initial management in people aged 12 and over

Question 4Long-term oxygen therapyEasy

A patient with COPD meets criteria for long-term oxygen therapy. What minimum daily duration should usually be advised?

  1. A1 hour
  2. B4 hours
  3. C8 hours
  4. DOnly during episodes of breathlessness
  5. E15 hours
Show answer and explanation

Answer: E 15 hours

Long-term oxygen therapy (LTOT) improves survival in COPD only when it corrects chronic hypoxaemia for most of the day. The trials that showed benefit used oxygen for at least 15 hours a day, so NICE NG115 advises at least 15 hours daily, including overnight, when hypoxaemia worsens. Assess for LTOT when the person is clinically stable and on optimal treatment. Offer it if the PaO2 is below 7.3 kPa, or 7.3–8 kPa with secondary polycythaemia, peripheral oedema or pulmonary hypertension. Confirm this with two arterial blood gas measurements at least 3 weeks apart. Before prescribing, carry out a structured risk assessment, including fire risk from smoking in the home, falls from tripping over tubing, and exposure to smokers. Do not offer LTOT to people who continue to smoke despite support to stop. LTOT is different from ambulatory oxygen and from short-burst oxygen, which NICE does not recommend for breathlessness alone. Review people on LTOT at least once a year.

Key clue
Confirmed indication for LTOT
What it means
Benefit depends on prolonged daily correction of hypoxaemia
What to do
Advise at least 15 hours daily

Why the other options are less appropriate

  • A One hour a day corrects hypoxaemia far too briefly to give the survival benefit seen in the oxygen trials.
  • B Four hours is well below the 15-hour minimum and would leave the patient hypoxaemic for most of the day.
  • C Night-only use of about 8 hours falls short of the 15-hour minimum. Longer daily use is needed for benefit.
  • D LTOT treats chronic hypoxaemia, not episodes of breathlessness. Short-burst oxygen for breathlessness alone is not recommended.

Source: NICE NG115: Long-term oxygen therapy in COPD

Question 5Bronchiectasis long-term treatmentHard

An adult with CT-confirmed bronchiectasis has chronic Pseudomonas aeruginosa infection and three exacerbations in the last year despite optimised airway clearance. Previous non-tuberculous mycobacterial infection makes macrolide monotherapy inappropriate. Which long-term treatment should be offered?

  1. ARoutine high-dose inhaled corticosteroid without asthma or COPD
  2. BLong-term oral non-macrolide antibiotic as universal first-line prevention
  3. CNo preventive treatment unless another severe exacerbation requires ventilation
  4. DLong-term inhaled antibiotic with a defined trial and formal assessment of response
  5. ELong-term azithromycin monotherapy without reassessing NTM status
Show answer and explanation

Answer: D Long-term inhaled antibiotic with a defined trial and formal assessment of response

Chronic Pseudomonas aeruginosa infection with three exacerbations in a year despite good airway clearance places this patient at high risk of further exacerbations, hospital admission and faster lung function decline. The 2025 ERS guideline recommends long-term inhaled antibiotics in this group. Options include nebulised colistimethate or tobramycin, or dry-powder formulations. Long-term macrolides are the other main preventive option, but a history of non-tuberculous mycobacterial infection makes macrolide monotherapy unsafe because it can select macrolide-resistant NTM. Before starting, send sputum for mycobacterial culture where NTM is a concern. The first dose should be given under supervision with spirometry before and after, because bronchospasm is common. Treatment is prescribed for a defined trial with planned review of exacerbation frequency, symptoms, sputum and tolerability, then continued only if it helps. NICE NG117 advises specialist advice before starting long-term antibiotic prophylaxis in bronchiectasis.

Key clue
Chronic Pseudomonas, recurrent exacerbations despite airway clearance, and macrolide safety concern
What it means
High-risk bronchiectasis needs preventive antibiotic therapy targeted to airway infection
What to do
Offer a monitored trial of long-term inhaled antibiotic therapy

Why the other options are less appropriate

  • A Inhaled corticosteroids are not routine in bronchiectasis without asthma or COPD, and may increase infection risk.
  • B Long-term oral non-macrolide antibiotics are not the recommended first preventive step and risk resistance and side effects.
  • C Three exacerbations a year with chronic Pseudomonas already defines high risk. Waiting for ventilation-requiring illness is unsafe.
  • E Macrolide monotherapy after NTM infection risks selecting macrolide-resistant NTM, and active NTM must be excluded first.

Source: ERS 2025 clinical practice guideline for management of adult bronchiectasis

That is 5 of 327. Carry on with respiratory medicine in the practice bank, with progress tracking, flashcards and timed sessions.

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Topics covered

Show all 301 respiratory medicine topics
  • A confident multidisciplinary IPF diagnosis without biopsy
  • A dependent adolescent smoker
  • A fluoroquinolone is not casual empirical cover
  • A low-suspicion pulmonary embolism presentation
  • A new Burkholderia cepacia complex isolate in stable CF
  • A positive FeNO in an adult
  • Acid-base physiology
  • Acute eosinophilic pneumonia
  • Acute hypoxaemic respiratory failure
  • Acute laryngotracheitis differential
  • Acute non-invasive ventilation
  • Acute respiratory distress syndrome
  • Acute severe asthma
  • Adequate lung-cancer tissue for treatment planning
  • Adult stridor airway emergency
  • Age changes cytisinicline eligibility
  • Allergic bronchopulmonary aspergillosis
  • Alpha-1 antitrypsin augmentation
  • Alpha-1 antitrypsin deficiency
  • An inhaler with lower emissions but unusable technique
  • Antimicrobial response is not the only admission criterion
  • Asbestos-related disease
  • Aspergilloma
  • Aspiration pneumonia
  • Aspiration-pneumonia risk
  • Assessing IPF trajectory rather than a single walk distance
  • Asthma
  • Asthma diagnosis
  • Asthma exacerbation requiring oral steroids during pregnancy
  • Asthma initial treatment
  • Avoiding redundant bone scintigraphy after staging PET-CT
  • Avoiding SABA-only prescribing
  • Azithromycin safety work-up in COPD
  • Biomarkers in possible pneumonia treatment failure
  • Birt-Hogg-Dubé syndrome
  • Brain staging in stage III NSCLC
  • Bronchial challenge after inconclusive objective tests
  • Bronchiectasis
  • Bronchiectasis airway clearance
  • Bronchiectasis long-term treatment
  • Bronchiolitis obliterans syndrome
  • Bronchocentric granulomatosis
  • Bronchodilator response expressed relative to predicted FEV1
  • Bronchodilator response in context
  • Bronchodilator reversibility
  • Broncholithiasis
  • Bronchopleural fistula
  • Bullectomy threshold
  • Byssinosis
  • Carbon monoxide poisoning
  • Cardiac pseudoexudate after diuresis
  • Catamenial pneumothorax
  • Central sleep apnoea
  • Choosing hospital rather than home sleep testing
  • Chronic beryllium disease
  • Chronic eosinophilic pneumonia
  • Chronic pulmonary aspergillosis
  • Chronic thromboembolic pulmonary hypertension
  • Chylothorax
  • Coal workers pneumoconiosis
  • Combined pulmonary fibrosis and emphysema
  • Community-acquired pneumonia
  • Confirming an abnormal glucose-tolerance result in CF
  • Connective-tissue disease ILD
  • Contrast cannot be used
  • Controlled oxygen
  • COPD
  • COPD assessment
  • COPD exacerbation
  • COPD exacerbation with persisting ventilatory failure
  • COPD spirometry
  • COPD–OSAHS overlap
  • Cor pulmonale symptom treatment
  • Corticosteroid in high-severity CAP
  • Croup versus adult stridor
  • Cryptogenic organising pneumonia
  • Cystic fibrosis
  • Cytomegalovirus pneumonitis
  • D-dimer delay in an unlikely-PE pathway
  • Deep sulcus sign
  • Dendriform pulmonary ossification
  • Dental suitability before a mandibular advancement splint
  • Desquamative interstitial pneumonia
  • Diaphragmatic weakness
  • Diffuse alveolar haemorrhage
  • Diffuse panbronchiolitis
  • DIPNECH
  • Distal intestinal obstruction in an adult with CF
  • Drug-susceptible pulmonary tuberculosis
  • Dual bronchodilation without steroid-responsive features
  • Dynamic hyperinflation and auto-PEEP
  • Early review after starting CPAP
  • Early transplant discussion in idiopathic pulmonary fibrosis
  • Eligibility for prophylactic azithromycin
  • Epiglottitis airway handling
  • Equivocal chest-wall invasion on lung-cancer CT
  • Escalation from low-dose MART after appropriate review
  • Exercise assessment before lung cancer surgery
  • Exercise physiology
  • FeNO monitoring during adult asthma review
  • Fibrotic interstitial lung disease
  • First mucoactive treatment in established CF lung disease
  • Flexible bronchoscopy for a central target when nodal staging will not change treatment
  • Flow-volume loops
  • Follow-up imaging after pneumonia
  • Further assessment after negative oximetry
  • Gas exchange physiology
  • Gas transfer
  • High-altitude pulmonary oedema
  • High-severity community-acquired pneumonia
  • Hospital-acquired pneumonia
  • Hypersensitivity pneumonitis
  • Hypersensitivity pneumonitis lavage
  • Hypoxic challenge testing
  • Idiopathic pulmonary fibrosis
  • Imaging in likely pulmonary embolism
  • Incidental emphysema on chest CT
  • Indication for non-invasive ventilation
  • Inhalation injury warning signs
  • Inhaled foreign body collapse
  • Initial AIR therapy
  • Initial imaging for localised suspected bone metastasis
  • Initial MART for highly symptomatic asthma
  • Initial treatment of a highly symptomatic adult
  • Inpatient isolation for possible multidrug-resistant TB
  • Interim anticoagulation when CTPA is delayed
  • Interpreting bicarbonate when pre-test probability is low
  • Interpreting peak-flow amplitude percentage mean
  • Intrapulmonary shunt
  • Invasive pulmonary aspergillosis
  • Investigating suspected occupational asthma
  • KCO in extraparenchymal restriction
  • Large tonsils as a treatable contributor to OSAHS
  • Laryngeal cancer respiratory presentation
  • Laryngeal oedema after ACE inhibitor
  • Latent tuberculosis
  • Life-threatening asthma
  • Life-threatening haemoptysis
  • Limits of pulse oximetry
  • Löfgren syndrome
  • Long-term oxygen assessment
  • Long-term oxygen therapy
  • Long-term oxygen with borderline PaO2 and cor pulmonale
  • Low Epworth score does not exclude OSAHS
  • Low-severity community-acquired pneumonia
  • Lung allograft dysfunction
  • Lung cancer staging
  • Lung-volume-reduction referral screen
  • Lymphangioleiomyomatosis
  • Malignant pleural effusion
  • Malignant pleural mesothelioma
  • Managing dryness and rhinitis during otherwise effective CPAP
  • Mechanical ventilation is not a routine default in advanced IPF
  • Mepolizumab eligibility
  • Metastatic spinal cord compression
  • Mild OSAHS with important daytime impairment
  • Mild sleep apnoea without daytime functional impairment
  • Mounier-Kuhn syndrome
  • Nebulised adrenaline role
  • Nebulised therapy
  • Negative EBUS despite high suspicion of mediastinal malignancy
  • Negative first tests do not end asthma assessment
  • Negative imaging with persistent DVT suspicion
  • Neuromuscular disease
  • Neuromuscular respiratory failure
  • New cough in a patient with established IPF
  • New MRSA in a CF respiratory sample
  • Nodular pulmonary amyloidosis
  • Non-invasive ventilation to support difficult airway clearance
  • Non-small-cell lung cancer
  • Non-type-2 add-on asthma treatment
  • Normal FeNO after inhaled corticosteroid treatment
  • Normal resting saturation with exertional breathlessness in IPF
  • NTM exclusion before macrolide monotherapy
  • Objective confirmation with FeNO
  • Objective reassessment after OSAHS surgery
  • Obstructive sleep apnoea symptoms
  • Obtaining a lower-airway specimen after non-invasive sampling fails
  • Occupational asthma
  • OHS with severe OSAHS
  • OHS without severe OSAHS
  • Omalizumab eligibility
  • One new non-tuberculous mycobacterial result in CF
  • OSAHS diagnosis
  • OSAHS driving safety
  • Outpatient management of low-risk PE
  • Oxygen eligibility after recovery
  • Oxygen reassessment after an IPF admission
  • Pairing nicotine replacement formulations
  • Pancoast tumour
  • Partial benefit from the first non-type-2 asthma add-on
  • Persistent air leak in a non-surgical patient
  • Persistent hypercapnia despite an adequate CPAP trial in OHS
  • Physiological dead space
  • Pleural aspiration safety
  • Pleural effusion
  • Pleural infection
  • Pleuroparenchymal fibroelastosis
  • Pneumococcal urinary antigen in CAP
  • Pneumocystis pneumonia
  • Pneumonia risk with inhaled corticosteroids
  • Positional treatment in severe OSAHS
  • Post-extubation stridor
  • Potentially curable lung cancer
  • Pre-escalation assessment
  • Pregnancy changes medicine choices
  • Primary ciliary dyskinesia
  • Primary spontaneous pneumothorax
  • Prioritising suspected sleep apnoea before major surgery
  • Priority assessment for OSA and driving risk
  • Probable PE and delayed imaging
  • Progressive fibrosing ILD
  • Pseudochylothorax
  • Pulmonary alveolar microlithiasis
  • Pulmonary alveolar proteinosis
  • Pulmonary arterial hypertension
  • Pulmonary arteriovenous malformation
  • Pulmonary artery intimal sarcoma
  • Pulmonary capillary haemangiomatosis
  • Pulmonary decompression sickness
  • Pulmonary embolism
  • Pulmonary Langerhans cell histiocytosis
  • Pulmonary light-chain deposition disease
  • Pulmonary nodule risk modelling
  • Pulmonary rehabilitation at IPF diagnosis
  • Pulmonary rehabilitation eligibility
  • Pulmonary rehabilitation for functional limitation
  • Pulmonary sequestration
  • Pulmonary talcosis
  • Pulmonary tuberculosis
  • Pulmonary tumour thrombotic microangiopathy
  • Pulmonary veno-occlusive disease
  • QT safety before long-term macrolide
  • Reassessing CPAP after substantial weight loss
  • Reassessing ventilatory modality after acute OHS stabilisation
  • Recognising possible idiopathic pulmonary fibrosis
  • Recurrent laryngeal nerve palsy
  • Recurrent pulmonary embolism during anticoagulation
  • Repeated exacerbations and prevention
  • Residual hypoxaemia after optimisation of OHS ventilation
  • Residual sleepiness despite controlled OSAHS
  • Respiratory muscle testing
  • Restricted role of sputum cytology in suspected lung cancer
  • Restrictive ventilatory impairment
  • Retaining a useful add-on when converting to MART
  • Review frequency for rapidly progressing IPF
  • Reviewing oral mucolytic therapy
  • Rhinitis undermining CPAP adherence
  • Risk despite a reassuring asthma symptom report
  • Roflumilast eligibility
  • Rounded atelectasis
  • Sarcoidosis
  • Sarcoidosis hypercalcaemia
  • Seasonal influenza
  • Secondary spontaneous pneumothorax
  • Selecting biopsy for a peripheral lung lesion without nodal targets
  • Sensitive assessment when CF spirometry remains normal
  • Severe acute respiratory distress syndrome
  • Silica occupational health
  • Silicosis
  • Silo-filler disease
  • Small-cell lung cancer
  • Squamous-cell lung cancer
  • Stable Aspergillus-positive cultures without allergic disease
  • Stable assessment for long-term oxygen therapy
  • Steroids and a misleading negative test
  • Structured step-down after sustained asthma control
  • Superior sulcus tumour
  • Superior vena cava obstruction
  • Supportive care alongside antifibrotic treatment
  • Surgery after recurrent pneumothorax
  • Surgical assessment after supervised non-surgical OSAHS treatment fails
  • Suspected lung cancer
  • Suspected occupational asthma
  • Suspected pulmonary embolism
  • Swyer-James-MacLeod syndrome
  • Telemonitoring when CPAP is initiated
  • Tension pneumothorax
  • The previous sputum result is a treatment clue
  • Theophylline review when an interacting antibiotic is prescribed
  • Therapeutic pleural aspiration
  • Thoracic splenosis
  • Tracheobronchomalacia
  • Tracheostomy obstruction
  • Trapped lung
  • Uncertain interstitial lung disease and biopsy risk
  • Uncontrolled asthma
  • Uncontrolled asthma with raised type 2 biomarkers
  • Unilateral diaphragmatic paralysis
  • Upper-airway obstruction flow loop
  • Urinothorax
  • Vaccination despite limited exacerbation history
  • Varenicline needs a lead-in
  • Variable pressure requirements during otherwise effective CPAP
  • Ventilator liberation
  • Very low predicted postoperative lung function
  • Vocal-cord dysfunction clue
  • Why oximetry alone is insufficient in COPD–OSAHS overlap
  • Williams-Campbell syndrome
  • Worsening exacerbation needs a different diagnosis check
  • Yellow nail syndrome

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