NYACP Board Review Question of the Week
Every other Tuesday, NYACP members are sent a Board Review Question from ACP's MKSAP 18 to test professional knowledge and help prepare for the exam. Participant totals and answer percentages are distributed on the first Thursday of the month in IM Connected, the Chapter's eNewsletter, and are also published on this page.
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September 8th, 2026
MKSAP 19 Pulmonary & Critical Care Medicine, Question 48
A 29-year-old woman was hospitalized 24 hours ago with hypoxemic respiratory failure due to influenza pneumonia. She was intubated and placed on mechanical ventilation. Treatment includes lactated Ringer solution, intravenous peramivir, propofol, fentanyl, and norepinephrine.
On physical examination, temperature is 38.1 °C (100.6 °F), blood pressure is 109/59 mm Hg, pulse rate is 90/min, and respiration rate is 24/min. The arterial PO2 is 60 mm Hg on FIO2 of 0.65, and positive end-expiratory pressure is 10 cm H2O. Tidal volume is 6 mL/kg ideal body weight, and plateau pressure is 27 cm H2O. The patient is sedated but wakes to touch and is calm. Pulmonary rhonchi are present bilaterally.
Chest radiograph shows bilateral opacities. Echocardiogram reveals normal cardiac function and chamber size.
Which of the following is the most appropriate intervention to improve oxygenation?
A. Increase level of sedation
B. Perform recruitment maneuver
C. Prone positioning
D. Start diuretics
Responses Received from Members (Graph is uploaded on Thursday afternoon):
The Correct Answer is: C. Prone positioning
Educational Objective: Treat acute respiratory distress syndrome with prone positioning.
The most appropriate management is prone positioning (Option C). The patient has severe acute respiratory distress syndrome (ARDS) due to influenza pneumonia (arterial PO2/FIO2 = 92). Prone positioning reduces compression of portions of the lung behind the cardiac and mediastinal structures and improves ventilation/perfusion matching in patients with ARDS. Prone positioning for at least 12 to 16 hours daily should be considered for patients with moderate to severe ARDS with persistent hypoxemia despite use of low tidal volume ventilation and plateau pressure less than 30 cm H2O. The indications for prone positioning have been variably defined, but entry criteria in a pivotal clinical trial that showed benefit included: arterial PO2/FIO2 <150; FIO2 ≥0.60 on positive end- expiratory pressure >5 cm H2O. Study participants were intubated for less than 48 hours before initiating prone positioning. Although the patient is also meeting goals for lung protective ventilation, randomized trials show that the addition of prone positioning improves mortality in those patients.
The sedation level should not be increased (Option A). The patient is meeting goals for sedation and is calm and easily arousable. Light-sedation protocols or daily awakening trials are associated with decreased length of mechanical ventilation and length of ICU stay.
In patients with refractory hypoxemia, a recruitment maneuver (Option B)—applying a high level of CPAP to open collapsed alveoli (e.g., continuous pressure to 35 cm H2O for 40 seconds)—has been conditionally recommended. However, a randomized control trial demonstrated that recruitment maneuvers in patients with moderate to severe ARDS was associated with increased risk for barotrauma, pneumothorax, and death compared with standard care. The FACCT trial suggested that excessive fluid resuscitation is harmful to ARDS patients.
This trial compared conservative with liberal fluid strategies based on central venous pressure and pulmonary artery occlusion pressure (a surrogate for left atrial pressure) in patients with ARDS. Although mortality did not differ between groups, patients who were treated with conservative fluid management showed improved oxygenation and decreased time on the ventilator and in the ICU. In patients who are hemodynamically stable and do not have end-organ hypoperfusion, minimizing fluid administration is warranted. This patient still requires norepinephrine blood pressure support; diuresis is not indicated at this time (Option D).
Key Point
- Prone positioning for at least 12 hours daily should be considered for patients with acute respiratory syndrome and arterial PO2/FIO2 <150 mm Hg, FIO2 ≥0.60 on positive end- expiratory pressure >5 cm H2O, who have been intubated for less than 48 hours.
Bibliography
Thompson BT, Chambers RC, Liu KD. Acute respiratory distress syndrome. N Engl J Med. 2017;377:562-572. PMID: 28792873 doi:10.1056/NEJMra1608077
Multiple-choice questions reprinted with permission from the American College of Physicians.
MKSAP 19. © Copyright 2021 American College of Physicians.
ACP MKSAP. © Copyright 2026 American College of Physicians. All Rights Reserved All Rights Reserved.
August 25th, 2026
Pulmonary & Critical Care Medicine, Question 62
A 72-year-old man is evaluated for daytime sleepiness. His wife notes that he snores. He sleeps 8 hours each night. On most days of the week, he feels sleepy and will nap for 45 minutes. Medical history is significant for atrial fibrillation and heart failure. Medications are valsartan-sacubitril, metoprolol, furosemide, spironolactone, empagliflozin, and apixaban.
On physical examination, vital signs are normal. BMI is 27. Low-lying soft palate, irregularly irregular cardiac rhythm, normal central venous pressure, clear lung fields, and chronic venous stasis are present.
Transthoracic echocardiogram obtained 1 year ago showed left ventricular enlargement and left ventricular ejection fraction of 40%.
Which of the following is the most appropriate test?
A. Actigraphy
B. Home sleep apnea testing
C. Overnight oximetry
D. Polysomnography
Responses Received from Members (725 Responses):
The Correct Answer is: D. Polysomnography
Educational Objective: Diagnose sleep apnea with polysomnography.
The most appropriate management is polysomnography in a sleep laboratory (Option D). Objective testing is required for a diagnosis of obstructive sleep apnea (OSA) and central sleep apnea (CSA). In- laboratory polysomnography is the gold standard test for mission-critical workers, patients with complicated OSA, and patients with comorbid conditions such as heart failure, neuromuscular disease, and advanced pulmonary disease in which diagnostic and treatment algorithms are more complex. This patient has risk factors for both OSA (male sex, snoring, overweight) and CSA (heart failure and atrial fibrillation). Once the type of apnea is clarified during the diagnostic portion of polysomnography, the technician may then use the most appropriate mode of positive airway pressure therapy and assess the response to treatment.
An actigraph (Option A), a small device worn on the wrist, uses an accelerometer and an ambient light sensor to objectively measure disrupted sleep patterns and sleep-wake cycles over multiple days and nights. Actigraphy is not a substitute for a home sleep study or polysomnography and cannot diagnose sleep apnea syndromes.
Home sleep apnea testing (Option B) should be used in patients without comorbid cardiopulmonary disease who are likely to have OSA of at least moderate severity, such as a middle-aged man with obesity who snores loudly, pauses breathing, and gasps during sleep.
Overnight pulse oximetry (Option C) is poorly discriminative to diagnose OSA, but in those who are asymptomatic with a low pretest probability, normal overnight oximetry might be reassuring and support the decision to avoid further testing. The patient has daytime sleepiness, which is a strong indication for treatment of sleep-disordered breathing. Further screening with overnight oximetry will not add reliably important diagnostic information, nor will it alter the decision to treat.
Key Point
- In-laboratory polysomnography is the gold standard sleep apnea test for mission-critical workers, patients with complicated obstructive sleep apnea, and patients with comorbid conditions such as heart failure, neuromuscular disease, and advanced pulmonary disease in which diagnostic and treatment algorithms are more complex.
Bibliography
Kapur VK, Auckley DH, Chowdhuri S, et al. Clinical practice guideline for diagnostic testing for adult obstructive sleep apnea: an American Academy of Sleep Medicine clinical practice guideline. J Clin Sleep Med. 2017;13:479-504. PMID: 28162150 doi:10.5664/jcsm.6506
Multiple-choice questions reprinted with permission from the American College of Physicians.
MKSAP 19. © Copyright 2021 American College of Physicians.
ACP MKSAP. © Copyright 2026 American College of Physicians. All Rights Reserved All Rights Reserved.