100+ Free ABIM Pulmonary Practice Questions

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Question 1

Score: 0/0

A 66-year-old man with a 40 pack-year smoking history has post-bronchodilator FEV1 48% predicted and reports one moderate exacerbation in the past year with mMRC dyspnea score 3. Per GOLD 2024, which GOLD group applies and what is preferred initial maintenance therapy?

Group A — SABA as needed

Group B — LABA + LAMA combination

Group E — LABA + LAMA + ICS triple therapy

Group B — ICS monotherapy

to track

2026 Statistics

Key Facts: ABIM Pulmonary Exam

~220

Exam Questions

ABIM 2026

~10 hours

Exam Day Length

ABIM 2026

~$2,990

Application + Exam Fee

ABIM 2026

~85-90%

First-Attempt Pass Rate

ABIM Assessment Results

2 yr / 3 yr

Pulm vs PCCM Fellowship

ACGME

5-yr LKA

MOC Option

ABIM MOC

The ABIM Pulmonary Disease subspecialty exam certifies internists to practice as adult pulmonologists. It consists of approximately 220 single-best-answer MCQs administered across four ~2-hour modules over a single ~10-hour test day at Pearson VUE centers. The application + exam fee is approximately $2,990. Eligibility requires active ABIM Internal Medicine certification plus satisfactory completion of an ACGME-accredited 2-year Pulmonary Disease fellowship (or a combined 3-year PCCM fellowship for dual certification). The 2026 blueprint emphasizes COPD GOLD 2024 (ABE classification, LABA+LAMA primary bronchodilator, triple therapy for eos ≥300, ETHOS mortality data), asthma GINA 2024 (Track 1 ICS-formoterol as needed, T2 biologic selection), IPF with nintedanib/pirfenidone antifibrotics, progressive pulmonary fibrosis (2022 ATS/ERS), pulmonary hypertension (2022 ESC/ERS mPAP ≥20, sotatercept STELLAR FDA 2024), CTEPH with PTE/BPA/riociguat, acute PE management, ARDS with low-TV ventilation and prone positioning, lung cancer screening (USPSTF 2021 LDCT), and CFTR modulator therapy (Trikafta). Once certified, diplomates maintain certification via the Longitudinal Knowledge Assessment (LKA) or the 10-year recertification exam.

Sample ABIM Pulmonary Practice Questions

Try these sample questions to test your ABIM Pulmonary exam readiness. Each question includes a detailed explanation. Start the interactive quiz above for the full 100+ question experience with AI tutoring.

1A 66-year-old man with a 40 pack-year smoking history has post-bronchodilator FEV1 48% predicted and reports one moderate exacerbation in the past year with mMRC dyspnea score 3. Per GOLD 2024, which GOLD group applies and what is preferred initial maintenance therapy?

A.Group A — SABA as needed

B.Group B — LABA + LAMA combination

C.Group E — LABA + LAMA + ICS triple therapy

D.Group B — ICS monotherapy

Explanation: GOLD 2024 uses the ABE classification. Patients with ≤1 moderate exacerbation (no hospitalization) fall into Group A (mild symptoms, CAT <10 or mMRC 0-1) or Group B (higher symptom burden — CAT ≥10 or mMRC ≥2). This patient has high symptom burden (mMRC 3) and is not an exacerbator (only 1 moderate), so Group B. GOLD 2024 recommends LABA + LAMA combination as initial therapy for Group B — single bronchodilator monotherapy is no longer preferred.

2A 70-year-old COPD patient on LABA + LAMA combination has two moderate exacerbations in the past year and a peripheral blood eosinophil count of 380 cells/µL. What is the best next step?

A.Continue LABA + LAMA without change

B.Add inhaled corticosteroid (escalate to triple therapy)

C.Switch to ICS monotherapy

D.Start chronic oral prednisone 10 mg daily

Explanation: Per GOLD 2024, escalation from LABA + LAMA to triple therapy (LABA + LAMA + ICS) is indicated when patients continue to have exacerbations (≥2 moderate or ≥1 severe per year) AND blood eosinophil count is ≥300 cells/µL. ICS monotherapy is not recommended in COPD. The ETHOS trial demonstrated a mortality benefit of triple therapy (budesonide/glycopyrrolate/formoterol) over dual bronchodilator therapy in exacerbators, particularly those with elevated eosinophils.

3A 72-year-old COPD patient has chronic resting hypoxemia with SpO2 86% on room air and PaO2 52 mmHg. What is the indication and recommended duration for long-term oxygen therapy (LTOT)?

A.No indication for LTOT; reassess in 3 months

B.LTOT ≥15 hours per day to improve survival

C.LTOT only during exercise

D.Continuous BiPAP instead of oxygen

Explanation: LTOT is indicated in COPD when resting PaO2 ≤55 mmHg (or SaO2 ≤88%), or PaO2 56-59 mmHg in the presence of cor pulmonale, right heart failure, or secondary polycythemia (hematocrit >55%). LTOT used ≥15 hours per day (ideally continuously) improves survival in chronic hypoxemic COPD (NOTT and MRC trials). Ambulatory-only or nocturnal-only oxygen in patients with moderate hypoxemia has not shown mortality benefit (LOTT trial).

4A 64-year-old with severe COPD (FEV1 28% predicted) and frequent exacerbations has had three hospitalizations for COPD exacerbations this year despite optimized triple inhaler therapy. He has stopped smoking. What additional therapy is most likely to reduce his exacerbation frequency?

A.Chronic systemic prednisone 20 mg daily

B.Chronic azithromycin 250 mg daily or 500 mg three times weekly

C.Daily nebulized albuterol

D.Immediate lobectomy

Explanation: Chronic azithromycin (250 mg daily or 500 mg three times weekly) reduces exacerbation frequency in former-smoker COPD patients with frequent exacerbations on optimal inhaled therapy. Benefits are greatest in former smokers and older patients. Check baseline QTc and audiometry, monitor for hearing loss and macrolide resistance. Chronic systemic corticosteroids are not recommended in stable COPD due to adverse effects without proven benefit.

5A 58-year-old woman presents with an acute COPD exacerbation. She has increased dyspnea, increased sputum volume, and purulent sputum (all three Anthonisen criteria). Per the REDUCE trial evidence, which oral corticosteroid regimen is appropriate?

A.Prednisone 40 mg daily for 5 days

B.Prednisone 60 mg daily for 14 days with taper

C.Methylprednisolone 125 mg IV every 6 hours for 72 hours, then 14-day oral taper

D.Inhaled corticosteroid only, no systemic steroid

Explanation: The REDUCE trial (Leuppi JAMA 2013) demonstrated that 5 days of oral prednisone 40 mg daily is non-inferior to 14 days for treating COPD exacerbations and reduces corticosteroid-related adverse effects. This is the guideline-recommended regimen. Antibiotics are indicated when ≥2 of 3 Anthonisen criteria are present and at least one is purulent sputum — this patient meets criteria and should receive both steroids and antibiotics.

6A 42-year-old never-smoker with early-onset panlobular emphysema at the lung bases is diagnosed with alpha-1 antitrypsin deficiency. Which genotype is most associated with severe deficiency, and what is disease-modifying therapy?

A.Pi*MM; no augmentation needed

B.Pi*MZ; inhaled corticosteroids

C.Pi*ZZ; weekly IV augmentation with pooled human AAT

D.Pi*SS; oral colchicine

Explanation: The Pi*ZZ genotype produces severely deficient alpha-1 antitrypsin (AAT level typically <11 µM or <50 mg/dL) and causes early-onset panlobular basal-predominant emphysema. Disease-modifying therapy is weekly intravenous augmentation with pooled human AAT (60 mg/kg IV weekly), which has shown slowing of emphysema progression on CT densitometry (RAPID trial). Smoking avoidance is essential. Pi*MM is normal; Pi*MZ is intermediate risk.

7A 70-year-old man with severe COPD and upper-lobe-predominant emphysema on HRCT has FEV1 30% predicted, hyperinflation with RV 220% predicted, and 6-minute walk distance 200 m despite optimal medical therapy and pulmonary rehabilitation. Which intervention may improve symptoms and survival?

A.Daily oral theophylline

B.Lung volume reduction surgery or bronchoscopic lung volume reduction (endobronchial valves)

C.Chronic oral prednisone

D.Nightly CPAP for OSA screening

Explanation: Lung volume reduction in patients with upper-lobe-predominant emphysema and low exercise capacity improves dyspnea, exercise tolerance, and survival (NETT trial for surgical LVRS). Bronchoscopic lung volume reduction with one-way endobronchial valves (Zephyr or Spiration) is a less-invasive alternative for patients with little collateral ventilation (Chartis negative, intact fissures) who have severe hyperinflation. Chronic systemic steroids are not recommended and theophylline has a narrow therapeutic index.

8Which of the following best summarizes the GINA 2024 Track 1 approach to asthma therapy?

A.SABA-only therapy for all symptoms

B.ICS-formoterol as reliever at all steps (SABA-free care)

C.Daily SABA plus nighttime ICS monotherapy

D.Chronic oral corticosteroids as maintenance therapy at Step 2

Explanation: GINA 2024 Track 1 (preferred) uses ICS-formoterol as reliever at all steps — this provides anti-inflammatory relief and avoids SABA-only treatment, which is associated with increased asthma mortality. At Steps 1-2, patients use ICS-formoterol as needed only; at Steps 3-5, they use maintenance-and-reliever therapy (MART) with ICS-formoterol. Track 2 still allows SABA reliever with daily ICS controller when MART is impractical.

9A 34-year-old woman with severe asthma has persistent symptoms on high-dose ICS-LABA. Total IgE is 620 IU/mL, blood eosinophils are 80 cells/µL, and she has positive aeroallergen skin testing to dust mite. Which biologic is most appropriate?

A.Omalizumab (anti-IgE)

B.Mepolizumab (anti-IL-5)

C.Benralizumab (anti-IL-5Rα)

D.Dupilumab (anti-IL-4Rα)

Explanation: Omalizumab is FDA-approved for moderate-to-severe allergic asthma in patients ≥6 years old with positive aeroallergen skin testing or specific IgE and serum total IgE in the labeled range (30-1300 IU/mL depending on weight). Mepolizumab, reslizumab, and benralizumab target eosinophilic asthma (blood eos ≥150-300 cells/µL). Dupilumab is used for type-2 inflammation with elevated eosinophils or FeNO ≥25 ppb, or oral steroid dependence. This patient has elevated IgE with allergic sensitization and low eosinophils — omalizumab fits best.

10Which biologic for severe asthma is effective regardless of T2 biomarker status (i.e., useful for both T2-high and T2-low phenotypes)?

A.Omalizumab

B.Mepolizumab

C.Tezepelumab

D.Benralizumab

Explanation: Tezepelumab (anti-TSLP — thymic stromal lymphopoietin) targets an upstream alarmin and was shown in the NAVIGATOR trial to reduce exacerbations in severe asthma regardless of T2 biomarker status (eosinophils, FeNO, allergic sensitization). It is the only approved severe-asthma biologic without an eosinophil or IgE cutoff. The other biologics are T2-high-specific (omalizumab for allergic, mepolizumab/reslizumab/benralizumab for eosinophilic, dupilumab for type 2 including eos, FeNO, and OCS-dependent disease).

About the ABIM Pulmonary Exam

The ABIM Pulmonary Disease exam is the subspecialty board certification for internists who have completed an ACGME-accredited 2-year Pulmonary Disease fellowship, or a combined 3-year Pulmonary Disease and Critical Care Medicine (PCCM) fellowship. The exam covers the full spectrum of adult pulmonary medicine — obstructive lung disease (COPD GOLD 2024, asthma GINA 2024), interstitial lung disease (IPF, HP, CTD-ILD, sarcoidosis), pulmonary infection (CAP, TB, NTM, fungal), pulmonary hypertension and pulmonary embolism, critical care and mechanical ventilation, pleural disease, sleep-disordered breathing, lung cancer screening and nodule management, cystic fibrosis and bronchiectasis, occupational and environmental lung disease, and lung transplantation.

Questions

220 scored questions

Time Limit

~10-hour exam day (four ~2-hour modules)

Passing Score

Criterion-referenced scaled score (pass/fail)

Exam Fee

~$2,990 application + exam fee (American Board of Internal Medicine (ABIM))

ABIM Pulmonary Exam Content Outline

22%

Obstructive Lung Disease (COPD & Asthma)

COPD GOLD 2024 ABE, LABA+LAMA primary therapy, triple therapy when eos ≥300, azithromycin in exacerbators, LTOT SaO2 ≤88% or PaO2 ≤55, NIV hypercapnic failure, BLVR valves, REDUCE 5-day prednisone, Anthonisen criteria for antibiotics, ETHOS mortality benefit, alpha-1 antitrypsin Pi*ZZ augmentation. Asthma GINA 2024 Track 1 ICS-formoterol SABA-free, severe asthma biologics (omalizumab, mepolizumab, reslizumab, benralizumab, dupilumab, tezepelumab).

16%

Interstitial Lung Disease (ILD)

IPF UIP pattern (honeycomb, basal, peripheral, subpleural, reticular), nintedanib + pirfenidone antifibrotics, lung transplant referral. Progressive pulmonary fibrosis 2022 ATS/ERS. NSIP, hypersensitivity pneumonitis, SSc-ILD (SENSCIS nintedanib), RA-ILD, MDA5 rapidly progressive DM-ILD. Sarcoidosis Scadding staging, cardiac sarcoid CMR/PET. PLCH, AEP/CEP, alveolar proteinosis anti-GM-CSF antibody.

14%

Pulmonary Infection

CAP ATS/IDSA 2019, HAP/VAP pip-tazo + vancomycin with procalcitonin de-escalation, aspiration, latent TB IGRA screening, 4-month rifampin or 3HP, active TB RIPE 2+4, MDR-TB BPaL (bedaquiline-pretomanid-linezolid), NTM MAC 3-drug (clarithro + rifampin + ethambutol) ≥12 months, endemic fungi, COVID-19 and PASC/long COVID.

12%

Pulmonary Hypertension & PE

2022 ESC/ERS mPAP ≥20, PVR ≥2 WU. WHO groups 1-5. Group 1 PAH: vasoreactivity testing, upfront dual ERA+PDE5 (AMBITION), sotatercept STELLAR FDA 2024, selexipag, SC treprostinil. Group 4 CTEPH: PTE + BPA + riociguat. Acute PE: Wells+PERC, CTPA, DOAC first-line, systemic/catheter-directed thrombolysis for massive PE, PESI and home treatment for low-risk.

12%

Critical Care & Mechanical Ventilation

ARDS Berlin, low TV 4-6 mL/kg IBW, plateau ≤30, prone ≥12 hr for PF<150 (PROSEVA), NMB cisatracurium in severe ARDS, VV-ECMO per EOLIA. NIV for acute hypercapnic COPD and cardiogenic pulmonary edema. HFNC (FLORALI). SBT, RSBI <105, cuff leak, tracheostomy timing (TRACMAN).

Pleural & Thoracic Disease

Light's criteria for exudate vs transudate, parapneumonic effusion/empyema with tPA + DNase (MIST2), BTS pneumothorax sizing, chylothorax, malignant pleural effusion (IPC vs pleurodesis), mediastinal masses.

Sleep-Disordered Breathing

OSA AHI 5/15/30, CPAP titration, OHS, CSA Cheyne-Stokes in HF with ASV contraindicated for LVEF ≤45%, narcolepsy type 1 (orexin <110), RLS with ferritin 75-100 target and alpha-2-delta ligands first-line (2020 AASM), REM sleep behavior disorder as synucleinopathy prodrome.

Lung Cancer & Nodules

LDCT screening USPSTF 2021 (50-80, 20 pack-years, current or quit within 15 years), Fleischner 2017 nodule follow-up, AJCC 8 staging, EBUS-TBNA mediastinal staging, NSCLC biomarkers (EGFR, ALK, ROS1, BRAF, KRAS G12C, PD-L1).

Cystic Fibrosis & Bronchiectasis

CF genotype testing, CFTR modulators (ivacaftor, lumacaftor/tezacaftor, elexacaftor-tezacaftor-ivacaftor = Trikafta for F508del), airway clearance, Pseudomonas and Burkholderia infections, pancreatic enzymes. Non-CF bronchiectasis workup (IgG, NTM, ABPA, PCD), chronic macrolides.

Occupational, Hemoptysis & Transplant

Asbestosis/mesothelioma, silicosis/PMF, CWP, chronic beryllium disease (BeLPT), byssinosis, HP. Massive hemoptysis with bronchial artery embolization. Vocal cord dysfunction, tracheomalacia, subglottic stenosis. Lung transplant listing criteria and CLAD.

How to Pass the ABIM Pulmonary Exam

What You Need to Know

Passing score: Criterion-referenced scaled score (pass/fail)
Exam length: 220 questions
Time limit: ~10-hour exam day (four ~2-hour modules)
Exam fee: ~$2,990 application + exam fee

Keys to Passing

Complete 500+ practice questions
Score 80%+ consistently before scheduling
Focus on highest-weighted sections
Use our AI tutor for tough concepts

ABIM Pulmonary Study Tips from Top Performers

1Memorize COPD GOLD 2024 cold — ABE classification replaces ABCD (A = infrequent/mild symptoms, B = frequent/mild symptoms, E = exacerbator). First-line bronchodilator therapy is LABA + LAMA combination; escalate to triple therapy (LABA/LAMA/ICS) only if blood eosinophils ≥300 cells/µL or ≥2 moderate or 1 severe exacerbation per year. Chronic azithromycin reduces exacerbations in select patients. LTOT if SaO2 ≤88% or PaO2 ≤55 mmHg. Exacerbation: prednisone 40 mg × 5 days (REDUCE trial), antibiotics if 2/3 Anthonisen criteria plus purulent sputum. ETHOS showed mortality benefit for 3-drug inhaled therapy.

2Know asthma GINA 2024 Track 1 — ICS-formoterol as needed at all steps (SABA-free care). For severe asthma, match the biologic to the phenotype: omalizumab (anti-IgE) for allergic asthma, mepolizumab/reslizumab (anti-IL-5) and benralizumab (anti-IL-5R) for eosinophilic asthma, dupilumab (anti-IL-4R) for type 2 inflammation including nasal polyps and atopic dermatitis, tezepelumab (anti-TSLP) for both T2-high and T2-low severe asthma (no biomarker requirement).

3For IPF, recognize the UIP pattern on HRCT — honeycombing, basal and peripheral/subpleural predominance, reticular abnormality, traction bronchiectasis — and initiate antifibrotic therapy with nintedanib (OFEV) or pirfenidone (Esbriet) to slow FVC decline. Refer early for lung transplant evaluation. Know the 2022 ATS/ERS concept of progressive pulmonary fibrosis (PPF) — non-IPF ILDs that progress meet criteria for antifibrotic therapy (nintedanib approved). For scleroderma ILD, SENSCIS supports nintedanib.

4For pulmonary hypertension, memorize the 2022 ESC/ERS definition: mean PAP ≥20 mmHg at rest; precapillary PH adds PVR ≥2 Wood units and PCWP ≤15. For Group 1 PAH, initial therapy is upfront dual ERA + PDE5 inhibitor for intermediate-low risk (AMBITION ambrisentan + tadalafil). Add a prostacyclin pathway agent for intermediate-high risk. Sotatercept (STELLAR trial, FDA-approved 2024) is an activin signaling inhibitor added as a fourth-class agent. For Group 4 CTEPH, pulmonary thromboendarterectomy is first choice, balloon pulmonary angioplasty and riociguat for inoperable disease.

5For lung cancer screening, know USPSTF 2021 criteria — age 50 to 80, at least 20 pack-years, currently smoking or quit within the past 15 years — screen annually with low-dose CT. For incidental pulmonary nodules, apply Fleischner 2017: solid nodules <6 mm in low-risk patients need no routine follow-up, subsolid/part-solid nodules have separate algorithms, and size plus risk drive timing. For EBUS-TBNA, remember systematic N3 → N2 → N1 sampling to avoid upstaging errors in mediastinal staging.

Frequently Asked Questions

Who can take the ABIM Pulmonary Disease exam?

Candidates must hold active ABIM Internal Medicine certification and have satisfactorily completed an ACGME-accredited 2-year Pulmonary Disease fellowship, or a combined 3-year Pulmonary Disease and Critical Care Medicine (PCCM) fellowship. The fellowship program director must attest to clinical competence. Physicians completing a combined PCCM fellowship typically sit for both the Pulmonary Disease and Critical Care Medicine subspecialty exams and earn dual board certification.

How is the ABIM Pulmonary Disease exam structured?

The Pulmonary Disease exam contains approximately 220 single-best-answer multiple-choice questions administered across four ~2-hour modules on a single ~10-hour test day at Pearson VUE centers. Questions are case-based and emphasize clinical application of current guidelines (GOLD 2024 COPD, GINA 2024 asthma, 2022 ATS/ERS ILD guidance, 2022 ESC/ERS pulmonary hypertension, ATS/IDSA 2019 CAP) rather than rote recall.

What is the difference between the ABIM Pulmonary Disease exam and the PCCM fellowship path?

A stand-alone Pulmonary Disease fellowship is 2 years and leads to the ABIM Pulmonary Disease exam only. The combined Pulmonary Disease and Critical Care Medicine (PCCM) fellowship is 3 years and prepares candidates to sit for both the ABIM Pulmonary Disease exam and the ABIM Critical Care Medicine exam. Most academic pulmonologists in the US complete PCCM training because it provides broader career flexibility and ICU privileges.

What is the passing score for the ABIM Pulmonary Disease exam?

ABIM uses a criterion-referenced scaled passing score established through standard-setting methodology. The score is reported as pass/fail and the threshold is not publicly disclosed as a percentage. Historical first-time pass rates are approximately 85-90% for candidates who complete an ACGME-accredited Pulmonary Disease fellowship or PCCM fellowship.

How much does the ABIM Pulmonary Disease exam cost?

The application fee plus exam fee is approximately $2,990 for initial certification. Costs are subject to change — always confirm on the ABIM website. Total preparation cost including the CHEST SEEK Pulmonary Medicine question bank, ATS Pulmonary Board Review, Murray & Nadel's Textbook of Respiratory Medicine, and a high-yield question bank typically ranges from $3,500 to $5,500.

What topics are most heavily emphasized on the ABIM Pulmonary Disease exam?

The blueprint emphasizes Obstructive Lung Disease (COPD & Asthma, ~22%), Interstitial Lung Disease (~16%), Pulmonary Infection (~14%), Pulmonary Hypertension & PE (~12%), Critical Care & Mechanical Ventilation (~12%), Pleural Disease (~6%), Sleep-Disordered Breathing (~6%), Lung Cancer & Nodules (~6%), Cystic Fibrosis & Bronchiectasis (~4%), and Occupational/Hemoptysis/Transplant (~2%). High-yield content includes GOLD 2024 ABE classification, GINA 2024 Track 1 ICS-formoterol, IPF antifibrotic therapy, 2022 ESC/ERS PH definition with sotatercept, CTEPH, acute PE management with DOACs, and lung cancer screening (USPSTF 2021 LDCT).

How do I maintain ABIM Pulmonary Disease certification?

ABIM diplomates maintain Pulmonary Disease certification through the Longitudinal Knowledge Assessment (LKA) — an open-book, quarterly question set delivered over a 5-year cycle — or through the traditional 10-year recertification exam. Diplomates must also meet MOC activity requirements and hold an active unrestricted medical license.

How long should I study for the ABIM Pulmonary Disease exam?

Most candidates study 250-400 hours over 6-12 months in parallel with their 2- or 3-year Pulmonary Disease / PCCM fellowship. Preparation typically combines the CHEST SEEK Pulmonary Medicine question bank, the ATS Pulmonary Board Review course, Murray & Nadel's Textbook of Respiratory Medicine, and high-yield board review question banks. Clinical volume in pulmonary clinic, ILD clinic, bronchoscopy, and the MICU is the strongest predictor of exam success.