1
Q
Describe the age-related shift in the female/male balance of asthma prevalence.
A
Asthma is less common in females than males during childhood (<18 years), but more common in females than males during adulthood (≥18+ years).
2
Q
An abrupt increase in asthma deaths in the 1960s was attributed to a high-dose preparation of which potent, nonselective inhaled β-agonist?
A
The increase in asthma deaths was attributed to a high-dose preparation of isoproterenol.
3
Q
A dramatic increase in asthma mortality in New Zealand in the 1970s was attributed to sales of which specific β-agonist?
A
The increase in asthma mortality in New Zealand was attributed to sales of fenoterol.
4
Q
What is the summary term for the deposition of collagen and accumulation of blood vessels, smooth muscle, and glands in the asthmatic airway?
A
Airway remodeling.
5
Q
Genome-wide association studies (GWAS) have identified ethnic-specific asthma susceptibility loci such as PTCHD3, PYHIN1, ADRAB1, and PTGES in populations other than _____.
A
whites of European descent
6
Q
In the histopathology of asthma, what changes occur to goblet cells in the airway epithelium?
A
Goblet cell metaplasia and hyperplasia occur, increasing the amount of stored gel-forming mucins.
7
Q
The predominant contractile innervation of airway smooth muscle is _____ and _____, while the primary relaxant innervation is comprised of noncholinergic parasympathetic nerves.
A
parasympathetic; cholinergic
8
Q
What is neurogenic inflammation in the context of asthma?
A
It refers to inflammatory responses caused by tachykinins, which are peptidergic neurotransmitters like neurokinin A and substance P.
9
Q
In the nonadrenergic noncholinergic system, the _____ receptor primarily mediates gland secretion and plasma extravasation, while the _____ receptor mediates contraction of airway smooth muscle.
A
neurokinin-1; neurokinin-2
10
Q
What is the defining characteristic of T2-high asthma in terms of immune response?
A
T2-high asthma is characterized by T2 immune responses, including prominent eosinophil infiltration driven by T2 cytokines (IL-4, IL-5, and IL-13).
11
Q
What is the term for the asthma subtype that lacks airway eosinophilia or other markers of T2 inflammation?
A
T2-low asthma.
12
Q
Activated airway epithelial cells in T2-high asthma release which key cytokines that initiate immune responses?
A
They release TSLP, IL-33, IL-1β, and granulocyte-macrophage colony-stimulating factor (GM-CSF).
13
Q
What is the role of IL-5 in T2-high asthma?
A
IL-5 promotes the development and activation of eosinophils.
14
Q
Which interleukin is responsible for activating airway epithelial cell programs that increase expression of chemokines, mucins, and inducible nitric oxide synthase?
A
Interleukin-13 (IL-13).
15
Q
Antigen-induced cross-linking of IgE on mast cells and basophils leads to the release of mediators causing an immediate hypersensitivity reaction. What is a later reaction that can develop in some asthmatics?
A
A late phase reaction, typically beginning 2 to 6 hours after exposure and lasting for 24 to 48 hours.
16
Q
What is the term for long-term functional changes in innate immune cells, adaptive immune cells, or epithelial stem cells through metabolic and epigenetic programming, which may explain the persistence of T2 immunity in asthma?
A
Trained immunity.
17
Q
In T2-high asthma, eosinophil peroxidase catalyzes the oxidation of thiocyanate to generate oxidants that cross-link mucin polymers, leading to what change in mucus properties?
A
It stiffens the mucus gels, which can inhibit clearance and contribute to mucus plugging.
18
Q
What is paucigranulocytic asthma?
A
A subtype of asthma where granulocytes such as neutrophils and eosinophils are not present in excess in airway secretions or tissues.
19
Q
In some T2-low asthma patients, systemic inflammation is implicated, often associated with obesity and increased production of which cytokines by white adipose tissue?
A
Increased production of IL-1, IL-6, or TNF-α.
20
Q
The cysteinyl leukotrienes (cys-LTs) are inflammatory mediators derived from _____, and medications like montelukast target their pathway.
A
arachidonic acid
21
Q
In patients with aspirin-sensitive asthma, ingestion of cyclooxygenase-1 inhibitors shunts arachidonic acid metabolism towards the excessive generation of what products?
A
Cysteinyl leukotrienes (cys-LTs).
22
Q
Which prostanoid, primarily produced by mast cells, is most relevant to asthma pathogenesis and exerts its effects via DP1 and DP2/CRTH2 receptors?
A
Prostaglandin D2 (PGD2).
23
Q
What are the most common and important causes of asthma exacerbations in both children and adults?
A
Common upper respiratory tract viruses, especially rhinoviruses.
24
Q
Based on induced sputum analysis, what are the four cellular classifications of asthma?
A
Eosinophilic, neutrophilic, mixed eosinophilic and neutrophilic, and paucigranulocytic.
25
A patient with asthma symptoms that improve on weekends and vacations should raise suspicion for what type of asthma?
Occupational and/or work-exacerbated asthma.
26
What is the difference between sensitizer-induced and irritant-induced occupational asthma?
Sensitizer-induced asthma results from immunologically mediated sensitization, while irritant-induced asthma results from exposure to high concentrations of irritant compounds.
27
Reactive airway dysfunction syndrome is the best-defined form of what type of occupational asthma?
Irritant-induced asthma.
28
What defines the relationship between obesity and asthma development?
The relationship is bidirectional: obesity is a risk factor for developing asthma, and asthma is a risk factor for developing obesity.
29
Obesity is associated with a state of chronic low-grade systemic inflammation characterized by increased blood levels of which proinflammatory cytokines?
Interleukin (IL)-6, IL-1, tumor necrosis factor-α, and leptin.
30
How does obesity affect lung volumes, specifically functional residual capacity (FRC)?
Obesity decreases functional residual capacity (FRC) due to mechanical loading of the chest wall and abdomen with adipose tissue.
31
What is dysanapsis, and how is it related to childhood-onset obesity and asthma?
Dysanapsis is a discrepancy in size where the lungs grow more than the airways, leading to a decreased FEV1/FVC ratio; it is associated with obesity in children and contributes to airflow limitation.
32
Why might blood eosinophil counts be a poor biomarker of airway T2 inflammation in obese patients with asthma?
Because eosinophils also play key roles in metabolism, circulating blood eosinophils in obese patients could reflect changes in metabolism rather than solely airway inflammation.
33
What is the GINA guideline's definition of asthma?
Asthma is a heterogeneous disease, usually characterized by chronic airway inflammation, defined by a history of respiratory symptoms (wheeze, shortness of breath, chest tightness, cough) that vary over time and in intensity, together with variable expiratory airflow limitation.
34
In pulmonary function testing for asthma, what FEV1 response to a bronchodilator indicates reversible airflow obstruction?
An improvement in FEV1 of greater than 12% and 200 mL after bronchodilator treatment.
35
What is the PC20 in a methacholine challenge test used for assessing bronchial hyperresponsiveness?
PC20 is the provocative concentration of methacholine that results in a 20% fall in the FEV1.
36
A PC20 of less than _____ in a methacholine challenge is consistent with severe airway hyperresponsiveness (AHR).
1 mg/mL
37
What is the clinical significance of a normal or elevated diffusing capacity for carbon monoxide (DLCO) in a patient with obstructive lung disease?
It can be useful in distinguishing asthma from other obstructive lung diseases, as a decreased DLCO would suggest an alternative diagnosis like COPD.
38
According to GINA guidelines, how is asthma severity defined?
Asthma severity is defined by the amount of medication required to control asthma symptoms.
39
A low _____ is a strong predictor of a decline in asthma control and an increased risk of needing acute care.
FEV1
40
What is the fraction of exhaled nitric oxide (FeNO) used for clinically in asthma management?
FeNO is used as a noninvasive biomarker of T2 airway inflammation, particularly related to IL-4 and IL-13-mediated pathways.
41
A blood eosinophil count of greater than _____ is often used to define eosinophilic disease and predicts response to anti-IL-5 therapy.
$300/\mu L$
42
What is the primary mechanism of action of β2-agonists in asthma therapy?
They bind to β2-receptors on airway smooth muscle, leading to increased intracellular cyclic adenosine monophosphate (cAMP) and relaxation of the muscle.
43
Why is long-acting β2-agonist (LABA) monotherapy not recommended for the treatment of asthma?
LABA monotherapy is associated with more treatment failures and an increased risk of severe adverse events, including death, compared to inhaled corticosteroid (ICS) therapy.
44
What is the role of tiotropium, a long-acting anticholinergic agent, in asthma management?
Tiotropium is approved as an add-on therapy to both ICS and ICS/LABA combination therapy in patients with moderate to severe asthma.
45
Which asthma phenotype is most likely to show a significant response to low-dose inhaled corticosteroids (ICS)?
Patients with eosinophilic inflammation (>2–3% sputum eosinophils) demonstrate a significant response to low-dose ICS.
46
What is the mechanism of action for montelukast and zafirlukast in asthma treatment?
They are cysteinyl leukotriene-1 (CysLT1) receptor antagonists, blocking the final step in the leukotriene pathway.
47
What is the molecular target of the biologic agent omalizumab (Xolair)?
Omalizumab is a monoclonal antibody that targets and binds to circulating immunoglobulin E (IgE).
48
The biologic agent mepolizumab (Nucala) is a humanized monoclonal antibody that targets what cytokine?
Mepolizumab targets interleukin-5 (IL-5).
49
Benralizumab (Fasenra) is a monoclonal antibody that targets the _____ on the surface of eosinophils, leading to their depletion through antibody-dependent cell-mediated cytotoxicity.
IL-5 receptor α-subunit
50
Dupilumab (Dupixent) is a monoclonal antibody that blocks the signaling of which two key T2 cytokines by targeting the shared IL-4Rα receptor subunit?
It blocks the signaling of both interleukin-4 (IL-4) and interleukin-13 (IL-13).
51
What is the definition of uncontrolled asthma according to the International ERS/ATS Guidelines for Severe Asthma?
Presence of any of four criteria: poor symptom control (ACQ ≥1.5 or ACT ≤19), frequent severe exacerbations (≥2 steroid bursts/year), a serious exacerbation (≥1 hospitalization/year), or FEV1 <80% predicted.
52
What is the key difference in the GINA 2019 recommendation for managing mild intermittent asthma compared to previous guidelines?
GINA 2019 no longer recommends SABA-only treatment; instead, it recommends all patients with mild asthma receive a low-dose ICS, either as-needed with SABA, in combination with formoterol, or daily.
53
A patient with severe asthma has a blood eosinophil count of 500 cells/μL, a history of nasal polyps, and is dependent on oral corticosteroids. Which classes of biologic agents would be most appropriate to consider?
Anti-IL5/5R agents (mepolizumab, reslizumab, benralizumab) or an anti-IL4R agent (dupilumab) would be most appropriate.
54
What is vocal cord dysfunction (VCD)?
VCD is a condition characterized by intermittent, abnormal paradoxical adduction of the true vocal cords during breathing, which can mimic asthma.
55
What is the gold standard for diagnosing vocal cord dysfunction (VCD)?
Flexible laryngoscopy and videolaryngostroboscopy, which allow for direct visualization of abnormal vocal cord movement.
56
What finding on a flow-volume loop during a provocative challenge is suggestive of vocal cord dysfunction?
A flattening or truncation of the inspiratory curve.
57
What is the primary treatment for an acute asthma exacerbation in an emergency setting?
Repeated or continuous short-acting bronchodilator administration and systemic glucocorticoids.
58
What is the significance of a normal or elevated arterial PCO2 during a severe asthma exacerbation?
It suggests impending respiratory failure due to respiratory muscle fatigue.
59
A worker in a bakery develops wheezing and shortness of breath that worsens during the work week and improves on days off. This is most likely _____ occupational asthma caused by a _____ molecular-weight agent.
sensitizer-induced; high
60
A worker is exposed to a single, large chlorine gas leak at a chemical plant and subsequently develops persistent wheezing and airway hyperresponsiveness. What is this condition called?
Reactive airway dysfunction syndrome (RADS), a form of irritant-induced asthma.
61
According to GINA guidelines, a patient with mild asthma who uses a rescue SABA inhaler 3-4 times per week is considered to have _____ asthma.
uncontrolled
62
The phenomenon where asthma treatment with ICS or anti-T2 biologics could potentially worsen obesity is explained by the homeostatic role of T2 immune cells in _____.
adipose tissue
63
Studies of obese asthmatics suggest a predominance of airway disease in which part of the lung?
The small airways (peripheral lung).
64
What is the recommended timeframe for reassessing a patient's response after initiating a biologic therapy for severe asthma?
The patient should be reassessed in 4 months.
65
The _____ asthma phenotype is characterized by neutrophilia, is often seen in smokers or those with chronic infections, and typically responds poorly to inhaled corticosteroids.
T2-low
66
Which immune cells are key drivers of T2 immune responses and secrete cytokines like IL-4, IL-5, and IL-13?
Th2 subset of CD4+ T cells, group 2 innate lymphoid cells (ILCs), mast cells, and basophils.
67
What is the mechanism by which corticosteroids suppress inflammation in asthma?
They bind to a cytoplasmic receptor, translocate to the nucleus, and modulate inflammatory gene expression by inhibiting histone acetyltransferases and recruiting histone deacetylases.
68
For a patient with allergic asthma confirmed by skin testing and elevated IgE, which biologic therapy would be a primary consideration if they remain uncontrolled on ICS/LABA?
Omalizumab (anti-IgE) or Dupilumab (anti-IL4R).
69
How does bronchial thermoplasty work as a non-pharmacologic treatment for asthma?
It uses controlled thermal energy delivered via a radiofrequency catheter to reduce the mass of airway smooth muscle.
70
The NIH defines an asthma exacerbation as a worsening of asthma requiring the use of _____ to prevent a serious outcome.
systemic corticosteroids
71
What is the primary role of the plain chest radiograph in a patient with stable asthma?
To rule out asthma mimics in those with atypical symptoms and to evaluate difficult-to-control symptoms.
72
Which two atypical bacterial infections have been implicated in the development of chronic wheezing illnesses and may be associated with asthma exacerbations?
Chlamydia pneumoniae and Mycoplasma pneumoniae.
73
A patient with asthma is found to have eosinophils and Charcot-Leyden crystals in their mucus plugs. The crystals are formed from what eosinophil-derived protein?
Galectin-10.
74
How does the non-invasive biomarker, fraction of exhaled nitric oxide (FeNO), reflect underlying asthma pathophysiology?
Elevated FeNO reflects IL-13 activation of the airway epithelium, which upregulates inducible nitric oxide synthase (iNOS).
75
What is the primary concern with chronic overuse of short-acting β2-agonists (SABAs) related to their receptors?
Receptor desensitization, which can occur through receptor down-regulation and uncoupling from downstream signaling pathways.
76
In the cellular phenotype of asthma, what percentage of granulocytes in induced sputum is typically used as a cutoff to define eosinophilic asthma?
Greater than 2-3% eosinophils.
77
What is the proposed mechanism by which obesity may lead to an increased risk of viral exacerbations in asthma patients?
Obesity can result in cytotoxic T lymphocyte (e.g., natural killer cells, CD8+ T cells) dysfunction, impairing the ability to eliminate virus-infected cells.
78
What is the term for asthma that remains difficult to treat despite adequate control of modifiable factors like triggers, comorbidities, and adherence?
Severe asthma.
79
Which biologic therapy for severe asthma is administered intravenously?
Reslizumab (Cinqair).
80
In addition to asthma, for what other comorbid conditions is dupilumab FDA-approved, making it a potential choice for patients with overlapping disease?
Nasal polyps and atopic dermatitis.
81
The presence of _____ and horizontal corrugations in silicone rubber casts of autopsy lungs from asthma patients corresponds to elastic bundles and smooth muscle hypertrophy.
longitudinal ridges
82
The aggregate response to mediators released shortly after mast cell and basophil degranulation, including smooth muscle contraction and increased mucin secretion, is called a(n) _____ reaction.
immediate hypersensitivity (or early phase)
83
T3 immunity, a potential mechanism in some T2-low asthma, is mediated by group 3 ILCs and Th17 cells producing which signature cytokines?
IL-17, IL-22, or both.
84
The asthma susceptibility locus ORMDL3 is involved in biologic pathways related to airway inflammation, remodeling, and hyperresponsiveness in response to tobacco smoke, lipopolysaccharides, allergens, or alterations in _____ biosynthesis.
sphingolipid
85
The GINA guidelines recommend initiating controller therapy for asthma based on the assessment of symptom control and _____.
risk of future adverse outcomes (e.g., exacerbations, lung function decline)
86
In a patient hospitalized for a severe asthma exacerbation, what is the role of intravenous magnesium sulfate?
It may act as a smooth muscle relaxant and has been shown to reduce hospital admission rates.
87
A patient with Samter triad (aspirin sensitivity, nasal polyps, and asthma) would likely derive particular benefit from which class of oral controller medications?
Leukotriene modifiers (LTMs).
88
The clinical heterogeneity of asthma can be explained by different underlying mechanisms, which has led to the sub-grouping of patients into distinct _____.
endotypes
89
According to the 2017 NHIS data, asthma prevalence was highest among individuals of which ethnic heritage?
Puerto Rican heritage (12.8%).
90
What are lipoxins?
Enzyme-derived products of arachidonic acid metabolism that are counter-regulatory lipid mediators, inhibiting inflammation.
91
What is the first step in the GINA management cycle after confirming an asthma diagnosis?
Assess symptom control and modifiable risk factors.
92
A patient with early-onset allergic asthma is likely to have which asthma endotype?
T2-high asthma.
93
In a patient with suspected asthma but normal spirometry, what is the next diagnostic step recommended by the provided algorithm?
Consider a methacholine challenge.
94
A patient with asthma and co-morbid obesity is found to have high plasma levels of IL-6. This finding is associated with what features of their asthma?
More severe asthma, including lower lung function, worse symptoms, and higher exacerbation rates.
95
The risk of death from asthma is reduced in a dose-response manner with the use of which class of medication?
Inhaled corticosteroids (ICS).
96
What is a major limitation of using peak expiratory flow (PEF) measurements for asthma monitoring?
PEF measurements are not standardized and do not correlate well with other measures of lung function like FEV1.
97
The International Study of Asthma and Allergies in Childhood (ISAAC) found great geographic variability in asthma prevalence but also noted that some low- and middle-income countries had a prevalence _____ to those in western, developed countries.
similar
98
Deposition of collagen types I, III, and IV in the subepithelium is a feature of airway remodeling most prominently seen in which type of asthma?
T2 asthma.
99
What is the role of the TNFAIP3 gene in the context of asthma pathogenesis?
TNFAIP3 is a negative regulator of NF-κB activation; environmental exposures like farm dust can increase its expression and suppress the airway epithelial response to allergens.
100
In T2-high asthma, what is the physiologic consequence of IL-13-induced iNOS activity in the airway epithelium?
Production of nitric oxide (NO), a potent mediator of vascular permeability, which can be measured as exhaled nitric oxide (FeNO).
101
What is a potential adverse effect of leukotriene modifiers that requires monitoring, particularly in children?
Mood changes and suicidal ideation.
102
For which biologic agent is dosing based on both serum IgE level and body weight?
Omalizumab (Xolair).
103
In a patient on biologic therapy who shows only a partial response after 4 months, what is the recommended next step according to the management algorithm?
Continue the current therapy for an additional 6-9 months to fully assess response, or consider switching to an alternative biologic.
104
Which comorbidity, common in obese patients, is associated with poor asthma control and increased sputum neutrophils?
Obstructive sleep apnea (OSA).
105
According to GINA 2025, what key terminology changed regarding the diagnostic criteria for asthma?
The term changed from 'variable expiratory airflow limitation' to 'variable expiratory airflow'.
106
In GINA 2025, what are the primary biomarkers reflecting Type 2 airway inflammation?
Blood Eosinophil Count (BEC) and Fractional exhaled Nitric Oxide (FeNO).
107
For severe asthma patients being assessed for biologic therapy, how often should BEC and/or FeNO be measured if not initially above the target threshold according to GINA 2025?
They should be measured at least three times.
108
GINA 2025 reclassified the daily dose of fluticasone furoate 100mcg as _____.
low-medium dose
109
Which bronchodilator was added to the list of non-recommended treatments in GINA 2025 due to cardiovascular risks?
Fenoterol.
110
What is the recommended withholding period for formoterol and salmeterol before conducting spirometry for asthma diagnosis?
The recommended withholding period is 24 hours.
111
How is daily diurnal Peak Expiratory Flow (PEF) variability calculated according to GINA 2025?
It is calculated as (Day’s highest PEF - day’s lowest PEF) / (mean of day’s highest and lowest PEF) x 100, averaged over 2 weeks.
112
What numerical criteria define a positive bronchodilator responsiveness test for asthma diagnosis?
An increase from baseline in FEV1 or FVC of >12% AND >200ml.
113
A positive result for diurnal PEF variability in an adult is defined as a variability of greater than _____%.
10
114
In adults, a FeNO level of >_____ ppb in a patient with typical asthma symptoms supports a diagnosis of Type 2 asthma.
50
115
According to GINA, FeNO levels are typically lower in what patient population?
FeNO is lower in smokers and during bronchoconstriction.
116
Besides asthma, name two non-asthmatic conditions where blood eosinophil count can be elevated.
Parasitic infection, atopic dermatitis, allergic rhinitis, or chronic rhinosinusitis with nasal polyps are all correct answers.
117
For a patient with a clinical history consistent with asthma, what is the GINA recommendation for management during pregnancy?
Prompt initiation of ICS-containing medications is recommended, while diagnostic tests like provocation testing should be postponed.
118
In smokers and ex-smokers, a low diffusing capacity for carbon monoxide (DLCO) is more common in _____ than in asthma.
COPD
119
What is the average rate of decline in FEV1 in healthy nonsmoking adults?
The average rate of decline is 15-20 ml/year.
120
What are two local side effects of Inhaled Corticosteroids (ICS)?
Oral candidiasis (thrush) and dysphonia.
121
Co-administration of high-dose ICS with cytochrome P450 inhibitors like _____ increases the risk of systemic side effects.
ketoconazole, ritonavir, itraconazole, or clarithromycin
122
What is considered a strong independent predictor of the risk of asthma exacerbations?
A low FEV1, especially if it is less than 60% of the predicted value.
123
After starting regular ICS treatment, FEV1 typically improves within days and plateaus after approximately how long?
It plateaus after around 2 months.
124
What is the preferred reliever medication in GINA Track 1 for adults and adolescents?
Low-dose ICS-formoterol.
125
In GINA 2025, the low-dose ICS-formoterol reliever used in Track 1 is also called _____.
AIR (anti-inflammatory reliever)
126
For whom is GINA Track 2, which uses SABA as a reliever, considered an alternative approach?
Patients whose asthma is stable with good adherence and no exacerbations in the past year on their current therapy.
127
In GINA Track 2, what is the recommended controller therapy at Step 2 for a patient with asthma symptoms more than twice a week?
Low-dose maintenance ICS plus as-needed SABA.
128
What change was made to GINA Track 2, Step 4 treatment for adults and adolescents in the 2025 update?
The recommendation changed from medium-to-high dose ICS-LABA to medium-dose ICS-LABA.
129
When is it suggested to start treatment at Step 3 (low-dose MART) instead of Step 1-2 (as-needed ICS-formoterol)?
When symptoms occur most days or the patient wakes at night due to asthma more than once a week.
130
What is the maximum recommended daily dose of formoterol when using as-needed budesonide-formoterol (200/6 mcg MDI)?
The maximum dose is 12 actuations per day, which corresponds to 72mcg of formoterol.
131
In GINA Track 1, what does the acronym MART stand for?
Maintenance and Reliever Therapy.
132
Before stepping up asthma therapy, what are the four key factors that must be checked first?
Incorrect inhaler technique, poor adherence, environmental exposures, and confirming that symptoms are due to asthma.
133
In Step 5 of both GINA tracks, what is the recommended duration for a trial of high-dose ICS-LABA?
A trial basis of 3-6 months is recommended.
134
What is the mechanism of action of Omalizumab and for what type of severe asthma is it indicated?
It is an anti-IgE biologic therapy indicated for severe allergic asthma.
135
Mepolizumab, Benralizumab, and Reslizumab are biologic therapies that target the _____ pathway and are used for severe eosinophilic asthma.
IL-5/5Rα
136
What is the target of Dupilumab and for what type of severe asthma is it indicated?
It is an anti-IL-4Rα biologic indicated for severe eosinophilic/Type 2 asthma or asthma requiring maintenance oral corticosteroids (OCS).
137
For severe asthma, what is the target of Tezepelumab?
It targets thymic stromal lymphopoietin (TSLP).
138
What is the recommended treatment for a patient with persistent symptomatic asthma despite high-dose ICS-LABA, which involves a macrolide antibiotic?
A 6-month course of azithromycin three times a week may be considered after specialist consultation.
139
What are the three essential components of effective guided asthma self-management education?
Self-monitoring of symptoms/PEF, a written asthma action plan, and regular review by a healthcare provider.
140
What is the recommended weight loss percentage for obese patients to achieve improved asthma control and quality of life?
A 5-10% weight loss is recommended.
141
The presence of coexisting asthma is a strong risk factor for severe and fatal reactions in patients with _____.
food-induced allergic reactions (anaphylaxis)
142
Sublingual allergen immunotherapy (SLIT) may be considered for patients with suboptimally controlled asthma and sensitization to house dust mite, provided their FEV1 is >_____%.
70
143
During pregnancy, exacerbations are most common in which trimester?
The second trimester.
144
What is the primary treatment for exercise-induced bronchoconstriction (EIB)?
Regular ICS treatment.
145
In which patient population is asthma frequently underdiagnosed due to the presence of other comorbidities?
The elderly (patients >65 years old).
146
Aspirin-exacerbated respiratory disease (AERD) is a syndrome characterized by asthma, chronic rhinosinusitis with nasal polyps, and hypersensitivity to _____.
aspirin and other NSAIDs
147
What is the mainstay of treatment for Aspirin-Exacerbated Respiratory Disease (AERD)?
High-dose Inhaled Corticosteroids (ICS).
148
In a patient taking long-term high-dose ICS or OCS, what medication should be given perioperatively to reduce the risk of adrenal crisis?
Hydrocortisone.
149
According to GINA 2025, how does spirometry differ from PEF monitoring when confirming the diagnosis of asthma in a patient already taking controller therapy?
A positive test for asthma on PEF monitoring requires an increase of >20%, whereas spirometry requires an increase in FEV1/FVC of >12% and >200 mL.
150
What is the term for the characteristic pattern of atopic disease development during infancy and childhood, often beginning with atopic dermatitis and progressing to asthma?
Atopic march or allergic march.
151
The hygiene hypothesis proposes that reduced exposure to _____ in early childhood contributes to the rise in allergic diseases.
infections or bacterial products
152
Which respiratory virus, when causing wheezing episodes in early life, is an even stronger predictor of subsequent asthma than RSV?
Rhinovirus.
153
Sensitizer-induced asthma and irritant-induced asthma are two main types of what broader condition?
Occupational Asthma (OA).
154
What is the most replicated asthma risk locus with the highest statistical significance across studies in individuals of European descent?
The ORMDL3/GSDMB region on chromosome 17q12.
155
The deposition of collagen, and accumulation of smooth muscle and secretory cells in the airway is a process known as _____.
airway remodeling
156
In asthma pathophysiology, which type of immune response is characterized by eosinophil infiltration and the cytokines IL-4, IL-5, and IL-13?
Type 2 (T2) immune response.
157
Asthma that lacks airway eosinophilia or other markers of T2 inflammation is categorized as _____ asthma.
T2-low
158
The epithelial-derived cytokines TSLP, IL-33, and GM-CSF activate dendritic cells and what innate immune cells to produce IL-5 and IL-13?
Group 2 innate lymphoid cells (ILC2s).
159
Which cytokine is primarily responsible for promoting the development and activation of eosinophils in T2-high asthma?
Interleukin-5 (IL-5).
160
The physiologic response that occurs shortly after mast cell degranulation, including smooth muscle contraction and increased mucin secretion, is called the _____.
immediate hypersensitivity (or early phase) reaction
161
What is the most common and important cause of asthma exacerbations in both children and adults?
Common upper respiratory tract viruses, especially rhinoviruses.
162
Based on induced sputum analysis, what are the four cellular classifications of asthma?
Eosinophilic, neutrophilic, mixed eosinophilic and neutrophilic, and paucigranulocytic.
163
What is the term for a subgroup of patients who share an underlying disease biology, pointing to specific pharmaceutical targets?
Endotype.
164
What three epithelial genes, whose expression is driven by IL-13, are used as surrogate markers for T2-high asthma?
Periostin, CLCA1, and serpinB2.
165
Blood eosinophil counts between 150 to ____ /mcL have been used as cutoffs in large trials of monoclonal antibodies targeting the IL-5 pathway.
400
166
What is the effect of obesity on functional residual capacity (FRC)?
Obesity decreases FRC due to mechanical loading of the chest wall and abdomen with adipose tissue.
167
The phenomenon in obese children where there is a greater growth of the lungs than of the airways, leading to a decreased FEV1/FVC ratio, is known as _____.
dysanapsis
168
The Steroids in Eosinophil Negative Asthma (SIENA) study suggested that _____ may be a reasonable alternative to ICS for mild asthma control in patients with low sputum eosinophils.
tiotropium
169
In the context of occupational asthma, what is the term for new-onset asthma from a single high-dose exposure to irritants?
Reactive airways dysfunction syndrome (RADS).
170
Differentiating work-exacerbated asthma (WEA) from non-work-related asthma can be difficult. What is the definition of WEA?
WEA is preexisting or concurrent asthma that is exacerbated by, but not caused by, nonspecific stimuli in the workplace.
171
In sensitizer-induced occupational asthma, what is the primary immunologic mechanism for agents with a high molecular weight (HMW)?
It is an Immunoglobulin E (IgE)–dependent mechanism.
172
For which type of occupational agents has atopy been consistently demonstrated as an important host risk factor?
Atopy is a risk factor for occupational asthma caused by high-molecular-weight (HMW) agents.
173
What is considered the reference or 'gold standard' test for diagnosing occupational asthma when the diagnosis remains in doubt?
Specific inhalation challenge tests.
174
What is the optimal management for a patient diagnosed with sensitizer-induced occupational asthma?
Complete avoidance of exposure to the causal agent.
175
Which two cysteinyl leukotrienes are most relevant to asthma pathogenesis, acting on Cys-LT1R to induce muscle contraction?
Leukotriene C4 and LTD4.
176
The _____ receptor, targeted by dupilumab, binds both IL-4 and IL-13.
IL-4Rα
177
What diagnostic finding during flexible laryngoscopy is classic for vocal cord dysfunction (VCD)?
Abnormal adduction of the anterior two-thirds of the true vocal cords during inspiration with a posterior 'chink'.
178
During a severe asthma exacerbation, what does a normal or elevated partial pressure of carbon dioxide suggest?
It suggests impending respiratory failure.
179
The addition of what intravenous medication has been shown to reduce hospital admission rates in patients with severe asthma exacerbations?
Magnesium sulfate.
180
What is the recommended initial ventilator strategy for a patient intubated for a severe asthma exacerbation to minimize dynamic hyperinflation?
Use a low minute ventilation (low rate and tidal volume) with a high inspiratory flow rate to allow for a long expiratory time.
181
What term is used to describe the phenomenon of airway narrowing in asthma that is not fully reversible with bronchodilators?
Fixed airflow obstruction.
182
Among US adults in 2017, current asthma prevalence was highest in which ethnic/heritage group?
Those of Puerto Rican heritage (12.8%).
183
Mortality from asthma increased dramatically in New Zealand in the 1970s, attributed to the sales of which specific short-acting β-agonist?
Fenoterol.
184
A PC20 of less than _____ mg/mL during a methacholine challenge is consistent with severe airway hyperresponsiveness (AHR).
1
185
What role does IL-6 play in T2-low asthma?
A. It directly contributes to airway neutrophilia.
B. It reflects systemic inflammation and is associated with obesity.
C. It reduces airway hyperresponsiveness by stabilizing the epithelial barrier.
D. It exclusively affects airway smooth muscle contraction
B
186
Which noninflammatory mechanism might contribute to T2-low asthma?
A. Eosinophilic airway inflammation driven by IL-5
B. Excessive corticosteroid treatment leading to airway remodeling
C. Abnormal smooth muscle hyperplasia or hypertrophy
D. Increased Th2 cell activation in response to allergens
. Abnormal smooth muscle hyperplasia or hypertrophy
Noninflammatory mechanisms contribute to T2-low endotypes of asthma, which represent cases lacking significant Type 2 (T2) inflammation,. The sources specifically identify structural changes in the airway smooth muscle as a possible noninflammatory cause of the disease phenotype:
"Because a role for airway smooth muscle hyperplasia or hypertrophy has been demonstrated in patients with asthma, abnormal accumulation of smooth muscle and increased airway narrowing on that basis represents another possible noninflammatory mechanism for increased airway hyperresponsiveness in asthma".
The lack of inflammation in some patients with paucigranulocytic asthma (a T2-low subset) suggests that chronic inflammation may not be necessary for the expression of asthma's phenotypic features, including smooth muscle dysfunction
187
Which of the following is a pathological feature of asthma exacerbations?
A. Worsening of airway smooth muscle contraction, airway wall edema, and luminal
obstruction with mucus
B. Decreased vascular permeability in airway blood vessels
C. Complete absence of airway hyperresponsiveness
D. Reduced smooth muscle contraction during exacerbations
Asthma exacerbations represent an acute worsening of airflow obstruction due to worsening of airway smooth muscle contraction, airway wall edema, and luminal obstruction with mucus.
The resulting airway hyperresponsiveness includes concentric smooth muscle contraction, mucosal edema from vascular permeability, and excess mucus from mucin hypersecretion.
In fatal and acute severe asthma, analysis often shows extensive mucus plugging of airways, airway wall thickening, and smooth muscle hypertrophy
188
What is the primary reason corticosteroids are effective in preventing asthma exacerbations?
A. They reduce smooth muscle contraction in the airway.
B. They minimize airway hyperresponsiveness by improving epithelium integrity.
C. They reduce inflammatory cell numbers and improve pathological changes in airway
cells.
D. They inhibit the production of nitric oxide in airway epithelial cells.
C
* A. They reduce smooth muscle contraction in the airway: While the effects of corticosteroids improve pathologic changes to smooth muscle cells, their primary direct mechanism is anti-inflammatory (reducing cell numbers and edema), not immediate smooth muscle relaxation (which is the role of beta 2 -agonists).
* B. They minimize airway hyperresponsiveness by improving epithelium integrity: Corticosteroids improve pathologic changes to airway cells, which include epithelial cells and goblet cells, thereby reducing airway hyperresponsiveness (AHR). However, option C, encompassing the reduction of inflammatory cells and improvement in pathological changes, is a more comprehensive statement of their primary mechanism.
* D. They inhibit the production of nitric oxide (NO) in airway epithelial cells: While FeNO (exhaled NO) levels decline with inhibition of IL−4 and IL−13–mediated pathways, which are the pathways corticosteroids target in T2-high asthma, this is a specific downstream effect of their broad anti-inflammatory action, not the primary reason for preventing exacerbation
189
Which of the following best describes the role of airway epithelial cells in asthma
exacerbations?
A. They primarily act as passive barriers to infection.
B. They serve as active sentinels coordinating antiviral responses mediated by
interferons.
C. They directly produce corticosteroids to reduce inflammation.
D. They secrete mucus without any direct involvement in immune responses.
B. They serve as active sentinels coordinating antiviral responses mediated by
interferons.
Airway epithelial cells play a critical and active role, particularly during virus-induced exacerbations, by acting as active sentinels and master coordinators of antiviral responses in the lung, typically mediated by Interferons (IFNs).
This function is part of their broader role where they are activated by inhaled insults, including microbes and allergens, and release cytokines such as TSLP and IL−33 to coordinate immune responses. Changes in the epithelium, such as increased mucin stores, also predispose asthmatics to exaggerated airway responses to inhaled insults, including viruses, during exacerbations
190
What is the minimum percentage of body weight loss shown to improve asthma
control in obese patients?
Choose the best answer
Answer
A. 2%
B. 5%
C. 10%
D. 15%
5
191
What immune cells are primarily impaired in obesity, leading to increased susceptibility to viral infections?
Choose the best answer
Answer
A. B lymphocytes
B. Mast cells
C. Cytotoxic T lymphocytes (natural killer cells and CD8+ T cells)
D. Eosinophils
C
Obesity and metabolic dysfunction lead to impairments of airway host defense, which increases the risk of developing severe respiratory viral illnesses such as COVID-19 and influenza.
* The sources state that multiple immune cells involved in initiating adaptive immune responses are impaired in obesity.
* Specifically, cytotoxic T lymphocytes (natural killer cells and CD8 +
T cells) are essential for identifying and eliminating cells infected by a virus.
* Obesity can result in cytotoxic T cell dysfunction and an impaired ability of these cells to eliminate infected cells.
* This dysfunction of cytotoxic T lymphocytes increases susceptibility to viral infections
192
What is considered a marker of uncontrolled asthma according to the ERS/ATS guidelines?
Choose the best answer
Answer
A. Asthma Control Test score of 22 or greater
B. Two or more bursts of systemic corticosteroids in the previous year
C. Normal FEV1 levels with occasional symptoms
D. No history of exacerbations in the past year
According to the International European Respiratory Society (ERS)/American Thoracic Society (ATS) Guidelines for Severe Asthma, uncontrolled asthma is defined by the presence of any of four criteria. One of these criteria relates to frequent severe exacerbations:
* Frequent severe exacerbations, defined as two or more bursts of systemic corticosteroids (≥3 days each) in the previous year.
Why other options are incorrect:
* A. Asthma Control Test score of 22 or greater: An Asthma Control Test (ACT) score of 19 or less (or an Asthma Control Questionnaire score of consistently 1.5 or greater) is considered a marker of poor symptom control, which defines uncontrolled asthma. A score of 22 or greater would typically indicate controlled or well-controlled asthma (though the precise score for 'uncontrolled' is ≤19).
* C. Normal FEV 1 levels with occasional symptoms: Asthma is categorized as uncontrolled when FEV 1
is less than 80% predicted, or if the patient has persistent uncontrolled symptoms or exacerbations. Occasional symptoms do not indicate uncontrolled disease, and normal FEV 1 often suggests mild or controlled asthma, especially if symptoms are infrequent,.
* D. No history of exacerbations in the past year: This scenario indicates low risk for future adverse outcomes, rather than uncontrolled asthma
193
What is a common issue in asthma management, even for patients on long-term therapy?
Choose the best answer
Answer
A. Always adhering to prescribed medication dosages
B. Not using peak flow measurements regularly
C. Failing to take medications as directed at least some of the time
D. Overuse of short-acting beta-agonists (SABA)
C
ffective asthma management relies heavily on the clinician-patient partnership and self-management, but adherence remains a significant hurdle:
* Approximately 50% of patients on long-term therapy fail to take medications as directed at least some of the time.
194
What is the recommended initial dose of intravenous methylprednisolone for adults with an acute asthma exacerbation?
1.5 to 2 mg/kg
195
For patients who fail to respond to albuterol administration within 30 to 60 minutes with persistent dyspnea and peak flow less than 70% of baseline, what is the appropriate next step in treatment?
Choose the best answer
Answer
A. Administer additional albuterol doses
B. Reassess the need for hospitalization
C. Increase the dose of inhaled corticosteroids
D. Discharge the patient with a follow-up plan
If pretreatment FEV1 or PEF is <25%, or posttreatment FEV1 or PEF is <40%, hospitalization is recommended
If posttreatment lung function is 40-60%, discharge may be possible
If post treatment lung function is >60% discharge recommended
Other factors:
* Female, older age, non white
* >8 Beta agonist neb
* >Severity (rescuscitation or need for medical intervention, RR >22, O2 sat <95, PEF <50)
**
Ffup after 2-7 days**
196
This type of asthma is characterized by: latency period of weeks to decades, may be IgE or non IgE mediated and associated with high and low molecular weight protein exposure:
Sensitizer Induced Occupational Asthma
197
Which of the following high molecular weight agents is the most common cause of Sensitizer induced occupational asthma?
Choose the best answer
Answer
A. Latex
D. Enzymes
D. Rodents
D. Flours/grains
The high molecular weight (HMW) agent that is the most common cause of Sensitizer-induced Occupational Asthma is Flours/grains.
Based on a large European multicenter study detailing the frequency of agents causing sensitizer-induced occupational asthma:
* Flour/grains accounted for 369 reported cases, representing 31.3% of the total identified agents in that study.
* The other listed HMW agents accounted for much smaller percentages: Latex (3.0%), Enzymes (2.2%), and Rodents (0.9%).
Overall, occupational agents such as flour, latex, enzymes, and metals account for 50% to 90% of reported cases of occupational asthma. The highest incidence of occupational asthma is often observed in bakers and pastry makers due to exposure to flour
198
What is a consistent and important host risk factor for the development of occupational asthma?
Choose the best answer
Answer
A. Genetic markers
B. Pre-existing non specific bronchial hyperresponsiveness
C. Geneder – female
D. Atopy
Atopy has been consistently demonstrated to be an important host risk factor for the development of immunoglobulin E (IgE) sensitization and occupational asthma (OA), particularly for high-molecular-weight (HMW) agents. In classifications of potential risk factors for OA, atopy is given a "Strong" evidence rating for HMW agents, while it has a "Weak" rating for low-molecular-weight (LMW) agent
199
True or false: Normal airway responsiveness after a period at work at which time the workers experience their respiratory symptoms makes the diagnoses of OA and asthma improbable:
Triue
Normal airway responsiveness (or nonspecific bronchial hyperresponsiveness) after a period at work, during which the workers are experiencing respiratory symptoms, makes the diagnoses of OA and asthma improbable.
This diagnostic principle relies on the high reliability of a negative test result when the patient is currently exposed to the offending agent and symptomatic: the negative predictive value of normal airway responsiveness for Occupational Asthma (OA) while the worker is exposed to the suspected agent at the workplace has been reported to be as high as 98%. If the diagnosis is improbable, an alternative diagnosis should be investigated
200
Which of the non invasive tests for airway inflammation can aid in the diagnosis of
occupational asthma?
Choose the best answer
Answer
A. Total eosinophil count in the sputum
B. Percentage of neutrophils in the sputum
C. FeNO for HMW (high molecular weight) agents
D. None of the above
C. FeNO for HMW (high molecular weight) agents.
While the evidence regarding the general use of fractional exhaled nitric oxide (FeNO) for OA diagnosis is inconsistent and suffers from a lack of specificity, the sources specifically indicate that FeNO is highly specific and may be more useful in patients exposed to HMW agents (High Molecular Weight agents). This utility stems from the fact that HMW agents often involve an IgE-dependent immunological reaction, which is the type of inflammation (Type 2) that FeNO reflects
201
What is the term for a high level of exposure to irritants in the workplace?
Choose the best answer
Answer
A. Low dose reactive airway dysfunction
B. Gassings
C. Not-so-sudden IIA
D. IIA with latency
The term "gassings" is used to refer to exposures to high levels of irritants in the workplace, particularly in the context of epidemiological studies investigating irritant-induced asthma (IIA):
* Exposures to high levels of irritants in the workplace are called "gassings" and are often recalled by workers in epidemiologic studies
A, C, D (Low dose reactive airway dysfunction, Not-so-sudden IIA, and IIA with latency) are described as clinical phenotypes, typically associated with repeated or lower concentrations of irritant compounds, and are contrasted with the rapid onset IIA that results from high concentrations, such as Reactive Airways Dysfunction Syndrome (RADS)
202
criteria for RADS
Absence of Preexisting Asthma: The patient must not have had preexisting asthma symptoms or a history of asthma in remission.
* Single Exposure: The onset of asthma symptoms must follow a single specific inhalational exposure or accident.
* High Concentration: The exposure must involve an irritant vapor, gas, fume, or smoke in very high concentration.
* Rapid Onset: Asthma symptoms must begin quickly, within minutes to hours, and less than 24 hours after the exposure.
* Objective Evidence of Asthma: There must be a presence of airflow limitation confirmed by a significant bronchodilator response or by nonspecific bronchial hyperresponsiveness (to histamine or methacholine).
* Exclusion of Other Conditions: Other pulmonary disorders that could explain or simulate the symptoms must be excluded
203
What are the two primary biomarkers of Type 2 inflammation emphasized in the GINA 2025 key changes?
Blood eosinophil count (BEC) and Fractional exhaled Nitric Oxide (FeNO).
204
For a patient with severe asthma being assessed for Type 2-directed biologic therapy, how many times should BEC and/or FeNO be measured if they are not initially above the target threshold?
They should be measured at least three times.
205
According to GINA 2025, what is the recommended treatment for Track 2, Step 4 for adults and adolescents?
The recommendation was changed from medium to high dose ICS-LABA to medium dose ICS-LABA.
206
Which short-acting beta-agonist (SABA) was added to the list of not recommended bronchodilators in GINA 2025 due to cardiovascular risks?
Fenoterol.
207
What is the required withholding period for formoterol and salmeterol before conducting spirometry for an initial asthma diagnosis?
The required withholding period is 24 hours.
208
What is the required withholding period for tiotropium, umeclidinium, aclidinium, or glycopyrronium before diagnostic spirometry?
The required withholding period is 36-48 hours.
209
How is daily diurnal PEF variability calculated for asthma diagnosis?
It is calculated as [(Day’s highest PEF - day’s lowest PEF) / mean of day’s highest and lowest PEF] x 100, averaged over two weeks.
210
What is considered a positive result for diurnal PEF variability when diagnosing asthma in adults?
A diurnal variability of greater than 10% is considered a positive result.
211
What respiratory symptom pattern is characteristic of asthma?
Symptoms (wheeze, SOB, cough, chest tightness) that are worse at night or early morning, vary over time and intensity, and have specific triggers.
212
The presence of chronic production of sputum decreases the probability that respiratory symptoms are caused by ____.
asthma
213
According to GINA 2025, what constitutes a positive bronchodilator responsiveness test for confirming an asthma diagnosis?
An increase from baseline in FEV1 or FVC of >12% and >200ml, which corresponds to an increase of >10% of the patient’s predicted value.
214
In a non-smoking adult with typical asthma symptoms, what FeNO level supports a diagnosis of Type 2 asthma?
A FeNO level of >50 ppb supports the diagnosis.
215
How does smoking affect FeNO levels?
FeNO is lower in smokers.
216
A patient on inhaled corticosteroids (ICS) has their blood eosinophil count (BEC) measured. How might the ICS treatment affect the BEC result?
Inhaled corticosteroids can decrease the blood eosinophil count.
217
What is the recommended diagnostic approach for a pregnant woman with a clinical history consistent with asthma?
Prompt initiation of ICS-containing treatment is recommended, while diagnostic tests and provocation testing should be postponed.
218
How does GINA 2025 recommend distinguishing COPD from asthma in smokers and ex-smokers?
Characteristics favoring COPD include a low DLCO and less significant bronchodilator responsiveness, although asthma can also show responsiveness >12% and 200ml.
219
What is the average rate of decline in FEV1 in healthy non-smoking adults?
The average rate of decline is 15-20 ml/year.
220
What are three potential systemic side effects of high-dose inhaled corticosteroids (ICS)?
Easy bruising, increased risk of osteoporosis/fractures, cataracts, glaucoma, or adrenal suppression.
221
A patient taking high-dose ICS and ritonavir is at increased risk of ICS adverse effects. Why?
Ritonavir is a cytochrome P450 inhibitor, which increases systemic exposure to the ICS.
222
What is the single strongest independent predictor of the risk of asthma exacerbations?
A low FEV1.
223
How soon after starting regular ICS treatment does FEV1 typically improve and plateau?
FEV1 improves within days and generally plateaus after around 2 months.
224
In GINA 2025, Track 1 is the preferred treatment approach. What is the reliever medication used in this track?
Low-dose ICS-formoterol is the reliever medication in Track 1.
225
Under what conditions is GINA Track 2 considered an alternative treatment approach?
When Track 1 is not possible, or if the patient's asthma is stable with good adherence and no exacerbations in the past year on their current therapy.
226
The use of as-needed low-dose ICS-formoterol as a reliever is also referred to as ____.
AIR (anti-inflammatory reliever)
227
A non-smoking adult with asthma symptoms has a FeNO level >50ppb. What does this suggest regarding treatment?
It is associated with a good short-term symptomatic response to commencing ICS.
228
For a patient with severe asthma showing a good response to biologics, what is the recommended first step before reducing the ICS dose?
The reduction and cessation of oral corticosteroids (OCS) should be undertaken first.
229
What are three key patient characteristics that suggest starting treatment at GINA Step 3 (low-dose MART) instead of Step 1-2 (as-needed ICS-formoterol)?
Symptoms on most days, waking at night due to asthma more than once a week, or a history of a life-threatening exacerbation.
230
What is the maximum daily number of actuations of a single 200/6 mcg budesonide-formoterol inhaler when used for as-needed-only relief in mild asthma?
The maximum is 12 actuations per day, which equates to 72 mcg of formoterol.
231
In the MART strategy with low-dose budesonide-formoterol (200/6 mcg MDI), what is the maintenance dosing regimen?
The maintenance regimen is 1 inhalation twice daily (BID).
232
When a patient on low-dose ICS-formoterol MART is stepped up, what is the new maintenance dosing?
The maintenance dose is increased to 2 inhalations twice daily (BID) of the low-dose ICS-formoterol inhaler.
233
What is the medication regimen for GINA Track 2, Step 2?
Low-dose maintenance ICS plus an as-needed SABA.
234
What is the medication regimen for GINA Track 2, Step 4?
Medium-dose maintenance ICS-LABA plus an as-needed SABA or as-needed ICS-SABA.
235
How long should a trial of high-dose ICS-LABA be limited to in Track 2, Step 4, to reduce the risk of adverse effects?
The trial should be limited to 3-6 months.
236
In which patients might sublingual allergen immunotherapy (SLIT) be considered for asthma management?
In patients with sensitization to house dust mite with suboptimally controlled asthma despite ICS, provided their FEV1 is >70%.
237
For patients with persistent symptomatic asthma despite high-dose ICS-LABA, what is the dosing regimen for add-on azithromycin?
Azithromycin is given three times a week for six months.
238
What is the mechanism of action and indication for biologic agents like mepolizumab, benralizumab, and reslizumab?
They are anti-IL-5/5Ra antibodies used for severe eosinophilic asthma.
239
What is the mechanism of action and indication for the biologic agent Dupilumab?
It is an anti-IL-4Ra antibody used for severe eosinophilic/Type 2 asthma or asthma requiring maintenance OCS.
240
What is the mechanism of action for the biologic agent Tezepelumab?
It is an anti-TSLP (anti-thymic stromal lymphopoietin) antibody used for severe asthma.
241
What daily dose of prednisone equivalent is considered low-dose oral corticosteroids (OCS) for Step 5 treatment?
A daily dose of less than 7.5mg/day prednisone equivalent.
242
Why is the use of LAMA monotherapy not recommended in asthma?
It increases the risk of severe exacerbations when used without an ICS.
243
After initiating or changing asthma treatment, when should the patient be reviewed?
The patient should be reviewed 1-3 months after starting treatment, and then every 3-12 months thereafter.
244
What are the three essential components of effective guided asthma self-management education?
Self-monitoring of symptoms/PEF, a written asthma action plan, and regular review by a healthcare provider.
245
How can beta-2 agonists and theophylline potentially worsen GERD symptoms in an asthmatic patient?
They can cause relaxation of the lower esophageal sphincter (LES).
246
A patient with coexisting asthma and a food-induced anaphylactic reaction is at high risk for what outcome?
They are at a strong risk for severe and fatal reactions.
247
What is a potential risk to the neonate if the mother receives high doses of SABA within 48 hours before a preterm delivery?
There is a risk of neonatal hypoglycemia.
248
A patient reports acute asthma attacks, rhinorrhea, and a scarlet flush of the head and neck within an hour of taking ibuprofen. What condition should be suspected?
Aspirin-exacerbated respiratory disease (AERD).
249
What is the gold standard for diagnosing Aspirin-Exacerbated Respiratory Disease (AERD)?
An aspirin challenge test (oral, bronchial, or nasal).
250
What is the mainstay of treatment for Aspirin-Exacerbated Respiratory Disease (AERD)?
High-dose inhaled corticosteroids (ICS).
251
What is the first-line medical treatment for Allergic Bronchopulmonary Aspergillosis (ABPA)?
Oral corticosteroids (OCS), typically with a 4-month tapering schedule, plus itraconazole for patients with exacerbations.
252
In a patient with difficult-to-treat asthma, spirometry with bronchodilator responsiveness testing is negative. What is the next step before considering bronchial provocation testing?
Repeat the test after withholding bronchodilators, when symptomatic, or after stepping controller treatment up or down.
253
If spirometry is unavailable for confirming difficult-to-treat asthma, what PEF measurement indicates a positive response to a bronchodilator?
An increase in PEF of >20%.
254
How can adherence to oral prednisone be objectively assessed in a patient with suspected poor adherence?
By measuring blood prednisone levels.
255
For whom is breakthrough exercise-induced bronchoconstriction (EIB) particularly indicative of poor asthma control?
Patients on regular ICS treatment.
256
What is the recommended follow-up period after an asthma exacerbation?
A review visit should occur within one week.
257
According to GINA 2025, when should lung function be assessed in an asthmatic patient?
At diagnosis, 3-6 months after starting ICS-containing treatment, and periodically thereafter (every 1-2 years).
258
A patient on maintenance ICS-containing therapy demonstrates significant bronchodilator responsiveness. What does this suggest?
It suggests uncontrolled asthma.
259
What is the primary rationale for recommending as-needed ICS-formoterol over SABA-only treatment for mild asthma?
To reduce the risk of severe exacerbations, as these can occur unpredictably even in patients with infrequent symptoms.
260
When using budesonide-salbutamol as an as-needed reliever in GINA Track 2, Step 3, what is the maximum recommended daily dose?
The maximum is 6 as-needed doses, which is equivalent to 12 puffs of 100/100 mcg BUD-SALB in a day.
261
If a patient on medium-dose ICS-LABA has persistent poor asthma control and a history of severe exacerbations, what reliever strategy is an option in Track 2?
Maintenance medium-dose ICS-LABA plus as-needed ICS-SABA.
262
In patients with severe eosinophilic/Type 2 asthma requiring maintenance oral corticosteroids (OCS), which biologic agent is specifically indicated?
Dupilumab (anti-IL-4Ra).
263
What defines Catamenial Asthma?
Asthma that worsens in the premenstrual phase, affecting about 20% of women with asthma.
264
What is the defining characteristic of occupational asthma?
It is asthma acquired in the workplace, aggravated by exposure to allergens or other sensitizing agents at work.
265
Thunderstorms are noted as a trigger for asthma exacerbations. What is the fold-increase of acute exacerbations requiring an outpatient visit associated with this phenomenon?
There is a 2.3-fold increase in acute asthma exacerbations.
266
Patient already on ICS containing regimen, but still with synptoms of Asthma but no variable expirtory airflow.
Steps to confirm dx?
irometry or PEF after withholding bronchodilators
If FEV1 or PEF is >70%, consider stepping down ICS and reassess in 2-4 weeks, then consider bronchial provoation test or repeating bronchodilator responsiveness test
If FEV1 <70, start or step up ICS containng regimen treatment then reassess after 3 months
267
Daytime asthma symptoms twice a week
SABA reliever use twice a week
What is control?
Partly controlled
268
Risk factors for exacerbation?
269
Patient on moderate dose ICS LABA, how to stepdown?
Continue ICS-LABA and reduce ICS component by 50%
Switch to MART with ICS-Formoterol, with lower maintenance dose
270
In ACOS chapter of GINA, what is the dx if spirometric variables are as follows:
Post BD increase in FEV1 >12% and 400mL from baseline (marked response)
Asthma
271
Define Difficult-Treat Asthma vs Severe Asthma vs Uncontrolled Asthma
272
When is BEC higher and lower?
Murray
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