NURS 621 Assignment 7.1: Evidence-Based Asthma Case Study –
Applying 2026 GINA Guidelines for Diagnosis, Stepwise
Pharmacotherapy, Biologics, Inhaler Technique, Comorbidities,
Self-Management, and Reducing Health Disparities in Diverse
Populations
Instructions: Each question has 4 options (A–D). Select all that apply (one or more correct answers).
Correct answers are marked with ✅. Explanations follow evidence from 2026 GINA/NAEPP reports.
Section 1: Diagnosis and Confirmation of Asthma (Questions 1–10)
1. A 22-year-old with intermittent wheezing and normal spirometry. Which tests confirm asthma?
✅ A) Bronchoprovocation (methacholine challenge) – Detects airway hyperresponsiveness when
spirometry is normal
✅ B) Peak expiratory flow (PEF) variability ≥10% over 14 days – Supports diagnosis with twice-daily
measurements
C) Chest X-ray – Normal in uncomplicated asthma; cannot confirm diagnosis
D) Complete blood count – Eosinophilia may support but is not diagnostic
2. What is the minimum post-bronchodilator change in FEV1 diagnostic of asthma?
✅ A) Increase of ≥12% and ≥200 mL from baseline – GINA 2026 definition of significant reversibility
B) Increase of ≥5% – Within normal test-retest variability
C) Decrease of ≥10% – Suggests bronchoconstriction but not diagnostic without pre-test
D) Any increase – *Not specific; normal subjects can have 5-8% variation*
3. Which patient characteristics increase pretest probability of asthma? (Select 2)
✅ A) Symptoms worse at night or early morning – Classic circadian variation
✅ B) Triggers including exercise, cold air, or allergens – Hallmark of airway hyperresponsiveness
C) Smoking history 30 pack-years – Suggests COPD
D) Crackles on auscultation – Suggests fibrosis or heart failure
4. A patient on daily ICS has normal spirometry. How can you confirm asthma?
✅ A) Withhold ICS for 2–4 weeks then repeat spirometry – Reveals underlying reversibility
B) Order high-resolution CT chest – Not indicated for diagnosis
C) Check IgE level – Non-specific
D) Perform exercise challenge while on ICS – May be falsely negative
5. Which test is most useful for diagnosing exercise-induced bronchoconstriction (EIB)?
✅ A) FEV1 measured before and after standardized exercise challenge – ≥10% fall is diagnostic
B) Resting spirometry alone – Normal in many EIB patients
,C) FeNO alone – Elevated in allergic asthma but not specific for EIB
D) Peak flow diary – Less accurate than laboratory challenge
6. Fractional exhaled nitric oxide (FeNO) level that indicates type 2 inflammation?
✅ A) ≥50 ppb in adults not on ICS – High likelihood of eosinophilic inflammation
✅ B) ≥35 ppb in children – Age-adjusted threshold
C) 10–20 ppb – Normal range
D) <25 ppb on ICS – *Suggests good adherence or non-type 2 asthma*
7. Methacholine challenge positive threshold is?
✅ A) PC20 ≤8 mg/mL – Defines airway hyperresponsiveness
B) PC20 >16 mg/mL – Normal; essentially rules out asthma
C) Any fall in FEV1 – Not specific; must reach threshold
D) FEV1 rise – Not applicable
8. Which differential diagnosis should be considered in an adult with new wheezing? (Select 2)
✅ A) Heart failure with pulmonary edema – Cardiac wheeze (cardiac asthma)
✅ B) Vocal cord dysfunction – Inspiratory stridor, normal FeNO
C) Gastroesophageal reflux alone – May coexist but rarely sole cause
D) Panic disorder – Can mimic but not cause wheeze
9. Impulse oscillometry (IOS) is preferred over spirometry in which population?
✅ A) Young children unable to perform forced maneuvers – Requires only tidal breathing
✅ B) Elderly with poor effort – Passive measurement
C) Routine adult asthma diagnosis – Spirometry remains first-line
D) Severe exacerbation – Not validated
10. Which finding on flow-volume loop suggests vocal cord dysfunction (VCD) rather than asthma?
✅ A) Inspiratory truncation (flattened inspiratory loop) – Classic for VCD
B) Expiratory flow limitation – Asthma
C) Normal loop – Non-diagnostic
D) Post-bronchodilator improvement – Asthma
Section 2: Pharmacological Stepwise Management (Questions 11–30)
11. First-line as-needed therapy for mild intermittent asthma (Step 1, GINA 2026)?
✅ A) Low-dose ICS-formoterol taken as needed for symptoms – *Anti-inflammatory rescue preferred;
reduces severe exacerbations by ~65% vs SABA alone*
B) Albuterol alone – No longer recommended as sole therapy due to increased exacerbation risk
C) Oral montelukast – Second-line, slower onset, less effective
D) High-dose ICS daily – Over-treatment for mild intermittent
12. A patient uses as-needed ICS-formoterol 3 times per week. Next step?
✅ A) Step up to daily low-dose ICS + as-needed ICS-formoterol (Step 2) – *Symptoms >2 days/week
indicate need for regular controller*
, B) Add oral prednisone – Only for acute exacerbation
C) Switch to SABA alone – Backwards and unsafe
D) Add LAMA – *Reserved for Step 4-5*
13. Step 3 preferred therapy for adults?
✅ A) Low-dose ICS-LABA (maintenance) + as-needed ICS-formoterol – Reduces exacerbations vs ICS
alone
B) Medium-dose ICS alone – Alternative but less effective
C) LABA alone – Contraindicated (increased mortality)
D) LAMA alone – Not sufficient as monotherapy
14. Step 4 therapy includes which components? (Select 2)
✅ A) Medium-dose ICS-LABA – Foundation of Step 4
✅ B) Add-on LAMA (tiotropium) – *Reduces exacerbations by ~15-20%*
C) Oral steroids daily – Avoid; Step 5 last resort
D) Theophylline – Outdated, narrow therapeutic window
15. Step 5 therapy includes? (Select 2)
✅ A) High-dose ICS-LABA + LAMA – Maximized inhaled therapy
✅ B) Add-on biologic (anti-IgE, anti-IL5, anti-IL4/13, anti-TSLP) – Phenotype-driven
C) Daily oral steroids – Last resort due to systemic toxicity
D) Macrolide antibiotics – Consider only in non-eosinophilic severe asthma
16. When should asthma therapy be stepped down?
✅ A) Well-controlled for ≥3 months – Safe window
B) After 1 week of improvement – Too soon, risk relapse
C) At patient request without assessment – Not appropriate
D) After any normal spirometry – Insufficient
17. How much should ICS dose be reduced when stepping down?
✅ A) 25–50% reduction – GINA 2026 recommended
B) Stop ICS completely – High risk of exacerbation
C) Reduce by 75% – Too aggressive
D) Switch to montelukast monotherapy – Less effective
18. Which medication is absolutely contraindicated as monotherapy in asthma?
✅ A) LABA (e.g., salmeterol, formoterol) – Increased risk of asthma death (Salmeterol Multicenter
Asthma Research Trial)
B) ICS – Safe as monotherapy
C) Montelukast – Safe but weak
D) Cromolyn – Safe but outdated
19. Which statement about SABA use is correct per 2026 guidelines?
✅ A) SABA should never be used as monotherapy – Must always be accompanied by ICS
✅ B) SABA is acceptable as rescue alongside ICS – Part of SMART or as-needed ICS-SABA
C) SABA alone is safe for mild intermittent – False; GINA 2026 removed this recommendation
D) SABA is first-line in pregnancy – No; ICS is preferred
Applying 2026 GINA Guidelines for Diagnosis, Stepwise
Pharmacotherapy, Biologics, Inhaler Technique, Comorbidities,
Self-Management, and Reducing Health Disparities in Diverse
Populations
Instructions: Each question has 4 options (A–D). Select all that apply (one or more correct answers).
Correct answers are marked with ✅. Explanations follow evidence from 2026 GINA/NAEPP reports.
Section 1: Diagnosis and Confirmation of Asthma (Questions 1–10)
1. A 22-year-old with intermittent wheezing and normal spirometry. Which tests confirm asthma?
✅ A) Bronchoprovocation (methacholine challenge) – Detects airway hyperresponsiveness when
spirometry is normal
✅ B) Peak expiratory flow (PEF) variability ≥10% over 14 days – Supports diagnosis with twice-daily
measurements
C) Chest X-ray – Normal in uncomplicated asthma; cannot confirm diagnosis
D) Complete blood count – Eosinophilia may support but is not diagnostic
2. What is the minimum post-bronchodilator change in FEV1 diagnostic of asthma?
✅ A) Increase of ≥12% and ≥200 mL from baseline – GINA 2026 definition of significant reversibility
B) Increase of ≥5% – Within normal test-retest variability
C) Decrease of ≥10% – Suggests bronchoconstriction but not diagnostic without pre-test
D) Any increase – *Not specific; normal subjects can have 5-8% variation*
3. Which patient characteristics increase pretest probability of asthma? (Select 2)
✅ A) Symptoms worse at night or early morning – Classic circadian variation
✅ B) Triggers including exercise, cold air, or allergens – Hallmark of airway hyperresponsiveness
C) Smoking history 30 pack-years – Suggests COPD
D) Crackles on auscultation – Suggests fibrosis or heart failure
4. A patient on daily ICS has normal spirometry. How can you confirm asthma?
✅ A) Withhold ICS for 2–4 weeks then repeat spirometry – Reveals underlying reversibility
B) Order high-resolution CT chest – Not indicated for diagnosis
C) Check IgE level – Non-specific
D) Perform exercise challenge while on ICS – May be falsely negative
5. Which test is most useful for diagnosing exercise-induced bronchoconstriction (EIB)?
✅ A) FEV1 measured before and after standardized exercise challenge – ≥10% fall is diagnostic
B) Resting spirometry alone – Normal in many EIB patients
,C) FeNO alone – Elevated in allergic asthma but not specific for EIB
D) Peak flow diary – Less accurate than laboratory challenge
6. Fractional exhaled nitric oxide (FeNO) level that indicates type 2 inflammation?
✅ A) ≥50 ppb in adults not on ICS – High likelihood of eosinophilic inflammation
✅ B) ≥35 ppb in children – Age-adjusted threshold
C) 10–20 ppb – Normal range
D) <25 ppb on ICS – *Suggests good adherence or non-type 2 asthma*
7. Methacholine challenge positive threshold is?
✅ A) PC20 ≤8 mg/mL – Defines airway hyperresponsiveness
B) PC20 >16 mg/mL – Normal; essentially rules out asthma
C) Any fall in FEV1 – Not specific; must reach threshold
D) FEV1 rise – Not applicable
8. Which differential diagnosis should be considered in an adult with new wheezing? (Select 2)
✅ A) Heart failure with pulmonary edema – Cardiac wheeze (cardiac asthma)
✅ B) Vocal cord dysfunction – Inspiratory stridor, normal FeNO
C) Gastroesophageal reflux alone – May coexist but rarely sole cause
D) Panic disorder – Can mimic but not cause wheeze
9. Impulse oscillometry (IOS) is preferred over spirometry in which population?
✅ A) Young children unable to perform forced maneuvers – Requires only tidal breathing
✅ B) Elderly with poor effort – Passive measurement
C) Routine adult asthma diagnosis – Spirometry remains first-line
D) Severe exacerbation – Not validated
10. Which finding on flow-volume loop suggests vocal cord dysfunction (VCD) rather than asthma?
✅ A) Inspiratory truncation (flattened inspiratory loop) – Classic for VCD
B) Expiratory flow limitation – Asthma
C) Normal loop – Non-diagnostic
D) Post-bronchodilator improvement – Asthma
Section 2: Pharmacological Stepwise Management (Questions 11–30)
11. First-line as-needed therapy for mild intermittent asthma (Step 1, GINA 2026)?
✅ A) Low-dose ICS-formoterol taken as needed for symptoms – *Anti-inflammatory rescue preferred;
reduces severe exacerbations by ~65% vs SABA alone*
B) Albuterol alone – No longer recommended as sole therapy due to increased exacerbation risk
C) Oral montelukast – Second-line, slower onset, less effective
D) High-dose ICS daily – Over-treatment for mild intermittent
12. A patient uses as-needed ICS-formoterol 3 times per week. Next step?
✅ A) Step up to daily low-dose ICS + as-needed ICS-formoterol (Step 2) – *Symptoms >2 days/week
indicate need for regular controller*
, B) Add oral prednisone – Only for acute exacerbation
C) Switch to SABA alone – Backwards and unsafe
D) Add LAMA – *Reserved for Step 4-5*
13. Step 3 preferred therapy for adults?
✅ A) Low-dose ICS-LABA (maintenance) + as-needed ICS-formoterol – Reduces exacerbations vs ICS
alone
B) Medium-dose ICS alone – Alternative but less effective
C) LABA alone – Contraindicated (increased mortality)
D) LAMA alone – Not sufficient as monotherapy
14. Step 4 therapy includes which components? (Select 2)
✅ A) Medium-dose ICS-LABA – Foundation of Step 4
✅ B) Add-on LAMA (tiotropium) – *Reduces exacerbations by ~15-20%*
C) Oral steroids daily – Avoid; Step 5 last resort
D) Theophylline – Outdated, narrow therapeutic window
15. Step 5 therapy includes? (Select 2)
✅ A) High-dose ICS-LABA + LAMA – Maximized inhaled therapy
✅ B) Add-on biologic (anti-IgE, anti-IL5, anti-IL4/13, anti-TSLP) – Phenotype-driven
C) Daily oral steroids – Last resort due to systemic toxicity
D) Macrolide antibiotics – Consider only in non-eosinophilic severe asthma
16. When should asthma therapy be stepped down?
✅ A) Well-controlled for ≥3 months – Safe window
B) After 1 week of improvement – Too soon, risk relapse
C) At patient request without assessment – Not appropriate
D) After any normal spirometry – Insufficient
17. How much should ICS dose be reduced when stepping down?
✅ A) 25–50% reduction – GINA 2026 recommended
B) Stop ICS completely – High risk of exacerbation
C) Reduce by 75% – Too aggressive
D) Switch to montelukast monotherapy – Less effective
18. Which medication is absolutely contraindicated as monotherapy in asthma?
✅ A) LABA (e.g., salmeterol, formoterol) – Increased risk of asthma death (Salmeterol Multicenter
Asthma Research Trial)
B) ICS – Safe as monotherapy
C) Montelukast – Safe but weak
D) Cromolyn – Safe but outdated
19. Which statement about SABA use is correct per 2026 guidelines?
✅ A) SABA should never be used as monotherapy – Must always be accompanied by ICS
✅ B) SABA is acceptable as rescue alongside ICS – Part of SMART or as-needed ICS-SABA
C) SABA alone is safe for mild intermittent – False; GINA 2026 removed this recommendation
D) SABA is first-line in pregnancy – No; ICS is preferred
