NURS 621 Assignment 7.1 Master Version: Comprehensive
Asthma Management – Synthesis of 2026 GINA/NAEPP
Guidelines for Diagnosis, Personalized Pharmacotherapy,
Biologic Sequencing, Adherence Optimization, Comorbidity
Management, Inhaler Technique, Acute Exacerbations, Special
Populations, Health Equity, Climate Change, and Future
Directions
Section 1: Diagnosis and Confirmation of Asthma (Questions 1–15)
1. A 22-year-old with intermittent wheezing and normal spirometry. Which tests confirm asthma?
(Select 2)
✅ A) Bronchoprovocation (methacholine challenge) – Detects airway hyperresponsiveness when
spirometry is normal
✅ B) Peak expiratory flow (PEF) variability ≥10% over 14 days – GINA 2026 diagnostic criterion
C) Chest X-ray – Normal in uncomplicated asthma
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. A 34-year-old with episodic cough, chest tightness, and normal spirometry. What is the most
appropriate next diagnostic step?
✅ A) Bronchoprovocation challenge with methacholine – Detects AHR when baseline spirometry is
normal
B) High-resolution CT chest – Not indicated without suspicion of other pathology
C) Serum IgE level – Non-diagnostic; elevated in atopy but not specific
D) Empiric oral steroids – Inappropriate without confirmed diagnosis
4. 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
,5. A patient on daily ICS has normal spirometry. How can you confirm asthma?
✅ A) Withhold ICS for 2–4 weeks then repeat spirometry – Reveals masked 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
6. 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
7. Fractional exhaled nitric oxide (FeNO) level that indicates type 2 inflammation in an adult not on
ICS?
✅ A) ≥50 ppb – *ATS/ERS threshold for high type 2*
B) 25–49 ppb – Intermediate
C) <25 ppb – Low type 2
D) Any elevation – Not specific
8. FeNO level that indicates type 2 inflammation in a child not on ICS?
✅ A) ≥35 ppb – Age-adjusted threshold per ATS/ERS
B) ≥50 ppb – Adult threshold
C) 10–20 ppb – Normal range
D) <25 ppb – Low type 2
9. 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
10. Which differential diagnosis should be considered in an adult with new wheezing and normal
FeNO? (Select 2)
✅ A) Vocal cord dysfunction – Inspiratory stridor, normal FeNO
✅ B) Heart failure with pulmonary edema – Cardiac wheeze (cardiac asthma)
C) Eosinophilic asthma – Typically elevated FeNO
D) Allergic bronchopulmonary aspergillosis – Elevated IgE and eosinophils
11. 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
12. Impulse oscillometry (IOS) is preferred over spirometry in which population?
✅ A) Young children unable to perform forced maneuvers – Requires only tidal breathing
B) Adults with classic asthma – Spirometry remains first-line
, C) Acute exacerbation – Not validated
D) Routine screening – Not cost-effective
13. Blood eosinophil level that supports eosinophilic asthma phenotype and biologic consideration?
✅ A) ≥150 cells/μL – *GINA 2026 threshold for considering anti-IL5*
B) ≥300 cells/μL – *Higher likelihood of anti-IL5 response*
C) ≥500 cells/μL – Very high, still responsive
D) <100 cells/μL – Non-eosinophilic
14. A 55-year-old smoker with dyspnea and wheezing. Which test best distinguishes asthma from
COPD? (Select 2)
✅ A) DLCO (diffusing capacity) – Normal in asthma, low in COPD
✅ B) FeNO ≥50 ppb – Suggests eosinophilic (asthma) phenotype
C) Spirometry alone – Overlap common
D) Chest X-ray – Not diagnostic
15. Which chest CT finding is characteristic of allergic bronchopulmonary aspergillosis (ABPA)?
✅ A) Central bronchiectasis – Hallmark radiologic finding
B) Peripheral tree-in-bud nodules – Suggests infection
C) Ground glass opacities – Non-specific
D) Normal CT – Does not exclude ABPA
Section 2: Stepwise Pharmacotherapy (Questions 16–40)
16. According to GINA 2026, what is the preferred as-needed therapy for mild intermittent asthma
(Step 1) in adults?
✅ A) Low-dose ICS-formoterol taken as needed – *Anti-inflammatory rescue reduces exacerbations
by ~65% vs SABA alone*
B) Albuterol as needed – No longer recommended as monotherapy
C) Daily low-dose ICS – Acceptable alternative but overtreatment for truly intermittent
D) Oral montelukast daily – Second-line, slower onset
17. A patient using as-needed ICS-formoterol reports symptoms on 4 days per week and nighttime
awakenings once weekly. What is the appropriate step-up?
✅ A) Daily low-dose ICS plus as-needed ICS-formoterol (Step 2) – *Symptoms >2 days/week or any
nighttime symptoms indicate need for regular controller*
B) Increase as-needed ICS-formoterol to high dose – Not a step
C) Add oral montelukast – Not first-line step-up
D) Switch to SABA alone – Unsafe
18. Which regimen represents GINA 2026 Step 3 preferred therapy for adults with persistent
asthma?
✅ A) Low-dose ICS-LABA maintenance + as-needed ICS-formoterol – Single or dual inhaler approach
B) Medium-dose ICS alone – Alternative but less effective
Asthma Management – Synthesis of 2026 GINA/NAEPP
Guidelines for Diagnosis, Personalized Pharmacotherapy,
Biologic Sequencing, Adherence Optimization, Comorbidity
Management, Inhaler Technique, Acute Exacerbations, Special
Populations, Health Equity, Climate Change, and Future
Directions
Section 1: Diagnosis and Confirmation of Asthma (Questions 1–15)
1. A 22-year-old with intermittent wheezing and normal spirometry. Which tests confirm asthma?
(Select 2)
✅ A) Bronchoprovocation (methacholine challenge) – Detects airway hyperresponsiveness when
spirometry is normal
✅ B) Peak expiratory flow (PEF) variability ≥10% over 14 days – GINA 2026 diagnostic criterion
C) Chest X-ray – Normal in uncomplicated asthma
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. A 34-year-old with episodic cough, chest tightness, and normal spirometry. What is the most
appropriate next diagnostic step?
✅ A) Bronchoprovocation challenge with methacholine – Detects AHR when baseline spirometry is
normal
B) High-resolution CT chest – Not indicated without suspicion of other pathology
C) Serum IgE level – Non-diagnostic; elevated in atopy but not specific
D) Empiric oral steroids – Inappropriate without confirmed diagnosis
4. 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
,5. A patient on daily ICS has normal spirometry. How can you confirm asthma?
✅ A) Withhold ICS for 2–4 weeks then repeat spirometry – Reveals masked 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
6. 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
7. Fractional exhaled nitric oxide (FeNO) level that indicates type 2 inflammation in an adult not on
ICS?
✅ A) ≥50 ppb – *ATS/ERS threshold for high type 2*
B) 25–49 ppb – Intermediate
C) <25 ppb – Low type 2
D) Any elevation – Not specific
8. FeNO level that indicates type 2 inflammation in a child not on ICS?
✅ A) ≥35 ppb – Age-adjusted threshold per ATS/ERS
B) ≥50 ppb – Adult threshold
C) 10–20 ppb – Normal range
D) <25 ppb – Low type 2
9. 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
10. Which differential diagnosis should be considered in an adult with new wheezing and normal
FeNO? (Select 2)
✅ A) Vocal cord dysfunction – Inspiratory stridor, normal FeNO
✅ B) Heart failure with pulmonary edema – Cardiac wheeze (cardiac asthma)
C) Eosinophilic asthma – Typically elevated FeNO
D) Allergic bronchopulmonary aspergillosis – Elevated IgE and eosinophils
11. 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
12. Impulse oscillometry (IOS) is preferred over spirometry in which population?
✅ A) Young children unable to perform forced maneuvers – Requires only tidal breathing
B) Adults with classic asthma – Spirometry remains first-line
, C) Acute exacerbation – Not validated
D) Routine screening – Not cost-effective
13. Blood eosinophil level that supports eosinophilic asthma phenotype and biologic consideration?
✅ A) ≥150 cells/μL – *GINA 2026 threshold for considering anti-IL5*
B) ≥300 cells/μL – *Higher likelihood of anti-IL5 response*
C) ≥500 cells/μL – Very high, still responsive
D) <100 cells/μL – Non-eosinophilic
14. A 55-year-old smoker with dyspnea and wheezing. Which test best distinguishes asthma from
COPD? (Select 2)
✅ A) DLCO (diffusing capacity) – Normal in asthma, low in COPD
✅ B) FeNO ≥50 ppb – Suggests eosinophilic (asthma) phenotype
C) Spirometry alone – Overlap common
D) Chest X-ray – Not diagnostic
15. Which chest CT finding is characteristic of allergic bronchopulmonary aspergillosis (ABPA)?
✅ A) Central bronchiectasis – Hallmark radiologic finding
B) Peripheral tree-in-bud nodules – Suggests infection
C) Ground glass opacities – Non-specific
D) Normal CT – Does not exclude ABPA
Section 2: Stepwise Pharmacotherapy (Questions 16–40)
16. According to GINA 2026, what is the preferred as-needed therapy for mild intermittent asthma
(Step 1) in adults?
✅ A) Low-dose ICS-formoterol taken as needed – *Anti-inflammatory rescue reduces exacerbations
by ~65% vs SABA alone*
B) Albuterol as needed – No longer recommended as monotherapy
C) Daily low-dose ICS – Acceptable alternative but overtreatment for truly intermittent
D) Oral montelukast daily – Second-line, slower onset
17. A patient using as-needed ICS-formoterol reports symptoms on 4 days per week and nighttime
awakenings once weekly. What is the appropriate step-up?
✅ A) Daily low-dose ICS plus as-needed ICS-formoterol (Step 2) – *Symptoms >2 days/week or any
nighttime symptoms indicate need for regular controller*
B) Increase as-needed ICS-formoterol to high dose – Not a step
C) Add oral montelukast – Not first-line step-up
D) Switch to SABA alone – Unsafe
18. Which regimen represents GINA 2026 Step 3 preferred therapy for adults with persistent
asthma?
✅ A) Low-dose ICS-LABA maintenance + as-needed ICS-formoterol – Single or dual inhaler approach
B) Medium-dose ICS alone – Alternative but less effective
