~8% of US adults, ~7% of children. Higher prevalence in non-Hispanic Black and Puerto Rican populations. Most childhood-onset cases are atopic (Th2-high); adult-onset is more often non-atopic.
Try two board-style Asthma questions
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Question 1PulmonaryMedium
A 28-year-old woman with asthma reports symptoms every day and nighttime awakenings about three times per week. She uses her short-acting beta-agonist daily for relief, and her symptoms limit some normal activities. She is currently taking no controller medication. Spirometry shows an FEV1 of 72% predicted. Using the National Asthma Education and Prevention Program (NAEPP) framework, which of the following is the most appropriate initial treatment step?
AStep 2
BStep 3
CStep 4
DStep 1
EStep 5
Reveal answer & full explanation
Correct answer: B — Step 3
AStep 2
BStep 3✓
CStep 4
DStep 1
EStep 5
Why Step 3 is correct
Daily symptoms, nighttime awakenings more than once weekly, and an FEV1 of 60-80% predicted classify this as moderate persistent asthma
Per the NAEPP framework, moderate persistent asthma in an adolescent or adult is initiated at Step 3: low-dose inhaled corticosteroid (ICS) plus a long-acting beta-agonist (LABA), or low-dose ICS-formoterol used as both controller and reliever
Control is reassessed in a few weeks and therapy is stepped up if it is not achieved
Why the others are wrong
Step 1 — Step 1 is for intermittent asthma (symptoms two days per week or fewer, rare nighttime awakenings); daily symptoms exclude it (premature closure on the mildest category)
Step 2 — Step 2 corresponds to mild persistent asthma; daily symptoms and nighttime awakenings more than once weekly exceed mild criteria (buzzword-matching "persistent" without grading its severity)
Step 4 — Step 4 is reserved for severe persistent disease (symptoms throughout the day, awakenings often nightly, FEV1 under 60%); the FEV1 of 72% and three-nights-per-week awakenings defeat it (anchoring on the daily symptoms while ignoring the lung function)
Step 5 — a high-intensity step used for severe persistent asthma (where initial therapy is Step 4 or 5) or for asthma not controlled at Step 4; an FEV1 of 72% and awakenings three nights per week meet moderate, not severe, criteria (overestimating severity from daily rescue inhaler use)
Question 2PulmonaryEasy
A 32-year-old woman with a severe asthma exacerbation has SpO2 91% and peak flow 45% of predicted. After three back-to-back albuterol nebulizations she has only minimal improvement. Which of the following is the most appropriate next step?
AAdd IV magnesium sulfate and systemic corticosteroids
BAdminister IV aminophylline
CAdminister subcutaneous epinephrine
DContinue albuterol nebulization alone every 20 minutes
EEndotracheal intubation
Reveal answer & full explanation
Correct answer: A — Add IV magnesium sulfate and systemic corticosteroids
AAdd IV magnesium sulfate and systemic corticosteroids✓
BAdminister IV aminophylline
CAdminister subcutaneous epinephrine
DContinue albuterol nebulization alone every 20 minutes
EEndotracheal intubation
Why IV magnesium sulfate and systemic corticosteroids is correct
For a severe asthma exacerbation not responding to initial bronchodilator therapy, the next step is to add systemic corticosteroids and IV magnesium sulfate (a smooth muscle relaxant) and reassess every 30 minutes.
Why the others are wrong
Endotracheal intubation — Reserved for impending respiratory failure, indicated by a silent chest, exhaustion, altered mental status, or rising PaCO2, none of which are present here.
Administer subcutaneous epinephrine — Parenteral epinephrine is reserved for anaphylaxis or near-fatal asthma with poor aerosol delivery; this patient is still moving air and ventilating, so it adds systemic toxicity without outperforming inhaled beta-agonists plus corticosteroids and magnesium.
Continue albuterol nebulization alone every 20 minutes — Continuing bronchodilator therapy alone without escalating to corticosteroids and magnesium is insufficient for a severe exacerbation with poor initial response.
Administer IV aminophylline — a bronchodilator that was once a routine emergency department add-on, but current asthma guidelines advise against IV aminophylline because it adds little bronchodilation to inhaled beta-agonists while its narrow therapeutic range brings arrhythmias, seizures, and vomiting, and it is no substitute for the systemic corticosteroids that treat the airway inflammation.
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ABPA (allergic bronchopulmonary aspergillosis) — Poorly controlled asthma + central bronchiectasis + elevated total IgE (≥500 IU/mL per 2024 ISHAM criteria; classically >1000) and Aspergillus-specific IgE
Eosinophilic granulomatosis with polyangiitis (EGPA) — Asthma + peripheral eosinophilia + sinusitis + neuropathy or pulmonary infiltrates
Diagnostic workup
Diagnostic criteria
GINA: history of variable respiratory symptoms + confirmed variable expiratory airflow limitation (bronchodilator reversibility, methacholine positivity, or PEF variability).
Labs
CBC (eosinophilia supports allergic phenotype)
Total IgE and allergen-specific IgE if considering biologics or ABPA
FeNO (fractional exhaled nitric oxide) — elevated in Th2-high asthma
Imaging
CXR — usually normal or hyperinflation; obtain to exclude alternative diagnoses or complications (pneumothorax, pneumonia)
HRCT if bronchiectasis or alternative diagnosis suspected
Other studies
Spirometry with bronchodilator response — first-line: obstructive pattern (FEV1/FVC reduced) with ≥12% AND ≥200 mL improvement in FEV1 post-bronchodilator confirms reversibility
Methacholine challenge if spirometry normal but high clinical suspicion — PC20 ≤8 mg/mL is positive
Peak expiratory flow monitoring for home tracking; diurnal variability >10% supports diagnosis
Step 3 (moderate): low-dose ICS-formoterol as both daily maintenance and PRN reliever (MART); Track 2 alternative is daily low-dose ICS-LABA with PRN SABA
Step 4: medium-dose ICS-formoterol MART (Track 2: medium-dose ICS-LABA with PRN SABA)
Step 5: high-dose ICS-LABA, refer for biologic/specialist
Long-acting beta-agonist (LABA; like albuterol, stimulates β2 receptors to raise cAMP and relax bronchial smooth muscle): formoterol, salmeterol, vilanterol (NEVER as monotherapy in asthma)
NAEPP EPR-3 severity (untreated, age 12 and older; classify by the most severe feature): intermittent = symptoms and SABA use ≤2 days/wk, night awakenings ≤2/mo, no activity limitation, FEV1 >80% (Step 1); mild persistent = symptoms >2 days/wk but not daily, 3-4 awakenings/mo, minor limitation, FEV1 >80% (Step 2); moderate persistent = daily symptoms and SABA use, awakenings >1/wk but not nightly, some limitation, FEV1 60-80% (Step 3); severe persistent = symptoms throughout the day, nightly awakenings, SABA several times/day, extreme limitation, FEV1 <60% (Step 4 or 5). Two or more oral-steroid exacerbations/yr also means persistent; ages 5-11 add FEV1/FVC bands (>85%, >80%, 75-80%, <75%).
Leukotriene receptor antagonist (blocks the CysLT1 receptor): montelukast (FDA black-box warning for neuropsychiatric effects), zafirlukast
Biologics for severe uncontrolled asthma, chosen by phenotype: omalizumab (anti-IgE) for allergic asthma with perennial aeroallergen sensitization and total IgE in the dosing range (~30-700 IU/mL); mepolizumab/reslizumab/benralizumab (anti-IL-5/IL-5R) for blood eosinophils ≥150-300/µL; dupilumab (anti-IL-4Rα) for eosinophils ≥150/µL or FeNO ≥25 ppb, favored when atopic dermatitis or nasal polyps coexist; tezepelumab (anti-TSLP) regardless of phenotype
Oral corticosteroid burst for exacerbation: prednisone 40-60 mg daily × 5-7 days (no taper needed for short courses)
Acute exacerbation: inhaled SABA (albuterol) every 20 min for 3 doses in the first hour, plus ipratropium for moderate-severe exacerbations in the ED; early systemic corticosteroids; controlled oxygen to SpO2 93-95% in adults (94-98% in children 6-11; ≥95% in pregnancy); magnesium sulfate 2 g IV for severe exacerbations not responding to initial therapy
Exacerbation severity (NAEPP EPR-3/GINA): mild = PEF ≥70% predicted or personal best, talks in sentences; moderate = PEF 40-69%, talks in phrases; severe = PEF <40%, talks in words, accessory muscle use, SpO2 <90%; life-threatening = too dyspneic to speak, drowsiness or confusion, silent chest, PEF <25%. A normal or rising PaCO2 in a tachypneic, distressed patient signals impending respiratory failure (prepare for ICU and possible intubation)
Complications
Status asthmaticus, respiratory failure requiring intubation
Pneumothorax, pneumomediastinum from barotrauma
Airway remodeling with fixed obstruction (asthma-COPD overlap)
ICS side effects: oral candidiasis, dysphonia, small decrease in growth velocity in children (about 1 cm lower adult height; use the lowest effective dose)
Since 2019, GINA recommends an anti-inflammatory reliever (as-needed ICS-formoterol) rather than SABA-only treatment for adults and adolescents; the US NAEPP 2020 update still uses PRN SABA alone at Step 1 for intermittent asthma.
Silent chest, exhaustion, drowsiness, paradoxical thoracoabdominal motion, or pCO2 normalization (after initial hyperventilation) signal impending respiratory failure.
Exercise-induced bronchoconstriction: pretreat with SABA 15 min before exercise; if frequent, daily ICS.
Pregnancy: budesonide is the preferred ICS (most safety data). Uncontrolled asthma is more dangerous than medication.
Beta-blockers and NSAIDs can trigger severe exacerbations in susceptible patients — verify tolerance before use.
Trigger control: eliminate household tobacco smoke exposure and reduce exposure to indoor allergens the patient is sensitized to; during viral respiratory infections (including COVID-19), continue maintenance ICS-containing therapy at the usual dose rather than stopping or reducing it.
References
GINA 2026 — Global Initiative for Asthma. Global Strategy for Asthma Management and Prevention, 2026 Update (ginasthma.org)
NAEPP 2020 — 2020 Focused Updates to the Asthma Management Guidelines (Cloutier et al., J Allergy Clin Immunol 2020)
SYGMA 2 — As-Needed Budesonide-Formoterol versus Maintenance Budesonide in Mild Asthma (Bateman ED et al., N Engl J Med 2018;378:1877-1887)
ERS 2022 — European Respiratory Society Guidelines for the Diagnosis of Asthma in Adults (Louis R et al., Eur Respir J 2022;60:2101585)
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