~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
Real questions from the FirstPassPA bank, with the full explanation. Pick an answer — no signup, no email.
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 1
DStep 4
Reveal answer & full explanation
Correct answer: B — Step 3
AStep 2
BStep 3✓
CStep 1
DStep 4
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)
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?
AEndotracheal intubation
BAdd IV magnesium sulfate and systemic corticosteroids
CAdminister subcutaneous epinephrine
DContinue albuterol nebulization alone every 20 minutes
Reveal answer & full explanation
Correct answer: B — Add IV magnesium sulfate and systemic corticosteroids
AEndotracheal intubation
BAdd IV magnesium sulfate and systemic corticosteroids✓
CAdminister subcutaneous epinephrine
DContinue albuterol nebulization alone every 20 minutes
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.
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ABPA (allergic bronchopulmonary aspergillosis) — Poorly controlled asthma + central bronchiectasis + elevated total IgE (>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
Diagnostic algorithm
GINA Step
Preferred Controller
Reliever
1
As-needed low-dose ICS-formoterol
Low-dose ICS-formoterol PRN
2
Daily low-dose ICS OR PRN ICS-formoterol
Low-dose ICS-formoterol PRN
3
Low-dose ICS-LABA (formoterol)
Low-dose ICS-formoterol PRN (MART)
4
Medium-dose ICS-LABA
Low-dose ICS-formoterol PRN (MART)
5
High-dose ICS-LABA + add-on (LAMA, biologic)
Low-dose ICS-formoterol PRN; refer specialist
GINA 2024 stepwise treatment for adults and adolescents (Track 1, ICS-formoterol-based).
Treatment
First-line
GINA 2024 has eliminated SABA-only treatment; all adults and adolescents should receive ICS-containing therapy
Biologics for severe uncontrolled asthma: omalizumab (anti-IgE), mepolizumab/reslizumab/benralizumab (anti-IL-5/IL-5R), dupilumab (anti-IL-4Rα), tezepelumab (anti-TSLP)
Oral corticosteroid burst for exacerbation: prednisone 40-60 mg daily × 5-7 days (no taper needed for short courses)
Acute exacerbation: nebulized albuterol + ipratropium, systemic corticosteroids, oxygen to SpO2 ≥92% (≥94% in pregnancy), magnesium sulfate 2 g IV for severe
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, decreased growth velocity in children (small, reversible)
Educational use only. This outline is a study aid for PA students and is not medical advice or a substitute for clinical judgment. FirstPassPA is an independent study tool and is not affiliated with, endorsed by, or sponsored by NCCPA or PAEA. PANCE® and PANRE® are registered trademarks of the National Commission on Certification of Physician Assistants; End of Rotation™ is a program of the Physician Assistant Education Association.