Asthma is a chronic inflammatory disorder of the airways characterized by reversible bronchoconstriction, airway hyperresponsiveness, and airway inflammation. It affects millions worldwide and can significantly impact quality of life if not properly managed. For PharmD students, a comprehensive understanding of asthma’s pathophysiology, clinical presentation, diagnostic criteria, and the stepwise approach to its pharmacological and non-pharmacological management is essential. This includes knowledge of various reliever and controller medications, appropriate inhaler techniques, and the use of asthma action plans to empower patients and optimize therapeutic outcomes. This MCQ quiz will test your knowledge on the multifaceted aspects of asthma.
1. The three main pathophysiological characteristics of asthma are airway inflammation, bronchoconstriction, and:
- A. Pulmonary fibrosis
- B. Airway hyperresponsiveness
- C. Emphysema
- D. Pleural effusion
Answer: B. Airway hyperresponsiveness
2. Which type of inflammatory cells plays a predominant role in the chronic airway inflammation seen in most asthma phenotypes?
- A. Neutrophils
- B. Eosinophils, mast cells, and T-lymphocytes (especially Th2 cells)
- C. Macrophages only
- D. Basophils
Answer: B. Eosinophils, mast cells, and T-lymphocytes (especially Th2 cells)
3. Bronchoconstriction in asthma is primarily caused by the contraction of:
- A. Alveolar smooth muscle
- B. Airway smooth muscle
- C. Diaphragmatic muscle
- D. Intercostal muscles
Answer: B. Airway smooth muscle
4. Common triggers for asthma symptoms include all of the following EXCEPT:
- A. Allergens (e.g., pollen, dust mites, animal dander)
- B. Respiratory infections (viral)
- C. Beta-adrenergic blockers
- D. Cold air and exercise
Answer: C. Beta-adrenergic blockers (While non-selective beta-blockers can trigger asthma, they are not a common environmental or infectious trigger in the same category as the others for general asthma pathophysiology; they are a drug-induced trigger). Better option for an “EXCEPT” in common triggers: 4. Common triggers for asthma symptoms include all of the following EXCEPT:
- A. Allergens (e.g., pollen, dust mites)
- B. Respiratory viral infections
- C. High-dose inhaled corticosteroids
- D. Cold air and exercise
Answer: C. High-dose inhaled corticosteroids (ICS are a treatment, not a trigger).
5. Which immunoglobulin is central to the pathogenesis of allergic asthma?
- A. IgG
- B. IgA
- C. IgE
- D. IgM
Answer: C. IgE
6. Spirometry is a key diagnostic tool for asthma. A hallmark finding suggestive of asthma is:
- A. A restrictive pattern with reduced Total Lung Capacity (TLC).
- B. Reversible airflow obstruction (e.g., significant increase in FEV1 after bronchodilator administration).
- C. An increased FEV1/FVC ratio.
- D. Diffusing capacity impairment.
Answer: B. Reversible airflow obstruction (e.g., significant increase in FEV1 after bronchodilator administration).
7. Peak Expiratory Flow (PEF) monitoring is useful for asthma patients to:
- A. Diagnose asthma definitively.
- B. Assess day-to-day asthma control, identify worsening asthma, and guide asthma action plans.
- C. Measure lung volumes accurately.
- D. Determine the specific type of airway inflammation.
Answer: B. Assess day-to-day asthma control, identify worsening asthma, and guide asthma action plans.
8. Short-Acting Beta2-Agonists (SABAs) like albuterol provide quick relief of asthma symptoms by:
- A. Reducing airway inflammation.
- B. Relaxing airway smooth muscle through beta-2 receptor stimulation, leading to bronchodilation.
- C. Stabilizing mast cells.
- D. Blocking leukotriene receptors.
Answer: B. Relaxing airway smooth muscle through beta-2 receptor stimulation, leading to bronchodilation.
9. Which of the following is the cornerstone of long-term controller therapy for persistent asthma?
- A. Short-Acting Beta2-Agonists (SABAs) taken regularly
- B. Inhaled Corticosteroids (ICS)
- C. Oral corticosteroids taken daily
- D. Theophylline
Answer: B. Inhaled Corticosteroids (ICS)
10. The primary mechanism of action of Inhaled Corticosteroids (ICS) in asthma is:
- A. Direct bronchodilation
- B. Broad anti-inflammatory effects, reducing airway inflammation and hyperresponsiveness
- C. Inhibition of phosphodiesterase
- D. Leukotriene receptor antagonism
Answer: B. Broad anti-inflammatory effects, reducing airway inflammation and hyperresponsiveness
11. Long-Acting Beta2-Agonists (LABAs) such as salmeterol and formoterol, when used for asthma management, should:
- A. Always be used as monotherapy for long-term control.
- B. Only be used for quick relief of acute symptoms.
- C. Always be used in combination with an Inhaled Corticosteroid (ICS) in a fixed-dose combination inhaler or concurrently.
- D. Be administered orally for best effect.
Answer: C. Always be used in combination with an Inhaled Corticosteroid (ICS) in a fixed-dose combination inhaler or concurrently.
12. Montelukast, a leukotriene receptor antagonist (LTRA), works by blocking the action of cysteinyl leukotrienes at which receptor?
- A. LTD4 receptor (CysLT1 receptor)
- B. LTB4 receptor
- C. 5-lipoxygenase enzyme
- D. Histamine H1 receptor
Answer: A. LTD4 receptor (CysLT1 receptor)
13. Omalizumab is a biologic agent indicated for severe allergic asthma. Its mechanism of action involves:
- A. Inhibiting Interleukin-5 (IL-5).
- B. Binding to circulating IgE, preventing it from binding to mast cells and basophils.
- C. Antagonizing the IL-4 receptor alpha.
- D. Blocking Tumor Necrosis Factor-alpha (TNF-α).
Answer: B. Binding to circulating IgE, preventing it from binding to mast cells and basophils.
14. Common local adverse effects of Inhaled Corticosteroids (ICS) include:
- A. Tachycardia and tremor
- B. Oral candidiasis (thrush) and dysphonia (hoarseness)
- C. Weight gain and hypertension
- D. Bronchoconstriction
Answer: B. Oral candidiasis (thrush) and dysphonia (hoarseness)
15. An Asthma Action Plan is a written, individualized plan developed with the patient that outlines:
- A. Only their prescribed medications.
- B. How to manage daily asthma, recognize worsening symptoms, and what steps to take during an exacerbation.
- C. A fixed exercise regimen.
- D. Only dietary recommendations.
Answer: B. How to manage daily asthma, recognize worsening symptoms, and what steps to take during an exacerbation.
16. According to GINA (Global Initiative for Asthma) guidelines, for adults and adolescents with mild asthma (Step 1 or 2), preferred reliever therapy is often:
- A. Daily oral corticosteroids.
- B. As-needed low-dose ICS-formoterol (a LABA with fast onset).
- C. As-needed SABA alone (traditional approach, but GINA is shifting away from SABA-only for safety).
- D. Regular nebulized ipratropium.
Correction: GINA guidelines have evolved. As-needed low-dose ICS-formoterol is now preferred over SABA alone for safety even in mild asthma. Answer: B. As-needed low-dose ICS-formoterol (a LABA with fast onset).
17. The initial management of an acute severe asthma exacerbation in an emergency setting typically includes:
- A. Oral LABA and low-dose ICS
- B. Repeated doses of inhaled SABA, early administration of systemic corticosteroids (oral or IV), and supplemental oxygen
- C. Theophylline infusion
- D. Montelukast intravenously
Answer: B. Repeated doses of inhaled SABA, early administration of systemic corticosteroids (oral or IV), and supplemental oxygen
18. Which of the following is a critical component of patient education for individuals using metered-dose inhalers (MDIs)?
- A. Shaking the inhaler only if it contains a corticosteroid.
- B. Proper technique, including slow deep inhalation, breath-holding, and use of a spacer device if appropriate.
- C. Storing the MDI in the refrigerator.
- D. Using the MDI as many times as desired without counting doses.
Answer: B. Proper technique, including slow deep inhalation, breath-holding, and use of a spacer device if appropriate.
19. Mepolizumab, reslizumab, and benralizumab are biologic agents that target which cytokine pathway involved in eosinophilic asthma?
- A. IgE pathway
- B. Interleukin-5 (IL-5) pathway (IL-5 or its receptor)
- C. Tumor Necrosis Factor-alpha (TNF-α) pathway
- D. Interleukin-13 (IL-13) pathway
Answer: B. Interleukin-5 (IL-5) pathway (IL-5 or its receptor)
20. “Airway remodeling” in chronic asthma refers to persistent structural changes in the airways, including:
- A. Decreased airway smooth muscle mass.
- B. Thinning of the basement membrane.
- C. Subepithelial fibrosis, smooth muscle hypertrophy/hyperplasia, mucus gland hyperplasia, and angiogenesis.
- D. Increased airway elasticity.
Answer: C. Subepithelial fibrosis, smooth muscle hypertrophy/hyperplasia, mucus gland hyperplasia, and angiogenesis.
21. Exercise-Induced Bronchoconstriction (EIB) can be managed prophylactically by:
- A. Avoiding all forms of exercise.
- B. Using an inhaled SABA 10-15 minutes before exercise, or daily controller therapy if asthma is persistent.
- C. Taking oral corticosteroids before each exercise session.
- D. Using an inhaled LAMA only.
Answer: B. Using an inhaled SABA 10-15 minutes before exercise, or daily controller therapy if asthma is persistent.
22. The “stepwise approach” to asthma management involves:
- A. Starting all patients on the highest step of therapy.
- B. Adjusting medication intensity (stepping up or down) based on ongoing assessment of asthma control.
- C. Using only reliever medications.
- D. A fixed treatment regimen for all asthma patients.
Answer: B. Adjusting medication intensity (stepping up or down) based on ongoing assessment of asthma control.
23. Which mediator released from mast cells is a potent bronchoconstrictor and also increases vascular permeability and mucus secretion in asthma?
- A. Acetylcholine
- B. Histamine, leukotrienes (LTC4, LTD4, LTE4), and prostaglandins (PGD2)
- C. Nitric oxide
- D. Dopamine
Answer: B. Histamine, leukotrienes (LTC4, LTD4, LTE4), and prostaglandins (PGD2)
24. The FEV1/FVC ratio (Forced Expiratory Volume in 1 second / Forced Vital Capacity) in a patient with obstructive asthma is typically:
- A. Increased (>0.80)
- B. Reduced (<0.75-0.80 in adults, <0.90 in children, depending on age)
- C. Normal, with only FVC reduced
- D. Always zero
Answer: B. Reduced (<0.75-0.80 in adults, <0.90 in children, depending on age)
25. Zileuton, a leukotriene modifier, exerts its effect by inhibiting which enzyme?
- A. Cyclooxygenase-2 (COX-2)
- B. 5-Lipoxygenase (5-LOX), thereby preventing the synthesis of all leukotrienes
- C. Phosphodiesterase-4 (PDE4)
- D. Neprilysin
Answer: B. 5-Lipoxygenase (5-LOX), thereby preventing the synthesis of all leukotrienes
26. What is the primary advantage of using a spacer device with a metered-dose inhaler (MDI)?
- A. It increases the speed of medication delivery.
- B. It reduces the need to shake the MDI before use.
- C. It improves drug delivery to the lungs by reducing oropharyngeal deposition and the need for precise hand-breath coordination.
- D. It makes the medication taste better.
Answer: C. It improves drug delivery to the lungs by reducing oropharyngeal deposition and the need for precise hand-breath coordination.
27. In the GINA guidelines, “Maintenance and Reliever Therapy” (MART) typically refers to the use of which combination inhaler for both daily control and as-needed relief?
- A. SABA + SAMA
- B. ICS + formoterol (a LABA with a fast onset of action)
- C. LAMA + LABA
- D. Oral corticosteroid + SABA
Answer: B. ICS + formoterol (a LABA with a fast onset of action)
28. Dupilumab is a biologic agent approved for severe eosinophilic asthma or oral corticosteroid-dependent asthma. It targets:
- A. IgE
- B. The Interleukin-4 receptor alpha (IL-4Rα), thereby inhibiting signaling of both IL-4 and IL-13
- C. Tumor Necrosis Factor-alpha (TNF-α)
- D. Interleukin-5 (IL-5)
Answer: B. The Interleukin-4 receptor alpha (IL-4Rα), thereby inhibiting signaling of both IL-4 and IL-13
29. Tezepelumab is a newer biologic for severe asthma that works by blocking:
- A. IgE
- B. IL-5
- C. Thymic Stromal Lymphopoietin (TSLP), an upstream epithelial-derived cytokine
- D. The P2Y12 receptor
Answer: C. Thymic Stromal Lymphopoietin (TSLP), an upstream epithelial-derived cytokine
30. A short course of oral corticosteroids (e.g., prednisone, prednisolone) is used during asthma exacerbations primarily for their:
- A. Immediate bronchodilator effect.
- B. Potent anti-inflammatory effect to reduce airway inflammation and hasten recovery.
- C. Ability to stabilize mast cells within minutes.
- D. Mucolytic properties.
Answer: B. Potent anti-inflammatory effect to reduce airway inflammation and hasten recovery.
31. Which factor is most indicative of a severe, life-threatening asthma exacerbation?
- A. PEF >80% predicted
- B. Mild wheezing
- C. Difficulty speaking in full sentences, cyanosis, PEF <40-50% predicted, or silent chest
- D. Occasional cough
Answer: C. Difficulty speaking in full sentences, cyanosis, PEF <40-50% predicted, or silent chest
32. Long-term, high-dose systemic corticosteroid use for asthma can lead to which significant adverse effect?
- A. Bronchodilation
- B. Osteoporosis, adrenal suppression, weight gain, cataracts
- C. Improved immune function
- D. Tachycardia
Answer: B. Osteoporosis, adrenal suppression, weight gain, cataracts
33. Theophylline, a bronchodilator less commonly used now, has a narrow therapeutic index and its metabolism can be affected by many factors. Its mechanism of action is thought to involve:
- A. Selective beta-2 agonism
- B. Non-selective phosphodiesterase inhibition, adenosine receptor antagonism, and other effects
- C. Muscarinic receptor antagonism
- D. IgE neutralization
Answer: B. Non-selective phosphodiesterase inhibition, adenosine receptor antagonism, and other effects
34. Which of the following is a key component of assessing asthma control?
- A. Frequency of hospital admissions in the last 10 years
- B. Daytime symptoms, nighttime awakenings, reliever use, activity limitation, and lung function (FEV1 or PEF)
- C. Blood eosinophil count only
- D. Serum IgE levels only
Answer: B. Daytime symptoms, nighttime awakenings, reliever use, activity limitation, and lung function (FEV1 or PEF)
35. If a patient with persistent asthma is using their SABA reliever inhaler more than _______ per week for symptom relief (excluding pre-exercise use), their asthma is generally considered not well-controlled.
- A. Once a month
- B. Twice a week
- C. Once a day
- D. Only if used more than 5 times a day
Answer: B. Twice a week (GINA guidelines emphasize this as a marker of poor control).
36. Cromolyn sodium, a mast cell stabilizer, is most effective when used:
- A. For acute relief of bronchospasm.
- B. Prophylactically before exposure to known triggers or exercise.
- C. As a high-dose oral medication.
- D. In combination with omalizumab.
Answer: B. Prophylactically before exposure to known triggers or exercise.
37. A potential systemic side effect of long-term, high-dose inhaled corticosteroid therapy, especially in susceptible individuals, is:
- A. Increased bone mineral density
- B. Decreased risk of cataracts and glaucoma
- C. Adrenal suppression and reduced bone mineral density
- D. Significant weight loss
Answer: C. Adrenal suppression and reduced bone mineral density
38. Which of the following is a key characteristic of formoterol that allows its use in MART regimens?
- A. It is a short-acting beta2-agonist.
- B. It has both a rapid onset of action (similar to SABAs) and a long duration of action (LABA).
- C. It is only available as an oral tablet.
- D. It has potent anti-inflammatory effects.
Answer: B. It has both a rapid onset of action (similar to SABAs) and a long duration of action (LABA).
39. Non-pharmacological strategies for asthma management include:
- A. Regular exposure to tobacco smoke to build tolerance.
- B. Avoidance of identified allergens and irritants, smoking cessation, and weight management if obese.
- C. High-intensity exercise during acute exacerbations.
- D. Discontinuing all controller medications once symptoms improve.
Answer: B. Avoidance of identified allergens and irritants, smoking cessation, and weight management if obese.
40. The “hygiene hypothesis” has been proposed to explain the increasing prevalence of asthma. It suggests that:
- A. Poor personal hygiene directly causes asthma.
- B. Reduced exposure to certain childhood infections and microbial environments may alter immune development, predisposing individuals to allergic diseases like asthma.
- C. Asthma is primarily caused by air pollution in clean environments.
- D. Excessive use of cleaning products triggers asthma.
Answer: B. Reduced exposure to certain childhood infections and microbial environments may alter immune development, predisposing individuals to allergic diseases like asthma.
41. Bronchial thermoplasty is an invasive procedure considered for selected adult patients with severe persistent asthma. It involves:
- A. Administering heated oxygen.
- B. Delivering controlled thermal energy to the airway walls to reduce airway smooth muscle mass.
- C. Surgically removing parts of the lung.
- D. Implanting a device to stimulate bronchodilation.
Answer: B. Delivering controlled thermal energy to the airway walls to reduce airway smooth muscle mass.
42. What is the role of Fractional Exhaled Nitric Oxide (FeNO) measurement in asthma management?
- A. It is a direct measure of bronchoconstriction.
- B. It can be a non-invasive marker of eosinophilic airway inflammation and may help predict ICS responsiveness or guide ICS dosing.
- C. It is used to diagnose viral infections that trigger asthma.
- D. It measures the patient’s peak expiratory flow.
Answer: B. It can be a non-invasive marker of eosinophilic airway inflammation and may help predict ICS responsiveness or guide ICS dosing.
43. When stepping down asthma therapy, the goal is to:
- A. Discontinue all medications as quickly as possible.
- B. Find the lowest effective dose of controller medication that maintains asthma control and minimizes side effects.
- C. Switch all patients to SABA-only therapy.
- D. Increase the dose of reliever medication.
Answer: B. Find the lowest effective dose of controller medication that maintains asthma control and minimizes side effects.
44. Aspirin-exacerbated respiratory disease (AERD), also known as Samter’s triad, is a condition characterized by asthma, chronic rhinosinusitis with nasal polyps, and:
- A. Allergy to beta-blockers
- B. Hypersensitivity reactions (respiratory) to aspirin and other NSAIDs that inhibit COX-1
- C. Severe lactose intolerance
- D. Allergy to inhaled corticosteroids
Answer: B. Hypersensitivity reactions (respiratory) to aspirin and other NSAIDs that inhibit COX-1
45. Which of the following statements is TRUE regarding asthma in pregnancy?
- A. All asthma medications should be discontinued during pregnancy.
- B. Uncontrolled asthma poses a greater risk to the mother and fetus than most asthma medications; most ICS and SABAs are considered safe.
- C. Oral corticosteroids are absolutely contraindicated throughout pregnancy.
- D. Asthma severity always improves during pregnancy.
Answer: B. Uncontrolled asthma poses a greater risk to the mother and fetus than most asthma medications; most ICS and SABAs are considered safe.
46. “Status asthmaticus” refers to:
- A. Mild, intermittent asthma.
- B. A severe, prolonged asthma exacerbation that is refractory to standard initial treatment and can be life-threatening.
- C. Exercise-induced bronchoconstriction.
- D. Asthma that is well-controlled with an ICS.
Answer: B. A severe, prolonged asthma exacerbation that is refractory to standard initial treatment and can be life-threatening.
47. The mechanism of action of ipratropium bromide, a short-acting muscarinic antagonist (SAMA), when used as an adjunct in acute severe asthma exacerbations, is:
- A. Beta-2 adrenergic agonism
- B. Inhibition of acetylcholine-mediated bronchoconstriction via muscarinic receptor blockade
- C. Mast cell stabilization
- D. Leukotriene receptor antagonism
Answer: B. Inhibition of acetylcholine-mediated bronchoconstriction via muscarinic receptor blockade
48. For patients with severe asthma, a personalized medicine approach may involve using biomarkers like blood eosinophil count or FeNO to select:
- A. The most appropriate SABA.
- B. A specific biologic agent that targets the underlying inflammatory pathway.
- C. The brand of inhaled corticosteroid.
- D. The type of spacer device.
Answer: B. A specific biologic agent that targets the underlying inflammatory pathway.
49. What is a crucial element of an asthma action plan that tells the patient what to do if their symptoms or PEF fall into the “yellow zone” (caution)?
- A. Immediately go to the emergency department.
- B. Increase reliever medication use, potentially add or increase controller medication as pre-specified, and monitor closely.
- C. Discontinue all medications.
- D. Start a course of antibiotics.
Answer: B. Increase reliever medication use, potentially add or increase controller medication as pre-specified, and monitor closely.
50. The pharmacist’s role in asthma management includes all of the following EXCEPT:
- A. Educating patients on correct inhaler technique and the purpose of their medications.
- B. Helping patients develop and understand their asthma action plan.
- C. Performing diagnostic spirometry and definitively diagnosing asthma.
- D. Assessing asthma control, adherence, and identifying potential medication-related problems or triggers.
Answer: C. Performing diagnostic spirometry and definitively diagnosing asthma. (Pharmacists assess and educate, but definitive diagnosis is usually by a physician, though pharmacists can perform screening spirometry in some settings).