Asthma Management — MCQs
A 3-year-old is diagnosed with severe acute asthma exacerbation. Which medication is given first?
Which of the following is a long-acting beta-2 agonist?
Maximum effect of bronchodilatation in asthma is caused by -
What is the most appropriate method for administering asthma treatment to an infant under one year of age?
A patient presents with wheezing that improves with as-needed use of albuterol. Spirometry shows FEV1 ranging from 70 % to 83 %, and the patient experiences nighttime chest tightening twice a week. What is the most appropriate treatment?
A known case of COPD with acute exacerbation of symptoms. On examination patient was conscious and alert, pulse was 110 beats/ min and bilateral wheeze present. All of the following are true in the management of the patient except:
In a child with exercise-induced asthma, which action is recommended?
A patient develops acute respiratory distress, stridor, unilateral hyperinflation of the chest with decreased breath sounds on that side. What is the most likely cause?
Pneumatocele is commonest in which of the following conditions?
What is the main infectious agent associated with recurrent pulmonary infections in patients with cystic fibrosis?
Asthma Management Indian Medical PG Practice Questions and MCQs
Question 1: A 3-year-old is diagnosed with severe acute asthma exacerbation. Which medication is given first?
- A. Inhaled ipratropium
- B. IV corticosteroids
- C. Nebulized salbutamol (Correct Answer)
- D. IV magnesium sulfate
Explanation: ***Nebulized salbutamol*** - **Salbutamol** (albuterol) is a **short-acting beta-2 agonist (SABA)** which provides rapid bronchodilation by relaxing smooth muscles in the airways. - It is the **first-line treatment** for acute asthma exacerbations due to its quick onset of action and effectiveness in relieving bronchospasm. *Inhaled ipratropium* - **Ipratropium**, an anticholinergic, is often added to bronchodilators like salbutamol in **severe exacerbations** but is not the primary initial bronchodilator. - It works by blocking muscarinic receptors, causing **bronchodilation**, but its onset of action is slower than salbutamol. *IV corticosteroids* - **Corticosteroids** reduce airway inflammation and are crucial for preventing relapse and shortening recovery in severe asthma, but their **onset of action is delayed** (several hours). - They are typically administered after initial bronchodilation with SABAs and are not the first medication given for immediate symptom relief. *IV magnesium sulfate* - **Magnesium sulfate** is a smooth muscle relaxant that can be used in **severe, life-threatening asthma exacerbations** that are refractory to standard therapy. - It is considered a **second or third-line treatment** rather than an initial intervention for immediate bronchodilation.
Question 2: Which of the following is a long-acting beta-2 agonist?
- A. Isoprenaline
- B. Ephedrine
- C. Salbutamol
- D. Formoterol (Correct Answer)
Explanation: ***Formoterol*** - **Formoterol** is a **long-acting beta-2 agonist (LABA)** commonly used in the treatment of asthma and COPD. - It provides **bronchodilation** for up to 12 hours due to its high lipophilicity, allowing it to remain in the cell membrane and continuously activate beta-2 receptors. *Isoprenaline (non-selective adrenergic agonist)* - **Isoprenaline** is a **non-selective beta-adrenergic agonist**, meaning it activates both beta-1 and beta-2 receptors. - It is **short-acting** and primarily used as a vasodilator or to stimulate heart rate, not as a long-acting bronchodilator. *Ephedrine (non-selective adrenergic agonist)* - **Ephedrine** is a **mixed-acting sympathomimetic amine** that increases the release of norepinephrine and directly stimulates alpha and beta receptors. - It has a short duration of action and is primarily used as a decongestant or bronchodilator in emergency situations, not as a long-acting agent. *Salbutamol (short-acting beta-2 agonist)* - **Salbutamol** is a **short-acting beta-2 agonist (SABA)**, providing rapid onset but a short duration of action (typically 4-6 hours). - It is used for **relieving acute bronchospasm** and is not considered a long-acting medication for maintenance therapy.
Question 3: Maximum effect of bronchodilatation in asthma is caused by -
- A. Beta 2-Agonist (Correct Answer)
- B. Corticosteroids
- C. Theophylline
- D. Anticholinergic
Explanation: ***Beta 2-Agonist*** - **Beta-2 agonists** directly relax bronchial smooth muscle by stimulating beta-2 adrenergic receptors, leading to significant and rapid bronchodilation. - This direct action on airway muscle relaxation makes them the most potent and fastest-acting bronchodilators for acute asthma symptoms. *Corticosteroids* - **Corticosteroids** reduce airway inflammation and hypersensitivity over time but do not provide immediate or maximal bronchodilation. - Their primary role is in long-term control of asthma, preventing exacerbations rather than acutely reversing bronchospasm. *Theophylline* - **Theophylline** is a methylxanthine that causes modest bronchodilation by inhibiting phosphodiesterase and blocking adenosine receptors. - It has a narrow therapeutic index, numerous side effects, and is less effective than beta-2 agonists for bronchodilation. *Anticholinergic* - **Anticholinergics** (e.g., ipratropium) block muscarinic receptors, preventing acetylcholine-induced bronchoconstriction. - They provide bronchodilation but are generally less potent and have a slower onset of action compared to beta-2 agonists in asthma.
Question 4: What is the most appropriate method for administering asthma treatment to an infant under one year of age?
- A. MDI with Mask (no spacer)
- B. Nebulizer therapy
- C. MDI with Spacer (no mask)
- D. MDI with Spacer and Mask (Correct Answer)
Explanation: ***MDI with Spacer and Mask*** - For infants and young children, a **metered-dose inhaler (MDI)** used with a **spacer** and a **well-fitting mask** is the **most appropriate** method for delivering asthma medication. - The spacer helps to reduce the velocity of the aerosol and allows the infant to inhale the medication over several breaths, while the mask ensures the medication is delivered to the airways without significant loss. - This method is **portable**, **convenient**, and **cost-effective** for routine outpatient management. *MDI with Spacer (no mask)* - While a spacer is crucial for optimizing drug delivery from an MDI, an infant cannot effectively seal their lips around a spacer mouthpiece for proper inhalation. - This method would result in significant **medication loss** and insufficient dose delivery to the lungs. *MDI with Mask (no spacer)* - An MDI used directly with a mask without a spacer leads to inefficient drug delivery due to the **high velocity** of the aerosol spray. - The medication impinges on the back of the throat and face, reducing the amount that reaches the small airways. *Nebulizer therapy* - Nebulizers are also an **acceptable and effective option** for infants, particularly in acute settings or when families find them easier to use. - However, they are **time-consuming** (typically 10-15 minutes per treatment), require a power source or batteries, and are less portable than MDI systems. - For **routine outpatient management**, an MDI with spacer and mask is generally **preferred** due to its convenience, portability, and comparable efficacy when used correctly.
Question 5: A patient presents with wheezing that improves with as-needed use of albuterol. Spirometry shows FEV1 ranging from 70 % to 83 %, and the patient experiences nighttime chest tightening twice a week. What is the most appropriate treatment?
- A. Continue with albuterol
- B. Replace with salmeterol twice daily
- C. Start Tab prednisolone
- D. Add an inhaled corticosteroid (Correct Answer)
- E. Add a leukotriene modifier
Explanation: ***Add an inhaled corticosteroid*** * The patient has persistent asthma as evidenced by symptoms occurring twice a week (nighttime chest tightening), and **FEV1 variability** despite current albuterol use. * Adding a **low-dose inhaled corticosteroid** is the recommended *first-line controller treatment* for persistent asthma to reduce inflammation and prevent exacerbations per **GINA guidelines**. *Continue with albuterol* * Continuing albuterol alone is insufficient for persistent asthma, as it only provides **symptomatic relief** and does not address the underlying inflammation. * This approach would lead to continued symptoms and potential **asthma exacerbations**. *Replace with salmeterol twice daily* * Salmeterol is a **long-acting beta-agonist (LABA)**, and while it provides prolonged bronchodilation, it should never be used as monotherapy in asthma due to the risk of severe exacerbations. * LABAs should always be prescribed in combination with an **inhaled corticosteroid**. *Start Tab prednisolone* * **Oral prednisolone** is a systemic corticosteroid typically reserved for **severe asthma exacerbations** or for patients whose symptoms are not controlled by high-dose inhaled corticosteroids and other controller medications. * It carries more significant **side effects** with long-term use compared to inhaled corticosteroids. *Add a leukotriene modifier* * While **leukotriene receptor antagonists** (e.g., montelukast) can be used as alternative controller therapy for mild persistent asthma, they are considered **less effective** than inhaled corticosteroids. * They are typically reserved as an alternative for patients who cannot use or tolerate inhaled corticosteroids, or as **add-on therapy** in more severe cases.
Question 6: A known case of COPD with acute exacerbation of symptoms. On examination patient was conscious and alert, pulse was 110 beats/ min and bilateral wheeze present. All of the following are true in the management of the patient except:
- A. Non invasive ventilation is contraindicated (Correct Answer)
- B. Permissible hypercapnia allowed
- C. Inhalation with salbutamol
- D. I/V steroids
Explanation: ***Non invasive ventilation is contraindicated*** - This statement is **false**, therefore the correct exception. **Non-invasive ventilation (NIV)** is often indicated and beneficial in the management of acute exacerbations of COPD, especially in patients with **respiratory acidosis** or persistent dyspnea, as it can reduce the need for intubation and improve outcomes [2]. - The patient's presentation (conscious, alert, wheeze, tachycardia) suggests an acute exacerbation, for which NIV is a key intervention unless there are absolute contraindications like cardiac arrest or inability to protect the airway [3]. *Permissible hypercapnia allowed* - **Permissive hypercapnia** is a valid strategy in managing acute exacerbations of COPD, particularly during mechanical ventilation. The goal is to maintain an adequate pH (e.g., >7.20-7.25) rather than normalizing CO2, to avoid **barotrauma** and **volutrauma** from aggressive ventilation [3]. - This approach acknowledges that some CO2 retention is acceptable as long as acidosis is not severe, protecting the lungs from excessive pressure. *Inhalation with salbutamol* - **Inhaled bronchodilators**, such as **salbutamol (a short-acting beta-agonist)**, are a cornerstone of treatment for acute COPD exacerbations [1]. They act rapidly to relieve **bronchospasm** and improve airflow, addressing the wheeze observed in the patient. - Frequent administration of these agents is crucial in the initial management to open up the airways and reduce air trapping. *I/V steroids* - **Systemic corticosteroids**, such as intravenous methylprednisolone or oral prednisone, are essential in managing acute COPD exacerbations. They reduce **airway inflammation** and swelling, leading to improved lung function and reduced recovery time. - Steroids are typically given for a short course (e.g., 5-7 days) to minimize side effects while maximizing therapeutic benefits.
Question 7: In a child with exercise-induced asthma, which action is recommended?
- A. Prophylaxis with steroids
- B. Prophylaxis with theophylline
- C. Breathing exercise
- D. Prophylaxis with beta-agonist (Correct Answer)
Explanation: ***Prophylaxis with beta-agonist*** - **Short-acting beta-agonists (SABAs)** like albuterol are the first-line treatment for preventing **exercise-induced bronchoconstriction** when taken 15-30 minutes before physical activity. - They work by **relaxing the smooth muscles** of the airways, opening them up and making it easier to breathe during exercise. *Prophylaxis with steroids* - **Inhaled corticosteroids** are primarily used for **long-term control** of persistent asthma, reducing airway inflammation. - They are not typically used as a **preventative measure immediately prior to exercise** for exercise-induced bronchoconstriction. *Prophylaxis with theophylline* - **Theophylline** is a bronchodilator with a **narrow therapeutic index** and significant side effects, making it a less preferred option for asthma prophylaxis. - It is generally reserved for patients who are not well-controlled on other standard therapies and requires **therapeutic drug monitoring**. *Breathing exercise* - While **breathing exercises** can be beneficial for overall lung health and managing asthma symptoms, they are not a substitute for pharmacological prophylaxis in preventing **acute exercise-induced bronchoconstriction**. - They may complement medication but do not provide the **immediate bronchodilation** needed before exercise.
Question 8: A patient develops acute respiratory distress, stridor, unilateral hyperinflation of the chest with decreased breath sounds on that side. What is the most likely cause?
- A. Asthma
- B. Aspiration pneumonia
- C. Foreign body aspiration (Correct Answer)
- D. Pleural effusion
Explanation: ### Explanation The clinical presentation of **acute respiratory distress, stridor, and unilateral hyperinflation** is a classic triad for **Foreign Body Aspiration (FBA)**. **Why Foreign Body Aspiration is Correct:** When an object is aspirated, it often creates a **"check-valve" effect**. During inspiration, the airways dilate, allowing air to pass the object. During expiration, the airways narrow, trapping air distal to the foreign body. This leads to **obstructive emphysema (unilateral hyperinflation)** and decreased breath sounds on the affected side. Stridor indicates the object may be lodged in the upper airway or trachea, while localized wheezing or decreased air entry suggests a bronchial location (most commonly the right main bronchus). **Why Other Options are Incorrect:** * **Asthma:** Typically presents with bilateral diffuse wheezing and a history of atopy. It does not cause focal unilateral hyperinflation unless complicated by a secondary pneumothorax. * **Aspiration Pneumonia:** Usually presents with fever, cough, and crackles rather than acute stridor. Radiologically, it shows opacification/consolidation rather than hyperinflation. * **Pleural Effusion:** This would result in **stony dullness** on percussion and **collapsed/shifted lung** (mediastinal shift away from the lesion), but the affected side would show decreased expansion and opacification on X-ray, not hyperinflation. **High-Yield Clinical Pearls for NEET-PG:** * **Gold Standard Diagnosis & Management:** Rigid Bronchoscopy (both diagnostic and therapeutic). * **Most Common Site:** Right main bronchus (due to it being wider, shorter, and more vertical). * **Radiological Sign:** Mediastinal shift away from the affected side during expiration (due to air trapping). * **Age Group:** Most common in children aged 1–3 years (the "peanut" age).
Question 9: Pneumatocele is commonest in which of the following conditions?
- A. Pneumococcal pneumonia
- B. Staphylococcal pneumonia (Correct Answer)
- C. H. influenzae pneumonia
- D. Viral pneumonia
Explanation: **Explanation:** **Staphylococcal pneumonia** is the correct answer because it is a necrotizing infection characterized by the production of toxins (such as Panton-Valentine Leukocidin) and enzymes that cause tissue destruction. This leads to the formation of **pneumatoceles**—thin-walled, air-filled tension cysts within the lung parenchyma. These occur due to a "check-valve" mechanism where air enters the necrotic area during inspiration but becomes trapped during expiration. While pneumatoceles are transient and usually resolve spontaneously, they are a classic radiological hallmark of *Staphylococcus aureus* infection in children. **Analysis of Incorrect Options:** * **Pneumococcal pneumonia (A):** Caused by *Streptococcus pneumoniae*, this typically presents as lobar consolidation. While it is the most common cause of bacterial pneumonia, it rarely causes cavitation or pneumatoceles. * **H. influenzae pneumonia (C):** Usually presents as bronchopneumonia or lobar involvement. While it can cause pleural effusions, pneumatocele formation is not a characteristic feature. * **Viral pneumonia (D):** Typically presents with interstitial infiltrates and hyperinflation. It does not cause the focal parenchymal necrosis required to form pneumatoceles. **NEET-PG High-Yield Pearls:** * **Most common complication** of Staphylococcal pneumonia: Empyema or Pyopneumothorax. * **Radiological triad for Staph pneumonia:** Bronchopneumonia, Pneumatoceles, and Pleural effusion/Empyema. * **Management of Pneumatocele:** Most are asymptomatic and require **conservative management** (observation), as they regress over weeks to months. Surgery is only indicated if they cause tension pneumothorax or become infected.
Question 10: What is the main infectious agent associated with recurrent pulmonary infections in patients with cystic fibrosis?
- A. Mycoplasma
- B. Pseudomonas (Correct Answer)
- C. Pneumocystis
- D. Aspergillus
Explanation: **Explanation:** In Cystic Fibrosis (CF), a defect in the CFTR protein leads to thick, dehydrated endobronchial secretions. This impaired mucociliary clearance creates a niche for chronic bacterial colonization. While *Staphylococcus aureus* and *Haemophilus influenzae* are common in early childhood, **Pseudomonas aeruginosa** becomes the predominant pathogen by late childhood and adolescence. It is the most significant cause of progressive lung damage, bronchiectasis, and mortality in CF patients due to its ability to form protective biofilms and transition into a "mucoid" phenotype. **Analysis of Options:** * **Option A (Mycoplasma):** Typically causes "walking pneumonia" in school-aged children and young adults. While it causes respiratory infections, it is not the hallmark pathogen associated with the chronic, recurrent destruction seen in CF. * **Option C (Pneumocystis):** *Pneumocystis jirovecii* is an opportunistic fungal infection primarily seen in patients with T-cell immunodeficiency (e.g., HIV/AIDS or post-transplant). It is not a typical primary pathogen in CF. * **Option D (Aspergillus):** While *Aspergillus fumigatus* can cause **Allergic Bronchopulmonary Aspergillosis (ABPA)** in CF patients (a hypersensitivity reaction), it is not the primary "infectious agent" responsible for the majority of recurrent bacterial pulmonary exacerbations. **High-Yield Clinical Pearls for NEET-PG:** 1. **Age-wise Colonization:** *S. aureus* is the most common isolate in infants/young children; *P. aeruginosa* is the most common in adults. 2. **Burkholderia cepacia:** Colonization with this organism (the "Cepacia syndrome") is associated with a rapid decline in lung function and is often a contraindication for lung transplantation. 3. **Treatment:** Anti-pseudomonal coverage (e.g., Ceftazidime, Piperacillin-Tazobactam, or Aminoglycosides) is the cornerstone of managing CF pulmonary exacerbations.
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