Respiratory Board Prep

Asthma and COPD make up most respiratory questions on the ABFM. Learn the GINA and GOLD treatment ladders the way they actually appear on test day.

Respiratory medicine accounts for roughly 7 to 9 percent of the ABFM Family Medicine boards, and the content distribution is unusually concentrated. Two diseases — asthma and COPD — supply the majority of respiratory questions. Community-acquired pneumonia, pulmonary embolism, tuberculosis screening, and obstructive sleep apnea fill out the rest. If you master the current GINA and GOLD treatment ladders and can recognize the IDSA pneumonia categories, you have already covered most of the high-yield material.

Asthma management changed substantially with the GINA 2019 update and has continued to evolve through 2025. The single biggest shift: short-acting beta-agonist (SABA) monotherapy is no longer recommended for any age group. Even mild, intermittent asthma should be treated with as-needed low-dose ICS-formoterol (the so-called Track 1 approach). This is one of the most-tested updates on recent ABFM exams, and many older study resources are still wrong about it. If a question presents a patient with mild intermittent asthma and asks for "first-line therapy," the modern answer is as-needed low-dose ICS-formoterol, not albuterol monotherapy.

COPD follows the GOLD report, which is updated annually. The 2025 GOLD report continues the ABCD-to-ABE classification: group A (low symptoms, low risk), B (high symptoms, low risk), and E (high risk regardless of symptoms — formerly groups C and D). Initial therapy for group A is a bronchodilator (LABA or LAMA), group B gets dual bronchodilator (LABA plus LAMA), and group E gets LABA plus LAMA, with triple therapy (LABA plus LAMA plus ICS) reserved for ongoing exacerbations or eosinophilic phenotype. Smoking cessation remains the only intervention with mortality benefit.

Community-acquired pneumonia is tested through the IDSA/ATS 2019 guideline framework. Outpatient healthy adult: amoxicillin or doxycycline (or a macrolide if local resistance is low). Outpatient with comorbidities: respiratory fluoroquinolone or beta-lactam plus macrolide. Inpatient non-severe: beta-lactam plus macrolide or fluoroquinolone monotherapy. ICU: beta-lactam plus macrolide or beta-lactam plus fluoroquinolone, plus consideration of MRSA and Pseudomonas coverage if risk factors exist.

Pulmonary embolism and DVT are tested less often than the chronic conditions but reliably appear. The Wells score and Geneva criteria stratify pretest probability, the PERC rule rules out PE in low-pretest-probability patients, and D-dimer is useful only when pretest probability is low. CT pulmonary angiography is the gold standard for diagnosis. DOACs are first-line for treatment in most patients.

High-yield respiratory topics

• Asthma stepwise therapy per GINA 2025 (Track 1). Step 1 to 2: as-needed low-dose ICS-formoterol. Step 3: daily low-dose ICS-formoterol maintenance plus as-needed reliever. Step 4: medium-dose maintenance ICS-formoterol. Step 5: high-dose plus add-on (LAMA, biologic). SABA monotherapy is no longer recommended at any step.
• COPD initial therapy by GOLD 2025 group. Group A: bronchodilator. Group B: LABA plus LAMA. Group E (frequent or severe exacerbations): LABA plus LAMA, escalate to LABA plus LAMA plus ICS for ongoing exacerbations or blood eosinophils over 300. Smoking cessation, vaccines (flu, pneumococcal, COVID, RSV), pulmonary rehab.
• COPD exacerbation management. Short-acting bronchodilators, oral corticosteroids (prednisone 40 mg for 5 days per REDUCE trial), and antibiotics if increased sputum purulence or mechanical ventilation needed. Azithromycin or amoxicillin-clavulanate are first-line. Consider hospitalization for severe symptoms or comorbidities.
• Community-acquired pneumonia outpatient antibiotics (IDSA 2019). Healthy adult: amoxicillin 1 g three times daily or doxycycline 100 mg twice daily. Comorbidities (heart, lung, renal, liver, diabetes, immunocompromise): respiratory fluoroquinolone (levofloxacin, moxifloxacin) or beta-lactam plus macrolide.
• PE workup by pretest probability. Low probability (Wells under 4): apply PERC; if all 8 PERC criteria met, no further testing. If PERC positive, check D-dimer; negative D-dimer rules out PE. Moderate to high probability: go directly to CT pulmonary angiography. V/Q scan if contrast is contraindicated.
• Latent TB screening and treatment. Screen high-risk patients with IGRA (preferred) or TST. Positive test plus negative chest X-ray equals latent TB. Treat with rifampin for 4 months, isoniazid plus rifapentine weekly for 12 weeks (3HP), or isoniazid for 6 to 9 months. Active TB requires four-drug therapy.
• Obstructive sleep apnea diagnosis and treatment. Suspect with snoring, witnessed apneas, daytime sleepiness, hypertension. STOP-BANG questionnaire stratifies risk. Diagnose with home sleep apnea test or in-lab polysomnography. CPAP is first-line treatment; oral appliances for mild to moderate disease or CPAP intolerance.
• Pulmonary function test interpretation basics. Obstruction: FEV1/FVC ratio under 0.7 (or below lower limit of normal). GOLD severity by FEV1: mild over 80, moderate 50 to 80, severe 30 to 50, very severe under 30. Restriction suggested by reduced TLC, not by reduced FVC alone.

ABFM exam tips

SABA monotherapy is wrong on every exam now. This single update has reshaped asthma questions on the ABFM. If you see albuterol PRN as the only therapy and the question asks what is missing or what to recommend, the answer is as-needed low-dose ICS-formoterol. Memorize this.

Use the GOLD groups, not FEV1, to choose initial COPD therapy. Symptom burden (CAT or mMRC) and exacerbation history drive group assignment, and group drives drug choice. FEV1 informs prognosis and severity but not initial drug selection in current GOLD reports.

For pneumonia, ask "outpatient or inpatient?" first. CURB-65 or PSI score guides triage. Once you have triage, IDSA antibiotic choice falls out by category. Healthy outpatient is the most-tested scenario and the most commonly missed because old teaching was "macrolide monotherapy" — current guidelines prefer amoxicillin or doxycycline.

Know which patients need ICS in COPD. Indications: blood eosinophils over 300, history of asthma, frequent exacerbations despite dual bronchodilator. Avoid ICS in pure COPD without these indications because of pneumonia risk. The exam tests this discrimination directly.

For PE, anchor on pretest probability. D-dimer is a screening test only — it has high sensitivity but poor specificity. Order it only when the patient is low pretest probability. Ordering D-dimer in a high-pretest-probability patient is a tested error because a negative result still does not rule out PE in that population.

Recognize aspiration pneumonia features. Dependent lobe involvement (right lower lobe most common), risk factors like dysphagia or altered mental status, and anaerobic coverage requirement (amoxicillin-clavulanate or clindamycin) are all classic exam clues.

Common pitfalls

Do not prescribe albuterol monotherapy for asthma. This is the single biggest tested change. SABA-only therapy increases exacerbations and mortality risk. Even the mildest asthmatic should have access to ICS, ideally as-needed ICS-formoterol per GINA Track 1.

Do not give ICS to every COPD patient. Inhaled corticosteroids increase pneumonia risk in COPD without exacerbation history or eosinophilic phenotype. Reserve ICS for the right indications: blood eosinophils elevated, asthma overlap, or recurrent exacerbations on dual bronchodilator.

Do not use macrolide monotherapy as default for outpatient pneumonia. Macrolide resistance in S. pneumoniae now exceeds 25 percent in most US regions. Amoxicillin or doxycycline is preferred for healthy outpatients. Reserve macrolides for patients who cannot take penicillins or doxycycline.

Do not order D-dimer when pretest probability for PE is high. A negative D-dimer in a high-risk patient does not rule out PE. Skip the D-dimer and go directly to CT pulmonary angiography. Ordering D-dimer in this setting is a classic test error.

Do not over-treat positive PPD without context. A 10 mm PPD in a low-risk patient may be a false positive or BCG vaccination effect. Use IGRA (QuantiFERON, T-SPOT) for patients with prior BCG to clarify. Always rule out active TB with chest X-ray and symptom screen before treating latent TB.

Do not skip pulmonary rehab in COPD. Pulmonary rehabilitation has mortality and quality-of-life benefits comparable to medications. The exam tests this by including patients with persistent dyspnea on optimal medical therapy and asking what to add — pulmonary rehab is a frequent answer.

Do not assume hospitalized pneumonia patients need MRSA coverage. Add MRSA coverage only with risk factors: known prior MRSA infection, recent IV antibiotics, severe disease with cavitary lesion, or community high prevalence. Routine vancomycin in every admitted CAP patient is overuse.

Frequently asked questions

Does the ABFM test the new GINA asthma guidelines?

Yes, and this is one of the most important updates to study. GINA shifted away from SABA monotherapy in 2019 and has reinforced this through every update since. As-needed low-dose ICS-formoterol is now the recommended reliever for nearly all asthmatics. Older board prep materials are often wrong on this point.

How many respiratory questions are on the ABFM?

Respiratory content typically makes up 7 to 9 percent of the ABFM exam, or roughly 20 to 28 questions per full exam. Asthma and COPD together account for over half of these, with pneumonia, sleep apnea, PE, and TB filling out the rest.

What is the difference between GOLD groups A, B, and E?

Group A is low symptoms (mMRC 0 to 1 or CAT under 10) and low exacerbation risk (zero or one moderate exacerbation, no hospitalization). Group B is high symptoms with low exacerbation risk. Group E is high exacerbation risk regardless of symptoms (two or more moderate exacerbations, or one hospitalization). Groups C and D were merged into E in the 2023 GOLD update.

Should I learn pulmonary function test patterns for the ABFM?

Yes, but at a basic level. Know that FEV1/FVC under 0.7 is obstruction, that bronchodilator reversibility (FEV1 improvement of 12 percent and 200 mL) suggests asthma, and that restriction needs TLC for confirmation. The exam will not ask you to interpret raw flow-volume loops.

How is community-acquired pneumonia tested on the boards?

The exam wants you to triage with CURB-65 or clinical judgment, then choose IDSA-guideline antibiotics. Outpatient healthy adult: amoxicillin or doxycycline. Outpatient with comorbidities: respiratory fluoroquinolone or beta-lactam plus macrolide. Inpatient: beta-lactam plus macrolide or fluoroquinolone monotherapy.

Do I need to know biologic asthma therapies for the ABFM?

At a recognition level only. Know that omalizumab targets IgE (allergic asthma), mepolizumab and benralizumab target IL-5 (eosinophilic asthma), and dupilumab targets IL-4/IL-13. These are referrals to allergy or pulmonology — the family medicine question is "when to refer," not "which biologic to start."

How do I handle PE workup questions efficiently?

Anchor on pretest probability first. Use Wells or Geneva to stratify. Low probability: apply PERC, then D-dimer if PERC positive. Moderate or high probability: go straight to CT pulmonary angiography. The exam tests whether you skip D-dimer when you should and pursue imaging when D-dimer is unhelpful.