How would you classify the asthma of a 16-year-old female with a history of seasonal allergies, reversible airflow limitation, and an Forced Expiratory Volume in 1 second (FEV1) of 85% predicted, who experiences symptoms 2-3 days/month, has a history of severe exacerbation, and is currently controlled with daily albuterol (salbutamol) therapy?

Asthma Classification: Well Controlled with High Future Risk

This 16-year-old female patient has well-controlled asthma with high future risk based on her clinical presentation and history of severe exacerbation requiring ICU admission. 1

Assessment of Asthma Control

Current Impairment Domain

• Symptoms: Experiences symptoms 2-3 days per month (≤2 days/week = well controlled) 1
• Nighttime awakenings: Denies nighttime awakenings (≤2 times/month = well controlled) 1
• Interference with normal activity: Able to participate in soccer with pre-treatment (no limitation = well controlled) 1
• Short-acting beta-agonist use: Uses albuterol daily before practice, but this is for prevention of exercise-induced symptoms rather than rescue (preventive use not counted against control) 1, 2
• Lung function: FEV1 is 85% predicted (>80% = well controlled) 1

Based on these parameters from the impairment domain, the patient meets all criteria for well-controlled asthma according to the National Asthma Education and Prevention Program guidelines 1.

Future Risk Domain

• History of exacerbations: One severe exacerbation requiring ICU admission and oral corticosteroid treatment 1
• Specific triggers identified: Positive allergen testing to pet dander, dust mites, and mold with severe reaction to cat exposure 1

The history of a severe exacerbation requiring ICU admission places this patient in the high future risk category 1, 3. According to the Expert Panel Report 3 guidelines, patients who have had severe exacerbations requiring intensive care are considered to have increased future risk regardless of their current level of symptom control 1, 4.

Rationale for Classification

The classification of asthma control requires assessment of both current impairment and future risk 1:

1. Current impairment: The patient meets all criteria for well-controlled asthma:

   • Symptoms ≤2 days per week
   • No nighttime awakenings
   • No activity limitations
   • FEV1 >80% predicted
   • SABA use primarily for prevention, not rescue

2. Future risk: The patient has high future risk due to:

   • History of severe exacerbation requiring ICU admission
   • Known specific allergen triggers with documented severe reaction

Clinical Implications

This classification has important treatment implications:

• Despite good current symptom control, this patient requires careful monitoring and possibly step-up in controller therapy to reduce future risk 1
• A written asthma action plan should be provided with clear instructions for early intervention during exacerbations 1, 5
• Environmental control measures should be emphasized, particularly avoidance of identified allergens (pet dander, dust mites, mold) 1
• Consider additional controller medications beyond albuterol for exercise-induced symptoms 1

Common Pitfalls to Avoid

1. Focusing only on current symptoms: Many clinicians incorrectly classify asthma control based solely on current symptoms without considering future risk factors 1, 3

2. Misinterpreting pre-exercise albuterol use: Using SABA before exercise for prevention is not counted as rescue use in the assessment of control 1, 2

3. Overlooking severe exacerbation history: A history of even one severe exacerbation significantly increases future risk and should influence management decisions 1, 4

4. Assuming well-controlled symptoms mean low risk: As demonstrated in this case, patients can have well-controlled symptoms but still have high future risk 3, 4

The National Asthma Education and Prevention Program guidelines clearly state that the level of control is determined by the most severe category in either the impairment or risk domains 1. Therefore, despite the patient's well-controlled current symptoms, her history of severe exacerbation requiring ICU admission places her in the "well-controlled; high future risk" category.