In a long‑standing asthmatic using salmeterol/fluticasone metered‑dose inhaler (MDI) only as needed, who awakens at night twice weekly, has daily shortness of breath limiting activities and requires daily nebulization for two weeks, with no fever, no sputum production and a normal chest X‑ray, how should her asthma control be classified?

Bronchial Asthma, Poorly Controlled

This patient's asthma is poorly controlled (answer: a). She exhibits multiple clear indicators of inadequate control that directly violate established criteria for well-controlled asthma.

Assessment of Asthma Control

The classification of asthma control is based on specific, measurable criteria that this patient clearly fails to meet:

Criteria for Well-Controlled Asthma (All Must Be Met)

According to established guidelines, well-controlled asthma requires 1:

• Asthma symptoms ≤2 times per week — This patient has daily symptoms requiring nebulization
• Rescue bronchodilator use ≤2 times per week — This patient uses nebulization at least once daily for 2 weeks
• No nighttime or early morning awakening — This patient awakens 2 times per week
• No limitations on daily activities — This patient reports "some limitation" on daily activities
• Normal or personal best lung function — Not assessed but likely impaired given symptom burden
• Patient and physician consider asthma well controlled — Clearly not the case

Why This Patient Is Poorly Controlled

This patient violates at least four of the six criteria for well-controlled asthma 1:

1. Excessive rescue medication use: Daily nebulization for 2 weeks far exceeds the threshold of ≤2 times per week 1
2. Nighttime awakenings: Occurring 2 times per week when zero awakenings is required for well-controlled asthma 1
3. Activity limitations: She reports limitations on daily activities, which disqualifies well-controlled status 1
4. Daily symptoms: Requiring daily nebulization indicates daily symptomatic asthma 1

Why Not Other Classifications?

Not "Partly Controlled" (Option c)

The terminology "partly controlled" is not the standard classification used in major asthma guidelines 1. The dichotomous assessment is well-controlled versus not well-controlled (poorly controlled) 1. This patient clearly falls into the "not well-controlled" category.

Not "Well Controlled" (Option b)

This is definitively incorrect. As detailed above, she violates multiple criteria for well-controlled asthma 1.

Not "Acute Exacerbation" (Option d)

An acute exacerbation would present with acute worsening beyond baseline, often with fever, increased sputum production, or respiratory distress requiring urgent intervention 1. This patient:

• Denies fever [@question context@]
• Denies sputum production [@question context@]
• Has unremarkable chest X-ray [@question context@]
• Presents to outpatient clinic (not emergency department) [@question context@]

This represents chronic poor control, not an acute exacerbation 1.

Critical Management Implications

Immediate Medication Adjustment Required

This patient is using salmeterol/fluticasone only "as needed," which is fundamentally incorrect 2, 3. This represents a critical management error:

• Inhaled corticosteroids must be used daily as controller medication, not intermittently 3
• LABAs (salmeterol) should never be used as monotherapy or intermittently — they must always be combined with regular daily ICS 1, 2
• As-needed use of combination ICS/LABA is not standard therapy for established persistent asthma 2, 3

Recommended Treatment Escalation

Given her poor control on what is essentially no regular controller therapy, she requires 2, 3:

1. Initiate scheduled twice-daily salmeterol/fluticasone (not as-needed) 2, 3
2. Consider increasing to medium-dose ICS/LABA combination (e.g., fluticasone/salmeterol 250/50 mcg twice daily) given the severity of symptoms 2, 3
3. Provide separate short-acting beta-agonist (albuterol) for rescue use only 2
4. Reassess control in 2-6 weeks 2, 3

Common Pitfalls to Avoid

• Do not confuse chronic poor control with acute exacerbation — the absence of fever, sputum, and normal chest X-ray indicate this is chronic inadequate control, not acute worsening 1
• Do not accept "as-needed" use of ICS/LABA combinations — this is inappropriate for persistent asthma requiring controller therapy 2, 3
• Do not underestimate the level of control — physicians and patients frequently underestimate poor asthma control 1
• Verify inhaler technique before assuming treatment failure — most patients use inhalers incorrectly 2, 3