According to current NAEPP asthma‑severity guidelines, how should asthma be classified in a 23‑year‑old woman with cough and wheeze twice weekly, three nocturnal awakenings per month, no activity limitation, and a post‑bronchodilator forced expiratory volume in one second of 82 % predicted?

Asthma Severity Classification

This patient has mild persistent asthma according to NAEPP guidelines.

Clinical Presentation Analysis

The patient's symptom profile places her squarely in the mild persistent category based on the following criteria:

• Daytime symptoms twice weekly: She reports coughing and wheezing approximately twice per week, which is the defining threshold between intermittent and mild persistent asthma 1
• Nocturnal awakenings 3 times per month: This exceeds the intermittent asthma threshold (≤2 times per month) but falls well below the moderate persistent threshold (>1 time per week, which equals >4 times per month) 1, 2
• No activity limitation: Her daily activities remain unrestricted, consistent with mild disease 1
• FEV1 82% of predicted: This lung function measurement falls in the mild persistent range (FEV1 ≥80% predicted for mild persistent asthma) 1

NAEPP Classification Framework

The National Asthma Education and Prevention Program uses a severity classification system before treatment initiation that integrates multiple parameters 1:

Mild Persistent Asthma Criteria:

• Symptoms >2 days per week but not daily
• Nighttime awakenings 3-4 times per month
• Minor limitation in normal activity
• FEV1 ≥80% predicted
• FEV1/FVC ratio normal

This patient meets all these criteria precisely 1.

Important Distinction: Severity vs. Control

A critical caveat: The evidence emphasizes that asthma severity classification applies primarily to untreated patients at initial diagnosis 3. Once treatment begins, the focus shifts from "severity" to "control" assessment 3.

Since this patient has been using borrowed albuterol intermittently, she is technically not completely untreated, but she has never received appropriate controller therapy or formal diagnosis. Therefore, severity classification remains appropriate for initial treatment planning 3.

Clinical Implications

This patient requires initiation of daily controller therapy with a low-dose inhaled corticosteroid, as mild persistent asthma mandates regular anti-inflammatory treatment rather than rescue bronchodilator alone 4. The twice-weekly symptom pattern and nocturnal awakenings indicate inadequate control with rescue medication only 4.

Common Pitfalls to Avoid:

• Do not classify as intermittent asthma simply because symptoms occur only twice weekly—the presence of any nocturnal awakenings >2 times per month automatically elevates classification to at least mild persistent 1
• Do not rely solely on FEV1: The 82% predicted value might suggest near-normal function, but symptoms and nocturnal awakenings drive the classification when FEV1 is ≥80% 3, 5
• Do not mistake this for well-controlled asthma: Although symptoms are infrequent, any nocturnal awakening indicates suboptimal control by current standards 4