Based on current National Asthma Education and Prevention Program (NAEPP) guidelines, what is the best asthma classification for a 23‑year‑old female who coughs and wheezes twice weekly, awakens at night from coughing three times per month, has no activity limitation, and has a normal forced expiratory volume in one second (FEV1)?

Mild Persistent Asthma

This patient should be classified as having mild persistent asthma according to NAEPP guidelines. 1

Classification Rationale

The NAEPP classification system assigns asthma severity based on the most severe category in which any feature occurs across multiple domains of impairment. 1 For this 23-year-old patient, the key clinical features map to mild persistent asthma:

Impairment Domain Assessment

• Daytime symptoms: Coughing and wheezing twice weekly = >2 days/week but not daily → Mild persistent 1
• Nighttime awakenings: Three times per month = 3-4 times/month → Mild persistent 1
• Short-acting β2-agonist use: Uses albuterol intermittently (implied by twice-weekly symptoms) = >2 days/week but not daily → Mild persistent 1
• Interference with normal activity: No activity limitation = None to minor limitation → Intermittent to mild persistent 1
• Lung function (FEV1): 82% of predicted = >80% of predicted → Mild persistent 1

Why Not Intermittent Asthma?

Intermittent asthma requires symptoms ≤2 days/week and nighttime awakenings ≤2 times/month. 1 This patient exceeds both thresholds (symptoms occur twice weekly and nighttime awakenings occur three times monthly), definitively placing her in the persistent category. 1

Why Not Moderate or Severe Persistent?

• Moderate persistent requires either daily symptoms, nighttime awakenings >1 time/week, or FEV1 60-80% of predicted 1
• Severe persistent requires symptoms throughout the day, frequent nighttime awakenings (often 7 times/week), or FEV1 <60% of predicted 1

This patient's symptom frequency and lung function do not meet these more severe thresholds. 1

Important Clinical Considerations

Normal Spirometry Does Not Exclude Persistent Asthma

Physicians must recognize that patients with asthma can have normal lung function between exacerbations. 1 An FEV1 of 82% is still within the mild persistent range (>80% predicted) and does not downgrade severity when symptoms clearly indicate persistent disease. 1

Risk Domain Assessment

Although not explicitly stated in the question, the NAEPP guidelines emphasize assessing future risk based on exacerbation frequency requiring oral corticosteroids. 1 Patients with ≥2 exacerbations requiring oral steroids in the past year should be considered to have persistent asthma, even if impairment measures suggest intermittent disease. 1

Common Pitfall to Avoid

Do not underestimate asthma severity simply because the patient reports no activity limitation or has relatively preserved lung function. 1 Studies demonstrate that patients frequently underestimate their symptoms and disease severity. 1 The classification system requires assigning severity based on the worst category across all domains, not an average. 1

Clinical Implications

• This patient requires Step 2 therapy with a low-dose inhaled corticosteroid as the preferred controller medication 1
• Leukotriene receptor antagonists are an alternative (though not preferred) option for mild persistent asthma 1
• The patient should continue using a short-acting β2-agonist (albuterol) for rescue therapy only 1
• Using a rescue inhaler >2 days/week signals inadequate control and indicates the need for controller therapy 1