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Developing an Asthma Action Plan

(continued)

Review Your Asthma Action Plans

Asthma action plans should be reviewed with your asthma doctor at least once a year. Changes in the asthma action plan may be needed because of changes in your peak flow numbers or the medications you are taking.

Always keep your asthma action plan where it can be easily found by you or your family.

 

Print Out Asthma Action Plan

Print out and use this asthma action plan to record important information about your asthma or a family member’s asthma (including teenagers and children).

 

Date: Person's Name / Clinic Number
Disease Severity:
Doctor:
Phone:
Nurse or Therapist:
Phone:
Evening / Weekend
Phone:

 

Personal Best Peak Flow (PF):

GREEN ZONE: All Clear
Where you or your family member should be every day -- NO asthma symptoms. Able to do usual activities and sleep without coughing, wheezing, or difficulty breathing. Peak flow is 80% to 100% of personal best.

 

ACTION: Control asthma. Use these medicines every day, on good days and bad days, to prevent asthma symptoms. Use a spacer with metered dose inhalers (or other asthma inhaler and/or medications prescribed for a child).

 

Medication
____
Dose
____
Morning
____
Afternoon
____
Evening
____
Bedtime
____
Medication
____
Dose
____
Morning
____
Afternoon
____
Evening
____
Bedtime
____
Medication
____
Dose
____
Morning
____
Afternoon
____
Evening
____
Bedtime
____
Medication
____
Dose
____
Morning
____
Afternoon
____
Evening
____
Bedtime
____
Medication
____
Dose
____
Morning
____
Afternoon
____
Evening
____
Bedtime
____
Medication
____
Dose
____
Morning
____
Afternoon
____
Evening
____
Bedtime
____

 

Use ______ 15 to 20 minutes before exercise or exposure to a known trigger.

 

YELLOW ZONE: Caution
This is NOT where you should be. There may be coughing, wheezing, and mild shortness of breath. Sleep and usual activities may be disturbed. You may be more tired than usual. Peak flow is 50% to 80% personal best.


ACTION: Relief of Symptoms.

  • Keep taking green zone medicines listed above. Use spacer with metered dose inhalers (or other device prescribed for a child).
  • Add quick-relief medicine: Albuterol ____ puffs or ________ in nebulizer. May use every 4 hours as needed. Also add: ____________________.
  • After taking quick-relief medicine, symptoms should be relieved in 5 to 15 minutes. If symptoms do not improve completely, REPEAT quick-relief medicine 1 to 2 more times, 5 to 20 minutes apart (up to 3 treatments in one hour). (For children, repeat albuterol 1 to 2 more times, 15 to 20 minutes apart; use up to 3 treatments in one hour.)  If there is no improvement, call your doctor.
  • CALL your doctor or nurse/therapist for further advice.
  • If you or other family member improves completely after 2 to 3 treatments, continue the quick-relief medicine 4 times per day for the next 24 hours. Call for further advice.
  • For children: If symptoms completely go away but return in 4 hours or less, repeat albuterol dose and continue to use 4 times per day for the next 48 hours. Call your doctor.

WebMD Medical Reference

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