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Asthma Patient Action Plan

Name: ________________________       Personal Best Peak Flow: _________________________


Every Day Medications

Green (Go) Zone: _____ to _____
  • Green zone is 80-100% of your child’s personal best peak flow
  • These medicines are given everyday to control your child’s asthma. Your child’s breathing is normal without coughing or wheezing and your child can work or play without difficulty.
  • For exercise related symptoms, use prescribed medicine 20 minutes before exercise.
___Inhaled steroid:
. Flovent (MDI): ___44mg ___110mg ___220mg
. Pulmicort: ___Turbuhaler MDI (200mcg) ___Nebulizer:___0.25mg ___0.5mg
. Other: _____________________________________________________________
. Dose: ___ puff(s) ___inhalation(s) ___nebs ___time(s) a day

___Advair: ___100 ___250 ___500 One inhalation, twice a day

___Serevent (long acting asthma medicine):
. ___Diskus: Dose: 1 puff once a day
. ___MDI Dose: 2 puffs 2 times per day

___Singular (Leukotriene modifiers):
. ___4mg chewables ___5mg chewables ___10mg tabs
. Dose: 1 - 2 tabs 1 - 2 times per day

___Other: __________________________________________________________________________

Quick Relief (Rescue) Medications

Yellow (Caution) Zone: _____ to _____
  • Yellow zone is 50 to 80% of child’s personal best peak flow
  • Use for occasional asthma cough or wheeze, shortness of breath, coughing or difficulty breathing with exercise.
  • For exercise related symptoms, use prescribed medicine 20 minutes before exercise.
  1. Albuterol premix (0.083%) Inhalation Solution: ____one premix in Nebulizer
  2. Albuterol MDI: ____ puffs with spacer
  3. Albuterol Nebulizer solution (0.5%): ___0.25cc ___0.5cc Mix with 2 ml (cc) of saline. Saline is available in a pump dispenser or in 2 cc vials
    • Dose: Use above albuterol medicines every 4-6 hours until symptoms improved & peak flow readings are back into the green zone
    • Side effects: may cause jitteriness & increases heart rate
  4. Albuterol (by mouth): ___tsp (2mg/tsp) every 4-6 hours or ___mg tab every 12 hours
    • Can be used at school when Nebulizer or MDI not available. Side effects greater.
  5. Maxair Autohaler: (No Spacer Needed) Dose: 2 puffs (wait 2-3 minutes between puffs)
  6. Xopenex (premix for Nebulizer): ___0.31mg ___0.63mg ___1.25mg: ___1 ___1/2 vial. Similar to albuterol, but with fewer side effects. Doses needed are less than albuterol.

Action Plan for Worsening Asthma Attack

Red (Danger) Zone: Less than_____
  • Red zone is less than 50% of your child’s personal best peak flow
  • Breathing is faster than normal with retractions of the rib cage (chest is caving in and out)
  • Difficulty walking and talking
  • Use when Quick relief medicines have been used and symptoms are persisting or worsening.
  • Continue to check peak flows before and after treatments until better.
  • Continue to use other asthma medications.
Take The Following Medicines And Call Our Office
  1. Albuterol or Xopenex
    • Use every 2-4 hours until peak flow has increased into the yellow zone. Call office if unable to raise peak flow into the yellow zone within 4 hours or your child’s breathing becomes worse.
  2. Inhaled Steroid (Flovent): If presently taking Flovent, double your current dose until peak flow has increased and symptoms have improved (up to one week). If taking Advair, continue Advair and add Flovent or Pulmicort (another inhaled steriod): _________________________________
    • Do not double Advair dose as this will give your child too much Serevent.
  3. Oral Steroid (Prednisone): Call office if symptoms have not improved within 4 - 6 hours with above treatments. Prednisone may need to be added to other asthma medications
    • Dose: ___________________________________________
    • Prednisone can be taken once a day in the morning. If stomach becomes upset, split the dose and give ˝ dose in morning and ˝ dose at lunch. Take the first day’s total dose as soon as it is picked up.

How And Why To Use A Home Peak Flow Meter

A Peak Flow Meter must be used at home to help determine the following:
  • When your child requires a nebulizer treatment and how frequent treatments are needed.
  • Alert you to call our office because peak flow readings are abnormal.
  • When to stop treatments because your child is symptom-free and peak flows are normal.

How Do I Determine My Child's Personal Best Peak Flow Value?
  1. When your child is well, record your child's highest value.
  2. This will be used as the personal best value.
  3. This value is used to calculate the green, yellow, and red zones as follows:

Important Points Concerning Asthma Treatment
  • Always use a spacer when using a metered dose inhaler.
  • Always rinse mouth and spit after taking an inhaled steroid. Do not drink!
  • If using both albuterol and inhaled steroid, use albuterol first to open the airways. Take the inhaled steroid after waiting 5 to 10 minutes for best results.
  • Oral steroids take several hours to work: when they are prescribed, begin the medicine as soon as possible.
  • Start preventative medications as soon as they are prescribed, they may take 2-6 weeks to get to their maximal effect.
  • Quick relief medication may be taken during exercise, even if used pre-exercise. Call office if quick relief medication must be used regularly more than once during exercise.

Asthma Equipment

____ Nebulizer ____ Spacer ____ Peak Flow Meter



Education and Teaching Aids

1. ___Asthma Patient Action Plan - given to patient
2. ___Discussed How To Determine "Personal Best" Peak Flow
3. ___Guidelines For Using A Peak Flow Meter -- given to patient
4. ___Demonstrated How To Use MDI Properly With A Spacer
5. ___Demonstrated How To Tell When MDI Is Empty (floating in water)
6. ___Allergy Referral
7. ___Pulmonary Referral


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