Asthma Action Plan
ASTHMA ACTION PLAN FOR _________________________________________________________
PROVIDER’S NAME_________________________________________ DATE ____________________
PROVIDER’S PHONE NUMBER _______________________________________________________
HOSPITAL/EMERGENCY ROOM PHONE NUMBER __________________________________________
GREEN ZONE Doing Well
o cough, wheeze, chest tightness, or shortness of breath during the day or night,
N
can do usual activities
And, if a peak flow meter is used, peak flow:
More than: ______ (80% or more of my best peak flow) My best peak flow is: ______
Take these long-term control medicines each day (includes an anti-inflammatory):
MEDICINE
BEFORE EXERCISE
DOSAGE
l2
l 4 puffs
WHEN TO TAKE IT
5 to 60 minutes before exercise
YELLOW ZONE Getting Worse
Cough, wheeze, chest tightness, or shortness of breath or waking at night due to asthma, or can do
some, but not all, usual activities
OR Peak flow: _______ to _______
(50% to 80% of my best peak flow)
Add: quick-relief medicine – and keep taking your GREEN ZONE medicine.
______________________________ l 2 l 4 puffs, every 20 minutes for up to 1 hour
(short-acting beta2-agonist)
l Nebulizer, once
If your symptoms (and peak flow, if used) return to GREEN ZONE after 1 hou r of treatment:
l Take the quick-relief medicine every 4 hours for 1 to 2 days.
l Double the dose of your inhaled steroid for____________(7 to 10) days.
If your symptoms (and peak flow, if used) do not return to GREEN ZONE after 1 hour of above
treatment:
l Take: __________________________________ l 2 l 4 puffs or l Nebulizer
(short-acting beta2-agonist)
l Add: ______ mg per day for _______ (3 to 10) days.
(oral steroid)
l Call the doctor within _____ hours after taking the oral steroid.
RED ZONE Medical Alert!
Very short of breath, or quick-relief medicines have not helped, or cannot do usual activities, or
symptoms are same or get worse after 24 hours in YELLOW ZONE
OR Peak flow: less than ______ (50% of my best peak flow)
Take this medicine:
l _______________________________________ l 4
(short-acting beta2-agonist)
(oral steroid)
l 6 puffs or l Nebulizer
l ________ mg per day
Then call your doctor NOW! Go to the hospital or call for an ambulance if:
l You are still in the RED ZONE after 15 minutes AND l You have not reached your doctor.
DANGER SIGNS!
•T
rouble walking and talking due to
shortness of breath
• Lips or fingernails are blue
• Take l 4 l 6 puffs of your quick-relief medicine AND
• Go to the hospital or call 911 for an ambulance NOW!