Asthma Action Plan

Asthma Action Plan
for ___________________________

Date _________

Doctor's Name __________________

Doctor's Phone Number _________________
Hospital/ Emergency Room Phone Number __________________



GREEN ZONE: Doing Well

  • No cough, wheeze, chest tightness or shortness of breath during the day or night
  • 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: _____________

Medicine How Much to Take When to Take it
     
     
     


Take these long-term control medicines each day (include an anti-inflammatory)


YELLOW ZONE: Asthma Is 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)

First, add the following quick-relief medicine -- and keep taking your GREEN ZONE medicine:

_________________________
(short-acting beta-agonist)

Please circle one of the following:

  • 2 puffs every 20 minutes for up to one hour,
  • 4 puffs every 20 minutes for up to one hour, or
  • nebulizer once

Second, if your symptoms (and peak flow, if used) return to GREEN ZONE after 1 hour of above treatment:

Please circle one or both of the following:

  • Take the quick-relief medicine every 4 hours for 1 to 2 days
  • Double the dose of your inhaled steroid for _______________ (7-10) days

-Or-


If your symptoms (and peak flow, if used) do not return to Green Zone after 1 hour of above treatment:

Please circle one, two or all of the following:

  • Take: (short-acting beta-agonist) __________________ 2 or 4 puffs or nebulizer.
  • Add: (oral steroid) _________________________________ mg per day. For ___________ (3-10) days.
  • Call the doctor before/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:

___________________________________
(short-acting beta-agonist)

Please circle one of the following:

  • 4 puffs,
  • 6 puffs, or
  • nebulizer

-And/Or-

_______________________ ________mg
(oral steroid)

Then call your family doctor NOW.
Go to the hospital or call for an ambulance if:
You are still in the red zone after 15 minutes AND You have not reached your doctor.

DANGER SIGNS

  • Trouble walking and talking due to shortness of breath
  • Lips or fingernails are blue

Take 4 or 6 puffs (please circle) of your quick-relief medicine AND go to the hospital or call an ambulance (phone number ______________ ) NOW!


 

More Information

For more information talk to your doctor.

Other Organizations

Source

Written by familydoctor.org editorial staff.

American Academy of Family Physicians

Reviewed/Updated: 09/06
Created: 09/00