ASTHMA ACTION PLAN FOR_____________________________________    Doctor's Name_____________________________________     Date______________

 Doctor's Phone Number_____________________________________      Hospital/Emergency Room Phone Number_____________________________________
 GREEN ZONE: Doing Well Take These Long-Term-Control Medicines Each Day (include an anti-inflammatory)
  • 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
 
 
 
 
Before exercise ____________________________
2 or 4 puffs
5 to 60 minutes before exercise
 YELLOW ZONE: Asthma Is Getting Worse (=> FIRST)       Add Quick-Relief Medicine - and keep taking your GREEN ZONE medicine
  • 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% - 80% of my best peak flow)
______________________
(short -acting beta2-agonist)
 2 or 4 puffs, every 20 minutes for up to 1 hr
Nebulizer, once
(=> SECOND)      If your symptoms (and peak flow, if used) return to GREEN ZONE after 1 hour of about treatment:
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 about treatment
Take:____________________________________ 2 or 4 puffs or Nebulizer
(short -acting beta2-agonist)
  
Add:____________________________________ mg. per day     For______ (3-10) days
(oral steroid)
  
Call the doctor before/ within______________ hours after taking the oral steroid
 RED ZONE: Medical Alert! Take this medicine:  
  • 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)		 _____________________________________________ 4 or 6 puffs or Nebulizer
(short -acting beta2-agonist)
  
_____________________________________________ mg.
(oral steroid)
  

Then call your 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 of your quick-relief medicine AND
  • Go to the hospital or call for an ambulance (________________________) NOW!
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