Asthma: Your Child's Action Plan

Your Care Instructions

An asthma action plan tells you what medicines your child needs to take every day to control asthma symptoms. It also tells you what to do if your child has an asthma attack. Following your child's asthma action plan can help prevent and treat attacks.

Here is an asthma action plan form that you and your doctor can fill out together to use with your child.

Medicine List

Controller medicine action plan

Fill in the blank spaces and boxes that apply for all sections.

• Name of your child's controller medicine:
  • ____________________________________________
• How much of this medicine do you give your child?
  • ____________________________________________
• How often do you give your child this medicine?
  • ____________________________________________
• Other instructions?
  • ____________________________________________

Quick-relief medicine action plan

• Name of your child's quick-relief medicine:
  • ____________________________________________
• How much of this medicine do you give your child?
  • ____________________________________________
• How often do you give your child this medicine?
  • ____________________________________________
• Other instructions for giving your child quick-relief medicine:
  • ____________________________________________

Asthma Zones

GREEN ZONE: This is where you want your child to be!

Green zone symptoms

• Your child has no shortness of breath or chest tightness. He or she is not coughing or wheezing.
• Your child can do all of his or her usual activities.
• Your child sleeps well at night.

Green zone peak flow (if your child uses a peak flow meter)

• _______ or more (80% or more of your child's personal best)

Green zone actions (Check the boxes and fill in the blank spaces that apply.)

[ ] Your child takes controller medicine(s) every day.

[ ] Your child is staying away from his or her asthma triggers.

[ ] Your child takes quick-relief medicine (called __________________) ______ minutes before exercise.

YELLOW ZONE: Your child's asthma is getting worse.

Yellow zone symptoms

• Your child is short of breath or has chest tightness. He or she is coughing or wheezing.
• Your child has symptoms that keep your child up at night.
• Your child can do some, but not all, of his or her usual activities.

Yellow zone peak flow (if your child uses a peak flow meter)

• ______ to ______ (50% to 79% of your child's personal best)

Yellow zone actions (Check the boxes and fill in the blank spaces that apply.)

[ ] Give your child _____ puff(s) of quick-relief medicine called ________________________. Repeat _____ times.

[ ] If your child's symptoms don't get better or his or her peak flow has not returned to the green zone in 1 hour, then:

• [ ] Give your child _____ puff(s) of medicine called ____________________. Give it ____ times a day.
• [ ] Begin or increase treatment with corticosteroid pills. Give ______ mg of medicine called _________________________ every __________.
• [ ] Call your child's doctor at this number: __________________.

RED ZONE: Danger!

Red zone symptoms

• Your child is very short of breath.
• Your child can't do his or her usual activities.
• Quick-relief medicine doesn't help. Or your child's symptoms don't get better after 24 hours in the yellow zone.

Red zone peak flow (if your child uses a peak flow meter)

• Less than _______ (less than 50% of your child's personal best)

Red zone actions (Check the boxes and fill in the blank spaces that apply.)

[ ] Give _____ puff(s) of quick-relief medicine called _________________________. Repeat _____ times.

[ ] Begin or increase treatment with corticosteroid pills. Give ________ mg now.

[ ] Call your child's doctor at this number: _______________. If you can't contact your child's doctor, take your child to the emergency department. Call 911 or __________________.

[ ] Other numbers you might call are: __________________________________.

When should you call for help?

Call 911 anytime you think your child may need emergency care. For example, call if:

• Your child has severe trouble breathing.

Call your doctor now or seek immediate medical care if:

• Your child's symptoms do not get better after you have followed the asthma action plan.
• Your child has new or worse trouble breathing.
• Your child's coughing and wheezing get worse.
• Your child coughs up dark brown or bloody mucus (sputum).
• Your child has a new or higher fever.

Watch closely for changes in your child's health, and be sure to contact your doctor if:

• Your child needs to use quick-relief medicine more than 2 days a week within a month (unless it is just for exercise).