NOTE: Add patient header here / Protect the form / You will see med options
Infant and Young Child / ASTHMA ACTION PLAN _ / PAGE ONE

This plan will help you control your asthma, provide you with a summary of your medications, and help you remember what to do during an asthma episode. Please keep a copy with you at all times. Our goal is for you to:

Be active without having asthma symptoms, including exercise or sports.
Sleep through the night without having asthma symptoms
Prevent asthma episodes or attacks
Have the best possible peak flow
Avoid side effects from medications / Hospital Name
ADDRESS
City State Zip
Phone number Hospital
RESCUE: 911

For Infants and small children, you must rely upon symptoms and a change from the normal pattern of breathing and behaving to guide you on when the asthma is out of control.

Established Dx. Abdominal pain/54./789.0Acne/89/706.1Allergic Rhinitis, mites/molds/305/477.8Allergic Rhinitis,pollen/279/477.0Anaphylactic Rxnot food/002/995.0Anaphalactic Rxn, food unspec/540/995.60Angioedema/003/995.1Arthralgia/004/719.4Arthritis,Subacute/005/716.9Asthma w/COPD/140/493.2Asthma,Ext/138/493.00Asthma,Ext w/Status/141/493.01Asthma,Int/139/493.10Asthma Int w/Status/142/493.11Asthma,Unsp/006/493.90Asthma,Unspec w/Status/007/493.91Atopic Dermatitis/008/691.8Blood Pressure,Elevat/180/796.2Bronchitis/acute/009/466.0Bronchitis Acute w/COPD/135/491.21Bronchitis,Chronic,Unspec/010/491.90Bronchitis,Chroni w/COPD/136/491.20Bronchitis Chronic Simple/137/491.00 Candidiasis,Oral/110/112.0Cerumen,impaction/011/380.4Conjunctivitis,Acute/013/372.0Conjunctivitis.Allergic/014/372.14COPD/015/496.0Cough/016/786.2Dermatitis,Contact/017/692.9Diarrhea/090/008.8Drug Allergy/018/995.2Dyspnea/258/786.09Eczema/019/692.9Epistaxis/086/784.7Fatigue/021/780.7Fever/022/780.6Food Allergy/023/693.1Gastroenteritis/024/009.0Gastroesophageal Reflux/345/530.81Headache,unspec/025/784.0Hoarseness&Other Voice Dist./104/784.49Hyperlipidemia.Mixed/69/272.2Hypertension/26/401.9Hypertrophic T&A's/027/474.1Hypothyroidism,Unspec/086/244.9 Immune Disorder,Other/028/279.3Infection,Resp w/flu/029/487.1Latex Allergy/563/989.82Laryngitis,Acute/030/464.0Lymphadenopathy/031/785.6Lymphadenitis/032/683Migraine/033/346.9Nasal Septal Deviation/034/470.0Non-Allergic Rhinitis/035/472.0Otitis Externa/036/380.1Otitis Media/037/382.9Otitis Serous/038/381.1Pharyngitis/039/462Polyps,nasal/041/471.9Pruritis/042/698.9Rash,unspec./043/782.1Reaction,Drug/101/995.2Reflux Esphoagitis/469/530.11Resp Infection/Chronic/044/519.8Rosacea/151/695.3 Seborrhea/045/690.0Shortness of Breath/060/786.09Sinusistis,Acute/046/461.9Sinusitis, Chronic/047/473.9Sore Throat/091/462.0Stomatitis,Oral Aphepeous/213/528.2Tonsilitis/49/463.0URI,Acute/049/465.9Urticaria, Allergic/82/708.0 Urticaria Cholinergic/159/708.5Urticaria Chronic/294/708.8Urticaria,Dermagraphic/292/708.3Urticaria, Idiopathic/065/708.1Urticaria,unspecified/050/708.9Venomous Sting Rx./051/989.5Weight Loss/052/783.2Wheeze/327/786.09 / Drug Allergies: / Ht.
Abdominal pain/54./789.0Acne/89/706.1Allergic Rhinitis, mites/molds/305/477.8Allergic Rhinitis,pollen/279/477.0Anaphylactic Rxnot food/002/995.0Anaphalactic Rxn, food unspec/540/995.60Angioedema/003/995.1Arthralgia/004/719.4Arthritis,Subacute/005/716.9Asthma w/COPD/140/493.2Asthma,Ext/138/493.00Asthma,Ext w/Status/141/493.01Asthma,Int/139/493.10Asthma Int w/Status/142/493.11Asthma,Unsp/006/493.90Asthma,Unspec w/Status/007/493.91Atopic Dermatitis/008/691.8Blood Pressure,Elevat/180/796.2Bronchitis/acute/009/466.0Bronchitis Acute w/COPD/135/491.21Bronchitis,Chronic,Unspec/010/491.90Bronchitis,Chroni w/COPD/136/491.20Bronchitis Chronic Simple/137/491.00 Candidiasis,Oral/110/112.0Cerumen,impaction/011/380.4Conjunctivitis,Acute/013/372.0Conjunctivitis.Allergic/014/372.14COPD/015/496.0Cough/016/786.2Dermatitis,Contact/017/692.9Diarrhea/090/008.8Drug Allergy/018/995.2Dyspnea/258/786.09Eczema/019/692.9Epistaxis/086/784.7Fatigue/021/780.7Fever/022/780.6Food Allergy/023/693.1Gastroenteritis/024/009.0Headache,unspec/025/784.0Hoarseness&Other Voice Dist./104/784.49Hyperlipidemia.Mixed/69/272.2Hypertension/26/401.9Hypertrophic T&A's/027/474.1Hypothyroidism,Unspec/086/244.9Gastroesophageal Reflux/345/530.81 Immune Disorder,Other/028/279.3Infection,Resp w/flu/029/487.1Latex Allergy/563/989.82Laryngitis,Acute/030/464.0Lymphadenopathy/031/785.6Lymphadenitis/032/683Migraine/033/346.9Nasal Septal Deviation/034/470.0Non-Allergic Rhinitis/035/472.0Otitis Externa/036/380.1Otitis Media/037/382.9Otitis Serous/038/381.1Pharyngitis/039/462Polyps,nasal/041/471.9Pruritis/042/698.9Rash,unspec./043/782.1Reaction,Drug/101/995.2Reflux Esphoagitis/469/530.11Resp Infection/Chronic/044/519.8Rosacea/151/695.3 Seborrhea/045/690.0Shortness of Breath/060/786.09Sinusistis,Acute/046/461.9Sinusitis, Chronic/047/473.9Sore Throat/091/462.0Stomatitis,Oral Aphepeous/213/528.2Tonsilitis/49/463.0URI,Acute/049/465.9Urticaria, Allergic/82/708.0 Urticaria Cholinergic/159/708.5Urticaria Chronic/294/708.8Urticaria,Dermagraphic/292/708.3Urticaria, Idiopathic/065/708.1Urticaria,unspecified/050/708.9Venomous Sting Rx./051/989.5Weight Loss/052/783.2Wheeze/327/786.09 / Wt.
Abdominal pain/54./789.0Acne/89/706.1Allergic Rhinitis, mites/molds/305/477.8Allergic Rhinitis,pollen/279/477.0Anaphylactic Rxnot food/002/995.0Anaphalactic Rxn, food unspec/540/995.60Angioedema/003/995.1Arthralgia/004/719.4Arthritis,Subacute/005/716.9Asthma w/COPD/140/493.2Asthma,Ext/138/493.00Asthma,Ext w/Status/141/493.01Asthma,Int/139/493.10Asthma Int w/Status/142/493.11Asthma,Unsp/006/493.90Asthma,Unspec w/Status/007/493.91Atopic Dermatitis/008/691.8Blood Pressure,Elevat/180/796.2Bronchitis/acute/009/466.0Bronchitis Acute w/COPD/135/491.21Bronchitis,Chronic,Unspec/010/491.90Bronchitis,Chroni w/COPD/136/491.20Bronchitis Chronic Simple/137/491.00 Candidiasis,Oral/110/112.0Cerumen,impaction/011/380.4Conjunctivitis,Acute/013/372.0Conjunctivitis.Allergic/014/372.14COPD/015/496.0Cough/016/786.2Dermatitis,Contact/017/692.9Diarrhea/090/008.8Drug Allergy/018/995.2Dyspnea/258/786.09Eczema/019/692.9Epistaxis/086/784.7Fatigue/021/780.7Fever/022/780.6Food Allergy/023/693.1Gastroenteritis/024/009.0Headache,unspec/025/784.0Hoarseness&Other Voice Dist./104/784.49Hyperlipidemia.Mixed/69/272.2Hypertension/26/401.9Hypertrophic T&A's/027/474.1Hypothyroidism,Unspec/086/244.9Gastroesophageal Reflux/345/530.81 Immune Disorder,Other/028/279.3Infection,Resp w/flu/029/487.1Latex Allergy/563/989.82Laryngitis,Acute/030/464.0Lymphadenopathy/031/785.6Lymphadenitis/032/683Migraine/033/346.9Nasal Septal Deviation/034/470.0Non-Allergic Rhinitis/035/472.0Otitis Externa/036/380.1Otitis Media/037/382.9Otitis Serous/038/381.1Pharyngitis/039/462Polyps,nasal/041/471.9Pruritis/042/698.9Rash,unspec./043/782.1Reaction,Drug/101/995.2Reflux Esphoagitis/469/530.11Resp Infection/Chronic/044/519.8Rosacea/151/695.3 Seborrhea/045/690.0Shortness of Breath/060/786.09Sinusistis,Acute/046/461.9Sinusitis, Chronic/047/473.9Sore Throat/091/462.0Stomatitis,Oral Aphepeous/213/528.2Tonsilitis/49/463.0URI,Acute/049/465.9Urticaria, Allergic/82/708.0 Urticaria Cholinergic/159/708.5Urticaria Chronic/294/708.8Urticaria,Dermagraphic/292/708.3Urticaria, Idiopathic/065/708.1Urticaria,unspecified/050/708.9Venomous Sting Rx./051/989.5Weight Loss/052/783.2Wheeze/327/786.09 / Home Meter Mini WrightAccessAstechPersonel Best Mini WrightPersonal BestAccess
Abdominal pain/54./789.0Acne/89/706.1Allergic Rhinitis, mites/molds/305/477.8Allergic Rhinitis,pollen/279/477.0Anaphylactic Rxnot food/002/995.0Anaphalactic Rxn, food unspec/540/995.60Angioedema/003/995.1Arthralgia/004/719.4Arthritis,Subacute/005/716.9Asthma w/COPD/140/493.2Asthma,Ext/138/493.00Asthma,Ext w/Status/141/493.01Asthma,Int/139/493.10Asthma Int w/Status/142/493.11Asthma,Unsp/006/493.90Asthma,Unspec w/Status/007/493.91Atopic Dermatitis/008/691.8Blood Pressure,Elevat/180/796.2Bronchitis/acute/009/466.0Bronchitis Acute w/COPD/135/491.21Bronchitis,Chronic,Unspec/010/491.90Bronchitis,Chroni w/COPD/136/491.20Bronchitis Chronic Simple/137/491.00 Candidiasis,Oral/110/112.0Cerumen,impaction/011/380.4Conjunctivitis,Acute/013/372.0Conjunctivitis.Allergic/014/372.14COPD/015/496.0Cough/016/786.2Dermatitis,Contact/017/692.9Diarrhea/090/008.8Drug Allergy/018/995.2Dyspnea/258/786.09Eczema/019/692.9Epistaxis/086/784.7Fatigue/021/780.7Fever/022/780.6Food Allergy/023/693.1Gastroenteritis/024/009.0Headache,unspec/025/784.0Hoarseness&Other Voice Dist./104/784.49Hyperlipidemia.Mixed/69/272.2Hypertension/26/401.9Hypertrophic T&A's/027/474.1Hypothyroidism,Unspec/086/244.9Gastroesophageal Reflux/345/530.81 Immune Disorder,Other/028/279.3Infection,Resp w/flu/029/487.1Latex Allergy/563/989.82Laryngitis,Acute/030/464.0Lymphadenopathy/031/785.6Lymphadenitis/032/683Migraine/033/346.9Nasal Septal Deviation/034/470.0Non-Allergic Rhinitis/035/472.0Otitis Externa/036/380.1Otitis Media/037/382.9Otitis Serous/038/381.1Pharyngitis/039/462Polyps,nasal/041/471.9Pruritis/042/698.9Rash,unspec./043/782.1Reaction,Drug/101/995.2Reflux Esphoagitis/469/530.11Resp Infection/Chronic/044/519.8Rosacea/151/695.3 Seborrhea/045/690.0Shortness of Breath/060/786.09Sinusistis,Acute/046/461.9Sinusitis, Chronic/047/473.9Sore Throat/091/462.0Stomatitis,Oral Aphepeous/213/528.2Tonsilitis/49/463.0URI,Acute/049/465.9Urticaria, Allergic/82/708.0 Urticaria Cholinergic/159/708.5Urticaria Chronic/294/708.8Urticaria,Dermagraphic/292/708.3Urticaria, Idiopathic/065/708.1Urticaria,unspecified/050/708.9Venomous Sting Rx./051/989.5Weight Loss/052/783.2Wheeze/327/786.09 / Best Home
Abdominal pain/54./789.0Acne/89/706.1Allergic Rhinitis, mites/molds/305/477.8Allergic Rhinitis,pollen/279/477.0Anaphylactic Rxnot food/002/995.0Anaphalactic Rxn, food unspec/540/995.60Angioedema/003/995.1Arthralgia/004/719.4Arthritis,Subacute/005/716.9Asthma w/COPD/140/493.2Asthma,Ext/138/493.00Asthma,Ext w/Status/141/493.01Asthma,Int/139/493.10Asthma Int w/Status/142/493.11Asthma,Unsp/006/493.90Asthma,Unspec w/Status/007/493.91Atopic Dermatitis/008/691.8Blood Pressure,Elevat/180/796.2Bronchitis/acute/009/466.0Bronchitis Acute w/COPD/135/491.21Bronchitis,Chronic,Unspec/010/491.90Bronchitis,Chroni w/COPD/136/491.20Bronchitis Chronic Simple/137/491.00 Candidiasis,Oral/110/112.0Cerumen,impaction/011/380.4Conjunctivitis,Acute/013/372.0Conjunctivitis.Allergic/014/372.14COPD/015/496.0Cough/016/786.2Dermatitis,Contact/017/692.9Diarrhea/090/008.8Drug Allergy/018/995.2Dyspnea/258/786.09Eczema/019/692.9Epistaxis/086/784.7Fatigue/021/780.7Fever/022/780.6Food Allergy/023/693.1Gastroenteritis/024/009.0Headache,unspec/025/784.0Hoarseness&Other Voice Dist./104/784.49Hyperlipidemia.Mixed/69/272.2Hypertension/26/401.9Hypertrophic T&A's/027/474.1Hypothyroidism,Unspec/086/244.9Gastroesophageal Reflux/345/530.81 Immune Disorder,Other/028/279.3Infection,Resp w/flu/029/487.1Latex Allergy/563/989.82Laryngitis,Acute/030/464.0Lymphadenopathy/031/785.6Lymphadenitis/032/683Migraine/033/346.9Nasal Septal Deviation/034/470.0Non-Allergic Rhinitis/035/472.0Otitis Externa/036/380.1Otitis Media/037/382.9Otitis Serous/038/381.1Pharyngitis/039/462Polyps,nasal/041/471.9Pruritis/042/698.9Rash,unspec./043/782.1Reaction,Drug/101/995.2Reflux Esphoagitis/469/530.11Resp Infection/Chronic/044/519.8Rosacea/151/695.3 Seborrhea/045/690.0Shortness of Breath/060/786.09Sinusistis,Acute/046/461.9Sinusitis, Chronic/047/473.9Sore Throat/091/462.0Stomatitis,Oral Aphepeous/213/528.2Tonsilitis/49/463.0URI,Acute/049/465.9Urticaria, Allergic/82/708.0 Urticaria Cholinergic/159/708.5Urticaria Chronic/294/708.8Urticaria,Dermagraphic/292/708.3Urticaria, Idiopathic/065/708.1Urticaria,unspecified/050/708.9Venomous Sting Rx./051/989.5Weight Loss/052/783.2Wheeze/327/786.09 / Best Office
Abdominal pain/54./789.0Acne/89/706.1Allergic Rhinitis, mites/molds/305/477.8Allergic Rhinitis,pollen/279/477.0Anaphylactic Rxnot food/002/995.0Anaphalactic Rxn, food unspec/540/995.60Angioedema/003/995.1Arthralgia/004/719.4Arthritis,Subacute/005/716.9Asthma w/COPD/140/493.2Asthma,Ext/138/493.00Asthma,Ext w/Status/141/493.01Asthma,Int/139/493.10Asthma Int w/Status/142/493.11Asthma,Unsp/006/493.90Asthma,Unspec w/Status/007/493.91Atopic Dermatitis/008/691.8Blood Pressure,Elevat/180/796.2Bronchitis/acute/009/466.0Bronchitis Acute w/COPD/135/491.21Bronchitis,Chronic,Unspec/010/491.90Bronchitis,Chroni w/COPD/136/491.20Bronchitis Chronic Simple/137/491.00 Candidiasis,Oral/110/112.0Cerumen,impaction/011/380.4Conjunctivitis,Acute/013/372.0Conjunctivitis.Allergic/014/372.14COPD/015/496.0Cough/016/786.2Dermatitis,Contact/017/692.9Diarrhea/090/008.8Drug Allergy/018/995.2Dyspnea/258/786.09Eczema/019/692.9Epistaxis/086/784.7Fatigue/021/780.7Fever/022/780.6Food Allergy/023/693.1Gastroenteritis/024/009.0Headache,unspec/025/784.0Hoarseness&Other Voice Dist./104/784.49Hyperlipidemia.Mixed/69/272.2Hypertension/26/401.9Hypertrophic T&A's/027/474.1Hypothyroidism,Unspec/086/244.9Gastroesophageal Reflux/345/530.81 Immune Disorder,Other/028/279.3Infection,Resp w/flu/029/487.1Latex Allergy/563/989.82Laryngitis,Acute/030/464.0Lymphadenopathy/031/785.6Lymphadenitis/032/683Migraine/033/346.9Nasal Septal Deviation/034/470.0Non-Allergic Rhinitis/035/472.0Otitis Externa/036/380.1Otitis Media/037/382.9Otitis Serous/038/381.1Pharyngitis/039/462Polyps,nasal/041/471.9Pruritis/042/698.9Rash,unspec./043/782.1Reaction,Drug/101/995.2Reflux Esphoagitis/469/530.11Resp Infection/Chronic/044/519.8Rosacea/151/695.3 Seborrhea/045/690.0Shortness of Breath/060/786.09Sinusistis,Acute/046/461.9Sinusitis, Chronic/047/473.9Sore Throat/091/462.0Stomatitis,Oral Aphepeous/213/528.2Tonsilitis/49/463.0URI,Acute/049/465.9Urticaria, Allergic/82/708.0 Urticaria Cholinergic/159/708.5Urticaria Chronic/294/708.8Urticaria,Dermagraphic/292/708.3Urticaria, Idiopathic/065/708.1Urticaria,unspecified/050/708.9Venomous Sting Rx./051/989.5Weight Loss/052/783.2Wheeze/327/786.09

Major Inhalant Allergen:

Food Allergens to avoid:

Common Triggers for many asthmatics:Viral infections, exercise, laugh/cough, smoke, perfume, pollution, cold air or weather changes, stress, and allergen exposure.

  • Follow yourGREEN ZONE plan every day to keep most asthma symptoms from starting. Recognize your symptoms of an asthma episode and act quickly to stop them.
  • Follow your YELLOW ZONE plan to stop asthma symptoms and keep an asthma episode from getting serious.
  • Follow your RED ZONE plan to take care of a serious episode. THIS IS AN EMERGENCY PLAN!

GREEN ZONE:

DAILY PLAN TO KEEP ASTHMA SYMPTOMS UNDER CONTROL
TAKE MEDICATIONS EVEN IF YOU HAVE NO SYMPTOMS / GREEN ZONE:
1 Alupent Solution NebulizedAtrovent Solution NebulizedAlbuterol Solution NEBTornalate Sol. 0.75cc /2cc Saline Neb.Tornalate Sol. 1.5cc/ 2cc Saline Neb.Proventil/Ventolin /Saline Premixed Neb.Proventil/Ventolin Sol, 0.25cc/1 Intal NebulizedProventil/Ventolin Sol. 0.35cc/ 1 Intal NebulizedProventil/Ventolin Sol, 0.5cc/1 Intal NebProventil/Ventolin Sol. 0.25cc/ 2cc SalineProventil/Ventolin Sol. 0.35cc/ 2cc SalineProventil/Ventolin Sol. 0.5cc/ 2cc SalineProventil/Ventolin Sol. 1cc/ 2cc SalineProventil/Ventolin Sol, 1cc/ Saline 2cc NebMaxair Autohaler 1spMaxair Autohaler 1-2spMaxair Autohaler 2spMaxair Autohaler 4spProventil HFA MDIProventil/Ventolin MDI Ventolin MDISerevent MDI 1 spraySerevent MDI 2 spray AeroBid MDIAtrovent MDIAtrovent Solution NEBAzmacort MDIBeclovent MDIFloVent 44mcgFloVent 110mcgFlovent 220mcgIntal MDIIntal Solution NEBTiladeTornalate MDISerevent MDIVanceril MDIVanceril DS MDI Proventil SyrupSlo-bid GyrocapsTheodur SprinklesVentolinSyrupAccolate 20mg Uniphyl 400mg Uni-dur 600mg Uni-dur 400mg Proventil Repetabs 8mg Proventil Repetabs 4mgTheodur 450mg Theodur 300mg Theo-24 100mg Theodur 200mg Theodur 100mg Theo-24 400mg Theo-24 300mg Theo-24 200mg 1-2 sp every 4-6hrs.1-2 sprays every 6 hrs.2 sprays every 6 hrs.3 sp every 6hr4 sp every 6hr1 sprays every 12 hrs.1-2 sprays every 12 hrs.2 sprays every 12 hrs.3 sprays every 12 hrs.4 sprays every 12 hrs5 sprays every 12 hrs.6 sprays 3 x/day1-sp every 4-6hr 1-2 sp evey 4 hr2 sp every 4 hr2 sp 2x/day1sp1-2sp2sp3 sp4 sp5 sp6 sp ampmam & pmdailybedtime2x/day3x/day4x/day5x/day6x/dayevery 1-3hrevery 2hrevery 3hrevery 4hrevery 5hrevery 6hr3very 4-6hrevery 8 hrevery 12 hr1 1/2 daily2 daily2 every 12 hr as needed (CONTROLLER) / NO SIGNS OR SYMTPOMS OF ASTHMA
2 Alupent Solution NebulizedAtrovent Solution NebulizedAlbuterol Solution NEBTornalate Sol. 0.75cc /2cc Saline Neb.Tornalate Sol. 1.5cc/ 2cc Saline Neb.Proventil/Ventolin /Saline Premixed Neb.Proventil/Ventolin Sol, 0.25cc/1 Intal NebulizedProventil/Ventolin Sol. 0.35cc/ 1 Intal NebulizedProventil/Ventolin Sol, 0.5cc/1 Intal NebProventil/Ventolin Sol. 0.25cc/ 2cc SalineProventil/Ventolin Sol. 0.35cc/ 2cc SalineProventil/Ventolin Sol. 0.5cc/ 2cc SalineProventil/Ventolin Sol. 1cc/ 2cc SalineProventil/Ventolin Sol, 1cc/ Saline 2cc NebMaxair Autohaler 1spMaxair Autohaler 1-2spMaxair Autohaler 2spMaxair Autohaler 4spProventil HFA MDIProventil/Ventolin MDI Ventolin MDISerevent MDI 1 spraySerevent MDI 2 spray AeroBid MDIAtrovent MDIAtrovent Solution NEBAzmacort MDIBeclovent MDIFloVent 44mcgFloVent 110mcgFlovent 220mcgIntal MDIIntal Solution NEBTiladeTornalate MDISerevent MDIVanceril MDIVanceril DS MDI Proventil SyrupSlo-bid GyrocapsTheodur SprinklesVentolinSyrupAccolate 20mg Uniphyl 400mg Uni-dur 600mg Uni-dur 400mg Proventil Repetabs 8mg Proventil Repetabs 4mgTheodur 450mg Theodur 300mg Theo-24 100mg Theodur 200mg Theodur 100mg Theo-24 400mg Theo-24 300mg Theo-24 200mg 1-2 sp every 4-6hrs.1-2 sprays every 6 hrs.2 sprays every 6 hrs.3 sp every 6hr4 sp every 6hr1 sprays every 12 hrs.1-2 sprays every 12 hrs.2 sprays every 12 hrs.3 sprays every 12 hrs.4 sprays every 12 hrs5 sprays every 12 hrs.6 sprays 3 x/day1-sp every 4-6hr 1-2 sp evey 4 hr2 sp every 4 hr2 sp 2x/day1sp1-2sp2sp3 sp4 sp5 sp6 sp ampmam & pmdailybedtime2x/day3x/day4x/day5x/day6x/dayevery 1-3hrevery 2hrevery 3hrevery 4hrevery 5hrevery 6hr3very 4-6hrevery 8 hrevery 12 hr1 1/2 daily2 daily2 every 12 hr as needed(CONTROLLER) /
  • Breathing is good

3 Alupent Solution NebulizedAtrovent Solution NebulizedAlbuterol Solution NEBTornalate Sol. 0.75cc /2cc Saline Neb.Tornalate Sol. 1.5cc/ 2cc Saline Neb.Proventil/Ventolin /Saline Premixed Neb.Proventil/Ventolin Sol, 0.25cc/1 Intal NebulizedProventil/Ventolin Sol. 0.35cc/ 1 Intal NebulizedProventil/Ventolin Sol, 0.5cc/1 Intal NebProventil/Ventolin Sol. 0.25cc/ 2cc SalineProventil/Ventolin Sol. 0.35cc/ 2cc SalineProventil/Ventolin Sol. 0.5cc/ 2cc SalineProventil/Ventolin Sol. 1cc/ 2cc SalineProventil/Ventolin Sol, 1cc/ Saline 2cc NebMaxair Autohaler 1spMaxair Autohaler 1-2spMaxair Autohaler 2spMaxair Autohaler 4spProventil HFA MDIProventil/Ventolin MDI Ventolin MDISerevent MDI 1 spraySerevent MDI 2 spray AeroBid MDIAtrovent MDIAtrovent Solution NEBAzmacort MDIBeclovent MDIFloVent 44mcgFloVent 110mcgFlovent 220mcgIntal MDIIntal Solution NEBTiladeTornalate MDISerevent MDIVanceril MDIVanceril DS MDI Proventil SyrupSlo-bid GyrocapsTheodur SprinklesVentolinSyrupAccolate 20mg Uniphyl 400mg Uni-dur 600mg Uni-dur 400mg Proventil Repetabs 8mg Proventil Repetabs 4mgTheodur 450mg Theodur 300mg Theo-24 100mg Theodur 200mg Theodur 100mg Theo-24 400mg Theo-24 300mg Theo-24 200mg 1-2 sp every 4-6hrs.1-2 sprays every 6 hrs.2 sprays every 6 hrs.3 sp every 6hr4 sp every 6hr1 sprays every 12 hrs.1-2 sprays every 12 hrs.2 sprays every 12 hrs.3 sprays every 12 hrs.4 sprays every 12 hrs5 sprays every 12 hrs.6 sprays 3 x/day1-sp every 4-6hr 1-2 sp evey 4 hr2 sp every 4 hr2 sp 2x/day1sp1-2sp2sp3 sp4 sp5 sp6 sp ampmam & pmdailybedtime2x/day3x/day4x/day5x/day6x/dayevery 1-3hrevery 2hrevery 3hrevery 4hrevery 5hrevery 6hr3very 4-6hrevery 8 hrevery 12 hr1 1/2 daily2 daily2 every 12 hr as needed(CONTROLLER) /
  • No early warning signs or asthma

4 Alupent Solution NebulizedAtrovent Solution NebulizedAlbuterol Solution NEBTornalate Sol. 0.75cc /2cc Saline Neb.Tornalate Sol. 1.5cc/ 2cc Saline Neb.Proventil/Ventolin /Saline Premixed Neb.Proventil/Ventolin Sol, 0.25cc/1 Intal NebulizedProventil/Ventolin Sol. 0.35cc/ 1 Intal NebulizedProventil/Ventolin Sol, 0.5cc/1 Intal NebProventil/Ventolin Sol. 0.25cc/ 2cc SalineProventil/Ventolin Sol. 0.35cc/ 2cc SalineProventil/Ventolin Sol. 0.5cc/ 2cc SalineProventil/Ventolin Sol. 1cc/ 2cc SalineProventil/Ventolin Sol, 1cc/ Saline 2cc NebMaxair Autohaler 1spMaxair Autohaler 1-2spMaxair Autohaler 2spMaxair Autohaler 4spProventil HFA MDIProventil/Ventolin MDI Ventolin MDISerevent MDI 1 spraySerevent MDI 2 spray AeroBid MDIAtrovent MDIAtrovent Solution NEBAzmacort MDIBeclovent MDIFloVent 44mcgFloVent 110mcgFlovent 220mcgIntal MDIIntal Solution NEBTiladeTornalate MDISerevent MDIVanceril MDIVanceril DS MDI Proventil SyrupSlo-bid GyrocapsTheodur SprinklesVentolinSyrupAccolate 20mg Uniphyl 400mg Uni-dur 600mg Uni-dur 400mg Proventil Repetabs 8mg Proventil Repetabs 4mgTheodur 450mg Theodur 300mg Theo-24 100mg Theodur 200mg Theodur 100mg Theo-24 400mg Theo-24 300mg Theo-24 200mg 1-2 sp every 4-6hrs.1-2 sprays every 6 hrs.2 sprays every 6 hrs.3 sp every 6hr4 sp every 6hr1 sprays every 12 hrs.1-2 sprays every 12 hrs.2 sprays every 12 hrs.3 sprays every 12 hrs.4 sprays every 12 hrs5 sprays every 12 hrs.6 sprays 3 x/day1-sp every 4-6hr 1-2 sp evey 4 hr2 sp every 4 hr2 sp 2x/day1sp1-2sp2sp3 sp4 sp5 sp6 sp ampmam & pmdailybedtime2x/day3x/day4x/day5x/day6x/dayevery 1-3hrevery 2hrevery 3hrevery 4hrevery 5hrevery 6hr3very 4-6hrevery 8 hrevery 12 hr1 1/2 daily2 daily2 every 12 hr as needed /
  • Normal Activity and sleep

5 Alupent Solution NebulizedAtrovent Solution NebulizedAlbuterol Solution NEBTornalate Sol. 0.75cc /2cc Saline Neb.Tornalate Sol. 1.5cc/ 2cc Saline Neb.Proventil/Ventolin /Saline Premixed Neb.Proventil/Ventolin Sol, 0.25cc/1 Intal NebulizedProventil/Ventolin Sol. 0.35cc/ 1 Intal NebulizedProventil/Ventolin Sol, 0.5cc/1 Intal NebProventil/Ventolin Sol. 0.25cc/ 2cc SalineProventil/Ventolin Sol. 0.35cc/ 2cc SalineProventil/Ventolin Sol. 0.5cc/ 2cc SalineProventil/Ventolin Sol. 1cc/ 2cc SalineProventil/Ventolin Sol, 1cc/ Saline 2cc NebMaxair Autohaler 1spMaxair Autohaler 1-2spMaxair Autohaler 2spMaxair Autohaler 4spProventil HFA MDIProventil/Ventolin MDI Ventolin MDISerevent MDI 1 spraySerevent MDI 2 spray AeroBid MDIAtrovent MDIAtrovent Solution NEBAzmacort MDIBeclovent MDIFloVent 44mcgFloVent 110mcgFlovent 220mcgIntal MDIIntal Solution NEBTiladeTornalate MDISerevent MDIVanceril MDIVanceril DS MDI Proventil SyrupSlo-bid GyrocapsTheodur SprinklesVentolinSyrupAccolate 20mg Uniphyl 400mg Uni-dur 600mg Uni-dur 400mg Proventil Repetabs 8mg Proventil Repetabs 4mgTheodur 450mg Theodur 300mg Theo-24 100mg Theodur 200mg Theodur 100mg Theo-24 400mg Theo-24 300mg Theo-24 200mg 1-2 sp every 4-6hrs.1-2 sprays every 6 hrs.2 sprays every 6 hrs.3 sp every 6hr4 sp every 6hr1 sprays every 12 hrs.1-2 sprays every 12 hrs.2 sprays every 12 hrs.3 sprays every 12 hrs.4 sprays every 12 hrs5 sprays every 12 hrs.6 sprays 3 x/day1-sp every 4-6hr 1-2 sp evey 4 hr2 sp every 4 hr2 sp 2x/day1sp1-2sp2sp3 sp4 sp5 sp6 sp ampmam & pmdailybedtime2x/day3x/day4x/day5x/day6x/dayevery 1-3hrevery 2hrevery 3hrevery 4hrevery 5hrevery 6hr3very 4-6hrevery 8 hrevery 12 hr1 1/2 daily2 daily2 every 12 hr as needed
6 Alupent Solution NebulizedAtrovent Solution NebulizedAlbuterol Solution NEBTornalate Sol. 0.75cc /2cc Saline Neb.Tornalate Sol. 1.5cc/ 2cc Saline Neb.Proventil/Ventolin /Saline Premixed Neb.Proventil/Ventolin Sol, 0.25cc/1 Intal NebulizedProventil/Ventolin Sol. 0.35cc/ 1 Intal NebulizedProventil/Ventolin Sol, 0.5cc/1 Intal NebProventil/Ventolin Sol. 0.25cc/ 2cc SalineProventil/Ventolin Sol. 0.35cc/ 2cc SalineProventil/Ventolin Sol. 0.5cc/ 2cc SalineProventil/Ventolin Sol. 1cc/ 2cc SalineProventil/Ventolin Sol, 1cc/ Saline 2cc NebMaxair Autohaler 1spMaxair Autohaler 1-2spMaxair Autohaler 2spMaxair Autohaler 4spProventil HFA MDIProventil/Ventolin MDI Ventolin MDISerevent MDI 1 spraySerevent MDI 2 spray AeroBid MDIAtrovent MDIAtrovent Solution NEBAzmacort MDIBeclovent MDIFloVent 44mcgFloVent 110mcgFlovent 220mcgIntal MDIIntal Solution NEBTiladeTornalate MDISerevent MDIVanceril MDIVanceril DS MDI Proventil SyrupSlo-bid GyrocapsTheodur SprinklesVentolinSyrupAccolate 20mg Uniphyl 400mg Uni-dur 600mg Uni-dur 400mg Proventil Repetabs 8mg Proventil Repetabs 4mgTheodur 450mg Theodur 300mg Theo-24 100mg Theodur 200mg Theodur 100mg Theo-24 400mg Theo-24 300mg Theo-24 200mg 1-2 sp every 4-6hrs.1-2 sprays every 6 hrs.2 sprays every 6 hrs.3 sp every 6hr4 sp every 6hr1 sprays every 12 hrs.1-2 sprays every 12 hrs.2 sprays every 12 hrs.3 sprays every 12 hrs.4 sprays every 12 hrs5 sprays every 12 hrs.6 sprays 3 x/day1-sp every 4-6hr 1-2 sp evey 4 hr2 sp every 4 hr2 sp 2x/day1sp1-2sp2sp3 sp4 sp5 sp6 sp ampmam & pmdailybedtime2x/day3x/day4x/day5x/day6x/dayevery 1-3hrevery 2hrevery 3hrevery 4hrevery 5hrevery 6hr3very 4-6hrevery 8 hrevery 12 hr1 1/2 daily2 daily2 every 12 hr as needed(QUICK RELIEF)
EXERCISE ASTHMA: If you usually experience asthma symptoms with exercise, use your QUICK RELIEF MEDICATION 15 minutes before exercise.
Infant and Young Child / ASTHMA ACTION PLAN / PAGE 2

YELLOW ZONE:

1. USE YOUR QUICK RELIEF MEDICATION Alupent Solution NebulizedAtrovent Solution NebulizedAlbuterol Solution NEBSerevent MDI 1 spraySerevent MDI 2 sprayTornalate Sol. 0.75cc /2cc Saline Neb.Tornalate Sol. 1.5cc/ 2cc Saline Neb.Proventil/Ventolin /Saline Premixed Neb.Proventil/Ventolin Sol, 0.25cc/1 Intal NebulizedProventil/Ventolin Sol. 0.35cc/ 1 Intal NebulizedProventil/Ventolin Sol, 0.5cc/1 Intal NebProventil/Ventolin Sol. 0.25cc/ 2cc SalineProventil/Ventolin Sol. 0.35cc/ 2cc SalineProventil/Ventolin Sol. 0.5cc/ 2cc SalineProventil/Ventolin Sol. 1cc/ 2cc SalineProventil/Ventolin Sol, 1cc/ Saline 2cc NebMaxair Autohaler 1spMaxair Autohaler 1-2spMaxair Autohaler 2spMaxair Autohaler 4spProventil/Ventolin MDI 1-2spProventil/Ventolin MDI 1spProventil/Ventolin MDI 2spProventil/Ventolin MDI 4sp IMMEDIATLEY IMMEDIATELY / YELLOW ZONE: CAUTION!
Wait 20 minutes. / WORSENING ASTHMA
A If symptoms have resolved, /
  • Cough or wheezing more at night and day and noisy breathing

Return to your GREEN ZONE PLAN /
  • Breathing faster than normal

NOTE: If you enter your YELLOWZONE 3 or more times/week, call to /
  • Will not eat because of breathing trouble

set up an office visit with Dr. FILL IN without one week. /
  • Runny and stuffy nose

B If symptoms continue, /
  • Restlessness, fussiness

Repeat QUICK RELIEF MEDICATION (see above), wait 20 minutes, &
symptoms have improved:
1)Use Quick Relief Medication every 6 hours for 24 hours
2)Continue with Green Zone Medications.
C If after QUICK RELIEF MEDICATION has been used two times and you have reduced asthma symptoms follow the below plan. Otherwise go to RED ZONE plan:
1) Use Quick Relief Medication every 6 hours for 24 hours
2) Take all Green Zone Medication but make these Changes: as neededUntil seen by Dr.
a) AeroBid MDIAtrovent MDIAtrovent Solution NEBAzmacort MDIBeclovent MDIFloVent 44mcgFloVent 110mcgFlovent 220mcgIntal MDIIntal Solution NEBTiladeTornalate MDISerevent MDIVanceril MDIVanceril DS MDI 1-2 sp every 4-6hrs.1-2 sprays every 6 hrs.2 sprays every 6 hrs.3 sp every 6hr4 sp every 6hr1 sprays every 12 hrs.1-2 sprays every 12 hrs.2 sprays every 12 hrs.3 sprays every 12 hrs.4 sprays every 12 hrs5 sprays every 12 hrs.6 sprays 3 x/day1-sp every 4-6hr 1-2 sp evey 4 hr2 sp every 4 hr2 sp 3 x/day3 sp 3 x/day4 sp 3 x/day1 sp 4x/day2 sp 4 x/day3 sp 4 x/day4 sp 4 x/day5 sprays every 8hr/3 x/day5 sprays every 6hr/4 x/day Proventil SyrupSlo-bid GyrocapsTheodur SprinklesVentolinSyrupAccolate 20mg Uniphyl 400mg Uni-dur 600mg Uni-dur 400mg Proventil Repetabs 8mg Proventil Repetabs 4mgTheodur 450mg Theodur 300mg Theo-24 100mg Theodur 200mg Theodur 100mg Theo-24 400mg Theo-24 300mg Theo-24 200mg ampmam & pmdailybedtime2x/day3x/day4x/day5x/day6x/dayevery 1-3hrevery 2hrevery 3hrevery 4hrevery 5hrevery 6hr3very 4-6hrevery 8 hrevery 12 hr1 1/2 daily2 daily2 every 12 hr1-2 sp bedtime x2 daysx1 dayx3 daysx4 daysx5 daysx6 daysx7 daysuntil seen by Dr.as neededas needed until seen by Dr. as neededUntil seen by Dr.
b) AeroBid MDIAtrovent MDIAtrovent Solution NEBAzmacort MDIBeclovent MDIFloVent 44mcgFloVent 110mcgFlovent 220mcgIntal MDIIntal Solution NEBTiladeTornalate MDISerevent MDIVanceril MDIVanceril DS MDI 1-2 sp every 4-6hrs.1-2 sprays every 6 hrs.2 sprays every 6 hrs.3 sp every 6hr4 sp every 6hr1 sprays every 12 hrs.1-2 sprays every 12 hrs.2 sprays every 12 hrs.3 sprays every 12 hrs.4 sprays every 12 hrs5 sprays every 12 hrs.6 sprays 3 x/day1-sp every 4-6hr 1-2 sp evey 4 hr2 sp every 4 hr2 sp 3 x/day3 sp 3 x/day4 sp 3 x/day1 sp 4x/day2 sp 4 x/day3 sp 4 x/day4 sp 4 x/day5 sprays every 8hr/3 x/day5 sprays every 6hr/4 x/day Proventil SyrupSlo-bid GyrocapsTheodur SprinklesVentolinSyrupAccolate 20mg Uniphyl 400mg Uni-dur 600mg Uni-dur 400mg Proventil Repetabs 8mg Proventil Repetabs 4mgTheodur 450mg Theodur 300mg Theo-24 100mg Theodur 200mg Theodur 100mg Theo-24 400mg Theo-24 300mg Theo-24 200mg ampmam & pmdailybedtime2x/day3x/day4x/day5x/day6x/dayevery 1-3hrevery 2hrevery 3hrevery 4hrevery 5hrevery 6hr3very 4-6hrevery 8 hrevery 12 hr1 1/2 daily2 daily2 every 12 hr x2 daysx1 dayx3 daysx4 daysx5 daysx6 daysx7 daysuntil seen by Dr.as needed as neededUntil seen by Dr.
3)AddAeroBid MDIAtrovent MDIAtrovent Solution NEBAzmacort MDIBeclovent MDIFloVent 44mcgFloVent 110mcgFlovent 220mcgIntal MDIIntal Solution NEBTiladeTornalate MDISerevent MDIVanceril MDIVanceril DS MDI 1-2 sp every 4-6hrs.1-2 sprays every 6 hrs.2 sprays every 6 hrs.3 sp every 6hr4 sp every 6hr1 sprays every 12 hrs.1-2 sprays every 12 hrs.2 sprays every 12 hrs.3 sprays every 12 hrs.4 sprays every 12 hrs5 sprays every 12 hrs.6 sprays 3 x/day1-sp every 4-6hr 1-2 sp evey 4 hr2 sp every 4 hr2 sp 3 x/day3 sp 3 x/day4 sp 3 x/day1 sp 4x/day2 sp 4 x/day3 sp 4 x/day4 sp 4 x/day5 sprays every 8hr/3 x/day5 sprays every 6hr/4 x/day Proventil SyrupSlo-bid GyrocapsTheodur SprinklesVentolinSyrupAccolate 20mg Uniphyl 400mg Uni-dur 600mg Uni-dur 400mg Proventil Repetabs 8mg Proventil Repetabs 4mgTheodur 450mg Theodur 300mg Theo-24 100mg Theodur 200mg Theodur 100mg Theo-24 400mg Theo-24 300mg Theo-24 200mg ampmam & pmdailybedtime2x/day3x/day4x/day5x/day6x/dayevery 1-3hrevery 2hrevery 3hrevery 4hrevery 5hrevery 6hr3very 4-6hrevery 8 hrevery 12 hr1 1/2 daily2 daily2 every 12 hr x2 daysx1 dayx3 daysx4 daysx5 daysx6 daysx7 daysuntil seen by Dr.as needed as neededUntil seen by Dr.
4) AeroBid MDIAtrovent MDIAtrovent Solution NEBAzmacort MDIBeclovent MDIFloVent 44mcgFloVent 110mcgFlovent 220mcgIntal MDIIntal Solution NEBTiladeTornalate MDISerevent MDIVanceril MDIVanceril DS MDI 1-2 sp every 4-6hrs.1-2 sprays every 6 hrs.2 sprays every 6 hrs.3 sp every 6hr4 sp every 6hr1 sprays every 12 hrs.1-2 sprays every 12 hrs.2 sprays every 12 hrs.3 sprays every 12 hrs.4 sprays every 12 hrs5 sprays every 12 hrs.6 sprays 3 x/day1-sp every 4-6hr 1-2 sp evey 4 hr2 sp every 4 hr2 sp 3 x/day3 sp 3 x/day4 sp 3 x/day1 sp 4x/day2 sp 4 x/day3 sp 4 x/day4 sp 4 x/day5 sprays every 8hr/3 x/day5 sprays every 6hr/4 x/day Proventil SyrupSlo-bid GyrocapsTheodur SprinklesVentolinSyrupAccolate 20mg Uniphyl 400mg Uni-dur 600mg Uni-dur 400mg Proventil Repetabs 8mg Proventil Repetabs 4mgTheodur 450mg Theodur 300mg Theo-24 100mg Theodur 200mg Theodur 100mg Theo-24 400mg Theo-24 300mg Theo-24 200mg ampmam & pmdailybedtime2x/day3x/day4x/day5x/day6x/dayevery 1-3hrevery 2hrevery 3hrevery 4hrevery 5hrevery 6hr3very 4-6hrevery 8 hrevery 12 hr1 1/2 daily2 daily2 every 12 hr x2 daysx1 dayx3 daysx4 daysx5 daysx6 daysx7 daysuntil seen by Dr.as needed as neededUntil seen by Dr.
5)Call Dr. FILL IN for an office visit within 3 days

RED ZONE:

This is an EMERGENCY!! GET HELP!!! / RED ZONE: MEDICAL ALERT
1. USE YOUR QUICK RELIEF MEDICATION Alupent Solution NebulizedAtrovent Solution NebulizedAlbuterol Solution NEBSerevent MDI 1 spraySerevent MDI 2 sprayTornalate Sol. 0.75cc /2cc Saline Neb.Tornalate Sol. 1.5cc/ 2cc Saline Neb.Proventil/Ventolin /Saline Premixed Neb.Proventil/Ventolin Sol, 0.25cc/1 Intal NebulizedProventil/Ventolin Sol. 0.35cc/ 1 Intal NebulizedProventil/Ventolin Sol, 0.5cc/1 Intal NebProventil/Ventolin Sol. 0.25cc/ 2cc SalineProventil/Ventolin Sol. 0.35cc/ 2cc SalineProventil/Ventolin Sol. 0.5cc/ 2cc SalineProventil/Ventolin Sol. 1cc/ 2cc SalineProventil/Ventolin Sol, 1cc/ Saline 2cc NebMaxair Autohaler 1spMaxair Autohaler 1-2spMaxair Autohaler 2spMaxair Autohaler 4spProventil/Ventolin MDI 1-2spProventil/Ventolin MDI 1spProventil/Ventolin MDI 2spProventil/Ventolin MDI 4sp IMMEDIATLEY IMMEDIATELY 20 minutes x3 doses, then every 1-3hr as directedevery 15min x3 dosesIIMMEDIATLEY then every 20 minutes x3 doses, /
  • Wants to sit instead of lie down