11002 Veirs Mill Road, Suite 414 / / 5454 Wisconsin Avenue, Suite 700
Wheaton, MD 20902-2538 / Chevy Chase, MD 20815-6901
Tel (301) 962-5800 / Tel (301) 986-9262
Fax (301) 962-9585 / Fax (301) 907-7910
Michael A. Kaliner, MD / Martha V. White, MD / Athena Economides, MD / H. Henry Li, MD, PhD / Mark D. Scarupa, MD / Eyal Oren, MD
Asthma Action Plan
Patient Name:______DOB: ______Date: ______
Personal Best Peak Flow Result: ______Physician: MK, MW, AE, HL, MS, EO
Green Zone: Doing well.
· No Symptoms or mild cough, wheeze, chest tightness or shortness of breath easily relieved by bronchodilators
· And, can do usual activities
· And, peak flow is more than 80% of Personal Best, ( >______)
What to Do: Take normally prescribed medications as in the Treatment Plan
Yellow Zone: Asthma is getting worse
· More frequent cough, wheeze, chest tightness or shortness of breath
· Or, waking at night due to breathing difficulties or cough
· Or, can do some but not all usual activities
· Or, peak Flow 50%-80% of Personal Best, ______to ______
What to Do: Take all medications as listed in the Treatment Plan with the following changes:
______
______
______
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)
What to Do: Take ______4 or 6 puffs, or use nebulizer; start oral prednisone ___ mg, then call your doctor NOW. Go to the hospital or callfor anambulance if you are still in the red zone after 15 minutes AND you have not reached your doctor.
DANGER SIGNS: Trouble walking and/or talking due to shortness of breath; Lips or fingernails are blue
Take 4 or 6 puffs of ______ANDgo to the hospital or call an ambulance NOW!
Revised: 11/15/2011