Asthma Action Plan (Sample)

A Guideline for Managing Your Asthma

An asthma action plan can help you recognize early warning signs, and how to act to prevent an asthma attack.

But, what IS an Asthma Action Plan exactly?

An Asthma Action Plan is simply a written document that details your asthma triggers, usual symptoms, peak flow readings, and what actions to take at different stages of your symptoms getting worse. Such a plan is typically divided into 3 zones: green, yellow, and red, just like a traffic light.

If you're in the green zone, it means your asthma is under control, your peak flow readings are in your healthy range, and you're feeling healthy. But, if your symptoms start to worsen and /or your peak flow readings decline, you drop into the yellow zone, and there are certain actions, such as using your quick-relief inhaler, that can help you move quickly back to your green zone.

If you miss the cues that you've entered the yellow zone or the quick-relief treatment doesn't work, you may progress into your red zone, which indicates you are in a danger zone and need to seek medical help right away. Any delay at this point may result in a severe asthma attack and other serious complications.

An Asthma Action Plan is also a communications tool, between you and your doctor and if it is for your child with asthma between you and your child's caregivers. It can help make sure that treatment is consistent and timely.

But simply having a plan isn't enough – you also need to know how to use this tool to stop asthma attacks, before they get out of control.

Printable PDF Version of Asthma Action Plan

This action plan is for: _____________________________

Date plan developed: ____ / ____ / _____

Doctor’s Name: ____________________ Phone #: _______

Hospital / ER Address / Phone #: ___________________________________________
___________________________________________________________________

My Personal Asthma Triggers

• __ Pollen
• __ Mold
• __ Dust
• __ Cats
• __ Dogs
• __ Fumes
• __ Cold air
• __ Smoke
• __ Other: ____________________________

INSTRUCTIONS: This plan is divided into 3 zones, green, yellow, and red, similar to the colors on a traffic light. If you are in the GREEN zone, then you’re doing well. You probably don’t need to do anything other than take your daily medicines as prescribed.

If you are in the YELLOW zone, it means you are getting a warning. Yellow means that your asthma may be getting worse and you are probably having a flare up. Action is needed to prevent an asthma attack.

If you are in the RED zone, you are in danger, and you MUST take emergency action, as described on the plan, right away!

The steps you need to follow are listed in each zone. If you have any questions about your Asthma Action Plan, be sure to discuss it with your doctor before you get into the yellow or red zones.

GREEN ZONE means… You Are Doing Well!

Symptoms:

• You feel good
• You have no cough, wheezing, or other breathing problems

And / Or… Peak Flow Readings Are:
At least 80% or more of my best peak flow, which would be _________
My best peak flow is __________________

Take these medicines every day (name/dose/how often):

1. _____________________________________________
2. _____________________________________________
3. _____________________________________________

YELLOW ZONE means… Your Asthma Is Getting Worse

Symptoms:

• You are having mild cough, wheezing, chest tightness or shortness of breath
• You sometimes wake up at night due to asthma
• You can do some of your usual activities, but not all

Or… Peak Flow Readings Are:
only 50 to 80% of my best peak flow: ___________________________

Actions to Take:

1. Keep taking your daily medicine
2. Next, add the following quick-relief medicine: __________________________
3. If your symptoms do not improve, call your doctor

RED ZONE means… Medical Alert!

Symptoms:

• You are very short of breath & actively wheezing
• You cannot do your usual activities
• Quick-relief medicine is not relieving your symptoms
• You’ve been in the YELLOW zone for 24 hours with no improvement

Or… Peak Flow Readings Are:
less than 50% of your best peak flow: __________________

Actions to Take:

1. Keep taking your daily medicine
2. Next, add the following quick-relief medicine: __________________________
3. Call your family doctor NOW
4. If you are still in RED zone after 15 minutes AND you have not reached your doctor, then GO TO THE HOSPITAL OR CALL AN AMBULANCE!

Extreme Danger Signs: If you see any of these, you must get emergency help immediately:

• Lips or fingernails turning blue or purplish (cyanosis)
• Trouble walking or talking
• Chest sucking in
• Nostrils flaring open

It's important to know how to use your action plan to stop asthma attacks, before they get out of control.

Printable PDF Version of Asthma Action Plan

If you don't like our version of an Asthma Action Plan, then check out one of the alternate versions below: