Sample Asthma Action Plan For Children 0-5 Years (Page 2 of 2) in pdf

Patient Name

DOB

Asthma Action Plan, for Children 0 – 5 Years, continued

PROVIDER INSTRUCTIONS FOR ASTHMA ACTION PLAN

(Children ages 0-5)

Determine the Level of Asthma severity (see Table 1)

 Distribute copies of the plan



Fill In Medications

Give the top copy of the plan to the family, the next one to school, day care,



Fill in medications appropriate to that level (see Table 1) and include

caretaker, or other involved third party as appropriate, and file the last copy

instructions, such as “shake well before using” “use with spacer”,

in the chart.

and “rinse mouth after using”.

 Review Action plan Regularly (Step Up/Step Down Therapy)

 Address Issues Related To Asthma Severity

A patient who is always in the green zone for some months may be a candidate to

These can include allergens, smoke, rhinitis, sinusitis, gastro-

“step down” and be reclassified to a lower level of asthma severity and treatment.

esophaegeal reflux, sulfite sensitivity, medication interactions,

A patient frequently in the yellow or red zone should be assessed to make sure

and viral respiratory infections.

inhaler technique is correct, adherence is good, environmental factors are not in-

 Fill in and Review Action Steps

terfering with treatment, and alternative diagnoses have been considered. If these

Complete the recommendations for action in the different zones,

considerations are met, the patient should “step up” to a higher classification of

and review the whole plan with the family so they are clear on how to

asthma severity and treatment. Be sure to fill out a new asthma action plan when

adjust the medications, and when to call for help.

changes in treatment are made.

TABLE 1 SEVERITY AND MEDICATION CHART

(Classification is based on meeting at least one criterion)

Severe Persistent

Moderate Persistent

Mild Persistent

Mild Intermittent

≤ 2 days/week

Symptoms/Day

Consistent symptoms

Daily symptoms

> 2 days/week but < 1 time/day

Symptoms/Night

Frequent

> 1 night/week

> 2 nights/month

≤ 2 nights/month

Long Term

Preferred treatment:

NO daily medication needed.

Control

• Daily high-dose inhaled

• Daily low dose inhaled

corticosteroid

corticosteroid and long-act-

corticosteroid (with nebulizer

AND

ing inhaled B

– agonist

or MDI with holding chamber

• Log acting inhaled

with or without face mask

– agonist

• Daily medium-dose inhaled

or DPI)

corticosteroid

Alternative treatment:

AND, if needed:

Alternative treatment:

• Cromolyn (nebulizer is pre-

• Corticosteroid tablets or

• Daily low-dose inhaled

ferred or MDI with holding

syrup long term

corticosteroid and either

chamber)

(2 mg/kg/day, generally do

leukotriene receptor

not exceed 60 mg per day).

antagonist or theophylline

• Leukotriene receptor

(Make repeated attempts to

antagonist

If needed (particularly in

reduce systemic corticoste-

patients with recurring severe

roids and maintain control

exacerbations):

with high-dose inhaled

Note: Initiation of long-term

Preferred treatment:

corticosteroids.)

controller therapy should be

• Daily medium dose inhaled

considered if child has had

corticosteroid and long-act-

more then three episodes of

ing inhaled B

– agonist

wheezing in the past year that

Alternative treatment:

lasted more than one day and

• Daily medium-dose inhaled

affected sleep and who have

corticosteroid and either

risk factors for the development

leukotriene receptor

of asthma

antagonist or theophylline

Consultation With Asthma

Specialist Recommended

Quick Relief

Preferred treatment:

• Inhaled short-acting

– Agonist

Alternative treatment:

• Oral B

– agonist

• Oral B

– agonist

• Oral B

– agonist

• Oral B

– agonist

For infants and children use spacer or spacer AND MASK.

Risk factors for the development of asthma are parental history of asthma, physician-diagnosed etopic dermatitis or two of the following: physician-diagnosed

allergic rhinitis, wheezing apart from colds, peripheral blood eosinophilia. With viral respiratory infection, use bronchodilator every 4-6 hours up to 24 hours

(longer with physician consult); in general no more than once every six weeks. If patient has seasonal asthma on a predictable basis, long-term anti-inflammatory

therapy (inhaled corticosteroids, cromolyn) should be initiated prior to the anticipated onset of symptoms and continued through the season.

This Asthma Plan was developed by a committee facilitated by the Childhood Asthma Initiative, a program funded by the California Children and Families Commis-

sion, and the Regional Asthma Management and Prevention (RAMP) Initiative, a program of the Public Health Institute. This plan is based on the recommendations

from the National Heart, Lung, and Blood Institute’s. “Guidelines for the Diagnosis and Management of Asthma.” NIH Publication No. 97-4051 (April 1997) and

“Update on Selected Topics 2002.” NIH Publication No. 02-5075 (June 2002). The information contained herein is intended for the use and convenience of physi-

cians and other medical personnel, and may not be appropriate for use in all circumstances. Decisions to adopt any particular recommendation must be made by

qualified medical personnel in light of available resources and the circumstances presented by individual patients. No entity or individual involved in the funding

or development of this plan makes any warranty guarantee, express or implied, of the quality, fitness, performance or results of use of the information or products

described in the plan or the Guidelines. For additional information, please contact RAMP at (510) 622-4438,