Adult Asthma Action Plan (English, Spanish, Chinese Forms) Page 4
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4PROVIDER
INSTRUCTIONS
FOR
ASTHMA ACTION
PLAN (Adults and Children over 5)
o
DETERMINE THE
LEVEL
OF ASTHMA SEVERITY (see Table 1)
o
FILL
IN
MEDICATIONS
Fill in medications appropriate to that
level
(see Table 1) and include instructions, such as
"shake
well before using', "use with spacer", and 'rinse mouth after using'.
o
FILL
IN
PEAK FLOW VALUES ANDIOR SYMPTOMS
Patients over the age of six may be given peak flow meters
to
monitor their asthma.
Fill
in
the values for the patient's personal best peak flow in the green section (if a
personal
best
has not been established, use a predicted peak flow
from
outside reference charts). Use
80%
of the personal best
value
in the yellow section, and
50%
in the red. See peak flow
chart (Table 2) below to help with the
calculation.
Review symptoms in each
zone
and write
individualized
symptoms in blank
lines.
o
ADDRESS ISSUES RELATED
TO
ASTHMA SEVERITY
These
can include allergens, smoke, rhinitis, sinusitis, gastroesophageal
reflux,
sulfite
sensitivity, medication interactions, occupational exposures, and
viral
respiratory
infections.
o
FILL
IN
AND
REVIEW
ACTION STEPS
Put a check mark
in
the boxes next
to
the actions the patient should follow
and
complete
the recommendations. Review the whole plan with the patientlfamily so they are clear on
how to adjust the medications, and when to call for
help.
o
DISTRIBUTE COPIES OFTHE PLAN
Give the top copy of the plan to the patient, the next to school/day carelworkl caretaker/or
other involved third party, and file the last copy in
the
chart.
o
REVIEW
ACTION PLAN
REGULARY
(Step Up
I
Step
Down Therapy)
A
patient who
is
always in the green zone for some
months
may be a candidate to
'step
down" and be reclassified to a lower level of asthma severity and treatment. A patient
frequently in the yellow
or
red zone should be assessed to make sure
inhaler
technique is
correct, compliance is
good,
environmental factors are not interfering with treatment, and
alternative diagnoses
have
been considered. If these considerations are
met,
the patient
out a new asthma action plan when changes in treatment are made.
TABLE 1 :
Severity and medication chart (When categorizing. an
individual
should
be
assigned 10 the most
severe
grade
in
which anyone feature occurs.)
Mild
Intermittent
Mild Persistent
Moderate Persistent
Severe Persistent
Days with
~21
week
>21
week but
<11
day
Daily
Continuous
Symptoms
Nighttime
Symptoms
~21
month
>21
month
>1 I
week
Frequent
PEF or FEV1*
.::,80%
.::,80%
>60%-<80%
~60%
PEF
<20%
20-30%
>30%
>30%
Variability
Long Term
No daily medication
One daily medication:
One to two daily medications:
Three
daily
medications:
needed.
•
Inhaled
corticosteroid (low dose)
An anti-inflammatory
An anti-inflammatory
Control Daily
OR
•
Inhaled corticosteroid
•
inhaled
corticosteroid (high dose)
Medicines
•
Cromolyn OR nedocromil OR
(medium dose)
AND a long-acting bronchodilator
•
A leukotriene modifier
•
long--acting
inhaled
beta 2 -agonist OR
(check age specifications) OR
OR, especially
if
nighttime symptoms:
•
sustained-release
theophylline
OR
•
Sustained-release theophylline
An anti-inflammatory
•
long-acting
beta2-agonist tablets
(but not preferred therapy)
•
Inhaled
corticosteroid
AND corticosteroid tablets or syrul2
long
(low, medium, or high dose)
term
AND a lona-actina bronchodilator
TABLE
2:
Peak
flow value calculation chart
(100%,80%,50%)
Greiln
-
100%
100
110
120
130
'" '" '"
HO
'" '"
20'
'" '" '"
'"
'" '" '" '" '"
30'
'" '"
'30
'"
'"
'50
'" '"
'90
Yellow- 80%
"
88
'" '" '" '"
'"
136
'"
m
160
'"
H6
""
192
200
208
2"
'"
232
'"
'" '"
2"
'"
'"
288
29<l
'"
"2
Red
-
50%
60
"
60
88
70
"
80
88
'"
"
100
108
'"
'"
120
'"
130
138
'" '"
160
'88
160
188
'" '"
180
'"
''''
'98
Green
_
100%
'"
'" '"
'"
....
,
'"
'"
'"
'SO
'"
SO, OJ,
'" '"
'"
SO,
OS,
'"
'SO
'"
600
61'
'"
'30
...
'" '"
'"
'"
GO,
Yellow- 80%
320
328
336
'"
382
360
368
". '"
",
'00
'"
'" '" '" '" '" '" '"
'"
'"
'88
''''
'"
812
'"
'28
".
'"
'"
Red
-
50%
200
208
210
210
220
",
'"
'"
2"
,,,
"" '"
'"
'" '"
'"
280
288
""
'"
'00
308
310
'"
320
'"
'"
338
>I,
>I,
This Asthma AClion
Plan
was
dave/0p6d
by
/I
committee facilitated by the Regi<mal Asthma Management and Prevention (RAMP)
Initiativa.
a program of the Public Health
Institute.
/I is based on
th6
I"8COf11mendations from too National
Heart. Lung.
and
Blood
Institute·s. "Guidelines
~th"
Diagnosis
and
Management of Asthma: NIH PublicaUon No. 97-4051
(ApnI1997).
The information
conlained
herein is intended forthe IJse and convenience of physicians and other
medical (1<lrsonnel.
and
may
not
ba
appropn8fe
for IJse in 8/1 circumstances. Decisions
to
adopt 8ny particular recommandati<m mlJst be made by qlJalmed medical personnel
in
the light of
availabie
resources and the circumstances
presented by
individual
palifMlts.
Neither
the
Public
Health Instituta nor the
individuals,
and insiffoJtkmal parUeipants in the RAMP Initiative make any warranty Or guarantee, express or imp/lad, of
th6
quality. fitness.
(1<lrformance
or
results
OflJS6 of the information or products describad in the form or the GlJidelines For additional informali<m. please contact RAMP
at
(510) 883-9980.
e
2001
,
PlJbUe
HQaUh
Institute (RAMP)
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