Child Asthma Action Plan For Ages 0 To 5 Years Of Age Page 2
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Provider Instructions for Asthma Action Plan (Children Ages 0–5)
Ê
Complete All Demographic Information
Distribute Copies of the Plan
Give the top copy of the plan to the family, the next one to school, day
Determine the Level of Asthma Severity (see Table 1)
caretaker, or other involved third party as appropriate, and file the last
Address Issues Related to Asthma Severity
copy in the chart.
These can include allergens, smoke, rhinitis, sinusitis,
Review Action Plan Regularly
gastroesophageal reflux, sulfite sensitivity, medication interactions,
(Step Up/Step-Down Therapy)
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and viral respiratory infections.
A Patient who is always in the green zone for some months may
Fill In and Review Action Steps
be a candidate to “Step Down” and be reclassified to a lower level
Complete the recommendations for action in the different zones, and
of asthma severity and treatment. A patient frequently in the yellow
review the whole plan with the family so they are clear on how to
or red zone should be assessed to make sure inhaler technique is
adjust the medications, and when to call for help. Fill in medications
correct, adherence is good, environmental factors are not intefering
appropriate to the level (see Table 1).
with treatment, and alternative diagnosis have been considered. If
these considerations are met, the patient should “Step Up” to a higher
classification of asthma severity and treatment. Be sure to fill out a new
asthma action plan when changes in treatment are made.
Table 1: Severity and Medication Chart (Classification is Based on Meeting at Least One Criterion)
Mild Intermittent
Mild Persistent
Moderate Persistent
Severe Persistent
≤2 Days/Week
Symptoms/Day
>2 Days/Week but <1 Time/Day
Daily Symptoms
Continual Symptoms
Symptoms/Night
≤2 Nights/Month
>2 Nights/Month
>1 Night/Week
Frequent
Long Term
No daily medication needed
Preferred Treatment:
Preferred Treatment:
Preferred Treatment:
Control
1
• Daily high-dose inhaled
high-dose inhaled
high-dose
• Daily low-dose inhaled
• Daily low-dose inhaled
low-dose inhaled
w-dose
inhaled
corticosteriod
corticosteroid (with nebulizer
corticosteroid and long-acting
or MDI with holding chamber
inhaled Beta
-agonist
2
AND
with or without face mask
OR
• Long-acting inhaled
or DPI)
Beta
-agonist
• Daily medium-dose inhaled
medium-dose inhaled
medium-dose
2
Alternative Treatment:
corticosteriod
AND, if Needed:
• Mast cell stabilizer (nebulizer
Alternative Treatment:
• Corticosteroid tablets or
use is preferred or MDI with
syrup long term (2 mg/kg/day,
• Daily low-dose inhaled
low-dose inhaled
w-dose
inhaled
holding chamber)
generally do not exceed 60
corticosteroid and either
OR
mg per day). Make repeated
leukotriene receptor
attempts to reduce systemic
• Leukotriene receptor
antagonist or theophylline
corticosteroid and maintain
antagonist
If needed (particularly in
control with high-dose
Note: Initiation of long-term
patients with recurring
inhaled corticosteroids.
severe exacerbations):
controller therapy should be
considered if child has had more
Consulation with Asthma
Preferred Treatment:
than three episodes of wheezing
Specialist Recommended.
• Daily medium-dose inhaled
in the past year that lasted more
corticosteroid and long-acting
than one day and affected sleep
Beta
-agonist
and who have risk factors for the
2
development of asthma.
2
Alternative Treatment:
• Daily medium-dose inhaled
medium-dose inhaled
medium-dose
Consider Consultation with
corticosteriod and either
Asthma Specialist
leukotriene receptor
antagonist or theophyline
Consultaion with Asthma
Specialist Recommended
Quick Relief
Preferred Treatment:
Preferred Treatment:
Preferred Treatment:
Preferred Treatment:
• Inhaled short-acting
• Inhaled short-acting
• Inhaled short-acting
• Inhaled short-acting
Beta
-agonist
Beta
-agonist
Beta
-agonist
Beta
-agonist
2
2
2
2
1
FOR INFANTS AND CHILDREN USE SPACER OR SPACER AND MASK.
2
RISK FACTORS FOR THE DEVELOPMENT OF ASTHMA ARE PARENTAL HISTORY OF ASTHMA, PHYSICIAN-DIAGNOSED ATOPIC DERMATITIS, OR TWO OF THE FOLLOWING: PHYSICIAN-
DIAGNOSED ALLERGIC RHINITIS, WHEEZING APART FROM COLDS OR 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 CORTICOSTERIODS, CROMOLYN) SHOULD BE INITIATED PRIOR
TO THE ANTICIPATED ONSET OF SYMPTOMS AND CONTINUED THROUGH THE SEASON.
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