ASTHMA

Asthma Self-Management Action (A.S.M.A.) Plan

Directions for use:
The ASMA Plan is a tool that health care providers can use to engage patients and their families in ongoing conversations about the principles of good asthma management and control. The ASMA Plan is specifically designed to provide a concise plan for asthma management. The patient and family should be able to demonstrate an understanding of the plan and the appropriate use of all asthma medications. The ASMA Plan uses signs and symptoms and/or peak flow readings to monitor asthma control. Give the top 2 copies of the ASMA Plan form to the patient/family. Instruct the patient/family to keep 1 copy of the plan and to provide the other copy to the patients workplace, school, or day care. Keep the third copy for your records.

How to use the zones:

Fill in the numeric values for peak flow readings (not percentages). Use the table below to determine 50% and 80% of personal best peak flow readings.
100%

GREEN ZONE: List all daily medications and corresponding directions in the appropriate boxes.

The Green Zone is 100% to 80% of personal best, or when the patient is free of symptoms.

80%

50%

YELLOW ZONE: Instruct the patient to continue taking Green Zone medications and to take all medications listed in the Yellow Zone. The Yellow Zone is 79% to 50% of personal best, or when the patient experiences symptoms listed in the Yellow Zone. It is important to indicate the duration of time that the patient should continue taking these medications and at what point he or she should contact you. RED ZONE: List any medications that the patient should take before contacting you or while preparing to go to the emergency room. The Red Zone is less than 50% of personal best, or when the patient experiences symptoms listed in the Red Zone.

Peak flow measurement:

Patients aged 5 years may use peak flow meters to monitor their asthma. Parents of children aged <5 years should use the symptoms listed on the ASMA Plan to determine their childs zone. Personal best peak flow should be determined when the patient is symptom free. A diary, which is usually a part of the peak flow meter package, can be used to record personal best. For children, it is a good idea to obtain a peak flow reading at all asthma visits and reestablish personal best regularly. Calculations Green Zone Yellow Zone Red Zone Personal Best (PB) Calculate 80% of Personal Best Calculate 50% of Personal Best PB x 0.8 = PB x 0.5 = Peak Flow Values

Provided as an educational resource by Merck

Copyright 2010 Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc. All rights reserved. 21004938(3)-01/11-SGR Printed in USA Minimum 10% Recycled Paper

A.S.M.A. (Asthma Self-Management Action) Plan

A.S.M.A. plan for__________________________________________________________ Health care provider name_____________________________________________ Date_________________________________________________________ Health care provider phone_______________________________________ After hours_____________________________________ Hospital/Emergency Department phone_______________________________________________

GREEN ZONE: Doing Well

Signs and symptoms n  No cough, wheeze, chest tightness, or shortness of breath during the day or night n Can do usual activities If a peak flow meter is used: My personal best peak flow is __________________ (L/min) Peak flow: more than _______________________________
(80% or more of my best peak flow)

Even if you do not have symptoms, take these long-term control medicines each day.
Medicine How much to take When to take it

Before exercise, take (Medicine)

(Dose)

(Minutes/Hours before exercise)

YELLOW ZONE: Asthma Is Getting Worse

Signs and symptoms n  Cough, wheeze, chest tightness, or shortness of breath or n Waking at night due to asthma or n Can do some, but not all, usual activities

First

Add quick-relief medicine and keep taking your GREEN ZONE medicine.
________________________________________ q 2 to ___ puffs every ___ minutes for ___ treatments or (short-acting 2-agonist) q nebulizer treatments If your symptoms (and peak flow, if used) return to the GREEN ZONE after 1 hour of above treatment: Continue monitoring to be sure you stay in the GREEN ZONE.

second

or
Peak flow: __________ to ____________ (L/min) (50%79% of my best peak flow)

or

If your symptoms (and peak flow, if used) do not return to the GREEN ZONE after 1 hour of above treatment: q Take _________________________________ q 2 or q 4 puffs or q nebulizer every________ hours.
(short-acting 2-agonist) (oral steroid)

q Add _________________________________ _________ mg per day for_________ (310) days. q Add _________________________________________________________ per day for_________ days. q Call the health care provider q before or q within________ hours after taking the oral steroid.

RED ZONE: Medical Alert!

Take this medicine:

(short-acting 2-agonist) (oral steroid)

Signs and symptoms n Very short of breath or n Quick-relief medicines have not helped or n Cannot do usual activities or n Symptoms are the same or worse after 24 hours in YELLOWZONE

q ______________________________________

q 4 or q 6 puffs or q nebulizer

q ______________________________________ _________ mg

or

Peak flow: less than _________________ (L/min) (less than 50% of my best peak flow)

Call your health care provider NOW. Go to the hospital or call for an ambulance if: n You are still in the REDZONE after 15 minutes AND n You have not reached your health care provider

DANGER SIGNS

n Trouble walking and talking due to shortness of breath n Take q 4 or q 6 puffs of your quick-relief medicine AND n Lips or fingernails are blue n Go to the hospital or call for an ambulance (___________________________ ) _

NOW!

People who should have a copy of my A.S.M.A. plan: spouse, school nurse, coworkers, babysitter, family members, friends.
Adapted from National Heart, Lung, and Blood Institute. Asthma Action Plan. Bethesda, MD: US Dept of Health and Human Services: April 2007. NIH publication 07-5251.

Provided as an educational resource by Merck

Copyright 2010 Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc. All rights reserved. 21004938(3)-01/11-SGR Printed in USA Minimum 10% Recycled Paper Heath care provider signature _________________________________________________

Patient copy

Your Asthma Control Goals

Asthma control: What can it mean for you?
The goals of asthma treatment are to help you:
n G  et relief from asthma symptoms, such as wheezing, coughing, shortness of breath, and chest tightness n  Need a fast-acting inhaler fewer than 2 days a week n  Sleep through the night and not wake up because of asthma symptoms n  Go to work or school and not have to miss days because of asthma n  Join in activities, including sports and exercise n A  void unscheduled doctor, emergency room, or urgentcare visits Notes:

Tips to help control your asthma

Your health:
n  Take your asthma medicines as your health care provider recommends, even when you f eel well. n  Check with your health care provider before taking any over-the-counter medicines. n  Talk with your health care provider about ways to  stay healthier.

Where you live, work, or go to school:

n  Try

to keep your HOUSE clean of dust and molds.

n Avoid cigar and cigarette SMOKE as much as possible. n Avoid strong ODORS, such as paint, perfume, and hair spray. n  Wear a scarf or a COLD AIR mask over your mouth when its cold outside.

In addition, if you have allergies:

n  Wash blankets and sheets once a week in HOT WATER. n Wash clothing and stuffed toys in HOT WATER. n Keep PETS out of the bedroom and wash pets weekly. n Avoid going outside if the POLLEN COUNT is high. n  Cover mattress and pillows with airtight plastic covers.

A.S.M.A. (Asthma Self-Management Action) Plan

A.S.M.A. plan for__________________________________________________________ Health care provider name_____________________________________________ Date_________________________________________________________ Health care provider phone_______________________________________ After hours_____________________________________ Hospital/Emergency Department phone_______________________________________________

GREEN ZONE: Doing Well

Signs and symptoms n  No cough, wheeze, chest tightness, or shortness of breath during the day or night n Can do usual activities If a peak flow meter is used: My personal best peak flow is __________________ (L/min) Peak flow: more than _______________________________
(80% or more of my best peak flow)

Even if you do not have symptoms, take these long-term control medicines each day.
Medicine How much to take When to take it

Before exercise, take (Medicine)

(Dose)

(Minutes/Hours before exercise)

YELLOW ZONE: Asthma Is Getting Worse

Signs and symptoms n  Cough, wheeze, chest tightness, or shortness of breath or n Waking at night due to asthma or n Can do some, but not all, usual activities

First

Add quick-relief medicine and keep taking your GREEN ZONE medicine.
________________________________________ q 2 to ___ puffs every ___ minutes for ___ treatments or (short-acting 2-agonist) q nebulizer treatments If your symptoms (and peak flow, if used) return to the GREEN ZONE after 1 hour of above treatment: Continue monitoring to be sure you stay in the GREEN ZONE.

second

or
Peak flow: __________ to ____________ (L/min) (50%79% of my best peak flow)

or

If your symptoms (and peak flow, if used) do not return to the GREEN ZONE after 1 hour of above treatment: q Take _________________________________ q 2 or q 4 puffs or q nebulizer every________ hours.
(short-acting 2-agonist) (oral steroid)

q Add _________________________________ _________ mg per day for_________ (310) days. q Add _________________________________________________________ per day for_________ days. q Call the health care provider q before or q within________ hours after taking the oral steroid.

RED ZONE: Medical Alert!

Take this medicine:

(short-acting 2-agonist) (oral steroid)

Signs and symptoms n Very short of breath or n Quick-relief medicines have not helped or n Cannot do usual activities or n Symptoms are the same or worse after 24 hours in YELLOWZONE

q ______________________________________

q 4 or q 6 puffs or q nebulizer

q ______________________________________ _________ mg

or

Peak flow: less than _________________ (L/min) (less than 50% of my best peak flow)

Call your health care provider NOW. Go to the hospital or call for an ambulance if: n You are still in the REDZONE after 15 minutes AND n You have not reached your health care provider

DANGER SIGNS

n Trouble walking and talking due to shortness of breath n Take q 4 or q 6 puffs of your quick-relief medicine AND n Lips or fingernails are blue n Go to the hospital or call for an ambulance (___________________________ ) _

NOW!

People who should have a copy of my A.S.M.A. plan: spouse, school nurse, coworkers, babysitter, family members, friends.
Adapted from National Heart, Lung, and Blood Institute. Asthma Action Plan. Bethesda, MD: US Dept of Health and Human Services: April 2007. NIH publication 07-5251.

Provided as an educational resource by Merck

Copyright 2010 Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc. All rights reserved. 21004938(3)-01/11-SGR Printed in USA Minimum 10% Recycled Paper Heath care provider signature _________________________________________________ workplace/School/daycare

copy

I, (parent or guardian), hereby authorize that the following steps be taken in conjunction with the attached Asthma Action Plan:

q q q
Date

 y child, M , may carry and self-administer medications as outlined in the Asthma Action Plan, consistent with policies, for a period not to exceed 1 year. School district/child care personnel may assist my child with use and interpretation of the Asthma Action Plan, consistent with policies, for a period not to exceed 1 year. School district/child care personnel may administer medications to my child as outlined in the Asthma Action Plan, consistent with policies, for a period not to exceed 1 year.

Parent/Guardian (Signed authorization expires 1 year from this date.)

A.S.M.A. (Asthma Self-Management Action) Plan

A.S.M.A. plan for__________________________________________________________ Health care provider name_____________________________________________ Date_________________________________________________________ Health care provider phone_______________________________________ After hours_____________________________________ Hospital/Emergency Department phone_______________________________________________

GREEN ZONE: Doing Well

Signs and symptoms n  No cough, wheeze, chest tightness, or shortness of breath during the day or night n Can do usual activities If a peak flow meter is used: My personal best peak flow is __________________ (L/min) Peak flow: more than _______________________________
(80% or more of my best peak flow)

Even if you do not have symptoms, take these long-term control medicines each day.
Medicine How much to take When to take it

Before exercise, take (Medicine)

(Dose)

(Minutes/Hours before exercise)

YELLOW ZONE: Asthma Is Getting Worse

Signs and symptoms n  Cough, wheeze, chest tightness, or shortness of breath or n Waking at night due to asthma or n Can do some, but not all, usual activities

First

Add quick-relief medicine and keep taking your GREEN ZONE medicine.
________________________________________ q 2 to ___ puffs every ___ minutes for ___ treatments or (short-acting 2-agonist) q nebulizer treatments If your symptoms (and peak flow, if used) return to the GREEN ZONE after 1 hour of above treatment: Continue monitoring to be sure you stay in the GREEN ZONE.

second

or
Peak flow: __________ to ____________ (L/min) (50%79% of my best peak flow)

or

If your symptoms (and peak flow, if used) do not return to the GREEN ZONE after 1 hour of above treatment: q Take _________________________________ q 2 or q 4 puffs or q nebulizer every________ hours.
(short-acting 2-agonist) (oral steroid)

q Add _________________________________ _________ mg per day for_________ (310) days. q Add _________________________________________________________ per day for_________ days. q Call the health care provider q before or q within________ hours after taking the oral steroid.

RED ZONE: Medical Alert!

Take this medicine:

(short-acting 2-agonist) (oral steroid)

Signs and symptoms n Very short of breath or n Quick-relief medicines have not helped or n Cannot do usual activities or n Symptoms are the same or worse after 24 hours in YELLOWZONE

q ______________________________________

q 4 or q 6 puffs or q nebulizer

q ______________________________________ _________ mg

or

Peak flow: less than _________________ (L/min) (less than 50% of my best peak flow)

Call your health care provider NOW. Go to the hospital or call for an ambulance if: n You are still in the REDZONE after 15 minutes AND n You have not reached your health care provider

DANGER SIGNS

n Trouble walking and talking due to shortness of breath n Take q 4 or q 6 puffs of your quick-relief medicine AND n Lips or fingernails are blue n Go to the hospital or call for an ambulance (___________________________ ) _

NOW!

People who should have a copy of my A.S.M.A. plan: spouse, school nurse, coworkers, babysitter, family members, friends.
Adapted from National Heart, Lung, and Blood Institute. Asthma Action Plan. Bethesda, MD: US Dept of Health and Human Services: April 2007. NIH publication 07-5251.

Provided as an educational resource by Merck

Copyright 2010 Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc. All rights reserved. 21004938(3)-01/11-SGR Printed in USA Minimum 10% Recycled Paper Heath care provider signature _________________________________________________

health care provider/File copy

Asthma Assessment Tool

YES NO

q q q q

q q q q

 o you have asthma symptoms (such as coughing, wheezing, D breathlessness, or chest tightness) more than 2 days a week? Do you have to use your rescue inhaler or nebulizer medication more than 2 days a week? Does your asthma keep you from getting as much done as you would like at work, school, or home? Are you waking up at night because of asthma symptoms more than 2 times a month?

If you answered Yes to any of these questions, your asthma may not be under control. You should discuss your answers with your health care provider.