What is the recommended asthma action plan according to Global Initiative for Asthma (GINA) guidelines?

GINA Asthma Action Plan

All patients with asthma must receive a written asthma action plan that includes daily management instructions, recognition of worsening symptoms, medication adjustments, and clear criteria for seeking emergency care. 1, 2

Core Components of the Action Plan

Green Zone: Asthma is Well-Controlled

Daily preventive actions:

• Take long-term controller medications every day as prescribed (low-dose ICS or ICS-formoterol depending on severity) 1, 2
• Avoid identified triggers including tobacco smoke, allergens, irritants, and air pollution 1, 2
• Monitor symptoms: no daytime symptoms, no nighttime awakening, no activity limitation, minimal or no need for reliever medication 3, 4

Preferred reliever medication:

• Use as-needed low-dose ICS-formoterol (Track 1 preferred approach), which reduces severe exacerbations by ≥60% compared to SABA alone 2, 5, 6
• Alternative: as-needed SABA if using Track 2 approach 5, 6

Yellow Zone: Asthma is Getting Worse

Warning signs to recognize:

• Increased cough, wheeze, chest tightness, or shortness of breath 1
• Waking at night due to asthma symptoms 1
• Increased need for reliever medication (using SABA >2 days/week indicates need for controller adjustment) 1
• Peak flow dropping to 50-80% of personal best (if monitoring PEF) 1
• Difficulty with usual physical activities 1

Immediate actions:

• Increase reliever medication: take 2-4 puffs of ICS-formoterol or SABA every 20 minutes for first hour 1, 2
• Start or increase oral corticosteroids (typically prednisone 40-50mg daily for adults) if symptoms persist or worsen 1, 7
• Continue controller medications at current or increased dose 1, 2
• Contact your healthcare provider within 24 hours if not improving 1

Red Zone: Medical Emergency

Danger signs requiring immediate emergency care (call 911 or go to emergency department):

• Severe breathlessness (difficulty walking or talking due to asthma) 1, 2
• No improvement or worsening despite taking reliever medication 1
• Lips or fingernails turning blue 1
• Drowsiness or confusion 1, 2
• Peak flow <50% of personal best (if monitoring) 1, 2

Emergency treatment while waiting for help:

• Give 4-8 puffs of SABA or ICS-formoterol immediately, repeat every 20 minutes 1, 2
• Start oral corticosteroids immediately if available 1, 2
• Sit upright, stay calm, do not lie down 1

Essential Self-Management Skills

Patients must demonstrate competency in:

• Proper inhaler technique with return demonstration to healthcare provider 1, 2
• Use of spacer/valved holding chamber devices as prescribed 1
• Understanding difference between "relievers" (quick-relief medications like SABA or ICS-formoterol) and "preventers" (daily controller medications like ICS) 1, 2
• Self-monitoring of symptoms and peak flow if prescribed 1, 2
• Recognition of early warning signs specific to the individual patient 1

Medication Adjustment Algorithm

Step-up therapy when asthma is uncontrolled:

• Verify medication adherence, inhaler technique, and trigger avoidance before increasing medications 1, 5
• Move to next treatment step if symptoms persist despite correct technique and adherence 3, 4
• Reassess control after 2-3 months at new treatment level 5, 4

Step-down therapy when asthma is well-controlled:

• Consider reducing treatment after 3 months of good control 7, 5
• Reduce ICS dose by 25-50% at 3-month intervals 7, 5
• Maintain close monitoring during step-down 5, 4

High-Risk Patients Requiring Intensive Monitoring

Patients at increased risk of asthma-related death need special attention:

• Previous severe exacerbation requiring intubation or ICU admission 1
• Two or more hospitalizations or >3 emergency department visits in past year 1
• Using >2 canisters of SABA per month 1
• Difficulty perceiving airway obstruction or severity of worsening asthma 1
• Major psychosocial problems, psychiatric disease, or illicit drug use 1
• Low socioeconomic status or comorbidities 1

These patients should:

• Use peak flow-based action plans for objective monitoring 1
• Seek medical care early during any exacerbation 1
• Have more frequent follow-up appointments 2, 5

Common Pitfalls to Avoid

Do NOT rely on these ineffective home treatments:

• Drinking large volumes of liquids during exacerbations 1
• Breathing warm, moist air 1
• Over-the-counter antihistamines or cold remedies for asthma symptoms 1
• Doubling ICS dose during exacerbations (not effective; use oral corticosteroids instead) 1

Critical safety point:

• Never use LABA medications alone without ICS, as this increases risk of asthma-related death 2

Follow-Up and Monitoring Schedule

Regular assessment at each visit should include:

• Days per week with symptoms and nighttime awakening 1
• Days per week with activity limitation 1
• Number of puffs of reliever medication used daily 1
• Any asthma attacks or unscheduled healthcare visits since last appointment 1
• Review of peak flow chart if patient monitors at home 1
• Assessment of medication adherence and barriers 1
• Demonstration of inhaler technique 1, 2