What is the best approach to create an asthma action plan for a patient with asthma, considering their symptoms, lung function, and medical history?

Creating an Asthma Action Plan

Every patient with asthma should receive a written asthma action plan that includes specific instructions for daily management and clear criteria for recognizing and responding to worsening asthma, with this being particularly essential for patients with moderate-to-severe persistent asthma, history of severe exacerbations, or poorly controlled disease. 1

Essential Components of the Action Plan

Green Zone: Daily Management When Asthma is Well Controlled

Document the patient's baseline status and daily medications:

• List all long-term controller medications with specific doses and frequency (e.g., inhaled corticosteroids taken daily to prevent inflammation) 1
• Specify that quick-relief medications (short-acting beta-agonists) should be used ≤2 days per week for symptom relief 1
• Include the patient's personal best peak expiratory flow (PEF) value if using peak flow monitoring 1, 2
• List specific environmental triggers to avoid based on the patient's history and allergy testing results 1

Define "well controlled" using concrete criteria:

• Zero daytime symptoms requiring rescue medication 1
• Nighttime awakenings <2 times per month 1
• No interference with normal activities 1
• PEF >80% of predicted or personal best 1, 2

Yellow Zone: Worsening Asthma Requiring Action

Specify the warning signs that indicate declining control:

• Daytime symptoms occurring >2 days per week 1
• Nighttime awakenings 1-3 times per week 1
• PEF 60-80% of predicted or personal best 1, 2
• Increased use of short-acting beta-agonist (>2 days per week) 1
• Some limitation in normal activities 1

Provide explicit medication adjustment instructions:

• For patients ≥12 years on ICS/formoterol maintenance: increase to up to 8 additional puffs daily as needed 3
• For patients on other ICS/LABA combinations: increase short-acting beta-agonist frequency (e.g., 2-4 puffs every 4 hours) 1
• For children 4-11 years: use ICS/formoterol up to 8 puffs daily to reduce exacerbation risk 3
• Consider adding oral prednisolone 30-60 mg if symptoms persist despite increased bronchodilator use 1

Red Zone: Medical Emergency Requiring Immediate Care

Define life-threatening features that mandate emergency care:

• Severe breathlessness preventing completion of sentences in one breath 1
• Respiratory rate >25 breaths/minute 1
• Heart rate >110 beats/minute 1
• PEF <60% of predicted or personal best (severe if <50%, life-threatening if <33%) 1
• Silent chest, cyanosis, or feeble respiratory effort 1
• Exhaustion, confusion, or altered consciousness 1

Specify immediate actions:

• Take short-acting beta-agonist immediately (2-4 puffs via spacer, repeat every 20 minutes up to 3 times in first hour) 1, 3
• Take oral corticosteroids (prednisolone 30-60 mg) immediately 1, 3
• Call 911 or go directly to emergency department—do not delay 1

Tailoring the Plan to Individual Patient Factors

Assess and document severity classification to determine appropriate controller therapy:

• Intermittent: symptoms <1 time per week, PEF ≥80% predicted 2
• Mild persistent: symptoms >1 time per week but not daily, PEF ≥80% predicted 2
• Moderate persistent: daily symptoms, PEF 60-79% predicted 2
• Severe persistent: continuous symptoms or PEF <60% predicted 2

Address patient-specific factors:

• Adjust language and format for health literacy level (aim for 5th grade reading level or below) 1
• Consider cultural beliefs and practices in asthma management 1
• For patients with history of severe exacerbations or hospitalizations, emphasize early intervention and lower threshold for seeking care 1
• Include specific allergen avoidance measures based on skin or in vitro testing results for patients with persistent asthma 1

Implementation and Follow-up

Develop the plan collaboratively with the patient:

• Establish open communication and agree on treatment goals together 1
• Address patient concerns about asthma and medications 1
• Demonstrate and verify proper inhaler technique, having the patient return the demonstration 1
• Explain the difference between controller medications (prevent symptoms, must be taken daily) and quick-relief medications (provide prompt relief but don't provide long-term control) 1

Schedule appropriate monitoring intervals:

• Every 1-6 weeks while gaining control 1
• Every 1-6 months once control is maintained, depending on treatment step 1
• Every 3 months if considering stepping down therapy 1
• At every visit: assess control, review medication technique, review action plan adherence, and address patient concerns 1

Common pitfalls to avoid:

• Failing to provide written instructions—verbal education alone is insufficient 1
• Using overly complex language or medical jargon that patients cannot understand 1
• Not verifying that patients can correctly identify their zone based on symptoms and PEF 1
• Neglecting to review and update the plan at follow-up visits as asthma control changes 1
• Omitting specific trigger identification and avoidance strategies 1