What is the simplified asthma action plan for a pediatric patient, including the number of puffs and frequency of inhaled corticosteroids (ICS) and quick-relief medications, such as albuterol, for the green, yellow, and red zones?

Simplified Asthma Action Plan: Green, Yellow, and Red Zones

For pediatric patients with asthma, use a symptom-based three-zone action plan with albuterol 2-4 puffs every 4 hours as needed in the green zone, 4-8 puffs every 20 minutes for up to 3 doses in the yellow zone, and immediate medical attention with 4-8 puffs every 20 minutes in the red zone while calling for emergency help. 1

Green Zone: Doing Well (No Symptoms)

Daily Controller Medications:

• Continue daily inhaled corticosteroids (ICS) at prescribed dose 2
• For children 5+ years with mild persistent asthma: low-dose ICS twice daily 2
• For children under 5 years: low-dose ICS via nebulizer, DPI, or MDI with spacer 2

Quick-Relief (Albuterol):

• 2-4 puffs as needed for occasional symptoms 1
• If using more than once daily, contact your doctor 1
• Onset of action within 5 minutes 3

Yellow Zone: Getting Worse (Cough, Wheeze, Chest Tightness, or Trouble Breathing)

Immediate Action:

• Albuterol: 4-8 puffs every 20 minutes for 3 doses (using MDI with spacer) 1
• For nebulizer: 2.5 mg (age <2 years) or 5 mg (age ≥2 years) every 20 minutes for 3 doses 1

After Initial Treatment:

• If improved: Continue albuterol every 1-4 hours as needed 1
• Start oral prednisolone 1-2 mg/kg daily (maximum 60 mg) for 3-10 days 1, 3
• Contact your doctor within 24 hours 1

Do NOT increase inhaled corticosteroid dose during exacerbations - this is not effective 3

Red Zone: Medical Emergency (Severe Difficulty Breathing, Lips/Nails Blue, Cannot Speak in Full Sentences)

Immediate Actions:

1. Call 911 or go to emergency department immediately 1
2. Give albuterol 4-8 puffs every 20 minutes while waiting for help 1
3. Give oral prednisolone 1-2 mg/kg (maximum 60 mg) immediately 1, 3

Emergency Department Treatment:

• Albuterol continues every 20 minutes for 3 doses, then every 1-4 hours 1
• May add ipratropium bromide (8 puffs every 20 minutes for 3 doses) for severe exacerbations 1
• Systemic corticosteroids: prednisolone 1-2 mg/kg daily (maximum 60 mg) 1
• Oxygen to maintain saturations 4

Key Dosing Details by Age

Albuterol MDI (90 mcg/puff):

• Green Zone: 2-4 puffs as needed 1
• Yellow/Red Zone: 4-8 puffs every 20 minutes for 3 doses 1
• Always use with spacer device (and face mask if under 4 years) 1

Albuterol Nebulizer:

• Age <2 years: 2.5 mg every 20 minutes for 3 doses 1
• Age ≥2 years: 5 mg every 20 minutes for 3 doses 1
• After initial treatment: every 1-4 hours as needed 1

Oral Corticosteroids (Prednisolone/Prednisone):

• Dose: 1-2 mg/kg daily in 1-2 divided doses 1
• Maximum: 60 mg/day 1
• Duration: 3-10 days 1
• No tapering needed for courses under 10 days 1

Critical Pitfalls to Avoid

Common Mistakes:

• Never use inhaled corticosteroids alone for acute exacerbations - oral prednisone is significantly more effective and prevents hospitalizations 5
• Do not double inhaled steroid doses during worsening - evidence shows this is ineffective 3
• Never use oral albuterol - it has lower potency, longer onset, and more side effects than inhaled 3
• Do not give antibiotics unless bacterial infection confirmed 1
• Never give sedation during an asthma attack 1

Device Technique:

• MDI must be used with spacer device in children 1
• Check inhaler technique at every visit 1
• For children under 4 years: use spacer with face mask 1

When to Seek Follow-Up

After Yellow Zone Episode:

• See primary care provider within 1 week 1
• Consider stepping up maintenance therapy 4

After Emergency Department Visit:

• Continue prednisolone for full 3-10 day course 1
• See primary care provider within 1 week 1
• See respiratory specialist within 1 month 1
• Peak flow should be >75% predicted before discharge 1, 3

Reassess Treatment If:

• Using quick-relief more than once daily 1
• Waking at night with symptoms 1
• Missing school or limiting activities 1