My Asthma Action Plan for Home and School

Flu Vaccine―Date received: ________________ Next flu vaccine due: ________________ COVID19 vaccine―Date received: _______________

Control Medicine(s) Medicine How much to take When and how oen to take it Take at

Home School

Physical Activity Use Albuterol/Levalbuterol pus, 15 minutes before activity with all activity when you feel you need it

My Asthma Action Plan

For Home and School

Name: DOB: / /

Severity Classiﬁcation: Intermient Mild Persistent Moderate Persistent Severe Persistent

Asthma Triggers (list):

Peak Flow Meter Personal Best:

ALA Asthma AP Home_School V3 3 1 2023

1-800-LUNGUSA | Lung.org

Green Zone: Doing Well

Symptoms: Breathing is good – No cough or wheeze – Can work and play – Sleeps well at night

Peak Flow Meter (more than 80% of personal best)

Yellow Zone: Caution

Symptoms: Some problems breathing – Cough, wheeze, or tight chest – Problems working or playing – Wake at night

Peak Flow Meter to (between 50% and 79% of personal best)

Quick-relief Medicine(s) Albuterol/Levalbuterol pus, every 20 minutes for up to 4 hours as needed

Control Medicine(s) Continue Green Zone medicines

Add Change to

You should feel beer within 20-60 minutes of the quick-relief treatment. If you are geing worse or are in the Yellow Zone for more

than 24 hours, THEN follow the instructions in the RED ZONE and call the doctor right away!

Red Zone: Get Help Now!

Symptoms: Lots of problems breathing – Cannot work or play – Geing worse instead of beer – Medicine is not helping

Peak Flow Meter (less than 50% of personal best)

Take Quick-relief Medicine NOW! Albuterol/Levalbuterol pus, (how frequently)

Call 911 immediately if the following danger signs are present: • Trouble walking/talking due to shortness of breath

• Lips or ﬁngernails are blue

• Still in the red zone aer 15 minutes

School Sta: Follow the Yellow and Red Zone instructions for the quick-relief medicines according to asthma symptoms.

The only control medicines to be administered in the school are those listed in the Green Zone with a check mark next to “Take at School”.

Both the Healthcare Provider and the Parent/Guardian feel that the child has demonstrated the skills to carry and self-administer their

quick-relief inhaler, including when to tell an adult if symptoms do not improve aer taking the medicine.

Healthcare Provider

Name Date Phone ( ) - Signature

Parent/Guardian

I give permission for the medicines listed in the action plan to be administered in school by the nurse or other school sta as appropriate.

I consent to communication between the prescribing health care provider or clinic, the school nurse, the school medical advisor and school-based health

clinic providers necessary for asthma management and administration of this medicine.

Name Date Phone ( ) - Signature

School Nurse

The student has demonstrated the skills to carry and self-administer their quick-relief inhaler, including when to tell an adult if symptoms do not improve

aer taking the medicine.

Name Date Phone ( ) - Signature

Please send a signed copy back to the provider listed above.

Proper inhalation

technique is important

when taking your

asthma medicine(s)

and monitoring your

breathing. Make sure to

bring all your medicines

and devices to each visit

with your primary care

provider or pharmacist

to check for correct use,

or if you have trouble

using them.

For more videos,

handouts, tutorials and

resources, visit Lung.org.

Scan the QR Code to

access How-To Videos

You can also connect

with a respiratory

therapist for one-

on-one, free support

from the American

Lung Association’s

Lung HelpLine at

1-800-LUNGUSA.

Prime a brand-new inhaler: Before using it for the ﬁrst time, if you have not used

it for more than 7 days, or if it has been dropped.

1. Shake inhaler 10 seconds.

2. Take the cap o the inhaler and valved holding

chamber. Make sure the mouthpiece and valved

holding chamber are clean and there is nothing

inside the mouthpieces.

3. Put inhaler into the chamber/spacer.

4. Breathe out away from the device.

5. Put chamber mouthpiece in mouth.

6. Press inhaler once and breathe in deep and

steadily.

7. Hold your breath for 10 seconds, then breathe

out slowly.

If you need another pu of medicine, wait 1

minute and repeat steps 4-7.

8. Rinse with water and spit it out.

How to Use a Metered-Dose Inhaler with a

Valved Holding Chamber (Spacer)