Asthma

Assess symptoms/peak flow

• YELLOW ZONE — Mild-to-moderate exacerbation PEF 50–80% predicted or personal best or Signs and symptoms • Coughing, shortness of breath or chest tightness (correlate imperfectly with severity of exacerbation), or • Unable to sleep at night due to asthma, or • Decreased ability to perform usual activities • With or without wheezing
• RED ZONE — Severe exacerbation PEF <50% predicted or personal best or Signs and symptoms • Very hard time breathing; constant coughing • Trouble walking or talking due to asthma (unable to complete sentences; only using 2- to 3-word phrases) • Nails blue • Suprasternal or supraclavicular retractions • Albuterol not relieving symptoms within 10–15 minutes • With or without wheezing

Instructions to patient (Yellow Zone initial)

• Inhaled short-acting β2-agonist:
• • 2–4 puffs of inhaler or nebulizer treatment every 20 minutes up to 3 times in 1 hour
• • Assess asthma symptoms and/or peak flow 15–20 minutes after each treatment
• • Nurse to call family after 1 hour
• • If patient worsens during treatment, have parent call back immediately or call 9-1-1

GREEN ZONE — Good response (Mild exacerbation)

• PEF > 80% predicted or personal best or
• Signs and symptoms
• • No wheezing, shortness of breath, cough or chest tightness, and
• • Response to β2-agonist sustained for 4 hours
• Instructions to patient:
• • May continue 2–4 puffs (or nebulizer) β2-agonist every 3–4 hours for 24–28 hours prn
• • For patients on inhaled steroids, double dose for 7–10 days
• • Contact PCP within 48 hours for instructions

YELLOW ZONE — Incomplete response (Moderate exacerbation)

• PEF 50–80% predicted or personal best or
• Signs and symptoms
• • Persistent wheezing, shortness of breath, cough or chest tightness
• Instructions to patient:
• • Take 2–4 puffs (or nebulizer) β2-agonist every 2–4 hours for 24–48 hours prn
• • Add oral steroid* (see contraindications below)
• • Contact PCP urgently (within 24 hours) for instructions

RED ZONE — Poor response (Severe exacerbation)

• PEF < 50% predicted or personal best or
• Signs and symptoms
• • Marked wheezing, shortness of breath, cough, or chest tightness
• • Distress is severe and nonresponsive
• • Response to β2-agonist last 2 hours
• Instructions to patient:
• • Proceed to ED, or call ambulance or 9-1-1 and repeat treatment while waiting
• Instructions to patient — IMMEDIATELY:
• • Take 4-6 puffs (or nebulizer) β2-agonist
• • Start oral steroids* if available (see contraindications below)
• • Instruct parent to call back in 5 minutes after treatment finished
• • If still in RED ZONE proceed to ED, or call ambulance or 9-1-1 and repeat treatment while waiting
• • If in YELLOW ZONE, move to YELLOW ZONE protocol (top left box)