Your Doctor's Name:      Your Doctor's Telephone: 
Your Predicted Peak Flow:      Your Personal Best: 

GREEN ZONE   Go!   Breathing is good   No cough or wheeze   Can work and play   Peak Flow above  Take controller medicines every day: _________________________ Flovent 44 mcg Flovent 110 mcg Flovent 220 mcg Advair 100/50 Advair 250/50 Advair 500/50 Pulmicort Respules 0.25mg Pulmicort Respules 0.5mg PulmicortTurbuhaler ______________________ 1 puff 2 times a day 2 puffs 2 times a day 3 puffs 2 times a day 4 puffs 2 times a day 1 puff 3 times a day By nebulizer 2x a day As instructed _________________________ None Serevent DPI 50 mcg/puff Foradil 12mcg/cap ______________________ 1 puff 2 times a day 2 puffs 2 times a day As instructed _________________________ None Singulair 4mg 1 tab 1x day Singulair 5mg 1 tab 1x day Singulair 10mg tab 1x day  - Take rescue medicine 10-15 minute before exercising or contact with     triggers.  - Rinse mouth after use of controller medication.  - Always use a spacer or holding chamber with MDI. YELLOW     ZONE  Slow!   Cough   Wheeze   Tight chest   Wake up at night   Peak Flow between  and FIRST: Take your rescue medicines to feel better. _______________________________________________________ Albuterol MDI 2 puffs every 3 to 4 hrs Albuterol MDI 2 puffs every 4 to 6 hrs Albuterol Nebulizer 2.5mg(1 Unit dose) every 4 to 6 hrs Albuterol Nebulizer 2.5mg(0.5cc/2cc saline) every 4 to 6 hrs Maxair 2 puffs every 3 to 4 hrs Maxair 2 puffs every 4 to 6 hrs Xopenex 0.63 mg treatment every 3 to 4 hrs Xopenex 0.63 mg treatment every 4 to 6 hrs Xopenex 1.25 mg treatment every 3 to 4 hrs Xopenex 1.25 mg treatment every 4 to 6 hrs Xopenex HFA 2 puffs every 3-4 hours Xopenex HFA 2 puffs every 4-6 hours ___________________________ None Flovent 44 mcg Flovent 110 mcg Flovent 220 mcg Pulmicort Respules 0.25mg Pulmicort Respules 0.5mg Other Steroid ________________________ 1 puff 2 times a day 2 puffs 2 times a day 4 puffs 2 times a day as per special instructions NEXT: Take your controller medicines. ___________________________ Flovent 44mcg Flovent 110 mcg Flovent 220 mcg Advair 100/50 Advair 250/50 Advair 500/50 Pulmicort Respules 0.25mg Pulmicort Respules 0.5mg Pulmicort Turbuhaler ________________________ 1 puff 2 times a day 2 puffs 2 times a day 3 puffs 2 times a day 4 puffs 2 times a day 1 puff 3 times a day By nebulizer 2x a day As instructed ___________________________ None Serevent DPI 50mcg Foradil 12mcg/cap ________________________ 1 puff 2 times a day 2 puffs 2 times a day 4 puffs 2 times a day As instructed ___________________________ None Singulair 4mg 1 tab 1x day Singulair 5mg 1 tab 1x day Singulair 10mg 1 tab 1x day  - *Follow Yellow Zone for 2 - 5 days, then go to Green Zone.  - *If not better in 2 to 5 days, call your doctor. RED ZONE  Stop!     Medicine not helping   Very short of breath   Nasal flaring   Retractions   Can't walk   Can't talk well   Peak Flow below Take your rescue medicine. Get help from a Doctor _______________________________________________________ Albuterol MDI 4 Puffs Albuterol Nebulizer 2.5mg (1 unit dose) Treatment Albuterol Nebulizer 2.5mg (0.5cc/2cc saline) Treatment Xopenex HFA 2 puffs Xopenex HFA 4 puffs Xopenex Nebulizer 0.63 mg Treatment Xopenex Nebulizer 1.25 mg Treatment Maxair 4 puffs Every 20 minutes for 3 treatments (1 hour) DANGER! Follow these steps:  - *If you are using Red Zone Medicines, call your Doctor.  - *If skin color changes or your lips turn blue, call 911.  - *If you are still in the Red Zone after 2 to 3 treatments,     call 911.

 

CHILDREN'S MEDICAL CENTER DALLAS
1935 Medical District Dr - Dallas, Texas 75235
(214) 456-7000