Updated September 30, 2014.

Written or reviewed by a board-certified physician. See About.com's Medical Review Board.

Asthma action plans are essential when you begin to experience a loss of asthma control in the yellow zone. Effective treatment in the yellow zone can prevent transition into the red zone, visits to the emergency department and subsequent hospital admission.

Currently the Expert Guidelines for the Diagnosis and Management of Asthma recommend increasing your SABA for 24 to 48 hours to treat home exacerbations of asthma and adding an oral steroid if symptoms do not improve.

However, the guideline does not provide a lot of guidance about possible interventions in the yellow zone that might improve asthma outcomes.

The following recommendations are identified interventions from research that you can discuss with your doctor for possible inclusion in your asthma action plan.

Patients Commonly Self Treat

Patients commonly treat their own asthma, especially in the absence of an asthma action plan. Many patients report increasing both inhaled steroids as well as their short acting beta agonist when symptoms worsen. Of concern is that a large number of patients increase meds inappropriately, reinforcing the need for an asthma actions plan. Additionally, when patients self treat they are more likely to stop medications too soon leading to more poor control.

Make Sure You Can Identify Yellow Zone

In addition to monitoring your asthma, you need to make sure that you can identify when you are actually in the yellow zone. Common symptoms include:

• An increase in asthma symptoms

• An increase in use of fast acting, reliever medications
• A peak flow decrease of at least 15% or lower than 80% of your personal best
• Nocturnal asthma symptoms

A simple way to know your asthma is inadequately controlled is the Baylor Rule of Twos. If you use your relief inhaler more than two times per week, wake up with asthma symptoms more than 2 times per month, or refill your short acting inhaler more than two times per year, your asthma is poorly controlled.

Begin Yellow Zone Plan With Onset Of URI Or Other Trigger

If upper respiratory tract infections are a known trigger for your asthma, studies have demonstrated early intervention may prevent transition to known the yellow zone. One strategy to discuss with your asthma provider is to begin your yellow zone strategy before even developing asthma symptoms. This strategy could also be applied to other exposure to known asthma triggers such as:

• Tobacco smoke
• Animal dander
• Mold
• Pollen
• Extreme weather
• Exercise
• Stress

Step Up Therapy In The Yellow Zone

Once you experience asthma symptoms that place you in the yellow zone, you will need to step up therapy that:

• Prevents transition to red zone
• Avoids ER visits and admission
• Avoids systemic steroid use
• Is both safe and easily implemented
• Minimizes side effects

Possible options for you to discuss with your doctor include:

• Increasing short acting beta agonists
• Quadrupling inhaled steroid use
• Combining inhaled steroids and SABA

Increase SABA Use In Addition To Step Up Therapy

The 2007 Expert Guideline recommends 2 to 6 puffs of SABA or nebulized treatments every 3 to 4 hours for 24 to 48 hours for home exacerbations of asthma. In general, more than 12 puffs of your SABA in 24 hours ( or 8 puffs per day in young children) is considered a red zone exacerbation.

Increasing ICS When In Yellow Zone

Increasing inhaled steroids has been a commonly studied intervention for patients in the yellow zone. Quadrupling steroid dose is an effective step up therapy while doubling the steroid dose has not been effective. Increasing dose is more effective in patients at higher risk of asthma.

Asthma Predictive Index

We don’t always know that kids have asthma, especially when they are young. However, use of high dose inhaled corticosteroids in children at high risk of asthma who are experiencing yellow zone symptoms may decrease intensity of their illness.

Your wheezing child is more likely to develop asthma in the future (and benefit from treatment now) if they have one major or 2 minor risk factors noted below.

Major risk factors include:

• Parental history of asthma
• Diagnosis of eczema or atopic dermatitis
• Known history of allergy to allergens

Minor risk factors include:

• History of food allergies
• Increase eosinophils on blood testing
• Wheezing with upper respiratory tract infections

Symptom Driven Inhaled Steroids

A number of recent studies have examined treatment of mild persistent asthma with worsening symptoms utilizing short courses of inhaled steroids or oral systemic steroids with promising results. Other studies have demonstrated that combining a SABA with inhaled steroids is more effective than a SABA alone.

Combining multiple meds for the acute treatment of asthma in the yellow zone may be more effective regimen. It is certainly worth discussing with your asthma doctor if your asthma action plan is only utilizing a SABA.

Sources

1. Baylor Health System. Rules of Two. Accessed on September 7, 2014.
2. Dinakar C, Oppenheimer J, Portnoy J et al. Management of acute loss of asthma control in the yellow zone: a practice parameter.. Accessed on September 7, 2014.
3. National Heart, Lung, and Blood Institute. Expert Panel Report 3 (EPR3): Guidelines for the Diagnosis and Management of Asthma Accessed on September 7, 2014.