Plan prepared by Dr or Nurse
Practitioner:
Signed:
Date prepared:
Date of next review:
Emergency contact name:
Work ph:
Home ph:
Mobile ph:
ALWAYS give adrenaline autoinjector FIRST, and then asthma reliever puffer if someone with known asthma and
allergy to food, insects or medication has SUDDEN BREATHING DIFFICULTY (including wheeze, persistent cough or
hoarse voice) even if there are no skin symptoms.
Adrenaline autoinjector prescribed: Y N Type of adrenaline autoinjector:
LIFE-THREATENING
• Unable to speak
or 1–2 words
• Collapsed/exhausted
• Gasping for breath
• May no longer have
a cough or wheeze
• Drowsy/confused/
unconscious
• Skin discolouration
(blue lips)
SEVERE
• Cannot speak a full sentence
• Sitting hunched forward
• Tugging in of skin over
chest/throat
• May have a cough or wheeze
• Obvious difficulty breathing
• Lethargic
• Sore tummy (young children)
MILD TO MODERATE
• Minor difficulty breathing
• May have a cough
• May have a wheeze
• Other signs to look for:
I hereby authorise medications specified
on this plan to be administered according
to the plan
© Asthma Australia August 2019. This plan was developed as a medical document that can only be completed and
signed by the patient’s treating medical doctor or nurse practitioner and cannot be altered without their permission.
SIGNS AND
SYMPTOMS
ASTHMA FIRST AID
For Severe or Life-Threatening signs and symptoms, call for emergency assistance immediately on Triple Zero “000”
Mild to moderate symptoms do not always present before severe or life-threatening symptoms
1. Sit the person upright
Stay with the person and be calm and reassuring
2. Give separate puffs of Airomir, Asmol or Ventolin
Shake the puffer before each puff
Get the person to hold their breath for about 5 seconds or as long as
comfortably possible
3. Wait 4 minutes
If there is no improvement, repreat step 2
4. If there is still no improvement call emergency assistance
Dial Triple Zero “000”
Say ‘ambulance’ and that someone is having an asthma attack
Keep giving puffs every 4 minutes until emergency assistance arrives
Commence CPR at any time if person is unresponsive and not breathing normally.
• Remove cap from puffer and
shake well.
• Tilt the chin upward to open
the airways, breathe out
away from puffer.
• Place mouthpiece, between
the teeth, and create a seal
with lips.
• Press once firmly on puffer
while breathing in slowly
and deeply.
• Slip puffer out of mouth.
• Hold breath for 5 seconds or
as long as comfortable.
Blue/grey reliever
medication is unlikely
to harm, even if the
person does not
have asthma.
1800 ASTHMA (1800 278 462) | asthma.org.au
PHOTO
ASTHMA ACTION PLAN
Student’s name:
DOB:
Confirmed triggers:
VICTORIAN SCHOOLS
FOR USE WITH A PUFFER
Child can
self-administer
if well enough
Child needs to
pre-medicate prior
to exercise
