Patient's Clinic Number

Patient Name

Patient Address

Age: 00 Y, Sex: M/F/Other Birth date: 00/00/0000

Page 1 of 2

Respiratory Care Action Plan

Pediatric Pulmonology

Provider: RRT Service Date/Time:

Green Zone Stable (no new symptoms)

If you are:

• Comfortable with your symptoms

• Able to do usual daily activities

• In usual state of health

  
  

  15 − 30 minutes before exercise or activities generally causing shortness of breath take puffs of

  Take daily medications
  Medication	Dose	Times / Day
  Xopenex		With IPV and as needed
  hypertonic saline		with IPV and as needed
  0.9% saline		as needed

  Airway Clearance

  IPV via mask, 5 settings X5 minutes each, easy to hard. Do not let the IPV neb cup run dry. This followed by cough assist, +/− 40, i−time is 2.0 s, e−time is 1.5, Cough−Trak is on, 5 sets of 5 breats − ending on inspiration. Then lung expansion, +/− 40, i−time 2.0, e−time 0, Cough−Trak on. Perfrom this regimen once per day with nebs when well.

  Yellow Zone Acute (start of new symptoms)

  Increased symptoms requiring additional treamtent:

• Increased shortness of breath

• Increased wheezing/cough

• Change in sputum/tracheal secretions, volume, color or character

• Oxygen saturations below baseline

  Continue daily medications and add or increase the following

  Medication	Dose	Times / Day
  Xopenex		With IPV and as needed
  hypertonic saline		With IPV and as needed
  0.9% saline		as needed

  Airway Clearance

  IPV via mask, 5 settings X5 minutes each, easy to hard. This followed by cough assist, +/− 40, i−time is 2.0 s, e−time is 1.5, Cough−Trak is on, 5 sets of 5 breats − ending on inspiration. Then lung expansion, +/− 40, i−time 2.0, e−time 0, Cough−Trak on. Perfrom this regimen three to four per day with nebs when ill.

  	Add antibiotic		mg		times per day for		days
  	Add or increase Prednisone			mg		times per day for		days

  
  

  Red Zone Severe (worsening of symptoms that additional treatment does not relieve)

  Severe symptoms requiring immediate medical care :

• No improvement after yellow zone treatment

• Worsening shortness of breath, wheezing or cough

• No improvement in oxygen saturation

• Signs of increased respiratory distress: nasal flaring, chest retractions, abdominal (belly) breathing

Seek emergency care or call 911.

During clinical hours (8 a.m. to 5 p.m.) call 555-555-5555

After hours call 507−284−2511 and ask to speak with the pediatric pulmonologist on call.

O Additional Instructions

Patient Clinic Number

Patient Name

Patient Address

Age: 00 Y, Sex: M/F/Other Birth date: 00/00/0000

Page 2 of 2

Respiratory Care Action Plan

Pediatric Pulmonology

Provider: RRT Service Date/Time:

Authorization *Authorization for Administration of Medication Away from Mayo Clinic *

This authorization is provided by patient’s prescribing health professional to administer the prescribed medication in the event of medical need as directed in this Respiratory Care Action Plan

This consent may supplement the school or daycare’s consent to give medicine and allows my child’s medicine to be given at school/daycare or school/daycare−related events.

Parent / Guardian Signature Date

Parent / Guardian Signature Date

Printed Date, RRT Performed at Mayo Clinic