The “Rule of Two” is a guideline for managing asthma symptoms. If a person needs to use their quick-relief inhaler more than twice per week, or if they wake up at night due to asthma symptoms more than twice per month, they should make an appointment with a healthcare professional.

The Rule of Two is a helpful tool for people with asthma to track their symptoms and take proactive steps to manage their condition.

By following this rule, people with asthma can catch changes in their symptoms early on and work with their doctor to make necessary adjustments to their treatment plan.

This article covers the basics of the Rule of Two and how it can help people with asthma manage their symptoms more effectively.

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The Rule of Two is an easy-to-remember asthma assessment tool that aims to help people with asthma quickly determine if they need to alter their treatment plan.

According to the Rule of Two, a person should schedule an appointment with their doctor to review their asthma treatment plan if they do one or more of the following:

  • use their quick-relief inhaler (rescue inhaler) more than twice per week
  • wake up in the middle of the night more than twice per month with symptoms of asthma, such as:
    • coughing
    • wheezing
    • shortness of breath
  • refill their quick-relief inhaler more than two times per year

It is important to note that the Rule of Two is a basic guideline. Each person should have an individualized asthma management plan according to their needs and medical history in consultation with their doctor.

Learn more about asthma symptoms here.

Alongside following the Rule of Two, people with asthma should have an asthma action plan to manage their symptoms and respond to sudden flare-ups.

An asthma action plan is a written plan or worksheet that outlines what a person with asthma should do in different situations to manage their symptoms and prevent asthma attacks.

Every asthma action plan includes the following information.

General information

This section of the plan includes basic information about the person, including but not limited to:

  • factors that trigger their asthma symptoms
  • a list of medications they take to treat their condition
  • emergency contact information, such as the person’s doctor and local emergency services

Some plans may also include information about the person’s peak flow measurements and how to use a peak flow meter.

Asthma zones

Asthma action plans have three zones of asthma control, with an outlined plan of care for each.

In the green zone, asthma symptoms are well under control. A doctor may recommend baseline medications, which can include daily controller medications, to maintain control.

In the yellow zone, symptoms are more frequent or are at risk of becoming more frequent, indicating that a person should improve control with a modified medication plan, usually with the use of immediate relief medications when they need them.

In the red zone, symptoms are severe, indicating a need for immediate-relief medications as well as urgent medical attention.

Medication breakdown

In addition to a person’s asthma zones, their asthma action plan will also include a list of medications they should take and when to take them on the basis of their zone.

These medications include long-term control medicines or controllers and quick-relief medications or rescue medications.

Learn more about asthma medications here.

Emergency instructions

The asthma action plan should also include instructions for a severe asthma attack.

These can consist of steps to take before calling emergency services and how to use an epinephrine auto-injector if the person also has a severe allergy.

A person with asthma should share their action plan with their family, friends, and coworkers to ensure they receive support and assistance when they need it.

Learn more about asthma action plans here.

Asthma control tests are another way of assessing a person’s control of asthma symptoms.

These tests are usually simple questionnaires that measure various aspects of asthma, such as:

  • breathing difficulty
  • nighttime awakenings due to asthma symptoms
  • use of rescue inhalers
  • limitations on daily activities

Common asthma control tests include the Asthma Control Test and the Childhood Asthma Control Test.

Learn more about asthma control tests here.

Here are some answers to common questions about asthma.

Can you use an albuterol nebulizer every 2 hours?

A person should only use their albuterol nebulizer according to their doctor’s direction.

The average dosage for adults and children older than 12 is 2.5 milligrams (mg) of albuterol solution that a person administers 3–4 times daily.

Learn more about albuterol nebulizers here.

How many times can I use my albuterol inhaler in one day?

The number of times a person can use their albuterol inhaler in one day varies depending on the severity of their symptoms and the doctor’s instructions.

Typically, a person should not exceed more than 4 inhalations within 24 hours. In the case of an asthma attack, a person can take up to 10 inhalations.

If a person feels they need their rescue inhaler, they should definitely use it. However, if they are experiencing asthma symptoms frequently enough that they are using more than 4 inhalations in a day, this indicates that they are not adequately controlling their asthma. In this case, a person should discuss their care needs with a doctor to improve asthma control.

What happens if you take too much albuterol?

Taking albuterol can lead to adverse side effects, such as tremors, palpitations, and increased heart rate.

If these side effects do not subside within 30 minutes to a few hours after using albuterol, a person should contact a doctor as soon as possible.

Additionally, a person should get emergency help if they experience any signs of an allergic reaction, such as hives, difficulty breathing or swallowing, and swelling of the face, lips, tongue, or throat.

The Rule of Two can be a helpful reminder for people with asthma to keep track of their symptoms and seek medical attention if they are not in control of their asthma.

However, each person should have an individualized asthma management plan according to the severity of their symptoms and the guidance of their doctor. A person should contact their doctor if they have concerns about their asthma symptoms or current treatment plan.