Dr Anna Murphy
Consultant Respiratory Pharmacist, University Hospitals of Leicester NHS Trust. Respiratory Integrated Care Pharmacist, Leicestershire Partnership Trust (Honorary)
Bev Bostock RGN MSc MA QN
Advanced Nurse Practitioner in Gloucestershire, Editor in Chief Practice Nurse Journal & Asthma Lead for Association of Respiratory Nurse Specialists
Finding the right inhaler for each patient is crucial, so is considering the environmental impact.
The right choice of inhaler for a patient is critical for successful treatment. The decision, in discussion with healthcare professionals, can also consider health economics, environmental impact, inhaler type and medication.
Inhalers are fundamental elements of the treatment for conditions such as asthma or COPD (Chronic Obstructive Pulmonary Disease).
By picking the right inhaler, with the correct medication and an understanding of its usage, there may be increased patient adherence to the treatment, improved outcomes and cost-effective control of a condition.
The most commonly used inhalers, pressurised metered dose inhalers (pMDIs), still use greenhouse gases called hydrofluoroalkane, which contain HFCs (hydrofluorocarbons) as a propellant to push the medication out of the inhaler. Five doses from a pMDI have a global warming potential equivalent to a nine-mile car trip, with each dose having an estimated carbon footprint of up to 500g of carbon dioxide and emitting up to 36kg of CO2 in its lifetime.1
Propellant-free inhaler models, which have been available since the 1990s, are dry powder inhalers (DPIs) that deliver powdered medication, with the active ingredient expressed without a propellant.
DPIs can significantly diminish the climate impact, with lifecycle emissions 10-37 times lower than pMDIs.
As part of a drive to be net carbon zero by 2040, NHS England is supporting a move from MDI to DPI.2
Anna Murphy, a consultant respiratory pharmacist at University Hospitals of Leicester NHS Trust says: “There seems to be a great benefit to the environment by switching to a dry powder and potentially cost savings for the NHS, but we can’t just blanket switch patients to DPIs because we need to make sure patients are aware of what we’re doing and that they’re happy to make that switch.”
Not all inhalers are the same, with different techniques regarding the type of breath required, process to prepare the inhaler and also the carbon footprint. Engaging with patients and helping them make an informed choice about these factors is important.
Murphy says: “With over 20 different inhaler devices on the UK market, this process has become complicated for us as healthcare professionals and for patients.
“Getting patients to use their device correctly will also reduce unnecessary escalation of treatments.”
From an NHS perspective this cuts down unnecessary drug usage, with some £300 million worth of medicines being wasted each year.”
Opting for a ‘green’ inhaler could be a factor in the patient choice, though health professionals underline the importance that clinical need must come first. “The green agenda is something we need to take on board, but we should see it as an opportunity to also improve inhaled treatment to make sure we have the right device for the patient at the right time” says Murphy.
From an NHS perspective this cuts down unnecessary drug usage, with some £300 million worth of medicines being wasted each year.
Working with patients
There has been a 17% increase in the age standardised asthma death rate in the last six years in the UK. There are many reasons for this that include patients missing asthma reviews and not taking their medication as prescribed.3 Engaging with patients and asking questions to understand their knowledge of their condition and treatments could help.
“As clinicians, we need to discover what a patient knows about asthma and inhalers. If we started our consultations with these types of questions, we’d get far better outcomes, as we know adherence to treatment is a major issue with asthma care” says nurse practitioner Bev Bostock, who is also asthma lead for the Association of Respiratory Nurse Specialists. Furthermore, a patient being trained to use their inhaler properly is vital.
“If we don’t get that right, it doesn’t matter what drug we’re trying to deliver as it won’t get to the right area to make an impact,”
 Wilkinson AJK, Braggins R, Steinbach I, et alCosts of switching to low global warming potential inhalers. An economic and carbon footprint analysis of NHS prescription data in EnglandBMJ Open 2019;9:e028763. doi: 10.1136/bmjopen-2018-028763
 Royal College of Physicians. Why asthma still kills: the National Review of Asthma Deaths (NRAD) Confidential Enquiry report. London: RCP, 2014. Available at: http://bit.ly/1MhFvqv; SuissaS et al.N EnglJ Med 2000; 343: 332–6.