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Every asthma patient must have access to the best treatment in the event of an asthma emergency. This means having the right inhaler for them — and that they know how to use it.


There are typically three types of inhalers available for the estimated 5.4 million people in the UK living with asthma: pressurised metered dose inhalers (pMDI), soft mist inhalers (SMI) and dry powder inhalers (DPI).

Recently, research published in BMJ Open noted that metered dose inhalers release greenhouse gases and that patients should consider switching to DPIs, which do not release gases with global warming effects into the environment. What’s more, a 2018 report by the House of Commons Environmental Audit Committee recommended that the “NHS should set a target that by 2022 at least 50% of prescribed inhalers are low GWP (global warming potential).”

But not so fast, warns Dr Omar Usmani, Consultant, Respiratory Medicine, Royal Brompton and Imperial – London, and Chair of the UK Inhaler Group (UKIG). Dry powder inhalers might be more environmentally friendly, but children, the elderly and anyone having a severe asthma attack would find it difficult to use them — and the consequences could be tragic.

Making patient duty of care a priority

“I have real concerns about this,” he says. “A DPI relies on energy from the patient’s lung muscles to suck in the powder from the device. That won’t be possible if you’re breathing so quickly and gasping for air.” Indeed, the CRITical Inhaler mistaKes and Asthma controL (CRITIKAL) study, published in 2017, reported that 34% of current DPI users do not have sufficient inspiratory effort to actuate their DPI device. “Of course, I believe in protecting the planet,” stresses Dr Usmani. “But change needs to be done in a proper way because I have a duty of care to my patients, too.”

Dry powder inhalers might be more environmentally friendly, but children, the elderly and anyone having a severe asthma attack would find it difficult to use them — and the consequences could be tragic.

Dr Duncan Keeley, General Practitioner, Member of the UK Inhaler Group (UKIG) and Executive Committee Member of the Primary Care Respiratory Society, echoes this sentiment. “During an attack, it is also often hard to use spray inhalers well on their own without a spacer (a tube that attaches to the inhaler to make it easier to use and deliver the medication more effectively),” he says.

“Therefore, in a recent article in Lancet Respiratory Medicine, Dr Keeley and Martyn Partridge, Professor of Respiratory Medicine, Imperial College London, suggested that anyone who has had or is at risk of having an asthma attack should be given an emergency treatment pack. This would include a spacer, a ‘reliever’ pMDI, a steroid ‘preventer’ pMDI, and an advice sheet on how to use the devices in an attack and call for help.

The pack — kept for use in severe attacks only — could also be given to people who use dry powder inhalers for their regular preventer treatment. “Deaths from asthma are fortunately rare,” says Dr Keeley. “But people can and do die of asthma and it is obviously better for patients to know the best way of starting high dose inhaled treatment for a bad asthma attack — and to know that they should call for help if they are having one.”

Know how to use reliever inhalers and spacers

Sarah O’Connor, CEO of the Asthma Society of Ireland, underlines that GPs must prescribe the most appropriate inhaler treatment for the individual, and that, in an emergency, all patients should have access to, and know how to use, their reliever pMDI and spacer. “People think they know how to use them,” she says. “But Irish data indicates that 60% of patients are not using their inhaler properly. And they don’t understand the powerful impact of their own inhaler and spacer working together, and the way this can help them exit an asthma attack.”

O’Connor also cautions about making patients feel guilty about using their pMDIs in case switching to a different inhaler has serious ramifications for their health. “Patients who use inhalers mustn’t be stigmatised,” she says. “Otherwise they may be pushed into a change that might not be right for them without the appropriate support.”

Of course, it’s not just patients who need better inhaler education. Healthcare professionals need it too, notes Jane Scullion, Clinical Lead and Respiratory Nurse Consultant, University Hospitals Leicester (UHL). “Nurses, doctors and pharmacists have to know how to use inhalers if they are to assess their patients’ use properly,” she says.

Ultimately, Scullion points out that pMDI inhalers have a small carbon footprint, so change should never be undertaken lightly. “If patients are stable on their treatment, I’d be concerned about switching them. We shouldn’t change things for change’s sake.”

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UK AC 040 1219 | Date of preparation: December 2019

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