Dr Aarti Bansal on how promoting good asthma care not only improves health outcomes for patients but also reduces carbon emissions
Asthma care in the UK needs improvement. We have one of the highest asthma mortality rates in Europe. Over-reliance on reliever inhalers, underuse of preventer inhalers and poor inhaler technique are all common and known to be associated with poorer asthma outcomes.
The aim of asthma care is for patients to be symptom-free with no restrictions on their day-to-day activities. But unfortunately, many people with asthma continue to experience symptoms such as wheezing, coughing and chest tightness, and even avoidable asthma attacks.
Many people with asthma are over-reliant on their reliever inhalers. While these are important for temporarily opening the airways, they do not treat the underlying inflammation.
Over-reliance on reliever inhalers is associated with a much higher risk of asthma attacks and hospitalisation, and it should be suspected if a patient is needing to use their reliever inhaler three or more times a week or needs three or more reliever inhalers a year.
Inhaled corticosteroids – also known as preventer inhalers – are the main treatment for asthma. When taken every day, as prescribed, they reduce the inflammation of the airway lining and prevent symptoms and asthma attacks. Some people think we should call preventer inhalers ‘treatment’ inhalers and reliever inhalers ‘rescue’ inhalers to better communicate how they should be used.
If we can optimise asthma control, people will need fewer reliever inhalers, which would be better for patients and also the planet. Well controlled asthma has one-third of the carbon footprint of asthma that is not controlled, as fewer reliever inhalers are needed.
What type of inhaler device should be prescribed?
The other consideration for better and greener asthma care is the type of inhaler device prescribed. Asthma care in the UK is dominated by pressurised metered dose inhalers (pMDIs), also called puffers.
The UK prescribes pMDIs at a much higher rate than other European countries. In 2011, pMDIs made up 70% of UK inhaler sales compared with fewer than half in European countries and just 13% in Sweden. Our European neighbours prescribe far more dry powder inhalers (DPIs).
pMDIs have a high carbon footprint as the canisters contain powerful propellant gases, which are approximately 1,000 to 3,000 times more powerful than a carbon dioxide equivalent. This is why pMDIs are responsible for 13% of the NHS’s carbon emissions within primary care. However, DPIs do not contain propellant gases and have a much lower carbon footprint.
So, which inhaler is best? This is a shared decision with each patient and NICE’s decision aid could help with this conversation. But a good place to start would be considering what type of ‘breath in’ your patient can take. While MDIs require a slow and steady breath in and are usually best used with a spacer device, DPIs require a quick and deep breath in. Inhaler checking devices, such as the In-check dial and placebo devices, can be very useful in helping to decide the most appropriate inhaler device.
Most people with asthma can take a quick and deep breath in and I find that many patients use this technique with their pMDI, which makes them better suited to a DPI. DPIs do not require spacers and come with a dose counter, which can help people keep track of their medication use.
Many patients find DPIs easier and more convenient to use, but people who are using a pMDI effectively may still want to be offered a greener inhaler that works well for them.
Remember that a small proportion of patients cannot take the quick and deep breath in that DPIs require and should remain on pMDIs. This may include children under 12, the very elderly and those with severe asthma. For patients who need or prefer MDIs, we can still reduce the prescribing carbon footprint by optimising treatment, swapping to an equivalent MDI brand with a lower-carbon footprint and changing regimes so that fewer inhalers are needed.
Appropriately disposing inhalers is another easy way to be greener. When MDIs are put in the bin, they may end up in landfill and their greenhouse gases will be released into the atmosphere. We should therefore advise patients to return unused and unwanted inhalers to the pharmacy. Pharmacies can send inhalers for incineration, which degrades the propellant gases. And in the future, they may even be able to recycle them, too.
To get started, take a look at the Greener Practice asthma toolkit, which includes step-by-step guides and all the resources you need to implement better and greener asthma care.
Dr Aarti Bansal is a GP in Sheffield and net zero clinical lead for the Humber and North Yorkshire Health and Care Partnership. She founded the Greener Practice network in 2017