Inhalers and their carbon footprint – Blog by Aleksandra Gawliklipinski
by Aleksandra Gawlik-Lipinski
On the 7th of April, we were celebrating World Health Day, this time under the motto “Our planet, our health” and specifically raising awareness of the impact of pollution on health. World Health Organisation (WHO) reported that globally 13 million deaths are directly caused by an unhealthy environment (WHO 2022). Living in London I am acutely aware that I am inhaling a complex mixture of pollutants, with some of them being generated by the very healthcare system that I am working for. As of 2019 UK was listed as a major producer of healthcare emissions (Health Care Without harm 2019) and as stipulated in the NHS Long Term Plan (2019) the reduction of air pollution is currently on the plate.
Inhalers used in the management of respiratory diseases are one of the sources of carbon footprint. As you probably know, the commonly prescribed pressurised metered dose inhalers (pMDIs) contain a propellent hydrofluorocarbon, which is a greenhouse gas contributing to global warming. Yet, in the UK just over 70% of the prescribed inhalers are pMDIs (PrescQIPP 2021). We are unfortunately leading in that respect across Europe, even though propellent-free dry powder inhalers (DPIs) and soft mist inhalers (SMIs) have been available for a considerable time. And that is where we, respiratory practitioners, are uniquely positioned to help reduce the emissions.
Of course, we cannot change everyone using pMDI to DPI or SMI. DPI and SMI don’t suit everyone, and we must do right by the patient. I cannot emphasise enough how important it is for the patient to have a regular review, to ensure that the actual respiratory diagnosis is correct, that we check the inhaler technique and choose an inhaler that is suitable for the individual and appropriate. This includes consideration of the active substance, dosage and device. Also, we must be mindful that a large number of pMDIs are Salbutamol inhalers. If a patient’s condition is well managed they shouldn’t need more than 1 or 2 SABA inhalers per year.
In primary care, we have tools that can be used to help us change the practice. Firstly, our clinical systems (EMIS and SystmOne) allow us to easily audit prescribed medication. That permits, for instance, to identify patients who used 6 or more SABA inhalers and the ones that requested 3 or fewer ICS in the last 12 months. They will need urgent review during which there will also be an opportunity to discuss their use of inhaled therapy and a potential change to lower carbon footprint inhaler if the patient is interested. If you are not using the In-Check device, you can look at the flowchart produced by NICE to ascertain if the DPI or SMI is the right fit for your patient. It can be found here:
NICE Flowchart
At my workplace, I have also undertaken a search for specific inhalers that have a straightforward DPI equivalent. I won’t be giving inhalers’ names here, but if you use the BTS/SIGN Asthma guidance you can easily identify them in the tables compiling available inhalers. Once I had my lovely spreadsheet, I then texted the patients offering them a consultation to discuss changing to a more environmentally friendly inhaler if they are interested. It was encouraging as I had quite a positive response from many of them. Particularly young patients were almost instantly replying to my text requesting a call back to discuss the options. Few of them said how they appreciate that our practice is now so environmentally aware.
Another, rather simple thing that we can all do is to educate the patients and encourage them to safely dispose of the inhalers and not to over order inhalers. How many times have you discussed it during a consultation? I must admit that it used to slip my mind in the past. But now I do signpost them to the pharmacist and I also ensure that they are aware of how to tell if the inhaler is empty and to keep track of the number of doses they’ve taken if they use a device without a dose counter. The reality is that one can only tell that the inhaler is empty if it has a dose counter and it shows 0. For pMDIs without a dose counter the sole way to accurately tell that the inhaler is empty is to count the doses: divide the total number of doses in the device by the number of doses taken daily. This will allow us to establish for how many days the inhaler can be taken. Remember that even an empty pMDI will produce a mist of propellent but with insufficient medication, so please make sure you inform the patient about that.
And for interest only: did you know that researchers in Switzerland came up with an idea of weighing Salbutamol (specifically from GlaxoSmithKline) pMDI to establish how empty (or full) it is? You can find more details here, however, I do not recommend that method to my patients as the results were validated only on very specific scales and they apply solely to the Ventolin Evohaler available in the UK.
When I was writing this blog, PCRS just published the Greener Healthcare Quality Improvement Toolkit. This is an interesting read and a very useful document helping to review the current state of environmental affairs at our workplace, identify areas for improvement and set goals to achieve. I do recommend having a good look at the document and perhaps taking it from there?
Feel free to contact me at aleksandra.gawliklipinski@gmail.com for any questions
Health Care Without Harm (2019) Health care’s climate footprint. How the health sector contributes to the global climate crisis and opportunities for action. (Online) Available from: https://noharm-global.org/sites/default/files/documents-files/5961/HealthCaresClimateFootprint_092319.pdf Accessed 13.04.2022
NHS England (2019) NHS Long Term Plan. (Online) Available from: https://www.longtermplan.nhs.uk/wp-content/uploads/2019/08/nhs-long-term-plan-version-1.2.pdf Accessed 13.04.2022
PrescQIPP (2021) Inhaler carbon footprint. (Online) Available from: https://www.prescqipp.info/umbraco/surface/authorisedmediasurface/index?url=%2fmedia%2f5721%2f295i-inhaler-carbon-footprint-22.pdf Accessed: 13.04.2022
WHO (2022) World Health Day 2022. 7 April 2022. Our planet, our health. (Online) Available from: https://www.who.int/campaigns/world-health-day/2022 Accessed 13.04.2022