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Green with Asthma

Neal Tucker - 15 Aug, 2019

How can I be more green? Cycle to work? No more steak? Stop my inhaler…?

Many us of are becoming more carbon-conscious. Whether this means cutting down on red meat (turns out the vegans were right all along), using the car less (until we can actually afford a Tesla), or camping in a soggy British field for the summer holiday instead of getting on a plane (which may actually be preferable to managing small children in an enclosed space at 10,000ft), there is more that most of can do.

But if you have asthma, how should you react to the recommendation in the latest BTS / SIGN guideline on asthma management to use inhalers with a low-global warming potential? BTS and SIGN are not alone here. In April NICE also made similar recommendations. While it made the headlines, it seems to have passed by clinicians leaving many patients somewhat confused.

Context is useful. BTS / SIGN quotes that 3.5% of the total NHS carbon footprint comes from metered dose inhalers. Sounds small but that’s significant for such a tiny part of all the NHS does. MDI devices were banned from using CFCs in the early 2000s, replaced with HFAs. Turns out that these hydrofluoroalkane propellants also have “high global warming potential”. A single inhaler has the same carbon footprint as driving a car for 180miles. Of course there are simple alternatives – dry powder inhalers have 25x less carbon footprint than MDIs or breath-actuated inhalers.

So, what’s stopping us? The biggest barrier is familiarity. Clinicians have spent decades with the good old “blue inhaler” and when we talk about treating asthma most of us describe using a MDI. Likewise for patients, even with no personal history of asthma or inhaler use, consider this to be what an inhaler to be. The image of an asthmatic squeezing their inhaler, its iconic puff, the sharp breath in, is ingrained in pop culture. 

However, patients can be flexible – most would be happy to try something different and given the relevant information many would be doubly keen to. So now is the time for us to educate ourselves a bit more on the plethora of options at our fingertips. The good news is while there is a confusing array of different inhalers on the market, there are also excellent resources to help. is a fantastic UK website produced by a handful of London pharmacists and doctors. It has details of every available asthma and COPD inhaler in the UK, allows each searching for type (e.g. short-acting beta agonist, LABA/LAMA combination, etc.) and has handy instructional videos for patients (and clinicians if you wish).

NICE has produced a useful PDF patient decision aid (which only comes in at 14 pages in total, pretty restrained for NICE) which has a neat flow chart for clinicians and patients to guide on which type of inhaler might be best for them, with clear information about the relative merits of each type, including a discussion on the environmental impacts of each.

For further information, Asthma UK is a veritable font of knowledge with lots of instructional resources for ensuring good inhaler technique.

Blanket switching, of course, is not recommended. Dry powder inhalers will not be appropriate for everyone, particularly patients who cannot take a quick, deep breath in for 2-3 seconds. And while there is a small chance it could alter a person’s asthma control on a reassuring note other countries have much lower rates of MDI use – 10-30% in Scandinavia versus 70% in the UK – and their asthma outcomes are certainly not worse than here. Time for a change?

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