When a respiratory condition is not well controlled, it has a negative impact on an individual’s health, and the environment.

Inhalers are a key treatment for many respiratory conditions, however emissions from inhalers account for approximately 3% of the NHS carbon footprint.

Whilst carbon footprint reduction is just one aspect of clinical care and good patient outcomes, the propellant in some inhalers are powerful greenhouse gases which are responsible for most of these emissions.  These gases are harmful to our environment, pollute the air we breathe and have a detrimental impact on air quality.

Coinciding with World Asthma Day on Tuesday 2nd May, we spoke to Claire Adams, Respiratory Programme Manager at the AHSN NENC and Primary Care Clinical Lead for the Respiratory Network in the North East and North Cumbria, about how we can improve asthma care outcomes while also reducing carbon footprint and cleaning up our air.

Claire is an experienced nurse with a passion for improving the care of people with respiratory disease.  Over the 25 years of her nursing career, she has worked in the NHS,  in the private sector and as a guest lecturer in respiratory disease within a university setting. She has also worked independently to provide respiratory education to primary care teams on a local, regional and national basis.

We are all working towards a cleaner, greener NHS. The Delivering a Net Zero National Health Service report sets out some of the ambitions to help us achieve this and a commitment to reach net zero carbon emissions by 2040 for the emissions directly controlled by the NHS, and by 2045 for the emissions the NHS can influence.

In relation to asthma care, the report discusses interventions that will support a reduction in emissions from inhalers including optimising prescribing, substituting high carbon products for low-carbon alternatives, and improvements in production and waste processes.

Why is good respiratory care more important than ever?

Suboptimal respiratory disease control not only negatively impacts on a patient and their family, but also the healthcare system and the environment.

Climate change is everyone’s business and with the green agenda in mind, our beautiful region has made a commitment to work towards a net zero carbon emissions target by 2030. If we can achieve better respiratory disease control for conditions such as asthma and COPD, this can have a positive impact on the environment too.

The national and local picture for asthma care

Inhalers account for approximately 3% of all NHS carbon emissions. The carbon emissions from inhalers can mostly be attributed to the hydrofluoroalkane (HFA) propellants used in pressured metered dose inhalers (pMDIs) to deliver the drug to the lungs. In the UK, around 70% of our inhaler prescribing is for pMDIs, whereas in other EU countries, giving Sweden as an example, only 30% of their prescribing is in pMDIs, preferring to use Dry powder inhalers (DPIs) instead.  DPIs do not emit harmful greenhouse gases and so are much better for the environment.

When used or unwanted inhalers, especially pMDIs are disposed of in landfill, they can continue to leak harmful greenhouse gases into the atmosphere, polluting our air. We need to ensure that all inhalers are returned to a community pharmacy for safe disposal and this usually means that they are disposed of through high temperature incineration, which is believed to much better for the environment.

In line with national averages, the North East and North Cumbria prescribes a higher proportion of pMDIs compared to DPIs, therefore contributing to the high carbon footprint. With the national aspiration to reduce overall carbon footprint, Primary Care Network contracts now include sustainability targets for respiratory inhalers. (It’s important to note that reduction of carbon footprint is only one aspect of clinical care and good patient outcomes – there should be no blanket switching. Any device changes should be part of a clinical review with shared decision-making.)

Short acting beta agonists (SABAs) are also used for relief or rescue in conditions such as asthma and COPD, but are not the maintenance treatment which can help to control these respiratory conditions. A strong marker of poor asthma control is when someone is using their SABA more than three times per week. Some patients with COPD may be overusing their SABA, as their usual maintenance therapy should consist of long-acting bronchodilator therapy, which should reduce the need for excess SABA. 70% of the total carbon footprint of inhaler devices in the UK is represented by SABAs, and we have three times more greenhouse gas emissions than is observed in other large European countries.

The unintended consequence of poor asthma control, is that it is harmful for the environment, both from a carbon emissions point of view from inhalers themselves (pMDIs), but also the carbon emissions that result from any hospital admission.

You can read more on the impact of medicines/carbon emissions related to admission to hospital in the NICE Medicines Optimisation Sustainability report.

How are we addressing this in the North East and North Cumbria?

Our regional Respiratory Network have created a guide which aims to help NHS professionals prescribe the most appropriate inhaler for each individual patient with consideration for lower carbon options, where suitable. You can download the guide here.

At the AHSN NENC, we’re closely aligned to our regional ICS sustainability group. With their support and the support of industry partners, we are proud to be leading on a project in Middlesbrough to improve respiratory care outcomes for patients. The project involves working with GP practices and community pharmacy to identify patients who are overusing SABA, and therefore have evidence of poor disease control which can put them at risk of an asthma attack.

Patients are reviewed and their management is optimised in line with local protocols to help reduce the risk of adverse events and/or an asthma attack. When this is successfully achieved, not only is this positive for the patient, but it also benefits the healthcare system and the environment and that’s what we are hoping to demonstrate when this project concludes later this year. You can read more about this project on the AHSN NENC website, where you can also find downloadable resources to help communicate messages about returning inhalers to community pharmacies for safe disposal.

In summary

• Identifying and reviewing at risk patients will help improve outcomes in respiratory care, which will consequently have a positive impact on the environment
• Correct disposal of inhalers is an important message – return to a community pharmacy
• Think about clean air and the contributions you can make as an individual or an organisation.

Thank you for taking the time to read this and if you’ve found it helpful, pass it on!

Find out more about our North East Improving Outcomes for Respiratory Patients programme.