Sustainability 3: how nurses can reduce the environmental impact of inhalers | nursing times

Inhalers, which are commonly prescribed to manage respiratory conditions, have a significant carbon footprint. This article, the third in a three-part series on sustainability, explains how

nurses can help to minimise the negative environmental impact of these devices ABSTRACT Although inhaler devices are important in managing respiratory conditions, they have a significant

carbon footprint and contribute to climate change. This article – the last in a three-part series on sustainability – explains how inhalers affect the environment and how nurses can help to

reduce their negative impact, while maintaining patient safety and outcomes, through device selection and patient education on their use. CITATION: SCULLION J (2020) Sustainability 3: how

nurses can reduce the environmental impact of inhalers. _Nursing Times _[online]; 116: 9, 38-40. AUTHOR: Jane Scullion is consultant respiratory nurse, University Hospitals of Leicester NHS

Trust. * This article has been double-blind peer reviewed * Scroll down to read the article or download a print-friendly PDF here (if the PDF fails to fully download please try again using a

different browser) * Click here to see other articles in this series INTRODUCTION Many of our everyday actions have a carbon footprint – meaning they cause carbon dioxide (CO2) to be

released into the atmosphere – and, therefore, contribute to climate change. Driving to work, using a refrigerator, flying to go on holiday, eating meat, using aerosols, plastics waste, and

heating and cooling our houses all come with a carbon footprint. We can also have a negative impact on the environment at work – the NHS has a large carbon footprint. Pressurised

metered-dose inhalers (pMDIs), which are commonly prescribed to people with respiratory conditions such as asthma and chronic obstructive pulmonary disease (COPD), are a significant

contributor to the NHS’s carbon footprint. Both the production and disposal of pMDIs have a carbon footprint, while the propellants used to deliver the drug to patients are fluorinated gases

(F-gases); known as ‘greenhouse gases’, these also contribute to climate change. This article aims to raise nurses’ awareness of how inhalers affect the environment and consider the scale

of the issue, the alternatives and the nurse’s role. It also explores the challenges and practicalities of responding to the House of Commons Environmental Audit Committee’s (2018) target of

a 50% reduction in the global warming potential (GWP) of pMDIs by 2022. WHAT IS GLOBAL WARMING? Global warming occurs when CO2 and other air pollutants and greenhouse gases collect in the

atmosphere and absorb sunlight and solar radiation that have bounced off the earth’s surface. Normally this radiation would escape into space, but these pollutants – some of which can remain

in the atmosphere for centuries – trap the radiation and increase the global temperature; this is known as the ‘greenhouse effect’ (MacMillan, 2016). Global warming increases the risk of

drought, wildfires and heatwaves, and changes rain and snow patterns, causing less snow and ice, stronger storms and flooding. Warmer oceans and melting glaciers; changes in plant and animal

lifecycles result in the extinction of some species, the possibility of new pests, and more asthma, allergies and infectious disease outbreaks (MacMillan, 2016). The standard unit for

measuring a carbon footprint is CO2-equivalent: each greenhouse gas is calculated in terms of the amount of CO2 that would create the same amount of GWP. A carbon footprint can stem from

CO2, methane, nitrous oxide and also the F-gases used in pMDIs. INHALERS AND THE ENVIRONMENT The most commonly prescribed inhaler in the UK is the pMDI, followed by the dry-powder inhaler

(DPI), then a small proportion of other types such as the soft-mist inhaler (SMI). It is commonly stated that >65 million inhalers are prescribed every year in the UK (Public Health

England and NHS England, 2018); however, the HCEAC’s (2018) parliamentary report states that the PHE and NHSE gave an annual figure of 35 million pMDIs and 15 million DPIs, and it is

unlikely that other devices accounted for the remaining 15 million. The F-gas used in pMDIs accounts for only a very small proportion of the global use of F-gas; the majority is used in

refrigeration, fire extinguishers and air-conditioning equipment. However, the impact of the propellant gases released from inhaler use each year in England is estimated to be equivalent to

around 850,000 tonnes of carbon emissions; this is comparable to the annual carbon emissions of all NHS road mileage in England, including business travel and emergency vehicles, or the

carbon footprint of a small country (PHE and NHSE, 2018). A typical pMDI with 10g of propellant can have a carbon footprint of 13-33kg, depending on the type of propellant. This is estimated

to be the equivalent of driving an average car for 45-115 miles, depending on inhaler type (Department for Business, Energy and Industrial Strategy, 2018; PHE and NHSE, 2018). > _“A 

typical pMDI with 10g of propellant can have a carbon > footprint equivalent to driving an average car for 45-115 miles”_ ADVANTAGES AND DISADVANTAGES OF THE ALTERNATIVES Alternatives to

pMDIs are DPIs and SMIs, which do not include F-gases. However, inhalers are not interchangeable and the delivered dose of medication varies between types: one device should not be switched

for another on the basis of pharmaceutical drug dose equivalence, as the engineering characteristics and formulation properties of an inhaler determine the actual dose that reaches the lungs

(Usmani et al, 2019). The inspiratory flow rate necessary to deliver the medication to the lungs also differs between inhalers and – while errors are common with all inhalers – if patients

cannot achieve a sufficient inspiratory flow rate, they cannot activate a DPI. Even if a patient is able to inspire with sufficient effort to activate a DPI, good practice requires a

face-to-face review before any change of device, which comes with its own costs. Any change must also be safe for the patient and made with their consent. The disadvantages arising from

switching inhaler type on non-medical grounds without the patient’s consent can lead to: * A deterioration of disease control; * Increased symptoms; * An increase in the use of healthcare

resources (Melani and Paleari, 2016; Björnsdóttir et al, 2013). Studies also show that stable patients receiving pMDI maintenance treatment for asthma and COPD achieve better health outcomes

than those receiving the same drug through a DPI (Jones et al, 2017; Price et al, 2011). The pMDI is the most commonly prescribed inhaler type for a number of reasons. It is the most

commonly used reliever inhaler containing salbutamol which gives emergency relief during an asthma attack, and can be used with a spacer, which can make it easier for users to inspire the

right amount of medicine. PMDIs are often the only licensed inhaler type for children of certain ages and are commonly prescribed for older people who may have insufficient inspiratory flow

to activate a DPI. For these patients, there are currently no alternatives to pMDIs. Levy et al (2019) argued that the intervention that would make the biggest difference in reducing the

overall GWP of respiratory treatments would be to improve overall standards of care for people using inhalers, reducing wasted resources and improving health outcomes. This requires nurses

to consider, not just the issues of propellants and plastic waste, but also the potential waste and environmental damage caused by poorly managed asthma and COPD. These can lead to time off

school or work, unnecessary use of emergency healthcare, and more trips to GP surgeries and hospitals. Resources would be saved if nurses taught patients more about effective

self-management, both for routine treatment and exacerbations (Levy et al, 2019). Evidence suggests that the correct delivery of drugs by an inhaler device, which a patient can use

efficiently and reliably improves symptoms and quality of life, and reduces morbidity, mortality and hospital acute care costs (Lavorini et al, 2008; Melani and Paleari, 2016; Press et al,

2011). Usmani et al (2019) also discussed reducing the impact of inhalers on climate change through more general measures (Box 1). BOX 1. HOW TO REDUCE INHALERS’ ENVIRONMENTAL IMPACT *

Primary prevention * Reduce over-prescribing, especially of short-acting beta-agonist (SABA) inhalers * Promote adherence * Train health professionals in device use Source: Usmani et al

(2019) Industry has a role too in reducing the carbon footprint of inhalers: the development of inhaler propellants that have a lower impact on climate change should be considered alongside

innovation in device efficiency (Usmani et al, 2019). For example, producing inhalers that can be reused for longer would reduce the carbon footprint of manufacturing, packaging and waste. 

Recycling of inhalers is also important. THE NURSE’S ROLE Nurses – often the patient’s advocate and the health professional most often involved in inhaler choice – should never switch an

inhaler type without consulting the patient. Usmani et al (2019) stated that switching a patient’s inhaler(s) without consent may: * Increase symptoms; * Reduce good disease management; *

Damage the relationship between the patient and the health professional; * Increase the use of resources; * Waste medication. Before considering any change of device, nurses should assess

the patient’s current inhaler technique to ensure it is being used correctly, as errors in technique are common. This should be assessed alongside the patient’s current level of symptom

control. If inhaler technique and symptom control are good, it would be difficult to justify a change in inhaler. The Royal College of Physicians (2015) highlighted an overreliance on SABA

inhalers as an important factor in asthma deaths. It is important that nurses: * Consider overall inhaler use; * Ensure patients understand their corticosteroid inhaler used to prevent

inflammation is the most important inhaler. This includes explaining the risks of overreliance on their SABA inhaler and how only using it when necessary could also help to reduce the

overall carbon footprint of pMDIs. Nurses could discuss with asthma patients the option of using a combination inhaler containing formoterol and inhaled corticosteroid; this can be used as

both a maintenance and reliever treatment, and reduces the need for a SABA inhaler. However, combination inhalers containing salmeterol or vilanterol cannot be prescribed in this way, as

these drugs are not fast-acting. There are also cumulative effects of additional salmeterol including: * Chest pain or tightness; * Confusion; * Decreased urine output; * Dry mouth; *

Feeling faint or lightheaded when getting up suddenly from a lying or sitting position; * General feeling of discomfort or illness; * High blood pressure; * Loss of appetite; * Mood changes;

* Nervousness. We do not know if these effects apply to vilanterol as the drug is only licensed in combination with fluticasone, but it is likely because of a similar dose–response curve

(Lötvall, 2001). Nurses can ensure the minimal number of inhalers are prescribed to deliver the required medication; additionally stratifying devices to the same ‘type’ helps, so different

inspiratory flow rates are not required for the different inhalers. The use of multiple respiratory inhalers has been shown to have an adverse effect on COPD outcomes (Bosnic-Anticevich et

al, 2016). SABA pMDIs are the most commonly prescribed inhalers used to relieve symptoms and exacerbations; nurses can consider prescribing the smaller-volume hydrofluoroalkane (HFA) 134a

inhalers (for example, Salamol) in preference to larger-volume or HFA227ea-containing inhalers (for example, Ventolin). Larger inhalers are associated with almost double the GWP compared

with smaller devices (Janson, 2020), so offering pMDIs requiring fewer actuations (or puffs) per dose can help reduce the overall GWP load. Prescribing inhalers with visible dose meters, or

ensuring patients whose inhalers do not have this feature know how many doses their inhaler contains, helps them to avoid running out or throwing away half-full inhalers. pMDIs are often

returned or replaced without all the doses being taken – indeed, many are returned half full (Conner and Buck, 2013). Encouraging patients to return used inhalers to pharmacies for proper

disposal would also help – some propellant remains in pMDIs when they are finished and this could be recycled. Perhaps most important for nurses is to ensure patients requiring an inhaler do

not feel stigmatised or blamed for the environmental footprint of taking what, for them, is a necessity not a luxury. Long-term conditions can be difficult enough for patients to deal with,

without them also being made to feel responsible for global warming. CONCLUSION All inhalers have a carbon footprint associated with their manufacture, packaging, emissions from F-gases,

and ultimate disposal into landfill or through recycling. As they constitute around 0.1% of the UK’s total carbon footprint, considering their appropriate prescription can have a positive

impact – however, non-prescription should not be at the expense of patient safety or choice (HCEAC, 2018). Nurses need to consider many factors when selecting the most appropriate medication

and inhaler device. Where clinically appropriate, they may offer lower-carbon options, but it is crucial to ensure the selected device is suitable for the individual patient’s needs, both

when they are well and during an exacerbation. Any change should not just be based on the cost of the device and its effect on the environment, but also on the cost to the healthcare system,

and with each patient’s safety and best interests at heart (Bjermer, 2014). KEY POINTS * The production and disposal of inhaler devices contribute to the NHS’s carbon footprint *

Propellants used in pressurised metered-dose inhalers – the most commonly prescribed inhaler type – are greenhouse gases * Inhalers are not interchangeable, as different characteristics

influence the dose of drug delivered to the lung * Device selection should be based on patient needs and safety rather than environmental concerns * Patient education can help to reduce

inappropriate use of inhalers ALSO IN THIS SERIES * Declaration of interests: Jane Scullion is director of education for UK Inhaler Group, a member of the Aerosol Drug Management Improvement

Team (ADMIT), and has worked with or received support from Boehringer Ingelheim, Teva, Nursing in Practice, the Association of Respiratory Nurse Specialists, Napp Pharmaceutical Group,

Chiesi and the Monthly Index of Medical Specialities. This article was initiated and written independently. REFERENCES BJERMER L (2014) The importance of continuity in inhaler device choice

for asthma and chronic obstructive pulmonary disease. _Respiration_; 88: 4, 346-352. BJÖRNSDÓTTIR US ET AL (2013) Potential negative consequences of non-consented switch of inhaled

medications and devices in asthma patients. _International Journal of Clinical Practice_; 67: 9, 904-910. BOSNIC-ANTICEVICH S ET AL (2016) The use of multiple respiratory inhalers requiring

different inhalation techniques has an adverse effect on COPD outcomes. _International Journal of Chronic Obstructive Pulmonary Disease_; 12: 59-71. CONNER JB, BUCK PO (2013) Improving

asthma management: the case for mandatory inclusion of dose counters on all rescue bronchodilators. _Journal of Asthma_; 50: 6, 658-663. DEPARTMENT FOR BUSINESS, ENERGY AND INDUSTRIAL

STRATEGY (2018) _Greenhouse Gas Reporting: Conversion Factors 2018_. London: DBEIS. HOUSE OF COMMONS ENVIRONMENTAL AUDIT COMMITTEE (2018) _UK Progress on Reducing F-Gas Emissions: Fifth

Report of Session 2017-2019_. London: HCEAC. JANSON C ET AL (2020) Carbon footprint impact of the choice of inhalers for asthma and COPD. _Thorax_; 75: 1, 82-84. JONES R ET AL (2017) The

comparative effectiveness of initiating fluticasone/salmeterol combination therapy via pMDI versus DPI in reducing exacerbations and treatment escalation in COPD: a UK database study.

_International Journal of Chronic Obstructive Pulmonary Disease_; 12: 2445-2454. LAVORINI F ET AL (2008) Effect of incorrect use of dry powder inhalers on management of patients with asthma

and COPD. _Respiratory Medicine_; 102: 4, 593-604. LEVY ML ET AL (2019) Inhaler devices and global warming: flawed arguments. [Letter] _BMJ Open_. 7 November. LÖTVALL J (2001)

Pharmacological similarities and differences between beta2-agonists. _Respiratory Medicine_; 95: Suppl B, S7-S11. MACMILLAN A (2016) _Global Warming 101_. nrdc.org, 11 March. MELANI AS,

PALEARI D (2016) Maintaining control of chronic obstructive airway disease: adherence to inhaled therapy and risks and benefits of switching devices. _Journal of Chronic Obstructive

Pulmonary Disease_; 13: 2, 241-250. PRESS VG ET AL (2011) Misuse of respiratory inhalers in hospitalized patients with asthma or COPD. _Journal of General Internal Medicine_; 26: 6, 635-642.

PRICE D ET AL (2011) Device type and real-world effectiveness of asthma combination therapy: an observational study. _Respiratory Medicine_; 105: 10, 1457-1466. PUBLIC HEALTH ENGLAND AND

NHS ENGLAND (2018) _Reducing the Use of Natural Resources in Health and Social Care: 2018 Report_. Cambridge: Sustainable Development Unit. ROYAL COLLEGE OF PHYSICIANS (2015) _Why Asthma

Still Kills: The National Review of Asthma Deaths (NRAD)_. London: RCP. USMANI OS ET AL (2019) Our planet or our patients: is the sky the limit for inhaler choice? _Lancet Respiratory

Medicine_; 7: 1, 11-13.