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Review inhaler technique regularly
4
When a new inhaler device has been prescribed, make sure the patient demonstrates they can use it effectively. This includes preparation of the dose, inhalation and an understanding of the dosing regimen. Inhaler technique should be checked and optimised to improve performance at every opportunity, by every member of the healthcare team. Planned reviews are an important part of this, so schedule a review four to six weeks after changing or starting a new inhaler. This could be a face-to-face or video consultation; a phone appointment may not be suitable as it limits the ability to check inhaler technique.
Prioritise the patient when considering environmental impact
5
The propellent gases used in MDIs are recognised as a significant contributor to the NHS carbon footprint 6 and, as part of the primary care network contract, the Impact and Investment Fund 7 is incentivising a move to more environmentally friendly inhalers and better disease control in England.
This needs to be done, but in a considered, personalised way, with thought given to any potential consequences for patient care. It is not appropriate to make blanket switches of patients to different inhalers. A switch from an MDI to a DPI involves different preparation and actuation of the dose and a different inhaler technique, so should only be done following consultation with the patient, with guidance and support on adjusting technique where needed.
Not all patients will find the switch to a DPI appropriate, particularly children and elderly patients, but also those who have achieved good disease control or have previously tried and failed with a DPI. Patients must be involved in the choice and supported to make an informed decision during the consultation. Most are keen to improve the environmental impact, but no one should be made to feel guilty about choice of inhaler. If not engaged in the process, a patient may decide to stop inhaled medication, with potentially serious consequences. Some may express an interest in changing to a more environmentally friendly inhaler, but this may not always be appropriate. Nurses can reassure patients that better disease control will reduce the amount of rescue medication required, reduce the need for unscheduled healthcare and improve symptoms – all of which have a beneficial environmental impact without changing the device.
A simple prescribing regimen change may reduce environmental impact
6
One way to improve the carbon footprint of inhaled medication is to use a more environmentally friendly regimen. For example, if a patient is prescribed beclomethasone 200mcg twice daily, consider using an inhaler that contains 200mcg per actuation rather than 100mcg. This will reduce the number of puffs required and the device will last longer, thus reducing the environmental impact. Although we are concerned with the effect of propellants in MDIs, there is a potential environmental impact of plastics from all devices. Better disease control with effective preventive medication will also reduce the need for rescue medication – research suggests minimising salbutamol use can reduce carbon emissions by up to 48 %. 8
Consider the environmental aspect as part of a routine review
7
Most patients with respiratory conditions will attend an appointment for a routine annual review. This always presents a good opportunity for checking and optimising inhaler technique, and is also a good time to discuss the environmental impact of inhalers if appropriate for the patient. On checking inhaler technique, you may find patients prescribed an MDI use a fast-and-hard inhalation technique more suited to a DPI, so a switch may also improve technique without the need to teach a new method.
A quality improvement tool, which includes a video consultation demonstrating how to incorporate the environmental conversation, is available from the Greener Practice initiative. ⁹
Involve the team
8Patients will see different members of the healthcare team as part of the management of their disease, so it is vital they receive a consistent message from all team members. Ideally, inhaler technique should be checked and optimised at every opportunity – patients might demonstrate good inhaler technique initially when they receive the prescription, then fall into bad habits. GPs, the practice nursing team, clinical and community pharmacists all have a part to play, but need to be able to teach and coach inhaler technique competently themselves. Share and promote the UK Inhaler Group competency document⁵ across the whole team.
Always consider spacers with MDIs
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When an MDI is the most appropriate device for the patient, the use of a spacer should be considered. Spacers can play an important part in ensuring the patient receives the maximal dose into the lungs while reducing potential side-effects from inhaled steroids resting in the mouth and throat. 10 The addition of a spacer can also help to address co-ordination with actuation.
A spacer can be prescribed with a face mask for children or adults, or with a mouthpiece. Selecting the appropriate spacer for the individual is as important as selecting the correct inhaler device.
Know where to look for help
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As well as the support mentioned above, make use of the wealth of information available online( see Resources). This includes peerreviewed patient videos for inhaler technique on the Asthma and Lung UK website, details of which can be texted to patients following their appointment to reinforce what good inhaler technique is. It is worth advising the patient to watch the videos with a relative or friend to help advise if any changes are required. The Primary Care Respiratory Society features a range of resources for clinicians, including a Greener Respiratory Pathway and Greener Healthcare Quality Improvement toolkit. These cover inhaled medication but also take a more holistic approach to delivering greener respiratory healthcare.
However, the best, most environmentally sound inhaler remains one that a patient can and will use to control their symptoms.
Carol Stonham is a senior nurse practitioner in Gloucestershire and chair of the Primary Care Respiratory Society Executive Committee
References 1 NICE CKS. What is the prevalence of asthma? 2022. bit. ly / 3M1eMl8 2 Rayner L et al. The prevalence of COPD in England: An ontological approach to case detection in primary care. Resp Med 2017; 132:217-255 3 British Lung Foundation. The battle for breath – the impact of lung disease in the UK. 2016. bit. ly / 3N1CTBC 4 Prasad S et al. Confidence and aptitude of healthcare professionals at demonstrating inhaler technique. Thorax 2018; 73( Suppl 4): A204.1-A204 5 UK Inhaler Group. Inhaler Standards and Competency Document. 2019. bit. ly / 3Gw1axf 6 Green Inhaler. Making your inhaler more environmentally friendly. greeninhaler. org 7 NHS England. Network Contract Directed Enhanced Service. Investment and Impact Fund 2021 / 22. bit. ly / 3z8wvEr 8 Pernigotti D et al. Reducing carbon footprint of inhalers: analysis of climate and clinical implications of different scenarios in five European countries. BMJ Open Resp Res 2021; 8: e001071 9 Greener Practice. High quality and low carbon asthma care. bit. ly / 3lY7kN5 10 Vincken W et al. Spacer devices for inhaled therapy: why use them, and how? Eur Respir J Open Res 2018; 4( 2): 00065-2018
Resources
• Asthma and Lung UK. asthma. org. uk
• Primary Care Respiratory Society. pcrs-uk. org /
• RightBreathe. rightbreathe. com