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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
9
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
10
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