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On demonstrating her inhaler technique, she uses a quick and deep inhalation with her pressurised metered dose inhaler and does not use her spacer device. Asthma is one of the most common non-communicable diseases and carries a substantial morbidity and mortality burden worldwide.1 A cross-sectional study from 17 countries carried out by the Global Asthma Network in 2022 found that about 7% of adults were affected by asthma symptoms that were not well controlled, resulting in a high burden of preventable symptoms, restrictions on activity, and an increased risk of asthma attacks.2 Sub-optimally …" /> <meta name="DC.Contributor" content="Aarti Bansal" /> <meta name="DC.Contributor" content="Lauren Franklin" /> <meta name="DC.Contributor" content="Helen Twohig" /> <meta name="article:published_time" content="2024-09-20" /> <meta name="article:section" content="Practice" /> <meta name="citation_title" content="Optimising inhaled therapy for patients with asthma" /> <meta name="citation_journal_title" content="BMJ" /> <meta name="citation_publisher" content="British Medical Journal Publishing Group" /> <meta name="citation_publication_date" content="2024/09/20" /> <meta name="citation_mjid" content="bmj;386/sep20_3/e080353" /> <meta name="citation_id" content="386/sep20_3/e080353" /> <meta name="citation_public_url" content="https://www.bmj.com/content/386/bmj-2024-080353" /> <meta name="citation_abstract_html_url" content="https://www.bmj.com/content/386/bmj-2024-080353.abstract" /> <meta name="citation_full_html_url" content="https://www.bmj.com/content/386/bmj-2024-080353.full" /> <meta name="citation_pdf_url" content="https://www.bmj.com/content/bmj/386/bmj-2024-080353.full.pdf" /> <meta name="citation_issn" content="1756-1833" /> <meta name="citation_journal_abbrev" content="BMJ" /> <meta name="citation_doi" content="10.1136/bmj-2024-080353" /> <meta name="citation_pmid" content="39304315" /> <meta name="citation_volume" content="386" /> <meta name="citation_article_type" content="Other" /> <meta name="citation_section" content="Practice" /> <meta name="citation_author" content="Aarti Bansal" /> <meta name="citation_author_institution" content="Humber and North Yorkshire Integrated Care Board, Willerby HU10 6DT, UK" /> <meta name="citation_author" content="Lauren Franklin" /> <meta name="citation_author_institution" content="School of Medicine, Keele University, Keele ST5 5BG, UK" /> <meta name="citation_author" content="Helen Twohig" /> <meta name="citation_author_institution" content="School of Medicine, Keele University, Keele ST5 5BG, UK" /> <meta name="citation_reference" content="Global Asthma Network. 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She says her asthma is well controlled, but she has been issued two inhaled corticosteroid (ICS) preventer inhalers and six short acting beta agonist (SABA) reliever inhalers in the past year. On further questioning, she says that she limits her exercise because this brings on her asthma symptoms, and she experiences occasional night-time waking with cough. She describes irregular use of her ICS preventer inhaler, especially during the summer months, and almost daily use of her SABA reliever inhaler. On demonstrating her inhaler technique, she uses a quick and deep inhalation with her pressurised metered dose inhaler and does not use her spacer device. Asthma is one of the most common non-communicable diseases and carries a substantial morbidity and mortality burden worldwide.1 A cross-sectional study from 17 countries carried out by the Global Asthma Network in 2022 found that about 7% of adults were affected by asthma symptoms that were not well controlled, resulting in a high burden of preventable symptoms, restrictions on activity, and an increased risk of asthma attacks.2 Sub-optimally …" /> <meta name="og-title" property="og:title" content="Optimising inhaled therapy for patients with asthma" /> <meta name="og-url" property="og:url" content="https://www.bmj.com/content/386/bmj-2024-080353" /> <meta name="og-site-name" property="og:site_name" content="The BMJ" /> <meta name="og-description" property="og:description" content="### What you need to know A 30 year old woman attends her general practice for her annual asthma review. She says her asthma is well controlled, but she has been issued two inhaled corticosteroid (ICS) preventer inhalers and six short acting beta agonist (SABA) reliever inhalers in the past year. On further questioning, she says that she limits her exercise because this brings on her asthma symptoms, and she experiences occasional night-time waking with cough. She describes irregular use of her ICS preventer inhaler, especially during the summer months, and almost daily use of her SABA reliever inhaler. On demonstrating her inhaler technique, she uses a quick and deep inhalation with her pressurised metered dose inhaler and does not use her spacer device. Asthma is one of the most common non-communicable diseases and carries a substantial morbidity and mortality burden worldwide.1 A cross-sectional study from 17 countries carried out by the Global Asthma Network in 2022 found that about 7% of adults were affected by asthma symptoms that were not well controlled, resulting in a high burden of preventable symptoms, restrictions on activity, and an increased risk of asthma attacks.2 Sub-optimally …" /> <meta name="og-type" property="og:type" content="article" /> <meta name="og:image" property="og:image" content="https://www.bmj.com/sites/default/files/highwire/bmj/387/8449.cover-source.jpg"/> <meta name="twitter:card" content="summary_large_image"><meta name="twitter:image" property="twitter:image" content="https://www.bmj.com/sites/default/files/sites/defautl/files/attachments/bmj-article/2024/09/asthma_inhaler_2.jpg"><meta name="twitter:title" content="Optimising inhaled therapy for patients with asthma" /><link rel="alternate" 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class="block block-system clearfix"> <div class="panel-display" > <div class="hero"> <div class="hero-wrapper"> <div class="hero-content" style="position: relative; left: 0px; top: 35.5px;"> </div>  </div>  </div>  <div class="row"> <div class="left-content col-xs-12 col-sm-8 col-md-8 col-lg-8"> <article> <div class="panel-pane pane-highwire-article-citation" > <div class="pane-content"> <div class="highwire-article-citation highwire-citation-type-highwire-article node1101129" data-node-nid="1101129" id="node-1101129--2330585692" data-pisa="bmj;386/sep20_3/e080353" data-pisa-master="bmj;bmj-2024-080353" data-apath="/bmj/386/bmj-2024-080353.atom"><cite class='highwire-cite highwire-citation-bmj-article-top'> <span class='highwire-cite-article-type'>Practice</span> <span class='bmj-series-title'>10-Minute Consultation</span> <h1 class="highwire-cite-title" id="page-title">Optimising inhaled therapy for patients with asthma</h1> <span class='highwire-cite-journal'>BMJ</span> <span class='highwire-cite-published-year'>2024</span>; <span class='highwire-cite-volume-issue'>386</span> <span class='highwire-cite-doi'> doi: <a href="https://doi.org/10.1136/bmj-2024-080353">https://doi.org/10.1136/bmj-2024-080353</a></span> <span class='highwire-cite-date'>(Published 20 September 2024)</span> <span class='highwire-cite-article-as'> Cite this as: <span class="italic">BMJ</span> 2024;386:e080353 </span> </cite> </div> </div> </div> <div class="panel-separator"></div><div class="panel-pane pane-highwire-panel-tabs pane-panels-ajax-tab-tabs" > <div class="pane-content"> <ul class="tabs inline panels-ajax-tab"><li class="first"><a title="Article Tab - Article" href="/content/386/bmj-2024-080353" class="panels-ajax-tab-tab" data-panel-name="jnl_bmj_tab_art" data-target-id="highwire_article_tabs" data-entity-context="node:1101129" data-trigger="" data-url-enabled="1"><span>Article</span></a><a title="Article Tab - Article" 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They enable our users to debate issues raised in articles published on bmj.com. A rapid response is first posted online. If you need the URL (web address) of an individual response, simply click on the response headline and copy the URL from the browser window. A proportion of responses will, after editing, be published online and in the print journal as letters, which are indexed in PubMed. Rapid responses are not indexed in PubMed and they are not journal articles. <i>The BMJ</i> reserves the right to remove responses which are being wilfully misrepresented as published articles or when it is brought to our attention that a response spreads misinformation. </p> <p> From March 2022, the word limit for rapid responses will be 600 words not including references and author details. We will no longer post responses that exceed this limit. </p> <p> The word limit for letters selected from posted responses remains 300 words. </p> </div> </div> <div class="view-filters"> <form action="/" method="get" id="views-exposed-form-bmj-rapid-responses-bmj-rr-article" accept-charset="UTF-8"><div><div class="views-exposed-form"> <div class="views-exposed-widgets clearfix"> <div class="views-exposed-widget views-widget-sort-by"> <div class="form-type-select form-item-sort-by form-item form-group"> <label for="edit-sort-by">Sort by </label> <select class="form-control form-select" id="edit-sort-by" name="sort_by"><option value="field_highwire_a_epubdate_value" selected="selected">Date Published</option></select> </div> </div> <div class="views-exposed-widget views-widget-sort-order"> <div class="form-type-select form-item-sort-order form-item form-group"> <label for="edit-sort-order">Order </label> <select class="form-control form-select" id="edit-sort-order" name="sort_order"><option value="ASC">Ascending</option><option value="DESC" selected="selected">Descending</option></select> </div> </div> <div class="views-exposed-widget views-widget-per-page"> <div class="form-type-select form-item-items-per-page form-item form-group"> <label for="edit-items-per-page">Items per page </label> <select class="form-control form-select" id="edit-items-per-page" name="items_per_page"><option value="5">5</option><option value="10" selected="selected">10</option><option value="20">20</option><option value="40">40</option><option value="60">60</option></select> </div> </div> <div class="views-exposed-widget views-submit-button"> <input class="btn btn-info form-submit" type="submit" id="edit-submit-bmj-rapid-responses" name="" value="Apply" /> </div> </div> </div> </div></form> </div> <div class="view-content"> <div class="views-row views-row-1 views-row-odd views-row-first views-row-last"> <div class="node node-highwire-comment node-promoted clearfix"> <div class="row rr-header"> <div class="rr-left-column" class=""> <div class="response-title"> <a href="/content/386/bmj-2024-080353/rr"><h3>Addressing Climate Catastrophe Concerns in Asthma Medication Delivery: Rethinking Inhaler Use for Environmental and Clinical Efficacy</h3> </a> </div> <div class="content"> <div class="response-body"> <p>Dear Editor</p> <p>The article by Bansal et al. raises pivotal concerns about optimizing asthma management and highlights the environmental impacts of certain inhaler types. While the article provides valuable insights on improving patient adherence and technique, it also mentions, almost in passing, that pressurized metered-dose inhalers (pMDIs), due to their greenhouse gas-emitting propellants, may not align with sustainable practices. Given the looming threat of climate catastrophe, this reference to the environmental implications of inhaler devices appears understated. This discussion will argue for a more critical stance on the environmental and clinical implications of pMDIs and advocate for alternative methods, such as dry powder inhalers (DPIs) and nebulizers, which not only have a lower environmental footprint but may also be more clinically effective for certain patients.</p> <p>Environmental Implications of Inhaler Propellants</p> <p>The link between pMDI propellants and greenhouse gas emissions is well-established. Studies indicate that the use of hydrofluoroalkane (HFA) propellants in pMDIs contributes significantly to the carbon footprint of asthma treatment (Panigone et al., 2020). According to the Global Initiative for Asthma (GINA) and the British Thoracic Society (BTS), pMDIs account for nearly 4% of the carbon emissions associated with the healthcare sector in the UK (Janson et al., 2020). Given these findings, it is essential that health professionals actively consider the environmental impact of inhaler prescriptions and guide patients toward lower-emission alternatives when clinically appropriate.</p> <p>Clinical Efficacy of Alternative Inhalation Methods</p> <p>In addition to their environmental benefits, DPIs and nebulizers may offer superior clinical efficacy for certain patients. Research has shown that DPIs can provide better drug deposition in the lungs and require no propellant, thus eliminating the environmental downsides of pMDIs (Chrystyn et al., 2019). Furthermore, DPIs often require less intensive patient education, as they are typically easier to use correctly than pMDIs, which require coordinated timing of inhalation and actuation (Melani et al., 2017). Consequently, transitioning patients from pMDIs to DPIs or nebulizers could lead to improved asthma control and fewer exacerbations.</p> <p>Implications for Prescribing Practice in Asthma Care</p> <p>Given these considerations, healthcare providers should actively encourage patients with asthma to consider alternative inhaler options. Recommendations from sustainability-focused organizations, such as Greener Practice, support this approach, emphasizing the importance of low-carbon asthma care (Greener Practice, 2023). The shift away from pMDIs toward DPIs and nebulizers should be viewed not merely as a suggestion but as a necessary adjustment to align clinical practice with global climate goals and reduce the environmental impact of asthma care.</p> <p>Therefore, as climate catastrophe looms ever closer, healthcare professionals, must adopt environmentally responsible practices in their prescribing choices. This includes promoting the use of DPIs and nebulizers over pMDIs where clinically viable, not only to improve patient outcomes but also to mitigate the healthcare sector’s carbon footprint. In the context of asthma management, addressing both clinical efficacy and environmental impact can help forge a path toward a more sustainable future.</p> <p>References</p> <p>Bansal, A., Franklin, L., & Twohig, H. (2024). Optimising inhaled therapy for patients with asthma. BMJ, 386, e080353. doi: <a href="https://doi.org/10.1136/bmj-2024-080353">https://doi.org/10.1136/bmj-2024-080353</a></p> <p>Chrystyn, H., Lavorini, F., & Mann, R. (2019). Comparative effects of pressurized metered-dose inhalers versus dry powder inhalers in asthma treatment. European Respiratory Journal, 54(2), 1802232.</p> <p>Greener Practice. (2023). High Quality and Low Carbon Asthma Care Quality Improvement Toolkit. Retrieved from <a href="https://www.greenerpractice.co.uk/">https://www.greenerpractice.co.uk/</a></p> <p>Janson, C., Menzies-Gow, A., & El-Gamel, A. (2020). Carbon footprint of inhalers: A study of the environmental impact of inhaler usage. Thorax, 75(5), 369-371.</p> <p>Melani, A. S., Bonavia, M., & Cricelli, C. (2017). Inhaler mishandling remains common in real life and is associated with reduced disease control. Respiratory Medicine, 107(1), 12-20.</p> <p>Panigone, S., Sandri, F., & Ferri, R. (2020). Environmental impact of propellant-based inhalers and comparison with dry powder inhalers. 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class="nlm-given-names">Aarti</span> <span class="nlm-surname">Bansal</span> <span class="nlm-role">GP and clinical lead for sustainability</span></span>, <span data-delta="1"><span class="nlm-given-names">Lauren</span> <span class="nlm-surname">Franklin</span> <span class="nlm-role">medical student</span></span>, <span data-delta="2"><span class="nlm-given-names">Helen</span> <span class="nlm-surname">Twohig</span> <span class="nlm-role">GP and NIHR clinical lecturer in primary care</span></span></div> <div class="highwire-cite highwire-cite-highwire-article highwire-citation-bmj-article-citation-export clearfix" > <span class="highwire-cite-authors" ><!DOCTYPE html PUBLIC "-//W3C//DTD HTML 4.0 Transitional//EN" "http://www.w3.org/TR/REC-html40/loose.dtd"> <html><body><span data-delta="0"><span class="nlm-surname">Bansal</span> <span class="nlm-given-names">A</span></span>, <span data-delta="1"><span class="nlm-surname">Franklin</span> <span class="nlm-given-names">L</span></span>, 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