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The Excessive Carbon Footprint of Inhalers Used in Airway Disease and its Remedies

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Published Online: Oct 5th 2023 touchREVIEWS in Respiratory & Pulmonary Diseases. 2024;9(1):13-15 DOI: http://doi.org/10.17925/USPRD.2023.8.2.1
Authors: Laurence Désy, Philippe Lachapelle, Simon Couillard
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Abstract:
Overview

The carbon footprint of human activities is a conversation topic worldwide. Many fields, including healthcare, have attempted to reduce their carbon footprint. For example, in Canada, 4.6% of greenhouse gases are manufactured by healthcare institutions. When it comes to the accountable parties in healthcare, the current treatments for asthma and chronic obstructive pulmonary disease are the main contributors. These highly prevalent diseases affect 11% and 10% of the Western populations, respectively. This editorial aims to discuss the impact of pressurized metered dose inhalers on the environment, alternatives and changes to current diagnostic and therapeutic practices, public awareness, potential changes to regulations and paths forward.

Keywords

Asthmacarbon dioxidecarbon footprintchronic obstructive pulmonary diseasedry powder inhalersglobal warminginhalerspressurized metered dose inhalersvaporizers and nebulizers

Article:

The topic of the carbon footprint of human activities is one frequently discussed worldwide. There have been conscious efforts across multiple fields, including healthcare, to reduce their carbon footprint. In Canada, 4.6% of greenhouse gases (GHG) are manufactured by the healthcare institutions, ranking it second worldwide. 1,2 The treatments for asthma and chronic obstructive pulmonary disease (COPD) are two of the main contributors, this includes pressurized metered dose inhalers (pMDIs), dry powder inhalers (DPIs) and soft mist inhalers (SMIs). These highly prevalent diseases affect 11% and 10% of the Western populations, respectively.3 This editorial aims to highlight the impact of pressurized metered dose inhalers on the environment, discussing alternatives and changes to current diagnostic and therapeutic practices, public awareness, potential changes to regulations and pathways moving forward.

Impacts of pressurized metered dose inhalers

Used in patients with respiratory diseases like asthma and COPD, pMDIs represent 0.03% of the annual worldwide carbon footprint.4 Due to their effects on the environment, the Montreal Protocol5,6 was established in 1987 and signed by 197 countries, regulating the use of many substances affecting the ozone layer, such as the chlorofluorocarbons (CFCs) contained in pMDIs. Following this historical pact, CFCs were replaced by hydrofluorocarbons (HFCs), which had potentially fewer consequences on global warming. However, HFCs remain important vectors for GHG emissions.6 HFCs are synthetic gases used as a substitute for ozone-depleting substances, however, they do still contribute to GHG emissions.7 For instance, a single dose from a pMDI, which includes two inhalations, is the equivalent of driving two kilometres with a hybrid vehicle, with regards to carbon dioxide emissions.8

Alternatives to pressurized metered dose inhalers using hydrofluorocarbons

Beyond pMDIs, different types of inhalers with different delivery mechanisms are available on the market. DPIs use peak inspiratory flow to deliver the medication inside the respiratory tract without the use of propellants. Comparing the different inhaler types on the market, one can notice that DPIs and SMIs have a carbon footprint approximately 10 times smaller, compared with pMDIs.8 However, >70% of inhalers currently sold to adult patients are pMDIs.9 It must be mentioned that, if the inhalation technique/strength with DPIs is adequate, their efficacy parallels that of pMDIs, but has a much lower impact on the environment.10 In a recent study, patients using pMDIs were switched to DPIs, resulting in reducing their carbon footprint by more than half with no impact on their disease control.11 If 5% of patients per year substituted their pMDIs to DPIs, there would be a reduction of 27% of GHGs related to inhaler use over the course of 10 years.12

There are many factors to consider when prescribing inhalers. For example, the therapeutic efficacy of DPIs will be lower for individuals with advanced pulmonary disease, due to inadequate drug delivery. Indeed, with inspiratory muscle weakness and associated pulmonary hyperinflation, the maximal inspiratory pressure is insufficient for dry powder inhalation.13 Additionally, it can be difficult for patients to inhale properly during an acute airway attack. Personal preference and the varying costs of inhalers must also be considered. Nevertheless, in a study comparing costs, device handling and the environmental impact of the inhalers, only 14% of the participants indicated that carbon footprint was not a decisional factor in the choice of inhalers.14

The importance of an established diagnosis for prescribing or renewing treatment

A formal diagnosis of asthma or COPD with objective tests is crucial. Unfortunately, in one study, it was found that 33% of randomly recruited patients that received a diagnosis for asthma within the last 5 years had no evidence of the disease during the pulmonary function test.15 Of those individuals in whom an asthma diagnosis was ruled out, 79% had used inhalers prior to the re-evaluation, and thus have contributed to the ecological damages caused by HFCs.15

The frequently overlooked inhaler technique

Aside from considering a substitution from pMDIs to DPIs and/or SMIs, it is crucial to educate patients in proper inhaler technique, since most GHG emissions are produced during the inhalation phase.7 When choosing a pMDI, the use of a spacer allows for the optimal medication quantity without wasting and overutilization. This also reduces the number of inhalers used yearly, as less drug is used with each use of the inhaler, which decreases GHG. An estimated 68% of patients do not properly use their inhalers, perhaps due to most of them not receiving adequate education on the proper techniques.16 Furthermore, for many patients using pMDIs, it is often challenging to determine if the inhaler is empty, with the absence of a numerical dial indicating the number of remaining doses. In contrast, a dial is present on the majority of the DPI devices. Studies have shown that 40% of patients use empty inhalers, which contributes to poor control of the disease.17 Conversely, some patients tend to renew their inhalers prior to finishing all of the doses, which increases product waste and overutilization. In summary, to reduce GHG emissions in airway disease, it is important to educate patients on the use of inhalers, identify poor symptom control and discuss strategies to prevent disease exacerbations.

Controlling asthma to control greenhouse gas emissions

The impact of inadequate asthma control must not be underestimated, both in terms of morbidity and carbon footprint. Compared with patients with adequate control of their disease, poorly controlled airway disease is associated with threefold greater GHG emissions.18 The most adequate way to maintain a proper control of disease is to limit tobacco use, identify and target unchecked airway inflammation and reduce exposure to allergens, but also to verify treatment use and inhalation technique with patients. Furthermore, in patients aged 12 and up with well-controlled mild asthma, guidelines from the Global Initiative for Asthma recommend that treatment with budesonide-formoterol inhalers (usually a DPI) is preferred to a daily inhaled corticosteroid paired with a short-acting bronchodilator (usually pMDIs).19 Airway disease that is well-controlled requires less reliever use and healthcare use, effectively reducing the associated carbon footprint.

Returning inhalers to the local pharmacist

The carbon footprint associated with the manufacturing and disposal of pMDIs may represent an estimated 30% of the total footprint of the inhaler.9 The incineration and recycling of the devices reduces the impact on global warming.7 To this day, no systematic programme has been implemented with regards to recycling or packaging of the inhalers. At the very least, devices should be disposed of adequately.20

Awareness

There are programmes in place to educate patients and healthcare professionals in taking an eco-friendly approach. CASCADE is an organization funded by the Canadian Government partnering with the Canadian Thoracic Society, which is similar to its counterpart PrescQIPP.info in the UK.21,22 These programmes aim to guide the healthcare systems towards a more durable environment with a neutral carbon use. To reach their objectives, they offer multiple resources explaining how to reduce carbon emissions. These include videos on inhalation techniques, information posters and letters explaining the proper use of inhalers.23

Regulations

Regulation can limit the use of polluting gases as witnessed in the Montreal Protocol.5 In addition to the efforts put in since 1987, the Kigali Amendment to the Montreal Protocol in 2019 aims to reduce carbon emissions further, imposing a mandated reduction of HFCs worldwide.6 Hydrofluoroolefins (HFOs) are currently in development to assure an alternative pMDIs propellant.24 Replacing HFCs with HFOs would substantially reduce the global warming potential of pMDIs.

Conclusions

In conclusion, healthcare systems must take part in reducing their carbon footprint. This is especially true for airway disease and its associated inhalers (Figure 1). pMDIs constitute a healthcare risk by decreasing the air quality and as a result increase symptoms and exacerbations of pulmonary diseases. The choice of inhalers depends on a multitude of factors, including personal preference, price, inhalation technique and simplicity, as well as their carbon footprint. Efforts have been made to reduce GHG emissions, such as the CASCADE program, recycling programmes in pharmacies, the Kigali Amendment aiming to progressively reduce the HFCs, and developing new alternatives to the propulsion mechanism with HFO.

Figure 1: The excessive carbon footprint of inhaler devices used in airway disease and its remedies

COPD = chronic obstructive pulmonary disease; GHG = greenhouse gases.

Finally, a proposition: after CFCs, why not regulate the progressive removal of HFC-based pMDIs in order to promote HFO-based pMDIs? We can and should be as ambitious for the environment as for our patients.

Article Information:
Disclosure

Philippe Lachapelle reports speaker honoraria from AstraZeneca, Boehringer Ingelheim, GlaxoSmithKline, Novartis and Sanofi-Regeneron. Simon Couillard reports the following: non-restricted research grants from AstraZeneca, bioMérieux, Sanofi-Genyme-Regeneron, the Fondation Québécoise en Santé Respiratoire, the NIHR Oxford BRC and the Quebec Respiratory Health Research Network; speaker honoraria from AstraZeneca, GlaxoSmithKline, Sanofi-Regeneron and Valeo Pharma; consultancy fees for AstraZeneca, FirstThought, GlaxoSmithKline and Sanofi-Regeneron; sponsorship to attend/speak at international scientific meetings by/for AstraZeneca and Sanofi-Regeneron; is an advisory board member and will have stock options for Biometry Inc, a company which is developing a FeNO device (myBiometry); advised the Institut national d’excellence en santé et services sociaux (INESSS) for an update of the asthma general practice information booklet for general practitioners; is the holder of the Association Pulmonaire du Québec’s Research Chair in Respiratory medicine and is a clinical research scholar of the Fonds de recherche du Québec. Laurence Désy has no conflicts of interest to declare in relation to this article.

Compliance With Ethics

This article is an opinion piece and does not report on new clinical data, or any studies with human or animal subjects performed by any of the authors.

Review Process

Double-blind peer review.

Authorship

The named authors meet the International Committee of Medical Journal Editors (ICMJE) criteria for authorship of this manuscript, take responsibility for the integrity of the work as a whole, and have given final approval for the version to be published.

Correspondence

Simon CouillardCentre Hospitalier Universitaire de Sherbrooke3001, 12e Avenue Nord, pièce 2616, Sherbrooke, Québec, Canada; s.couillard@usherbrooke.ca

Support

Funding from the research chair in Respiratory Health of the Lung Association of Quebec and the Fonds de recherche du Québec.

Access

This article is freely accessible at touchRESPIRATORY.com © Touch Medical Media 2024.

Acknowledgements

The authors wish to thank the patients with severe asthma and the respiratory therapists, nursing team and pulmonologists at the Centre Hospitalier Universitaire de Sherbrooke for their inspiration and support.

Data Availability

Data sharing is not applicable to this article as no datasets were generated or analyzed during the writing of this article.

References

1. Romanello MMcGushin ADi Napoli Cet alThe 2021 report of the Lancet Countdown on health and climate change: Code red for a healthy futureLancet2021;398:161962DOI10.1016/S0140-6736(21)01787-6.

2. Eckelman MJSherman JDMacNeill AJLife cycle environmental emissions and health damages from the Canadian healthcare system: An economic-environmental-epidemiological analysisPLoS Med2018;15:e1002623DOI10.1371/journal.pmed.1002623.

3. Public Health Agency of CanadaReport from the Canadian Chronic Disease Surveillance System: Asthma and chronic obstructive pulmonary disease (COPD) in Canada, 20182018Available atwww.canada.ca/content/dam/phac-aspc/documents/services/publications/diseases-conditions/asthma-chronic-obstructive-pulmonary-disease-canada-2018/pub-eng.pdf (Date last accessed30 May 2023).

4. Association pulmonaire du QuébecCrise climatiqueAvailable athttps://poumonquebec.ca/sante-pulmonaire/environnement/crise-climatique/ (Date last accessed15 June 2023). French.

5. The U.S. Department of StateThe Montreal protocol on substances that deplete the ozone layerAvailable atwww.state.gov/key-topics-office-of-environmental-quality-and-transboundary-issues/the-montreal-protocol-on-substances-that-deplete-the-ozone-layer/ (Date last accessed13 September 2023).

6. UN Environment ProgrammeAbout Montreal protocolAvailable atwww.unep.org/ozonaction/who-we-are/about-montreal-protocol (Date last accessed15 June 2023).

7. Wilkinson AJKBraggins RSteinbach ISmith JCosts of switching to low global warming potential inhalers. An economic and carbon footprint analysis of NHS prescription data in EnglandBMJ Open2019;9:e028763DOI10.1136/bmjopen-2018-028763.

8. Panigone SSandri FFerri Ret alEnvironmental impact of inhalers for respiratory diseases: Decreasing the carbon footprint while preserving patient-tailored treatmentBMJ Open Respir Res2020;7:e000571DOI10.1136/bmjresp-2020-000571.

9. Janson CHenderson RLöfdahl Met alCarbon footprint impact of the choice of inhalers for asthma and COPDThorax2020;75:824DOI10.1136/thoraxjnl-2019-213744.

10. Brocklebank DRam FWright Jet alComparison of the effectiveness of inhaler devices in asthma and chronic obstructive airways disease: A systematic review of the literatureHealth Technol Assess2001;5:1149DOI10.3310/hta5260.

11. Woodcock AJanson CRees Jet alEffects of switching from a metered dose Inhaler to a dry powder Inhaler on climate emissions and asthma control: Post-hoc analysisThorax2022;77:118792DOI10.1136/thoraxjnl-2021-218088.

12. Pernigotti DStonham CPanigone Set alReducing carbon footprint of inhalers: Analysis of climate and clinical implications of different scenarios in five European countriesBMJ Open Respir Res2021;8:e001071DOI10.1136/bmjresp-2021-001071.

13. Clark ARWeers JGDhand RThe confusing world of dry powder Inhalers: It is all about Inspiratory pressures, not Inspiratory flow ratesJ Aerosol Med Pulm Drug Deliv2020;33:111DOI10.1089/jamp.2019.1556.

14. Liew KWilkinson AP280 how do we choose Inhalers? patient and physician perspectives on environmental, financial and ease-of-use factorsThorax2017;72:A2357DOI10.1136/thoraxjnl-2017-210983.422.

15. Aaron SDVandemheen KLFitzGerald JMet alReevaluation of diagnosis in adults with physician-diagnosed asthmaJAMA2017;317:26979DOI10.1001/jama.2016.19627.

16. Haidl PHeindl SSiemon Ket alInhalation device requirements for patients’ inhalation maneuversRespir Med2016;118:6575DOI10.1016/j.rmed.2016.07.013.

17. Conner JBBuck POImproving asthma management: The case for mandatory inclusion of dose counters on all rescue BronchodilatorsJ Asthma2013;50:65863DOI10.3109/02770903.2013.789056.

18. Wilkinson AMaslova EJanson Cet alGreenhouse gas emissions associated with asthma care in the UK: Results from SABINA CARBONEur Respir J2022;58:A76DOI10.1183/13993003.congress-2021.OA76.

19. Global Initiative for Asthma2023 GINA Report, Global Strategy for Asthma management and prevention2023Available athttps://ginasthma.org/2023-gina-main-report/ (Date last accessed16 August 2023).

20. Health Products Stewardship AssociationReturning MedicationsAvailable athttps://healthsteward.ca/consumers/returning-medications/ (Date last accessed15 June 2023).

21. CASCADESAvailable athttps://cascadescanada.ca/ (Date last accessed13 September 2023).

22. PrescQIPPAvailable athttps://prescqipp.info/ (Date last accessed13 September 2023).

23. Cascades CanadaSustainable pharmacy and prescribing: Implenetation resources for sustainable pharmacy and prescribing practicesAvailable athttps://cascadescanada.ca/action-areas/pharmacy-and-prescribing/ (Date last accessed15 June 2023).

24. Hargreaves CBudgen NWhiting Aet alS60 A new medical Propellant HFO-1234Ze(E): Reducing the environmental impact of inhaled medicinesThorax2022;77:A389DOI10.1136/thorax-2022-BTSabstracts.66.

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