What are the options when a ‘greener’ inhaler results in worsening asthma symptoms?

Practice dilemma: Respiratory nurse specialist Maria Eurton explains how to approach the tricky scenario where a patient’s asthma control deteriorates after switching to a more environmentally friendly, or ‘greener’, inhaler

The dilemma: A 52‑year‑old female with asthma was switched from a pressurised metered‑dose inhaler (pMDI) to a dry powder inhaler (DPI) at their last medication review as part of the move to greener, more environmentally friendly inhalers. Now their symptoms have started to worsen. They are keen to minimise their impact on the environment, but you are concerned about their symptom control. What’s the best way to manage this?

Switching to greener inhalers can be complicated

Inhalers are a notable source of emissions, contributing roughly 3% to the NHS carbon footprint. The hydrofluoroalkane propellants in pMDIs are classified as potent greenhouse gases.

As part of the NHS Long Term Plan and wider sustainability goals, there is a drive to reduce the use of MDIs where clinically appropriate and to encourage greener alternatives such as DPIs and soft mist inhalers.

For practice nurses, this creates a new dimension to routine asthma reviews. Alongside checking control and technique, there is now an expectation to consider environmental impact.

Switching an inhaler isn’t always straightforward. Even if the medication stays the same, different inhaler types require specific techniques to ensure the dose is delivered correctly. Often patients are open to change to a more sustainable inhaler, but if they aren’t confident with the new inhaler technique required and don’t receive appropriate follow-up, then asthma control can get worse – which is bad both for the patient and the environment.

Patients may be motivated to switch for sustainability reasons, but the priority must remain safe and effective symptom management. Poor control not only increases the risk of exacerbations and hospital admissions, but these admissions themselves carry a large environmental burden – from ambulance journeys to energy use and disposable equipment.

This means nurses are often balancing two important goals: supporting patients to make environmentally responsible choices, while ensuring their condition remains well controlled.

In this kind of scenario it’s important to take a structured approach, first reassessing control and inhaler technique, then exploring the patient’s values, reviewing greener alternatives, and using shared decision‑making to choose the most suitable device.

Reassess control and check inhaler technique

Always use validated tools such as the Asthma Control Test (ACT) to measure control. Ask about frequency of daytime symptoms, night‑time waking, and reliever use.

Check inhaler technique and adherence carefully. DPIs require a strong inspiratory effort, which some patients cannot achieve consistently. Poor technique is a common cause of treatment failure.

Explore the patient’s values and concerns

Patients often feel conflicted. They want to protect the environment but also need good control.

Firstly, acknowledge their motivation positively, for example: ‘It’s great that you’re thinking about the environment; many people don’t realise inhalers differ in their carbon footprint.’

Then balance priorities: ‘The most important thing is keeping your condition under control. Poor control increases the risk of hospital admission, which itself has a large environmental impact – from ambulance journeys to energy use and disposable equipment.’

This reframing helps patients see that health and sustainability are not mutually exclusive.

Offer alternative inhalers

Other greener options

It is worth exploring other greener inhaler options for the same drug and type of inhaler with your patient. Not all DPIs are alike, and some may be easier to use depending on inspiratory effort or patient preference. If a DPI is not suitable, soft mist inhalers can be considered as an alternative, offering a lower carbon footprint while potentially improving ease of use.

Consider a combination inhaler

You should also consider their suitability for combination therapy. If escalation is required, check whether greener options are available in the relevant drug class to maintain control while reducing environmental impact.

Combination therapy means MART (Maintenance and Reliever Therapy) or AIR (Anti-Inflammatory Reliever) regimes:

AIR involves using an ICS/formoterol inhaler only when symptoms occur, and is appropriate for people whose asthma is well controlled on lower‑intensity treatment.
MART uses a single ICS/formoterol inhaler for both daily maintenance and symptom relief.

Both these combination approaches can reduce reliance on separate reliever MDIs, improve control, and are often available in greener DPI formats.

Return to a pMDI if necessary

If no greener option provides adequate control, reverting to a pMDI is justified. Different brands of pMDI can also vary in their environmental impact due to different types and amounts of propellant. NHS resources such as PrescQIPP can help to compare the carbon footprint of different inhaler devices.

Environmental impact can still be reduced by:

Avoiding generic prescribing – prescribing by brand can help minimise use of inhalers with a higher environmental impact.
Using the lowest effective dose to maintain asthma control. For example, prescribing a 200‑mcg inhaler once a day, rather than two puffs of a 100‑mcg inhaler, could cut emissions by half.
Recycling inhalers through pharmacy inhaler return programmes.
Minimising unnecessary reliever use through good control.
Considering future greener pMDIs: newer pMDIs using low‑impact propellants are being developed and will provide patients who need pMDIs with a more sustainable option.

Shared decision‑making

Present the options clearly, including the pros and cons of each inhaler type. Use visual aids or carbon footprint comparisons to support understanding. Involve the patient in the decision, so they feel empowered rather than guilty if reverting to a pMDI is necessary.

Follow-up

Arrange a review after a few weeks to reassess asthma control. Remember you should also always review inhaler technique at every opportunity.

Document the discussion, including patient preferences and the rationale for the chosen inhaler.

Key points

Always prioritise symptom control over environmental considerations – patient safety comes first.
Take time to check inhaler technique carefully, as this is a common cause of poor asthma control.
Actively engage with patients to explore their values and concerns, especially in relation to sustainability.
Offer practical advice on recycling and safe disposal of inhalers, highlighting any inhaler return and recycling programmes.
Stay up to date with local formularies that highlight greener options, including MART and AIR regimes.
Reassure patients that innovation is ongoing – greener MDIs using low‑impact propellants are expected in the future.
Remember: preventing hospital admissions is both safer for the patient and better for the environment.

Switching to greener inhalers is an important step towards sustainable healthcare, but it must never compromise patient safety. Practice nurses play a central role in balancing these priorities.

By reassessing control, exploring values and offering alternatives including MART and AIR, where appropriate, as well as using shared decision‑making, nurses can ensure that patients achieve both effective symptom management and a reduced environmental impact.

Preventing hospital admissions is not only vital for patient wellbeing but also reduces the significant environmental footprint of acute care.

Maria Eurton is a Respiratory Nurse Specialist and Independent Prescriber at the Living Well Partnership PCN, Southampton

Sources and further information

NHS England. Greener NHS: Improving health outcomes for respiratory patients while reducing carbon emissions
NHS England. Green plan guidance
Green Inhaler. Making your inhaler more environmentally friendly
NICE. Asthma: diagnosis, monitoring and chronic asthma management (BTS, NICE, SIGN). [NG245] 2024
NICE. Patient information: Asthma inhalers and the environment: BTS, NICE and SIGN patient decision aid
Asthma and Lung UK. Patient information: inhaler videos
Asthma and Lung UK. Patient resource: AIR action plan
Asthma and Lung UK. Patient resource: MART action plan
PrescQIPP. Bulletin 375. Inhaler carbon footprint – November 2025