The environmental impact of inhalers

Carbon footprint

Pressurised metered dose inhalers (pMDI) contain hydrofluorocarbon (HFC) propellants that do not have an effect on the ozone layer but are powerful greenhouse gases and can contribute to global warming.

Dry powder inhalers (DPI) do not use these propellants and have substantially lower global warming potential, producing 20g CO2 equivalent (CO2eq) per dose compared with 500g CO2eq for some pressurised metered dose inhalers.

Estimated carbon footprints for comparison indicate an average trip (9 miles) in a typical car produces 2,610g CO2eq (or 290g CO2eq per mile).

As Breath Actuated Inhalers (BAIs) contain the same propellants as pMDIs, the estimated carbon footprints for pMDIs can reasonably be extrapolated to BAIs. Available data consistently show that there is a significant difference between DPIs and pMDIs / BAIs, and due to the absence of HFC propellants, DPIs have a low carbon footprint compared to other inhalers.

The Respimat device is a soft mist inhaler (SMI) that does not contain propellants, and so also has a lower carbon footprint than pMDIs and BAIs.

pMDI use in England is responsible for nearly 1 million tonnes of CO2 equivalent per year.

The NHS Long Term Plan identifies a shift to lower carbon inhalers as a way of significantly reducing the carbon footprint of health and social care.

With this in mind, dry powder inhalers or soft mist inhalers are generally preferred locally, unless there is a specific clinical or dexterity reason that an individual requires a pMDI or BAI.

In young children, a pMDI and a spacer is the preferred method of delivery; a face mask is required until the child can breathe reproducibly using the spacer mouthpiece. A pMDI plus spacer is also recommended for patient of any age for the treatment of mild and moderate acute asthma attacks. Other factors to consider include the choice of drug, patient preference, and acquisition cost.

NICE has produced a patient decision aid to help people with asthma and their healthcare professionals discuss their options for inhaler devices (available here), which includes consideration of the carbon footprint of the inhaler. It is suitable for use by people aged 17 years and over, and many of the considerations are also applicable to patients with COPD.

Carbon footprint comparison tables

Data on the actual carbon footprint of individual inhalers is very limited, therefore the following tables provide indicative rather than actual values. The figures are based on usual daily doses recommended in the Devon Formulary and median CO2eq values per inhaler as estimated by PrescQIPP. Equivalent care miles for comparison have been estimated on the basis of an average trip (9 miles) in a typical car producing 2,610g CO2eq (or 290g CO2eq per mile) (see NICE).

These figures are intended to highlight the environmental impact of inhaler devices containing hydrofluorocarbon (HFC) propellants compared to dry powder / soft mist inhalers. When relevant clinical factors have been taken into account, the potential environmental benefits of selecting products with lower CO2eq per puff and/or dosing regimens that require fewer puffs per day are also noted.

Short acting beta-agonists (SABA)

Dry Powder inhalers (DPI)
Active
ingredient
DeviceCO2eq per puff (g)Daily doseAnnual CO2eq (Kg)Equivalent
annual car miles
TerbutalineBricanyl Turbohaler4.1Up to 4 puffsUp to 5.99Up to 21
Pressurised metered dose inhalers (pMDI) and breath-actuated inhalers (BAI)
Active
ingredient
DeviceCO2eq per puff (g)Daily doseAnnual CO2eq (Kg)Equivalent
annual car miles
SalbutamolSalamol CFC-free (pMDI)
60.4Up to 8 puffsUp to 176.37Up to 608
SalbutamolSalamol Easi-breathe (BAI)59.8Up to 8 puffsUp to 174.62Up to 602
SalbutamolAiromir Autohaler (BAI)48.6Up to 8 puffsUp to 141.91Up to 489

Ventolin Evohaler 100 micrograms is a non-formulary product. The CO2eq per puff is 141 grams. The equivalent annual car miles for a daily dose of up to 8 puffs is up to 1,420 car miles.

Long acting beta agonists (LABA)

Dry Powder inhalers (DPI)
Active
ingredient
DeviceCO2eq per puff (g)Daily doseAnnual CO2eq (Kg)Equivalent
annual car miles
FormoterolFormoterol Easyhaler4.532 puffs3.3111
FormoterolOxis Turbohaler6.172 puffs4.5016
IndacaterolOnbrez Breezhaler18.751 puff6.8524
SalmeterolSerevent Accuhaler122 puffs8.7630
Pressurised metered dose inhalers (pMDI)
Active
ingredient
DeviceCO2eq per puff (g)Daily doseAnnual CO2eq (Kg)Equivalent
annual car miles
FormoterolAtimos Modulite1302 puffs94.9327
SalmeterolSoltel1304 puffs189.8654

Short acting muscarinic agonists (SAMA)

Pressurised metered dose inhalers (pMDI)
Active
ingredient
DeviceCO2eq per puff (g)Daily doseAnnual CO2eq (Kg)Equivalent
annual car miles
Ipratropium
bromide
Atrovent733 to 8 puffs79.94 to 213.16276 to 735

Long acting muscarinic antagonists (LAMA)

Dry Powder inhalers (DPI) and Soft Mist Inhalers (SMI)
Active
ingredient
DeviceCO2eq per puff (g)Daily doseAnnual CO2eq (Kg)Equivalent
annual car miles
TiotropiumBraltus Zonda (DPI)18.751 puff6.8424
TiotropiumSpiriva Respimat (SMI)12.922 puffs9.4333
Glycopyrronium
bromide
Seebri Breezhaler (DPI)18.751 puff6.8424
Aclidinium
bromide
Eklira Genuair (DPI)8.672 puffs6.3322

Combination inhalers: Inhaled corticosteroid (ICS) + Long acting beta2 agonists (LABA)

Dry Powder inhalers (DPI)
Active
ingredients
DeviceCO2eq per puff (g)Daily doseAnnual CO2eq (Kg)Equivalent
annual car miles
BDP (extrafine)/ formoterol
fumarate
Fostair NEXThaler17.412 to 4 puffs5.41 to 10.8219 to 37
Budesonide/ formoterol fumarateFobumix Easyhaler14.042 to 4 puffs2.95 to 5.9010
Budesonide/ formoterol
fumarate
Symbicort Turbohaler 100/6
4.832 to 4 puffs3.53 to 7.0512 to 24
Budesonide/ formoterol fumarateSymbicort Turbohaler 200/616.672 to 4 puffs4.87 to 9.7417 to 34
Budesonide/ formoterol fumarateSymbicort Turbohaler 400/1217.752 puffs12.7844
Budesonide/ formoterol fumarateDuoResp Spiromax16.82 to 4 puffs4.96 to 9.9317 to 34
Fluticasone
furoate/
vilanterol
Relvar Ellipta2261 puff9.4933
Fluticasone propionate/ salmeterolFusacomb Easyhaler9.532 puffs6.9624
Fluticasone
propionate/
salmeterol
Seretide Accuhaler
152 puffs10.9538

1 estimates do not include additional “prn” use as part of MART regimens; 2 first line for COPD

Pressurised metered dose inhalers (pMDI)
Active
ingredients
DeviceCO2eq per puff (g)Daily doseAnnual CO2eq (Kg)Equivalent
annual car miles
BDP (extrafine)/
formoterol
fumarate
Luforbec193.742 to 4 puffs68.43 to 136.86236 to 472
BDP (extrafine)/ formoterol fumarateFostair 200/6
117.944 puffs172.19594
Fluticasone
propionate/
salmeterol
AirFluSal MDI
1614 puffs235.06811
Fluticasone propionate/ salmeterolSeretide Evohaler162 4 puffs236.52816

1 estimates do not include additional “prn” use as part of MART regimens

Combination inhalers: Long-acting beta2 agonists (LABA) + Long-acting muscarinic antagonists (LAMA)

Dry Powder inhalers (DPI) and Soft Mist Inhalers (SMI)
Active
ingredients
DeviceCO2eq per puff (g)Daily doseAnnual CO2eq (Kg)Equivalent
annual car miles
Indacaterol
maleate/
glycopyrronium
bromide
Ultibro Breezhaler (DPI)18.751 puff6.8424
Olodaterol / tiotropium
bromide
Spiolto Respimat (SMI)12.922 puffs9.4333
Vilanterol / umeclidinium bromideAnoro Ellipta (DPI)24.001 puff8.7630
Formoterol fumerate / aclidinium
bromide
Duaklir Genuair (DPI)9.172 puffs6.6923

Triple combination inhalers: Inhaled corticosteroid (ICS) + Long-acting beta2 agonists (LABA) + Long-acting muscarinic antagonists (LAMA)

Dry Powder inhalers (DPI)
Active
ingredients
DeviceCO2eq per puff (g)Daily doseAnnual CO2eq (Kg)Equivalent
annual car miles
Fluticasone
furoate/
umeclidinium
bromide/
vilanterol
trifenatate
Trelegy Ellipta261 puff9.4933
BDP (extrafine)/ formoterol fumarate dihydrate/ glycopyrronium bromideTrimbow NEXThaler7.414 puffs10.8237
Pressurised metered dose inhalers (pMDI)
Active
ingredients
DeviceCO2eq per puff (g)Daily doseAnnual CO2eq (Kg)Equivalent
annual car miles
BDP (extrafine)/
formoterol
fumarate
dihydrate/
glycopyrronium
Trimbow118.364 puffs172.81596

Corticosteroids

Dry Powder inhalers (DPI)
Active
ingredients
DeviceCO2eq per puff (g)Daily doseAnnual CO2eq (Kg)Equivalent
annual car miles
BudesonideEasyhaler Budesonide3.252 to 4 puffs2.37 to 4.758 to 16
BudesonidePulmicort Turbohaler 100 micrograms72 to 4 puffs5.11 to 10.2218 to 35
BudesonidePulmicort Turbohaler 200 micrograms142 to 4 puffs10.22 to 20.4435 to 70
BudesonidePulmicort Turbohaler 400 micrograms342 to 4 puffs24.82 to 49.6486 to 171
Pressurised metered dose inhalers (pMDI) and breath-actuated inhalers (BAI)
Active
ingredients
DeviceCO2eq per puff (g)Daily doseAnnual CO2eq (Kg)Equivalent
annual car miles
BDP
extrafine
Kelhale (pMDI)

86.642 to 8 puffs63.39 to 253.57219 to 874
BDP extrafineQvar (pMDI)
Qvar Autohaler (BAI)
Qvar Easi-breathe (BAI)
101.752 to 8 puffs74.28 to 297.11256 to 1,025
BDPClenil Modulite (pMDI)81.902 to 8 puffs59.78 to 239.15206 to 825

Waste and recycling

Used pMDI canisters still contain propellants; all used pMDI canisters should be returned to a pharmacy (or dispensing GP practice) to dispose of in an environmentally safe way.

Used inhalers should not be placed in general waste.

Used inhalers that are not returned to pharmacies but are placed in general waste for kerbside collection may end up in landfill, depending on local authority arrangements. As well as plastic pollution, this risks crushing or piercing the pMDI / BAI canister and releasing additional propellants into the atmosphere.

Inhalers should be placed in the pharmacy's pharmaceutical waste bins, which are incinerated (destroying the greenhouse gases); steel and aluminium may be recovered and recycled at some incinerators. Spacers cannot currently be recycled.

Last updated: 07-03-2022

 

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