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 Turbohaler (DPI)18.75Up to 8 puffsUp to 27.38Up to 94
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)
Salamol Easi-breathe (BAI)
Airomir Autohaler (BAI)
48.6Up to 8 puffsUp to 141.91Up to 489

Long acting beta agonists (LABA)

Dry Powder inhalers (DPI)
Active
ingredient
DeviceCO2eq per puff (g)Daily doseAnnual CO2eq (Kg)Equivalent
annual car miles
FormoterolOxis Turbohaler (DPI)18.752 puffs13.6947
IndacaterolOnbrez Breezhaler (DPI)18.751 puff6.9124
SalmeterolSerevent Accuhaler (DPI)18.752 puffs13.6947
Pressurised metered dose inhalers (pMDI)
Active
ingredient
DeviceCO2eq per puff (g)Daily doseAnnual CO2eq (Kg)Equivalent
annual car miles
FormoterolAtimos Modulite (pMDI)1302 puffs94.9327
SalmeterolSoltel (pMDI)1304 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
Atrovent (pMDI)71.53 to 4 puffs78.29 to 104.39270 to 360

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)132 puffs9.4933
Glycopyrronium
bromide
Seebri Breezhaler (DPI)18.751 puff6.8424
Aclidinium
bromide
Eklira Genuair (DPI)18.752 puffs13.6847

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/ formoterol
fumarate
Fostair NEXThaler (DPI)118.752 to 4 puffs13.69 to 27.3847 to 94
Budesonide/
formoterol
fumarate
Duoresp Spiromax (DPI)1
Symbicort Turbohaler (DPI)1
18.752 to 4 puffs13.69 to 27.3847 to 94
Fluticasone
furoate/
vilanterol
Relvar Ellipta (DPI)218.751 puff6.8424
Fluticasone
propionate/
salmeterol
Seretide Accuhaler (DPI)
18.752 puffs13.6947

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/
formoterol
fumarate
Fostair (pMDI)1163.52 to 4 puffs119.36 to 238.71412 to 823
Fluticasone
propionate/
salmeterol
AirFluSal MDI (pMDI)
Seretide Evohaler (pMDI)
163.54 puffs238.71823

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
Tiotropium
bromide/
olodaterol
Spiolto Respimat (SMI)132 puffs9.4933
Aclidinium
bromide/
formoterol
fumarate
Duaklir Genuair (DPI)18.752 puffs13.6947

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 Ellipta (DPI)18.751 puff6.8424
Pressurised metered dose inhalers (pMDI)
Active
ingredients
DeviceCO2eq per puff (g)Daily doseAnnual CO2eq (Kg)Equivalent
annual car miles
BDP/
formoterol
fumarate
dihydrate/
glycopyrronium
Trimbow (pMDI)163.54 puffs238.71823

Corticosteroids

Dry Powder inhalers (DPI)
Active
ingredients
DeviceCO2eq per puff (g)Daily doseAnnual CO2eq (Kg)Equivalent
annual car miles
BudesonidePulmicort Turbohaler (DPI)18.752 to 4 puffs13.69 to 27.3847 to 94
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)
Qvar (pMDI)
Qvar Autohaler (BAI)
Qvar Easi-breathe (BAI)
Clenil Modulite (pMDI)
101.752 to 8 puffs74.28 to 297.11256 to 1,025

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: 08-03-2021

 

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