While common in managing respiratory conditions, taking medication by the inhaled route is not the norm for most other medical conditions. This can mean that inhalers may be regarded as less serious medicines than tablets and capsules. Sometimes, patients can overlook their inhaled medicines when they are asked about all the medicines they take. On admission to hospital, patients are asked to hand in all their medication but sometimes they are allowed to keep their inhalers with them. This perpetuates mixed messages so, we think it is important to campaign for inhalers to be taken seriously as medicines. We have started a piece of research exploring what patients think about their inhalers and their understanding of inhalers as a medicine. Understanding the patient perspective is important and findings from this first phase of the research was presented at the Winter BTS meeting 2019. A second phase of research focusing more on primary care is in the planning stages and a full publication of the findings to date is expected in 2020.
- Inhalers contain medicines so need to be taken as seriously as medicines which are taken by mouth.
- As the medicine is delivered through a device, the medication they are taking is a combination of medicine and device. They will not receive benefit from the medicine unless they understand how to use the device.
NICE Generic guidance on good practice in prescribing does not highlight inhaled treatment.
- Every inhaler device is different, and people need to be taught how to use them to benefit from them – and reminded of how to use them properly at every opportunity which is why healthcare practitioners need to be effectively trained to undertake this role.
While there are many different types of inhaler for patients to use, the most effective way to get medicine into the lungs of people who are short of breath is using a metered dose inhaler (pMDI) with a spacer (a plastic cylinder attached to the inhaler which enables the patient to breath in and out in their own time to get the medicine deep into their lungs). Many patients find a dry powder inhaler (DPI) is useful for general use, as they may be easier to use and some have the benefit of dose counters, for example. However, when patients are having an exacerbation or are breathless, it is pMDI plus spacer which is the optimal treatment.
For this reason, we believe it is essential that pMDIs continue to be available, and want to campaign for all patients to have access to an pMDI and spacer – where appropriate. We are interested to understand what guidance patients are given if they call 111 for advice, or 999, before an ambulance arrives. This is a critical period when symptoms can worsen so it is essential that patients are given good advice. Once ambulances arrive, the paramedics also need to give appropriate medication in the form that the lungs will receive it most quickly, so we want to work more closely with emergency services to explore how to make sure patients get optimal care before they arrive at emergency departments.
- pMDI with spacers play a critical role when the patient is becoming breathless or having an exacerbation.
- Patients with respiratory conditions should all have emergency medication available in pMDI formulation, plus a spacer.
-Emergency staff taking 999/111 calls and working in ambulances need to be aware of the best way to deliver emergency medication to patients and give appropriate advice.
-Dr Duncan Keeley and team are currently working to make Emergency packs widely available to patients, where appropriate.
The switch from CFC propellants to CFC-free propellants in pMDIs took place around the turn of the century, in order to reduce damage to the ozone layer. All pMDIs switched to using HFA propellants and although these did not harm the ozone layer, it was recognised that they are a greenhouse gas that contributes to global warming. There is currently mounting interest in whether newer propellants can be developed for medical use which do not harm either the ozone layer or create greenhouse gases.
We are aware of the concerns around propellants having a negative effect on the environment but our message is clear. Discontinuing pMDIs and switching patients to other alternatives is not as straight-forward as it may seem. PMDIs remain a mainstay of treatment of respiratory conditions, and could be lifesaving when a patient is having an exacerbation. We are keen to encourage further discussion in which patient safety and the environment are considered alongside the development of and switch to non-environmentally damaging propellants in pMDIs.
Responsibility for our environment falls to us all – healthcare practitioners, NHS managers, and patients/the public alike. We believe that patients should be informed about the environmental impact of their medical treatment, so that they can play their part in asking for less environmentally harmful treatment options, and can also play an active role in driving greater use of inhaler recycling schemes. We plan to explore current awareness of such recycling schemes, and the extent to which they are being used, as a basis for promoting greater use of such schemes.
A virtual re"cycling" campaign is set to be launched next year to identify what services and schemes are currently available and we would like to hear from you if you have a scheme you are involved in.
Here at UKIG, we will also work closely with the NHS sustainable development unit, which is spearheading initiatives to minimise environmental damage from the NHS. In the government response to a report by the Environmental Audit Committee in 2017, they encouraged the NHS to set a target of reducing the use of inhalers, which have high global warming potential, by 50% by 2022. They also want to see far greater recycling of inhalers.
The critical points to take away include:
- It is important to develop environmentally friendly propellants for pMDIs.
- We will engage patients, the public, and the NHS on how best to minimise harm to the environment from inhaler use, while still retaining a range of treatment options for patients.
- We will raise awareness of and encourage the use of schemes available to recycle inhalers both within the NHS and with patients and the public.