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Optimising inhaler device choice in asthma

This Project takes less than 10 hours for a practice with 10,000 patients

Can be done by a GP, Pharmacist, Nurse, Trainee or Student

Green Impact for Health Toolkit area: Prescribing & Quality Improvement

CQC Areas

  • Effective (Delivering Evidenced Based Care)
  • Well-led (Learning, Improvement & Innovation)
  • Well-led (Environmental Sustainability)

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The benefits of this project

Project benefits for Your Patients

Benefits for Your Patients

  • Ensuring patients with asthma are on the most appropriate inhaler device can improve asthma control
  • Patients have greater choice in the inhaler device they can use effectively
Project benefits for Your Practice

Benefits for Your Practice

  • May reduce demand for urgent appointments as fewer patients with undertreated asthma due to poor inhaler technique.
  • Team is up to date and confident prescribing the inhaler devices in your local guidance.
Project benefits for The Planet

Benefits for The Planet

  • Higher proportion of patients likely to be prescribed Dry Powder Inhalers (DPIs) which have a much lower carbon footprint than pressurised Metered Dose Inhalers pMDISs).
  • Well controlled asthma has 1/3rd of the carbon footprint of uncontrolled asthma.

Opportunity for improvement

  • Assessing inhaler technique is essential for checking that medicine is getting to where it is needed in the airways. Poor inhaler technique is common and is a significant factor is inadequate asthma control.
  • There are two main types of inhaler devices available for use in asthma, pressurised metered dose inhalers (pMDIs) and dry powder inhalers (DPIs). However patients have often not been offered this choice. Many patients prefer DPIs as they find the inhalation technique easier. Also DPIs come with dose counters to track medicine use and do not require spacers.
  • Pressurised metered dose inhalers (pMDIs) contain hydrofluoroalkanes (HFA) propellants which are potent greenhouse gases, 1300 – 3350 times more potent than carbon dioxide. In England approximately 70% of inhalers prescribed are pMDIs, in contrast to Sweden which prescribes 13% as pMDIs.
  • The NHS has set the target of reaching net zero by 2040 for the greenhouse gas emissions which it can control (‘NHS Carbon Footprint’). Inhalers are included in this scope and account for approximately 13% of this carbon footprint in 2019.
  • Alternatives to pMDIs, such as DPIs have a much lower carbon footprint as they do not contain any propellant gases. They and can be safely and effectively used by the majority of people with asthma. They require a quick and deep inhalation so some patients such as young children and people with severe asthma may not be able to use them effectively.
  • You might like to create a SMART goal for this project. Here are some examples. To have ordered placebo devices for all inhalers devices types on your local formulary for each clinician in your team within 1 month. To run a training session on how to use different inhaler devices at a clinical meeting within 3 months. To create text message templates with video links on how to use the inhaler for different inhaler devices to be sent to patients when their inhaler device type has changed within 1 month.
  • See disclaimers

How to carry out this project

  1. Study

    How does your practice compare with other practices in your area, region or nationally in terms of your prescribing of lower carbon dry powder inhalers? We know that in most European countries the majority of patients needing inhalers are prescribed DPIs and in some Scandinavian countries the proportion of DPIs is greater than 80%. The UK is an outlier prescribing more metered dose inhalers than lower carbon inhalers.

    Practices in England can look at the following prescribing data sets:

    ePACT2 data. Respiratory – Carbon Impact Dashboard. Measure: Prescribing of low carbon preventer inhalers as a proportion of all preventer inhaler prescribing. (The higher the better).

    Open Prescribing: Greener NHS measures.  Measure: MDIs prescribed as a proportion of all inhalers in BNF Chapter 3, excluding salbutamol. (The lower the better)

  2. Obtain Placebo devices

    There are many different inhaler devices available to treat asthma and it is crucial that clinicians are familiar with how to use the ones recommended in their local guidance.

    Order placebo devices for the inhalers on your local formulary to use at the clinical learning session and during consultations. These are available for free for pharmaceutical companies and are crucial to building the confidence of the clinical team. Clinicians are more likely to prescribe a device they are familiar with and patients are more likely to be offered a choice of inhaler device type.

    This guide on obtaining placebo inhaler devices from 2023 may be useful.

    Chiesi allows placebo devices to be ordered directly from its website. Request a Placebo Training Inhaler from Chiesi I Chiesi Air

    Turbohaler training inhalers are useful to teach technique as these have a  whistle inside the trainer will sound when the inspiration flow required to use the actual Turbohaler is achieved.

    Some people find inhaler training devices, such as the In-Check Dial, useful for assessing a patient’s inspiratory flow. It can help clinical staff and patients visually understand which type of inhaler may suit them best.

     

     

  3. Educate the clinical team

    Organise a learning session with your clinical team.

    Prior to the meeting you may wish to send your clinical team a link to our device choice video. Other useful videos are the improving asthma reviews which demonstrate how to discuss inhaler devices in an asthma consultation.

    You may also wish to download or print out copies of the visual aid for improving asthma reviews which has a simple section on device choice.

    Discuss your practice level data if you have this.

    Is everyone confident and competent to teach the inhaler techniques of the low carbon inhalers on your formulary? Does everyone understand how to ensure that device choice focuses on improved asthma control.

     

     

    Resource: Greener Practice Asthma Toolkit Device Choice Video

    View

  4. Improve patient resources

    It is useful to create text message templates with links to inhaler technique videos so that these are easy to find and routinely send to patients any time their inhaler device has been changed on their inhaler technique needs reinforcing.

    This reinforcement should be in addition to assessment and demonstration of good inhaler technique in the consultation.

    Pharmacies who are part of the phamacy quality scheme should show patients how to use their inhaler device as part of the new medicines service.

    Resource: SMS templates

    General SMS: Here is a video link to show you how to use your new inhaler (insert appropriate link). If there are any issues, please book a review. Remember, if you’re needing to use your inhaler for relief of symptoms more than twice per week, this may mean your asthma is not be well controlled and you should book an asthma review. Some examples for different inhaler devices. You may need to adjust according to your local guidance. Turbohaler You have been prescribed a type of inhaler called a Turbohaler. Please click on the link to watch a short video which explains how to use this inhaler. https://www.asthmaandlung.org.uk/living-with/inhaler-videos/turbohaler. If there are any issues, please book a review. Remember, if you regularly need to use your inhaler for relief of symptoms more than twice a week, this may mean your asthma may not be well controlled and you should book an asthma review, NEXThaler You have been prescribed a type of inhaler called a NEXThaler. Please click on the link to watch a short video which explains how to use this inhaler. https://www.asthmaandlung.org.uk/living-with/inhaler-videos/nexthaler Remember, if you regularly need to use your inhaler for relief of symptoms more than twice a week, this may mean your asthma may not be well controlled and you should book an asthma review, Easyhaler You have been prescribed a type of inhaler called an Easyhaler. Please click on the link to watch a short video which explains how to use this inhaler. https://www.asthmaandlung.org.uk/living-with/inhaler-videos/easyhaler Remember, if you regularly need to use your inhaler for relief of symptoms more than twice a week, this may mean your asthma may not be well controlled and you should book an asthma review, Ellipta (for Relvar) You have been prescribed a type of inhaler called an Ellipta inhaler. Please click on the link to watch a short video which explains how to use this inhaler. https://www.asthmaandlung.org.uk/living-with/inhaler-videos/ellipta

  5. Information to all asthma patients

    You may  wish to send all your asthma patients information on low carbon inhaler devices so that they have some information on these prior to their asthma review. You can consider changing your inhaler review invite. Have a look at the project Optimising asthma reviews.

     

  6. Follow-up patients

    Consider how you will follow up patients who have had their device or medication changed 6-8 weeks later. Will you organise a face-to-face appointment or a video/telephone check? Will you send everyone a text message?

    Resource: Follow up SMS

    We hope you are getting on well with your new inhaler. If there are any issues, please book a review. Remember, if you’re needing to use your inhaler to for asthma symptoms more than twice a week, this may mean your asthma may not be well controlled and you should book an asthma review as soon as possible.

  7. Study

    Decide when to study again to ensure the change has lasted e.g. 6-12 months and use the Project Monitoring form to keep track.

    Practices in England can look at the following prescribing data sets:

    ePACT2 data. Respiratory – Carbon Impact Dashboard. Measure: Prescribing of low carbon preventer inhalers as a proportion of all preventer inhaler prescribing. (The higher the better).

    Open Prescribing: Greener NHS measures.  Measure: MDIs prescribed as a proportion of all inhalers in BNF Chapter 3, excluding salbutamol. (The lower the better)

    You may wish to bring this back to a clinical meeting to see if the clinical team feel confident about prescribing lower carbon inhalers or if a refresher session is required.

     

     

Top tip

Order plenty of placebo inhaler devices for the inhalers on your formulary and ensure clinicians know how to use them and teach about their use.

How to scale this project up or down

You could choose to order placebo devices for all the practices in your PCN and run the training session at this level.

Have you completed this QIP?

Tell us a little about your project in order to generate a certificate showing the probable benefits. The carbon savings data from this project are best calculated after average figures can be obtained 6 or 12 months after the initial intervention. This project may help with CQC evidence submission (see disclaimers).

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