Professor Omar Usmani, a UK-based respiratory physician and international authority on aerosol science and inhalation medicine, shares his insights on the growing tension between environmental concerns and optimal asthma management.

Several years ago, the UK government began incentivising primary care physicians to switch patients from metered-dose inhalers (MDIs) to dry powder inhalers (DPIs). The reasoning was sound: MDIs contain propellants called F-gases with significant global warming potential, while DPIs have a much lower environmental impact.

However, Professor Usmani says these well-intentioned policies led to unintended consequences.

“There were blanket switches occurring remotely and without consent,” he explained.

Rather than being clinical decisions made in consultation with patients, these were administrative changes often made without patient knowledge or education.

The results were troubling.

Patients found themselves with unfamiliar devices they hadn’t been trained to use, leading to poor technique, suboptimal drug delivery, and worsening symptoms. This frequently resulted in unscheduled visits to healthcare providers and, in some cases, hospital admissions—ironically creating a larger carbon footprint than would have been saved by the inhaler switch.

Education on inhaler use sorely lacking

A fundamental issue is that respiratory medicine uniquely prescribes two components: the drug and the device. Yet healthcare professionals receive extensive training on pharmacology, but minimal education on inhaler devices, Professor Usmani explains.

This knowledge gap is startling. A Spanish survey of over 6,000 healthcare professionals, including doctors, pharmacists, nurses, and physiotherapists, found that only 11-12% knew how to properly instruct patients on inhaler use.

As Professor Usmani put it, “If we don’t know how to instruct our patients, therein lies the problem.”

The patient perspective

Beyond technical considerations, there’s a psychological dimension to inhaler use that is often overlooked. Professor Usmani’s research shows that patients develop conditioned responses to their inhalers—from the sensation of aerosol or powder in their throat to the taste and physical feel of the device.

“I could be a guinea pig, that’s how I feel. It’s affected my relationship with the doctor,” one patient said.

“I think it’s made me more aware that me as a patient hasn’t got any control really. It’s out of my hands and I find it scary,” is how another patient described their experience.

These reactions highlight how non-consensual inhaler switching can damage the doctor-patient relationship and patient autonomy. As healthcare becomes increasingly personalised across specialties, respiratory medicine risks moving backward by taking a one-size-fits-all approach to inhaler devices, Professor Usmani argues.

Practical considerations for Australian GPs

For Australian GPs faced with similar pressures to prescribe more environmentally friendly inhalers, Professor Usmani offers valuable guidance.

If it isn’t broken, don’t fix it: If a patient has stable, well-controlled asthma with their current device, switching may introduce unnecessary risk.

Focus on reliever overuse: The “low-hanging fruit” for reducing environmental impact is addressing overuse of short-acting beta-agonist (SABA) relievers, which make up nearly 60% of MDI prescriptions in the UK. “So that’s the one that we really need to focus on. If we cut back on that we’ll cut back on the F-gas and that will lead to better asthma control because our patients will be on an ICS and that will lead to better planetary health,” Professor Usmani says.

Practice tip: Since patients can relievers over the counter, it’s important to proactively ask about their device use, and check to make sure they’re using them correctly. – Dr Marita Long

Ensure proper device matching: The inhalation technique differs significantly between devices. MDIs require slow, steady inhalation, while DPIs need fast, forceful inhalation. Mixed devices can lead to technique confusion and poorer outcomes.

Be aware of storage requirements: DPIs should not be stored in bathrooms or car glove compartments, as humidity and heat can compromise the medication.

Consider all environmental factors: While MDIs have a higher atmospheric impact, DPIs contain more plastic, potentially creating greater plastic pollution and marine ecological impact.

Eco-friendly MDIs in development

Pharmaceutical companies are responding to environmental concerns, Professor Usmani says, noting that new MDIs with global warming potential equivalent to DPIs are expected to be available within a year to a year and a half.

In the meantime, he suggests these practical approaches:

• Become “device detectives” who can spot errors in a patient’s inhaler technique
• All inhaler switches should be done face-to-face, never remotely
• Consider broader lifestyle changes for environmentally conscious patients
• Address the complete picture of asthma management, including correct diagnosis, comorbidities, and non-pharmacological treatments.

For Australian GPs, the additional challenges of over-the-counter SABA availability and 60-day dispensing create further complexity, making regular review of inhaler technique and usage patterns even more critical.

A reminder to ‘do no harm’

Professor Usmani’s message is that while climate action is essential, our primary duty as healthcare providers remains to “do no harm.”

“When clinically appropriate, obviously, and when it’s safe and acceptable to patients, then certainly one needs to consider tailoring the right device to the right patient. But I wouldn’t support blanket switching of patients from one to another type, particularly remotely,” he sums up.

The lesson from the UK experience is clear: environmental goals and optimal patient care need not be in opposition, but achieving both requires careful, individualised decision-making and proper patient education.

By becoming “device detectives” who ensure patients can use their inhalers effectively, GPs can improve clinical outcomes while still contributing to environmental sustainability.

As healthcare systems worldwide navigate this complex intersection of planetary and patient health, the principle of personalised medicine—matching the right patient with the right device, with proper education and consent—offers the most promising path forward.

This article was based on a podcast Professor Usmani recorded with Dr Marita Long for Healthed. Listen to the full episode here.