We have detected you are using Internet Explorer. To provide the best and most secure experience, please use a modern browser as we do not support Internet Explorer.

Green with Asthma

20 August 2019 - Dr Neal Tucker


Many of us of are becoming more carbon-conscious. Whether this means cutting down on red meat (turns out the vegans were right all along), using the car less (until we can actually afford a Tesla), or skiing in Australia instead of getting on a plane (which may actually be preferable to managing small children in an enclosed space at 10,000ft), there is more that most of us can do.

But if you have asthma, how should you react to the recommendation in the latest BTS / SIGN guideline on asthma management to use inhalers with a low-global warming potential? BTS and SIGN are not alone here. In April NICE also made similar recommendations. While changes are happening overseas, it seems to have not made much of a splash in Australia, leaving many somewhat confused.

Context is useful.

You might remember hearing about "CFCs" — chlorofluorocarbons — and their dire effect on the ozone layer. These were phased out of various uses, including in the metered dose inhaler, in accordance with the international treaty, the Montreal Protocol, starting in August 1989.

But CFCs were replaced with "HFCs" — hydrofluorocarbons. Safe for the ozone layer, but potent global warming gases. 

A recent amendment to the Montreal Protocol has now planned a phase-out of HFCs too. But it's slow, with deadlines decades away. Earlier prudent management of these gases could make a big difference to climate change.

A person using a preventer inhaler monthly, plus the odd reliever inhaler, could easily release the annual equivalent of a quarter of a ton of carbon dioxide. That's like burning 100 litres of petrol.

There are simple alternatives

Dry powder inhalers have 25x less carbon footprint than MDIs or breath-actuated inhalers.

It's feasible for many people, but not all, to use either sort of device. Young children do better with metered dose inhalers and spacers, as do people who struggle to inhale. But most asthmatics can inhale well from dry powder inhalers.

The two types of inhaler seem to work just as well as each other. If anything the dry powder ones might be a little better.

Metered dose inhalers are more often prescribed than dry powder devices in many countries. But this has more to do with history and familiarity than effectiveness.

However, patients can be flexible. Most would be happy to try something different and, given the relevant information, many would be doubly keen to. So now is the time for us to educate ourselves a bit more on the plethora of options at our fingertips. The good news is that, while there is a confusing array of inhalers on the market, there are also excellent resources to help. 


The Asthma and COPD Medications chart was developed independently by the National Asthma Council Australia and has the details of most commonly available asthma and COPD inhalers in Australia. The Australian Asthma Handbook is also a fantastic resource.

For further information, Asthma Australia is a veritable font of knowledge with lots of instructional resources for ensuring good inhaler technique.

Australia switched smoothly from CFC to HFA inhalers in order to protect our environment. Is it time for another change?

This article was originally published on the NB Medical Education Hot Topics Blog on 15 August 2019. Edited by El Carey 29 August 2019.

Dr Neal Tucker
Dr Neal Tucker

Neal is the E-learning lead for NB Medical Education and a lecturer on the Hot Topics course. Having previously been a partner in an Oxford practice, he now works on a sessional basis around Oxford to facilitate his educational work.

Related Tags
Related Categories
Get Medcast Plus

Become a member and get unlimited access to 100s of hours of premium education.

Learn more
Latest News
Tools for your practice: VETERAN lens autofill template
Brand icon

This useful tool shows the aspects of the Veteran Health Check to incorporate into all relevant consultations with Veterans at any time after transition, including a useful autofill template.

5 mins READ
Keep the Fire Burning: bridging gaps and building trust

Australia's healthcare system, often lauded for its comprehensive and accessible nature, has a glaring gap when it comes to addressing the unique needs of First Nations people.

5 mins READ
New resources to optimise veteran healthcare
Brand icon

Launching tomorrow, the Department of Veterans’ Affairs has partnered with medical education company Medcast, to provide freely available resources for health professionals to assess and manage veterans’ health.

5 mins READ