In this commentary from the Respiratory Effectiveness Group (REG), Professor Omar Usmani and colleagues outline a pragmatic approach to inhaler choice that prioritises individual patient needs while acknowledging the environmental impact of inhaler prescribing. Drawing on real-world evidence and global survey data, they argue that personalising treatment is key to improving outcomes in respiratory disease without compromising sustainability.
Inhaled medications are vital for managing chronic conditions such as asthma and chronic obstructive pulmonary disease (COPD), but choosing the right inhaler can be complex. There are many factors to balance, including cost and the environment.
With over 230 drug-delivery system combinations available for COPD and asthma treatment, healthcare professionals (HCPs) have a wide choice in device types and medications to find the right ‘fit’ for each patient.1
Despite this variety, achieving and maintaining disease control remains challenging, with patients having sub-optimal device use often due to poor inhaler technique, suboptimal adherence or mismatched devices and medications.1,2
The challenges of maintaining disease control
Patients with poor disease control face a high risk of adverse health outcomes and increased exacerbations. Inhalers are essential for maintaining control in asthma and COPD, making it critical to personalise inhaler choice by considering both the medication and delivery method.3
Each inhaler type has its unique characteristics and handling requirements that must match the patient’s abilities: pressurised metered-dose inhalers (pMDIs) require careful coordination of actuation and inhalation, dry powder inhalers rely on sufficient inspiratory effort, and soft mist inhalers generate a slow mist requiring minimal inhalation force but are limited in medication options.1,4,5
These differences highlight the importance of selecting devices tailored to individual patient needs to maximise adherence, ensure correct inhaler technique and achieve effective treatment.
An additional challenge in inhaler choice is environmental impact. This concern arose due to the chlorofluorocarbon (CFC) propellants used in pMDIs, contributing to the depletion of the ozone layer and leading to the Montreal Protocol in 1987.6
As a result, manufacturers switched to CFC-free pMDIs using hydrofluorocarbons (HFCs).7 However, recent international pressure has prompted the European Commission to propose a quota system aimed at reducing high global warming potential (GWP) propellants like HFCs in favour of those with lower GWP.8 Indeed, environmental concerns have become more prominent, with international policy encouraging shifts away from high-GWP inhalers.
The Respiratory Effectiveness Group and its mission for inhaler choice
The Respiratory Effectiveness Group is an international not-for-profit initiative founded by experts in real-world respiratory research. The group generates evidence that reflects everyday clinical practice to inform guidelines, prescribing and policy.
By bringing together a collaborative global network of clinical respiratory specialists, academic researchers and industry representatives, the group undertakes high-quality research to enhance the visibility of real-world evidence and integrate it into clinical guidelines and policy decision-making, ultimately improving respiratory patient care.
The Respiratory Effectiveness Group’s mission is to generate actionable insights that advance patient outcomes. In this respect, in 2025, we published a position statement on inhaler choice in the context of personalised patient healthcare and environmental responsibility.9
We undertook research across 42 countries, showing that both healthcare professionals and patients with COPD or asthma prioritise disease control and patient capability when choosing inhalers over and above environmental concerns and sustainability.10
Our survey questionnaire found that while respondents were concerned about climate change, environmental impact ranked well below efficacy, adherence and patient need as a driver of inhaler choice.10 These data informed the position statement, advocating a pragmatic approach: patient needs must come first, alongside greener inhaler options and better recycling initiatives where clinically appropriate.9
While patients and HCPs are concerned about climate change, patient wellbeing must come first in treatment decisions, including when prescribing inhalers with a higher GWP.
Inhaler choice mitigating the environmental burden of exacerbations
The effective management of asthma or COPD aims to reduce exacerbations and disease attacks. This will decrease the carbon footprint burden associated with healthcare resource utilisation, such as driving to a practitioner, the use of reliever inhalers and the need for emergency treatment and hospital admission.
A study of UK adults found that annual severe or life-threatening asthma exacerbations accounted for approximately 448,037 tonnes of CO2 equivalent (CO2e) emissions.11 At the same time, inhalers prescribed in England, Scotland and Wales contribute around 1.34 billion kilogrammes of CO2e, with pMDIs contributing the greatest share of between 66.6% and 71.5% across the three nations.12
This emphasises the importance of good disease control, with minimal use of short-acting pMDIs in relation to GWP, and supports the Group’s position that patient needs must come first.
Our position statement also reflects on the recyclability of the inhaler as a consideration. However, neither HCPs nor patients in our survey were aware of recycling schemes or had schemes available to them,10 highlighting a gap that could help reduce GWP without compromising patient care.
Conclusion
Inhaler prescribing must remain patient-centred, balancing individual clinical needs while recognising the importance of reducing environmental impact.
The Respiratory Effectiveness Group supports innovation in greener inhaler technologies and improved recycling initiatives but advocates that decisions to switch inhalers should never be driven solely by environmental factors. Prioritising the right device for each patient is essential to achieving optimal clinical outcomes alongside environmental sustainability.
Ongoing innovation and collaborative efforts across healthcare, industry, and policy will be critical to achieving these goals and ensuring a sustainable future for respiratory care.
Authors
Omar Usmani MBBS PhD FHEA FRCP FERS
Professor of respiratory medicine, National Heart and Lung Institute, Imperial College London, UK
Helena Emery PhD
Scientific researcher, Respiratory Effectiveness Group
Valeria Perugini PhD
Scientific researcher, Respiratory Effectiveness Group
References
- Cataldo D et al. How to choose the right inhaler using a patient-centric approach? Adv Ther 2022;39(3):1149–63.
- Usmani OS et al. The impact of inhaler device regimen in patients with asthma or COPD. J Allergy Clin Immunol Pract 2021;9(8):3033–40.e1.
- Usmani OS et al. Critical inhaler errors in asthma and COPD: a systematic review of impact on health outcomes. Respir Res 2018;19(1):10.
- Sanchis J et al. Systematic review of errors in inhaler use: has patient technique improved over time? Chest 2016;150(2):394–406.
- Usmani OS. Choosing the right inhaler for your asthma or COPD patient. Ther Clin Risk Manag 2019:461–72.
- United Nations Environment Programme: Ozone Secretariat. The Montreal Protocol on Substances that Deplete the Ozone Layer. [Accessed August 2025].
- Leach CL. The CFC to HFA transition and its impact on pulmonary drug development. Respir Care 2005;50(9):1201–8.
- European Medicines Agency. Questions and answers on data requirements when transitioning low global warming potential (LGWP) propellants in oral pressurised metered dose inhalers. [Accessed August 2025].
- Usmani OS et al; Respiratory Effectiveness Group. Letter: Respiratory Effectiveness Group Position Statement: Inhaler Choice: Balancing Personalized Health Care and Environmental Responsibility. J Aerosol Med Pulm Drug Deliv 2025 Jun;38(3):145–7.
- Lough G et al. Patient and provider perspectives driving inhaler choice: Optimizing sustainable health care. Chest 2024;166(5):934–7.
- Kponee-Shovein K et al. Carbon footprint and associated costs of asthma exacerbation care among UK adults. J Med Econ 2022;25(1):524–31.
- Homan K. Bulletin 295: Inhaler carbon footprint. PrescQIPP C.I.C.2021.
