October 08, 2025

00:25:03

GOSHpods Goes Green S3 - Episode 5: Inhalers

Hosted by

Emma Forman Dr Rhian Thomas
GOSHpods Goes Green S3 - Episode 5: Inhalers
GOSHpods
GOSHpods Goes Green S3 - Episode 5: Inhalers

Oct 08 2025 | 00:25:03

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Show Notes

 

In this episode, Sarah Ahmed, GOSH Digital Fellow, hosts a dynamic conversation with Stephen Tomlin (Director of the Children’s Research and Innovation Centre and Medicines Sustainability Lead for North Central London ICB), alongside Stacey Moris and Nicola Moodey, Complex Asthma Clinical Nurse Specialists at Great Ormond Street Hospital.

Together, they explore the environmental impact of asthma care—balancing carbon footprints with
the challenge of non-recyclable plastics in inhalers. The team dives into the complexities of inhaler
swaps in paediatrics, and why patient-centred prescribing is key to both sustainability and safety.

Highlights include:
- Why switching inhalers isn’t always straightforward in children
- The importance of prescribing inhalers that patients can—and will—use
- A call to action: return unused medications to your pharmacy
- How asthma care can evolve to support both health outcomes and the planet

This episode is essential listening for clinicians, sustainability advocates, and anyone passionate
about greener, smarter healthcare.


Tune in now to discover how small changes in asthma care can make a big difference.

Sound effects obtained from https://www.zapsplat.com

View Full Transcript

Episode Transcript

This Podcast is brought to you by the GOSH Learning Academy. [00:00:04] SA: Welcome to the third season of GOSHpods Goes Green. In this season, we're going to be focusing on medicine sustainability. In 2021, Great Ormond Street Hospital was the first UK children's hospital to declare a climate and health emergency. The NHS as an employer is responsible for 4 percent of the UK's total carbon emissions. And medicines are responsible for 25 percent of that. We're going to explore this topic further, taking a journey through the life cycle of a medicine, covering everything from production and procurement, use of medicines in hospitals and homes, all the way through to medicines disposal, to properly explore how we can change the impact that medicines have on the environment. [00:00:46] Sarah: I am so excited to be joined by various members of the team at Great Ormond Street today to have a conversation about inhalers and how they tie into this greater conversation we've been having about medicine sustainability. So I wonder if we can start with a round of introductions. So do you want to just tell everyone. Who you are and what it is that you do at GOSH. Stephen, let's start with you. [00:01:10] ST: Thanks very much. I'm Steve Tomlin. I'm the director of the Children's Medicines Research and Innovation Centre, but I'm a consultant clinical pharmacist by trade. And I have the, I'm going to say the joy and the privilege of leading on medicine sustainability within North Central London. [00:01:30] Stacy: I am Stacey Morris. I am one of the asthma, CNS's part of the complex asthma team here at GOSH. [00:01:36] Nicola: and I'm Nicola Moody. I am Stacey's colleague. I'm also a clinical nurse specialist for complex asthma here at Great Ormond Street. So we generally cover patients that have been seen in primary care, referred on to secondary care, and then are still having difficulties maintaining their control, their asthma control, so they're referred over to us here at Great Ormond Street. [00:01:57] Sarah: Wonderful. It's so great that we're going to have a variety of opinions about this and inputs with Steve coming from the pharmacist point of view, and then Stacey and Nicola talking kind of about frontline and how this relates to kids who are being treated for their asthma. So I suppose we should start by setting the scene a little bit. So why is it important that we talk about inhalers in this greater conversation about medicine sustainability? [00:02:24] ST: So important that we touch on inhalers, because whilst we know that medicines per se are about 25 percent of the NHS carbon footprint in totality, the two biggest parts of that are anaesthetic gases and the other is inhalers. Therefore, so important that we talk about this specifically. And in terms of children, so important because I'm going to say asthma is one of those bread-and-butter topics of paediatrics. [00:02:56] Nicola: I mean, it's one of the most common diseases in childhood in the uk. So I think we're currently at one in 11 children have had the diagnosis of asthma. So therefore you can imagine that the impact of that, if all of those children are prescribed an inhaler, whether it be a preventer or a reliever, both you know, the impact of that on the environment will be massive. [00:03:18] ST: Think about 3 percent of NHS footprint is just inhalers. Therefore, it's a standalone thing. It's significant. And the UK had a fairly skewed model compared with the rest of Europe in terms of what they use. I think our usage of the meter dose inhalers, which are the ones with all the gas in, which is the primary issue we're talking about here, are about 70 percent of the use. That's across the board. This isn't in paediatrics, but 70 percent of the inhalers we use are the ones which are seen as not great for the environment. So MDIs, whereas you go to parts of Scandinavia, and that goes as low as sort of 10 or 20 percent in some places. And so within the UK, it's really important that we do consider what it is we're using, as it is such a significant part of what we do. [00:04:06] Sarah: And what is it about an MDI inhaler, which is less good for the environment? You said it was the gases what's wrong in inverted commas with the gases? [00:04:15] ST: It's a good question, because many years ago, we thought we'd solved this. There used to be a different propellant that was actually in the inhalers. They became banned because they were actually destroying the ozone layer. The ones that we've replaced it with aren't specifically destroying, but they are a very potent greenhouse gas in their own right. And therefore, again, I'm hoping that they will change at some point, but that is the significant part of it. But also, there's a lot of plastic involved and there's a lot of aluminium involved in terms of what the gas is that actually held in. Don't know if we want to pick up sort of what we're using currently within paediatrics and why are we using so many meter dose inhalers at the moment. [00:05:05] Stacy: Most of our children, obviously, under the age of 12, we obviously prescribe them the MDIs more than the breath actuated ones, purely because of technique, and understanding of how to take it. yeah, just the education side of things with We've taken, it's easier to explain how to take , the MDIs with the spacers and get that breathing under control, get those good breaths with the spacer and the MDI rather than taking the breath actuated inhalers. [00:05:34] Sarah: And just to clarify, the MDI is like what I would describe as a picture inhaler, the blue one that you take a breath, and you breathe in, whereas the dry powder, the technique is different, isn't it? [00:05:45] Nicola: Yeah. So, there's a few things with them. First of all, prescription licensing issues. As you can imagine, there's lots of different brands, there's lots of different preparations and different preparations of brands are licensed in the younger children versus the older children. So, a lot of the regimes as you say do see the picture-perfect inhaler the meter dose inhaler, which is exactly that. And that's what you would see on all of the pictures, but yeah, there are licensing issues that mean that certain children of certain ages wouldn't even be eligible for the inhalers as well that we need to consider. [00:06:17] ST: I was going to say, it's not that children can't use MDIs, but it's the ages. So, when we talk about children here, this is significantly under the age of 12. There are children under the age of 12 who do use dried powder devices, but it's generally not the preferred one. And there's a lot of discussion on what happens between 6 and 12 that sort of thing. But I suppose the significance in terms of the environment, and obviously there's lots of different data, but I think the most extreme data is that one meter dose inhaler, the carbon footprint of that is the same as 175 mile journey. And a dry powder device is about four miles. So, it's hugely different that there are others which bring them a bit closer together, and it obviously lots of different brands and lots of different devices. But at the extremes, that is the difference and just switching one patient from a meter dose inhaler to a dry powder device saves about one flight from London to New York. So just obviously many different ways of explaining carbon footprints. But when you look at it like that, that shows the significance of why we have to understand why we're using the metered dose inhalers because often it is appropriate, but it is a significant harm to the environment. [00:07:35] Sarah: But I've also heard an argument that dry powder inhalers might not be the solution that they also cause harm to the environment. Could you tell us a little bit more about that? [00:07:46] ST: Yes, I suppose there's a carbon footprint and there is everything else to the environment that that products do. And if you look at a dry powder device, there's probably a lot more plastic in those than there is in a meter dose inhaler. And they are quite solid things with lots of different layers within them and those plastics, most of those are not recyclable. So, whilst we tend to think of recycling lots of plastics in our home waste That all of the complex plastics that are in the dry powder device aren't recyclable and therefore you've got a An issue in its own right so the carbon footprint might be better but in terms of plastic They are that there's even more plastic involved with the dry powder device. So it's not all good. When you look at that swap, and I think that's really important for people to know, particularly in paediatrics, where we're struggling to do the swap and the drive to swap. On a clinical basis, isn't there [00:08:47] Sarah: And Stacey and Nicola, I was wondering if you could tell us a little bit about whether or not this is something that you're considering in clinics when you see kids. Whether or not from a clinician point of view, but also from a family and public point of view, whether or not these are conversations that are being had about possibly switching over if appropriate for the child. [00:09:09] Nicola: Yeah, so absolutely. I think it definitely is. I'd say we go about it probably from a slightly different tact. So, we take all of the considerations of the family into consideration, basically. And what we do is we kind of go back to it from back to the basics, essentially. What we quite often find is that a lot of patients will come into our clinics and somewhere along the way, that education has just been lost. So, they don't quite understand the basics of their asthma control, and how to achieve optimal control and good asthma management. So we go back to the basics and revisit all of that. So we quite often find that they don't understand the difference between their preventer and their reliever inhaler. So they quite heavily rely on their reliever inhaler because they notice that's the one that they feel that instant relief and that benefit from essentially. So we go back and we talk about their asthma. We talk about exactly what is happening. And what we want to achieve is the optimum control so that they don't have to use their reliever. So therefore, if we can achieve that good control on their preventive medication, they won't need the extra reliever doses. So they won't need those harmful meter dose inhalers, which is normally, you know, the blue subutamol, and they won't need to use that because they will be well controlled. And then what we look at inside of that is, Is the preparation that they're on, is that suitable? So is that, can they take it? Can they take it well? And we go through sort of their techniques. We go through what device they're using. Are they using it correctly? Is it effective? Is their technique effective while they're using that? And if they are able to switch to a dry powder device, for example, we want to see that we want to assess that technique because I think poor understanding, poor technique. leads to the poor compliance and that potentially then leads to the overuse of the short acting beta agonist, which we know are really harmful for the environment. So it's definitely a multifactorial sort of view that we want to look at all these steps and see can these patients be switched? But if they can be switched, can either ourselves or their local team assess their technique? Because if we're unable to dispense that inhaler from us, we want to know that. That actually they can take it once they've received it. And that can either be via us, via a local team or via a video call as well, if needs be. [00:11:27] Sarah: It's, I mean, difficult is the wrong word, but it's not as simple as it, as just switching over to what might be the most environmentally friendly option, because compliance is important and it's hard enough to get kids to take medicine as it is. And if something works for a child and it's controlling their asthma, then yeah, I can just imagine it is more of a complex conversation, isn't it? Than just making switches. Because it's the, again, quote unquote, right thing to do. [00:11:57] Stacy: I'd say our biggest thing in our clinics with our patients, especially the age group that we deal with, is compliance and understanding and education of their medication. So, that's basically been our main goal. How we've arranged our reviews and how we do them is we focus them around, like Nick said, going back to the basics, but also making sure that the families understand, like having the education, using information sheets and stuff like that and just providing all the basic education and then checking every single technique every single time, even if we've seen them three months ago and that we've done this before, we still do it because we know it's a day-to-day task that they don't want to do at the age that they are. They're not invested into it. And so that's why they end up having to use their blue inhaler a lot more. It's just the age group we're dealing with. So, we try and hone it in on them that the preventor is key. We also, we do like monitoring on our inhalers as well. So to check adherence and check that they're taking that correctly, check that they're taking it at the right times, or if there's ways we can improve their routine to improve their compliance, which then hopefully will improve their control to reduce the inhaler use. [00:13:05] Sarah: I think that brings us on to a really important point about the monitoring because we're going to have kids that use MDIs. We're going to have some kids that use dry powder inhalers. So, what can we do in those situations to reduce the impact as much as we can, even if a child is going to use an MDI. And I suppose one of those things is making sure we're not prescribing a new inhaler if they don't need it. Recycling. Can we talk a little bit about kind of some of those concepts? [00:13:29] Nicola: Yeah, so, one of the things that we do quite often with our cohort of patients is we look at the prescriptions that they receive from the GP. So exactly as you're saying, we are able to look at what they are obtaining from their GP every year and then we can pick up. So, patients often have their reliever, their salbutamol inhalers to prescribed every month. and then we'll look at what they're receiving at their preventive medication and they're only maybe receiving 50 percent of it. But they've got this poor control and they're receiving salbutamol as a reliever. So, we work quite closely with GPs to try and tackle that and then discuss those issues. So when the patients come to our clinic and they have poor asthma control. We say, well, we can pick up that you're only having 50 percent of your medication and you're having a lot of extra salbutamol. So what can we do to combat this? Is there something we can switch you over to that would be more suitable for you to take? Is there a technique issue? And we can liaise between ourselves to combat that and tackle that and discuss with the GP, there are occasions when you would need to prescribe at the start of the school term, for example. But that shouldn't be, that's not sustainable to have that. We know it's a massive risk factor for, asthma attacks and admissions to hospital is having. all of those sabers prescribed. So that's one of the things we work quite closely. And we also always ask patients to bring their medications to clinic with them. So we call the patients before and say, please, can you bring everything that you would normally use for your asthma so we can go through everything with you? And one of the things that we often find is that patients are bringing empty inhalers to the clinics with them because they don't understand, that even if the dose counter is empty, the propellant that Steve has talked about is still released, it's still actuated, it's still released. So they see a gas come out. Well for the environment, that's terrible because they don't realise that even though their inhaler is empty, it will still expel the gas, even though there's no medication. So, it's education on inhalers that have dose counters, inhalers that don't and keeping a conscious monitoring of that, because that's a really high impact that we have found. And it's just continually going through it through education, through, primary, secondary, tertiary care. All of us go through it, I think. [00:15:32] ST: Certainly most of the meter dose inhalers currently don't have counters and it's a huge issue, both clinically and for the environments. If you're unsure whether you've actually still got doses left in your meter dose inhaler, obviously, there's a clinical worry, particularly in an emergency. But that's just been said. It also means that you could just be squirting around propellants, the worst bit for it for the environments for absolutely no gain that there is current work with the industry for that to change. And I think legislation will change, but it's going to take quite a while for that to turn over. So I think we are left with no counters foreseeable future. [00:16:11] Stacy: Yeah, we have found that a lot actually recently. We've often just asked the GPs to. Just prescribe a better one to say, to not do those ones. Unfortunately, I think it's obviously the cheaper model. But yeah, it's really difficult. That's one of the education things that we use is checking dose counters and how to know when to like, when you're running out and stuff like that. And when they're like, give us the inhaler that hasn't got a dose count. We're like, Oh how do we teach you? [00:16:32] Nicola: That's the thing. I mean, we've often said the best thing for our patients and the environmental impact is that the patient's prescribed an inhaler, which they can and will take. So actually, regardless of whether that is a dry powder or an MDI, if that reduces the amount of salbutamol or reliever that they use, and they will take it because they can, the impact of that is less than the latter sort of thing. So it's an inhaler that he can and will take well you know, is the best thing for the patient and for the environment because they won't be so reliant on extra reliever inhalers, trips to the hospital, which, it's not even covered in this topic, but that's another impact, on, on top of that, with poor asthma control. [00:17:14] ST: Obviously there's a benefit to the environment if you're giving two or three drugs with one propellant, I suppose, let's put it that way. And therefore, within the adult community, there is quite a drive to use the combination ones. Could you just talk how you think about that within paediatrics? [00:17:32] Stacy: Well, I think most of our patients, cause we're the complex asthma team. Most of our patients are on combination inhalers. And it's usually the two one with the steroid and the longer acting the LABA. So we usually have. The patient's on that and then they would have salbutamol, or they'll have an additional therapy if salbutamol wasn't working, or we do the SMART with the Simbacort, and then they use that as their reliever and their maintenance therapy. But again, that depends on the patient, the age, their techniques and stuff like that. If they've tried the MGI's with the combined inhalers, and they're on high dose and it's still not working for them and we've checked everything, we've checked education, we've checked their techniques, we've done monitoring, we've done investigations, then we sort of look at, okay, maybe this isn't the right medication for them and then we have a step up a dose or switch to a different inhaler, maybe at the same dose, but type of inhaler might work for them. A lot of our teenagers, we do the SMART therapy on, so the maintenance and relief therapy on, because they don't want to carry around the spacers. And we find that a lot of the patients just don't use a spacer. Again, that's another reason why there's a high use of Salbutamol because they're not taking it with their spacer, so they're needing more of it and then they're losing, they're using a lot more and then needing more inhalers to be brought in. So, we do a lot of encouragement with the spacer and explaining that you only get 5 percent of that medication if you're doing it straight into your mouth without spacer, so that is, it's just a continuous work with that and then, yeah. [00:19:04] Nicola: Yeah, no, it's exactly as you say, the patients that continue to be symptomatic and are needing those extra doses, we look to switch them to a combined inhaler because you are tackling the two things there in a bid to reduce the extra medication that they are using. [00:19:18] Sarah: I do like that idea that the best inhaler for the patient and for the environment is the one that they are going to use. I think that's such an important takeaway from what we've been talking about. I just wanted to wrap up a little bit to talk about recycling. So, I've seen so many QI projects recently presented at various different places of projects in hospitals where for the people who are using MDIs and dry powder inhalers, where you can recycle them. Steve, can you tell us a little bit about how those work? [00:19:52] ST: So currently, there's only one company in the UK who actually recycles meter dose inhalers. And obviously there is a charge for that. There are 2 pilot sites that have been looking at projects. 1 has finished. They looked at everybody posting their meter dose inhalers back to a central point and then going. And then there is another 1 going on, which is where people are dropping them off at their local pharmacy. I think we're all hoping that in the near future, that project will give us some indication as to how we should move forward. With this, and obviously the more people who return to the recycler, hopefully the cheaper that will become, because at the moment the recycling probably costs more than the inhaler itself in the 1st place. And so there is obviously an economy of scale here. So that we are all looking forward to in terms of the actual being able to recycle and it is recycling. They recycle the gas into things such as refrigerators. So, it gets reused. It doesn't they don't get rid of it. The aluminium is recycled and reused. Again, the hardest bit is the plastic to actually recycle that, but the aluminium, certainly, and the gas are put back into the system, which is good. It's obviously, carbon footprint is already there and therefore to carry on using it is good. But just in terms of, Patients and a drive. The best thing that people can do is return to their pharmacy. Now, a lot of people worry about that, because if you return to a pharmacy, it generally gets incinerated, and incineration is generally always got a bad sort of concept in people's minds. In terms of the environment, there must be fire involved. In terms of incineration, but if you just put your meter dose inhaler in the bin, and it goes to a landfill site. That gas is leaking out over many years. And the work that's been done so far would suggest that is far worse than it being incinerated. So, I suppose the call to action really is that people return their meter dose inhalers to their local pharmacy. Any scheme that's been done so far, trying to promote that has only had a return of 4 percent of all inhalers in the country. So. Most people don't and come back to our clinicians in a minute as to that looks. But I think that would be the ideal that people return it. If everybody did return, local pharmacies would actually have a bit of a problem and it's in terms of that recycling and things, but that's, that should be the goal for where we go. Now, whether people do, whether they're encouraged to and why they don't, I think is an interesting question. Question. I [00:22:41] Stacy: To be honest, we were talking about this a little while ago, like we weren't entirely sure how to recycle as well, where's the best and what information to give to the patients And no one really asks us either, do they, Nicola? I don't know. So it's hard, like we obviously, as part of our education and stuff now, we can add it in to tell the patients education wise what to do with it when you, when it finishes. But yeah, it's very, it's not really spoken about at all and it's only like dawned on us when we were having the last conversation about what actually do, how do we recycle these inhalers effectively. But yeah, [00:23:15] Sarah: Well, hopefully we can get the message out with this. [00:23:17] Stacy: yeah. [00:23:18] Sarah: That's the call to action. The best inhaler is the one that's right for the patient. And everyone should be taking their inhalers to the pharmacy afterwards to be disposed of appropriately. [00:23:28] Stacy: Exactly. [00:23:30] Sarah: On that note, thank you so much for having this conversation with me. It's been so fantastic hearing different perspectives from pharmacy point of view, an institutional point of view, but also clinicians on the ground. So Stacey, Nicola, Steve, thank you so much for talking with me today. [00:23:46] ST: Thank you very much. [00:23:48] SA: Thank you for listening to this episode of GOSH Pods Goes Green. We would love to get your feedback on the podcast and any ideas you may have for future episodes. You can find a link to the feedback page in the episode description or email us at digital.learning@gosh. nhs. uk If you want to find out more about the work of the GOSH Learning Academy, you can find us on social media on Twitter, Instagram, and LinkedIn. You can also visit our website at www.gosh.nhs.uk and search Learning Academy. We have lots of exciting new podcasts coming soon, so make sure you're subscribed wherever you get your podcasts. We hope you enjoy this episode and we'll see you next time. Goodbye.

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