How one clinic in Montreal is making the switch to greener inhalers

Physicians, nurses and pharmacists at the Clinique médicale du Sud-Ouest in Montreal have successfully reduced the amount of greenhouse gas released into the environment. How? By working with patients to reduce unnecessary use of pressurized metered-dose inhalers. Pressurized metered dose inhalers, used for treating asthma or COPD, use hydrofluorocarbon propellants that contribute to greenhouse gases. Inhalers used to use chlorofluorocarbons (CFCs) as a propellant but they were replaced with ones that used hydroflouroalkanes (HFAs) thanks to the 1987 Montreal protocol on substances that deplete the ozone layer. HFAs still send out greenhouse gases unfiltered into the environment. According to an initiative of the University of Toronto called the sustainable health system community of practice, 100 pressurized metered-dose inhaler doses are equivalent to a 290 km car ride. All those doses have an impact: HFA inhalers alone contribute to three percent of the U.K.’s National Health Service (NHS)’s carbon footprint. The alternative is dry-powder inhalers or soft-mist inhalers. They contribute less than 20 g of carbon dioxide equivalency per inhalation, compared to HFA inhalers which contribute 100 g carbon dioxide equivalency per inhalation, according to a March 2022 paper in CMAJ. A post-hoc analysis published in Thorax in 2022 showed switching inhalers not only decreased the carbon footprint, but patients were able to maintain their asthma control. Read: Waste not, why not? From anesthetic gases to circular-use resource, hospitals need to green up their acts Staff at the Clinique médicale du Sud-Ouest in Montreal saw the literature and wanted to make a change in their clinic. Family medicine residents sometimes take on sustainable inhalers as a quality improvement project, but the clinic is not a teaching site, so it was up to the 35 family physicians and other staff to initiate the change. One of the clinic’s pharmacists, Léa Prince-Duthel, extracted data from the clinic’s EMR, which showed that 50% of the inhalers prescribed were dry powder or soft mist, and 50% were HFA. “Every time you stop HFA inhalers that are not needed and switch to non-HFA inhalers, it has a huge impact,” said Dr. Geneviève Ferdais, a family physician at the clinic. The goal is to get close to Swedish prescription statistics, where only 13% of inhalers are pressurized metered-dose inhalers, Dr. Ferdais said. A discussion of the Swedish experience is in a 2020 paper in Thorax. “We know we can reach that without compromising the quality of care.” Read: Net-zero healthcare by 2050: What Canada needs to succeed One key step in the initiative was education, both for providers and for patients. Dr. Ferdais helped created a CME webinar with University of Montreal on inhalers, focusing on five cases that may present in clinical practice. It's available for free for physicians and other healthcare professionals, and was shown at the clinic. The initiative leaders also made a poster showing all the inhalers, with a big X on the ones that have high greenhouse gas emissions. The poster is displayed in all the clinical areas, and some other posters about green inhalers are in the waiting room. One of the nurses took a training session to ensure she could teach patients on how to use dry powder inhalers appropriately. There's also a strategy in place so a pharmacist can evaluate if the patient’s asthma or COPD is being adequately controlled with the new inhaler and, if not, they can adjust the treatment if necessary and create an action plan with the patient. They also checked for appropriate prescribing of inhalers, and nurses did a medication review with patients. Previous studies suggest up to a third of people on inhalers for asthma don’t have asthma when tested. “We’re not only trying to reduce greenhouse gas emissions, but also make sure the quality of care is even better than it was,” Dr. Ferdais said. The idea is that every time a clinic physician sees a patient on an inhaler, or has a fax to renew inhalers, they take the opportunity to see if that patient can switch or even needs an inhaler. “It becomes a reflex,” Dr. Ferdais said. “I know it’s not always easy, because often patients come to you with five other problems and that’s not even on his radar, and you have limited time to see him,” she said. Read: Wildfire smoke can damage the brain long after flames are extinguished, research says The Clinique médicale du Sud-Ouest’s initiative to reduce the number of HFA inhalers started in December 2022 with the webinar presentation and posters. Every physician was sent a survey about inhaler prescribing in January, and the initiative was discussed at the clinic's annual general meeting in February. Six months later, Prince-Duthel reviewed the clinic’s EMR data and found prescriptions had changed to 65% dry powder inhalers and 35% HFA inhalers. While many physicians switched patients to greener inhalers, about half hadn’t changed ttheir prescribing habits at all. The initiative team contacted physicians one by one to see if they needed more support in changing patients over to the dry inhalers. They also posted each doctor’s inhaler prescription statistics beside the coffee machine to spark a friendly competition. In six months, the initiative leaders will look at the numbers again. There'll be a celebration for those who have changed the most, Dr. Ferdais said. “Hopefully we can be close to the Swedish numbers.” “Greenhouse gas emissions from inhalers are so much worse than our other prescriptions or even the amount of garbage we produce, so it really is worth it,” she said. Patients reacted to the switch differently. Young people with asthma tended to be very receptive, Dr. Ferdais said. “Climate crisis is definitely something that will affect their life directly: being asthmatic and having wildfires and heat waves. They can relate quite directly to their own health.” Parents of children were also on board. “Parents are usually very interested that we’re not only taking care of their respiratory disease, but actually thinking of a more global health and the climate at the same time,” she said. Older patients with COPD who have had the same prescription for years sometimes had a reluctance to change, Dr. Ferdais said. Everything was considered on a case-by-case basis and patient choice was taken into account. Some patients tried the new inhalers and said “not for me.” The switch has to be made on a case-by-case basis. The Scottish government recently published draft guidance noting that a switch to greener inhalers should only be made if effectiveness, safety or adherence is not compromised. Some patients, of course, need the pressurized metered-dose inhalers. These include patients six years and younger and sick patients who can’t inhale with enough vigour to get an appropriate dose of the medicine, Dr. Ferdais said. Yet even in these cases, it's possible to reduce the carbon footprint by choosing an inhaler that uses less HFA per dose, or one that uses a combination of molecules or one with a higher concentration of medicine so a patient needs fewer doses. Read: Updated Canadian guidelines on pharmacotherapy of stable COPD The Clinique médicale de Sud-Ouest’s initiative used material provided by CASCADES, an initiative of a number of institutions and funded by Environment and Climate Change Canada. It has a playbook with patient and provider education on inhalers, prescribing tools and how to search the EMR for dry powder inhalers, soft mist inhalers and metered dose inhalers. “It’s time consuming, but it’s worth it, because in terms of climate impact it’s the worst medication we’re prescribing,” Dr. Ferdais said.

How one clinic in Montreal is making the switch to greener inhalers

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