General Notes

• British Thoracic Society (BTS) and SIGN guidelines on the management of asthma - SIGN 158 - British Guideline on the Management of Asthma

• NHSL Guideline: Asthma Treatment Guide (Adults): including step-wise approach to formulary inhaler choices, information guide on asthma review and step down guide.

• NICE Guideline (NG115) for Chronic Obstructive Pulmonary Disease (COPD)
• NHSL Guidelines for the Pharmacological Management of COPD
• Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2024.

Smoking cessation for patients with asthma and/or COPD is extremely important. Patients can be referred to NHSL Stop Smoking Service for support and supply of medication (e.g. NRT, varenicline).

For further information see Chapter 4. Central Nervous System: Nicotine Dependence.

Additional important points for COPD patients include: ensuring pneumococcal and influenza vaccines are up to date, optimising BMI, promoting exercise, and enrolment onto a pulmonary rehabilitation programme if MRC score >3.

A patient-centred decision on inhaler device will help ensure optimised disease management. Device choice may be considered on the basis of patient acceptability, ease of use, environmental impact and cost.

It is essential to specify inhaler strength and dose. Branded products may need stated so that individuals receive the correct device they are trained to use.

The propellant used in metered dose inhalers (MDIs) are powerful greenhouse gases which have global warming potential. The Scottish Government aim to reduce emissions from inhaler propellants by 70% by 2028.¹ The formulary outlines the carbon footprint per puff of each inhaler, as either Low (<35 g CO2e) or High (≥35 g CO2e)².

Before changing medication or increasing/decreasing dose consider the following points:

1. Review inhaler technique – every time!
2. Check exposure to trigger factors.
3. Review compliance with treatment – consider modifiable factors.

References

1. NHS Scotland climate emergency and sustainability strategy: 2022-2026 https://www.gov.scot/publications/nhs-scotland-climate-emergency-sustainability-strategy-2022-2026/ [accessed 02/05/2023]
2. PrescQIPP Bulletin 295: Inhaler carbon footprint https://www.prescqipp.info/our-resources/bulletins/bulletin-295-inhaler-carbon-footprint/ [accessed 02/05/2023]