Supporting clinicians to deliver personalised and environmentally friendly asthma reviews

Wednesday, June 19, 2024

Respiratory Futures spoke to Dr Aarti Bansal, GP, Director of Greener Practice and Clinical Net Zero Lead for Humber and North Yorkshire ICB. In this article, Aarti shares about the recent creation of a Visual Aid for Optimising Asthma reviews, why this is important and how it can be used to support shifts to greener practice in asthma care.

What were some of the reasons behind the creation of this Visual Aid for Optimising Asthma reviews?

We know that asthma morbidity and mortality is high in the UK and has been for decades, with many people living with preventable symptoms and exacerbations. Preventer adherence remains low, SABA over-reliance is common and inhaler technique is often poor, even though annual asthma reviews have been standard practice for a long time. 

Our main reason for creating this aid, was to provide clinicians with a visual support to enable personalised asthma conversations at asthma reviews, focused on empowering patients to self-manage and ensuring they are using the right medicine, and that it is getting to the right place in their airways.

Secondly, we wanted to ensure that greener care was integrated into a focus on optimising asthma care. Greener care has sometimes been thought of as optional, or separate to better asthma care. This is a misunderstanding. As with nearly all clinical conditions, greener care is aligned to better care. In this case, greener asthma care is achieved through that same focus: improving asthma control and ensuring people have the best inhaler for them.

Greener care has sometimes been thought of as optional, or separate to better asthma care. This is a misunderstanding. As with nearly all clinical conditions, greener care is aligned to better care.


Developing the Visual Aid has involved lots of expert reviewers, dozens of iterations and it has been endorsed by the Primary Care Respiratory Society, the Association of Respiratory Nurses, Asthma and Lung UK as well as Greener NHS.

How do you hope that this visual aid will help healthcare professionals and people with asthma?

We hope that healthcare professionals will find it a useful guide to refer to whilst conducting asthma reviews. It is designed to be used either as a PDF, in which case the embedded links will take people to additional resources, or as a printout. We have suggested ‘prompt questions’ to encourage meaningful conversations with patients, rather than conducting a tick-box exercise.

In terms of ensuring people are using the right medicine, we specifically suggest that professionals look at the objective data on how many preventer and rescue inhalers have been prescribed and correlate this with asthma control tests. We also encourage questions on whether people understand their condition and have links to airways diagrams to help explain this. We suggest explicit conversations on what may help adherence, including a suggestion around ICS-formoterol combination inhalers.

In terms of ensuring medicine gets to the right place, our flowchart is intended to move the conversation towards ensuring we fit the inhaler to the patient, rather than instructing the patient to use an inhaler that may not be the most appropriate choice for them. So, the flowchart starts with the question “show me how you use your inhalers”.

If, for example, patients are using a quick and deep inhalation with a pressurised metered dose inhaler, not using their spacer, or would benefit from a dose counter, then the flowchart suggests they may be more suitable for a dry powder inhaler. Environmental impact is only considered for patients where there is not a clear clinical preference of inhaler device type.

How does this resource support a move towards high quality and low carbon asthma care? Why is this important?

It's important to remember that the climate crisis is a health crisis and affects the health of all people. For our asthma patients, outdoor air pollution, largely caused by the burning of fossil fuels, is known to both cause and worsen asthma. Climate change is causing longer and stronger allergen seasons which can trigger asthma exacerbations.

It's important to remember that the climate crisis is a health crisis and affects the health of all people.

Pressurised metered dose inhalers (pMDIs) are a carbon hotspot for the NHS, responsible for 13% of the emissions related to direct delivery of care, and NHSE has set a target for a 50% reduction in the carbon footprint of inhalers by 2028. These inhalers contain hydrofluorocarbon greenhouse gases, over a thousand times more powerful than carbon dioxide. In the UK we mostly prescribe high carbon pressurised MDIs, which is out of step with other European countries who prescribe a far higher proportion of lower carbon dry powder inhalers (DPIs), which are just as clinically effective for most asthma patients.  

This resource supports good asthma control and ensuring that patients have the best inhaler for them. We know that well controlled asthma has one-third of the carbon footprint of asthma that is not controlled. This is by reducing SABA over-reliance and therefore the number of inhalers prescribed. We also know that low carbon DPIs are often a good fit for many patients with asthma from a clinical perspective. By focusing on where there are clinical reasons to switch to DPI inhalers for patients, we are more likely to prescribe more DPIs. Furthermore, we are not situating environmental considerations in opposition to health considerations, but rather integrated with them.

If people are keen to learn more about optimising their asthma review process, what other resources might they find helpful?

At Greener Practice we have developed a high quality and low carbon asthma care toolkit. Our aim in developing the toolkit has been to make it as easy as possible for busy clinicians in general practice to undertake quality improvement activities. The toolkit contains educational material, step-by-step projects, and all the resources needed to complete them such as searches, information on how to make clinical system changes, SMS messages to patients and patient videos. It has been reviewed and approved by the NHSE Inhaler working group and we have had input from Asthma and Lung UK on the patient materials. It is available free of charge at The Visual Aid for Optimising Asthma Reviews is available in the resources tab.