Consider Maddie, a 12-year-old girl in your ED with a virally induced moderate asthma exacerbation, currently having her third set of 12 puffs in her burst therapy; thankfully, she’s responding pretty well, and you’re hoping to avoid an admission at this stage.
This is her third presentation with a viral exacerbation of asthma. You take a history and discover that she takes her salbutamol every week before and during her soccer matches. Her other triggers include weekly visits to her grandmother, who has a cat, and she wakes with symptoms once or twice per week.
She carries her salbutamol puffer but not the spacer because it’s bulky and makes her feel self-conscious.
She’s been prescribed fluticasone as a regular preventer but tends to forget it….
What advice would you give her?
If you recommended that she stick with her regular inhaled corticosteroid and use her salbutamol as needed, you might be surprised to learn that there’s been a major update in the guidelines. The new recommended regimens are designed to be safer, simpler to follow, and more environmentally friendly.
For everyone over twelve with asthma, new guidelines from the GINA International and the RCH/Australian Paediatric Improvement Collaborative recommend a treatment approach called Anti-Inflammatory Reliever (AIR) therapy at Steps 1-2. In this approach, patients use a combination inhaler with an inhaled corticosteroid (ICS) and formoterol only when needed. Research shows this method improves symptom control and reduces flare-ups, even in people with mild asthma.
For those needing more control at Steps 3-5, the guidelines suggest a Maintenance And Reliever Therapy (MART) regimen. This involves taking a daily dose of ICS/formoterol while also using the same combination inhaler as a reliever. These updates reflect a safer, simpler approach that effectively manages asthma across different levels of severity.
The UK’s NICE/BTS guideline (currently in draft consultation) is expected to adopt these same changes. Meanwhile, the Australian Asthma Handbook is also under review, with updated recommendations on AIR and MART anticipated for release in early 2025.
Last month, Australian Assistant Federal Health Minister Ged Kearney launched the National Sustainable Asthma Care Roadmap – Roundtable Report. This report addresses Action 4.14 of the National Health and Climate Strategy, focusing on improving respiratory health outcomes while reducing emissions from inhalers.
Asthma Australia hosted the Roadmap roundtables with support from Deakin University researchers led by Dr Mike Forrester, who shared a preview of the findings at the DFTB26 conference in Christchurch. These roundtables brought together representatives from 50 key organisations, including consumers, researchers, healthcare professionals, peak bodies, the pharmaceutical industry, and government agencies. The goal was to co-develop a set of evidence-based, system-oriented recommendations to enhance asthma care. A significant focus was on supporting a shift to lower-carbon inhalers where suitable, aiming to improve respiratory health outcomes while reducing environmental impact.
Why does this Roadmap matter?
Asthma affects one in nine Australians, and unfortunately, about half have poorly controlled disease. Asthma is the leading cause of disease among children aged 5 to 14 in Australia.
Over-reliance on short-acting beta-agonists, predominantly salbutamol, via pressurised metered-dose inhalers (pMDI) and underuse of inhaled corticosteroid preventer medicine are the main causes of poor disease control and hospital presentations. Only about 28% of young people adhere to their ICS preventers.
Traditional “puffer” inhalers, or pressurised metered-dose inhalers (pMDIs), use hydrofluorocarbon (HFC) propellants with a high global warming potential. These HFCs are approximately 1,500 to 3,600 times more potent than COâ‚‚ in terms of greenhouse effects. In Australia alone, around 25 million inhalers are sold annually, with 80% being pMDIs. This widespread use results in emissions comparable to the annual output of 350,000 cars. Offsetting this carbon footprint would require planting 60 million trees annually.
The NHS has highlighted the significant environmental benefit of shifting to low-carbon inhalers. They estimate that such a switch could reduce the “asthma footprint” by up to 95%. This single change could have a more substantial impact on decarbonising the health sector than switching the sector’s electricity supply entirely to renewable sources.
A single Salbutamol inhaler has the same greenhouse gas impact as driving an average petrol car for 285 km.
In contrast, dry powder inhalers (DPIs) can deliver the same medication with only 3% of the greenhouse impact. Also, many patients find DPIs easier to use and appreciate that they do not need a spacer.
A recent systematic review suggests most school-age children can use a DPI. The START study compared daily low-dose ICS to a placebo in children with mild persistent asthma who had symptom onset in the last two years. Daily ICS reduced severe exacerbations by 40%, reduced days away from school, increased symptom-free days, and improved lung function.
Check if a DPI is right for your patient by asking them to show you if they can inhale in <3 seconds and check their technique.
In recent years, evidence-based guidelines for asthma best practice have fundamentally changed (See GINA24 and Paed Improvement Collab).
Salbutamol alone, as required, is no longer recommended for anyone with asthma from school age up, including those with ‘mild’ disease.
For children over twelve, guidelines now recommend using a combination inhaler containing inhaled corticosteroid and formoterol, a specific type of long-acting beta2-agonist (LABA). This has a rapid onset of action as an anti-inflammatory reliever (AIR) and should be used instead of a SABA.
In this strategy, low-dose ICS–formoterol serves two purposes. For patients at Steps 1-2, it is used as a reliever medication in an “AIR-only” regimen. For those with more persistent symptoms at Steps 3-5, it is used both as a daily maintenance treatment and as a reliever, following the Maintenance and Reliever Therapy (MART) regimen.
These regimens significantly reduce the risk of severe asthma exacerbation and the need for urgent health care compared with regimens that use a SABA reliever. This makes asthma management easier, safer and more effective for most adults and adolescents with asthma. (Example of an AIR/MART template click here).
Watch this space for children ages 6-11, as 5 AIR-MART clinical trials are underway in this age group.
In Australia, ICS–formoterol is available in several dry powder inhalers (DPIs), which are propellant-free and have a low carbon footprint. This offers a valuable opportunity to simplify asthma management and improve patient and healthcare outcomes. Additionally, using DPIs can greatly reduce the overall carbon footprint associated with asthma care.
A coordinated and strategic approach is essential to quickly turn this evidence into practical policy and action. The roadmap outlines eight collaborative goals, along with system-focused recommendations and priority actions, aimed at enhancing asthma management and sustainability. For more details on the background, supporting evidence, and specific recommendations, please refer to the attached report.
And what about the best device for Maddie?
Well, she’ll have to tell us, but she has options.
ICS––formoterol is readily available in various dry powder inhalers in Australia.
Perhaps most importantly, the ‘greenest’ inhaler remains the one that the person can use correctly, which will reduce their risk of SABA overuse and severe exacerbations.
What’s next?
The National Sustainable Asthma Care Roadmap presents an exciting opportunity to improve health outcomes and promote sustainability, driven by individuals with asthma and the wider asthma care sector.
To achieve this new approach’s health, environmental, and economic benefits, funding and resources are needed to support a coordinated national implementation plan.
You can help shape a new asthma care model that simplifies and improves treatment. With the AIR or MART regimens, patients use a single inhaler device that’s easier to manage and helps reduce asthma flare-ups, regardless of severity. This model represents a win-win, delivering better patient care while supporting environmental sustainability.
