Net Zero, patient choice and the future of sustainable respiratory Care

Reducing environmental impact of respiratory care

Sustainability was a reoccurring topic under the congress theme «United for Better Breathing: Partnership between Patients, Clinicians and Researchers.» How can healthcare reduce its environmental impact without compromising patient outcomes?

From inhalers to healthcare systems: a shared sustainability responsibility

Several sessions highlighted that choosing the right treatment goes beyond efficacy and safety. Treatments must fit the individual patient’s needs while at the same time support our shared sustainability ambitions. Importantly, speakers emphasised that achieving net zero healthcare is a collective responsibility shared by industry, healthcare professionals, policymakers and patients. The need for action is clear. Global healthcare sector ranks among the world’s largest contributors to greenhouse gas emissions.

As inhalers contribute to the carbon footprint associated with asthma and COPD treatment, emissions from respiratory care are, and should be examined.

DPI versus pMDI

The two main inhaler types used in asthma and COPD are dry powder inhalers (DPIs) and pressurised metered-dose inhalers (pMDIs). As pMDIs contains propellants that are greenhouse gases, their carbon footprint is higher. With increasing awareness of climate impact, several Nordic national and regional guidelines have adopted a «powder-first» approach, encouraging the use of DPIs whenever clinically appropriate.

Non-clinical switching has clinical consequences

Sustainability should not come at the expense of patient care. Several presentations highlighted risks associated with non-clinical switching. Non-clinical switching is when patients are changed from one inhaler device triggered by financial or environmental reasons but not clinical motivated. One of the largest real-world studies evaluating a cost-driven switch from pMDIs to DPIs in the United States included approximately 250,000 patients.¹ Following the device switch, the study reported increased rates of emergency department visits, hospitalisations and overall healthcare utilisation. The findings serve as an important reminder that inhaler choice is not indifferent for patients and that individual needs must remain central to treatment decisions.

Environmental cost of poor disease control

This is particularly relevant because poorly controlled asthma and COPD bring additional environmental burden. Exacerbations, emergency department visits, hospital admissions and additional healthcare contacts all contribute substantially to a patient’s carbon footprint. Improving disease control therefore benefits both patients and the environment.

Next-generation inhalers have reduced carbon footprint

Encouragingly, major progress is being made. Over recent years, scientists and industry have developed new inhaler propellants with dramatically lower global warming potential compared with traditional propellants. In 2026, the first inhaled corticosteroid treatment using a next-generation low-carbon propellant became commercially available in the UK.

More environmentally equivalent options

With these innovations, the choice between a pMDI and a DPI is environmentally equivalent in terms of carbon footprint. For clinicians, this means patient needs can be met without compromising on sustainability targets.

Life-cycle environmental impact

While reducing footprint of propellant is an important step, it is not enough. Every stage of a product’s life cycle contributes to its overall environmental impact, from raw materials and manufacturing to transportation, use and disposal. This makes standardised life-cycle assessment (LCA) methodologies essential.

The recent endorsement of PAS 2090 by EFPIA provides an industry standard for consistent and harmonised measurements of environmental impact.² This will make it easier to compare product-level carbon footprints when balancing environmental sustainability with optimal patient care.

Access matters: a patient view on individualized care

Another perspective raised during the congress came from patient representatives. Mikaela Odemyr, President of the Swedish Asthma and Allergy Association, emphasized that individualized treatment depends not only on having products available on the market, but also access to them in clinical practice.

She noted that in Sweden, regional pharmaceutical committees determine recommendation lists. While intended to support evidence-based prescribing, it may limit treatment choices, in conflict with the principle of individualised treatment.

Financial penalties are in place to foster high adherence to the list, even for products that are recommended in other regions. For diseases with high heterogenicity such as asthma, fewer treatment options are accessible, potentially excluding the inhaler that would be the best fit for the individual patient’s need, preferences and inhalation capacity.

Continuous improvements are needed on multiple fronts

Climate considerations are essential and should continue to drive innovation and improvements across healthcare. Yet sustainable respiratory care cannot be achieved through environmental metrics alone. It requires balancing climate impact, clinical outcomes and patient preference. The discussions at ERS reinforced the importance of keeping the patient at the centre of sustainability efforts.

Ultimately, the most sustainable inhaler is likely to be the one that the patient can and will use correctly, so that optimal disease control is achieved.   The value chain of inhalers should be transparent and continuously improving. The future of respiratory care should not force a choice between sustainability and patient-centred care. Instead, it should deliver both.