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Types of inhalers

Why switch?

Alternatives to pMDIs

Decision Aid

About this resource

FAQs

References

For Australian GPs

Lower-emission inhaler choices Start with You

Prescribe the Inhaler, Protect the Planet

Our Aim:

Forest Reflecting Lake

Support Australian GPs to reduce the environmental impact from pressurised metred-dose inhalers, by encouraging the transition toward appropriate lower-emission inhalers, while ensuring patient suitability. 

Types of Inhalers

A commonly prescribed type of inhaler that delivers a measured dose of medication using a propellant.¹

 

Pressurised metered-dose inhalers (pMDIs) are widely used, accounting for approximately 80–85% of respiratory inhalers dispensed annually in Australia and around 50% of inhalers prescribed under the Pharmaceutical Benefits Scheme (PBS).   While effective in the management of respiratory diseases, incorrect pMDI technique is common and can reduce treatment effectiveness and patient adherence.⁴ Effective use requires correct device handling and, when appropriate, the use of a spacer. In addition, many pMDIs use hydrofluorocarbon (HFC) propellants to deliver medication into the lungs.⁵ HFCs are potent greenhouse gases, with a global warming potential more than 1,000 times greater than carbon dioxide per unit.⁵ The emissions from a single 200-dose pMDI can be equivalent to driving a petrol car approximately 300 km.⁶

2,3

Dry powder inhalers deliver medication in the form of dry powder and rely on patient's inhalation effort, rather than propellant, to transport medication into the lungs.⁷ This means that DPIs produce no greenhouse gases during use.⁷

 

Although dry powder inhalers (DPIs) are not dispensed as frequently as pMDIs in Australia, they are the preferred device for some medications, with approximately 60% of budesonide-formoterol inhalers sold as DPIs.² Unlike pMDIs, DPIs do not use propellant gases and, therefore, may not be suitable for patients who are unable to generate a sufficiently deep and forceful breath.⁷ When considering their manufacture, packaging, and raw materials, DPIs have an overall carbon footprint that is approximately 20–40 times smaller than that of pMDIs.⁸ In addition, many DPIs used for asthma and chronic obstructive pulmonary disease (COPD) are available under the Pharmaceutical Benefits Scheme (PBS), providing a cost-effective treatment option for patients.⁹

Soft mist inhalers (SMIs) deliver medication as a slow-moving mist and do not rely on propellant gases. Instead, the device mechanically generates an aerosol that is inhaled into the lungs.¹

 

Compared with pMDIs and DPIs, soft mist inhalers (SMIs) are used less frequently in Australia, largely because they are a newer technology and are available for a more limited range of medications. Reusable SMIs also require regular cleaning and cartridge replacement, which may reduce patient adherence.¹¹ Despite their relatively recent introduction, medications such as Spiriva Respimat are fully subsidised under the Pharmaceutical Benefits Scheme (PBS).⁹ SMIs have a carbon footprint that is approximately 100–200 times lower than that of pMDIs, making them a more environmentally sustainable option.¹²

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See More

Climate change is not only an environmental issue, but a public health threat.¹³ By reducing emissions and moving towards net-zero healthcare, the extreme weather, air pollution and disease burden that climate change creates can be minimised, while also reducing future demands for high-carbon healthcare.¹³ Inhalers are one example of how this cycle can be reduced.¹⁴ When suitable patients are offered lower-emission devices, it supports a shift towards lower-carbon healthcare.¹⁴

2023 Australian PBS data

High-emission inhalers (pMDIs and breath-actuated inhalers) accounted for 59.5% of PBS-subsidised inhalers.¹⁵

59.5%

Climate Impact 

2023 Australian PBS data

High-emission inhalers were estimated to produce 242,053 tons of CO₂e in 2023, equivalent to approximately 1.78 billion km driven in a petrol car.

242 Kt

17, 18

Janson et al⁸

99%

99% of asthma patients rated their DPIs as good or very good, compared to 39% for their previous pMDIs.¹⁷

2023 Australian PBS data

High-emission inhalers produced about 98% of estimated inhaler-related emissions compared to the remaining 2% accounting for DPI and SMI emissions.¹⁵

98%

Why Switch?

Current evidence shows that switching suitable patients from pMDIs to DPIs or SMIs, can reduce environmental impact without compromising disease control. DPIs and SMIs are designed to improve medication delivery and inhaler technique, leading to better symptom control. Studies have shown that patients who switched to DPIs experienced improved disease control, lung function, quality of life, and satisfaction, while SMIs delivered more medication to the lungs and less to the mouth and throat than pMDIs.     Together, these findings demonstrate that more sustainable inhalers can maintain or even improve patient outcomes while reducing carbon emissions.

8, 17

Health Outcomes

Brand et al¹⁷

SMIs had a 53% whole lung deposition compared to 21% for pMDIs.¹⁸

53%

Janson et al⁸

95%

95% of COPD patients rated their DPIs as good or very good, compared to 45% for their previous pMDIs.¹⁷

Inhaler prescribing does not have to be a choice between patient health and environmental harm. With appropriate education, shared decision-making and clinically suitable prescribing, GPs can support both effective respiratory care and a shift towards lower-carbon healthcare.

Review The Evidence

What are the options? 

If your patient is using a pMDI or treatment is being initiated and you are considering what DPI or SMI options may be clinically appropriate, use the following table to gain an understanding of common available inhaler classes. For a more comprehensive comparison click 'See More' at the bottom of the table.

Table 1. Alternative to common pMDIs. Adapted from Montgomery and Blakey; Royal Australian College of General Practitioners¹⁸

Medications class

Common pMDIs

Lower-emission inhaler alternatives

Inhaled Corticosteroids – single-agent treatment

QVAR (Beclometasone)

Pulmicort Turbuhaler (Budesonide)

Flixotide (Fluticasone propionate)

Arnuity Ellipta (Fluticasone furoate)

Flixotide / Axotide Accuhaler (Fluticasone propionate)

Alvesco (Ciclesonide)

No direct DPI/SMI equivalent, consider alternative ICS if clinically appropriate

ICS / LABA

maintenance ± reliever

Symbicort Rapihaler (Budesonide/formoterol)

Symbicort Turbuhaler or DuoResp Spiromax (Budesonide/formoterol) 

Seretide MDI (Fluticasone prop./salmeterol)

Seretide / Axotide Accuhaler (Fluticasone prop./salmeterol)

Fostair (Beclometasone/formoterol)

Breo Ellipta (Fluticasone furoate/vilanterol)

Flutiform (Fluticasone prop./formoterol)

Atectura Breezhaler (Mometasone/indacaterol)

Triple therapy

ICS/LABA/LAMA

Trimbow (Beclometasone/formoterol/glycopyrronium)

Trelegy Ellipta (Fluticasone furoate/umeclidinium/vilanterol)

Breztri Aerosphere (Budesonide/glycopyrronium/formoterol)

Enerzair Breezhaler (Mometasone/indacaterol/glycopyrronium)

Short-acting beta-agonist

Ventolin, Asmol, Airomir & other salbutamol brands (Salbutamol)

Bricanyl Turbuhaler (Terbutaline)

Common Inhalers that are not marketed in Australia as pMDIs

LAMA: 
Spiriva Respimat (SMI) / HandiHaler, Braltus Zonda (DPI) (Tiotropium)
Incruse Ellipta (DPI) (Umeclidinium)
Seebri Breezhaler (DPI) (Glycopyrronium)
Bretaris Genuair (DPI) (Aclidinium)

LABA/LAMA:
Anoro Ellipta (DPI) (Umeclidinium/vilanterol)
Spiolto Respimat (SMI) (Tiotropium/olodaterol)
Ultibro Breezhaler (DPI) (Indacaterol/glycopyrronium)
Brimica Genuair (DPI) (Aclidinium/formoterol)

See More

Decision Aid

Choosing an inhaler is not just about environmental impact; it also depends on symptom control, inhaler technique, cost, access and patient preference. This shared decision-making aid is designed to help GPs and patients compare suitable inhaler options together and decide whether continuing, improving technique, or considering a lower-emission alternative is most appropriate.

See Decision Aid
Download Decision Aid

Final product made.

NHCS objective and action identified, as well as relevant SDGs.

Help GPs consider lower emission inhalers where clinically appropriate.

​

Designed for Australian GPs, this website serves as a planetary health education and decision-support resource that converts national policy into practical clinical guidance, supporting both National Health and Climate Strategy (NHCS) objectives and relevant Sustainable Development Goals (SDGs).

About This Resource 

Health system decarbonisation.¹⁹

 

We support health-system decarbonisation by helping GPs identify opportunities to reduce avoidable inhaler-related emissions while maintaining safe, effective respiratory care.

Reducing respiratory inhaler emissions.¹⁹

 

We support Action 4.14 by helping GPs consider lower-emission inhaler options during prescribing and review, while maintaining clinical safety, patient preference and appropriate inhaler technique.

Good health and wellbeing

 

By 2030, reduce by one third premature mortality from non-communicable diseases through prevention and treatment and promote mental health and well-being.²⁰

 

We support SDG 3.4 by promoting safe, evidence-based asthma and COPD care that maintains disease control while considering lower-emission options where appropriate.

Climate action

 

Improve education, awareness-raising and human and institutional capacity on climate change mitigation, adaptation, impact reduction and early warning.²⁰

 

We support SDG 13.3 by providing GP-focused education about inhaler-related emissions and practical ways to reduce avoidable healthcare emissions through clinically appropriate

prescribing.

How This Resource Was Developed

Australian GPs, seeking to integrate planetary health principles into clinical practice.

Our Targets

Climate change mitigation through reducing avoidable greenhouse gas emissions from healthcare where safe and feasible.

Our Co-design Process

About Us

We are second-year Bond medical students who have an interest in environmentally conscious patient care.

Lisa Walsham

Cuan Human 

​

Peter Setrak

Parva Patel

Saahil Dahiya

Yashodhan Rayani

Refinement of product and consultation with GPs and Patients with asthma.

Meeting with academics and feedback used to guide final product.

Research on respiratory inhalers conducted and proposal written.

Frequently asked questions

Reference list

  1. Beckett RS, Fairbrother CB, Gilchrist FJ, Rubin BK, Carroll WD. Pressurised metered-dose inhalers: how do they work? A short guide for clinicians. Paediatr Respir Rev. Published online November 19, 2025. doi:10.1016/j.prrv.2025.11.006

  2. Forrester M, Needham C, Allender S, et al. The National Sustainable Asthma Care Roadmap: roundtable report September 2024. Asthma Australia. September 2024. Accessed June 28, 2026. https://asthma.org.au/wp-content/uploads/2024/09/Asthma-Roundtable-Report_DIGITAL.pdf

  3. Lam SWL, Navaratnam VV, Wurzel DF, Montgomery B, Blakey JD. Prescribing trends and environmental impact of prescribed inhaled medicines in Australia. Chron Respir Dis. 2026;23:14799731261429092. doi:10.1177/14799731261429092

  4. Lavorini F. The challenge of delivering therapeutic aerosols to asthma patients. ISRN Allergy. 2013;2013:102418. doi:10.1155/2013/102418

  5. Urrutia-Pereira M, Chong-Neto HJ, Winders TA, Solé D. Environmental impact of inhaler devices on respiratory care: a narrative review. J Bras Pneumol. 2022;48(6):e20220270. doi:10.36416/1806-3756/e20220270

  6. Fidler L, Green S, Wintemute K. Pressurized metered-dose inhalers and their impact on climate change. CMAJ. 2022;194(12):E460. doi:10.1503/cmaj.211747

  7. Woodcock A, Beeh KM, Sagara H, et al. The environmental impact of inhaled therapy: making informed treatment choices. Eur Respir J. 2022;60(1):2102106. doi:10.1183/13993003.02106-2021

  8. Janson C, Hisinger-Mölkänen H, Tamasi L, Vartiainen V, Lehtimäki L. Switching to the dry powder inhaler: disease control with a lower carbon footprint. Pulm Ther. 2025;11(4):753-763. doi:10.1007/s41030-025-00319-w

  9. Rigby D. Inhaler therapy for COPD. Respir Med Today. 2021;6(2):13-17. Accessed June 28, 2026. https://respiratory.medicinetoday.com.au/system/files/pdf/RMT2021-09-013-RIGBY.pdf

  10. Komalla V, Wong CY, Sibum I, et al. Advances in soft mist inhalers. Expert Opin Drug Deliv. 2023;20(8):1055-1070. doi:10.1080/17425247.2023.2231850

  11. Asthma + Lung UK. Choosing the right inhaler device for your patients. Asthma + Lung UK. Updated January 10, 2026. Accessed June 28, 2026. https://www.asthmaandlung.org.uk/healthcare-professionals/adult-asthma/choosing-inhaler-device

  12. National Asthma Council Australia. Greener inhaler choices: better for patients and the planet. National Asthma Council Australia. June 4, 2024. Accessed June 28, 2026. https://www.nationalasthma.org.au/news/2024/greener-inhaler-choices-better-for-patients-and-the-planet

  13. Emeryk AW, Sosnowski TR, Kupczyk M, et al. Impact of inhalers used in the treatment of respiratory diseases on global warming. Adv Respir Med. 2021;89(4):427-438. doi:10.5603/ARM.a2021.0092

  14. Scottish Government. Respiratory conditions: quality prescribing strategy: improvement guide 2024 to 2027: environmental impact of inhalers. Scottish Government. April 22, 2024. Accessed June 21, 2026. https://www.gov.scot/publications/quality-prescribing-strategy-respiratory-guide-improvement-2024-2027/pages/12/

  15. Kazda L, Barratt AL, Docking SI, et al. Estimated carbon emissions for PBS-subsidised prescription respiratory inhalers, Australia, 2019-2023: a descriptive analysis. Med J Aust. 2025;223(4):214-217. doi:10.5694/mja2.52715

  16. OpenCO2net Oy. CO2 converter. OpenCO2net. Accessed June 21, 2026. https://www.openco2.net/en/co2-converter/

  17. Brand P, Hederer B, Austen G, Dewberry H, Meyer T. Higher lung deposition with Respimat Soft Mist inhaler than HFA-MDI in COPD patients with poor technique. Int J Chron Obstruct Pulmon Dis. 2008;3(4):763-770. doi:10.2147/COPD.S3930

  18. Montgomery BD, Blakey JD. Respiratory inhalers and the environment. Aust J Gen Pract. 2022;51(12):929-934. doi:10.31128/AJGP-08-22-6536

  19. Australian Centre for Disease Control. National Health and Climate Strategy. Australian Centre for Disease Control. December 3, 2023. Accessed June 28, 2026. https://www.cdc.gov.au/resources/publications/national-health-and-climate-strategy

  20. United Nations. The 17 Goals. United Nations. Accessed June 28, 2026. https://sdgs.un.org/goals

  21. Kaplan A, van Boven JFM. Switching inhalers: a practical approach to keep on UR RADAR. Pulm Ther. 2020;6(2):381-392. doi:10.1007/s41030-020-00133-6

  22. Rigby D. Inhaler device selection for people with asthma or chronic obstructive pulmonary disease. Aust Prescr. 2024;47(5):140-147. doi:10.18773/austprescr.2024.046

  23. Mahé J, Muller G, Roche N, et al. Increasing propellant gas emissions from pressurized metered-dose inhalers in obstructive lung diseases in France over 11 years. Respir Res. 2026;27(1):171. doi:10.1186/s12931-026-03527-3

  24. Wurzel DF, Montgomery BD, Anderson N, et al. Environmental impact of inhaled medicines: a Thoracic Society of Australia and New Zealand position statement. Respirology. 2025;30(2):101-112. doi:10.1111/resp.14852

  25. Tong B, Tejani A. Environmentally responsible inhaler disposal in hospitals: is there such a thing? Can J Hosp Pharm. 2025;78(1):e3662. doi:10.4212/cjhp.3662

  26. National Asthma Council Australia. Asthma & COPD Medications Chart. National Asthma Council Australia. Updated September 2025. Accessed June 28, 2026. https://www.nationalasthma.org.au/living-with-asthma/resources/health-professionals/charts/asthma-copd-medications-chart

  27. Dudvarski Ilic A, Zugic V, Zvezdin B, et al. Influence of inhaler technique on asthma and COPD control: a multicenter experience. Int J Chron Obstruct Pulmon Dis. 2016;11:2509-2517. doi:10.2147/COPD.S114576

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