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Greener paediatrics: A good practice guide to sustainable asthma care

Health Policy team
This good practice guide for health professionals summarises the key points for sustainable asthma care highlighted within the BTS, NICE, SIGN guidance on asthma, including some additional sustainable practice recommendations from RCPCH Climate Change Member Reference Group (CC-MRG).

For more on sustainable paediatric care, see Greener paediatrics

Asthma control

Focusing efforts on improving control follows sustainable principles hierarchy as acute asthma management is more resource intensive than good chronic management.1

Controlled asthma means children can participate in normal activities without symptoms, night-time disturbances, or using their reliever medication more than three times a week. 2 

Uncontrolled asthma is defined as any exacerbation (flare up) requiring oral corticosteroids (prednisolone) or frequent, regular symptoms (such as using a reliever inhaler three or more days a week or night-time waking one or more times a week).2  

Key principles of good asthma care and achieving good asthma control

  • All children should be provided with an asthma action plan.3
  • Known asthma triggers, such as smoking, vaping and air pollution should be minimised.3
  • Asthma reviews should be scheduled every year and after every attack.
  • Inhaler technique should be reviewed regularly.
  • It’s important that carers and patients understand the difference between types of inhalers, especially when there is an interchange from ‘preventer’ and ‘reliever’ regimes to Maintenance and Reliever Therapy (MART) regimes..3 
  • The lowest number of inhalations used to deliver the required dose represents best prescribing for inhalers.4 
  • The lowest dose of all therapy required to achieve good asthma control should be utilised.7
  • If there are multiple suitable devices, prioritise those with the lowest environmental impact and the presence of an integral dose counter if possible [5. Section 1.6.5]. 
  • NICE has a patient information leaflet to help patients over the age of 12 make informed choices around their asthma care [5. Section 1.6.5].  

The best device is one that the patient is willing and able to use correctly following these key asthma principles. 

Diagnosis

See NICE guidance 1.2-1.3 including a summary of objective tests 

Sustainable practice recommendation: Diagnosis

Where FeNO is not possible and BDR is being utilised, services should consider how to minimise single patient equipment use, for example use of one MDI canister for multiple patients. Robust local processes for safe reuse (including infection control) must be in-place to do this.6 

Consideration of the best place to perform diagnostic tests is also important within a local system; community diagnostic hubs or outreach clinics in primary care settings which reduce patient travel are likely to have reduced carbon footprints compared to those based in acute hospitals. 

Management

Inhaled corticosteroid dosages for people aged 12 years and over

Our short downloadable guide presents the NICE inhaled corticosteroid doses tables for the asthma guideline (Nov 2025) (PDF) with the carbon cost highlighted and colour coded.

Download our guide at the bottom of this page

Acute management

The acute management of paediatric asthma has changed very little from the updated guidance. It is always recommended to follow the most up-to-date local or national guidelines available.  

  • Children for whom inhaled therapy is trialled and escalation is required - inhalers should follow them through their inpatient journey as these are likely to be required at discharge.
  • We recommend remaining doses are calculated from drug charts prior to discharge.
  • Carers should be encouraged to keep an ongoing record of dose use to avoid early disposal or attempts to use empty inhalers.8   
  • Children for whom inhaled therapy is trialled but ineffective should not be given an inhaler to take home and alternative diagnosis should be considered.9 
  • Clinical teams should responsibly dispose of inhalers via medical waste, or recycling if available locally.2 Carers should be encouraged to bring their own spacer and inhalers to any primary and secondary healthcare contacts.10, 11, 12
Sustainable practice recommendation: Bronchodilator prescriptions

Guidance recommends that bronchodilators should be prescribed to be used as required on discharge.13 

The previous practice of formal bronchodilator weaning plans is associated with excess salbutamol use and mounting evidence suggests they are likely to be driving salbutamol overuse.14, 15 Local guideline updates may be required to promote best practice. 

Chronic management

In all cases, striving for the best control of asthma symptoms will ensure the most sustainable care is delivered, as asthma exacerbations and chronic short-acting beta agonists (SABA) overuse carry a significant carbon footprint. Chronic SABA-overuse is a driver of airway inflammation and also causes tachyphylaxis; the vicious cycle that drives further overuse which can decrease its efficacy and increase side effects.16

Of specific note is recommendation 1.6.3 in the NICE guidelines : ‘Do not prescribe short-acting beta2 agonists to people of any age with asthma without a concomitant prescription of an ICS’. For in-depth information on NICE Asthma guidelines by age visit the guidance.  

Sustainable practice recommendation: Talk about environmental risks

Carers and patients should be informed of the potential impact of environmental risks such as mould, damp and air pollution on their or their child’s asthma control, in the same way smoking and exposure to pets and dust should be explored.

For support on how to conduct conversations around air pollution as well as further resources for clinicians looking to take their advocacy around the health implications of air pollution beyond the clinic room, visit the RCPCH Air Pollution Companion and see the template letter which can be used to advocate to local councils on behalf of patients and carers.  

Responsible disposal and dose counting

Clinical teams should responsibly dispose of inhalers via medical waste, or recycling if available locally.2

  • Responsible disposal involves returning any empty, expired or unwanted inhalers to a pharmacy or dispensary for recycling or incineration. Incineration thermally degrades the propellant hydrofluoroalkane gases (HFAs) into less potent greenhouse gases when compared to regular refuse disposal. 
  • Inhalers should not be put into household waste as this allows the release of remaining HFAs into the atmosphere. 
  • Inhaler recycling may be available, allowing the plastics and gases to be recycled.
  • Recycling can be commissioned across the country through Grundon Waste.
  • Explore local options with your trust waste management officer and green team
  • It is recognised that financial constraints and current waste disposal contracts may make this unfeasible.   
Sustainable practice recommendation: Include information about disposal and dose counting in discharge plans 

We advocate that all discharge information, wheeze plans and asthma plans are reviewed to ensure information is provided to patients and carers around the importance of responsible disposal. 

Consider including a dose counter in this information to allow carers to track salbutamol use and reduce the risk of running out of salbutamol or disposing prematurely. These can be included in discharge plans and carers should be informed of the number of doses left in the inhalers they are discharged with/receive (see Acute Management). Alternatively, carers could be directed to the resources from BEAT Asthma about disposal and dose counting (PDF).