Information for healthcare professionals only.
This supplement has been commissioned and funded by Boehringer Ingelheim Ltd and developed in partnership with Guidelines in Practice. Please see bottom of page for full disclaimer.
Dr Steve Holmes, GP, Shepton Mallet; Educational Lead, Primary Care Respiratory Society UK
The NHS long term plan published in January 2019 set a challenging agenda for the whole NHS to develop better care and outcomes for patients, while recognising its responsibility to use resources mindfully.1 The respiratory community is delighted that the needs of respiratory patients have been recognised in the long term plan; one of the important aspects we support is the focus on improved outcomes in terms of quality of life, reduced hospital admissions, and reduced mortality.1
A point highlighted in several areas of the long term plan is the NHS’ responsibility to look beyond healthcare provision and address some of the environmental issues linked to its global impact, supported by the rising profile of the NHS Sustainability Unit looking at the impact of the NHS on the environment. The Unit has published a report entitled ‘Identifying high greenhouse gas intensity procured items for the NHS in England’, which identifies 25 items with high carbon footprint needing further investigation;2 they also reported that anaesthetic gases account for 5% of the carbon footprint in acute organisations, equivalent to around half the emissions from the gas used to heat buildings and water;3 finally, they have also looked into inhaler devices, suggesting that 3.5% of the total NHS carbon footprint is associated with their use.4
We know that the NHS spending on medicines is growing on average 5% every year,5 and we have the duty to use these medicines in the most effective way. The re-usable Respimat® Soft Mist™ inhaler is a welcomed innovation that can be used by patients; it has a patient-friendly delivery system (with improved dose counter and new cartridge counters and easy-to-change cartridges), and a lower environmental impact compared to traditional pressurised metered dose inhalers, thanks to the lack of propellants and to its re-usability.6
Our responsibilities as commissioners include helping clinicians supporting their patients; we have an overriding commitment to commend inhalers that patients can use properly, because with optimal inhaler use it is possible to improve outcomes and reduce admissions.7–9 Furthermore, we have a responsibility towards our environment and a responsibility to use the NHS’ financial resources efficiently. The re-usable Respimat inhaler appears to go in the right direction and is worth careful consideration when prescribing the medications for which Respimat is an option.
Conflicts of interest
Steve Holmes has undertaken work for five CCG areas in the last two years, he has involvements with the NHS cardiovascular and respiratory board, and works with the Primary Care Respiratory Society and the Royal College of General Practitioners. He has received advisory board honoraria, lecture fees or travel grants from most of the respiratory orientated pharmaceutical companies (including Boehringer Ingelheim) and has worked for several publishers/medical communication agencies (including Guidelines in Practice/MGP).
- NHS England. NHS long term plan 2019. Available at: www.longtermplan.nhs.uk
- NHS Sustainability Unit. Identifying high greenhouse gas intensity procured items for the NHS in England. Available at: www.sduhealth.org.uk/
- NHS Sustainability Unit. Anaesthetic gases. www.sduhealth.org.uk/areas-of-focus/carbon-hotspots/anaesthetic-gases.aspx (Accessed 6 November 2019)
- House of Commons Environmental Audit Committee. UK progress on reducing F-gas emissions. House of Commons, 2018. Available at: https://publications.parliament.uk/pa/cm201719/cmselect/cmenvaud/469/469.pdf
- The King’s Fund. The rising cost of medicines to the NHS. What’s the story? Available at www.kingsfund.org.uk/sites/default/files/2018-04/Rising-cost-of-medicines.pdf
- Hänsel M et al. Adv Ther 2019; doi.org/10.1007/s12325-019-01028-y
- Maricoto T et al. JAGS 2019; 67: 57–66.
- Al-Jahdali H et al. Allergy Asthma Clin Immunol 2013; 9: 8.
- Molimard M et al. Eur Resp J 2017; 49: doi 10.1183/13993003.01794-2016
The re-usable Respimat® Soft Mist™ inhaler
Dr Kevin Gruffydd-Jones, FRCGP, GP, Box, Wiltshire
The Respimat® Soft Mist™ inhaler (SMI) is a handheld propellant-free device that produces a slow-moving, long-lasting mist of drug for inhalation. The original Respimat inhaler has been available since 2007, but in September 2019 it became available in the UK as a re-usable device.
This article highlights the main features of the Respimat SMI, compares it with other inhaler types, describes the key features of the re-usable device, and discusses the environmental impact of its use.
Mechanism of action of the Respimat SMI
The active drug used with the Respimat inhaler is formulated in aqueous solution with benzalkonium chloride as a preservative.1 When a cartridge containing the drug is inserted into the base of the inhaler, the device needs to be primed to expel air from the drug solution flow path. To load a dose, the patient has to turn the base of the device by half a turn. This tightens the helical spring that lowers and opens up the non-return valve, drawing a metered volume of the drug solution via the capillary tube into the loading chamber. The drug is delivered when the patient presses the dose-release button, which uncoils the spring.1 Figure 1 shows the internal design of the Respimat inhaler.
The mechanical power of this action drives the drug solution through a series of fine channels of silicon wafer enclosed in a ‘uniblock’ (see Figure 2), causing two fine jets of liquid to emerge through the twin nozzles of the uniblock. These fine jets converge on each other at such an angle that a slow-moving aerosol, ‘soft mist’, is produced.1
The soft mist is delivered with a high fine particle fraction of 75% (nearly double the value reported for aerosols emitted by a standard pressurised metered dose inhaler [pMDI] or dry powdered inhaler [DPI]) and with a slow velocity (3–10 times slower than the aerosol emitted from a pMDI).1 This allows low oropharyngeal deposition and high lung deposition, minimising oropharyngeal side-effects and reducing the dose of drug that needs to be used to be effective. In addition, the spray duration of the Respimat SMI is considerably longer than for pMDIs (1.2 seconds vs. 0.15–0.36 seconds, respectively), allowing a longer time for the patient to coordinate their inhalation with the release of the drug.1
Respimat SMI vs other devices
A study analysing lung and oropharyngeal deposition of fenoterol[A] (a short-acting beta2 - agonist) when administered via the Respimat SMI compared to when administered via a pMDI or pMDI plus spacer in healthy volunteers, showed that the mean oropharyngeal deposition of fenoterol was significantly lower via Respimat SMI than via pMDI (37.1% vs 71.1%, respectively). Lung deposition was significantly higher via Respimat SMI than via pMDI (39.2% vs 11%, respectively).4 Comparable results were obtained in a similar study performed on patients with asthma.5
The re-usable Respimat SMI
In the UK, the re-usable version of the Respimat inhaler was launched in September 2019. The original Respimat inhaler was updated to simplify assembly, optimise daily use, and make it re-usable with up to six cartridges.
Figure 3 highlights the differences and retained features between the disposable and re-usable inhalers.
Key features of the re-usable device compared to the disposable are:
- a locking device attached to the cartridge rather than to the device, which prevents further use of the device when the cartridge is empty and releases a safety catch allowing the clear base to be pushed away, alerting the user that the cartridge needs replacing
- an improved dose counter on the cartridge, with the number of doses left clearly displayed; the dose counter changes colour when only 10 doses are left, clearly indicating to the patient that the cartridge will need to be replaced soon (Figure 4)
- a longer base to improve grip and to make twisting the device easier.
Comparative studies performed by Dhand et al. showed that the re-usable Respimat inhaler has improved usability compared to the disposable device, but no differences in drug delivery, aerosol particle size, and required inhalation method across multiple cartridge use.6 Performance of the re-usable Respimat inhaler has been shown to be comparable to that of the disposable inhaler, so lung deposition and clinical data established on the disposable inhaler can be applied to the re-usable one.6
Moreover, small-scale studies in patients with asthmas and/or COPD (n=16) showed that 4 people out of 16 felt that the process was ‘equally easy’ in both inhalers, while the remaining 12 people considered the cartridge insertion process to be ‘easier’ or ‘much easier’ with the reusable Respimat than with the disposable Respimat.Patients particularly liked the easily readable dose counter.6
Environmental benefits of the re-usable Respimat SMI
The NHS Long Term Plan for England 20197 has committed the NHS to reducing greenhouse gas emissions from inhalers. Traditional pMDIs use hydrofluoroalkane (HFA) propellants, which have a high global warming potential.
The re-usable Respimat SMI is propellant-free, and, due to its re-usability, is potentially more environmentally friendly. In fact, re-using the inhaler with more than one cartridge further reduces its product carbon footprint (PCF).
These potential environmental benefits were examined in a study which compared the PCF of Respimat with that of pMDIs.8 The PCF looks at the carbon footprint of the product during its life cycle, including production, packaging, usage, and disposal, and is expressed in kg CO2 equivalent (eq). This study found that the PCF of the Respimat was approximately 20 times lower than a pMDI (0.78 kgCO2eq vs. 14.59 kgCO2eq, respectively), mainly due to the lack of propellant in the Respimat, and found a further reduction of 73% in the PCF after 6 months’ use of the re-usable versus disposable Respimat when six cartridges are used with one inhaler (due to the lower carbon impact of using less material in manufacturing the device).8
Use of the re-usable Respimat SMI in clinical practice
International9,10 and national11,12 asthma and COPD guidelines emphasise the importance of inhaler choice and technique linked to outcomes. It is generally acknowledged that there is no one inhaler type that ‘fits all’ and inhaler prescription should be tailored to the individual patient. The National Institute for Health and Care Excellence (NICE) produced a clinical decision aid for patients with asthma to help them and the prescriber to come to a decision on which inhaler to prescribe.13
The key features that a patient is asked to consider are:
- being able to use the inhaler correctly and easily
- being able to tell how many doses are left in the inhaler
- having to clean the inhaler frequently
- being able to carry the inhaler around
- that the inhaler has a low carbon footprint.
In line with this, the re-usable Respimat SMI has been shown to have high patient acceptability,1 a distinct cartridge counter, a clear dose indicator,6 and lower carbon footprint compared to pMDIs.8
Instructions on how to use the re-usable Respimat SMI are shown in Figure 5.
The re-usable Respimat SMI was introduced in the UK in September 2019. It incorporates many of the features of the original Respimat device, which delivers a propellant-free slow-moving, long-lasting soft mist aerosol with improved lung deposition, lower environmental impact, and more time for co-ordinated inhalation with release of drug, than traditional pMDIs. The re-usable inhaler has the additional advantage of an updated design to to improve cartridge exchange and a clearer dose counter.
The ability to use the same device with up to six cartridges increases convenience for the patients and further reduces the environmental impact of inhaler use.
Conflicts of interest
Kevin Gruffydd-Jones has acted as a consultant and spoken on behalf of GlaxoSmithKline, AstraZeneca, Teva, Napp, Boehringer Ingelheim, Novartis, and Chiesi. He is a member of the NHS England Sustainable Inhaler Committee.
- Dalby R, Eicher E, Zierenberg B. Development of Respimat® Soft MistTM Inhaler and its clinical utility in respiratory disorders. Med Devices (Auckl) 2011; 4: 145–155.
- Boehringer Ingelheim Ltd. Data on file. Pharmaceutical development report for Respimat® ReUsable® 2017; document number: q00240658-01.
- Watchel H, Kattenbeck S, Dunne S et al. The Respimat® development story: patient-centered innovation. Pulm Ther 2017; 3: 19–30.
- Newman S, Brown J, Steed K et al. Lung Deposition of fenoterol and flunosolide delivered using a novel device for inhaled medicines. Chest 1998; 113: 957–963.
- Pitcairn G, Reader S, Pavia D et al. Deposition of corticosteroid aerosol in the human lung by Respimat Soft Mist inhaler compared to deposition by metered dose inhaler or by Turbohaler dry powder inhaler. J Aerosol Med 2005; 18: 264–272.
- Dhand R, Eicher J, Hansel M et al. Improving usability and maintaining performance: human-factor and aerosol—performance studies evaluating the new reusable Respimat inhaler. Int J COPD 2019; 14: 509–523.
- NHS England. NHS Long Term Plan 2019. Available at: www.longtermplan.nhs.uk (accessed 26 November 2019).
- Hänsel M, Bambach T, Wachtel H. Reduced Environmental Impact of the reusable Respimat® Soft MistTM Inhaler compared with pressurised metered-dose inhalers. Adv Ther 2019; doi.org/10.1007/s12325-019-01028-y
- Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. 2019 report. Available at: goldcopd.org/gold-reports/ (accessed 26 November 2019).
- Global Strategy for Asthma Management and Prevention 2019. Global Initiative for Asthma (GINA) 2019. Available at: www.ginasthma.org (accessed 26 November 2019).
- NICE. Chronic obstructive pulmonary disease in over 16s: diagnosis and management. NICE guideline 115. NICE, 2019. Available at: www.nice.org.uk/NG115
- British Thoracic Society/Scottish Intercollegiate Guidelines Network. British guideline on the management of asthma. SIGN 158. Available at: www.sign.ac.uk/assets/sign158.pdf (accessed 26 November 2019).
- NICE. Asthma: diagnosis, monitoring and chronic asthma management. Tools and resources. NICE guideline 80. NICE, 2017 www.nice.org.uk/ng80/resources (accessed 26 November 2019).
This supplement has been commissioned and funded by Boehringer Ingelheim Ltd and developed in partnership with Guidelines in Practice. Boehringer Ingelheim Ltd suggested the topic and author, and carried out full medical approval on all materials to ensure factual accuracy and compliance with the ABPI Code of Practice. The sponsorship fee included an honorarium for the author. The views and opinions of the author are not necessarily those of Boehringer Ingelheim Ltd, or of Guidelines in Practice, its publisher, advisers, or advertisers. No part of this publication may be reproduced in any form without the permission of the publisher.
Date of preparation: January 2020