Carbon Emissions and Treatment Efficiency in Chronic Obstructive Pulmonary Disease: The Impact of Inhaled Bronchodilators and Corticosteroids

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Background: Inhaled therapies are essential for chronic obstructive pulmonary disease (COPD) management but also contribute to healthcare-related carbon emissions. Real-world evidence linking inhaler-related carbon burden to clinical outcomes remains limited. This study evaluated the relationship between inhaler-related CO 2 emissions and clinical effectiveness of different treatment regimens. Methods: This retrospective single-center observational study included patients with COPD. Patients were categorized into four groups based on the inhaled therapy: long-acting muscarinic antagonists (LAMA) monotherapy, LAMA/long-acting β 2-agonists (LABA), LABA/inhaled corticosteroids (ICS), and triple therapy (LAMA/LABA/ICS). Clinical outcomes, including pulmonary function test (PFT) parameters and health-related quality of life (HRQL), were assessed over one year. Total inhaler-related CO 2 emissions were calculated using published conversion factors. Emission-adjusted outcomes were derived to evaluate the clinical benefits per unit of CO 2 emission. Results: Clinical improvements in HRQL and PFT were comparable across groups, with no significant differences in ΔFEV1, ΔFVC, or ΔCAT. However, CO 2 emissions differed significantly, being the lowest in the LAMA monotherapy group and the highest in the LABA/ICS and triple therapy groups (p < 0.001). Emission-adjusted analysis demonstrated that lower-intensity regimens, particularly LAMA monotherapy, were associated with more favorable CO 2 -adjusted treatment efficiency, particularly in ΔmMRC/CO 2 (p = 0.001) and ΔFEV1 (%)/CO 2 (p = 0.026), indicating higher clinical benefit per unit carbon emission. After adjustment for baseline severity-related variables, including age, sex, smoking status, baseline FEV1, baseline CAT score, and baseline mMRC score, higher-intensity regimens remained associated with lower CO 2 -adjusted pulmonary function improvement compared with LAMA monotherapy. Conclusion: High-intensity regimens were associated with substantially increased inhaler-related CO 2 emissions. Although major clinical outcomes were generally comparable across groups, lower-emission regimens showed relatively more favorable CO 2 -adjusted outcomes in this cohort. These findings highlight the importance of balancing clinical effectiveness with environmental considerations while maintaining guideline-based, individualized COPD management according to disease severity and clinical needs. Keywords: chronic obstructive pulmonary disease, inhaler, carbon emissions, treatment efficiency, pulmonary function, health-related quality of life

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