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Introduction
The inhalation of medication through Dry powder inhalers (DPI) is becoming increasingly more popular amongst the pharmaceutical market. This is because this technique of drug administration is very effective in delivering the drug to the patient and the actual method of administration itself has a low incidence of side-effects. Furthermore, medication that directly enters the patients respiratory system in this technique pose fewer adverse effects compared to oral medication. The drug is also able to take its effect for the treatment of the condition that the inhaler is used for in a very short period of time which again is another advantage in comparison to oral medication (Kumaresan 2006). The Turbuhaler fits into the categories of the Dry powder inhaler which is specifically designed to accomplish this sort of drug administration. Its design and mechanism of use is more preferred by many users over the conventional aerosol metered-dose inhalers because patients find that Turbuhalers are easier to use. They do not contain potentially harmful carbon propellants, lubricants and surfactants which aspire to have ill consequences on the health of the patient unlike other inhalers (Bisgaard 2001). Turbuhalers are newly developed breath actuated devices which function by preloading them with around 200 doses of medication such as salbutamol (500 ). Each one of the doses is dispensed by rotating a plastic ring at the base of the inhaler, with the absence of carrier powders or propellants, allowing the drug to be inhaled in its purest form. However, many patients cannot encompass the full benefit of using a Turbuhalers even when first made to have careful tuition because of the poor techniques implemented during the procedure. The inability to correctly use this inhaler is most frequently encountered by patients who improperly synchronize inhaler actuation with inspiration. The efficiency of this device is directly dependent upon the generation of adequate inspiratory flow when breathing in. Many users, especially asthmatic users or users that have other severe respiratory illnesses can not produce a high enough force when inhaling to obtain the recommended inspiratory flow and find this difficult to achieve through no fault of their own due to their illness. There are several disadvantages that have been associated with the use of DPIs which require improvements to be made on the design of the device to further progress its function (Smith 2002). A typical Turbuhaler DPI contains medicine conditioned to be in powder form which is inhaled using this device so that it can enter the respiratory system. The inhalation is preceded either through the mouth or the nose. In this device, the powder comes from a prefilled container that is punctured before inhaling. The inhalation requires to be deep and fast to ensure a correct quantity of the administered drug comes out of the inhaler and enters deep within the lungs. There are many different types of Turbuhalers available in the market but they all use the same theory and mechanism in delivering the drug (The Ohio State University 2009).
The Turbuhaler relies upon the force of inspiration to elevate particles which are deposited on a dosing disc within the container of the device, which travels by these applied forces caused by suction into the patients respiratory system. When inhalation is preceded through suction on the mouthpiece of the Turbuhaler, the fine powder particles are forced to travel through the inhalation channel towards a disaggregation zone where the powder particles are disintegrated and separated. This part of the Turbuhaler consists of two spiral channels designed to create turbulent air flow hence the name Turbuhaler. This newly created flow of air breaks the powder particles into even smaller units thus creating a more therapeutically effective drug. This is because the size of the powder by this stage of the process are roughly less than 7 in diameter thus allowing the drug absorption by the respiratory system to be done at a faster rate (Daniella.B 2012). Studies that have been conducted show that the minimum required inspiratory flow rate to attain a therapeutic dosage is at least 30 L/min. This makes the effectiveness of the medication greater promoting the treatment of the condition. This is a low target flow rate in comparison to other inhalers that use a similar mechanism, therefore making this device increasingly more desirable in treating acute and severe asthmatic patience in the emergency department. However, a further increased inspiratory flow has increasing benefits as there would be a higher lung deposition of medication as both relationships are directly proportional. For this reason, it is important to teach and encourage patience to inhale forcefully when using this device (Daniella.B 2012).
Figure 1: Image showing the design and internal layout of a Turbuhaler (Nesbitt 2006)
2) When placing the powdered medication into the inhaler ensure that the Turbuhaler is in an upright position so that the mouthpiece is directed upwards.
3) When loading the device what requires to be done is to rotate the coloured handle in one direction as far as possible; then it is required to rotate it back into the opposite direction until a click noise is heard. This is an indication by the device that it has prepared a correct dose. It is not possible to load the device more than one dose at a time without having to undergo this procedure once medicine has been inhaled as the measuring device is not compactable to hold more than one does at a time
The Turbuhaler must be held upright at a angle between 45o-90o otherwise the measuring device will not fill correctly and you either over load or under load the device with the powder. This will mean a proper dose will not be administered if under loaded or the medication may go to waste if over loaded What has been noticed when patience carry out this step is that they shake the inhaler as they have adapted this habit when associating with the use of PMSIs. This step is not required as there is nothing to mix and could in fact have a negative consequence as it could potentially cause some of the loaded dose to be lost.
4) It is important to ensure that when inhaling it is done forcefully and deeply by placing mouth piece between the teeth and closing lips around it, so that all the air entering goes first through the inhaler. Many times patients are not able to feel or even taste any of the medication as it is being supplied at a very low dosage and is in very fine powder form.
Another noticeable mistake made by many patience is that they at times actuate the device twice or even three times before loading. Any dosages loaded after the second time would be returned to the reservoir which means that it would go to waste. This occurs because the dosing indicator wheel will still advance each time the handle is rotated. It is important that the patient is aware of the openings found on the side of the Turbuhaler. When using the device, air must enter here first before medication can be inhaled and is also important for turbulent conditions to be created. Many of the devices are designed to signal a successful administration. This occurs as some Turbuhalers are designed to have auditory indicators whilst others have light indicators. By using these types of Turbuhalers the patient would become increasingly more motivated to exercise correct techniques as Patients may be unable to smell, taste or even feel the sensation
of the fine ( Continuous....) Particles as there is such a small quantity of medication given in each dose. These indicators would reassure patients that they have received their medication in a correct manner and quantity.
5) When exhaling once device has been used it must be ensured that the exhaled air does not enter the inhaler. This is because the powder inside could be blown away and also humidity cannot be introduced to the inhalers
Humidity introduced into the inhaler would cause aggregation of the powder particles forming clumps and ultimately block the air from travelling through the inhaler. This humidity is commonly caused by exhaling air into the inhaler which has devastating consequences to the device. This may cause small holes in the dosing disk to form and could also cause other parts of the device to become partially or fully blocked due to the contact between liquid caused by the humid air and powder particles. This would result in doses being administered at unspecified quantities or even make the drug unobtainable.
6) Once medication has been inhaled the patient can breathe normally without the need to worry if drug is being absorbed by the body. Again exhaling needs to be done away from the inhaler.
7) In case the first dose does not seem effective enough in relieving the illness, or if a qualified professional prescribed a higher dosage, the steps 1-6 need to be repeated to have a successful second administration. 8) The protective cap requires to be screwed back on 9) Clean the outside of the mouthpiece once a week
Recent studies have shown that it is not necessary to hold the breath or change breathing patterns after inhalation of the medication. As the powder dissolves as soon as there is contact made with the membrane which happens instantly on the first breath of inhalation. Many patients require a higher concentration of the medicine as that prescribed by the device in one dosage. These instructions must be completed in a correct manner to ensure that the medication is delivered in the most effective approach possible. It is important when carrying out this stage that the patient does not accidently reload the device by turning the bottom plastic handle. It is important to ensure that no liquid is used to carry out this procedure
breathing is carried out in a normal manner. Due to the presence of this air that always exists in the lungs, when inhaling not as much air can enter the lungs (ehow 2008). The mean peak inspiratory air when inhaling through a Turbuhaler was measured to be 60L/min while the Peak expiratory air subsequent to breathing through a Turbuhaler was found to be 89L/min. After carrying out this investigation and analysing the data collected it was found that two patients failed to produce the minimum inspiratory flow that is required for a successful administration of medicine through the employment of a Turbuhaler which is 30L/min. Both these patients recorded an intake of air through a Turbuhaler of 26L/min which if practiced in an actual situation where the drug was loaded into the device would not be sufficient enough to intake a correct quantity of the medication. From the research carried out 98% of patients with acute asthma generated a high enough inspiratory flow when inhaling through a Turbuhaler which would therapeutically activate a correct amount of bronchodilator medication such as salbutamol to be delivered to the airways relieving the sufferer of the condition. Nevertheless, due to the severity of the conditions a Turbuhaler is generally used to treat, it is very important that especially in times of emergencies a Turbuhaler can be used safely and effectively by all patients. As not everyone was able to seek the full benefits of this device, and even though it is only a very small percentage of people, there could still be improvements made to the inhaler design such as installing a assisted air flow component to the device for the weaker population to further reduce the minimum amount of inspiratory air flow required (Brown 1995).
Low inspiratory flow rate required of 30-60L/min which is easily achieved even by weaker patients that have severe conditions thus allowing most patients to use it Installation of whistle or light on device to give indication of a successful and adequate inspiratory flow Can generally be used for a wide variety of people even if the severity of the condition required to be treated is high Only requires one forceful inhalation by breath-actuation so requires no breath coordination unlike other inhalers such as metered-dose inhalers making them more efficient to use CFC free so imposes no serious risks to the user and therefore has a very minimum amount of adverse side effects Allows medication to directly target the lungs therefore medication has a rapid onset. This method of administration has lower side effects. As nothing in the actual device is being used up it therefore can be re-used even when first batch of medication has been used by just simply replacing the medication that has been administered Inhaler is set to extract a set quantity of medication in each dose making the extraction procedure easier as the patient does not need to worry about the quantity of medication needed to extract thus making it also easier to keep a record of quantity of drug taken Relatively cheap to purchase
A big concern by many users is the lack of tolerance Turbuhalers and DPIs in general have towards liquids. The humidity normally enters the inhaler via ambient air or more directly from patients exhaling into the mouth piece. It was established from the results of the survey that on average 20% of patients exhale into the mouthpiece. The design of Turbuhalers influences the effect of humidity, as it contains multi dose reservoirs which are more vulnerable as there is no protection around the powdered drug such as that in capsules or blister packs which adds to the problem. It has been found that the effects of ambient air on the Turbuhaler within 2hours after exposure to this air reduced the amount of drug released to 40% of its normal quantity. This reduction lasted for a period of 4 days starting from the time of initial exposure and it was ensured that there was no further exposure. The graph in figure x gives a visual representation of results obtained during a similar procedure conducted but the difference here was continuous exposure to high ambient humidity at 30oC and 75% relative humidity over a period of 8 weeks. Humidity conditions were designed to match conditions when using a Turbuhaler in a Bathroom. The measurement made in this scenario is the percentage decrease of fine particle mass due to the effects of the introduced humidity (Joseph 1999).
Figure 2: Effects of Humidity on the fine particle mass over a period of 8 weeks
The graph clearly indicates a gradual decrease in fine particle mass over the period of 8 weeks. It is essential for optimum function that the drug located within the Turbuhaler consists of pure fine powder. This is because only powder particles are small enough to travel through the inhaler without causing blockages. Therefore if fluid enters the inhaler the patient may find it difficult to inhale through the device and would ultimately result in the inhaler not functioning properly. The type of drug used also influances the effect umidity would have if introduced into the inhaler. This is because some powder react differently when exposed to humidity. Some drugs have shown greater adhesion between powder particles and therfore reduced particle mass as humidity increases. While some drugs show decreased adhesion with higher
humidity due to having electro static forces. For this reason humidity has the effect in causing a varaince in delivery from DPIs with different drugs (Joseph 1999). Other disadvantges associated with the use of turbuhalers is that there is no definate guide as to when the inhaler is empty. As there is not taste of the drug some patients continue to use the inhaler in the abscence of the medication without realsiing this. Additionally, some patients are not able to produce required flow rate so are unable to use device (UHN 2011)
Conclusion
Turbuhalers have benifited in helping to treat many individual regardless of how severe their conditions may be. This is because a very low flow rate is required to be produced during inhalation to deliver the drug to the patient. Through research conducted it was foud that only a very small percentage of people would find it difficult to use this inhaler as they were unable to produce the required flow rate during inhalation while 98% still managed to produce the required flow rate even while suffering from accute asthma. The simplicity of the
design and the procedure required to load the device is a reason to why many choose to use this inhaler. Its also a much safer option to use this device and most importantly it has no side effects. The instructions required to follow to have a successfull delivery of the medication are not complicated and are easy to achieve. Nevertheless, studies have shown that people still are using this device in a incorrect manner and therfore can not fully benefit by using the device. Therfore, more information needs to be provided to the patients to ensure they do not make erros while operating the device. A major problem associated with the use of this device is the lack of tolerance it has towards liquids as it causes blockages within the system. Extra care must therfore be taken to ensure no liquid enters the Turbuhaler.
Referances
C.Kumaresan. (2006). Dry Powder Inhaler - Formulation aspects. Inhalers. 2 (1), p15-19. H. Bisgaard. (2001). Fine particle mass from the Diskus inhaler and Turbuhaler inhaler in children with asthma. European Respiratory journal. 3 (3), p4 The Ohio State University. (2009). Turbuhaler Dry Powder Inhaler (DPI).Available: https://patienteducation.osumc.edu/Documents/turbuhaler-dpi.pdf. Last accessed 15/04/2013 Smith.A. (2002). Turbuhalers and their application. Inhalers. 5 (2), p5-7 Daniella.B (2012). USING INHALATION DEVICES. Cambridge: McGraw-Hill. p80-140. Nesbitt.S. (2006). Medication Devices. Available: http://www.bcdecker.com/SampleOfChapter/1-009-174-3.pdf. Last accessed 24/04/2013 Prat.B. (2008). Lung delivery of salbutamol by dry powder inhaler (Turbuhaler) and small volume antistatic metal spacer (Airomir CFC-free MDI plus NebuChamber). Inhaler Devices. 3 (1), p11-12 Brown.PH. (1995). Peak inspiratory flow through Turbuhaler in acute asthma.. Treating Asthma. 1 (2), p3-9. ehow. (2008). How Much Air Can Your Lungs http://www.ehow.com/about_5466024_much-air-can-lungs-hold.html. 30/04/2013 Hold?. Available: Last accessed
UHN. (2011). Asthma and Airway Centre Medication. Available: http://www.uhn.ca/Clinics_&_Services/services/asthma/medication/common_advantages.asp. Last accessed 30/04/2013 Joseph L Rau (1999). Practical Problems With Inhalers. London: FAARC. p200-260. Andrew.P. (2012). Turbuhalers application: Advantages and Disadvantages. Turbuhalers DPI. 1 (5), p3-8