Errors in Turbuhaler technique in a Spanish population of asthmatic patients.

Appropriate use of inhalers requires a number of steps to be performed correctly to ensure adequate medication delivery and to minimize side effects. Currently, with the advancements in asthma treatment, there is a wide variety of new inhaler devices, which are intended to improve drug administration. However, a recent literature review has shown that misuse of inhaler devices is frequent in practice,1 leading to poor asthma control.2–4 Basheti et al5 have recently described the most frequent inhaler technique errors for patients treated with Turbuhaler and Diskus devices in Jordan and Australia. Studies aimed at identifying frequent errors regarding inhaler technique are essential, since health strategies can be designed in order to educate asthmatic patients, reinforcing the most common problems related to each inhaler device. Pharmacists are ideally positioned to teach inhaler technique, as they are highly accessible health professionals who see asthmatic patients regularly. In Spain, asthma guidelines recommend that pharmacists should form part of a team approach to patient education about the use of inhalers.6 According to national and international asthma guideline recommendations, the AFasma project integrated 51 community pharmacies in the Spanish provinces of MadridandMálaga intomultidisciplinary teams supporting patients with asthma. As part of this study aiming to investigate the effect of an educational intervention on the control of asthma, we collected information about errors in the Turbuhaler technique performed by 362 asthmatic patients treated with budesonide/formoterol (Symbicort Turbuhaler, AstraZeneca). To our knowledge, this is the first approach in Spain to the most frequent inhaler errors for Turbuhaler users. Inhaler technique was assessed according to guidelines in the Spanish Guide for Asthma Management,6 using a 10 step Turbuhaler checklist. Interestingly, this checklist integrated additional steps (Table 1: steps 8, 9, and 10) not considered by other authors, which are also included in the package leaflet of the product as important steps that should be performed for proper inhaler use. A descriptive analysis of the errors observed is shown in Table 1. In our study, 21.3% of patients performed the 10 Turbuhaler steps correctly, 47% of the patients failed to “breathe out gently, not breathing into the Turbuhaler” (step 4), and 42.5% failed to “remove inhaler from mouth, hold breath for 8 seconds, and exhale away from the mouthpiece” (step 7). Despite using a different inhaler technique assessment tool, these results are similar to those described by Basheti et al,5 who found that a high proportion of Turbuhaler users failed to exhale to residual volume, to exhale away from the mouthpiece, and to hold the breath for 5 seconds. A relevant finding of our study is that neither the 51.6% of patients prescribed a double dose performed step 8 (if further doses are needed, wait 30 seconds and repeat steps from 2 to 7), nor did 42.8% perform step 10 (rinse mouth with water, do not swallow). As previously commented, these steps were not assessed by other authors. In our opinion, they should be considered when giving a complete inhaler technique education. First, patients treated with inhaled corticosteroids risk having local side effects when not rinsing the mouth with water. Second, waiting 30 seconds between consecutive doses (step 8), which was performed by more than one third of our cohort (34.8%), allows patients to administer a deeper second inhalation, which could improve the effectiveness of the asthma medication. In conclusion, we have identified an opportunity to reinforce and complete educational interventions for asthmatic patients. Moreover, given the high proportion of patients who failed to perform steps 8 and 10, and the clinical relevance related to effectiveness and safety of asthma treatment, they should be integrated in every inhaler technique assessment tool and taken into account when designing educational programs to improve asthma control.