CRITical Inhaler mistaKes and Asthma controL (CRITIKAL) study

Improper use of inhaler device is a common and well-established reason for failure to achieve asthma control. Previously, however, there was no study which investigates the impact of each specific inhalation errors towards asthma outcome. The CRITical Inhaler mistaKes and Asthma (CRITIKAL) project was thus initiated to answer the pertinent question of which inhaler technique errors represent the “critical” errors which were common and negatively impacts asthma outcomes.

This is a systematic, investigative and experimental project conceived using our expertise in real-life respiratory research in-collaboration with iHARP (initiative Helping Asthma in Real-life Patients). The iHARP is an asthma review service supported by the Respiratory Effectiveness Group, which prospectively collects data from primary care practices encompassing Australia and 7 European countries. The iHARP conducts questionnaire-led and practitioner-led assessments to collect extensive information about patients’ demographic characteristics, asthma symptoms, lung function, inhaler technique, and occurrence of exacerbations.

A cross-sectional, real-life study was conducted using data collected for iHARP asthma review. More than 5000 patients with asthma who were using either dry powder inhalers (DPI) or metered-dose inhalers (MDI) for delivery of fixed-dose inhaled corticosteroid and long-acting beta-agonist was recruited. A checklist of predefined inhaler technique errors was also created with inputs from multiple respiratory experts involved in this project. Patients’ inhaler technique was assessed in reference to this checklist.

Insufficient inspiratory effort was identified as one of the critical errors among DPI users. This error was common (32-38% of users) and was observed to be associated with uncontrolled symptoms and increased exacerbation rates. Within MDI users, actuation of medication before inhalation was identified as one of the critical errors, observed in 24.9% patients and associated with uncontrolled asthma. Several other errors were also identified as critical errors.

This project is the first in the world to identify the “critical” inhaler technique errors which were frequent and associated with poor asthma outcomes. Findings from this study were published in the Journal of Allergy and Clinical Immunology: In Practice (Impact factor: 7.0). Results of this project will enable healthcare practitioners to formulate effective training strategies to reduce these critical errors.


David B. Price, Miguel Román-Rodríguez, R. Brett McQueen, Sinthia Bosnic-Anticevich, Victoria Carter, Kevin Gruffydd-Jones, John Haughney, Svein Henrichsen, Catherine Hutton, Antonio Infantino, Federico Lavorini, Lisa M. Law, Karin Lisspers, Alberto Papi, Dermot Ryan, Björn Ställberg, Thys van der Molen, Henry Chrystyn. Inhaler errors in the CRITIKAL study: type, frequency, and association with asthma outcomes. J Allergy Clin Immunol Pract 2017; 5(4): 1071-81.e9.
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