title: Inhaler Errors in the CRITIKAL Study: Type, Frequency, and Association with Asthma Outcomes.
abstract: BACKGROUND
  Poor inhaler technique has been linked to poor asthma outcomes. Training can reduce the number of inhaler errors, but it is unknown which errors have the greatest impact on asthma outcomes.
  
  
  OBJECTIVE
  The CRITical Inhaler mistaKes and Asthma controL study investigated the association between specific inhaler errors and asthma outcomes.
  
  
  METHODS
  This analysis used data from the iHARP asthma review service-a multicenter cross-sectional study of adults with asthma. The review took place between 2011 and 2014 and captured data from more than 5000 patients on demographic characteristics, asthma symptoms, and inhaler errors observed by purposefully trained health care professionals. People with asthma receiving a fixed-dose combination treatment with inhaled corticosteroids and long-acting beta agonist were categorized by the controller inhaler device they used-dry-powder inhalers or metered-dose inhalers: inhaler errors were analyzed within device cohorts. Error frequency, asthma symptom control, and exacerbation rate were analyzed to identify critical errors.
  
  
  RESULTS
  This report contains data from 3660 patients. Insufficient inspiratory effort was common (made by 32%-38% of dry-powder inhaler users) and was associated with uncontrolled asthma (adjusted odds ratios [95% CI], 1.30 [1.08-1.57] and 1.56 [1.17-2.07] in those using Turbohaler and Diskus devices, respectively) and increased exacerbation rate. In metered-dose inhaler users, actuation before inhalation (24.9% of patients) was associated with uncontrolled asthma (1.55 [1.11-2.16]). Several more generic and device-specific errors were also identified as critical.
  
  
  CONCLUSIONS
  Specific inhaler errors have been identified as critical errors, evidenced by frequency and association with asthma outcomes. Asthma management should target inhaler training to reduce key critical errors.
authors.affiliation: Academic Primary Care, University of Aberdeen, Aberdeen; Observational and Pragmatic Research Institute Pte Ltd, Singapore. Electronic address: dprice@opri.sg.
authors.forename: David B
authors.initials: DB
authors.lastname: Price
authors.affiliation: Primary Care Respiratory Research Unit, Instituto de Investigación Sanitaria de Palma (IdisPa), Palma de Mallorca.
authors.forename: Miguel
authors.initials: M
authors.lastname: Román-Rodríguez
authors.affiliation: Department of Clinical Pharmacy, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado Anschutz Medical Campus, Aurora, Colo.
authors.forename: R Brett
authors.initials: RB
authors.lastname: McQueen
authors.affiliation: Woolcock Institute of Medical Research, University of Sydney, Sydney; Sydney Local Health District, Sydney.
authors.forename: Sinthia
authors.initials: S
authors.lastname: Bosnic-Anticevich
authors.affiliation: Optimum Patient Care, Cambridge.
authors.forename: Victoria
authors.initials: V
authors.lastname: Carter
authors.affiliation: General Practitioner, Box Surgery, Box.
authors.forename: Kevin
authors.initials: K
authors.lastname: Gruffydd-Jones
authors.affiliation: Academic Primary Care, University of Aberdeen, Aberdeen.
authors.forename: John
authors.initials: J
authors.lastname: Haughney
authors.affiliation: General Practitioner, Langbølgen Legesenter, Oslo.
authors.forename: Svein
authors.initials: S
authors.lastname: Henrichsen
authors.affiliation: Observational and Pragmatic Research Institute Pte Ltd, Singapore.
authors.forename: Catherine
authors.initials: C
authors.lastname: Hutton
authors.affiliation: Special Interest Respiratory Area, Italian Interdisciplinary Society for Primary Care, Bari.
authors.forename: Antonio
authors.initials: A
authors.lastname: Infantino
authors.affiliation: Department of Experimental and Clinical Medicine, University of Florence, Florence.
authors.forename: Federico
authors.initials: F
authors.lastname: Lavorini
authors.affiliation: Observational and Pragmatic Research Institute Pte Ltd, Singapore.
authors.forename: Lisa M
authors.initials: LM
authors.lastname: Law
authors.affiliation: Department of Public Health and Caring Sciences, Family Medicine and Preventive Medicine, Uppsala University, Uppsala.
authors.forename: Karin
authors.initials: K
authors.lastname: Lisspers
authors.affiliation: Department of Medical Sciences, University of Ferrara, Ferrara.
authors.forename: Alberto
authors.initials: A
authors.lastname: Papi
authors.affiliation: Optimum Patient Care, Cambridge; Centre for Population Health Sciences, University of Edinburgh, Edinburgh.
authors.forename: Dermot
authors.initials: D
authors.lastname: Ryan
authors.affiliation: Department of Public Health and Caring Sciences, Family Medicine and Preventive Medicine, Uppsala University, Uppsala.
authors.forename: Björn
authors.initials: B
authors.lastname: Ställberg
authors.affiliation: Department of Primary Care, University of Groningen, University Medical Centre Groningen, Groningen.
authors.forename: Thys
authors.initials: T
authors.lastname: van der Molen
authors.affiliation: Observational and Pragmatic Research Institute Pte Ltd, Singapore; Faculty of Health and Human Sciences, Plymouth University, Peninsula Allied Health Centre, Derriford Road, Plymouth.
authors.forename: Henry
authors.initials: H
authors.lastname: Chrystyn
mesh_terms: D000280:Administration, Inhalation; D000293:Adolescent; D000328:Adult; D018927:Anti-Asthmatic Agents / Q000008:administration & dosage*; D001249:Asthma / Q000188:drug therapy*; D058995:Dry Powder Inhalers / Q000706:statistics & numerical data*; D005260:Female; D006801:Humans; D008297:Male; D008508:Medication Errors / Q000706:statistics & numerical data*; D036501:Metered Dose Inhalers / Q000706:statistics & numerical data*; D008875:Middle Aged; D016896:Treatment Outcome; D055815:Young Adult
chemical_list: D018927:Anti-Asthmatic Agents
keywords: Asthma control; Exacerbation; Inhaler errors; Inhaler technique