International Study highlights importance of Inhaler Technique on Asthma Patient Outcomes

10:19 EDT 13 Mar 2017 | BioPortfolio

  • International CRITIKAL Study1 is one of the largest to investigate inhaler technique and the first to analyse the direct associations between specific inhaler errors and asthma outcomes
  • Critical errors were identified that were frequent, made by over 30% of patients in some cases, and were associated with worse asthma outcomes1
  • Study highlights how primary and secondary care asthma management could target inhaler training to reduce these critical errors and improve patient outomes1

CAMBRIDGE, 13 MARCH 2017 – A new study published in the Journal of Allergy and Clinical Immunology: In Practice highlights important findings from the international CRITIKAL study1 (CRITical Inhaler mistaKes and Asthma controL). CRITIKAL is the first study to assess the associations between specific inhaler errors and poorer asthma outcomes in patients receiving a fixed-dose combination treatment with inhaled corticosteroids and long-acting beta agonist (ICS/LABA) via dry-powder inhalers (DPIs) and metered-dose inhalers (MDIs).  The CRITIKAL analysis used data from 3,660 patients included in the iHARP asthma review service2 (initiative Helping Asthma in Real-life Patients) – a multi-centre, cross-sectional review of over 5,000 adults with asthma delivered by Optimum Patient Care ( This was an investigator initiated trial with data analysis undertaken by the Observational and Pragmatic Research Institute in collaboration with members of the Respiratory Effectiveness Group and part-funded by a grant from Mundipharma Research Limited. 

“When managing asthma, our aim is to reduce the risk of exacerbations and control patients’ symptoms.  If patients are not aware how to use their inhaler devices correctly, the effectiveness of their treatment is diminished, which can lead to poorly controlled asthma impacting the patient’s quality of life and can also lead to unnecessary costs to healthcare systems.  The real-world CRITIKAL study identified the specific critical inhaler errors that are frequent and impact asthma outcomes. This study could help routine patient management by targeting training to reduce these critical errors with the aim of improving overall patient outcomes,” said Professor David Price, Chair of Primary Care Respiratory Medicine at the University of Aberdeen, Aberdeen, UK, Director of the Observational and Pragmatic Research Institute and ex-Chairman of the Respiratory Effectiveness Group.

The results of the CRITIKAL analysis showed that certain errors were frequent, made by over 30% of patients in some cases, and associated with poor asthma control. Some errors were device-specific whereas others were generic across devices.1

Previous studies have shown that poor or improper inhaler technique in asthma is associated with reduced control3,4 and an increase in hospital visits.3  However, these results provide crucial insights into which specific inhaler errors are linked to poor asthma outcomes (including increased likelihood of having uncontrolled symptoms and increased exacerbation rate). The study highlights that choosing the right inhaler type for each patient along with training by primary and secondary healthcare management teams is needed to help reduce the number of critical inhaler errors and ultimately improve patient health.1

About Observational and Pragmatic Research Institute (OPRI)

OPRI aims to improve disease management and patient outcomes by undertaking the highest quality observational and pragmatic clinical research in real-life factors that influence outcomes and real life effectiveness both in terms of disease management and pharmacological interventions. By collaborating with clinical, academic and industry partners, OPRI drives a vision for inclusion of real-life research into all aspects of medical research. Professor David Price has been a world leader in respiratory real-life research for over 20 years.

About Respiratory Effectiveness Group (REG)

The Respiratory Effectiveness Group ( is a not-for-profit initiative established by international experts in real-life and comparative effectiveness research in respiratory medicine. The Group sets quality standards in the field of real-life research and improves understanding of the optimum role of real-life data to inform meaningful clinical practice guidelines, drug licensing and post-marketing surveillance processes and improved patient care.

About Mundipharma Research

Mundipharma Research comprises of two independent associated companies, Mundipharma Research Limited in Cambridge England and Mundipharma Research GmbH of Limburg, Germany who are wholly dedicated to the research and development of innovative medications in three main therapeutic areas - pain, oncology and respiratory diseases.

Mundipharma Research works on behalf of a network of independent associated companies and also in collaboration with other pharmaceutical companies to bring medications to an international market. For more information, visit the company’s website at

About Optimum Patient Care

Optimum Patient Care is a social enterprise providing clinical reviews and observational research support services to over 600 GP practices across the UK. OPC has established one of the largest healthcare databases in the world, called the Optimum Patient Care Research Database (OPCRD) which holds over 3.4 million anonymised electronic health records linked to information on patient reported data from 50,000 patients with asthma and COPD. OPC delivered and is the guardian of the global iHARP database. OPC’s mission is to collaborate with clinical, academic and industry partners across the globe, to drive its vision for the collection and inclusion of real-life data into medical research and clinical practice.

About Asthma 

Asthma is a chronic inflammatory disorder of the airways which leads to recurrent episodes of wheezing, breathlessness, chest tightness and coughing. Patients with poorly managed asthma are at an increased risk of exacerbations, hospitalisation and death. Poorly managed asthma can also have a huge impact on a person’s quality of life and day-to-day activities.5 


CRITical Inhaler mistaKes and Asthma control (CRITIKAL) study is a multi-national, cross-sectional, observational analysis investigating direct relationships between specific inhaler errors in DPI and MPI inhalers and asthma outcomes, and determined the critical errors for each inhaler type. It was an investigator initiated trial (IIT) conducted by the Respiratory Effectiveness Group. The analysis used data from the Helping Asthma in Real-life Patients (iHARP) asthma review service – a multi-centre cross-sectional review of adults with asthma in Australia and seven European countries (United Kingdom, Italy, Spain, the Netherlands, France, Norway and Sweden). The review took place between 2011 and 2014 and captured data from over 5,000 patients on demographics, asthma symptoms and inhaler errors observed by purposefully trained healthcare professionals.


[1] D.Price et al. “Inhaler errors in the CRITIKAL Study: type, frequency and association with asthma outcomes”. Journal of Allergy and Clinical Immunology: In Practice. 2017 DOI:
[2] iHARP database. Last accessed 6 March 2017
[3] Al-Jahdali H, Ahmed A, Al-Harbi A, Khan M, Baharoon S, Bin Salih S, et al. Improper inhaler technique is associated with poor asthma control and frequent emergency department visits. Allergy Asthma Clin Immunol. 2013;9(1):8.
[4] Baddar S, Jayakrishnan B, Al-Rawas OA. Asthma control: importance of compliance and inhaler technique assessments. J Asthma. 2014;51(4):429-34.
[5] Chen H et al. Asthma control, severity, and quality of life: quantifying the effect of uncontrolled disease
J Allergy Clin Immunol. 2007;120(2):396-402

Nicola Lilley SO What Global Ltd Tel: 44 (0) 7983 128 712 Professor David Price Observational and Pragmatic Research Institute Catherine Hutton Respiratory Effectiveness Group Victoria Carter Optimum Patient Care NEXT ARTICLE

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