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      The Relationship Between Clinical Trial Participation and Inhaler Technique Errors in Asthma and COPD Patients

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          Incorrect inhaler use is associated with poorer health outcomes, reduced quality of life, and higher healthcare utilisation in patients with asthma and COPD.


          We performed an observational study of pressurized metered-dose inhaler technique in patients with asthma or COPD. Patients were assessed using a six-point inhaler checklist to identify common critical inhaler technique errors. An inadequate inhaler technique was defined as the presence of one or more critical errors. A multivariate logistic regression model was used to determine the odds of an inadequate inhaler technique.


          During the 14-month study period, 357 patients were enrolled. At least one critical error was executed by 66.7% of participants, and 24.9% made four or more critical errors. The most common errors were failure to exhale completely prior to pMDI activation and inhalation (49.6%), failure to perform a slow, deep inhalation following device activation (48.7%), and failure to perform a breath-hold at the end of inspiration (47.3%). The risk of a critical error was higher in COPD patients (aOR 2.25, 95% CI 1.13–4.47). Prior training reduced error risk specifically when trained by a doctor (aOR 0.08, 95% CI 0.1–0.57) or a pharmacist (aOR 0.02, 95% CI 0.01–0.26) compared to those with no training. Previous clinical trial participation significantly reduced error risk and rate: <3 trials (aOR 0.35, 95% CI 0.19–0.66) and ≥3 trials (aOR 0.17, 95% CI 0.07–0.42). The rate of critical errors was not significantly associated with age, sex, or prior pMDI experience.


          This study found a high rate of critical inhaler technique errors in a mixed population of asthma and COPD patients; however, prior training and, in particular, multiple previous clinical trial participation significantly reduced the risk of errors.

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          Most cited references 36

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          Inhaler competence in asthma: common errors, barriers to use and recommended solutions.

          Whilst the inhaled route is the first line administration method in the management of asthma, it is well documented that patients can have problems adopting the correct inhaler technique and thus receiving adequate medication. This applies equally to metered dose inhalers and dry powder inhalers and leads to poor disease control and increased healthcare costs. Reviews have highlighted these problems and the recent European Consensus Statement developed a call to action to seek solutions. This review takes forward the challenge of inhaler competence by highlighting the issues and suggesting potential solutions to these problems. The opportunity for technological innovation and educational interventions to reduce errors is highlighted, as well as the specific challenges faced by children. This review is intended as a policy document, as most issues faced by patients have not changed for half a century, and this situation should not be allowed to continue any longer. Future direction with respect to research, policy needs and practice, together with education requirements in inhaler technique are described. Copyright © 2012 Elsevier Ltd. All rights reserved.
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            Misuse of corticosteroid metered-dose inhaler is associated with decreased asthma stability.

             V Giraud,  N. Roche (2002)
            This study assessed whether the improper use of pressurized metered-dose inhalers (pMDIs) is associated with decreased asthma control in asthmatics treated by inhaled corticosteroids (ICS). General practitioners (GPs) included consecutive asthmatic outpatients treated by pMDI-administered ICS and on-demand, short-acting beta2-agonists. They measured an asthma instability score (AIS) based on daytime and nocturnal symptoms, exercise-induced dyspnoea, beta2-agonist usage, emergency-care visits and global perception of asthma control within the preceding month; the inhalation technique of the patient also was assessed. GPs (n=915) included 4,078 adult asthmatics; 3,955 questionnaires were evaluable. pMDI was misused by 71% of patients, of which 47% was due to poor coordination. Asthma was less stable in pMDI misusers than in good users (AIS: 3.93 versus 2.86, p<0.001). Among misusers, asthma was less stable in poor coordinators (AIS: 4.38 versus 3.56 in good coordinators, p<0.001). To conclude, misuse of pressurized metered-dose inhalers, which is mainly due to poor coordination, is frequent and associated with poorer asthma control in inhaled corticosteroid-treated asthmatics. This study highlights the importance of evaluating inhalation technique and providing appropriate education in all patients, especially before increasing inhaled corticosteroid dosage or adding other agents. The use of devices which alleviate coordination problems should be reinforced in pressurized metered-dose inhaler misusers.
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              Inhaler Errors in the CRITIKAL Study: Type, Frequency, and Association with Asthma Outcomes.

              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.

                Author and article information

                Int J Chron Obstruct Pulmon Dis
                Int J Chron Obstruct Pulmon Dis
                International Journal of Chronic Obstructive Pulmonary Disease
                02 June 2020
                : 15
                : 1217-1224
                [1 ]Division of Pulmonology, Department of Medicine, Faculty of Health Sciences, University of Cape Town , Western Cape, South Africa
                [2 ]UCT Lung Institute, University of Cape Town , Western Cape, South Africa
                Author notes
                Correspondence: Rubeshan Perumal Email
                © 2020 Perumal et al.

                This work is published and licensed by Dove Medical Press Limited. The full terms of this license are available at and incorporate the Creative Commons Attribution – Non Commercial (unported, v3.0) License ( By accessing the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed. For permission for commercial use of this work, please see paragraphs 4.2 and 5 of our Terms (

                Page count
                Figures: 1, Tables: 4, References: 53, Pages: 8
                Original Research

                Respiratory medicine

                copd, asthma, clinical trials, pressurised metered-dose inhaler, inhaler


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