Digital Inhalers for Asthma or Chronic Obstructive Pulmonary Disease: A Scientific Perspective

Filling the gaps in the evaluation and selection of mobile health technologies in respiratory medicine

INTRODUCTION

Mobile health (mHealth) technology in respiratory medicine is a fast-growing and promising technology that is popular among patients and healthcare providers (HCPs). They provide reminders and step-by-step instructions for the correct inhalation technique, monitor patients' adherence to treatment, and facilitate communication between patients and HCPs.

AREAS COVERED

While numerous mHealth apps have been developed over the years, most applications do not have supporting evidence. Selecting the best mHealth app in respiratory medicine is challenging due to limited studies carrying out mHealth app selection. Although mHealth technologies play an important part in the future of respiratory medicine, there is no single guide on the evaluation and selection of mHealth technologies for patients with pulmonary diseases. This paper aims to provide an overview of mHealth technologies, particularly emphasizing digital inhalers and standalone applications used in asthma. Additionally, it offers insights into the evaluation, selection, and pertinent considerations surrounding mHealth applications in respiratory medicine.

EXPERT OPINION

Evaluating mHealth apps will take time, resources, and collaboration between stakeholders such as governmental regulatory bodies, subject-matter experts, and industry representatives. Filling the gaps in the evaluation and selection of the mHealth app will improve clinical decision-making, personalized treatments, self-management and disease monitoring in respiratory medicine.

Acoustic biomarkers in asthma: a systematic review

OBJECTIVE

Current monitoring methods of asthma, such as peak expiratory flow testing, have important limitations. The emergence of automated acoustic sound analysis, capturing cough, wheeze, and inhaler use, offers a promising avenue for improving asthma diagnosis and monitoring. This systematic review evaluated the validity of acoustic biomarkers in supporting the diagnosis of asthma and its monitoring.

DATA SOURCES

A search was performed using two databases (PubMed and Embase) for all relevant studies published before November 2023.

STUDY SELECTION

27 studies were included for analysis. Eligible studies focused on acoustic signals as digital biomarkers in asthma, utilizing recording devices to register or analyze sound.

RESULTS

Various respiratory acoustic signal types were analyzed, with cough and wheeze being predominant. Data collection methods included smartphones, custom sensors and digital stethoscopes. Across all studies, automated acoustic algorithms achieved average accuracy of cough and wheeze detection of 88.7% (range: 61.0 - 100.0%) with a median of 92.0%. The sensitivity of sound detection ranged from 54.0 to 100.0%, with a median of 90.3%; specificity ranged from 67.0 to 99.7%, with a median of 95.0%. Moreover, 70.4% (19/27) studies had a risk of bias identified.

CONCLUSIONS

This systematic review establishes the promising role of acoustic biomarkers, particularly cough and wheeze, in supporting the diagnosis of asthma and monitoring. The evidence suggests the potential for clinical integration of acoustic biomarkers, emphasizing the need for further validation in larger, clinically-diverse populations.

Telemedicine with special focus on allergic diseases and asthma-Status 2022: An EAACI position paper

Efficacious, effective and efficient communication between healthcare professionals (HCP) and patients is essential to achieve a successful therapeutic alliance. Telemedicine (TM) has been used for decades but during the COVID-19 pandemic its use has become widespread. This position paper aims to describe the terminology and most important forms of TM among HCP and patients and review the existing studies on the uses of TM for asthma and allergy. Besides, the advantages and risks of TM are discussed, concluding that TM application reduces costs and time for both, HCP and patients, but cannot completely replace face-to-face visits for physical examinations and certain tests that are critical in asthma and allergy. From an ethical point of view, it is important to identify those involved in the TM process, ensure confidentiality and use communication channels that fully guarantee the security of the information. Unmet needs and directions for the future regarding implementation, data protection, privacy regulations, methodology and efficacy are described.

The application of nanoparticles as advanced drug delivery systems in Attenuating COPD

Chronic Obstructive Pulmonary Disease (COPD) is a dilapidating condition which is characterized by inflammation, an excess in free radical generation and airway obstruction. Currently, the drugs commercially available for the management of COPD pose several limitations such as systemic adverse effects, including bone density loss and an increased risk of developing pneumonia. Moreover, another limitation includes the need for regular and frequent dosing regimens; which can affect the adherence to the therapy. Furthermore, these current treatments provide symptomatic relief; however, they cannot stop the progression of COPD. Comparatively, nanoparticles (NPs) provide great therapeutic potential to treat COPD due to their high specificity, biocompatibility, and higher bioavailability. Furthermore, the NP-based drug delivery systems involve less frequent dosing requirements and in smaller doses which assist in minimizing side effects. In this review, the benefits and limitations of conventional therapies are explored, while providing an in-depth insight on advanced applications of NP-based systems in the treatment of COPD.

Effectiveness of a Maintenance and Reliever Digihaler System in Asthma: 24-Week Randomized Study (CONNECT2)

BACKGROUND

Digital health tools have been shown to help address challenges in asthma control, including inhaler technique, treatment adherence, and short-acting β2-agonist overuse. The maintenance and reliever Digihaler System (DS) comprises 2 Digihaler inhalers (fluticasone propionate/salmeterol and albuterol) with an associated patient App and web-based Dashboard. Clinicians can review patients' inhaler use and Digihaler inhalation parameter data to support clinical decision-making.

OBJECTIVE

CONNECT2 evaluated asthma control in participants using the DS versus standard-of-care (SoC) maintenance and reliever inhalers.

METHODS

Participants (13 years or older) with uncontrolled asthma (Asthma Control Test [ACT] score <19) were randomized 4:3 (open-label) to the DS (n = 210) or SoC (n = 181) for 24 weeks. The primary endpoint was the proportion of patients achieving well-controlled asthma (ie, an ACT score ≥20 or increase from baseline of ≥3 units at week 24).

RESULTS

There was an 88.7% probability that participants using the DS would have greater odds of achieving improvement in asthma control compared with SoC after 24 weeks. The mean odds ratio (95% credible interval) for DS versus SoC was 1.35 (0.846-2.038), indicating a 35% higher odds of improved asthma control with the DS. The DS group had more clinician-participant interactions versus SoC, mainly addressing a poor inhaler technique. DS participants' maintenance treatment adherence was good (month 1: 79.2%; month 6: 68.6%); reliever use decreased by 38.2% versus baseline. App and Dashboard usability was rated "good."

CONCLUSION

The positive results in asthma control in this study after 24 weeks demonstrate the effectiveness of the DS in asthma management.

Telemonitoring in patients with asthma: a systematic review

BACKGROUND

Monitoring and managing asthma using technology can help increase patient adherence and achieve better asthma control. This study aimed to evaluate the effectiveness of telemonitoring using smartphones and telephone communication compared to usual outpatient clinical evaluation in patients with asthma.

DATA SOURCES

This systematic review was conducted in 2023. Databases PubMed, Scopus, Web of Science, and the Google Scholar search engine, were searched from 2013 to 2022.

DATA SELECTION

The selected studies were randomized clinical trials that used telemonitoring in patients with asthma. The quality of the studies was evaluated using the JADAD scale. Data were collected using a data extraction form, and the findings were synthesized narratively. This systematic review was conducted following the PRISMA checklist.

RESULTS

Initially, 4,147 articles were found, of which 14 were included in the study. The results showed that in some cases, telemonitoring using smartphones and telephone communication in patients with asthma is effective, while in other studies, its effectiveness was not observed.

CONCLUSIONS

Telemonitoring using smartphones and telephone communication in patients with asthma can be considered an appropriate strategy to reduce the use of healthcare resources and improve quality of life. However, further studies are recommended to investigate the effectiveness of each of these technologies and their specific outcomes.

Factors Associated with Veteran Self-Reported Use of Digital Health Devices

BACKGROUND

Digital health devices (DHDs), technologies designed to gather, monitor, and sometimes share data about health-related behaviors or symptoms, can support the prevention or management of chronic conditions. DHDs range in complexity and utility, from tracking lifestyle behaviors (e.g., pedometer) to more sophisticated biometric data collection for disease self-management (e.g., glucometers). Despite these positive health benefits, supporting adoption and sustained use of DHDs remains a challenge.

OBJECTIVE

This analysis examined the prevalence of, and factors associated with, DHD use within the Veterans Health Administration (VHA).

DESIGN

National survey.

PARTICIPANTS

Veterans who receive VHA care and are active secure messaging users.

MAIN MEASURES

Demographics, access to technology, perceptions of using health technologies, and use of lifestyle monitoring and self-management DHDs.

RESULTS

Among respondents, 87% were current or past users of at least one DHD, and 58% were provided a DHD by VHA. Respondents 65 + years were less likely to use a lifestyle monitoring device (AOR 0.57, 95% CI [0.39, 0.81], P = .002), but more likely to use a self-management device (AOR 1.69, 95% [1.10, 2.59], P = .016). Smartphone owners were more likely to use a lifestyle monitoring device (AOR 2.60, 95% CI [1.42, 4.75], P = .002) and a self-management device (AOR 1.83, 95% CI [1.04, 3.23], P = .037).

CONCLUSIONS

The current analysis describes the types of DHDs that are being adopted by Veterans and factors associated with their adoption. Results suggest that various factors influence adoption, including age, access to technology, and health status, and that these relationships may differ based on the functionalities of the device. VHA provision of devices was frequent among device users. Providing Veterans with DHDs and the training needed to use them may be important factors in facilitating device adoption. Taken together, this knowledge can inform future implementation efforts, and next steps to support patient-team decision making about DHD use.

Key Features of Smart Medication Adherence Products: Updated Scoping Review

BACKGROUND

Older adults often face challenges in self-managing their medication owing to physical and cognitive limitations, complex medication regimens, and packaging of medications. Emerging smart medication dispensing and adherence products (SMAPs) offer the options of automated dispensing, tracking medication intake in real time, and reminders and notifications. A 2021 review identified 51 SMAPs owing to the rapid influx of digital technology; an update to this review is required.

OBJECTIVE

This review aims to identify new products and summarize and compare the key features of SMAPs.

METHODS

Gray and published literature and videos were searched using Google, YouTube, PubMed, Embase, and Scopus. The first 10 pages of Google and the first 100 results of YouTube were screened using 4 and 5 keyword searches, respectively. SMAPs were included if they were able to store and allowed for the dispensation of medications, tracked real-time medication intake data, and could automatically analyze data. Products were excluded if they were stand-alone software applications, not marketed in English, not for in-home use, or only used in clinical trials. In total, 5 researchers independently screened and extracted the data.

RESULTS

This review identified 114 SMAPs, including 80 (70.2%) marketed and 34 (29.8%) prototypes, grouped into 15 types. Among the marketed products, 68% (54/80) were available for consumer purchase. Of these products, 26% (14/54) were available worldwide and 78% (42/54) were available in North America. There was variability in the hardware, software, data collection and management features, and cost of the products. Examples of hardware features include battery life, medication storage capacity, availability of types and number of alarms, locking features, and additional technology required for use of the product, whereas software features included reminder and notification capabilities and availability of manufacturer support. Data capture methods included the availability of sensors to record the use of the product and data-syncing capabilities with cloud storage with short-range communications. Data were accessible to users via mobile apps or web-based portals. Some SMAPs provided data security assurance with secure log-ins (use of personal identification numbers or facial recognition), whereas other SMAPs provided data through registered email addresses. Although some SMAPs were available at set prices or free of cost to end users, the cost of other products varied based on availability, shipping fees, and subscription fees.

CONCLUSIONS

An expanding market for SMAPs with features specific to at-home patient use is emerging. Health care professionals can use these features to select and suggest products that meet their patients' unique requirements.

Survey of Transfer Learning Approaches in the Machine Learning of Digital Health Sensing Data

Machine learning and digital health sensing data have led to numerous research achievements aimed at improving digital health technology. However, using machine learning in digital health poses challenges related to data availability, such as incomplete, unstructured, and fragmented data, as well as issues related to data privacy, security, and data format standardization. Furthermore, there is a risk of bias and discrimination in machine learning models. Thus, developing an accurate prediction model from scratch can be an expensive and complicated task that often requires extensive experiments and complex computations. Transfer learning methods have emerged as a feasible solution to address these issues by transferring knowledge from a previously trained task to develop high-performance prediction models for a new task. This survey paper provides a comprehensive study of the effectiveness of transfer learning for digital health applications to enhance the accuracy and efficiency of diagnoses and prognoses, as well as to improve healthcare services. The first part of this survey paper presents and discusses the most common digital health sensing technologies as valuable data resources for machine learning applications, including transfer learning. The second part discusses the meaning of transfer learning, clarifying the categories and types of knowledge transfer. It also explains transfer learning methods and strategies, and their role in addressing the challenges in developing accurate machine learning models, specifically on digital health sensing data. These methods include feature extraction, fine-tuning, domain adaptation, multitask learning, federated learning, and few-/single-/zero-shot learning. This survey paper highlights the key features of each transfer learning method and strategy, and discusses the limitations and challenges of using transfer learning for digital health applications. Overall, this paper is a comprehensive survey of transfer learning methods on digital health sensing data which aims to inspire researchers to gain knowledge of transfer learning approaches and their applications in digital health, enhance the current transfer learning approaches in digital health, develop new transfer learning strategies to overcome the current limitations, and apply them to a variety of digital health technologies.

The 2023 GOLD Report: Updated Guidelines for Inhaled Pharmacological Therapy in Patients with Stable COPD

Over the past 22 years, annual GOLD Reports have documented important changes in guidance and recommendations for uniformly treating patients with chronic obstructive pulmonary disease (COPD) with the goal of improving outcomes in patients suffering from this condition. The most recent GOLD Report, released in 2023, shows continued refinement in several areas, including more precise definitions of COPD and exacerbations of COPD, a new set of parameters to assess exacerbation severity, an updated COPD assessment tool, updated guidelines for initial and follow-up treatment, new information regarding the association between pharmacological triple therapy and reduction in mortality, and new discussions of inhaler device choice and adherence to COPD medications. Whereas we do not address all of the new or updated material in GOLD's 2023 Report, we summarize key changes in GOLD's recommendations regarding inhalation therapy for stable COPD and frame these changes in the context of previous GOLD recommendations.

A Systematic Review of Patient-Reported Adherence Measures in Asthma: Which Questionnaire Is Most Useful in Clinical Practice?

BACKGROUND

Suboptimal adherence to inhaled corticosteroid in asthma is a worryingly prevalent yet modifiable factor in uncontrolled disease. Several objective measures of adherence exist, but they are time-consuming. The use of patient-reported adherence measures (PRAMs) could therefore offer a time-efficient pragmatic approach to assessing adherence in clinical practice and potentially the appropriate interventions to improve it.

OBJECTIVES

To identify the PRAMs available for asthma and assess their psychometric quality, accessibility, and usefulness in clinical practice, as well as to provide recommendations for clinicians based on these findings.

METHODS

We conducted a systematic review of six databases. Articles included in this study were English language, full-text, original, asthma-specific PRAMs or development/validation studies of a generic PRAM that had been administered to adults with asthma, investigated inhaled corticosteroid adherence in adults (aged 18 years and older), and assessed at least one COnsensus-based Standards for the selection of health Measurement INstruments measurement property.

RESULTS

We included 15 PRAM developmental and/or validation studies in this systematic review. Studies evaluated a range of COnsensus-based Standards for the selection of health Measurement INstruments measurement properties, but none evaluated all of them.

CONCLUSIONS

Based on this review, we recommend that when a PRAM is used, it should be the Test of the Adherence to Inhalers. However, the Adherence Starts with Knowledge-20 and Adherence Starts with Knowledge-12 may also be useful. Our results highlight the need for PRAM developers to assess questionnaires robustly and provide guidance for clinicians regarding how to act on PRAM answers by developing materials such as decision support tool kits.

Aerosol pulmonary immune engineering

Aerosolization of immunotherapies poses incredible potential for manipulating the local mucosal-specific microenvironment, engaging specialized pulmonary cellular defenders, and accessing mucosal associated lymphoid tissue to redirect systemic adaptive and memory responses. In this review, we breakdown key inhalable immunoengineering strategies for chronic, genetic, and infection-based inflammatory pulmonary disorders, encompassing the historic use of immunomodulatory agents, the transition to biological inspired or derived treatments, and novel approaches of complexing these materials into drug delivery vehicles for enhanced release outcomes. Alongside a brief description of key immune targets, fundamentals of aerosol drug delivery, and preclinical pulmonary models for immune response, we survey recent advances of inhaled immunotherapy platforms, ranging from small molecules and biologics to particulates and cell therapies, as well as prophylactic vaccines. In each section, we address the formulation design constraints for aerosol delivery as well as advantages for each platform in driving desirable immune modifications. Finally, prospects of clinical translation and outlook for inhaled immune engineering are discussed.

Recognizing and Tackling Inhaler Technique Decay in Asthma and Chronic Obstructive Pulmonary Disesase (COPD) Clinical Practice

A poor inhaler technique continues to represent a substantial barrier to effective asthma and chronic obstructive pulmonary disease management. It can result in perceived lack of treatment effectiveness even with apparent adherence to a prescribed regimen of inhaled maintenance therapies, potentially resulting in an unnecessary change or escalation of treatment. Many patients are not trained to inhaler mastery in real-world practice; furthermore, even where mastery is initially achieved, an ongoing assessment and education are seldom maintained. In this review, we present an overview of the evidence for deterioration of the inhaler technique over time after training, investigate the factors that contribute to this deterioration, and explore innovative approaches to addressing the problem. We also propose steps forward drawn from the literature and our clinical insights.

Up-to-date guidance towards improving medication adherence in patients with chronic obstructive pulmonary disease

INTRODUCTION

Despite efficacious treatment for chronic obstructive pulmonary disease (COPD), medication adherence remains quite poor, with most estimates based on electronic monitoring devices ranging from 20-30%. This degree of nonadherence represents a significant missed opportunity to realize the benefits of treatment of this disease.

AREAS COVERED

In this article, we review research on the prevalence of nonadherence among patients with COPD, the association of nonadherence with health outcomes, barriers to adherence in this patient population, and potential interventions.

EXPERT OPINION

Integrating research into practice involves assessing patients' adherence, identifying modifiable barriers to adherence, open discussion of these barriers with patients, and tailored interventions to address them. These interventions may include treatment of previously unrecognized comorbid disease, providing educational or behavioral interventions, optimizing prescribing strategies, use of adherence aids, or addressing cost and other access barriers. Electronic inhaler monitors are promising interventions for both monitoring and improving adherence. However, remaining concerns about integration into patient care, data management, cost, acceptability, and ethical and privacy issues must be overcome prior to their implementation in clinical practice.

Current Perspectives of Pharmacotherapies for COPD

Pharmacotherapies and avoidance of environmental/inhaled toxins are core to managing COPD. Compared to the drugs available 50 years ago, there has been substantial progress with COPD pharmacotherapies, but gaps in adherence and inhaler use persist. Personalizing inhaled pharmacotherapies is now possible with digital technologies by objectively documenting adherence and guiding inhaler technique. Another means to improve existing pharmacotherapies is through phenotyping and biomarkers. This is especially important considering the heterogeneity of the disease COPD. Blood eosinophils are now a recommended biomarker to guide use of inhaled corticosteroids and biologics in COPD. On the near horizon, we will see new inhaled medications as dual phosphodiesterase inhibitors, drugs to treat basic protein abnormalities as in alpha-1 antitrypsin deficiency that could have remarkable benefits, and biologic drugs targeting specific cell/mediator types in the COPD population. Characterization of COPD phenotypes, as asthma/COPD overlap and comorbid heart disease are vital to understand how to optimize pharmacotherapies. Importantly, we must determine how to optimize current medications; otherwise, we will repeat the same mistakes with new medications. But as we know so well, as we peel one layer of complexity, we encounter many more questions, all the while dedicated to limiting the burden of COPD.

Advances in soft mist inhalers

INTRODUCTION

Soft mist inhalers (SMIs) are propellant-free inhalers that utilize mechanical power to deliver single or multiple doses of inhalable drug aerosols in the form of a slow mist to patients. Compared to traditional inhalers, SMIs allow for a longer and slower release of aerosol with a smaller ballistic effect, leading to a limited loss in the oropharyngeal area, whilst requiring little coordination of actuation and inhalation by patients. Currently, the Respimat® is the only commercially available SMI, with several others in different stages of preclinical and clinical development.

AREAS COVERED

The primary purpose of this review is to critically assess recent advances in SMIs for the delivery of inhaled therapeutics.

EXPERT OPINION

Advanced particle formulations, such as nanoparticles which target specific areas of the lung, Biologics, such as vaccines, proteins, and antibodies (which are sensitive to aerosolization), are expected to be generally delivered by SMIs. Furthermore, repurposed drugs are expected to constitute a large share of future formulations to be delivered by SMIs. SMIs can also be employed for the delivery of formulations that target systemic diseases. Finally, digitalizing SMIs would improve patient adherence and provide clinicians with fundamental insights into patients' treatment progress.

Digital health in chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease (COPD) can be prevented and treated through effective care, reducing exacerbations and hospitalizations. Early identification of individuals at high risk of COPD exacerbation is an opportunity for preventive measures. However, many patients struggle to follow their treatment plans because of a lack of knowledge about the disease, limited access to resources, and insufficient clinical support. The growth of digital health-which encompasses advancements in health information technology, artificial intelligence, telehealth, the Internet of Things, mobile health, wearable technology, and digital therapeutics-offers opportunities for improving the early diagnosis and management of COPD. This study reviewed the field of digital health in terms of COPD. The findings showed that despite significant advances in digital health, there are still obstacles impeding its effectiveness. Finally, we highlighted some of the major challenges and possibilities for developing and integrating digital health in COPD management.

Clinical Impact of Electronic Monitoring Devices of Inhalers in Adults with Asthma or COPD: A Systematic Review and Meta-Analysis

We conducted a systematic review and meta-analysis to gain insight into the characteristics and clinical impact of electronic monitoring devices of inhalers (EMDs) and their clinical interventions in adult patients with asthma or COPD. The search included PubMed, Web of Science, Cochrane, Scopus and Embase databases, as well as official EMDs websites. We found eight observational studies and ten clinical trials, assessing a wide range of clinical outcomes. Results from the meta-analysis on adherence to inhalers in a period over three months were favourable in the EMD group (fixed effects model: SMD: 0.36 [0.25–0.48]; random effects model SMD: 0.41 [0.22–0.60]). An exploratory meta-analysis found an improvement in ACT score (fixed effect model SMD: 0.25 [0.11–0.39]; random effects model: SMD: 0.47 [−0.14–1.08]). Other clinical outcomes showed mixed results in the descriptive analyses. The findings of this review highlight the benefits of EMDs in the optimization of adherence to inhaled therapy as well as the potential interest in other clinical outcomes.

Electronic Monitoring Devices to Support Inhalation Technique in Patients with Asthma: a Narrative Review

Purpose of Review

Improper inhaling technique is common and is associated with poor patient outcomes. However, digital e-health devices may offer novel opportunities for educational support. This narrative review provides an overview of electronic monitoring devices (EMDs) measuring patient inhalation technique. We summarise their technical features, capabilities and limitations and discuss the steps necessary for implementation in clinical practice.

Recent Findings

Six EMDs measuring inhalation were identified. The quality of published evidence varied widely. Devices differed in the inhalation technique steps measured, the feedback provided and the type of sensor employed. Sustainability and battery life differed according to whether devices were built into inhalers or add-ons. Nevertheless, all EMDs could reliably capture diverse inhaler technique errors, and some can guide educational interventions and follow-up treatment. In addition, some EMDs may serve as an early warning system for exacerbations.

Summary

New-generation EMDs can measure patient inhalation technique, yet there is limited data on patient preferences, acceptability of inhaler technique monitoring, cost-effectiveness and the influence of inhaler technique monitoring on clinical outcomes, all representing areas for further research.

Feedback systems in multi-dose dry powder inhalers

Dry powder inhalers (DPIs) are a large, highly diverse group of inhalation devices. DPIs differentiate the process of measuring the dose of the drug and preparing the inhaler for use, but also the way of transmitting and the scope of feedback on the inhalation process that the user receives. The functioning of simple and technologically advanced systems of feedback on the inhalation process in the most commonly used multi-dose DPIs is discussed. All these DPIs have a dose counter. Only three DPIs - Novolizer^®, Genuair^® and NEXThaler^® provide feedback to the patient in the form of auditory and visual signals confirming the correctness of the inhalation performed. This is important for the correct use of the inhaler, and thus for obtaining the expected therapeutic effects.

Advancing Digital Solutions to Overcome Longstanding Barriers in Asthma and COPD Management

Maintenance therapy delivered via inhaler is central to asthma and chronic obstructive pulmonary disease (COPD) management. Poor adherence to inhaled medication and errors in inhalation technique have long represented major barriers to the optimal management of these chronic conditions. Technological innovations may provide a means of overcoming these barriers. This narrative review examines ongoing advances in digital technologies relevant to asthma and COPD with the potential to inform clinical decision-making and improve patient care. Digital inhaler devices linked to mobile apps can help bring about changes in patients' behaviors and attitudes towards disease management, particularly when they build in elements of interactivity and gamification. They can also support ongoing technique education, empowering patients and helping providers maximize the value of consultations and develop effective action plans informed by insights into the patient's inhaler use patterns and their respiratory health. When combined with innovative techniques such as machine learning, digital devices have the potential to predict exacerbations and prompt pre-emptive intervention. Finally, digital devices may support an advanced precision medicine approach to respiratory disease management and help support shared decision-making. Further work is needed to increase uptake of digital devices and integrate their use into care pathways before their full potential in personalized asthma and COPD management can be realized.

Smart dry powder inhalers and intelligent adherence management

Adherence to inhaled treatments is a complex challenge for patients with chronic obstructive pulmonary disease (COPD) and asthma, it not only involves following the prescribed treatment plans but also administering the medications correctly. When using a dry powder inhaler (DPI), the inhalation flow is particularly critical. Patients frequently fail to use a rapid enough onset and fast enough inhalation when using DPIs. At the same time, there is increasing pressure on physicians to switch patients to DPIs, to minimise the environmental impact of pMDI propellants. This makes it critical to understand whether a patient will maintain or improve disease control by using their new inhaler correctly. However, it is challenging for health care professionals to understand how a patient behaves away from the clinic. Therefore, it would be beneficial to obtain real-world data through the use of monitoring tools, i.e., "smart inhalers". This paper reviews the technologies used to monitor DPIs, how effective they have been in a clinical setting, and how well these have been adopted by patients and health care providers.

Integrating digital inhalers into clinical care of patients with asthma and chronic obstructive pulmonary disease

Modernizing inhaled medications through digital technology can help address persistent problems of non-adherence and poor inhaler technique in patients with obstructive lung diseases. With a growing body of supportive clinical studies, advances in digital inhaler sensors and platforms, greater support from payers and healthcare organizations, significant growth with these technologies is expected. While all digital (smart) inhalers record adherence, these are distinguished by their compatibility with commercial inhalers, capabilities to guide inhaler technique, use of patient-reported outcomes, and user-friendliness for both the healthcare professional (HCP) and patient. Due to the complexity and novelty of employing digital inhalers, collaboration with multiple entities within health systems is necessary and a well-planned integration is needed. For HCPs and patients, cybersecurity and privacy are critical, it will require review by each healthcare organization. In the US, some payers reimburse for remote monitoring using digital inhalers, but reimbursement is currently unavailable in other countries. There are several models for remote patient care, as employing an active, ongoing digital interface between the HCP and patient or they may choose to only review data at clinical encounters. Personalization of therapies and feedback are key to success. While digital inhaler malfunction uncommonly occurs, patient attrition over a year is significant. Some patients will be challenged to use digital platforms or have the necessary technology. Additional research is needed to address cost-effectiveness, in vivo accuracy of inspiratory measurement capable devices, ability to teach inhaler technique, their application for monitoring lung function, and lastly real-world adoption and implementation in routine clinical practice.

Measurement of adherence to inhaled corticosteroids by self-report and electronic medication monitoring

OBJECTIVE

Poor adherence to daily inhaled corticosteroids (ICS) is an important factor contributing to asthma morbidity. Assessing adherence in clinical settings using self-reported adherence often overestimates actual adherence. Electronic monitoring devices (EMDs) are objective means of assessing adherence, but are not routinely used in practice. Here, we aimed to establish adherence rates to ICS using EMDs in an inner-city, minority population in the Bronx, NY, and to compare two methods of self-reported adherence with EMD-measured adherence.

METHODS

Patients with physician-confirmed persistent asthma and daily ICS prescription were recruited. Self-reported adherence to ICS was measured by parental report for children and self-report for adults and the Medication Adherence Report Scale for Asthma (MARS-A). Two weeks after enrollment, EMD data were accessed for analysis. Daily adherence was calculated based on the number of puffs actuated per day as captured by EMD divided by the prescribed number of puffs.

RESULTS

41 children and 40 adults participated. Median EMD-measured ICS adherence was 41% (children) and 43% (adults). This was significantly lower than the median self-reported adherence (100% for children, p < 0.001; 100% for adults, p < 0.001). MARS-A score in children did not correlate with EMD adherence data (p = 0.18), while in adults, this correlation tended to be more consistent (p = 0.07).

CONCLUSIONS

Adherence to daily ICS as measured using EMD is low in this population. In both adults and children, self-reported adherence was a poor indicator of true adherence. Further efforts using objective measures of medication adherence for patients with high asthma morbidity may be warranted to guide therapeutic decisions.

Digital Inhalers and Remote Patient Monitoring for Asthma

Digital inhaler systems, remote patient monitoring, and remote therapeutic monitoring offer great promise as diagnostic tools and therapeutic interventions to improve adherence and inhaler technique for patients with difficult-to-control asthma. In turn, improvements in adherence and inhaler technique may translate into decreasing the need for high side effect treatments such as oral corticosteroids and costly therapies including biologics. Although more clinical trials are needed, studies that use digital inhaler systems to collect objective real-time data on medication-taking behavior via electronic medication monitors and feed this data back to patients on their mobile asthma app, and to health care professionals on the clinician dashboard to counsel patients, show positive outcomes. This article addresses the use of these diagnostic and therapeutic tools in asthma care, how to choose a digital inhaler system, how to teach patients to use the system, strategies for the adoption of these technologies in large health care systems as well as smaller practices, coding and reimbursement, liability concerns, and research gaps.

Remote patient monitoring in the management of chronic obstructive pulmonary disease

Remote patient monitoring allows monitoring high-risk patients through implementation of an expanding number of technologies in coordination with a healthcare team to augment care, with the potential to provide early detection of exacerbation, prompt access to therapy and clinical services, and ultimately improved patient outcomes and decreased healthcare utilization.In this review, we describe the application of remote patient monitoring in chronic obstructive pulmonary disease including the potential benefits and possible barriers to implementation both for the individual and the healthcare system.

Improving Medication Adherence in Asthma

In little over a generation, the ingenuity of scientists and clinician researchers has developed inhaled medications and pathway-specific biological agents that control the inflammation and physiology of asthma. Unfortunately, whether it is because of cost or difficulty understanding why or how to use inhaled medications, patients often do not take these medications. The consequences of poor treatment adherence, loss of control and exacerbations, are the same as if the condition remained untreated. Furthermore, poor adherence is difficult to detect without direct measurement. Together this means that poor treatment adherence is easily overlooked and, instead of addressing the cause of poor adherence, additional medicines may be prescribed. In other words, poor treatment adherence is a risk for the patient and adds cost to healthcare systems. In this article, we discuss the rationale for and the delivery of successful interventions to improve medication adherence in asthma. We contextualize these interventions by describing the causes of poor treatment adherence and how adherence is assessed. Finally, future perspectives on the design of new interventions are described.

Electronic Inhaler Monitoring for Chronic Airway Disease: Development and Application of a Multidimensional Efficacy Framework

Inhaled therapy is the cornerstone of chronic airway disease therapy, but poor adherence to controller inhalers worsens clinical outcomes and increases cost. Monitoring of controller use is needed to improve adherence, and monitoring of reliever use can predict impending exacerbations. Both can be accurately achieved by electronic inhaler monitoring (EIM). However, evidence for EIM use in clinical practice is limited and varied, and knowledge gaps remain across different outcomes and health settings. We aimed to develop a framework to assess EIM systematically across all aspects of efficacy, apply this framework to the current literature, and identify gaps in efficacy to inform future development in the field. We adapted an existing framework for diagnostic tests, consisting of six levels of efficacy with ascending clinical relevance: technical, diagnostic accuracy, diagnostic thinking, therapeutic, patient outcome, and societal efficacy. Tailoring this framework to EIM, we incorporated expert feedback and applied it to the EIM efficacy literature. We found that EIM has good diagnostic accuracy, diagnostic thinking, and therapeutic efficacies, but evidence is lacking for specific aspects of technical, patient outcome, and societal efficacies. Further development of EIM requires improved reliability, usability, and data security for patients, and optimal integration with electronic medical records and overall patient care. Defining appropriate target patient groups and pairing EIM data with effective interventions, in conjunction with reducing costs through technological innovation and economies of scale, will enhance patient and societal outcome efficacies.

Analyzing the Treatment of Patients with Acute Exacerbation of COPD with the Aid of Intelligent Diagnosis Method

To observe the clinical efficacy of heat clearing phlegm mixture combined with vibration sputum excretion instrument in the treatment of patients with acute exacerbation of COPD with phlegm-heat obstructing lung, 90 patients with acute exacerbation of COPD are selected and divided into three groups, namely, control group, traditional medicine group, and combined group: the control group (conventional western medicine treatment), traditional medicine group (heat clearing and phlegm mixture), and combined group (heat clearing and phlegm mixture + vibratory sputum excretion instrument) with 30 cases each. All the patients in the three groups were given conventional western medicine treatment. On this basis, the traditional medicine group was given the oral administration of the heat-clearing and phlegm-clearing mixture, and the combined group was given the oral administration of the heat-clearing and phlegm-clearing mixture and the vibratory sputum discharge apparatus. Machine learning is used to classify the patients into three groups based on the characteristics of their biomarkers, physical attributes, and medical history. The TCM syndrome score, blood gas analysis, lung function, and inflammatory indexes of the three groups were compared. TCM syndrome scores of the three groups were all lower than before; both the combined group and the TCM group were better than the control group ( $P$  < 0.05). Although the improvement degree of the combined group was better than that of the TCM group, the difference was not statistically significant ( $P$  > 0.05). TCM syndrome effect is seen to be 96.55% in the combined group, 89.29% in the TCM group, and 63.33% in the control group. Blood gas analysis is also performed; PO2 and PCO2 of the three groups were significantly improved after treatment. The combination group was superior to the traditional medicine group and the control group ( $P$  < 0.05), and the traditional medicine group was superior to the control group ( $P$  < 0.05). It is concluded that the combination of heat clearing phlegm mixture and vibration sputum excretion instrument can improve TCM syndrome score, CAT score, blood gas analysis, lung function, and inflammatory indicators in patients with acute exacerbation of COPD with phlegm-heat obstructing lung.

Difficult-to-Treat Asthma Management in School-Age Children

The World Health Organization divides severe asthma into three categories: untreated severe asthma; difficult-to-treat severe asthma; and severe, therapy-resistant asthma. The apparent frequency of severe asthma in the general population of asthmatic children is probably around 5%. Upon referral of these children, it is important to evaluate the diagnosis of asthma carefully before modifying management and applying a long-term monitoring plan. Identification of pathophysiologic phenotypes using objective biomarkers is essential in our routine assessments of severe asthma. Although conventional pharmacologic approaches should be attempted first, there is growing recognition that children with difficult-to-treat asthma may have unique clinical phenotypes that may necessitate alternative treatment approaches including asthma biologics. These new medications, especially those with effects on multiple pathologic features of asthma, raise the hope that new treatment strategies could induce remission. Besides introducing new medications, the opportunity for closer monitoring is feasible with advances in digital health. Therefore, we have the opportunity to improve response to medications, individualize treatment, and monitor response along with potential steps to prevent severe asthma.