Advertisement

The Utility of Electronic Inhaler Monitoring in COPD Management

Promises and Challenges
Published:January 22, 2020DOI:https://doi.org/10.1016/j.chest.2019.12.034
      COPD is a common respiratory disorder that poses a major health-care burden with societal and financial ramifications. Although effective inhaled therapies are available, nonadherence is common among patients with COPD and potentially contributes to the burden of this disease. Electronic inhaler monitoring (EIM) is a novel modality that enables real-time assessment of adherence to inhaled therapy and informs the assessment of treatment effectiveness. EIM can be combined with physician feedback, automated audiovisual reminders, and text messaging to bolster adherence. Clinical studies have suggested that EIM can diagnose nonadherence, improve adherence, and predict exacerbations. Using an EIM-guided protocol has the potential to avoid treatment escalation in the nonadherent. Coupling EIM to behavioral intervention is an area of ongoing research with mixed results, with some studies showing benefit and others showing minimal or no significant change in clinical outcomes. Further investigation is necessary to understand the incremental benefits of EIM features, delineate optimal program implementation, and target patient populations that would benefit the most from monitoring.

      Key Words

      Abbreviations:

      AVR (audiovisual reminder), EIM (electronic inhaler monitoring), EMD (electronic monitoring device), HIPAA (Health Insurance Portability and Accountability Act of 1996), IE (intensive education), INCA (Inhaler Compliance Assessment), RCT (randomized controlled trial), SABA (short-acting β₂ agonist)
      To read this article in full you will need to make a payment
      Subscribe to CHEST
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Karner C.
        • Chong J.
        • Poole P.
        Tiotropium versus placebo for chronic obstructive pulmonary disease.
        Cochrane Database Syst Rev. 2014; : CD009285
        • Martinez F.J.
        • Vestbo J.
        • Anderson J.A.
        • et al.
        Effect of fluticasone furoate and vilanterol on exacerbations of chronic obstructive pulmonary disease in patients with moderate airflow obstruction.
        Am J Respir Crit Care Med. 2017; 195: 881-888
        • Bender B.G.
        Nonadherence in chronic obstructive pulmonary disease patients: What do we know and what should we do next?.
        Curr Opin Pulm Med. 2014; 20: 132-137
        • Blackstock F.C.
        • Wallack R.Z.
        • Nici L.
        • Lareau S.C.
        Why don’t our patients with chronic obstructive pulmonary disease listen to us? The enigma of nonadherence.
        Ann Am Thorac Soc. 2016; 13: 317-323
        • Toy E.L.
        • Beaulieu N.U.
        • McHale J.M.
        • et al.
        Treatment of COPD: relationships between daily dosing frequency, adherence, resource use, and costs.
        Respir Med. 2011; 105: 435-441
        • Sulaiman I.
        • Cushen B.
        • Greene G.
        • et al.
        Objective assessment of adherence to inhalers by patients with chronic obstructive pulmonary disease.
        Am J Respir Crit Care Med. 2017; 195: 1333-1343
        • Bourbeau J.
        • Bartlett S.J.
        Patient adherence in COPD.
        Thorax. 2008; 63: 831-838
        • Simmons M.S.
        • Nides M.A.
        • Rand C.S.
        • Wise R.A.
        • Tashkin D.P.
        Unpredictability of deception in compliance with physician-prescribed bronchodilator inhaler use in a clinical trial.
        Chest. 2000; 118: 290-295
        • Rand C.S.
        • Wise R.A.
        • Nides M.
        • et al.
        Metered-dose inhaler adherence in a clinical trial.
        Am Rev Respir Dis. 1992; 146: 1559-1564
        • Suissa S.
        • Ernst P.
        • Benayoun S.
        • Baltzan M.
        • Cai B.
        Low-dose inhaled corticosteroids and the prevention of death from asthma.
        N Engl J Med. 2000; 343: 332-336
        • Vestbo J.
        • Anderson J.A.
        • Calverley P.M.A.
        • et al.
        Adherence to inhaled therapy, mortality and hospital admission in COPD.
        Thorax. 2009; 64: 939-943
        • Simoni-Wastila L.
        • Wei Y.J.
        • Qian J.
        • et al.
        Association of chronic obstructive pulmonary disease maintenance medication adherence with all-cause hospitalization and spending in a Medicare population.
        Am J Geriatr Pharmacother. 2012; 10: 201-210
        • Patel M.
        • Perrin K.
        • Pritchard A.
        • et al.
        Accuracy of patient self-report as a measure of inhaled asthma medication use.
        Respirology. 2013; 18: 546-552
        • Sulaiman I.
        • Seheult J.
        • MacHale E.
        • et al.
        A method to calculate adherence to inhaled therapy that reflects the changes in clinical features of asthma.
        Ann Am Thorac Soc. 2016; 13: 1894-1903
        • Mawhinney S.L.
        • Kinsman R.A.
        • Siegel S.C.
        • Rachelefsky G.S.
        • Katz R.M.
        • Rohr A.S.
        Compliance in clinical trials of two nonbronchodilator, antiasthma medications.
        Ann Allergy. 1991; 66: 294-299
        • Merchant R.K.
        • Inamdar R.
        • Quade R.C.
        Effectiveness of population health management using the Propeller Health Asthma Platform: a randomized clinical trial.
        J Allergy Clin Immunol Pract. 2016; 4: 455-463
        • Campbell J.I.
        • Eyal N.
        • Musiimenta A.
        • Haberer J.E.
        Ethical questions in medical electronic adherence monitoring.
        J Gen Intern Med. 2016; 31: 338-342
        • Howard S.
        • Lang A.
        • Sharples S.
        • Shaw D.
        What are the pros and cons of electronically monitoring inhaler use in asthma? A multistakeholder perspective.
        BMJ Open Respir Res. 2016; 3: e000159
        • Chan A.H.Y.
        • Harrison J.
        • Black P.N.
        • Mitchell E.A.
        • Foster J.M.
        Using electronic monitoring devices to measure inhaler adherence: a practical guide for clinicians.
        J Allergy Clin Immunol Pract. 2015; 3: 335-349
        • Normansell R.
        • Kew K.M.
        • Stovold E.
        Interventions to improve adherence to inhaled steroids for asthma.
        Cochrane Database Syst Rev. 2017; 4: CD012226
        • Apter A.J.
        • Wang X.
        • Bogen D.K.
        • et al.
        Problem solving to improve adherence and asthma outcomes in urban adults with moderate or severe asthma: a randomized controlled trial.
        J Allergy Clin Immunol. 2012; 128: 516-523
        • Foster J.M.
        • Usherwood T.
        • Smith L.
        • et al.
        Inhaler reminders improve adherence with controller treatment in primary care patients with asthma.
        J Allergy Clin Immunol. 2014; 134: 1260-1268
        • Onyirimba F.
        • Apter A.
        • Reisine S.
        • et al.
        Direct clinician-to-patient feedback discussion of inhaled steroid use: its effect on adherence.
        Ann Allergy Asthma Immunol. 2003; 90: 411-415
        • Vasbinder E.C.
        • Goossens L.M.A.
        • Rutten-Van Mölken M.P.
        • et al.
        E-Monitoring of Asthma Therapy to Improve Compliance in children (e-MATIC): a randomised controlled trial.
        Eur Respir J. 2016; 48: 758-767
        • Charles T.
        • Quinn D.
        • Weatherall M.
        • Aldington S.
        • Beasley R.
        • Holt S.
        An audiovisual reminder function improves adherence with inhaled corticosteroid therapy in asthma.
        J Allergy Clin Immunol. 2007; 119: 811-816
        • Morton R.W.
        • Elphick H.E.
        • Rigby A.S.
        • et al.
        STAAR: a randomised controlled trial of electronic adherence monitoring with reminder alarms and feedback to improve clinical outcomes for children with asthma.
        Thorax. 2017; 72: 347-354
        • Sulaiman I.
        • Greene G.
        • MacHale E.
        • et al.
        A randomised clinical trial of feedback on inhaler adherence and technique in patients with severe uncontrolled asthma.
        Eur Respir J. 2018; 51
        • Barrett M.A.
        • Humblet O.
        • Marcus J.E.
        • et al.
        Effect of a mobile health, sensor-driven asthma management platform on asthma control.
        Ann Allergy Asthma Immunol. 2017; 119: 415-421
        • van Sickle D.
        • Magzamen S.
        • Truelove S.
        • Morrison T.
        Remote monitoring of inhaled bronchodilator use and weekly feedback about asthma management: an open-group, short-term pilot study of the impact on asthma control.
        PLoS One. 2013; 8
        • Sulaiman I.
        • Seheult J.
        • MacHale E.
        • et al.
        Irregular and ineffective: a quantitative observational study of the time and technique of inhaler use.
        J Allergy Clin Immunol Pract. 2016; 4: 900-909.e2
        • Beeh K.M.
        • Hederer B.
        • Glaab T.
        • et al.
        Study design considerations in a large COPD trial comparing effects of tiotropium with salmeterol on exacerbations.
        Int J Chron Obstruct Pulmon Dis. 2009; 4: 119-125
        • Sabaté E.
        Adherence to long-term therapies: Evidence for action. Geneva: World Health Organization, 2003.
        • Viswanthan M.
        • Golin C.
        • Jones C.
        • et al.
        Interventions to improve adherence to self-administered medications for chronic diseases in the United States.
        Ann Intern Med. 2014; 157: 785-795
        • Normansell R.
        • Kew K.M.
        • Stovold E.
        Interventions to improve adherence to inhaled steroids for asthma.
        Cochrane Database Syst Rev. 2017; 4: CD012226
        • Dima A.L.
        • Hernandez G.
        • Cunillera O.
        • Ferrer M.
        • de Bruin M.
        • ASTRO-LAB Group
        Asthma inhaler adherence determinants in adults: systematic review of observational data.
        Eur Respir J. 2015; 45: 994-1018
        • Lee J.
        • Tay T.R.
        • Radhakrishna N.
        • et al.
        Nonadherence in the era of severe asthma biologics and thermoplasty.
        Eur Respir J. 2018; 51
        • Wilson S.R.
        • Strub P.
        • Buist A.S.
        • et al.
        Shared treatment decision making improves adherence and outcomes in poorly controlled asthma.
        Am J Respir Crit Care Med. 2010; 181: 566-577
        • Gamble J.
        • Stevenson M.
        • Heaney L.G.
        A study of a multi-level intervention to improve non-adherence in difficult to control asthma.
        Respir Med. 2011; 105: 1308-1315
        • Simmons M.S.
        • Nides M.A.
        • Rand C.S.
        • Wise R.A.
        • Tashkin D.P.
        Trends in compliance with bronchodilator inhaler use between follow-up visits in a clinical trial.
        Chest. 1996; 109: 963-968
        • Hung W.W.
        • Wisnivesky J.P.
        • Siu A.L.
        • Ross J.S.
        Cognitive decline among patients with chronic obstructive pulmonary disease.
        Am J Respir Crit Care Med. 2009; 180: 134-137
        • Park S.K.
        • Richardson C.R.
        • Holleman R.G.
        • Larson J.L.
        Frailty in people with COPD, using the National Health and Nutrition Evaluation Survey dataset (2003–2006).
        Heart Lung. 2013; 42: 163-170
        • Alshabani K.
        • Attaway A.A.
        • Smith M.J.
        • et al.
        Electronic inhaler monitoring and healthcare utilization in chronic obstructive pulmonary disease.
        J Telemed Telecare. 2019; (1357633X19850404)
        • Sumino K.
        • Locke E.R.
        • Magzamen S.
        • et al.
        Use of a remote inhaler monitoring device to measure change in inhaler use with chronic obstructive pulmonary disease exacerbations.
        J Aerosol Med Pulm Drug Deliv. 2017; 31: 191-198
        • Fan V.S.
        • Gylys-Colwell I.
        • Locke E.
        • et al.
        Overuse of short-acting beta-agonist bronchodilators in COPD during periods of clinical stability.
        Respir Med. 2016; 116: 100-106
        • van Boven J.F.
        • Ryan D.
        • Eakin M.N.
        • et al.
        Enhancing respiratory medication adherence: the role of health care professionals and cost-effectiveness considerations.
        J Allergy Clin Immunol Pract. 2016; 4: 835-846
        • van Boven J.F.
        • Cushen B.
        • Sulaiman I.
        • et al.
        Personalising adherence-enhancing interventions using a smart inhaler in patients with COPD: an exploratory cost-effectiveness analysis.
        NPJ Prim Care Respir Med. 2018; 28: 24
        • Robinson J.C.
        Insurers' strategies for managing the use and cost of biopharmaceuticals.
        Health Aff (Millwood). 2006; 25: 1205-1217
        • Propeller
        Commercial website privacy policy.
        • U.S. Food and Drug Administration
        Medical devices: cybersecurity.
        • Bender B.
        • Wamboldt F.
        • O’Connor S.L.
        • et al.
        Measurement of children’s asthma medication adherence by self report, mother report, canister weight, and Doser CT.
        Ann Allergy Asthma Immunol. 2000; 85: 416-421
        • Bartlett S.J.
        • Lukk P.
        • Butz A.
        • Lampros-Klein F.
        • Rand C.S.
        Enhancing medication adherence among inner-city children with asthma: results from pilot studies.
        J Asthma. 2002; 39: 47-54
        • Moran C.
        • Doyle F.
        • Sulaiman I.
        • et al.
        The INCATM (Inhaler Compliance Assessment TM): a comparison with established measures of adherence.
        Psychol Health. 2017; 32: 1266-1287
        • Taylor T.E.
        • Zigel Y.
        • De Looze C.
        • Sulaiman I.
        • Costello R.W.
        • Reilly R.B.
        Advances in audio-based systems to monitor patient adherence and inhaler drug delivery.
        Chest. 2018; 153: 710-722
        • Pépin J.L.
        • Jullian-Desayes I.
        • Sapène M.
        • et al.
        Multimodal remote monitoring of high cardiovascular risk patients with OSA initiating CPAP: a randomized trial.
        Chest. 2019; 155: 730-739
        • Stepnowsky C.J.
        • Palau J.J.
        • Marler M.R.
        • Gifford A.L.
        Pilot randomized trial of the effect of wireless telemonitoring on compliance and treatment efficacy in obstructive sleep apnea.
        J Med Internet Res. 2007; 9: e14
        • Malhotra A.
        • Crocker M.E.
        • Willes L.
        • Kelly C.
        • Lynch S.
        • Benjafield A.V.
        Patient engagement using new technology to improve adherence to positive airway pressure therapy: a retrospective analysis.
        Chest. 2018; 153: 843-850
        • Collier R.
        Rethinking EHR interfaces to reduce click fatigue and physician burnout.
        CMAJ. 2018; 190: E994-E995