May 31, 2022 – After years going on and off medications for occasional asthma symptoms, things went downhill for Brian Blome in November 2020. The retired carpenter started feeling short of breath and wheezing during bike rides. At home, he struggled with chores.
“I was having a hard time climbing a flight of stairs, just doing laundry,” says Blome, who lives in the Chicago suburb of Palatine.
To get things under control, he saw an allergist and started regular medications – two tablets, two nasal sprays, and inhaled corticosteroids each day, plus an albuterol inhaler for flare-ups.
The inhalers have an extra feature: an electronic monitor that attaches to the device and automatically tracks where and when the medication is used. Bluetooth sends this information to an app on the patient’s mobile phone and to a dashboard where the medical team can see, at a glance, when symptoms are popping up and how regularly medications are taken – leading to the devices often being called “smart inhalers.”
At this year’s American Academy of Allergy, Asthma, and Immunology (AAAAI) conference in Phoenix, AZ, researchers explained how digital monitoring devices can help diagnose and treat hard-to-control asthma, potentially reducing the need for oral steroids or biologic therapies.
Even though electric monitors have been on the market for years, their use has been slow to catch on due to uncertainties around insurance coverage, liability, and how to manage and best use the data. One recent study said these devices cost $100-$500, but that price depends on many things, such as insurance.
About 17% of adult asthma patients have “difficult-to-control” asthma, meaning they limit their activity due to breathing symptoms and use reliever medications multiple times a week.
But research suggests that correcting inhaling technique and sticking to the use of the meds can cut that 17% down to just 3.7%, says Blome’s allergist, Giselle Mosnaim, MD, of NorthShore University HealthSystem. Mosnaim spoke about digital monitoring at a conference session on digital technologies for asthma management.
A study of more than 5,000 asthma patients “showed that if you have critical errors in inhaler technique, this leads to worse asthma outcomes and increased asthma exacerbations,” she says. It also shows that despite new devices and new technologies, “we still have poor inhaler technique.”
Yet adherence is poorly gauged by doctors and patient self-reporting. “The ideal measure of adherence should be objective, accurate, and unobtrusive to minimize impact on patient behavior and allow reliable data collection in real-world settings,” Mosnaim says. “So electronic medication monitors are the gold standard.”
Patients not following instructions or guidelines “is something we saw nonstop with kids,” says Caroline Moassessi, founder of the allergy and asthma blog Gratefulfoodie.com who formerly served on a regional board of the American Lung Association. She’s also the mother of two asthmatic children, now in college, who years ago used electronic medication monitors as part of a research trial.
They were “unimpressed – mostly since I think they thought their asthma was controlled,” she says. “When patients are not in crisis, they don’t manage their asthma well.”
Even in research studies such as the one Rachelle Ramsey, PhD, presented at the conference, it’s not only hard to determine if better adherence leads to improved health, but when.
“For example, does your adherence this week impact your asthma control this week, or does it impact your asthma control next week? Or is it even further out? Do you need to have some level of adherence over the course of a month in order to have better outcomes at the end of that month?” says Ramsey, a pediatric research psychologist at Cincinnati Children’s Hospital Medical Center. “I think it’s a little complicated.”
That said, results from several small studies do show a connection between remote monitoring and better clinical outcomes. One study enrolled asthma patients in the United Kingdom, and another was done by Mosnaim with Chicago-area patients.
In the U.K. quality improvement project, nurses asked patients with difficult-to-control asthma if they knew how to use their inhalers and were following treatment guidelines.
Those who said “yes” were invited to swap their steroid/inhalers for a controller fitted with a device that tracks use and measures acoustics to test inhaler technique. After 28 days of monitoring, many people in the study had better clinical outcomes.
And after 3 months of digital monitoring, patients didn’t use their rescue medication quite as often.
Blome has seen a marked improvement in his asthma since starting regular appointments and getting back on daily medications a year and a half ago. He says that now and then, he has wheezing and shortness of breath, usually while biking or exercising. But those symptoms aren’t as severe or frequent as before.
From a doctor’s perspective, “digital inhaler systems allow me to discern patterns in order to determine what triggers his asthma symptoms and to adjust medications at different times of the year,” Mosnaim says.
Electronic systems can monitor pollen counts and air quality as well as how often a patient uses a quick reliever medication. Thus, she says, tracking these measures year-round could raise attention to impending asthma attacks and suggest when to increase the dose of controller medications or add other treatments.