Potential is high’ for remote patient monitoring in difficult-to-control asthma

PHOENIX — Although challenges remain, remote digital health practices can be implemented for most aspects of asthma evaluation and management, according to a speaker at the American Academy of Allergy, Asthma & Immunology Annual Meeting.

Presenting the 24th year of the Elliot F. Ellis Memorial Lectureship during the meeting’s presidential plenary session, Andrew Liu, MD, FAAAAI, director of the Airway Inflammation, Resilience & the Environment (AIRE) Program, co-director of the Asthma Clinical Research Center and member of The Breathing Institute in the section of pediatric pulmonary and sleep medicine at Children’s Hospital Colorado, as well as professor of pediatrics at University of Colorado Denver School of Medicine, discussed how well technology and digital health can help clinicians with the evaluation and management of patients with difficult-to-treat asthma.

“What happened in the start of the pandemic is a good example for all of us,” Liu said. “Many of us got really familiar with digital health tools quickly as we had to pivot to telehealth.

“I remember in that first week of telehealth implementation, the physician in charge of doing this for our section said, ‘It’s like flying a plane while you’re building it.’ And yet she did it, and we’re doing it, and we know that digital tech has been absolutely essential to pandemic health care,” he added.

Patient-specific interventions

A number of studies have shown a substantial benefit in adherence, improvement in asthma impairment and reduction in health care utilization with a digital health intervention that incorporates patient feedback, according to Liu.

“Digital health interventions that seem to benefit patients most are the ones that are patient specific and provide patient feedback,” he said.

To provide an example of what such an intervention looks like, Liu described a study by Mosnaim and colleagues, in which 100 participants with uncontrolled asthma were randomly assigned to a treatment group that received reminders and feedback on inhaled corticosteroid (ICS) and short-acting beta2-agonists (SABAs) use via a smartphone app and clinician phone calls, or a control group without feedback.

“They had inhaler sensors for their controller medication and their rescue albuterol,” Liu said. “The patient-feedback intervention takes that information, alerts them if they miss doses of their controller and it also engages clinician feedback for support of adherence to the controller medication.”

Over the 3 months of the study, results showed a significant 19% increase in the percentage of SABA-free days in the treatment group, compared with a nonsignificant 6% increase in the control group (P = .04). Also, adherence to ICS was retained in the treatment group but decreased in the control group (P < .01).

“It appears that digital health interventions are most effective when they provide patients feedback and link back to us as providers,” Liu said.

AIRE experiences

The AIRE Program at Children’s Hospital Colorado and University of Colorado School of Medicine is a collaborative clinical research group for difficult asthma in children that “functions like a clinical practice lab,” Liu said.

“The AIRE group is facile in digital life, and they really bring that to our relationships with our patients, our study participants and their families,” Liu said. “They’ve been able to do that during the pandemic to keep our science moving forward. I’d like to think that what they’re doing is developing better tools for our current and future practices.”

What they’ve learned during the pandemic may have application to clinical practices, Liu added.

For instance, clinical research studies that continued throughout the pandemic using remote practices employed app-based virtual video visits; digital remote questionnaires and consent-assent forms; app-based daily symptoms dairies; home spirometry; inhaler sensers; and biospecimen collection from the nose, blood, stool and environment.

The HEROS COVID-19 surveillance study sponsored by NIAID was in the field completely remotely within 6 weeks of the start of the pandemic, Liu said. Nasal swab collections occurred every 2 weeks for more than 360,000 samples collected, with 94% of samples meeting acceptability criteria for detecting respiratory virus.

The AIRE lab group also has focused on the ability to conduct environmental sampling remotely, beyond using community-level information from EPA monitors, and pollen levels and outdoor mold levels from the AAAAI-sponsored National Allergy Bureau.

“At the start of the pandemic, we were conducting home inspections and we pivoted to home virtual tours,” Liu said. “We continued to collect dust samples but had them collected remotely to look at home allergens and microbes. There are ways that we can assess home environments for ambient pollution exposures, either indoors or outdoors. Urine can provide us information about toxin exposures like tobacco smoke, and we can get information on respiratory viruses from nasal swabs.”

The AIRE group also has been interested in assessing an individual’s breathing zone — the area from forehead to elbows — using wearable monitors that can assess personal exposure to particulate matter, ozone and nitrogen dioxide levels.

“Virtual visits can’t capture it all, but families and patients took to it better than we thought,” Liu said. “They appreciate the greater flexibility in scheduling and time savings by doing things at home. This allowed some to participate in our research who may not have been able to otherwise. Some also felt more comfortable with going to consent/assent at home, so they could take more time and ask questions.”

The home-based approach represents a shift in responsibility for some of these tasks, such as nasal swabs and dust collection, moving from the provider to the patient.

“We used to do it, now they have to do it,” Liu said. “So that means our partnership with our participants and their families has to be stronger. When we share with them a visualization of their exposure activity location, that’s that kind of personalized feedback that they love.”

Detecting imminent exacerbations

Liu also discussed the possibility of remote patient monitoring to detect beginning signs of an asthma exacerbation.

Data from Covar and colleagues of the PACT study revealed that measures of daily cough/wheeze, rescue albuterol and morning peak flows all significantly changed within 2 days of asthma exacerbations.

“That’s important, because that gives enough time to address it with an oral corticosteroid course, which can improve things in a hurry,” Liu said. “But it’s also important to know that the positive-predictive value for any one of these signals was poor, and the combination of the signals was better, but still not that strong.”

Reporting each of these signals daily can also be hard to maintain for “relatively rare events,” Liu added.

“I’d like to believe that early detection of imminent exacerbation is an important and worthy goal, and remote patient monitoring is likely to get us there,” he said. He added that monitors and apps that detect cough and wheeze are improving, as are activity limitation wearable monitors, in addition to the rescue albuterol inhaler sensors, home pulse oximetry measurers, and other widely available smartphone and app-based platforms.

“The know-how is there to figure out what signals matter most, and to figure out how to combine them and how to interpret them for a highly active signal on predicting imminent exacerbations,” Liu said.

“The potential is high for digital health and remote patient monitoring for difficult asthma, and there is hope for a better future,” he added.