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Abstract: Non-transmissible chronic respiratory diseases (CRDs) are very prevalent. In this chapter, we focus on the different dimensions through which telemedicine can be delivered and used in the management of patients with chronic obstructive pulmonary disease (COPD) and asthma, the major obstructive CRDs. Telerehabilitation, health education, telemonitoring, early detection of exacerbations, psychosocial support, and smoking cessation through telemedicine programs allow the delivery of quality healthcare to COPD patients who have limited access to health services. In asthma patients, telemedicine is effective in improving inhalation technique, increasing adherence to medication/self-management, and health education. We discuss the importance of virtual visits and mobile/web-based tools in the management and monitoring of patients with CRDs, the rising promise of telespirometry performed outside the hospitals, and the most relevant limitations to expand the implementation of telemedicine, such as the lack of digital literacy in patients and the issues of privacy and security when sharing data online.

Keywords: telemedicine for asthma; telemedicine for chronic respiratory diseases; telemedicine for COPD; telemonitoring; telespirometry

INTRODUCTION

Telemedicine is defined as the use of electronic information and communication technology by medical personnel to provide and support health care to patients when they are far away from the health care institutions (1–3). It encompasses a wide range of technologies such as videoconferencing, wearable devices, internet platforms, mobile applications, store-and-forward devices, streaming media, and terrestrial and wireless communication. Telemedicine can be used for a wide range of purposes, such as to decrease the demand on existing hospital and healthcare services, to promote health education, to reduce the cost of care, to measure and endorse treatment adherence, to quickly identify disease worsening, and to extend the accessibility of services to patients living in remote locations. Telemedicine is therefore a broad concept that involves diagnosis, treatment, monitoring, education, health promotion, and disease prevention (4). Telehealth is thought to support self-management by providing access to information, and at the same time enables transference of monitored data (5).

The global market of telemedicine has been emerging as an effective alternative to the usual clinical management in chronic respiratory diseases. In addition, the development of new easy to use and inexpensive technologies will certainly increase the number of patients requesting telemedicine services. Some pointed disadvantages of these technologies are the fact that they supposedly change the interaction between patient and provider (6); also some questions remain uncertain, such as legal, safety, and privacy issues (1). In the context of the coronavirus disease 2019 (COVID-19) pandemic, telemedicine acquired special relevance, especially to assess patients with suspected infection or with chronic diseases, avoiding visits to health centers (7, 8). Face-to-face visits in controlled asthma patients have been broadly recommended to be postponed or replaced by virtual visits (9). Non-transmissible chronic respiratory diseases (CRDs) are very prevalent, with significant morbidity and mortality. In this chapter, we focus on the different dimensions through which telemedicine can be delivered and used in the management of patients with chronic obstructive pulmonary disease (COPD) and asthma, the major non-transmissible obstructive CRDs.

TELEMEDICINE IN THE MANAGEMENT OF COPD

COPD is a disease mainly characterized by a progressive non-reversible narrowing of the airways. COPD carries a vast economic and social burden worldwide (10, 11). Telemedicine encompasses a variety of telecommunication strategies to remotely deliver health information and interventions to participants. Telemedicine is expected to enhance remote communication between patients and practitioners, and it is especially recognized as a supplementary tool to increase healthcare access for individuals with transport difficulties or those living in rural and remote areas (12). Several studies have been published focusing on the effects of different telemedicine programs for patients with different phenotypes and stages of COPD.

Telerehabilitation

The benefits of pulmonary rehabilitation in COPD patients are well established (13). Recent studies showed home-based telerehabilitation programs to reduce healthcare consumption, due to a decrease in the number of COPD exacerbations, emergency department (ED) visits, and COPD-related hospitalizations (14, 15). Interventions are noted to be heterogeneous in design, however the most common form of telerehabilitation programs are based on delivery of exercise in a clinical or home-based setting using video conferencing. Walking and cycling are the most frequent form of aerobic training. The monitoring hardware generally includes a pulse oximeter, a laptop/tablet or smartphone, step counter or a wearable physical activity monitor. An emergency plan is mandatory and thresholds for discontinuing exercise usually use a combination of heart rate, oxygen saturation, and dyspnea monitoring. Telerehabilitation seems to have similar benefits to outpatient pulmonary rehabilitation improving health-related quality of life, respiratory symptoms, and exercise tolerance. Likewise, rehabilitation through telemedicine, especially by video platforms, seems safe and well accepted by COPD patients. Acute exacerbations of COPD, ED visits and hospital admissions reduce after a telerehabilitation program, and a video consultation prior to a pulmonary rehabilitation program seems an adequate alternative to a face-to-face consultation (15–20).

Health education and self-management

Health education and self-management is characterized by interventions that empower patients to manage their diseases with confidence (21). The complexity of the digital health for self-management of COPD has escalated with recent developments in technology. A faster and easier way to communicate with healthcare providers has the potential to improve self-management of CRDs by the patients; however, it is important that this change in the delivery of healthcare does not result in inferior or unsafe health care. The majority of the studies determined that telemedicine and e-health interventions have a positive impact in self-management, adherence to treatment and symptom management ability. Programs that include health education sessions seem more effective (22, 23); however, the number of COPD exacerbations and hospital-admissions have failed to reduce.

Telemonitoring

Telemonitoring in COPD is not generally accepted yet because of a lack of compelling evidence of its beneficial long-term effects. Studies report improvements in some outcomes assessed: quality of life (24), hospital readmissions at three months after discharge, and decrease in exacerbation rate but with limited or inconsistent evidence (24, 25). However, telemonitoring have not consistently reduced ED visits, hospitalizations, and time to readmission in recent studies (24). In addition, the designs of the various telemonitoring interventions that have been studied to date are heterogeneous, differing mostly in the number and types of vital parameters transmitted (pulse measurements, spirometry results, blood oxygen saturation), cut-offs to trigger a medical intervention, and COPD stage of the target population (24). Acute exacerbations of COPD are an important factor to disease progression and COPD-related mortality. In the future, interventional plans are important to increase the capacity of telemonitoring to early diagnose an acute exacerbation of COPD. The continuous monitoring of various physiological parameters of patients during everyday activities by digital devices and algorithms to differentiate between expectable progression of the disease and acute exacerbation seems vital. Relying on this information, physicians might be able to adapt medications to the specific needs of the patients and reduce the severity of COPD acute exacerbations (26). Recognizing acute exacerbations in COPD at an early stage and arrange timely countermeasures might be an effective way to reduce hospitalization rates due to COPD.

Psychosocial support

COPD, especially in advanced stages, is often followed by anxiety, depression, and lack of social support. COPD patients with mental disorders frequently have difficult-to-treat respiratory symptoms. This difficulty in controlling respiratory symptoms leads to a greater use of unscheduled health care. The majority of the reports about psychosocial support interventions in telemedicine have favorable outcomes. This effect seems related to a more regular communication between the patient and healthcare professionals (27). Allowing COPD patients to share experiences to other patients and medical staff seems helpful to achieve an improvement of respiratory symptoms and better mental health (28).

Smoking cessation

Cigarette smoking is the leading behavioral risk factor for COPD. Preventing progression of COPD via smoking cessation remains of paramount importance. Mobile applications as an add-on to psychopharmacological therapy seems effective to achieve smoking cessation. In addition, the easy integration of these tools in primary healthcare settings has the potential to improve knowledge about possible treatments and integrate smoking cessation into routine of care (29, 30).

TELEMEDICINE IN THE MANAGEMENT OF ASTHMA

The non-inferiority of telemedicine, when compared to standard care, seems an opportunity to deliver good quality health care to patients with asthma. Telemedicine can contribute to increased patient safety. A significant number of articles had been published validating the advantages and limitations of telemedicine in managing and monitoring asthma in multiple dimensions.

Inhalation technique and adhesion to inhalers

E-health and virtual education interventions seem valid alternatives to improve inhaler technique in asthma patients (31). Besides that, using e-health through mobile apps, short text messages and monitoring devices (trackers) increase adherence to inhalers in asthma patients, with good acceptance by the patients (32–44); however, benefits were not always found (45).

Portable spirometry and telespirometry

Regarding electronic portable spirometry, there are contradictory information on clinical outcomes for asthma patients (46–48). Electronic portable spirometers provide valuable information about lung function, but with limitations related to the lack of instructions on how to perform breathing maneuvers correctly; also, many devices are inaccessible due to high cost and lack of regulatory authority’s approval (46). Nevertheless, for patients living in regions with poor access to specialty care, remote spirometry via telemedicine would allow guidelines-based recommendations to monitor lung function. There are reports of successful implementation of remote spirometry in rural settings with no adverse events. Rates of interpretable spirometry data resembles rates of in-person spirometry (47), and telespirometry was found to be effective in diagnosing and ruling out CRDs, detecting lung abnormalities, and managing patients with COPD and asthma (48).

Self-management and health education

Many reports tried to show the short and long-term benefits of telemedicine in patients with asthma, and most of them determined that telemedicine and e-health interventions have a positive impact on self-management (49), quality of life (50, 51), symptom management ability (52), and motivation to treatment adherence and medication use (53). The evaluated interventions were well accepted by patients (33), having the potential to facilitate patient-health care provider relationship (54, 55). Bruton et al. (51) showed that a breathing retraining program, delivered as a self-guided digital audiovisual program, besides improving quality of life, reduced health care expenses in patients with uncontrolled asthma. No reports found negative effects (49–59), but literature recommends further studies to consolidate the knowledge regarding the impact of these technologies in self-management and health education in patients with asthma.

Virtual visits versus face-to-face appointments

This field has been especially appealing for asthma, and it has been particularly developed to be implemented in schools and rural areas. Some studies demonstrated better outcomes, including asthma control, in patients receiving asthma care via telemedicine (symptom-free days, less emergency department visits or hospitalizations) (60, 61). Other studies reported a non-inferiority relation when compared to in-person visits (62), being an alternative to conventional appointments, which enables its occasional replacement, achieving the same outcomes in asthma control (63). One review established that teleconsultations in combination with telecase management could be effective in improving asthma control and quality of life (64). On the other hand, two reviews recognized that there is still too little evidence supporting its widespread use (65, 66), and one randomized controlled trial failed to demonstrate differences in outcomes, such as quality of life, self-efficacy, asthma knowledge or lung function in patients receiving asthma education via telemedicine; nonetheless an improvement in adherence to asthma medications was observed (67). A virtual asthma clinic for children was found as an effective and cost-effective eHealth intervention to improve asthma care (68). This intervention is an attractive option to optimize monitoring strategies in a more personalized way.

Telemonitoring

In contrast to what happens with COPD, where telemonitoring is well developed and applied for monitoring vital signs and other parameters that can detect deterioration or exacerbations at an earlier stage, in asthma, it is mainly used for monitoring symptoms and peak expiratory flow (PEF) (69). A recent Cochrane systematic review did not support telemonitoring as it was not superior to the usual care and the benefits pointed by the studies reviewed were a subject of significant risk of bias (70). Promising tools for telemonitoring are new wearable devices (71) that continuously measure personal physiologic parameters (heart rate, skin temperature, blood oxygen levels, and physical activity) which might predict and prevent exacerbations or help to diagnose other underlying health conditions. Utilization of health monitoring devices by patients will become an important aspect of self-care and preventive medicine. The data provided by these wearable devices will allow providing patients with personalized tools and tailored solutions to improve their health and encourage fitness and diet goals. They may also help to enhance accurate symptom reports, improve the accuracy of diagnosis, and streamline appropriate specialty referral when appropriate (71).

MOBILE APPLICATIONS AND WEBSITES

Mobile healthcare (mHealth) which includes apps running on consumer smart devices (i.e., smartphones and tablets), is becoming increasingly popular (72). Whether including mobile telephone or internet-based systems, mHealth will be an important part of the armamentarium needed for personalized medicine in the future (73). The majority of the currently available devices focus on medication adherence. For example, an application developed in Portugal (mINSPIRERS) aims to transform the process of adherence to inhaled medication for asthmatic patients into a positive experience through immediate and pleasant rewards (elements of gamification and social interaction) (74). From the available literature, data concerning outcomes are still limited. Most reports find overall benefit in the use of these tools in asthma management (35, 75, 76) and control (35, 75, 77), improving adherence to inhalers (10), patient acceptance (75), easy availability (35) and cost-effectiveness (76), and improved quality of life (78, 79). Other studies state that the usefulness of these tools is still debatable and more quality research is needed to define how these tools can be part of routine care (80–82). Another report failed to demonstrate better improvements in asthma control test (ACT) and PEF in patients submitted to mobile and internet interventions when compared to usual care (83).

CONCLUSION

For COPD, telemedicine offers some benefits through telerehabilitation, health education, psychosocial support, and smoking cessation (24). Telemonitoring interventions have contradictory results, especially in long-term outcomes. The extent and significance of benefits to patients and healthcare organizations are not always consistent. Nonetheless, telemedicine can be a key add-on in COPD care, not only during but also after the COVID-19 pandemic, reducing both inpatient and outpatient health care burden (24). Patients’ age, education, experience in technological devices, cognitive, motor, and visual abilities, along with their family and home environment play an important role in the use of these technologies (2). Therefore, technology-based interventions may not be as effective in some populations, which might limit the wider diffusion of telemedicine programs (84). The majority of the available trials are from high income countries which may not reflect the outcomes in less developed regions. Nevertheless, implementation of low-cost technology, its wider use throughout the world in different social/age groups, and additional training in communication technology of the population, might balance this matter in the near future. Also, future clinical trials must include a cost analysis in their reporting to provide financial insights related to the implementation of the intervention (85). The lack of detailed data on program costs and health care service savings makes it tricky for home-based telemedicine programs to make a solid economic case when considering reimbursement or investment in these programs (86).

Conflicting results have been pointed out regarding the use of telemedicine and telehealth tools in asthma management. From our analysis, it seems that a positive tendency is emerging and many asthma patients that we care for can be helped using telemedicine. These positive outcomes are mostly in improvement of inhalation technique, adherence to medication and self-management or health education of asthma patients. Combining teleconsultations (virtual visits and mobile or web-based tools) seems also effective in improving asthma control.

Telemonitoring used for prediction and early detection of asthma exacerbations is still not validated but promising tools are being evaluated, such as wearable devices. Unfortunately, scarce evidence is available regarding the use of telespirometry. Since home-based spirometry has several potential benefits, it could decrease the burden on hospital services, avoid gathering of patients in high-risk facilities, and obviate the need for transportations of patients to crowded health care centers (87). A high cost-effectiveness was previously identified (80, 88), but well-designed studies of cost-effectiveness is needed.

Apart from the above-mentioned advantages, telemedicine has some benefits in the context of the current pandemic, such as increasing social distancing, being a safer option for health care providers and patients (reducing potential infectious exposure), enabling maintenance of continuity of care, and avoiding negative consequences from delayed routine care. Thus, the uptake of telemedicine was recently hastened, but it is likely to be an important part of CRDs care practice in the post-pandemic era.

Patients report high levels of acceptance and satisfaction with telemedicine interventions (88–91). However, some patients and/or their parents might have poor digital literacy and lack of technological infrastructure to perform an adequate telemedicine visit (88). As the field grows, continued oversight in quality assurance, reimbursement, and regulations is needed (92). The issue of privacy and security for both data in transit and stored data remains a challenge and is yet to be thoroughly addressed (93). Also, there is still some misconceptions regarding telemedicine: the technology is untrustworthy, hard to use, insecure, and that a provider will not be paid if they use it (94). Regarding expenses, some authors state that telemedicine decreases the cost of medical care (95). Others claim high cost of using these technologies, and the need for more robust cost-effectiveness studies in this area. Governments and payers are rapidly expanding coverage and payment in an effort to ensure a wide public access to healthcare in the midst of an infectious pandemic (96–98). Safety of patients and providers is important; however, this should not be a demotivating factor for the implementation of telemedicine programs in daily practice.

Although asthma digital health is a promising area (99), current evidence is only of moderate quality, and there is significant heterogeneity in study end points and trials design (100). The non-inferiority of several telemedicine interventions and tools, when compared to standard care, seems to be an opportunity to offer the best possible quality of care to patients, without compromising patient safety and with no increase in costs (101). Technology-based interventions can improve asthma management by facilitating patient education, symptom monitoring, environmental trigger control, comorbid condition management, medication adherence, and overall patient-reported outcomes (102). A new era of precision digital medicine is emerging in health services with the potential to revolutionize the management of CRDs patients. Telemedicine could be a significant add-on in health care, reducing inpatient and outpatient health care burden (103–105).

Conflict of Interest: The authors declare no potential conflict of interest with respect to research, authorship and/or publication of this chapter.

Copyright and Permission Statement: The authors confirm that the materials included in this chapter do not violate copyright laws. Where relevant, appropriate permissions have been obtained from the original copyright holder(s), and all original sources have been appropriately acknowledged or referenced.

REFERENCES

1. Ambrosino N, Vitacca M, Dreher M, Isetta V, Montserrat JM, Tonia T, et al. Tele-monitoring of ventilator-dependent patients: a European Respiratory Society Statement. Eur Respir J. 2016;48(3):648–663. https://doi.org/10.1183/13993003.01721-2015
2. Ambrosino N, Fracchia C. The role of tele-medicine in patients with respiratory diseases. Expert Rev Respir Med. 2017;11(11):893–900. https://doi.org/10.1080/17476348.2017.1383898
3. Solli H, Bjørk IT, Hvalvik S, Hellesø R. Principle-based analysis of the concept of telecare. J Adv Nurs. 2012;68(12):2802–2815. https://doi.org/10.1111/j.1365-2648.2012.06038.x
4. Vitacca M, Montini A, Comini L. How will telemedicine change clinical practice in chronic obstructive pulmonary disease? Ther Adv Respir Dis. 2018;12:1753465818754778. https://doi.org/10.1177/1753465818754778
5. Pinnock H, McKinstry B. Digital technology in respiratory diseases: Promises, (no) panacea and time for a new paradigm. Chron Respir Dis. 2016;13(2):189–191. https://doi.org/10.1177/1479972316637788
6. Portnoy JM, Pandya A, Waller M, Elliott T. Telemedicine and emerging technologies for health care in allergy/immunology. J Allergy Clin Immunol. 2020;145(2):445–454. https://doi.org/10.1016/j.jaci.2019.12.903
7. Malipiero G, Heffler E, Pelaia C, Puggioni F, Racca F, Ferri S, et al. Allergy clinics in times of the SARS-CoV-2 pandemic: an integrated model. Clin Transl Allergy. 2020;10:23. https://doi.org/10.1186/s13601-020-00333-y
8. Oreskovic NM, Kinane TB, Aryee E, Kuhlthau KA, Perrin JM. The Unexpected Risks of COVID-19 on Asthma Control in Children. J Allergy Clin Immunol Pract. 2020;8(8):2489–2491. https://doi.org/10.1016/j.jaip.2020.05.027
9. Shaker MS, Oppenheimer J, Grayson M, Stukus D, Hartog N, Hsieh E, et al. COVID-19: Pandemic Contingency Planning for the Allergy and Immunology Clinic. J Allergy Clin Immunol Pract. 2020;8(5):1477–1488.e5. https://doi.org/10.1016/j.jaip.2020.03.012
10. Barnes PJ. Cellular and molecular mechanisms of asthma and COPD. Clin Sci (Lond). 2017;131(13):1541–1558. https://doi.org/10.1042/CS20160487
11. Steel N, Ford JA, Newton JN, Davis ACJ, Vos T, Naghavi M, et al. Changes in health in the countries of the UK and 150 English Local Authority areas 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet. 2018;392(10158):1647–1661. Erratum in: Lancet. 2018 Nov 3;392(10158):1628. https://doi.org/10.1016/S0140-6736(18)32207-4
12. Solli H, Bjørk IT, Hvalvik S, Hellesø R. Principle-based analysis of the concept of telecare. J Adv Nurs. 2012;68(12):2802–15. https://doi.org/10.1111/j.1365-2648.2012.06038.x
13. McCarthy B, Casey D, Devane D, Murphy K, Murphy E, Lacasse Y. Pulmonary rehabilitation for chronic obstructive pulmonary disease. Cochrane Database of Systematic Reviews 2015, Issue 2. Art. No.: CD003793. https://doi.org/10.1002/14651858.CD003793.pub3
14. Vasilopoulou M, Papaioannou AI, Kaltsakas G, Louvaris Z, Chynkiamis N, Spetsioti S, et al. Home-based maintenance tele-rehabilitation reduces the risk for acute exacerbations of COPD, hospitalisations and emergency department visits. Eur Respir J. 2017;49(5):1602129. https://doi.org/10.1183/13993003.02129-2016
15. Almojaibel AA. Delivering Pulmonary Rehabilitation for Patients with Chronic Obstructive Pulmonary Disease at Home Using Telehealth: A Review of the Literature. Saudi J Med Med Sci. 2016;4(3):164–171. https://doi.org/10.4103/1658-631X.188247
16. Bernocchi P, Vitacca M, La Rovere MT, Volterrani M, Galli T, Baratti D, et al. Home-based telerehabilitation in older patients with chronic obstructive pulmonary disease and heart failure: a randomised controlled trial. Age Ageing. 2018;47(1):82–88. https://doi.org/10.1093/ageing/afx146
17. Marquis N, Larivée P, Saey D, Dubois MF, Tousignant M. In-Home Pulmonary Telerehabilitation for Patients with Chronic Obstructive Pulmonary Disease: A Pre-experimental Study on Effectiveness, Satisfaction, and Adherence. Telemed J E Health. 2015;21(11):870–9. https://doi.org/10.1089/tmj.2014.0198
18. Bonnevie T, Smondack P, Elkins M, Gouel B, Medrinal C, Combret Y, et al. Advanced telehealth technology improves home-based exercise therapy for people with stable chronic obstructive pulmonary disease: a systematic review. J Physiother. 2021;67(1):27–40. https://doi.org/10.1016/j.jphys.2020.12.006
19. Vasilopoulou M, Papaioannou AI, Kaltsakas G, Louvaris Z, Chynkiamis N, Spetsioti S, et al. Home-based maintenance tele-rehabilitation reduces the risk for acute exacerbations of COPD, hospitalisations and emergency department visits. Eur Respir J. 2017;49(5):1602129. https://doi.org/10.1183/13993003.02129-2016
20. Knox L, Dunning M, Davies CA, Mills-Bennet R, Sion TW, Phipps K, et al. Safety, feasibility, and effectiveness of virtual pulmonary rehabilitation in the real world. Int J Chron Obstruct Pulmon Dis. 2019;14:775–780. https://doi.org/10.2147/COPD.S193827
21. Murphy LA, Harrington P, Taylor SJ, Teljeur C, Smith SM, Pinnock H, et al. Clinical-effectiveness of self-management interventions in chronic obstructive pulmonary disease: An overview of reviews. Chron Respir Dis. 2017;14(3):276–288. https://doi.org/10.1177/1479972316687208
22. Metting E, Dassen L, Aardoom J, Versluis A, Chavannes N. Effectiveness of Telemonitoring for Respiratory and Systemic Symptoms of Asthma and COPD: A Narrative Review. Life (Basel). 2021;11(11):1215. https://doi.org/10.3390/life11111215
23. Morrison D, Mair FS, Yardley L, Kirby S, Thomas M. Living with asthma and chronic obstructive airways disease: Using technology to support self-management - An overview. Chron Respir Dis. 2017;14(4):407–419. https://doi.org/10.1177/1479972316660977
24. Barbosa MT, Sousa CS, Morais-Almeida M, Simões MJ, Mendes P. Telemedicine in COPD: An Overview by Topics. COPD. 2020;17(5):601–617. https://doi.org/10.1080/15412555.2020.1815182
25. Tupper OD, Gregersen TL, Ringbaek T, Brøndum E, Frausing E, Green A, et al. Effect of tele-health care on quality of life in patients with severe COPD: a randomized clinical trial. Int J Chron Obstruct Pulmon Dis. 2018;13:2657–2662. https://doi.org/10.2147/COPD.S164121
26. Fekete M, Fazekas-Pongor V, Balazs P, Tarantini S, Nemeth AN, Varga JT. Role of new digital technologies and telemedicine in pulmonary rehabilitation: Smart devices in the treatment of chronic respiratory diseases. Wien Klin Wochenschr. 2021;133(21–22):1201–1207. https://doi.org/10.1007/s00508-021-01930-y
27. Rzadkiewicz M, Nasiłowski J. Psychosocial Interventions for Patients with Severe COPD-An Up-to-Date Literature Review. Medicina (Kaunas). 2019;55(9):597. https://doi.org/10.3390/medicina55090597
28. Hunter R, Barson E, Willis K, Smallwood N. Mental health illness in chronic respiratory disease is associated with worse respiratory health and low engagement with non-pharmacological psychological interventions. Intern Med J. 2021;51(3):414–418. https://doi.org/10.1111/imj.15225
29. Haluza D, Saustingl M, Halavina K. Perceptions of Practitioners on Telehealth and App Use for Smoking Cessation and COPD Care-An Exploratory Study. Medicina (Kaunas). 2020;56(12):698. https://doi.org/10.3390/medicina56120698
30. Carrasco-Hernandez L, Jódar-Sánchez F, Núñez-Benjumea F, Moreno Conde J, Mesa González M, Civit-Balcells A, et al. A Mobile Health Solution Complementing Psychopharmacology-Supported Smoking Cessation: Randomized Controlled Trial. JMIR Mhealth Uhealth. 2020;8(4):e17530. https://doi.org/10.2196/17530
31. Knibb RC, Alviani C, Garriga-Baraut T, Mortz CG, Vazquez-Ortiz M, Angier E, et al. The effectiveness of interventions to improve self-management for adolescents and young adults with allergic conditions: A systematic review. Allergy. 2020;75(8):1881–1898. https://doi.org/10.1111/all.14269
32. Press VG, Arora VM, Kelly CA, Carey KA, White SR, Wan W. Effectiveness of Virtual vs In-Person Inhaler Education for Hospitalized Patients With Obstructive Lung Disease: A Randomized Clinical Trial. JAMA Netw Open. 2020;3(1):e1918205. https://doi.org/10.1001/jamanetworkopen.2019.18205
33. Bonini M, Usmani OS. Novel methods for device and adherence monitoring in asthma. Curr Opin Pulm Med. 2018;24(1):63–69. https://doi.org/10.1097/MCP.0000000000000439
34. Jeminiwa R, Hohmann L, Qian J, Garza K, Hansen R, Fox BI. Impact of eHealth on medication adherence among patients with asthma: A systematic review and meta-analysis. Respir Med. 2019;149:59–68. https://doi.org/10.1016/j.rmed.2019.02.011
35. Poowuttikul P, Seth D. New Concepts and Technological Resources in Patient Education and Asthma Self-Management. Clin Rev Allergy Immunol. 2020;59(1):19–37. https://doi.org/10.1007/s12016-020-08782-w
36. Yasmin F, Banu B, Zakir SM, Sauerborn R, Ali L, Souares A. Positive influence of short message service and voice call interventions on adherence and health outcomes in case of chronic disease care: a systematic review. BMC Med Inform Decis Mak. 2016;16:46. https://doi.org/10.1186/s12911-016-0286-3
37. Patel M, Pilcher J, Travers J, Perrin K, Shaw D, Black P, et al. Use of metered-dose inhaler electronic monitoring in a real-world asthma randomized controlled trial [published correction appears in J Allergy Clin Immunol Pract. 2013;1(3):314]. J Allergy Clin Immunol Pract. 2013;1(1):83–91. https://doi.org/10.1016/j.jaip.2012.08.004
38. Merchant RK, Inamdar R, Quade RC. Effectiveness of Population Health Management Using the Propeller Health Asthma Platform: A Randomized Clinical Trial. J Allergy Clin Immunol Pract. 2016;4(3):455–463. https://doi.org/10.1016/j.jaip.2015.11.022
39. Kosse RC, Bouvy ML, de Vries TW, Koster ES. Effect of a mHealth intervention on adherence in adolescents with asthma: A randomized controlled trial. Respir Med. 2019;149:45–51. https://doi.org/10.1016/j.rmed.2019.02.009
40. Himes BE, Leszinsky L, Walsh R, Hepner H, Wu AC. Mobile Health and Inhaler-Based Monitoring Devices for Asthma Management. J Allergy Clin Immunol Pract. 2019;7(8):2535–2543. https://doi.org/10.1016/j.jaip.2019.08.034
41. Nguyen E, Miao B, Pugliese N, Huang D, Sobieraj DM. Systematic Review of mHealth Applications That Interface with Inhaler Sensors in Asthma. J Allergy Clin Immunol Pract. 2021;9(2):844–852.e3. https://doi.org/10.1016/j.jaip.2020.08.049
42. Carpenter DM, Roberts CA, Sage AJ, George J, Horne R. A Review of Electronic Devices to Assess Inhaler Technique. Curr Allergy Asthma Rep. 2017;17(3):17. https://doi.org/10.1007/s11882-017-0684-3
43. Johnson KB, Patterson BL, Ho YX, Chen Q, Nian H, Davison CL, et al. The feasibility of text reminders to improve medication adherence in adolescents with asthma. J Am Med Inform Assoc. 2016;23(3):449–455. https://doi.org/10.1093/jamia/ocv158
44. Prabhakaran L, Chun Wei Y. Effectiveness of the eCARE programme: a short message service for asthma monitoring. BMJ Health Care Inform. 2019;26(1):e100007. https://doi.org/10.1136/bmjhci-2019-100007
45. Koufopoulos JT, Conner MT, Gardner PH, Kellar I. A Web-Based and Mobile Health Social Support Intervention to Promote Adherence to Inhaled Asthma Medications: Randomized Controlled Trial. J Med Internet Res. 2016;18(6):e122. https://doi.org/10.2196/jmir.4963
46. Carpenter DM, Jurdi R, Roberts CA, Hernandez M, Horne R, Chan A. A Review of Portable Electronic Spirometers: Implications for Asthma Self-Management. Curr Allergy Asthma Rep. 2018;18(10):53. https://doi.org/10.1007/s11882-018-0809-3
47. Perry TT, Margiotta CA. Implementing Telehealth in Pediatric Asthma. Pediatr Clin North Am. 2020;67(4):623–627. https://doi.org/10.1016/j.pcl.2020.04.003
48. Sagaro GG, Di Canio M, Talevi E, Amenta F. Telemedicine for Pre-Employment Medical Examinations and Follow-Up Visits on Board Ships: A Narrative Review on the Feasibility. Healthcare (Basel). 2021;9(1):69. https://doi.org/10.3390/healthcare9010069
49. Niznik JD, He H, Kane-Gill SL. Impact of clinical pharmacist services delivered via telemedicine in the outpatient or ambulatory care setting: A systematic review. Res Social Adm Pharm. 2018;14(8):707–717. https://doi.org/10.1016/j.sapharm.2017.10.011
50. Zairina E, Abramson MJ, McDonald CF, Dharmasiri T, Stewart K, Walker SP, et al. Telehealth to improve asthma control in pregnancy: A randomized controlled trial. Respirology. 2016;21(5):867–874. https://doi.org/10.1111/resp.12773
51. Bruton A, Lee A, Yardley L, Raftery J, Arden-Close E, Kirby S, et al. Physiotherapy breathing retraining for asthma: a randomised controlled trial. Lancet Respir Med. 2018;6(1):19–28. https://doi.org/10.1016/S2213-2600(17)30474-5
52. Culmer N, Smith T, Stager C, Wright A, Burgess K, Johns S, et al. Telemedical Asthma Education and Health Care Outcomes for School-Age Children: A Systematic Review. J Allergy Clin Immunol Pract. 2020;8(6):1908–1918. https://doi.org/10.1016/j.jaip.2020.02.005
53. Morton K, Dennison L, May C, Murray E, Little P, McManus RJ, et al. Using digital interventions for self-management of chronic physical health conditions: A meta-ethnography review of published studies. Patient Educ Couns. 2017;100(4):616–635. https://doi.org/10.1016/j.pec.2016.10.019
54. Morrison D, Mair FS, Yardley L, Kirby S, Thomas M. Living with asthma and chronic obstructive airways disease: Using technology to support self-management - An overview. Chron Respir Dis. 2017;14(4):407–419. https://doi.org/10.1177/1479972316660977
55. Hanlon P, Daines L, Campbell C, McKinstry B, Weller D, Pinnock H. Telehealth Interventions to Support Self-Management of Long-Term Conditions: A Systematic Metareview of Diabetes, Heart Failure, Asthma, Chronic Obstructive Pulmonary Disease, and Cancer. J Med Internet Res. 2017;19(5):e172. https://doi.org/10.2196/jmir.6688
56. McLean G, Murray E, Band R, Moffat KR, Hanlon P, Bruton A, et al. Interactive digital interventions to promote self-management in adults with asthma: systematic review and meta-analysis. BMC Pulm Med. 2016;16(1):83. https://doi.org/10.1186/s12890-016-0248-7
57. Miller L, Schüz B, Walters J, Walters EH. Mobile Technology Interventions for Asthma Self-Management: Systematic Review and Meta-Analysis. JMIR Mhealth Uhealth. 2017;5(5):e57. https://doi.org/10.2196/mhealth.7168
58. Song X, Hallensleben C, Zhang W, Jiang Z, Shen H, Gobbens R, et al. Blended Self-Management Interventions to Reduce Disease Burden in Patients With Chronic Obstructive Pulmonary Disease and Asthma: Systematic Review and Meta-analysis. J Med Internet Res. 2021;23(3):e24602. https://doi.org/10.2196/24602
59. Newhouse N, Martin A, Jawad S, Yu L-M, Davoudianfar M, Locock L, et al. Randomised feasibility study of a novel experience-based internet intervention to support self-management in chronic asthma. BMJ Open. 2016;6(12):e013401. https://doi.org/10.1136/bmjopen-2016-013401
60. Halterman JS, Fagnano M, Tajon RS, Tremblay P, Wang H, Butz A, et al. Effect of the School-Based Telemedicine Enhanced Asthma Management (SB-TEAM) Program on Asthma Morbidity: A Randomized Clinical Trial. JAMA Pediatr. 2018;172(3):e174938. https://doi.org/10.1001/jamapediatrics.2017.4938
61. Estrada RD, Ownby DR. Rural Asthma: Current Understanding of Prevalence, Patterns, and Interventions for Children and Adolescents. Curr Allergy Asthma Rep. 2017;17(6):37. https://doi.org/10.1007/s11882-017-0704-3
62. Portnoy JM, Waller M, De Lurgio S, Dinakar C. Telemedicine is as effective as in-person visits for patients with asthma. Ann Allergy Asthma Immunol. 2016;117(3):241–245. https://doi.org/10.1016/j.anai.2016.07.012
63. van den Wijngaart LS, Roukema J, Boehmer ALM, Brouwer M, Hugen C, Niers L, et al. A virtual asthma clinic for children: fewer routine outpatient visits, same asthma control. Eur Respir J. 2017;50(4):1700471. https://doi.org/10.1183/13993003.00471-2017
64. Chongmelaxme B, Lee S, Dhippayom T, Saokaew S, Chaiyakunapruk N, Dilokthornsakul P. The Effects of Telemedicine on Asthma Control and Patients’ Quality of Life in Adults: A Systematic Review and Meta-analysis. J Allergy Clin Immunol Pract. 2019;7(1):199–216.e11. https://doi.org/10.1016/j.jaip.2018.07.015
65. Kew KM, Cates CJ. Remote versus face-to-face check-ups for asthma. Cochrane Database Syst Rev. 2016;4:CD011715. https://doi.org/10.1002/14651858.CD011715.pub2
66. Kim CH, Lieng MK, Rylee TL, Gee KA, Marcin JP, Melnikow JA. School-Based Telemedicine Interventions for Asthma: A Systematic Review. Acad Pediatr. 2020;20(7):893–901. https://doi.org/10.1016/j.acap.2020.05.008
67. Perry TT, Halterman JS, Brown RH, et al. Results of an asthma education program delivered via telemedicine in rural schools. Ann Allergy Asthma Immunol. 2018;120(4):401–408. https://doi.org/10.1016/j.anai.2018.02.013
68. van den Wijngaart LS, Kievit W, Roukema J, Boehmer A, Brouwer M, Hugen C, et al. Online asthma management for children is cost-effective. Eur Respir J. 2017;50(4):1701413. https://doi.org/10.1183/13993003.01413-2017
69. Waller M, Stotler C. Telemedicine: a Primer. Curr Allergy Asthma Rep. 2018;18(10):54. https://doi.org/10.1007/s11882-018-0808-4
70. Kew KM, Cates CJ. Home telemonitoring and remote feedback between clinic visits for asthma. Cochrane Database Syst Rev. 2016;2016(8):CD011714. https://doi.org/10.1002/14651858.CD011714.pub2
71. Greiwe J, Nyenhuis SM. Wearable Technology and How This Can Be Implemented into Clinical Practice. Curr Allergy Asthma Rep. 2020;20(8):36. https://doi.org/10.1007/s11882-020-00927-3
72. Bousquet J, Arnavielhe S, Bedbrook A, Bewick AM, Laune D, Mathieu-Dupas E, et al. MASK 2017: ARIA digitally-enabled, integrated, person-centred care for rhinitis and asthma multimorbidity using real-world-evidence. Clin Transl Allergy. 2018;8:45. https://doi.org/10.1186/s13601-018-0227-6
73. Chung KF. Personalised medicine in asthma: time for action: Number 1 in the Series “Personalised medicine in respiratory diseases” Edited by Renaud Louis and Nicolas Roche. Eur Respir Rev. 2017;26(145):170064. https://doi.org/10.1183/16000617.0064-2017
74. Pereira AM, Jácome C, Almeida R, Fonseca JA. How the Smartphone Is Changing Allergy Diagnostics. Curr Allergy Asthma Rep. 2018;18(12):69. https://doi.org/10.1007/s11882-018-0824-4
75. Bonini M. Electronic health (e-Health): emerging role in asthma. Curr Opin Pulm Med. 2017;23(1):21–26. https://doi.org/10.1097/MCP.0000000000000336
76. Huang X, Matricardi PM. Allergy and Asthma Care in the Mobile Phone Era. Clin Rev Allergy Immunol. 2019;56(2):161–173. https://doi.org/10.1007/s12016-016-8542-y
77. Hui CY, Walton R, McKinstry B, Jackson T, Parker R, Pinnock H. The use of mobile applications to support self-management for people with asthma: a systematic review of controlled studies to identify features associated with clinical effectiveness and adherence. J Am Med Inform Assoc. 2017;24(3):619–632. https://doi.org/10.1093/jamia/ocw143
78. Snoswell CL, Rahja M, Lalor AF. A Systematic Review and Meta-Analysis of Change in Health-Related Quality of Life for Interactive Telehealth Interventions for Patients With Asthma. Value Health. 2021;24(2):291–302. https://doi.org/10.1016/j.jval.2020.09.006
79. Montalbano L, Ferrante G, Cilluffo G, Gentile M, Arrigo M, La Guardia D, et al. Targeting quality of life in asthmatic children: The MyTEP pilot randomized trial. Respir Med. 2019;153:14–19. https://doi.org/10.1016/j.rmed.2019.05.008
80. Katwa U, Rivera E. Asthma Management in the Era of Smart-Medicine: Devices, Gadgets, Apps and Telemedicine. Indian J Pediatr. 2018;85(9):757–762. https://doi.org/10.1007/s12098-018-2611-6
81. Marcolino MS, Oliveira JAQ, D’Agostino M, Ribeiro AL, Alkmim MBM, Novillo-Ortiz D. The Impact of mHealth Interventions: Systematic Review of Systematic Reviews. JMIR Mhealth Uhealth. 2018;6(1):e23. https://doi.org/10.2196/mhealth.8873
82. Lancaster K, Abuzour A, Khaira M, Mathers A, Chan A, Bui V, et al. The Use and Effects of Electronic Health Tools for Patient Self-Monitoring and Reporting of Outcomes Following Medication Use: Systematic Review. J Med Internet Res. 2018;20(12):e294. https://doi.org/10.2196/jmir.9284
83. Nemanic T, Sarc I, Skrgat S, Flezar M, Cukjati I, Malovrh M. Telemonitoring in asthma control: a randomized controlled trial. J Asthma. 2019;56(7):782–790. https://doi.org/10.1080/02770903.2018.1493599
84. Witry M, Comellas A, Simmering J, Polgreen P. The association between technology use and health status in a chronic obstructive pulmonary disease cohort: multi-method study. J Med Internet Res. 2018;20(4):e125. https://doi.org/10.2196/jmir.9382
85. Gaveikaite V, Grundstrom C, Winter S, Chouvarda I, Maglaveras N, Priori R. A systematic map and in-depth review of European telehealth interventions efficacy for chronic obstructive pulmonary disease. Respir Med. 2019;158:78–88. https://doi.org/10.1016/j.rmed.2019.09.005
86. Michaud TL, Zhou J, McCarthy MA, Siahpush M, Su D. Costs of home-based telemedicine programs: a systematic review. Int J Technol Assess Health Care. 2018;34(4):410–418. https://doi.org/10.1017/S0266462318000454
87. Morais-Almeida M, Barbosa MT, Sousa CS, Almeida I, Pimenta L, Aguiar R. Spirometry Outside the Hospital. Arch Bronconeumol. 2021;57(3):236. https://doi.org/10.1016/j.arbres.2020.10.011
88. Eze ND, Mateus C, Cravo Oliveira Hashiguchi T. Telemedicine in the OECD: An umbrella review of clinical and cost-effectiveness, patient experience and implementation. PLoS One. 2020;15(8):e0237585. https://doi.org/10.1371/journal.pone.0237585
89. Nguyen M, Waller M, Pandya A, Portnoy J. A Review of Patient and Provider Satisfaction with Telemedicine. Curr Allergy Asthma Rep. 2020;20(11):72. https://doi.org/10.1007/s11882-020-00969-7
90. Sabina Sousa C, Trigueiro Barbosa M, Aguiar R, Benito-Garcia F, Morais-Almeida M. What do asthmatic patients think about telemedicine visits?. Eur Ann Allergy Clin Immunol. 2021;53(3):138–142. https://doi.org/10.23822/EurAnnACI.1764-1489.182
91. Taylor L, Capling H, Portnoy JM. Administering a Telemedicine Program. Curr Allergy Asthma Rep. 2018;18(11):57. https://doi.org/10.1007/s11882-018-0812-8
92. Elliott T, Shih J. Direct to Consumer Telemedicine. Curr Allergy Asthma Rep. 2019;19(1):1. https://doi.org/10.1007/s11882-019-0837-7
93. Licari A, Ferrante G, Marseglia Md GL, Corsello Md G, La Grutta S. What Is the Impact of Innovative Electronic Health Interventions in Improving Treatment Adherence in Asthma? The Pediatric Perspective. J Allergy Clin Immunol Pract. 2019;7(8):2574–2579. https://doi.org/10.1016/j.jaip.2019.08.008
94. Shih J, Portnoy J. Tips for Seeing Patients via Telemedicine. Curr Allergy Asthma Rep. 2018;18(10):50. https://doi.org/10.1007/s11882-018-0807-5
95. Hare N, Bansal P, Bajowala SS, Abramson SL, Chervinskiy S, Corriel R, et al. Work Group Report: COVID-19: Unmasking Telemedicine. J Allergy Clin Immunol Pract. 2020;8(8):2461–2473.e3. https://doi.org/10.1016/j.jaip.2020.06.038
96. Bajowala SS, Milosch J, Bansal C. Telemedicine Pays: Billing and Coding Update. Curr Allergy Asthma Rep. 2020;20(10):60. https://doi.org/10.1007/s11882-020-00956-y
97. Sculley JA, Musick H, Krishnan JA. Telehealth in chronic obstructive pulmonary disease: before, during, and after the coronavirus disease 2019 pandemic. Curr Opin Pulm Med. 2022;28(2):93–98. https://doi.org/10.1097/MCP.0000000000000851
98. Greiwe J. Telemedicine Lessons Learned During the COVID-19 Pandemic. Curr Allergy Asthma Rep. 2022;22(1):1–5. https://doi.org/10.1007/s11882-022-01026-1
99. Guarnieri G, Caminati M, Achille A, Vaia R, Chieco Bianchi F, Senna G, et al. Severe Asthma, Telemedicine, and Self-Administered Therapy: Listening First to the Patient. J Clin Med. 2022;11(4):960. https://doi.org/10.3390/jcm11040960
100. Holgate ST, Walker S, West B, Boycott K. The Future of Asthma Care: Personalized Asthma Treatment. Clin Chest Med. 2019;40(1):227–241. https://doi.org/10.1016/j.ccm.2018.10.013
101. Alvarez-Perea A, Dimov V, Popescu F-D, Zubeldia JM. The applications of eHealth technologies in the management of asthma and allergic diseases. Clin Transl Allergy. 2021;e12061. https://doi.org/10.1002/clt2.12061
102. Doshi H, Hsia B, Shahani J, Mowrey W, Jariwala SP. Impact of Technology-Based Interventions on Patient-Reported Outcomes in Asthma: A Systematic Review. J Allergy Clin Immunol Pract. 2021;9(6):2336–2341. https://doi.org/10.1016/j.jaip.2021.01.027
103. Edgerley S, Zhu R, Quidwai A, Kim H, Jeimy S. Telemedicine in allergy/immunology in the era of COVID-19: a Canadian perspective. Allergy Asthma Clin Immunol. 2022;18:16. https://doi.org/10.1186/s13223-022-00657-3
104. Persaud YK, Portnoy JM. Ten Rules for Implementation of a Telemedicine Program to Care for Patients with Asthma. J Allergy Clin Immunol Pract. 2021;9(1):13–21. https://doi.org/10.1016/j.jaip.2020.10.005
105. Simeone S, Condit D, Nadler E. Do Not Give Up Your Stethoscopes Yet-Telemedicine for Chronic Respiratory Diseases in the Era of COVID-19. Life (Basel). 2022;12(2):222. https://doi.org/10.3390/life12020222