An Inhaler Tracking System Based on Acoustic Analysis:Hardware and Software

In treating asthma and chronic obstructive pulmonary disorder (COPD), acquisition of authentic and effective feedback from patients on regimen adherence is difficult. Face-to-face and oral reporting methods do not satisfy current intelligent medication best practices. This paper presents a system to track and analyze daily inhaler usage. A portable electronic device that attaches to the inhaler uses an accelerometer and capacitive sensors to detect users’ motion and an embedded digital microphone to capture sounds while the inhaler is in use. In terms of analysis, sound features are extracted, and breath phases are identified by employing a hidden Markov model with a Gaussian mixture model. A feature template is also constructed and used to search for and identify “canister pressed” events. The system provides objective feedback, quantifying asthma, and COPD patients’ adherence to medication regimens. Although interest in asthma adherence to medication regimens is growing, there is still a relative paucity of research and, indeed, compliance devices in this area; the tracking system can help doctors better understand the patient’s condition and choose an appropriated treatment plan. At the same time, patients can also improve their self-management by system feedback

Impact of an electronic monitoring intervention for improving adherence to inhaled therapy in patients with asthma and COPD

Asthma bronchiale and chronic obstructive pulmonary disease (COPD) are two of the leading chronic respiratory diseases worldwide and associated with high morbidity, mortality, and a major economic burden. Despite progress in pharmacological and non-pharmacological treatment in recent years, the burden of disease among asthma and COPD patients is high. Reasons for uncontrolled diseases are manifold, but are often associated with poor inhalation technique and non-adherence to the prescribed treatment plan. As observed in many chronic diseases, poor adherence to medication is also a common phenomenon among asthma and COPD patients. This causes deterioration of symptoms and recurrent exacerbations resulting in increased rates of morbidity, physician visits, hospitalizations, mortality, reduced quality of life, and increased healthcare expenditures. However, it has been demonstrated that the frequency of exacerbation can be reduced by the administration of certain medication. Furthermore, high adherence is associated with reduced exacerbation rates in patients with asthma and COPD. As outlined above, maintaining adequate adherence to inhaled medication is of major importance for achieving therapeutic success, in particular for the treatment of chronic diseases. Different interventions and strategies are already described in the literature aiming to enhance adherence. The greatest success was attained with complex interventions combining several strategies. Nevertheless, to date no intervention was determined to be particularly successful. Therefore, this thesis aims to contribute to this challenging but important research field by investigating the impact of two simple interventions on adherence to inhaled therapy in patients with asthma and COPD. Prior to the study start, we provided a training course for each participant regardless of the treatment group to guarantee a comparable level of disease knowledge and inhalation technique. Further, each patient was equipped with an electronic monitoring device, which was used as the method of choice for the assessment of objective adherence. Overall, the performed intervention consisted of a reminder in form of phone calls and a daily alarm clock as well as feedback on patients’ individual adherence profile. The combination of these two common types of interventions has been chosen since they appeared to be easily applicable in daily clinical practice. We considered this to be one of the important factors in order to guarantee an efficient improvement of patients’ adherence. By the intervention, we expected a prolongation of time to next exacerbation, which was defined as the primary endpoint of this study. Moreover, we assumed an improvement of patients’ taking and timing adherence as well as quality of life, determined as the two secondary endpoints. The thesis is divided into the following three parts:   The aim of Part I was to design and write a study protocol taking into account the above-mentioned aims and under consideration of the current state of the literature as well as the studies already conducted in this field. Part II describes a cross-sectional analysis to evaluate baseline data on compliance in accordance with current treatment guidelines (Global Initiative for Asthma (GINA) and Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines). Furthermore, baseline data is provided on inhaler application after a training course and its impact on quality of life and symptom control in a typical population with chronic lung diseases from the Adherence-Trial. Overall, correct inhalation technique ranged from 55% to 100% depending on the type of inhaler. 112 participants (68%) participants were treated corresponding to the global guidelines. COPD patients with incorrect device application had a higher CAT sum score compared to those with a correct device application (p=.02). Moreover, COPD patients with incorrect device application had to cough more often (p=.03) and were more breathless while walking up hills or one flight of stairs (p=.02). While there was no significance to be found in asthma patients, COPD patients who used their devices correctly had a significantly better mean FEV1% predicted at baseline compared to those who applied their devices incorrectly (p=.04). In the last part of this thesis (Part III), time to next exacerbation - the primary endpoint of the study - was evaluated and compared between the intervention and the control group. Furthermore, the objective adherence was analyzed by evaluating the taking and timing adherence, as well as the gaps during the study period. Patients’ quality of life was assessed by the St. George Respiratory Questionnaire (SGRQ). Time to next exacerbation was longer (172 days [95% CI, 161 to 182] vs. 161 days [95% CI, 149 to 174], p=.27) and the risk for experiencing an exacerbation lower (HR, 0.67 [95% CI, 0.36 to 1.33], p=.14) in the intervention compared to the control group, but failed to reach statistical significance. In the intervention group significantly more days with a taking adherence between 80-100% were observed with both inhalation techniques (puff inhalers: 81.6±14.2 vs.60.1±30.3, p.05). In conclusion this thesis showed: •At baseline, a large number of the participating asthma, COPD or asthma-COPD overlap patients were treated on target based on the GINA and GOLD guidelines valid at the time of the patient’s inclusion into the Adherence-Trial. •Correct handling of inhaler devices was largely dependent on the device used. In the Adherence-Trial population, metered dose inhalers were applied more frequently in an incorrect way compared to dry powder inhalers. This particularly applies to the Ellipta® device, which has just recently been introduced to the market and which showed a very good applicability. •A correct inhalation technique of the prescribed medication had a positive impact on the health status and the lung function of COPD patients. This was achieved by a comprehensive training of correct inhalation technique. •Regular, automatic and personal reminders seem to have caused a significant improvement in taking and timing adherence with regard to the inhalation with puff inhalers and dry powder capsules. Moreover, reminders can help to avoid forgetting the inhalation of the prescribed medication. Patients who experienced support in their adherence had significantly fewer days without inhalation and fewer gaps over several consecutive days compared to patients receiving no support. •Regular, automatic and personal reminders, led to a substantial improvement in patients’ adherence to inhaled medication. However, this was not associated with an improvement in health-related quality of life in patients with chronic airway diseases. •Higher adherence to the prescribed medication plan was not only associated with a trend towards longer time to next exacerbation but also with a reduced risk of experiencing an exacerbation

Mobile Health Technologies

Mobile Health Technologies, also known as mHealth technologies, have emerged, amongst healthcare providers, as the ultimate Technologies-of-Choice for the 21st century in delivering not only transformative change in healthcare delivery, but also critical health information to different communities of practice in integrated healthcare information systems. mHealth technologies nurture seamless platforms and pragmatic tools for managing pertinent health information across the continuum of different healthcare providers. mHealth technologies commonly utilize mobile medical devices, monitoring and wireless devices, and/or telemedicine in healthcare delivery and health research. Today, mHealth technologies provide opportunities to record and monitor conditions of patients with chronic diseases such as asthma, Chronic Obstructive Pulmonary Diseases (COPD) and diabetes mellitus. The intent of this book is to enlighten readers about the theories and applications of mHealth technologies in the healthcare domain

Use of the Smartphone Camera to Monitor Adherence to Inhaled Therapy

Self-management strategies can lead to improved health outcomes, fewer unscheduled treatments, and improved disease control. Compliance with inhaled control drugs is essential to achieve good clinical outcomes in patients with chronic respiratory diseases. However, compliance assessments suffer from the difficulty of achieving a high degree of trustworthiness, as patients often self-report high compliance rates and are considered unreliable. This thesis aims to enable reliable adhesion measurement by developing a mobile application module to objectively verify inhalation usage using image snapshots of the inhalation counter. To achieve this, a mobile application module featuring pre and post processing techniques and a default machine learning framework was built, for inhaler and dosage counter numbers detection. In addition, in an effort to improve the app’s capabilities of text recognition on a worst-performing inhaler, a machine learning model was trained on an inhaler image dataset. Some of the features worked on during this project were incorporated on the current version of the app InspirerMundi, a medication management mobile application, planned to be made available at the PlayStore by the end of 2021. The proposed approach was validated through a series of different inhaler image datasets. The carried-out tests with the default machine learning configuration showed correct detection of dosage counters for 70% of inhaler registration events and 93% for three commonly used inhalers in Portugal. On the other hand, the trained model had an average accuracy of 88 % in recognizing the digits on the dose counter of one of the worst-performing inhaler models. These results show the potential to explore mobile and embedded capabilities to gain additional evidence for inhaler compliance. These systems can help bridge the gap between patients and healthcare professionals. By empowering patients with disease selfmanagement and drug adherence tools and providing additional relevant data, these systems pave the way for informed disease management decisions

Electronic reminders and rewards to improve adherence to inhaled asthma treatment in adolescents: a non-randomised feasibility study in tertiary care

OBJECTIVE: To test the feasibility and acceptability of a short-term reminder and incentives intervention in adolescents with low adherence to asthma medications. METHODS: Mixed-methods feasibility study in a tertiary care clinic. Adolescents recruited to a 24-week programme with three 8-weekly visits, receiving electronic reminders to prompt inhaled corticosteroid (ICS) inhalation through a mobile app coupled with electronic monitoring devices (EMD). From the second visit, monetary incentives based on adherence of ICS inhalation: £1 per dose, maximum £2 /day, up to £112/study, collected as gift cards at the third visit. End of study interviews and questionnaires assessing perceptions of asthma and ICS, analysed using the Perceptions and Practicalities Framework. PARTICIPANTS: Adolescents (11-18 years) with documented low ICS adherence (<80% by EMD), and poor asthma control at the first clinic visit. RESULTS: 10 out of 12 adolescents approached were recruited (7 males, 3 females, 12-16 years). Eight participants provided adherence measures up to the fourth visits and received rewards. Mean study duration was 281 days, with 7/10 participants unable to attend their fourth visit due to COVID-19 lockdown. Only 3/10 participants managed to pair the app/EMD up to the fourth visit, which was associated with improved ICS adherence (from 0.51, SD 0.07 to 0.86, SD 0.05). Adherence did not change in adolescents unable to pair the app/EMD. The intervention was acceptable to participants and parents/guardians. Exit interviews showed that participants welcomed reminders and incentives, though expressed frustration with app/EMD technological difficulties. Participants stated the intervention helped through reminding ICS doses, promoting self-monitoring and increasing motivation to take inhalers. CONCLUSIONS: An intervention using electronic reminders and incentives through an app coupled with an EMD was feasible and acceptable to adolescents with asthma. A pilot randomised controlled trial is warranted to better estimate the effect size on adherence, with improved technical support for the EMD

Effectiveness of myAirCoach: A mHealth Self-Management System in Asthma

Background: Self-management programs have beneficial effects on asthma control, but their implementation in clinical practice is poor. Mobile health (mHealth) could play an important role in enhancing self-management. Objective: To assess the clinical effectiveness and technology acceptance of myAirCoach-supported self-management on top of usual care in patients with asthma using inhalation medication. Methods: Patients were recruited in 2 separate studies. The myAirCoach system consisted of an inhaler adapter, an indoor air-quality monitor, a physical activity tracker, a portable spirometer, a fraction exhaled nitric oxide device, and an app. The primary outcome was asthma control; secondary outcomes were exacerbations, quality of life, and technology acceptance. In study 1, 30 participants were randomized to either usual care or myAirCoach support for 3 to 6 months; in study 2, 12 participants were provided with the myAirCoach system in a 3-month before-after study. Results: In study 1, asthma control improved in the intervention group compared with controls (Asthma Control Questionnaire difference, 0.70; P = .006). A total of 6 exacerbations occurred in the intervention group compared with 12 in the control group (hazard ratio, 0.31; P = .06). Asthma-related quality of life improved (mini Asthma-related Quality of Life Questionnaire difference, 0.53; P = .04), but forced expiratory volume in 1 second was unchanged. In study 2, asthma control improved by 0.86 compared with baseline (P = .007) and quality of life by 0.16 (P = .64). Participants reported positive attitudes toward the system. Discussion: Using the myAirCoach support system improves asthma control and quality of life, with a reduction in severe asthma exacerbations. Well-validated mHealth technologies should therefore be further studied

The Problem of Adherence in Paediatric Asthma

Non-adherence to inhaled corticosteroids (ICS) is a key barrier in asthma management. However, few studies have explored patterns of non-adherence and the reasons for variations in adherence in young people with problematic asthma. The aim of this thesis is to explore the potentially modifiable determinants of non-adherence in young people with problematic severe asthma in a tertiary care setting. This PhD comprises a systematic review of interventions to improve adherence in children with asthma; an analysis of patterns of non-adherence; a qualitative study of patients with poor adherence; and an adaptation study of the Beliefs About Medicine Questionnaire (BMQ). Each of these informs identification of interventions to improve adherence. The review found that current interventions have limited effectiveness, with only half of the included trials able to improve ICS adherence (9/18). More complex interventions, tailored to the patient, which addressed both perceptions and practical aspects of non-adherence were more likely to be effective. Secondary analysis of electronic adherence data from this population (n=93) identified adherence patterns which have implications for intervention development. The interview study (n=20) identified perceptual determinants (e.g. poor understanding of asthma and ICS) and practical determinants (e.g. no routine and forgetfulness) of non-adherence. These findings informed an adaption of the BMQ to identify beliefs underlying treatment non-adherence in this population; initial piloting (n=30) revealed high overall internal reliability but further research is needed to validate the questionnaire. This PhD highlights the need for a tailored intervention for non-adherent young people with problematic asthma which addresses perceptual and practical barriers to adherence. The PhD identified new barriers to adherence including key differences between adults and young children. A belief-based questionnaire could be used to identify modifiable beliefs for inclusion in a tailored intervention addressing both perceptual and practical barriers for adherence to ICS