DISCUSSION
The current study showed that clinical and spirometric home
telemonitoring was applicable. In the majority of cases, it was possible
to define the profile of clinical perception of bronchial obstruction in
asthmatic children, but collegial discussion among professionals to
reach an acceptable level of agreement was required. In addition, there
was a non-significant trend towards improved asthma control (ACT score)
after 3 months of follow-up, as well as a significant decrease in FEV1
and PEF variability. The observed changes in the distribution of
treatment levels are the result of a therapeutic decision based on a
better understanding of the perception profile. Based on the
telemonitoring data, treatment may have been decreased in some
well-controlled children, and increased in others with truly severe
asthma. The device was well accepted by the asthmatic children and their
family.
Among the 23 out of 26 children who could be classified, the
distribution of perception profiles was as follows: anarchic perceivers
(44%)> poor perceivers (30%) > good
perceivers (17%) > excessive perceivers (9%). The study
of Brouwer et al. on 36 asthmatic children found the following
distribution: poor perceivers (36%) > anarchic perceivers
(25%) > good perceivers (19.5%) = excessive perceivers
(19.5%). These differences could be explained by the severity of the
asthma being monitored (less severe in their population) or the way in
which symptoms are recorded (written diary versus electronically). The
existence of different perception profiles could explain why some
studies have not demonstrated a net benefit from the application of
telemonitoring of childhood asthma21, and could have
an implication in the design of clinical trials by selecting a certain
category of perception profile as the study population. The
classification of patients according to their perception profile of
bronchial obstruction could also have practical applications by enabling
healthcare professionals to propose personalized management to promote
optimal disease control. Patients defined as poor perceivers could more
easily have their background treatment increased, and conversely a
decrease in treatment could be envisaged in overperceiver patients. This
aid to therapeutic adaptation was one of the major expectations of the
patients in our study. Finally, it could make it possible to target the
profiles that would benefit most from objective measurements of airway
obstruction over the long term. Once a patient has been identified as a
good perceiver, its follow-up could be simplified based on the
evaluation of symptoms alone. On the contrary, patients who are poor
perceivers could benefit from the use of a peak flow meter or a portable
spirometer at home over the long term.
Children and their parents were generally very satisfied with the
follow-up. They appreciated the playfulness and ease of use of the
device. This enthusiasm for connected devices is part of the era of
smart-medicine where more and more devices, gadgets, and applications
are being offered to patients22. However, the clinical
effectiveness of most of these technology-based strategies is not
evidence-based and further studies are needed to assess their
reliability. Most parents appreciated having access to their children’s
spirometry results. This highlights patients’ desire to be actors in
their own therapeutic management, a desire that increases with the rate
of health crises23. Nevertheless, they still reported
a feeling of reassurance from this close medical follow-up with the
Spirobank Smart®, even to the point of apprehension when it was stopped.
Despite the advice given to parents to be careful to maintain their
usual lifestyle, the introduction of the device inevitably created a
need, even a form of dependency.
Three patients refused Spirobank Smart® follow-up and one patient did
not take any measurements at home. The reasons cited were a lack of time
and the constraint of using a new device in addition to daily treatment.
The implementation of a new therapeutic object in the patient’s daily
life should therefore not add too great of a burden24.
The recommended frequency of use of the device should also be taken into
account. Indeed, some children in our study mentioned the constraint of
having to perform the measurement daily during the first ten days. To
stimulate compliance over the long term, automatic reminders were sent
out after 7 days without a recorded value. A decrease in compliance is
found in longer-term studies, such as in the Côté study where compliance
with daily spirometry measurements dropped from 63% in the first month
to 33% at 12 months25. On the other hand, a decrease
in technical efficiency during the 3 months of follow-up was observed in
some patients in our study using flow-volume curves, although other
studies do not report a decrease in the technical quality of maneuvers
over time26. Moreover, this device is not adapted to
children under 6 years old because it requires to know how to perform
spirometric measurements of good quality. Regular sessions of
therapeutic education in the classroom or in e-TPE (Therapeutic Patient
Education) are therefore necessary to reinforce compliance and
technique. To compensate for age and technical requirements, the
usefulness of remote monitoring devices that do not require the active
participation of the patient should be studied. Lastly, the lack of
significant improvement in asthma control could be partly explained by
poor adherence to treatment, one of the major causes of uncontrolled
asthma27. The combination of this system with the use
of connected inhalers allowing the collection of adherence data on the
same platform could be an even more comprehensive remote monitoring
tool28.
In conclusion, the current study shows that clinical and spirometric
home telemonitoring is applicable and can be used to characterize the
perception profile of bronchial obstruction in asthmatic children to
help obtain better control and adapted therapeutic management. Research
projects studying the role of such a telemonitoring system on a longer
term basis and including other clinical evaluation criteria such as
quality of life, unscheduled visits and hospitalization remain to be
conducted.