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.