Electronic monitoring devices in asthma: translating from study use into clinical practice

Adejumo, Ireti D. (2021) Electronic monitoring devices in asthma: translating from study use into clinical practice. PhD thesis, University of Nottingham.

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Asthma is increasingly recognised to be a heterogeneous disease with outcomes mediated by psychosocial and behavioural factors as well as by pathophysiological mechanisms. Inhaled corticosteroids (ICS) have long been the mainstay of treatment for asthma and poor ICS adherence has been shown to be associated with adverse outcomes. Despite this, poor ICS adherence has remained a persistent challenge for clinicians and patients with difficulties in both its measurement and management.

In recent times, electronic monitoring has emerged as a gold standard for adherence measurement and a possible interventional tool for poor adherence. This thesis aimed to assess trial evidence for the use of electronic monitoring devices (EMDs) in asthma and assess whether there was adequate justification for their widespread clinical uptake.


Two literature reviews were conducted. The first was a systematic review and meta-analysis of the use of EMDs to measure adherence in adult asthma studies. The second was a review of the use of EMDs as interventional tools in both adults and children.

A randomised controlled pilot study of adherence was conducted to investigate the effect of EMD-based feedback in a real-world study design. As part of this, testing data for based on previously published validation protocols were also presented.

Finally, a series of semi-structured interviews were conducted to explore the experiences and perspectives of EMD users.


The first literature review estimated population adherence to be 64% of prescribed ICS doses. The second review demonstrated that EMD-based interventions were effective at improving adherence but that evidence of improvement in clinical outcomes was not consistent.

Across all devices tested in the pilot study, 94% of actuation, installation and removal events were correctly detected pre-study. Despite this, 12% of devices failed pre-study testing. Of devices issued to study participants, a further 12% were found to have failed post-study.

The pilot study of adherence found that the intervention group actuated 11% more of their prescribed ICS doses than the control group (p=0.319). An unexpected increase in exacerbations in the intervention group suggested that the relationship between adherence and outcomes may be more complex than previously thought. Across the whole study, greater frequency of short-acting beta-agonist (SABA) use was associated with poorer asthma control (p=0.003), lower asthma-related quality of life (p=0.001), lower percentage predicted forced expiratory volume in one second (FEV1, p=0.019) and an increased proportion of individuals suffering an exacerbation over the study period (p=0.038).

Finally, in a qualitative study, participants described their desire to feel in control of their asthma. EMDs were generally acceptable and some reported impact on their awareness and behaviours. For others, there were frustrations around perceived technical faults and concerns about data reliability. Future desirability centred on the potential impact of EMDs in helping users take control of their asthma, including through integrating with other wearable technology and enhancing self-monitoring.


Whilst inhaler monitoring technology holds significant promise in both identifying individuals with asthma who may benefit from targeted adherence intervention and as part of targeted adherence interventions, there remains concern with regards to their real-world reliability and inadequate evidence of their clinical benefit. This thesis puts forward considerations in both study and intervention design with the aim of building a better evidence base for their adoption into real-world use.

Item Type: Thesis (University of Nottingham only) (PhD)
Supervisors: Shaw, Dominick E.
McKeever, Tricia M.
Bains, Manpreet
Keywords: asthma, inhaler technology, mhealth, ehealth, adherence, compliance, inhaled corticosteroids, smartinhalers, Hailie, inhaler
Subjects: W Medicine and related subjects (NLM Classification) > WF Respiratory system
Faculties/Schools: UK Campuses > Faculty of Medicine and Health Sciences > School of Medicine
Item ID: 64632
Depositing User: Adejumo, Ireti
Date Deposited: 04 Aug 2021 04:40
Last Modified: 04 Aug 2021 04:40
URI: http://eprints.nottingham.ac.uk/id/eprint/64632

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