Digitally monitored inhaled therapy: a 'smart' way to manage severe asthma?

INTRODUCTION: One of the fundamental challenges of managing patients with severe asthma is treatment adherence, particularly with inhaled corticosteroids. Adherence is difficult to measure objectively and poor adherence is associated with worse outcomes. In this study, assess the ability of a 'smart' inhaler to record adherence in severe asthma patients and measure the impact of this on asthma control. METHODS: Consecutive consenting patients meeting criteria for biologics had their existing high-dose ICS/LABA//LAMA combination inhaler/s switched to mometasone/indacaterol/glycopyrronium (114/46/136). Routine clinical data, including blood eosinophils, FeNO, and ACQ-6 scores were collected at baseline and at 4 wk. Adherence was then checked on the Propeller Health app, and good adherence was defined as >80% of prescribed usage. Participants were then followed-up at 12 months to record the proportion of patients who were initiated on biologics. RESULTS: 77 patients (mean [SD] age = 50.4 [15.7] years, 67.5% female [n = 52]) participated. 71 participants were able to use the device and 65% (n = 46) of these attained good asthma control and were not initiated on biologics at 12-month follow-up. Both groups demonstrated a significant reduction in ACQ6 score at follow-up (2.81 vs. 1.92, p < 0.001 and 3.05 vs. 2.60, p < 0.001, respectively), but there was no statistically significant difference in improvement between groups. Patients with optimal adherence also demonstrated a significant reduction in median FeNO at follow-up (47 ppb vs. 40 ppb, p = 0.003). CONCLUSIONS: In severe asthma patients, 'smart' inhalers may represent an effective management tool to improve adherence and asthma control, therefore avoiding the need for patients to commence biological therapies.

Improving asthma care through implementation of the SENTINEL programme: findings from the pilot site.

Aim: Short-acting ß2-agonist (SABA) overuse adversely impacts asthma-related outcomes and the environment. The SABA rEductioN Through ImplemeNting Hull asthma guidELines (SENTINEL) programme aims to reduce SABA overuse through supported implementation of an adult asthma guideline, which advocates for a SABA-free maintenance and reliever therapy (MART)-preferred treatment where appropriate, across six primary care networks (PCNs) in the UK. We present findings on patient/disease characteristics, asthma prescribing patterns and exacerbation rates from the pilot PCN. Methods: Patients (aged ≥18 years, prescribed at least one inhaled therapy) and their prescribed asthma treatments were characterised using National Health Service data. Asthma treatments and exacerbations were analysed for three periods: 24‒12 months pre-, 12 months pre- and 12 months post-SENTINEL implementation (November 2020‒January 2021). Results: Of the 2571 registered asthma patients, 33.6% (n=864) underwent an asthma review, of whom 44.7% (n=386) were transitioned to MART. Fewer patients were prescribed three or more SABA canisters per year post-implementation in the overall asthma population (45.4% and 46.2% during 24‒12 months and 12 months pre-implementation, respectively, and 23.9% 12 months post-implementation), and in the two subgroups: 1) those who had an asthma review (74.5% and 83.6% during 24‒12 months and 12 months pre-implementation, respectively, and 26.5% post-implementation); and 2) those transitioned to MART following a review (76.4% and 86.5% during 24‒12 months and 12 months pre-implementation, respectively, and 16.3% post-implementation). A higher proportion of patients were exacerbation-free post-implementation in the overall asthma population and in the two subgroups. At least 71.5% of patients transitioned to MART were still prescribed MART 12 months post-implementation, of whom ≥86.7% were SABA-free. Conclusion: SENTINEL implementation led to reduced SABA prescribing, increased inhaled corticosteroid uptake and fewer asthma exacerbations. MART was considered appropriate for ∼50% of reviewed patients, with improved prescribing patterns sustained post-implementation.

Towards codesign in respiratory care: development of an implementation-ready intervention to improve guideline-adherent adult asthma care across primary and secondary care settings (The SENTINEL Project).

Short-acting beta agonist (SABA) overuse (≥3 canisters annually) is associated with worse asthma outcomes and accounts for the majority of greenhouse gas emissions from asthma inhalers in England. Reducing SABA overuse aligns with the National Health Service long-term plan to optimise asthma treatment while minimising environmental impact, but adoption of local asthma guidelines for a SABA-free maintenance and reliever therapy strategy for step 3 asthma patients is limited. In this Perspective, we describe patient and staff involvement in a codesign process adapted from experience-based codesign (EBCD) principles to develop an implementation-ready intervention within a practice-relevant timescale.The codesigned intervention consists of five pillars: healthcare professional education; implementation of 'gold standard' prescribing practices; targeted asthma reviews; patient education and support; and real-time data monitoring and reporting of asthma care metrics. The codesign process contributed to all pillars and, by identifying potential individual and organisational barriers to implementation, enabled the development of plans to address these barriers.In this Perspective, we reflect on the strengths and weaknesses of our codesign process, outline how EBCD principles can be used in respiratory research and propose actions for patients, health professionals, researchers and funders to develop the potential of EBCD in respiratory research.

Suppression of F ENO with observed inhaled corticosteroid therapy in severe asthma: is it a useful test in clinical practice?

F ENO suppression testing is practical and feasible during assessment for biologics in severe asthma. Patients with significant F ENO suppression were less likely to be recommended biologics but saw similar reductions in exacerbation frequency. http://bit.ly/35oSoxP.

Hidden morbidity: The results of a collaborative community chronic obstructive pulmonary disease screening initiative.

Chronic obstructive pulmonary disease (COPD) often goes unrecognised resulting in people living with the disease without a diagnosis. We investigated the characteristics, symptom burden and flow of participants in a community COPD screening initiative. Screening was undertaken during four events over 2-weeks. Participants completed symptom questionnaires and FEV-1/FEV-6 measurement. Patients with FEV-1 <80% predicted or FEV-1 ≥ 80% predicted and FEV-1/FEV-6 <0.72 were considered 'screen-positive' and invited to attend a 1-stop diagnostic clinic. Two hundred and fifty-seven individuals participated (mean ± SD age 58 ± 16, 24% current smokers). Seventy-seven were screen-positive with 27 ultimately attending a 1-stop clinic and 18 having confirmed COPD. The CAT score of participants with COPD was 19.3 ± 11.4. Two-thirds had moderate airflow obstruction on spirometry. The diagnosis rate in this screening initiative was comparable to trials of systematic case finding. Further research is required to explore the broader clinical impact of COPD screening.