Editor’s note: To mark World COPD Day, which took place on November 16, we are running a multi-part series on COPD. Organized by the Global Initiative for Chronic Obstructive Lung Disease (GOLD), World COPD Day is aimed at raising awareness of COPD and sharing current knowledge of the disease, its burden, and treatment approaches.
Emerging digital technologies allow patients with chronic obstructive pulmonary disease (COPD) more options for managing their disease outside of the physician’s office. The ultimate goal: to improve patient outcomes.
“The most important tool is the pulse oximeter, and it would be best if everyone with COPD had one,” said Richard Castriotta, MD. FCCP, FAASM, pulmonologist and sleep medicine specialist and professor of clinical medicine at the Keck School of Medicine at the University of California in Los Angeles . “These can be integrated into telemedicine visits to assess patients’ status remotely” in addition to aiding in self-monitoring.
To date, most research findings on the effectiveness of COPD self-management tools have been low-quality and largely inconclusive. However, limited evidence supports their benefits in COPD.1
In a 2022 single-site pilot study, 19 patients with COPD received training on the use of “smart” versions of a nebulizer, spirometer, and pulse oximeter, as well as the Wellinks mHealth app for self-management.2 Participants used these tools for 8 weeks, and attending physicians received data from these devices once monthly along with patient-reported data regarding medication use and symptoms. The results showed high patient engagement and satisfaction, with many participants perceiving the technology as valuable (81%) and easy to use (94%).
A 2019 study found high rates of symptom reporting and inhaler adherence in a small sample of COPD patients with heart failure who used an eHealth self-management intervention, and an earlier study found promising results with the use of a COPD self-management app that provided automated treatment advice based on detection of exacerbations.3,4
In a 2021 Cochrane review, the authors concluded that evidence is insufficient to draw conclusions about the benefits or harms of using digital technology in COPD management, though findings point to potential short-term improvements in quality of life and improvements in dyspnea after long-term use of digital strategies.1
Similarly, a 2020 systematic review and meta-analysis found inconsistent evidence regarding the effectiveness of various mobile health apps compared to usual care in COPD patients.5 However, the significant heterogeneity in outcome measures used across studies indicate the need for a standardized framework for reporting outcomes in future studies focused on COPD self-management using digital interventions.
Additional research is needed to elucidate the benefits of the vast range of digital tools now available to facilitate care in this patient population. Among other remaining needs, “It would be a good idea to have the means to measure blood CO2 levels and also ambulatory blood pressure to have information during sleep,” Dr Castriotta said.
To learn more about the application of digital tools in COPD treatment and self-management, we interviewed Brian D. Gelbman, MD, clinical associate professor in the division of pulmonary and critical care medicine at Weill Cornell Medical College in New York and author of the previously referenced 2022 study of COPD self-management tools2, and Jennifer J.B.J. Williams, MD, clinical assistant professor in the division of pulmonary, allergy, and critical care medicine at the Stanford University School of Medicine in California.
What are some of the current digital approaches used for COPD self-management?
Dr Gelbman: Home digital monitoring for COPD is slowly gaining traction, though it has certainly picked up speed during the pandemic. Many COPD patients have become familiar with home pulse oximetry, and now several home digital spirometry companies have entered the marketplace. Teva Pharmaceuticals introduced digital inhalers that can record medication compliance.6 Development is still in the early stages for more robust COPD self-monitoring and management tools that could ultimately combine all of these approaches into one unified platform.
Dr Williams: There are different digital approaches used in current clinical practice to assist in evaluating individual signs and symptoms in patients with COPD with the aim of improving overall chronic disease management. Many of the digital systems have been created to improve communication and symptom management, which will allow for improvement of patient support, care, and mindfulness.
In addition to digital pulse oximetry, some of the current digital technologies include wearable devices that measure activity levels, heart rate, stress and more; a home air quality-sensing device and related smartphone app; smart digital metered dose inhalers; an app-based personal spirometer with peak flow and FEV1; a COPD breathing techniques app; a personalized mobile health and self-management app for patients with COPD; digital peak flow meters; remote pulmonary rehabilitation; and COPD medication management apps.
Based on observations in your practice, how effective do these approaches seem to be, and how do patients feel about them?
Dr Gelbman: I believe patients enjoy having the knowledge to monitor their own disease state, and this empowers them to feel they have some control over their disease. As a pulmonologist, I believe these digital therapeutics can be highly effective. They may be able to detect exacerbations earlier and reduce unscheduled office visits, emergency room visits, and hospitalizations. Proving that efficacy can be more challenging, as it will require large-scale studies. Digital COPD solutions may provide better access to pulmonary rehabilitation as well.
Dr Williams: Feasibility and usability features are key components to patient satisfaction with digital technology. Additionally, patients typically require some form of training in the use of digital products. Patients are generally positive about the digital technology experience, especially if they find the device easy to use and can perceive a clear benefit in the path to achieving their own health goal. Some patients perceive definite health benefits from using digital technology.
Patients are frequently willing to use the technology and are capable of doing so regardless of age, gender, or disease severity. The digital practices also support clinicians in improving patient care and optimizing decision-making for disease management in COPD patients.
Based on observations in my practice, I foresee 2 main barriers to digital use: The first is an economic barrier, as digital methods typically come at a cost and thus may not provide a realistic opportunity for everyone. The second barrier is in health and technical literacy, with some patients having difficulty understanding and using digital methods.
I am working on new research in this area and plan to implement a COPD severity monitoring intervention. I currently use patient education to instruct and encourage patients in self-care COPD management at home.
What would you recommend to clinicians seeking to integrate the use of these tools into practice?
Dr Gelbman: At the present stage, I think we should be educating our patients and familiarizing them with basic monitoring tools such as pulse oximetry. That way, when complete applications are ready to assist with disease management, they will be familiar with the tools that will be utilized as inputs.
Dr Williams: The most common tools currently are the wearable electronic devices. Patients are likely to use the digital tools if they are user-friendly and demonstrate convenience and accessibility. It is important to target economic barriers and work-flow issues and to set realistic patient expectations in regards to patient-provider communication.
What is needed to further refine or develop effective digital tools for COPD self-management?
Dr Gelbman: Currently, the approaches are disparate which is preventing widespread adoption. Some home COPD monitoring companies work by charging the clinician for the service with the promise that they will be renumerated by billing for remote patient monitoring services. This reimbursement model is a paradigm shift that involves clinicians accepting some financial risk. Ultimately, I expect that third-party payers will have to cover the cost of these COPD digital therapeutics, as they have for other chronic disease states such as diabetes and heart failure, before we see widespread acceptance.
Dr Williams: Future research on digital devices for clinician and patient management are needed. These digital devices are aimed at improving machine learning and deep learning with the capacity to monitor symptoms and help predict COPD exacerbations while aiding in self-management and clinician monitoring of chronic airway disease.
Among other needs, further research and policy work should focus on wearable electronic devices, integration of COPD coaches, care managers, or community health workers into the care team to manage the remote care and alerts, business models that encourage technology development, and clinic budget models that allow for a reorganization of workflow.
What additional points would you like to note regarding the value of digital interventions in COPD management?
Dr Williams: COPD patients are particularly at risk of living day-to-day with uncontrolled symptoms. These factors make many of these patients vulnerable to exacerbations, poor quality of life, and increased mortality. Given the clear disparities in providing standard-of-care interventions for these individuals, there is a need to do more to lessen these gaps and enable healthy living. Many digital devices allow self-monitoring and offer clinicians the opportunity to provide early intervention with aims to deliver high-quality patient care, reduce hospital admissions, and improve overall quality of life in COPD.
Disclosures: Dr Brian D. Gelbman serves as a consultant for Wellinks.