Unsupervised home spirometry versus supervised clinic spirometry for respiratory disease: a systematic methodology review and meta-analysis

Multimodal Technologies for Remote Assessment of Neurological and Mental Health

PURPOSE

Automated remote assessment and monitoring of patients' neurological and mental health is increasingly becoming an essential component of the digital clinic and telehealth ecosystem, especially after the COVID-19 pandemic. This review article reviews various modalities of health information that are useful for developing such remote clinical assessments in the real world at scale.

APPROACH

We first present an overview of the various modalities of health information-speech acoustics, natural language, conversational dynamics, orofacial or full body movement, eye gaze, respiration, cardiopulmonary, and neural-which can each be extracted from various signal sources-audio, video, text, or sensors. We further motivate their clinical utility with examples of how information from each modality can help us characterize how different disorders affect different aspects of patients' spoken communication. We then elucidate the advantages of combining one or more of these modalities toward a more holistic, informative, and robust assessment.

FINDINGS

We find that combining multiple modalities of health information allows for improved scientific interpretability, improved performance on downstream health applications such as early detection and progress monitoring, improved technological robustness, and improved user experience. We illustrate how these principles can be leveraged for remote clinical assessment at scale using a real-world case study of the Modality assessment platform.

CONCLUSION

This review article motivates the combination of human-centric information from multiple modalities to measure various aspects of patients' health, arguing that remote clinical assessment that integrates this complementary information can be more effective and lead to better clinical outcomes than using any one data stream in isolation.

Telemedicine and home spirometry in cystic fibrosis: A prospective multicenter study

OBJECTIVES

Telehealth and home spirometry feasibility for children has been established, but their impact on cystic fibrosis (CF) disease progression remains unassessed. We aimed to evaluate the effects of telehealth and home spirometry on CF disease progression and care.

METHODS

Children with CF aged 5-17 years from all Swedish CF centers were provided with home spirometers. A minimum of two in-person visits were replaced with telemedicine visits and participants were instructed to conduct home spirometry before visits. Linear mixed-effects models were used to compare annual CF disease trajectories during the intervention period and prepandemic period (1 January 2019 to 28 February 2020). Participants and caregivers completed study questionnaires.

RESULTS

A total of 59 individuals completed the study over a mean (SD) period of 6.8 (1.4) months, made 3.1 (1.0) physical visits and 2.2 (0.6) telehealth visits per patient year during the study period. The mean difference (95% CI) between the intervention and prepandemic period progression rate for FEV1%, lung clearance index and BMI were -0.4 (-1.3 to 0.5, p = 0.39), 0.11 (-0.07 to 0.28, p = 0.25) and -0.02 (-0.13 to 0.08, p = 0.70), respectively. There were no major shifts in the incidence of airway pathogens, sputum cultures, or antibiotics use between the periods (p > 0.05). The intervention did not increase stress. Almost all participants and caregivers expressed a desire to continue with home spirometry and telemedicine.

CONCLUSION

Combining telehealth and physical visits with access to home spirometry demonstrated comparable effectiveness as exclusively in-person care with enhanced flexibility and personalization of CF care.

Digital twins for chronic lung diseases

Digital twins have recently emerged in healthcare. They combine advances in cyber-physical systems, modelling and computation techniques, and enable a bidirectional flow of information between the physical and virtual entities. In respiratory medicine, progress in connected devices and artificial intelligence make it technically possible to obtain digital twins that allow real-time visualisation of a patient's respiratory health. Advances in respiratory system modelling also enable the development of digital twins that could be used to predict the effectiveness of different therapeutic approaches for a patient. For researchers, digital twins could lead to a better understanding of the gene-environment-time interactions involved in the development of chronic respiratory diseases. For clinicians and patients, they could facilitate personalised and timely medicine, by enabling therapeutic adaptations specific to each patient and early detection of disease progression. The objective of this review is to allow the reader to explore the concept of digital twins, their feasibility in respiratory medicine, their potential benefits and the challenges to their implementation.

Day-to-Day Variability in Measurements of Respiration Using Bioimpedance from a Non-Standard Location

Non-invasive monitoring of pulmonary health may be useful for tracking several conditions such as COVID-19 recovery and the progression of pulmonary edema. Some proposed methods use impedance-based technologies to non-invasively measure the thorax impedance as a function of respiration but face challenges that limit the feasibility, accuracy, and practicality of tracking daily changes. In our prior work, we demonstrated a novel approach to monitor respiration by measuring changes in impedance from the back of the thigh. We reported the concept of using thigh-thigh bioimpedance measurements for measuring the respiration rate and demonstrated a linear relationship between the thigh-thigh bioimpedance and lung tidal volume. Here, we investigate the variability in thigh-thigh impedance measurements to further understand the feasibility of the technique for detecting a change in the respiratory status due to disease onset or recovery if used for long-term in-home monitoring. Multiple within-session and day-to-day impedance measurements were collected at 80 kHz using dry electrodes (thigh) and wet electrodes (thorax) across the five healthy subjects, along with simultaneous gold standard spirometer measurements for three consecutive days. The peak-peak bioimpedance measurements were found to be highly correlated (0.94 ± 0.03 for dry electrodes across thigh; 0.92 ± 0.07 for wet electrodes across thorax) with the peak-peak spirometer tidal volume. The data across five subjects indicate that the day-to-day variability in the relationship between impedance and volume for thigh-thigh measurements is smaller (average of 14%) than for the thorax (40%). However, it is affected by food and water and might limit the accuracy of the respiratory tidal volume.

Current technological advancement in asthma care

INTRODUCTION

Asthma is a common chronic respiratory disease affecting 262 million people globally, causing half a million deaths each year. Poor asthma outcomes are frequently due to non-adherence to medication, poor engagement with asthma services, and a lack of objective diagnostic tests. In recent years, technologies have been developed to improve diagnosis, monitoring, and care.

AREAS COVERED

Technology has impacted asthma care with the potential to improve patient outcomes, reduce healthcare costs, and provide personalized management. We focus on current evidence on home diagnostics and monitoring, remote asthma reviews, and digital smart inhalers. PubMed, Ovid/Embase, Cochrane Library, Scopus and Google Scholar were searched in November 2023 with no limit by year of publication.

EXPERT OPINION

Advanced diagnostic technologies have enabled early asthma detection and personalized treatment plans. Mobile applications and digital therapeutics empower patients to manage their condition and improve adherence to treatments. Telemedicine platforms and remote monitoring devices have the potential to streamline asthma care. AI algorithms can analyze patient data and predict exacerbations in proof-of-concept studies. Technology can potentially provide precision medicine to a wider patient group in the future, but further development is essential for implementation into routine care which in itself will be a major challenge.

Home spirometry appears accurate and feasible for monitoring chronic respiratory disease

Spirometry is underutilised and can be difficult to access. This study assessed the accuracy and feasibility of home spirometry compared to gold standard. Findings suggest home spirometry is accurate and feasible across many respiratory disease groups. https://bit.ly/42TLoYd.

Remote pulmonary function testing allows for early identification of need for non-invasive ventilation in a subset of persons with ALS

The traditional ALS multidisciplinary clinical practice of quarterly respiratory assessment may leave some individuals in danger of developing untreated respiratory insufficiency between visits or beginning non-invasive ventilation (NIV) later than would be optimal. Remote, or home-based, pulmonary function testing (rPFT) allows patients with ALS to perform regular respiratory testing at more frequent intervals in the home. The aim of this study was to determine the clinical benefit of weekly rPFT compared to standard, quarterly in-clinic respiratory assessments: the number of individuals with earlier identification of NIV need, the magnitude of this advance notice, and the individual factors predicting benefit. Participants with ALS (n = 39) completed rPFT training via telemedicine and then completed one year of weekly self-guided assessments in the home. Over this period, 17 individuals exhibited remotely-measured FVC dropping below 50% of predicted, the value often used for recommendation of NIV initiation. In 13 individuals with clinical detection of this event, the median and range of advance notice of need for NIV was 53 (-61-294) days. Prescription of NIV occurred for 21 individuals on the study, six of whom began NIV as a result of remote testing, prior to indication of need as determined by in-person assessments. Weekly home assessments appeared to be of greatest clinical value in a subset of patients with low baseline respiratory test values and rapid respiratory decline. This has potential implications for clinical management of ALS as well as the conduct of clinical trials that rely on respiratory endpoints.