Digital Inhalers May Improve Asthma Control with Minimal Harm

A meta-analysis suggests that patient-facing digital inhalers may improve asthma control and reduce severe asthma exacerbations with minimal harm.1

“The findings…are consistent with the high-certainty evidence for inhaled asthma maintenance and/or reliever therapies in promoting optimal asthma outcomes,” wrote investigators, led by Leonardo Ologundudu, from McMaster University, in Ontario, Canada.

Approximately 43% of patients with asthma globally do not use their inhalers as prescribed.2 Using patient-facing digital inhalers, equipped with a sensor that provides patients with immediate feedback on adherence and technique, may improve asthma outcomes. However, the benefits and harms of digital inhalers have not been outlined.

Investigators aimed to systematically synthesize treatment outcomes of patient-facing digital inhalers for asthma.1 The study was conducted to help inform the upcoming severe and difficult-to-control asthma guidelines, currently being developed by the American Academy of Allergy, Asthma & Immunology and the American College of Allergy, Asthma, and Immunology Joint Task Force.

Outcomes included asthma symptom control, asthma-related quality of life, severe asthma exacerbations, asthma-related hospitalizations or emergency department visits, serious or overall adverse events, discontinuation due to adverse events, mortality, and medication adherence. Investigators also looked for digital inhaler-specific harms, such as privacy breaches, connectivity issues, and device malfunctions.

The team searched MEDLINE, Embase, CENTRAL, CINAHL, PsychINFO, ICTRP, and LILACs up to April 1, 2025, for randomized controlled trials evaluating patient-facing digital inhalers for asthma. They selected 12 trials with 2483 children (aged 4 – 17 years) and adults with asthma. The sample included 57% females, a mean age of 44.7 years, and the mean baseline asthma control status was 16.23 on the Asthma Control Test.

The analysis indicated that digital inhalers most likely improve asthma control, as seen with a 3-point increase in the Asthma Control Test (mean difference, 0.63; 95% confidence interval [CI], 0.29 – 0.96; 44.3% vs 39.8%; moderate certainty). Digital inhalers may also reduce severe exacerbations in patients at high risk (risk ratio [RR], 0.89; 95% CI, 0.69-1.16); the risk difference was 45 fewer per 1000 (low certainty).

“The clinical implications of the potentially small benefits in asthma symptom control and potentially modest reduction in severe asthma exacerbations must be contextualized with how clinicians and health systems intend to implement digital inhalers…its associated resource implications, competing treatments, and patient values and preferences,” investigators wrote.

For instance, patients who respond to inhaled asthma therapies but struggle with optimal adherence or inhalation technique may benefit from digital inhalers. However, those who already have good adherence and technique may benefit more from alternative therapies with higher certainty.

Regarding harm, digital inhalers had a 12% mean device failure rate, with trials reporting issues of sensor synchronization with smartphones (low certainty). Another trial reported that the device exposed protected health information. However, in general, digital inhalers lead to minimal harm.

Investigators cited several limitations, including limited data on severe asthma exacerbations and digital inhaler-specific outcomes, lack of blinded outcome assessors, inconsistent enrollment methods, most studies evaluating the combined effect of digital inhalers with remote patient-monitoring clinician feedback, and no participants > 60 years.

“Altogether, these findings should encourage updated guidelines, whether they be from the perspective of individual patients and clinicians making decisions, or from the perspective of a systems-level intervention for a clinical practice, health system or insurer, which weigh the potential benefits and downsides of digital inhalers for specific subgroups of patients with asthma (e.g. those struggling with adherence and who value more regular and intensive feedback),” investigators concluded.

References

1. Ologundudu L, Rayner DG, Oppenheimer J, Sumino K, Hoyte F, Rivera-Spoljaric K, Perry TT, Nyenhuis SM, Chipps B, Israel E, Shade LE, Press VG, Rangel S, Guyatt GH, McCabe E, O'Byrne PM, Hall L, Orr H, Sue-Wah-Sing D, Melendez A, Winders T, Przywara K, Gardner DD, Rank MA, Bacharier LB, Mosnaim G, Chu DK. Patient-facing digital inhalers for asthma: a systematic review and meta-analysis. J Allergy Clin Immunol Pract. 2025 Apr 30:S2213-2198(25)00408-8. doi: 10.1016/j.jaip.2025.04.039. Epub ahead of print. PMID: 40312010.

2. Hassan M, Davies SE, Trethewey SP, Mansur AH. Prevalence and predictors of adherence to controller therapy in adult patients with severe/difficult-to-treat asthma: a systematic review and meta-analysis. J Asthma. 2020 Dec;57(12):1379-1388. doi: 10.1080/02770903.2019.1645169. Epub 2019 Jul 30. PMID: 31311359.