Patient-facing digital inhalers for asthma: a systematic review and meta-analysis
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BACKGROUND: The benefits and harms of patient-facing digital inhalers (inhalers with a sensor providing patients immediate feedback on adherence and technique) for asthma remain unclear. OBJECTIVE: To systematically synthesize treatment outcomes of patient-facing digital inhalers for asthma. METHODS: As part of developing upcoming American Academy of Allergy, Asthma & Immunology and American College of Allergy, Asthma, and Immunology Joint Task Force on Practice Parameters severe and difficult-to-control asthma guidelines, we searched MEDLINE, Embase, CENTRAL, CINAHL, PsycINFO, ICTRP, and LILACS, and monitored for additional studies to April 1, 2025 for randomized controlled trials evaluating patient-facing digital inhalers in asthma. Paired reviewers independently screened records and extracted data. Individual patient-level data in mixed-effects ANCOVA models addressed asthma control and asthma-related quality of life (QoL). Random-effects meta-analyses addressed severe exacerbations and harms. We used the GRADE approach to assess certainty of evidence. PROSPERO (CRD42024525051). RESULTS: Twelve trials enrolled 2483 children (aged 4-17) and adults with asthma. Patient-facing digital inhalers probably improve asthma control (Asthma Control Test, mean difference: 0.63 [95%CI 0.29-0.96]; 44.3% vs. 39.8% achieving 3 point increase, moderate certainty) and may reduce severe exacerbations in patients at high risk for future exacerbations (risk ratio: 0.89 [95%CI 0.69-1.16]; risk difference: 45 fewer per 1000 [95%CI 127 fewer to 66 more per 1000], low certainty), with little to no difference in asthma-related QoL (low certainty). The median of mean device failure rate was 12%, with trials reporting issues regarding sensor synchronization with smartphones (very low certainty). One trial reported a protected health information exposure while using patient-facing digital inhalers. CONCLUSION: Patient-facing digital inhalers probably improve asthma control and may reduce severe asthma exacerbations in patients at high risk for future exacerbations with minimal harm.
