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, International Clinical Trials Registry Platform (ICTRP), and Latin American and Caribbean Literature on Health Sciences (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 random effects analysis of covariance models addressed asthma control and asthma-related quality of life. Random-effects meta-analyses addressed severe exacerbations and harms. We used the Grading of Recommendations Assessment, Development and Evaluations (GRADE) approach to assess certainty of evidence (PROSPERO CRD42024525051). RESULTS: Twelve trials enrolled 2,483 children (aged 4-17 y) and adults with asthma. Patient-facing digital inhalers probably improve asthma control (Asthma Control Test, mean difference 0.63 [95% confidence interval {95% CI} 0.29-0.96]; 44.3% vs 39.8% achieving a 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 1,000 [95% CI 127 fewer to 66 more per 1,000], low certainty), with little to no difference in asthma-related quality of life (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. CONCLUSIONS: 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.
