The Effect of Monitoring Devices on Inhaler Adherence and Other Asthma Outcomes

Child at medical appointment.
A meta-analysis identified the effects of the electronic adherence monitoring devices on inhaler adherence, exacerbations, and asthma control in children.

Electronic monitoring adherence devices significantly improve inhaler adherence in children with asthma, according to results of a systemic review and meta-analysis published in the International Journal of Nursing Studies. However, the analysis did not find these devices significantly affected asthma exacerbations, lung function, or asthma control.

The analysis was conducted by a team of researchers from Singapore who reviewed English-language randomized controlled trials on the use of electronic adherence monitoring devices in children with asthma. The review resulted in a meta-analysis of 10 trials with 1123 children and adolescents (under 19 years of age) with asthma who were prescribed inhaled corticosteroids alone or with a long-acting β2-agonist.

The studies reviewed involved electronic adherence monitoring devices that were either attached to inhalers or built into inhalers. The electronic devices were designed to improve treatment adherence by providing audio–visual reminders, reminder information via text messages, and/or physician-provided feedback based on the recorded or transmitted data. Comparator arms included usual care, waitlist, or placebo.

A pooled meta-analysis was used to identify the effects of the electronic adherence monitoring devices on inhaler adherence, asthma exacerbation, asthma control, lung function, and accessibility.

The meta-analysis showed that patients who received an electronic adherence monitoring device were 1.50 times more likely to adhere to inhalers (relative ratio [RR], 1.50; 95% CI, 1.19–1.90) compared with those assigned a control (P <.001). In a pooled analysis of 3 trials that reported asthma exacerbations, there was no significant difference between electronic adherence monitoring devices and control in regard to the rate of asthma exacerbations (RR, 0.89; 95% CI, 0.45–1.75; P =.72).

Additionally, there were no differences between electronic adherence devices and control in regard to asthma control, as demonstrated by pooled analyses of Asthma Control Questionnaire scores (P =.36) and Asthma Control Test (ACT) scores (P =.34). In contrast, the meta-analysis revealed a significant improvement in childhood ACT in those assigned to electronic adherence devices compared with control (P =.02). These inconsistencies suggested that further investigation was needed, said investigators.

Only 1 trial reported on the acceptability of electronic adherence monitoring devices among children. In this study, the researchers found higher acceptability scores with the electronic adherence monitoring devices vs control. The majority of children (95%) said the device was “user friendly,” but because only 1 study reported the acceptability outcome, the researchers suggested that more trials are needed.

Limitations of this meta-analysis included the small sample sizes of the reviewed studies as well as the short monitoring periods, which made it difficult to investigate the long-term effects of the monitoring devices. Additionally, given that the electronic adherence monitoring devices only measure actuation vs inhalation, the researchers suggest true adherence to asthma therapy remains uncertain.

The researchers concluded that “with the increased emphasis on addressing medication behavior such as adherence feedback and the input of healthcare professionals and parents in asthma management, electronic adherence monitoring devices should measure actuation and inhalation to confirm actual inhalation.”


Lee JR, Leo S, Liao S, et al. Electronic adherence monitoring devices for children with asthma: A systematic review and meta-analysis of randomised controlled trials. Int J Nurs Stud. Published online July 15, 2021. doi:10.1016/j.ijnurstu.2021.104037