Although inhaled therapies have been found to reduce the frequency of exacerbations and improve quality of life in individuals with chronic obstructive pulmonary disease (COPD), treatment nonadherence is a persistent issue in this population.1 In various studies, adherence rates ranging from 20% to 60% have been noted in patients with COPD.2 Given the established link between nonadherence to inhaled therapies and increased mortality, healthcare costs, and hospitalizations, there is a clear need for strategies to improve treatment adherence in this group.1

Electronic inhaler monitoring (EIM) is one such tool that has increasingly shown promise for this purpose, according to a review published in June 2020 in Chest by Attaway and colleagues.1 An electronic monitoring device (EMD) attached to an inhaler can sense and store the date and time of each actuation, and the data are transmitted and compiled for analysis of adherence. This technique has demonstrated greater accuracy in adherence monitoring compared to patient self-report, canister weighing, and dose monitoring.1

“EIM allows objective assessment of nonadherence and treatment plans, especially before considering advanced interventions,” said Neeraj R. Desai, MD, MBA, FCCP, FACP, D-AABIP, clinical associate professor of medicine at the University of Illinois, Chicago, system director at AMITA Health Pulmonary Endoscopy and Interventional Pulmonology, and director of the Chicago Chest Center.

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“In addition, EIM can help to improve adherence directly through patient reminders, and indirectly by allowing providers to diagnose nonadherence and to implement effective strategies for improving adherence,” he told Pulmonology Advisor in an interview.

Most of the research conducted on EIM to date has focused on utilization in patients with asthma, with findings supporting the effectiveness of EIM in improving adherence, though the effect on clinical outcomes remains to be elucidated. In a multicenter randomized controlled trial (RCT) of 209 children with asthma, for example, those using EIM with tailored reminders via text messaging demonstrated higher mean adherence levels than those using EIM without reminders (69.3 vs 57.3%).3

An earlier single-blinded RCT including 110 adults and adolescents with asthma found better inhaled corticosteroid adherence in participants who received EIM with an audiovisual reminder function compared with those who received an EIM without this function (93% vs 74% in the last 12 weeks of the 24-week trial; 95% CI, 10%-26%; P <.0001).4

A small body of research also points to the effectiveness of EIM in improving adherence in COPD. In the Lung Health Study, 231 patients were assigned to 1 of 2 groups that used EIM. Patients in the intervention group were informed that instances of actuation were being recorded and received ongoing feedback regarding adherence, whereas patients in the control group were aware their utilization was being monitored but did not know that instances of actuation were being recorded.1

Better adherence was noted in the intervention group compared with controls (1.65 ± 0.89 vs 1.16 ± 0.95 actuations per day; P =.0006), and dose dumping was observed in 30% of control participants.1

Additionally, EIM may be useful in identifying adherence stemming from technique errors, allowing providers the opportunity to advise patients on proper technique. In a 2017 prospective study of 244 elderly patients with COPD who were discharged from the hospital with an EIM device using Inhaler Compliance Assessment (INCA) technology, 59% of patients showed mild-to-moderate cognitive impairment.5 The results revealed that the mean actual adherence rate (doses taken at appropriate times and with proper technique) was only 22.6%, and 25.2% of patients showed frequent technique errors despite high rates of inhaler use.5

“Advanced age and cognitive deficits with poor lung function were predictive of poor adherence and technique errors,” Attaway and colleagues wrote.1 “EIM was helpful to diagnose the degree of technique errors in this cohort, which would have otherwise gone unknown without objective assessment.”

EIM may also reduce healthcare utilization in COPD as seen in asthma patients, and other results indicate that detection of increased SABA use via EIM may predict exacerbations, thus prompting early intervention and optimization of therapy. “Although these findings await confirmation in larger-scale studies, the possibility exists that early intervention algorithms in the face of increased SABA use could attenuate the severity of an exacerbation, if not prevent them altogether,” noted Attaway and colleagues.1

While findings thus far have been largely positive, it is important to consider several potential drawbacks that may be associated with EIM.1,6 For instance, technical problems and user-related issues represent challenges that may affect widespread patient acceptance of EIM.1 “Other potential drawbacks include cost, patients’ privacy concerns due to the use of electronic data, and the possible use of EIM data by insurance companies for denial of additional therapies,” Desai explained.

Overall, however, the available evidence suggests that EIM data could be useful in improving adherence and preventing unnecessary treatment escalation, especially in patients with more severe disease. Evidence also suggests that EIM may help patients to avoid greater healthcare utilization and to identify problematic adherence patterns such as poor technique or irregular use despite good technique.1

Further research is needed to determine the cost-effectiveness of EIM for various patient subgroups and to clarify the value of EIM in reducing healthcare utilization and improving clinical outcomes in individuals with COPD. 1,7


Neeraj R. Desai, MD, has disclosed a consulting role for Veran Medical, Level Ex, and Boston Scientific.8

Bruce Bender, MD, one of the authors of the Chest review, reported funding from the National Institutes of Health, a consulting role for Propeller Health, and advisor role for Sanofi.1


1. Attaway AH, Alshabani K, Bender B, Hatipoğlu US. The utility of electronic inhaler monitoring in COPD management: promises and challenges. Chest. 2020;157(6):1466-1477. doi:10.1016/j.chest.2019.12.034

2. Bengtson LGS, Bancroft T, Schilling C, Buikema AR, Stanford RH. Development and validation of a drug adherence index for COPD. J Manag Care Spec Pharm. 2021;27(2):198-209. doi:10.18553/jmcp.2021.27.2.198

3. Vasbinder EC, Goossens LM, Rutten-van Mölken MP, et al. e-Monitoring of Asthma Therapy to Improve Compliance in children (e-MATIC): a randomised controlled trial. Eur Respir J. 2016;48(3):758-67. doi:10.1183/13993003.01698-2015

4. Charles T, Quinn D, Weatherall M, Aldington S, Beasley R, Holt S. An audiovisual reminder function improves adherence with inhaled corticosteroid therapy in asthma. J Allergy Clin Immunol. 2007;119(4):811-816. doi:10.1016/j.jaci.2006.11.700

5. Sulaiman I, Cushen B, Greene G, et al. Objective assessment of adherence to inhalers by patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 2017;195(10):1333-1343. doi:10.1164/rccm.201604-0733OC

6. Chan AHY, Pleasants RA, Dhand R, et al. Digital inhalers for asthma or chronic obstructive pulmonary disease: a scientific perspective. Published online August 11, 2021. Pulm Ther. doi:10.1007/s41030-021-00167-4

7. Jansen EM, van de Hei SJ, Dierick BJH, Kerstjens HAM, Kocks JWH, van Boven JFM. Global burden of medication non-adherence in chronic obstructive pulmonary disease (COPD) and asthma: a narrative review of the clinical and economic case for smart inhalers. J Thorac Dis. 2021;13(6):3846-3864. doi:10.21037/jtd-20-2360

8. Desai NR, Diamond EJ. Emerging role of remote patient monitoring in pulmonary care: telemedicine to smart phone. Chest. 2021;159(2):477-478. doi:10.1016/j.chest.2020.10.015.