Using remote directly observed therapy (R-DOT) for optimising asthma therapy

Background: Ensuring adherence and correct inhaler use is problematic and directly observed therapy has been used to ensure these are in place. Aims: To determine if R-DOT could monitor adherence and inhaler technique in children with Difficult to Treat Asthma (DTA). Methods: A mobile phone platform was used to record and send a short video clip (timed and dated, twice a day) of children using their inhaler. The videos were reviewed by a nurse and if needed the child/parent was provided with reminders/re-instruction. In our pilot study 22 children (aged <15 yrs) with DTA were randomised to either immediate R-DOT for 6 weeks or delayed entry (R-DOT after 6 weeks) and asthma control was assessed at 12 weeks. Results: Despite all children being able to demonstrate good inhaler technique at study entry, 80% were deemed not to have good inhaler technique while using R-DOT at home during the first week. By the end of the 3rd week after nurse led re-instructions all children had good inhaler technique. Both groups improved equally. The child-Asthma Control Test (c-ACT) increased between 3-5 points and FeNO decreased from 38 and 39 to 19 ppb. The R-DOT platform performed well, allowing clear observation of home inhaler technique. Engagement with the process was generally good although cases of non-adherence with video uploads included living with a different parent at weekends, life too busy and mobile phone memory issues (which were easily corrected). Conclusion: R-DOT can test for and improve inhaler technique and monitor adherence and can be used to ensure that a period of optimised therapy has been delivered in DTA. The approach is not device specific and can be used with any type of inhaled therapy.