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The COVID-19 pandemic has boosted the use of forced expiratory volume in 1 second (FEV1) telemonitoring in pediatric asthma, but a consensus on its most efficient and effective implementation is still lacking. To find answers, it is important to study how such an intervention is perceived, experienced, and used by both patients and health care professionals (HCPs).
The aim of this study was to provide perspectives on how FEV1 home monitoring should be used in pediatric asthma.
This is a qualitative, multicenter, prospective, observational study which included patients with asthma aged 6-16 and HCPs. Primary outcomes were results of 2 surveys that were sent to all participants at study start and after 3-4 months. Secondary outcomes consisted of FEV1 device usage during 4 months after receiving the FEV1 device.
A total of 39 participants (26 patients and 13 HCPs) were included in this study. Survey response rates were 97% (38/39) at the start and 87% (34/39) at the end of the study. Both patients and HCPs were receptive toward online FEV1 home monitoring and found it contributive to asthma control, self-management, and disease perception. The main concerns were about reliability of the FEV1 device and validity of home-performed lung function maneuvers. FEV1 devices were used with a median frequency of 7.5 (IQR 3.3-25.5) during the 4-month study period.
Patients and HCPs are receptive toward online FEV1 home monitoring. Frequency of measurements varied largely among individuals, yet perceived benefits remained similar. This emphasizes that online FEV1 home monitoring strategies should be used as a means to reach individual goals, rather than being a goal on their own.
The primary aim of asthma care is to reach and maintain asthma control by early recognition and treatment of pulmonary exacerbations (PEx) [
The value of FEV1 telemonitoring has been a subject of debate since portable spirometers became available. Although generally accepted as a feasible intervention in children with limited disease perception, concerns regarding the reliability of the measurements persist, and studies have failed to convincingly show an added value of FEV1 home monitoring in general asthma care [
This study aimed to develop new perspectives on how to use FEV1 telemonitoring in the future of pediatric asthma care. To achieve this we combined FEV1 home monitoring with an online eHealth platform [
This was a qualitative, multicenter, prospective, observational study on FEV1 home monitoring combined with an online eHealth platform for 4 months. The eHealth platform is used in regular pediatric asthma care to monitor asthma control using the validated (childhood) Asthma Control Test ([C]-ACT), and to support self-management with personalized online asthma action plans [
Screenshots of the instruction screen (left panel), measurement screen (middle panel) and feedback screen (right panel) of the smartphone app. The text in the instruction screen provides a short description on how to use the FEV1 device appropriately. The measurement screen shows a successfully performed measurement with buttons to upload (upper) or repeat (lower) the measurement. The feedback in the feedback screen is based on individual thresholds. Language is in Dutch.
Screenshot of the graphical presentation of FEV1 measurements on the online eHealth platform of one of the participants. Language is in Dutch. Colors represent individual color zones (green, orange, red).
Participants were recruited during outpatient visits in specialized asthma clinics from a university hospital (Radboudumc, Nijmegen, the Netherlands) and 2 general hospital (Canisius Wilhelmina Hospital, Nijmegen, the Netherlands and Spaarne Gasthuis, Haarlem, the Netherlands). Participants were eligible for inclusion if they had a doctor’s diagnosis of asthma based on the Global Initiative for Asthma (GINA) criteria, were aged 6-18 years, and already used the online eHealth platform for regular pediatric asthma care [
The primary outcome included survey results of patients (or their parents in case of young patients) and HCPs before and 3-4 months after the introduction of FEV1 devices. We used modified validated research questionnaires originally designed by Grol et al [
The secondary outcome was FEV1 device usage over the 4-month study period. All statistical analyses were performed using Statistical Package for the Social Sciences (SPSS version 25; IBM).
A total of 39 participants (26 patients and 13 HCPs) were included in this study. Patient characteristics at baseline are summarized in
Baselinea patient characteristics (N=26).
Characteristics | Value | ||
Age (years), median (IQR) | 13.4 (11.4-14.6) | ||
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6-11 years | 8 (31) | |
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12-18 years | 18 (69) | |
Male, n (%) | 12 (46) | ||
Initial ICSb dose µg/dayc, mean (SD) | 488.5 (353.6) | ||
(C-)ACTd score (n=7), median (IQR) | 20 (15-23) | ||
ACTd score (n=17), median (IQR) | 22 (18-27) | ||
(C-)ACT <20 points (n=21), mean (SD) | 8 (38.1) | ||
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z-FEV1e, mean (SD) | –0.30 (0.80) | |
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z-FVCf, mean (SD) | 0.26 (0.50) | |
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Tiff (%), median (IQR) | 84.08 (73.19-92.00) | |
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z-FEF25-75g, mean (SD) | –0.22 (1.49) | |
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Color zone not green, n (%) | 0 (0) | |
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z-FEV1, mean (SD) | –1.53 (1.47) | |
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z-FVC, mean (SD) | –0.65 (2.47) | |
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Tiff (%), median (IQR) | 81.87 (77.84-89.20) | |
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z-FEF25-75, mean (SD) | –1.37 (1.07) | |
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Color zone not green, n (%) | 6 (35) |
aBaseline lung function outcomes were defined as the first measurement within 31 days of receiving the FEV1 measurement device. Three of the included participants did not perform a baseline lung function measurement.
bICS: inhaled corticosteroids
cBeclomethasone or equivalent dose.
d(C-)ACT: (Childhood) Asthma Control Test.
eFEV1: forced expiratory volume in 1 second.
fFVC: forced vital capacity.
gFEF: forced expiratory flow.
Survey response rates at start were 96% (25/26) for patients and 100% (13/13) for HCPs, whereas those at the end were 85% (22/26) and 92% (12/13), respectively. Survey results and intragroup comparisons over time are summarized in
A total of 18 (69%) patients used their FEV1 device more than 3 times during the study period. FEV1 devices were used with a median frequency of 7.5 (IQR 3.3-25.5) distributed over 5.5 unique days (IQR 2.3-19.0). Two patients did not use their FEV1 device at all, because one quit the study and another experienced technical difficulties. Most measurements were performed in the morning (154/421, 36.6%) or evening (156/421, 37.1%). 30.6% (129/421) of measurements were not in the personalized green zones, and 11.6% (49/421) of measurements were in the personalized red zone, leading to closer inspection by HCPs.
Seven patients reported that they did not want to decide themselves how often they measured their lung function (
Patient survey outcomes.
Statementa | Start, median (IQR) | End, median (IQR) | Significance ( |
Q1. I am experienced with using smartphones. | 5 (4-5) | N/Ac | — |
Q2. Using innovations in health care is normal. | 4 (3-5) | N/A | — |
Q3. The FEV1b measurement device looks nice. | N/A | 4 (3-5) | — |
Q4. The FEV1 measurement device is easy to use. | N/A | 4 (2-4) | — |
Q5. The manual of the FEV1 measurement device was clear. | N/A | 4 (3-4) | — |
Q6. Measuring my FEV1 at home is new for me (innovative). | 4 (4-5) | N/A | — |
Q7. I should be able to measure my FEV1 for a longer period of time. | 4 (4-5) | N/A | — |
Q8. Measuring my FEV1 at home is a good addition to my daily asthma care. | 4 (4-5) | 4 (4-5) | .83 |
Q9. The FEV1 measurements will provide me with more insights into my disease. | 4 (4-5) | 4 (3.75-4) | .20 |
Q10. Measuring my FEV1 at home will cost a lot of time. | 2 (2-2.5) | 2 (2-3) | .23 |
Q11. I am glad that I am able to check my FEV1 by myself. | 4 (4-5) | 4 (3-4.25) | .34 |
Q12. I would only measure my FEV1 when I experience symptoms. | 2 (2-3) | 3 (2-4) | .33 |
Q13. Measuring my FEV1 regularly will help me to better handle my disease. | 4 (3-5) | 4 (3-4) | .13 |
Q14. The home measurements of FEV1 will make me insecure. | 2 (1-2) | 1.5 (1-2) | .49 |
Q15. The home measurements of FEV1 will give me stress. | 2 (1-2) | 2 (1-2.25) | .42 |
Q16. I only want to know my FEV1 when it’s not going well. | 2 (1.5-2.5) | 2 (1-3) | .27 |
Q17. I want to decide myself how often I measure my lung function. | 3 (3-4) | 3 (2.75-4) | .86 |
Q18. I want to receive feedback on my home measurements. | 4 (3-4) | 4 (3-4.25) | >.99 |
Q19. I wouldn’t mind to fill out a short symptom survey if my FEV1 is lower than expected. | 4 (4-5) | 4 (4-4) | >.99 |
Q20. I would like to receive reminders in the online asthma clinic to measure my FEV1. | 4 (3.5-4.5) | 4 (4-5) | .37 |
Q21. The graphical presentation of my FEV1 measurements is useful. | N/A | 4 (3-4) | — |
Q22. If I don’t succeed to measure my FEV1 at home, I know whom to contact. | N/A | 4 (4-5) | — |
Q23. I don’t worry as long as I feel good, even if my FEV1 is lower than expected. | N/A | 3 (3-4) | — |
Q24. I wouldn’t mind if my health care professionals can see my home measurements. | 4 (4-5) | 4 (4-5) | .48 |
Q25. I would feel controlled by my health care professionals if they can see my home measurements. | 2 (1-3) | 2 (1-2.25) | .21 |
aResponses were collected on a 5-point Likert scale, where 1=strongly disagree; 2=disagree; 3=neutral; 4=agree; and 5=strongly agree.
bFEV1: forced expiratory volume in 1 second.
cN/A: not applicable.
Health care professional survey outcomes.
Statementa | Start, median (IQR) | End, median (IQR) | Significance ( |
Q1. I am experienced with using smartphones. | 4 (3.5-4.5) | 4 (4-4.75) | >.99 |
Q2. Using innovations in health care is normal. | 4 (4-5) | 4 (4-5) | >.99 |
Q3. The FEV1b measurement device looks nice. | N/Ac | 4 (4-4.75) | — |
Q4. The FEV1 measurement device is easy to use. | N/A | 4 (3-4) | — |
Q5. The manual of the FEV1 measurement device was clear. | N/A | 4 (4-4) | — |
Q6. Letting patients measure their FEV1 at home is innovative. | 4 (4-5) | N/A | — |
Q7. Patients should be able to measure their FEV1 at home for a long period of time. | 4 (4-5) | N/A | — |
Q8. Home monitoring of FEV1 is a good addition to patients’ daily asthma care. | 4 (4-5) | 4 (4-5) | .77 |
Q9. The graphical presentation of the FEV1 measurements is useful. | N/A | 4 (4-5) | — |
Q10. The FEV1 measurements will provide me with more insights into my patients’ disease. | 4 (4-4.5) | 4 (4-4) | .48 |
Q11. I only want patients to measure their FEV1 when they experience symptoms. | 2 (2-3) | 2 (2-2.75) | >.99 |
Q12. Possible deteriorations will be detected earlier thanks to the home measurements. | 4 (4-4.5) | 4 (4-4.75) | .74 |
Q13. If technical problems arise with the measurements, I know whom to contact. | 4 (3.5-4) | 4 (3.25-4.75) | .48 |
Q14. The FEV1 measurements will pose an additional time burden for me. | 3 (3-4) | 3 (2-3) | .02d |
Q15. I only want to know the FEV1 measurements when they are lower than expected. | 4 (2.5-4) | 4 (2.25-4) | .41 |
Q16. Patients themselves should be responsible about how often they measure their FEV1. | 3 (2-3.5) | 3.5 (3-4) | .84 |
Q17. If FEV1 measurements are lower than expected, a short symptom survey will provide sufficient information for me. | 3 (3-4) | 4 (3.25-4) | .10 |
Q18. Patients should receive reminders in the online asthma clinic to measure their FEV1. | 4 (3-4) | 4 (2.25-4) | .10 |
Q19. I know which patients are eligible for home monitoring of FEV1. | 4 (4-4) | 4 (3.25-4.75) | .32 |
aResponses were collected on a 5-point Likert scale, where 1=strongly disagree; 2=disagree; 3=neutral; 4=agree; 5=strongly agree.
bFEV1: forced expiratory volume in 1 second.
cN/A: not applicable.
dStatistically significant change between survey outcomes at end and start.
Patients were interested in knowing all of their measured FEV1 values. By contrast, HCPs at both start and study end were more interested in only knowing their patients’ FEV1 outcomes when they were lower than expected (
More insights into my/my child’s asthma
Improved asthma control
Less frequent hospital visits
Always being able to know how I am/my child is doing
It helps me with my/my child’s disease perception
More insights into my/my child’s lung function
Facilitates easy and quick adjustment of treatment
Signaling of low lung function
Wrong values when the measurement is performed incorrectly
The device does not always work
It is easy to lose the device
It is easy to forget to perform measurements
The FEV1 device is less reliable than the device in the hospital
Performing the FEV1 measurements is time consuming
The mouthpiece is too large for small children
Reminders should be sent to perform an FEV1 measurement
The FEV1 device should be easier to use
Instructions on how to clean the device
Smaller mouthpiece for smaller children
Provision of objective measures of asthma control
Aids patients with disease perception
Continuity of monitoring
Earlier recognition of pulmonary exacerbations
Taking a simple and quick lung function test is possible when needed
Facilitates easy and quick adjustment of treatment
More stress for both patients and caregivers
More emphasis on patients’ asthma
FEV1 measurements might be performed incorrectly which can falsely comfort or alarm patients
Compulsive FEV1 testing and less attention for perceived symptoms
Decreased motivation when FEV1 remains low while symptoms are barely present
Time consuming for both patients and health care professionals
Technological difficulties of FEV1 devices
Good instructions at baseline
FEV1 devices should be calibrated at every outpatient visit
FEV1 home measurements should be used as a means to aid patients in achieving their individual goals. FEV1 home measurements should not be a goal on their own
Better instructions for patients on what to do when their FEV1 is lower than expected
Less notifications for health care professionals during pulmonary exacerbations
A notification when patients are back in their green zone
Protective case for a fragile FEV1 device
Our findings show that both patients/their parents and HCPs are receptive toward online FEV1 telemonitoring in pediatric asthma care. The participants in this study agreed that FEV1 telemonitoring in pediatric asthma care is innovative and improves asthma care, self-management, and disease perception. Most of the expectations patients and HCPs had about FEV1 telemonitoring matched their experiences. Initially, HCPs had concerns regarding the additional time burden and increased stress and insecurities of patients. However, HCPs’ experienced time burden was eventually lower than expected and increased stress and insecurities of patients were not reflected in the patients’ own experiences.
In our self-paced monitoring protocol, 69% (18/26) of patients used their FEV1 device regularly, which affirms survey-reported receptiveness of patients. However, the large interindividual range in the frequency of use between patients emphasizes the different approaches of individuals. Only 11.6% (49/421) of measurements were in the “red zone.” The vast majority of measurements required no intervention or could be resolved with automatic feedback prompts using patients’ personalized online asthma action plans.
To our knowledge, this is the first study on patients’ and HCPs’ receptiveness of FEV1 home monitoring combined with an online eHealth platform in pediatric asthma care. The existing body of literature often reports acceptance of FEV1 home monitoring, but it is rarely quantified [
How patients achieve personal benefits should be a result of shared decision making between patients and their HCPs. We now know that standalone FEV1 monitoring with strict monitoring regimes in most patients does not work out [
Recurring concerns of FEV1 telemonitoring are toward the reliability of the measurements. These were also present in our population and are generally shared among the scientific community [
This study was limited by its small study population and short study duration, which were chosen due to the nature of this viewpoint study. Only including patients and HCPs from specialized asthma clinics who also had experience using our eHealth platform would have introduced selection bias. In our opinion this does not invalidate our findings; by selecting patients and HCPs who already have experience with the eHealth platform we avoid confounding of our qualitative outcomes by the introduction of the eHealth platform. We also still observed a large interindividual variation in FEV1 device usage. Finally we believe that home monitoring strategies like this will be reliant on some form of selection bias as they should primarily be applied in patients that are receptive. This might imply that our results are not extrapolatable to settings without previous eHealth experience, general practitioner services, or to low-resource settings. Furthermore, we performed no post measurement quality control of the FEV1 measurements, which may have led to technically incorrect measurements being recorded. However, the software of the FEV1 device performs a quality check based on the American Thoracic Society (ATS)/European Respiratory Society (ERS) consensus statement [
Our findings show that patients and HCPs are receptive toward online FEV1 home monitoring combined with an online eHealth platform. Frequency of measurements varies largely among individuals, yet perceived benefits remain similar. This emphasizes that online FEV1 home monitoring strategies should be used as a means to reach individual goals, rather than being a goal on their own. During the COVID-19 pandemic we have seen eHealth being integrated more into daily medical practice and this will undoubtedly increase even more in the near future. With this increasing use of eHealth, we will see an equal surge of different ways to monitor our patients. In this data tangle it is easy to lose sight of what really matters: patient quality of life and needs. If we want to continuously monitor our patients, we should not only study the clinical relevance, but also the experienced benefits, invasiveness, and perceptions of our patients, while keeping in mind that one size does not fit all. Even after implementation we should repeatedly monitor patient satisfaction. eHealth is a dynamic entity and strongly bound to technologic advances. Patients should have a say in how these advances will be utilized and in which way they add value to their lives. HCPs have to remember that the goal should not be to gather outcomes, but to use these outcomes to reach personal goals in a personalized way.
Asthma Control Test
American Thoracic Society
(Childhood) Asthma Control Test
European Respiratory Society
forced expiratory flow
forced expiratory volume in 1 second
forced vital capacity
Global Initiative for Asthma
health care professional
pulmonary exacerbation
This study was funded by the Dutch Healthcare Insurers Innovation Foundation (project number 3.712)
None declared.