Telehealth for children and adolescents with chronic pulmonary disease: systematic review

Faiçal, Adriana Virgínia Barros; Mota, Laís Ribeiro; Correia, Danilo d’ Afonseca; Monteiro, Larissa Prazeres; Souza, Edna Lúcia de; Terse-Ramos, Regina

doi:10.1590/1984-0462/2024/42/2022111

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Brasil

Revista Paulista de Pediatria

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Original Article • Rev. paul. pediatr. 42 • 2024 • https://doi.org/10.1590/1984-0462/2024/42/2022111 copy

Telehealth for children and adolescents with chronic pulmonary disease: systematic review

Telessaúde para crianças e adolescentes com doenças pulmonares crônicas: revisão sistemática

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Objective:

To revise the impact of telehealth on the quality of life, reduction in pulmonary exacerbations, number of days using antibiotics, adherence to treatment, pulmonary function, emergency visits, hospitalizations, and the nutritional status of individuals with asthma and cystic fibrosis.

Data source:

Four databases were used, MEDLINE, LILACS, Web of Science and Cochrane, as well as manual searches in English, Portuguese and Spanish. Randomized clinical trials, published between January 2010 and December 2020, with participants aged 0 to 20 years, were included.

Data synthesis:

Seventy-one records were identified after the removal of duplicates; however, twelve trials were eligible for synthesis. Included trials utilized: mobile phone applications (n=5), web platforms (n= 4), mobile telemedicine unit (n=1), software with an electronic record (n=1), remote spirometer (n=1), and active video games platform (n=1). Three trials used two tools, including telephone calls. Among the different types of interventions, improvement in adherence, quality of life, and physiologic variables were observed for mobile application interventions and game platforms compared to usual care. Visits to the emergency department, unscheduled medical appointments, and hospitalizations were not reduced. There was considerable heterogeneity among studies.

Conclusions:

The findings suggest that better control of symptoms, quality of life, and adherence to treatment can be attributed to the technological interventions used. Nevertheless, further research is needed to compare telehealth with face-to-face care and to indicate the most effective tools in the routine care of children with chronic lung diseases.

Keywords:
Telehealth; Asthma; Cystic fibrosis; Quality of life

Author	Randomization	Blinding	Patients (n)	Total	Range of score quality
Deschildre et al.¹⁸18. Deschildre A, Béghin L, Salleron J, Iliescu C, Thumerelle C, Santos C, et al. Home telemonitoring (forced expiratory volume in 1 s) in children with severe asthma does not reduce exacerbations. Eur Respir J. 2012;39:290-6. https://doi.org/10.1183/09031936.00185310 https://doi.org/10.1183/09031936.0018531...	0	0	1	1	Low
Bender et al.¹⁹19. Bender BG, Cvietusa PJ, Goodrich GK, Lowe R, Nuanes HA, Rand C, et al. Pragmatic trial of health care technologies to improve adherence to pediatric asthma treatment a randomized clinical trial. JAMA Pediatr. 2015;169:317-23. https://doi.org/10.1001/jamapediatrics.2014.3280 https://doi.org/10.1001/jamapediatrics.2...	0	0	1	1	Low
Montalbano et al.¹⁷17. Montalbano L, Ferrante G, Cilluffo G, Gentile M, Arrigo M, La Guardia D, et al. Targeting quality of life in asthmatic children: the MyTEP pilot randomized trial. Respir Med. 2019;153:14-9. https://doi.org/10.1016/j.rmed.2019.05.008 https://doi.org/10.1016/j.rmed.2019.05.0...	2	0	1	3	High
Stukus et al.²⁰20. Stukus DR, Farooqui N, Strothman K, Ryan K, Zhao S, Stevens JH, et al. Real-world evaluation of a mobile health application in children with asthma. Ann Allergy Asthma Immunol. 2018;120:395-400.e1. https://doi.org/10.1016/j.anai.2018.02.006 https://doi.org/10.1016/j.anai.2018.02.0...	0	0	1	1	Low
van den Wijngaart et al.²⁷27. van den Wijngaart LS, Roukema J, Boehmer AL, Brower ML, Hugen CA, Niers LE, et al. A virtual asthma clinic for children: fewer routine outpatient visits, same asthma control. Eur Respir J. 2017;50:1700471. https://doi.org/10.1183/13993003.00471-2017 https://doi.org/10.1183/13993003.00471-2...	2	0	1	3	High
Perry et al.²¹21. Perry TT, Halterman JS, Brown RH, Luo C, Randle SM, Hunter CR, et al. Results of an asthma education program delivered via telemedicine in rural schools. Ann Allergy Asthma Immunol. 2018;120:401-8. https://doi.org/10.1016/j.anai.2018.02.013 https://doi.org/10.1016/j.anai.2018.02.0...	0	0	1	1	Low
Halterman et al.²²22. Halterman JS, Fagnano M, Tajon RS, Tremblay P, Wang H, Butz A, et al. Effect of the school-based telemedicine enhanced asthma management (SB-TEAM) program on asthma morbidity: a randomized clinical trial. JAMA Pediatr. 2018;172:e174938. https://doi.org/10.1001/jamapediatrics.2017.4938 https://doi.org/10.1001/jamapediatrics.2...	2	1	1	4	High
Del Corral et al.¹⁶16. Del Corral T, Iranzo MA, López-De-Uralde-Villanueva I, Martínez-Alejos R, Blanco I, Vilaró J. Effectiveness of a home-based active video game programme in young cystic fibrosis patients. Respiration. 2018;95:87-97. https://doi.org/10.1159/000481264 https://doi.org/10.1159/000481264...	2	0	1	3	High
Kosse et al.²⁶26. Kosse RC, Bouvy ML, Belitser SV, Vries TW, van der Wal PS, Koster ES. Effective engagement of adolescent asthma patients with mobile health-supporting medication adherence. JMIR Mhealth Uhealth. 2019;7:e12411. https://doi.org/10.2196/12411 https://doi.org/10.2196/12411...	2	0	1	3	High
Stark et al.²³23. Stark LJ, Opipari-Arrigan L, Filigno SS, Simon SL, Leonard A, Mogayzel PJ, et al. Web-based intervention for nutritional management in cystic fibrosis: development, usability, and pilot trial. J Pediatr Psychol. 2016;41:510-21. https://doi.org/10.1093/jpepsy/jsv108 https://doi.org/10.1093/jpepsy/jsv108...	2	0	1	3	High
Gustafson et al.²⁴24. Gustafson D, Wise M, Bhattacharya A, Pulvermacher A, Shanovich K, Phillips B, et al. The effects of combining web-based eHealth with telephone nurse case management for pediatric asthma control: a randomized controlled trial. J Med Internet Res. 2012;14:e101. https://doi.org/10.2196/jmir.1964 https://doi.org/10.2196/jmir.1964...	2	2	1	5	High
Perry et al.²⁵25. Perry TT, Marshall A, Berlinski A, Rettiganti M, Brown RH, Randle SM, et al. Smartphone-based vs paper-based asthma action plans for adolescents. Ann Allergy Asthma Immunol. 2017;118:298-303. https://doi.org/10.1016/j.anai.2016.11.028 https://doi.org/10.1016/j.anai.2016.11.0...	0	0	1	1	Low

Author/design	Participants (n), age range (years), diagnosis	Intervention	Outcomes
Gustafson et al.²⁴24. Gustafson D, Wise M, Bhattacharya A, Pulvermacher A, Shanovich K, Phillips B, et al. The effects of combining web-based eHealth with telephone nurse case management for pediatric asthma control: a randomized controlled trial. J Med Internet Res. 2012;14:e101. https://doi.org/10.2196/jmir.1964 https://doi.org/10.2196/jmir.1964... /RCT	n=301 Parents or legal responsible who had children aged 4–12 years with asthma	CHESS+CM	SFD improved for the CHESS+CM group (OR 1.38; p=0.010) and less for the control group (OR 1.20; p=0.29). There were no between-group differences (OR 0.18; p=1.000). ACQ improved significantly for CHESS+CM and not significantly for the control group (OR -0.11; p=0.220).
Bender et al,¹⁹19. Bender BG, Cvietusa PJ, Goodrich GK, Lowe R, Nuanes HA, Rand C, et al. Pragmatic trial of health care technologies to improve adherence to pediatric asthma treatment a randomized clinical trial. JAMA Pediatr. 2015;169:317-23. https://doi.org/10.1001/jamapediatrics.2014.3280 https://doi.org/10.1001/jamapediatrics.2... /Pragmatic RCT	n=871 3–12 years old Asthma	Health Care Technologies	Adherence in the IG was 25.4% higher than that in the UC group. No between-group differences for hospitalizations, ED visits, and β2-agonist use.
Stark et al.²³23. Stark LJ, Opipari-Arrigan L, Filigno SS, Simon SL, Leonard A, Mogayzel PJ, et al. Web-based intervention for nutritional management in cystic fibrosis: development, usability, and pilot trial. J Pediatr Psychol. 2016;41:510-21. https://doi.org/10.1093/jpepsy/jsv108 https://doi.org/10.1093/jpepsy/jsv108... /Pilot randomized trial	n=20 Mothers of children with CF ages 4–9 years	Web intervention BIC	Children in BIC gained an average of 116% of expected daily weight and UC gained an average of 52% of the expected daily weight, and increased by 27% from their baseline EER.
Perry et al.²⁵25. Perry TT, Marshall A, Berlinski A, Rettiganti M, Brown RH, Randle SM, et al. Smartphone-based vs paper-based asthma action plans for adolescents. Ann Allergy Asthma Immunol. 2017;118:298-303. https://doi.org/10.1016/j.anai.2016.11.028 https://doi.org/10.1016/j.anai.2016.11.0... /Randomized pilot study	n=34 12–17 years old Asthma	Personalized smartphone-based AAP	There was change in ACT for the smartphone group (p=0 .040) but not for the paper group (p=0.640).
Halterman et al.²²22. Halterman JS, Fagnano M, Tajon RS, Tremblay P, Wang H, Butz A, et al. Effect of the school-based telemedicine enhanced asthma management (SB-TEAM) program on asthma morbidity: a randomized clinical trial. JAMA Pediatr. 2018;172:e174938. https://doi.org/10.1001/jamapediatrics.2017.4938 https://doi.org/10.1001/jamapediatrics.2... /RCT	n=400 3–10 years old Asthma	SB-TEAM	SB-TEAM group had more SFDs compared with eUC group (11.6 vs 10.97; difference, 0.69; 95%CI 0.15–1.22; p=0.010), fewer symptom nights, and days with limited activity. SB-TEAM group had fewer ED visits or hospitalizations (7 vs 15%; OR 0.52; 95%CI 0.32–0.84).
Perry et al.,²¹21. Perry TT, Halterman JS, Brown RH, Luo C, Randle SM, Hunter CR, et al. Results of an asthma education program delivered via telemedicine in rural schools. Ann Allergy Asthma Immunol. 2018;120:401-8. https://doi.org/10.1016/j.anai.2018.02.013 https://doi.org/10.1016/j.anai.2018.02.0... /Cluster RCT	n=393 7–14 years old Asthma	School-based telemedicine intervention	Family activity domain of the CHSA, improved for the UC group, but not the IG (p=0.020). The use of peak flow to monitor asthma was 45% UC group vs 79% IG p<0.0001, there was no change in AMR, PedsQL did not reach statistical significance (p=0.060)
Stukus et al.,²⁰20. Stukus DR, Farooqui N, Strothman K, Ryan K, Zhao S, Stevens JH, et al. Real-world evaluation of a mobile health application in children with asthma. Ann Allergy Asthma Immunol. 2018;120:395-400.e1. https://doi.org/10.1016/j.anai.2018.02.006 https://doi.org/10.1016/j.anai.2018.02.0... /Prospective RCT	n=200 6 months–21 years old Asthma	AC	AC participants had a 72% decrease in total number (29 vs 11; mean 0.3 vs 0.11; p=0.020) of UC visits; controls had no significant difference (25 vs 19; 0.26 vs 0.2; p=0.430). AC participants reported improvement in asthma management 6 months after study enrollment (79 vs 64%; p=0.060)

Author, country, design	Participants (n), age range (years), diagnosis	Intervention	Outcomes
Deschildre et al.,¹⁸18. Deschildre A, Béghin L, Salleron J, Iliescu C, Thumerelle C, Santos C, et al. Home telemonitoring (forced expiratory volume in 1 s) in children with severe asthma does not reduce exacerbations. Eur Respir J. 2012;39:290-6. https://doi.org/10.1183/09031936.00185310 https://doi.org/10.1183/09031936.0018531... France, prospective RCT	n=44 6–16 years, asthma	Daily home telemonitoring	PAQLQ scores within each of the two groups (median in the HM group was -0.3 (-4.2–1.1) (p=0.240) and in the CT group was -0.1 (-3.8–0.5) (p=0.150).
Del Corral et al.,¹⁶16. Del Corral T, Iranzo MA, López-De-Uralde-Villanueva I, Martínez-Alejos R, Blanco I, Vilaró J. Effectiveness of a home-based active video game programme in young cystic fibrosis patients. Respiration. 2018;95:87-97. https://doi.org/10.1159/000481264 https://doi.org/10.1159/000481264... Spain, single-blinded RCT	n=40 7–18 years, cystic fibrosis	Home-based AVG Programme	The change in scores showed significant differences for the 6MWT and MSWT compared to the CT. All muscle strength variables increased after the intervention, as did HRQoL.
Kosse et al.,²⁶26. Kosse RC, Bouvy ML, Belitser SV, Vries TW, van der Wal PS, Koster ES. Effective engagement of adolescent asthma patients with mobile health-supporting medication adherence. JMIR Mhealth Uhealth. 2019;7:e12411. https://doi.org/10.2196/12411 https://doi.org/10.2196/12411... Netherland, cluster RCT	n=261 12–18 years, asthma	ADAPT	Total app use was not associated with a difference in self-reported adherence (p=0.120). CARAT (p=0.260), adherence questions (p=0.650), short movies p=0.800) and peer chat (p=0.210). Logged activity in pharmacist chat positively affected self-reported adherence (p=0.030)
Montalbano et al.,¹⁷17. Montalbano L, Ferrante G, Cilluffo G, Gentile M, Arrigo M, La Guardia D, et al. Targeting quality of life in asthmatic children: the MyTEP pilot randomized trial. Respir Med. 2019;153:14-9. https://doi.org/10.1016/j.rmed.2019.05.008 https://doi.org/10.1016/j.rmed.2019.05.0... Italy, non-blinded RCT	n=50 6–11 years, asthma	MyTEP	PAQLQ score increased in both groups. Increase in C-ACT score was only found in MyTEP. No differences were found in the MARS-9 score. Lab spirometry and BD response (%) values were similar
van den Wijngaart et al.,²⁷27. van den Wijngaart LS, Roukema J, Boehmer AL, Brower ML, Hugen CA, Niers LE, et al. A virtual asthma clinic for children: fewer routine outpatient visits, same asthma control. Eur Respir J. 2017;50:1700471. https://doi.org/10.1183/13993003.00471-2017 https://doi.org/10.1183/13993003.00471-2... Netherland, Prospective multicenter unblinded RCT	n=210 6–16 years, asthma	VAC	Number of SFD, after 16 months, was in favor of the VAC compared with UC (difference of 1.23 days; 95%CI 0.42–2.04; p=0.003). For the C-ACT, there was a difference in the mean outcome of 1.17 points (95%CI 0.09–2.25; p=0.030) in favor of VAC. It was demonstrated at 16 months compared with UC, in children aged 6–11 years. In children aged 12–16 years, asthma control was similar after 16 months of follow-up, as the ACT score did not differ between both groups (0.88 points; 95%CI -0.41–2.16; p=0.180)

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[1] Corresponding author. E-mail: adriana.barros@ufba.br (A. V. B. Faiçal)

Population	Children, adolescents, and young adults (0–20 years old) with a clinical diagnosis of severe asthma or cystic fibrosis.
Population	We excluded individuals with greater impairment of lung function and associated heart disease
Intervention	Any telehealth intervention with any currently available device, such as a smartphone, tablet, smart TV, or computer.
Intervention	We did not include hybrid interventions
Comparator	Individuals who were not provided with or did not have access to telehealth and face-to-face healthcare
Outcomes	Health-related quality of life, adherence to treatment, pulmonary function, pulmonary disease exacerbation, hospitalization, nutritional status, emergency visit, antibiotic therapy uses
Settings	Any health care setting
Study design	Studies were included if they were randomized controlled trials (RCTs)
Date range	The date range for all searches was January 1, 2010, to December 31, 2020
Databases	MEDLINE, LILACS, Web of Science and Cochrane library