Respiratory Futures recently spoke to Stephanie Mansell, Consultant Physiotherapist & Doctoral Research Fellow at Royal Free London NHS Foundation Trust & University College London. Stephanie tells us about remote monitoring in NIV and CPAP, how it can benefit patients and the challenges of implementing it in practice.
What does remote monitoring in NIV and CPAP look like in practice?
The use of remote monitoring for home positive airways pressure (PAP) therapy (both CPAP and NIV) has increased in response to the COVID-19 pandemic. Historically, there had been reticence amongst UK practitioners to implement remote monitoring due to a need for more high-quality evidence on its clinical and cost effectiveness. However, as policies drive care into the community and we continue to expand our remote services to patients, remote monitoring is becoming increasingly essential to many healthcare providers. Remote monitoring can be defined differently from different perspectives(1). In the context of home PAP therapy, this often means a modem or Wi-Fi-connected device which sends data to a web-based platform for clinicians to access. Data available varies by device and manufacturer but can include PAP usage, mask leak, apnoea hypopnoea index (AHI) and PAP prescription. For some devices, therapy prescriptions can be remotely manipulated. Additionally, physiological parameters can also be included, in particular, SpO2 and heart rate. Some manufacturers also have patient-facing m-health applications, which can also be used to send data(1) remotely. These applications often provide support to patients in the form of education, problem-solving and motivational interviewing style techniques.
The use of such technology could empower patients with long-term conditions to self-manage their care, resulting in reduced costs.
Are there any eligibility criteria for receiving this care? Who is it most suitable for?
Access to remote monitoring is currently a postcode lottery with no defined criteria for who should receive access to this care. With Brexit and ongoing recalls and manufacturing and supply chain delays due to the COVID-19 pandemic, there has been a global shortage of PAP therapy devices. This has forced services to procure many devices, some of which do not have remote capabilities or patient-facing m-health applications. Clinicians should consider the importance of remote monitoring when undertaking procurement of devices.
There is evidence for using remote monitoring particularly in the neuromuscular population. Pinto et al. reported a reduced emergency room attendance and hospital admission rates in patients with Amyotrophic Lateral Sclerosis (ALS) when remote monitoring was in place(2). These authors also reported a reduced annualised cost per patient with remote monitoring(2). Ando et al. (3) combined remote ventilator data and patients-reported measures and reported that this combination ensured ventilation was optimised with physiological measures maintained despite disease progression.
For COPD patients there has been some suggestion in the literature that ventilator data could be used to predict an exacerbation(4). However, this data is preliminary, and it is likely that the reliability of data from NIV devices will be improved when combined with other physiological and patient-reported measures. Perhaps there is potential for artificial intelligence algorithms to improve the usefulness of this data in the future,
Anecdotally, many services use remote monitoring for those new to treatment or post-exacerbation in a bid to optimise the use of limited resources.
As a respiratory community, we should work collaboratively to increase the evidence base for remote monitoring to establish which patients it is most useful for.
What are some of the benefits that it could provide for patients? Does it have a notable impact on adherence and compliance?
There is evidence that mobile health (m-health) applications can improve concordance with CPAP therapy in the initial phase of commencing treatment, but the long term benefits remain unclear(5, 6). The use of such technology could empower patients with long-term conditions to self-manage their care, resulting in reduced costs (7).
Remote monitoring and the data it provides can assist clinicians to optimise PAP therapy with an associated increase in concordance(8). Qualitative data(9) has indicated that patients feel more confident in their care when remote monitoring is in place. Additionally, healthcare professionals have reported that remote monitoring is more efficient and increases time for patient-focused care(9). For services with a large geographical spread, remote monitoring can reduce hospital outpatient appointments and help to prioritise home visits. Remote monitoring can also be an exceptionally useful tool when problem-solving over the phone.
Are there any particular challenges in providing remote CPAP and NIV?
The ongoing challenge to providing remote monitoring for PAP therapy patients is the need for compelling evidence supporting the clinical and cost-effectiveness of this intervention. As a respiratory community, we should work collaboratively to increase the evidence base for remote monitoring to establish which patients it is most useful for. There are the additional challenges of ongoing procurement delays of PAP therapy devices. Still, clinicians should work with procurement teams to include remote monitoring capabilities and patient-facing m-health application availability as part of the criteria for procuring.
The platforms used for remote monitoring provide an inbuilt flag or alert system. Anecdotally, this can impact the efficiencies of remote monitoring if not tailored correctly to the individual patient and service. Clinicians should also be aware that remote monitoring can provide patients with a false sense of security. A careful narrative is required to ensure patients do not delay seeking help(9). Concerns have been expressed by healthcare professionals that remote monitoring could impact the patient-healthcare professional relationship via perceived invasion of privacy(9). This narrative is not reflected by patients, and their privacy concerns are minimal(9).
What impact could remote monitoring have on the respiratory workforce and health system capacity?
If remote monitoring and m-health applications are correctly deployed and personalised to individual patients and services, then remote monitoring could enhance the capacity to care for the ever-increasing number of patients eligible for home PAP therapies. Interpreting the data from remote monitoring is a particular skill, and there is a need for tailored education for the multi-disciplinary team working in the sleep and ventilation field to optimise the potential of remote monitoring. Furthermore, we must recognise that the digital literacy of patients could be a limitation of the accessibility of m-health applications for patients and work with organisations in the digital field to ensure equitable access to care. Remote monitoring has exciting potential to interact with other patient data and artificial intelligence to enhance care.
Top tips:
- Be transparent with patients about the level of service you provide, how you will use the remote monitoring data and how often you will check it so they have realistic expectations
- If using a modem, ensure it is connected and dialling correctly at the initiation appointment
- Consider the impact of Cellular Vs Wi-Fi modems and the impact on those with digital poverty or poor digital literacy
- Liaise with your information governance team early
- If you are using a system with flags/alerts, ensure you tailor the flags to your patients and service
References
- Ambrosino N, Vitacca M, Dreher M, Isetta V, Montserrat JM, Tonia T, et al. Tele-monitoring of ventilator-dependent patients: a European Respiratory Society Statement. European Respiratory Journal. 2016;48:648-63.
- Pinto A, Almeida JP, Pinto S, Pereira J, Oliveira AG, de Carvalho M. Home telemonitoring of non-invasive ventilation decreases healthcare utilisation in a prospective controlled trial of patients with amyotrophic lateral sclerosis. Journal of Neurology, Neurosurgery & Psychiatry. 2010;81(1):1238-42.
- Ando H, Ashcroft-Kelso H, Halhead R, Young CA, Chakrabarti B, Levene P, et al. Incorporating self-reported questions for telemonitoring to optimize care of patients with MND on noninvasive ventilation (MND OptNIVent). Amyotrophic Lateral Sclerosis and Frontotemporal Degeneration. 2019;20(5-6):336-47.
- Borel J-C, Pelletier J, Taleux N, Briault A, Arnol N, Pison C, et al. Parameters recorded by software of non-invasive ventilators predict COPD exacerbation: a proof-of-concept study. Thorax. 2015;70(3):284-5.
- Hwang D, Chang JW, Benjafield AV, Crocker ME, Kelly C, Becker KA, et al. Effect of telemedicine education and telemonitoring on continuous positive airway pressure adherence. The tele-OSA randomized trial. American journal of respiratory and critical care medicine. 2018;197(1):117-26.
- Aardoom JJ, Loheide-Niesmann L, Ossebaard HC, Riper H. Effectiveness of eHealth Interventions in Improving Treatment Adherence for Adults With Obstructive Sleep Apnea: Meta-Analytic Review. J Med Internet Res. 2020;22(2):e16972.
- Martínez SAJ, Porras MdPA, del Olmo Chiches M, Diez MIM. Use of Telemonitoring for CPAP Therapy Control in OSA Patients: Impact on Cost and Process Improvements. Open Respiratory Archives. 2023;5(4):100263.
- Mansell SK, Cutts S, Hackney I, Wood MJ, Hawksworth K, Creer DD, et al. Using domiciliary non-invasive ventilator data downloads to inform clinical decision-making to optimise ventilation delivery and patient compliance. BMJ open respiratory research. 2018;5(1):e000238.
- Mansell SK, Kilbride C, Wood MJ, Gowing F, Mandal S. Experiences and views of patients, carers and healthcare professionals on using modems in domiciliary non-invasive ventilation (NIV): a qualitative study. BMJ Open Respiratory Research. 2020;7(1):e000510.