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Telehealth spirometry for children with cystic fibrosis
  1. Karla Logie,
  2. Liam Welsh,
  3. Sarath C Ranganathan
  1. Respiratory Medicine, Royal Childrens Hospital Melbourne, Parkville, Victoria, Australia
  1. Correspondence to Dr Liam Welsh, Respiratory Medicine, Royal Children's Hospital Melbourne, Parkville, VIC 3052, Australia; liam.welsh{at}rch.org.au

Abstract

Aim We assessed the feasibility of telehealth spirometry assessments for children with cystic fibrosis (CF) living in a regional setting.

Method Patients with acceptable computer hardware at home were provided with a SpiroUSB (Vyaire) spirometer. Spirometry was performed during ‘home admissions’ or for ongoing home monitoring in children living outside metropolitan Melbourne. At the end of the session, the family forwarded the data to the Royal Children’s Hospital, Melbourne.

Results Twenty-two patients aged 7 to 17 years participated, with spirometry successful in 55 of 59 (93%) attempted sessions according to American Thoracic Society/European Respiratory Society criteria. The median distance between the subject’s home and the hospital was 238 km (range 62–537 km) which equated to a travel time saving of 5 hours and 34 min per hospital visit.

Conclusion Home-based telehealth spirometry is feasible in children with CF and can support the CF team during home-based admissions and for ongoing outpatient monitoring.

  • cystic fibrosis
  • monitoring
  • technology

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What is already known?

  • Patients with cystic fibrosis (CF) living in regional areas have worse clinical outcomes and warrant closer clinical surveillance. These children are likely to benefit from clinical assessments conducted via telehealth, with the added advantage of reducing exposure to hospital-acquired and person-to-person transmission of pathogens.

What this study adds?

  • Telehealth spirometry, a key objective outcome in CF care, is feasible in children with CF living in regional areas and has the potential to enable more frequent consultations. These assessments also have the added benefit of convenience and minimise infection risk.

Introduction

Telehealth enables patients living outside metropolitan centres to access specialist services remotely. Providing such services eliminates the time and expense associated with travel to major centres and prevents time away from work, school and family commitments. Recent research shows patients with cystic fibrosis (CF) living in regional areas have worse clinical outcomes and warrant closer clinical surveillance.1 2 These children are likely to benefit from clinical assessments conducted via telehealth, with the added advantage of reducing exposure to hospital-acquired and person-to-person transmission of pathogens. We assessed the feasibility of performing telehealth spirometry assessments in the child’s home under the supervision of a respiratory scientist.

Objectives

The primary objective of this study was to assess the feasibility of spirometry assessments using telehealth. Secondary aims were to assess if telehealth spirometry could support the CF team during ‘home admissions’ and for ongoing home monitoring in children living outside metropolitan Melbourne. Home admissions were defined as home-administered intravenous antibiotics.

Methodology

Children with CF living outside metropolitan Melbourne were invited to participate in the study for up to 3 months. To increase the likelihood of successful measurements, we approached children aged 7 years or older with previous spirometry experience. Home spirometry was performed as part of ongoing monitoring or during a home admission.

Families were required to have a Windows computer or tablet (version 7 or latest), with an internet connection, microphone, video camera and Google Chrome installed. Participating families were given a SpiroUSB spirometer (Vyaire, USA) and either a CD or web link to install the required software on their home computer (Spirometry PC Software). Spirometers were calibrated with a 3 L syringe using a standardised three-flow protocol prior to use. A step-by-step guide was provided to aid families with the installation process. These guides included instructions regarding saving data and reports, how to select the appropriate units of measurement and instructions for performing spirometry when the internet connection be lost during a telehealth session. Equipment was supplied and, where applicable, returned via registered post or in-person at the next hospital visit.

Prior to dispatch, the respiratory scientist completed their own biological testing on the telehealth and hospital-based devices. The telehealth device was only dispatched if results agreed to within 100 mL for forced expiratory volume in 1 s (FEV1). Importantly, no device failed to meet these requirements.

Once a family had received their spirometer and installed the software, a mutually convenient time for the family and respiratory scientist to conduct the telehealth session was arranged. A web-based video call platform called ‘HealthDirect’ (Health Direct Australia, Australia)3 was used to perform the session.

During the appointment, the family agreed to share their computer screen so that the subject and flow-volume trace were simultaneously visible to the respiratory scientist. Throughout the session, each effort was reviewed using American Thoracic Society/European Respiratory Society (ATS/ERS) criteria4 with real-time feedback provided to the patient by the respiratory scientist to ensure the best possible lung function outcome. The subject’s most recently recorded height at the CF centre (within the previous month) was used with spirometry data converted to z-scores using the Global Lung Initiative equations.5

The family were instructed on which effort to select, how to encrypt a PDF of the results and how to email the result to the respiratory scientist at the end of the session. The lung function data were relayed to the CF team, with a summary written in the child’s medical record and a screenshot of the flow-volume loop (figure 1). The data file was later uploaded to the Royal Children’s Hospital electronic database. A telehealth spirometry session was determined to be successful if acceptable flow-volume loops could be obtained and uploaded to the medical record. At the completion of sessions, families were invited to provide feedback about their telehealth experience.

Figure 1

Flow-volume loop screenshot.

Importantly, patients were not advised to monitor their lung function without supervision from the respiratory scientist. However, parents were advised to arrange an additional telehealth spirometry assessment if they noticed that their child was symptomatic or feeling unwell.

This study was granted approval from the Royal Children’s Hospital, Melbourne, Human Research Ethics Committee (ID: 55683).

Results

Twenty-six patients were approached with 25 agreeing to participate. The median age of participants was 10.0 years (range 7.0–17.0 years) and there were 12 males and 13 females. Three were unable to be assessed due to incompatible home PC set-up. Telehealth spirometry was successful according to ATS/ERS criteria in 55 of 59 (93%) attempted sessions in the remaining 22 subjects. Average assessment times were approximately 22 min (range 15–47 min). Participants were a mixture of stable and unwell patients. Telehealth was performed during eight home admissions by unwell patients. Eleven patients used home spirometry multiple times for ongoing monitoring (range 2–12 sessions). The median distance between the subject’s home and the hospital was 238 km (range 62 km–537 km). This distance equated to a median travel time saving of 2 hours and 47 min one-way (range 55 min to 5 hours and 44 min), or 5 hours and 34 min per hospital visit.

Two failed sessions occurred for the same patient due to inexplicable equipment failure. On both occasions, the flow-volume trace appeared delayed on the computer screen and then became unresponsive (ie, frozen screen). When the device was returned to the hospital, it behaved normally and passed calibration suggesting that the fault was due to human error or interference in the patient’s home. Equipment failure occurred with one further patient and was suspected to be due to rough conduct in the patient’s home.

Other difficulties during telehealth sessions included intermittent internet connections with resultant video and sound delays. Although these events increased the duration of the home-based consults, the difficulties did not prevent the eventual success of the sessions.

Results obtained from telehealth spirometry led to immediate clinical intervention in two patients and triggered hospital admissions. These two patients were both unexpectedly symptomatic at the time of their assessments with declines in FEV1 of 9% and 13% predicted, respectively. Telehealth allowed these deteriorations to be detected earlier than they otherwise would have been under standard care and triggered expedited admissions to hospital.

Conversely, telehealth results also supported earlier than expected discharge in two other patients on ‘home admissions’. Both of these patients showed greater than expected improvements in their FEV1 (10% and 14% predicted) which led to an earlier than anticipated cessation of home-administered intravenous antibiotics.

Family feedback included statements, such as: “It is great because it has meant fewer trips to Melbourne, which is a 3.5 hour drive each direction” and “It allows me to make an appointment with the team if I am concerned about my daughter’s lung function.”

Discussion

Our pilot study identified that telehealth spirometry, a key objective outcome in CF care, was feasible in a small group of children with CF living in regional areas. The proportion of successful assessments (93%) was similar to those achieved in a specialist centre. Home-based telehealth spirometry supported the CF team during ‘home admissions’ and for ongoing outpatient monitoring. Telehealth results also led to altered clinical management in a small number of patients and thereby highlighted the potential of the innovation.

Families were enthusiastic about telehealth spirometry as it prevented unnecessary time away from school and work and removed the expenses associated with attending the CF centre. Positive feedback from families included that the equipment was user-friendly, the convenience the service offered, and that results were immediately available to the CF team.

Barriers to successful telehealth spirometry were mostly technology related with incompatible operating systems, inconsistent internet connections or unsuitable home computers. Active involvement was required from parents and children when navigating the telehealth platform; however, the service was overwhelmingly popular and saved considerable travel time to the specialist CF centre.

We acknowledge that our patient population was relatively small and highly selected. However, as a result of these findings our centre now uses telehealth services frequently in the management of our regional patients with CF. This includes ‘virtual’ multidisciplinary clinics which are equivalent to conventional face-to-face clinics.

Telehealth spirometry is feasible for patients with living in regional areas and has the potential to enable more frequent consultations. These assessments also have the added benefit of convenience and minimise infection risk. Incorporating home-based spirometry into telehealth services is feasible and recommended.

Acknowledgments

The Royal Children’s Hospital and Melbourne Foundation provided funding to enable to this study.

References

Footnotes

  • Contributors All authors contributed equally to the preparation of this manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data are available on reasonable request.

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