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Utilizing Telemedicine as a Tool to Enhance Outcomes in Individuals...
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Utilizing Telemedicine as a Tool to Enhance Outcomes in Individuals with Chronic Respiratory Diseases

A special issue of Life (ISSN 2075-1729). This special issue belongs to the section "Medical Research".

Deadline for manuscript submissions: closed (15 October 2021) | Viewed by 38807

Special Issue Editors

Prof. Dr. Claudio F. Donner

E-Mail Website
Guest Editor
Mondo Medico di I.F.I.M. srl, Multidisciplinary and Rehabilitation Outpatient Clinic, Borgomanero, 28100 Novara, Italy
Interests: pulmonary rehabilitation; airway obstruction; heart; lung; lung diseases; ventilation; pulmonary medicine; asthma; cost-effectiveness analysis
Prof. Dr. Linda Nici

E-Mail Website
Guest Editor
The Alpert Medical School, Brown University, Providence, RI 02912, USA
Interests: pulmonary rehabilitation; COPD; complications; interventions
Prof. Dr. Richard Zuwallack

E-Mail Website
Guest Editor
Pulmonary and Critical Care, St Francis Hospital and Medical Center, Hartford, CT 06105, USA
University of CT School of Medicine, Farmington, CT 06105, USA
Interests: pulmonary medicine; COPD; pulmonary rehabilitation

Special Issue Information

Dear Colleagues,

The world’s population is ageing; according to a United Nations report in 2019, 1 in 6 individuals is over the age of 65, which is an increase from 1 in 11 in 2019. This percentage is even higher in developed countries. Along with advancing age comes chronic medical conditions that must be addressed by health care systems, not only to increase quantity of life, but also to enhance quality of life. This is especially pertinent to individuals with chronic respiratory diseases, such as chronic obstructive pulmonary disease (COPD), bronchiectasis, chronic asthma, and interstitial lung disease. Individuals with these respiratory problems often have prominent daily symptom burdens, functional limitations, common co-morbid conditions, and frequent exacerbations of their respiratory disease or co-morbid conditions. The increased burden of increased morbidity, such as chronic respiratory disease, in the ageing population will undoubtedly burden healthcare systems even further; therefore, this calls for innovative approaches in order to achieve optimal medical care. Directing scarce resource allocation from an acute care model to a chronic care model of disease management will help in this regard. One such approach under a chronic care model is telemedicine. Telemedicine, which promotes interactions between patients and their families and healthcare providers, may enhance outcomes, while at the same time be more cost efficient. Examples of potential enhanced outcomes include: the provision of health care to patients who might not otherwise have access, such as those living in rural areas or those without transportation to clinics; better monitoring of disease state dynamics, such as vital signs, oxygen saturation, and weight in unstable patients with multiple morbidities such as COPD and heart failure; promoting better adherence to treatment algorithms through ongoing education; and early detection allowing for early (and more efficient) treatment of exacerbations. This paper summarizes the state of the science in telemedicine for chronic respiratory disease, supplemented by the expertise of authors experienced in the management of chronic respiratory disease.

Prof. Dr. Claudio F. Donner
Prof. Dr. Linda Nici
Dr. Richard Zuwallack
Guest Editors

Manuscript Submission Information

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Submitted manuscripts should not have been published previously, nor be under consideration for publication elsewhere (except conference proceedings papers). All manuscripts are thoroughly refereed through a single-blind peer-review process. A guide for authors and other relevant information for submission of manuscripts is available on the Instructions for Authors page. Life is an international peer-reviewed open access monthly journal published by MDPI.

Please visit the Instructions for Authors page before submitting a manuscript. The Article Processing Charge (APC) for publication in this open access journal is 2600 CHF (Swiss Francs). Submitted papers should be well formatted and use good English. Authors may use MDPI's English editing service prior to publication or during author revisions.

Keywords

  • telemedicine
  • telehealth
  • telerehabilitation
  • integrated care
  • chronic respiratory diseases

Published Papers (12 papers)

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Research

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7 pages, 229 KiB  
Communication
Telemedicine as a Means to an End, Not an End in Itself
by Michele Vitacca and Simonetta Scalvini
Life 2022, 12(1), 122; https://doi.org/10.3390/life12010122 - 15 Jan 2022
Cited by 2 | Viewed by 2041
Abstract
Telemedicine (TM)—the management of disease at a distance—has potential usefulness for patients with advanced respiratory disease. Underscoring this potential is the dramatic expansion of its applications in clinical medicine. However, since clinical studies testing this intervention often provide heterogeneous results, its role in [...] Read more.
Telemedicine (TM)—the management of disease at a distance—has potential usefulness for patients with advanced respiratory disease. Underscoring this potential is the dramatic expansion of its applications in clinical medicine. However, since clinical studies testing this intervention often provide heterogeneous results, its role in the medical management of respiratory disorders remains inconclusive. A major problem in establishing TM’s effectiveness is that it is not a single intervention; rather, it includes a number of divergent diagnostic and therapeutic modalities—and each must be tested separately. Reflecting the discord between the need for further documentation of its approaches and effectiveness and its rapid utilization without this needed information, a major challenge is the lack of international guidelines for its integration, regulation, operational plans, and guidance for professionals. Tailored TM, with increased flexibility to address differing healthcare contexts, has the potential to improve access to and quality of services while reducing costs and direct input by health professionals. We should view TM as a tool to aid healthcare professionals in managing their patients with respiratory diseases rather than as a stand-alone substitute to traditional medical care. As such, TM is a means rather than an end. Full article
(This article belongs to the Special Issue Utilizing Telemedicine as a Tool to Enhance Outcomes in Individuals with Chronic Respiratory Diseases)

Review

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12 pages, 780 KiB  
Review
eHealth in Self-Managing at a Distance Patients with COPD
by Sophie B. Kermelly and Jean Bourbeau
Life 2022, 12(6), 773; https://doi.org/10.3390/life12060773 - 24 May 2022
Cited by 5 | Viewed by 2381
Abstract
Worldwide, healthcare delivery for chronic diseases has been challenging due to the current SARS-COV-2 pandemic. The growing use of information and communication technologies via telehealth has gained popularity in all fields of medicine. In chronic respiratory diseases, self-management, defined as a structured but [...] Read more.
Worldwide, healthcare delivery for chronic diseases has been challenging due to the current SARS-COV-2 pandemic. The growing use of information and communication technologies via telehealth has gained popularity in all fields of medicine. In chronic respiratory diseases, self-management, defined as a structured but personalized multi-component intervention with the main goal of achieving healthy behavioral change, is an essential element of long-term care. Iterative interventions delivered by a well-trained health coach in order to empower and provide the patient with the tools and skills needed to adopt sustained healthy behaviors have proven to be effective in chronic obstructive pulmonary disease (COPD). Benefits have been shown to both improve patient quality of life and reduce acute exacerbation events and acute healthcare utilization. In COPD, the evidence so far has shown us that remote technologies such as telemonitoring or remote management may improve patient-reported outcomes and healthcare utilization. However, clear limitations are still present and questions remain unanswered. More and better designed studies are therefore necessary to define the place of eHealth in self-managing at a distance in patients with COPD. Full article
(This article belongs to the Special Issue Utilizing Telemedicine as a Tool to Enhance Outcomes in Individuals with Chronic Respiratory Diseases)
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9 pages, 3272 KiB  
Review
Remote Monitoring for Prediction and Management of Acute Exacerbations in Chronic Obstructive Pulmonary Disease (AECOPD)
by Jean-Louis Pépin, Bruno Degano, Renaud Tamisier and Damien Viglino
Life 2022, 12(4), 499; https://doi.org/10.3390/life12040499 - 29 Mar 2022
Cited by 11 | Viewed by 4204
Abstract
The progression of chronic obstructive pulmonary disease (COPD) is characterized by episodes of acute exacerbation (AECOPD) of symptoms, decline in respiratory function, and reduction in quality-of-life increasing morbi-mortality and often requiring hospitalization. Exacerbations can be triggered by environmental exposures, changes in lifestyle, and/or [...] Read more.
The progression of chronic obstructive pulmonary disease (COPD) is characterized by episodes of acute exacerbation (AECOPD) of symptoms, decline in respiratory function, and reduction in quality-of-life increasing morbi-mortality and often requiring hospitalization. Exacerbations can be triggered by environmental exposures, changes in lifestyle, and/or physiological and psychological factors to greater or lesser extents depending on the individual’s COPD phenotype. The prediction and early detection of an exacerbation might allow patients and physicians to better manage the acute phase. We summarize the recent scientific data on remote telemonitoring (TM) for the prediction and management of acute exacerbations in COPD patients. We discuss the components of remote monitoring platforms, including the integration of environmental monitoring data; patient reported outcomes collected via interactive Smartphone apps, with data from wearable devices that monitor physical activity, heart rate, etc.; and data from medical devices such as connected non-invasive ventilators. We consider how telemonitoring and the deluge of data it potentially generates could be combined with electronic health records to provide personalized care and multi-disease management for COPD patients. Full article
(This article belongs to the Special Issue Utilizing Telemedicine as a Tool to Enhance Outcomes in Individuals with Chronic Respiratory Diseases)
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12 pages, 285 KiB  
Review
Does Telemedicine Promote Physical Activity?
by Carolyn L. Rochester
Life 2022, 12(3), 425; https://doi.org/10.3390/life12030425 - 15 Mar 2022
Cited by 1 | Viewed by 2425
Abstract
Exercise capacity and physical activity are different concepts: the former refers to what an individual is capable of performing, while the latter refers to what the individual does in daily life. Low levels of physical activity (PA), which are very common in individuals [...] Read more.
Exercise capacity and physical activity are different concepts: the former refers to what an individual is capable of performing, while the latter refers to what the individual does in daily life. Low levels of physical activity (PA), which are very common in individuals with COPD, are associated with poor health outcomes, including increased symptoms, a more rapid decline in lung function, increased health care utilization and increased mortality risk. Because of these pervasive negative outcomes, attempts have been made to increase physical activity in individuals with COPD, hoping that success in this area will mitigate the negative effects of inactivity. Based on its ability to increase exercise capacity and reduce dyspnea in COPD and other chronic respiratory diseases, pulmonary rehabilitation (PR) would be expected also increase physical activity in these patients. However, accessibility to pulmonary rehabilitation programs is problematic in some areas, and studies testing its effectiveness in this outcome area have had inconsistent results. Using telehealth interventions using technology to provide medical care conveniently over a distance would have the benefit of reaching a larger proportion of individuals with COPD. A systematic review of clinical trials testing telehealth to promote physical activity had mixed results and low-certainty evidence, resulting in the inability to recommend any single type of intervention. Thus, using telehealth interventions to promote physical activity for individuals with chronic respiratory diseases, while promising, remains an area where future investigations are needed to identify its optimal modalities and clarify its benefits. Full article
(This article belongs to the Special Issue Utilizing Telemedicine as a Tool to Enhance Outcomes in Individuals with Chronic Respiratory Diseases)
12 pages, 251 KiB  
Review
Promoting Exercise Training Remotely
by Stephanie A. Robinson and Marilyn L. Moy
Life 2022, 12(2), 262; https://doi.org/10.3390/life12020262 - 9 Feb 2022
Cited by 3 | Viewed by 2365
Abstract
There has been increased incentivization to develop remote exercise training programs for those living with chronic respiratory diseases, such as chronic obstructive pulmonary disease (COPD). Remote programs offer patients an opportunity to overcome barriers to accessing traditional in-person programs, such as pulmonary rehabilitation [...] Read more.
There has been increased incentivization to develop remote exercise training programs for those living with chronic respiratory diseases, such as chronic obstructive pulmonary disease (COPD). Remote programs offer patients an opportunity to overcome barriers to accessing traditional in-person programs, such as pulmonary rehabilitation (PR). Methods to deliver exercise training remotely range in complexity and types of technological modalities, including phone calls, real-time video conferencing, web- and app-based platforms, video games, and virtual reality (VR). There are a number of studies demonstrating the effectiveness of these programs on exercise capacity, dyspnea, and health-related quality of life (HRQL). However, there is great variation in these programs, making it difficult to assess findings across studies. Other aspects that contribute to the effectiveness of these programs include stakeholder perceptions, such as motivation and willingness to engage, and adherence. Finally, while the intent of these remote programs is to overcome barriers to access, they may inadvertently exacerbate access disparities. Future program development efforts should focus on standardizing how remote exercise training is delivered, engaging stakeholders early on to develop patient-centered programs that patients will want to use, and understanding the heterogeneous preferences and needs of those living with chronic respiratory disease in order to facilitate engagement with these programs. Full article
(This article belongs to the Special Issue Utilizing Telemedicine as a Tool to Enhance Outcomes in Individuals with Chronic Respiratory Diseases)
16 pages, 269 KiB  
Review
Using Telemedicine to Provide Education for the Symptomatic Patient with Chronic Respiratory Disease
by Felicity C. Blackstock and Nicola J. Roberts
Life 2021, 11(12), 1317; https://doi.org/10.3390/life11121317 - 29 Nov 2021
Cited by 6 | Viewed by 2622
Abstract
Technology-enabled learning, using computers, smartphones, and tablets, to educate patients on their respiratory disease and management has grown over the last decade. This shift has been accelerated by the global COVID-19 pandemic and the need to socially distance for public health. Thirteen recently [...] Read more.
Technology-enabled learning, using computers, smartphones, and tablets, to educate patients on their respiratory disease and management has grown over the last decade. This shift has been accelerated by the global COVID-19 pandemic and the need to socially distance for public health. Thirteen recently published papers examined experience, knowledge, skills and attitude acquisition, behaviour change, and impact on health outcomes of patient education using technology (websites and mobile device applications) for people with chronic respiratory disease. Technology-enabled patient education that includes relevant information, with activities that encourage the patient to interact with the digital platform, appears to lead to better patient experience and may increase learning and behaviour change with improved quality of life. Developing online relationships with healthcare providers, lower digital capabilities, and poor access to a computer/smartphone/tablet, appear to be barriers that need to be overcome for equity in access. Maintaining the principles of quality educational design, ensuring interactive experiences for patient involvement in the educational activities, patient co-design, healthcare professionals connecting with experts in the field of technology-enabled learning for development of education models, and ongoing research lead to the best patient outcomes in technology-enabled education for respiratory disease. Full article
(This article belongs to the Special Issue Utilizing Telemedicine as a Tool to Enhance Outcomes in Individuals with Chronic Respiratory Diseases)
11 pages, 385 KiB  
Review
Will Remotely Based Pulmonary Rehabilitation Water Down Its Effectiveness?
by Himanshu Rawal, Sharon D. Cornelison, Sheryl M. Flynn and Jill A. Ohar
Life 2021, 11(11), 1270; https://doi.org/10.3390/life11111270 - 20 Nov 2021
Cited by 2 | Viewed by 2893
Abstract
Despite numerous benefits, traditional Pulmonary Rehabilitation (PR) as a resource remains underutilized in chronic lung disease. Less than 3% of eligible candidates for PR attend one or more sessions after hospitalization due to many barriers, including the ongoing COVID-19 pandemic. Emerging alternative models [...] Read more.
Despite numerous benefits, traditional Pulmonary Rehabilitation (PR) as a resource remains underutilized in chronic lung disease. Less than 3% of eligible candidates for PR attend one or more sessions after hospitalization due to many barriers, including the ongoing COVID-19 pandemic. Emerging alternative models of PR delivery such as home-based PR, tele-rehabilitation, web-based PR, or hybrid models could help address these barriers. Numerous studies have tested the feasibility, safety, and efficacy of these methods, but there is wide variability across studies and methods. We conducted a literature review to help determine if these alternative delivery methods watered down the effectiveness of PR. To evaluate the effectiveness of remotely based PR, the authors performed a literature search for randomized controlled trials (RCTs), cohort studies, and case series using PubMed, CINAHL, and Medline to identify relevant articles through 1 May 2021. Twenty-six applicable studies were found in which 11 compared tele-rehabilitation to conventional clinic-based PR; 11 evaluated tele-rehabilitation using the patient’s baseline status as control; and four compared tele-rehabilitation to no rehabilitation. Despite the different technologies used across studies, tele-rehabilitation was found to be both a feasible and an efficacious option for select patients with lung disease. Outcomes across these studies demonstrated similar benefits to traditional PR programs. Thus the existing data does not show that remotely based PR waters down the effectiveness of conventional PR. Use of remotely based PR is a feasible and effective option to deliver PR, especially for patients with significant barriers to conventional clinic-based PR. Additional, well-conducted RCTs are needed to answer the questions regarding its efficacy, safety, cost-effectiveness and who, among patients with COPD and other lung diseases, will derive the maximum benefit. Full article
(This article belongs to the Special Issue Utilizing Telemedicine as a Tool to Enhance Outcomes in Individuals with Chronic Respiratory Diseases)
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11 pages, 1577 KiB  
Review
The Need for Expanding Pulmonary Rehabilitation Services
by Aroub Lahham and Anne E. Holland
Life 2021, 11(11), 1236; https://doi.org/10.3390/life11111236 - 15 Nov 2021
Cited by 20 | Viewed by 6100
Abstract
Pulmonary rehabilitation is a strongly recommended and effective treatment for people with chronic lung disease. However, access to pulmonary rehabilitation is poor. Globally, pulmonary rehabilitation is accessed by less than 3% of people with chronic lung disease. Barriers to referral, uptake and completion [...] Read more.
Pulmonary rehabilitation is a strongly recommended and effective treatment for people with chronic lung disease. However, access to pulmonary rehabilitation is poor. Globally, pulmonary rehabilitation is accessed by less than 3% of people with chronic lung disease. Barriers to referral, uptake and completion of pulmonary rehabilitation are well documented and linked with organizational, practitioner and patient-related factors. Enhancing the knowledge of health care professionals, family carers, and people with chronic lung disease about the program and its benefits produces modest increases in referral and uptake rates, but evidence of the sustainability of such approaches is limited. Additionally, initiatives focusing on addressing organizational barriers to access, such as expanding services and implementing alternative models to the conventional center-based setting, are not yet widely used in clinical practice. The COVID-19 pandemic has highlighted the urgent need for health care systems to deliver pulmonary rehabilitation programs remotely, safely, and efficiently. This paper will discuss the pressing need to address the issue of the low accessibility of pulmonary rehabilitation. It will also highlight the distinctive challenges to pulmonary rehabilitation delivery in rural and remote regions, as well as low-income countries. Full article
(This article belongs to the Special Issue Utilizing Telemedicine as a Tool to Enhance Outcomes in Individuals with Chronic Respiratory Diseases)
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21 pages, 1359 KiB  
Review
Effectiveness of Telemonitoring for Respiratory and Systemic Symptoms of Asthma and COPD: A Narrative Review
by Esther Metting, Lizayra Dassen, Jiska Aardoom, Anke Versluis and Niels Chavannes
Life 2021, 11(11), 1215; https://doi.org/10.3390/life11111215 - 10 Nov 2021
Cited by 9 | Viewed by 4890
Abstract
Asthma and chronic obstructive pulmonary diseases (COPD) are highly prevalent chronic lung diseases that require ongoing self-management, which itself is often suboptimal. Therefore, telemonitoring has been used to help patients measure their symptoms, share data with healthcare providers and receive education and feedback [...] Read more.
Asthma and chronic obstructive pulmonary diseases (COPD) are highly prevalent chronic lung diseases that require ongoing self-management, which itself is often suboptimal. Therefore, telemonitoring has been used to help patients measure their symptoms, share data with healthcare providers and receive education and feedback to improve disease management. In this study, we conducted a narrative review of recent evidence on the effectiveness of telemonitoring for asthma and COPD in adults. Of the thirteen identified studies, eleven focused on COPD and two focused on asthma. All studies were reviewed, and effects were compared between intervention and care as usual groups. Of the study interventions, seven showed a positive outcome on at least one outcome measure, and six had no significant results on any of the outcome measures. All of the interventions with a positive outcome included an educational component, while only one of the six interventions without positive outcomes included an educational component. We conclude that telemonitoring interventions for asthma and COPD seem more effective if they included an educational component regarding different aspects of self-management. Full article
(This article belongs to the Special Issue Utilizing Telemedicine as a Tool to Enhance Outcomes in Individuals with Chronic Respiratory Diseases)
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11 pages, 2308 KiB  
Review
Telemedicine and Remote Monitoring as an Adjunct to Medical Management of Bronchiectasis
by Soontharee Congrete and Mark L. Metersky
Life 2021, 11(11), 1196; https://doi.org/10.3390/life11111196 - 6 Nov 2021
Cited by 6 | Viewed by 2139
Abstract
The limited resources and the practice of social distancing during the COVID pandemic create a paradigm shift in the utilization of telemedicine in healthcare. However, the implementation of best practices is hampered in part by a lack of literature devoted to telehealth in [...] Read more.
The limited resources and the practice of social distancing during the COVID pandemic create a paradigm shift in the utilization of telemedicine in healthcare. However, the implementation of best practices is hampered in part by a lack of literature devoted to telehealth in bronchiectasis. In this commentary, we examine multiple approaches to structuring of telemedicine care for patients with bronchiectasis, highlight current evidence-based interventions that can be incorporated into the management of bronchiectasis, and describe our experience with telemedicine at the University of Connecticut Center for Bronchiectasis Care during the COVID-19 pandemic. The structural model must be adapted to different local dynamics and available technologies with careful attention to patient characteristics and access to technology to avoid the potential paradoxical effects of increasing patients’ burden and healthcare disparities in underserved populations. Full article
(This article belongs to the Special Issue Utilizing Telemedicine as a Tool to Enhance Outcomes in Individuals with Chronic Respiratory Diseases)
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12 pages, 282 KiB  
Review
Using Telemedicine to Monitor the Patient with Chronic Respiratory Failure
by Nicolino Ambrosino and Paola Pierucci
Life 2021, 11(11), 1113; https://doi.org/10.3390/life11111113 - 20 Oct 2021
Cited by 9 | Viewed by 3010
Abstract
Background: Advances in management have improved mortality of individuals with chronic respiratory failure (CRF), leading to an increase in need for long-term oxygen therapy and/or ventilatory support. These individuals require frequent visits and monitoring of their physiological parameters as well as of [...] Read more.
Background: Advances in management have improved mortality of individuals with chronic respiratory failure (CRF), leading to an increase in need for long-term oxygen therapy and/or ventilatory support. These individuals require frequent visits and monitoring of their physiological parameters as well as of the functioning of their devices, such as ventilators or oxygen concentrators. Telemedicine is a clinical application of Information Communication Technology connecting patients to specialised care consultants. This narrative review aims to explore the current available telemonitoring options for individuals with CRF and reported or potential results. Methods: The research focused on EMBASE, CINALH, PubMed, and Scopus databases. Papers published between 2003 and 2021 in English were considered. Results: Different sensors, transmission devices and systems, and interventions are used with promising but not conclusive clinical results. However, legal problems are still unsolved, and economic advantages for health care systems, although potentially high, are still under debate. Conclusions: Telemonitoring systems for individuals with CRF are increasingly used; with promising results still to be clarified, legal, economical and organisational issues must be defined. Full article
(This article belongs to the Special Issue Utilizing Telemedicine as a Tool to Enhance Outcomes in Individuals with Chronic Respiratory Diseases)

Other

Jump to: Research, Review

11 pages, 254 KiB  
Perspective
Do Not Give Up Your Stethoscopes Yet—Telemedicine for Chronic Respiratory Diseases in the Era of COVID-19
by Stephen Simeone, Daniel Condit and Evan Nadler
Life 2022, 12(2), 222; https://doi.org/10.3390/life12020222 - 31 Jan 2022
Cited by 2 | Viewed by 2502
Abstract
Telemedicine in its many forms has been utilized across numerous medical specialties to facilitate and expand access to medical care, optimize existing healthcare infrastructure to encourage patient–provider communication, reduce provider burnout, and improve patient surveillance. Since the emergence of the novel coronavirus (COVID-19) [...] Read more.
Telemedicine in its many forms has been utilized across numerous medical specialties to facilitate and expand access to medical care, optimize existing healthcare infrastructure to encourage patient–provider communication, reduce provider burnout, and improve patient surveillance. Since the emergence of the novel coronavirus (COVID-19) pandemic there has been widening of existing socioeconomic disparities in healthcare access for those with chronic respiratory diseases, sparking interest in expanding the use of telemedicine modalities to enhance access to pulmonology specialist care, pulmonary rehabilitation, symptom monitoring, and early identification of clinical exacerbations. Furthermore, the use of telemedicine has been expanded into the intensive care setting to improve patient outcomes and offset provider demands following the increase in critically ill patients due to COVID-19. While an invaluable modality by which to broaden healthcare access and increase the efficacy of care delivery, telemedicine must be used in conjunction with face-to-face physical evaluation and appropriate clinical testing to optimize its benefit. We present here our view of the benefits and disadvantages of the use of telemedicine in the management of chronic respiratory disorders from the perspective of practicing clinicians. Full article
(This article belongs to the Special Issue Utilizing Telemedicine as a Tool to Enhance Outcomes in Individuals with Chronic Respiratory Diseases)
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