**5. Lung transplantation**

in an unattended surrounding, without continuous supervision. A technician hooks-up the device, and this factor limits the wide us of this technique [58]. Since the loss of data is still a big issue with type 2 or 3 devices, potential future developments include the use of assistive

To enhance the quality of H-PSG signal, real-time telematics data transmission has been tested generating successful and high-fidelity recordings through a cell phone for an easily deployed home monitor device [59], and a failure rate of 11% of telemonitored in-hospital unattended PSG compared to a 23% failure for unattended H-PSG was observed in another study [60]. Moreover, a pilot study, where 90% of recordings were of excellent quality, consisted in a wireless device to obtain real-time remote supervision of H-PSG from the sleep lab [61]. With this amount of evidence, it seems telemedicine for sleep studies recordings is feasible and may be an important step to reduce the failure rates of home devices; however, there are important barriers for implementing telemedicine for sleep studies regularly. Telemonitoring devices are complex as well as their software; hence, incompatibility problems with other computer programs should be expected. Furthermore, the cost-effectiveness of these systems is yet to be determined considering the fact that the home must be equipped with a computer and Internet connection, along with high specifications for computer programs. However, investigations using integrated circuits available on the market (mobile telephony) have been conducted to simplify access to these technologies [62]. Last but not least, there are also problems related to privacy protection and security of medical data transmission [58]. An ongoing telehealth outof-laboratory "Fast Track for Sleep Apnea" program for veterans has been reported, that has helped to relieve clinical load at the central sleep program, improved local access to sleep care, and improved patient satisfaction with health care for sleep-related breathing disorders. Nonetheless, the following challenges have been acknowledged so far: the programs needed to be properly integrated with other data management systems and data storage devices must be interfaced with computers attached to the VA server; data loss; and maintaining quality control using metrics [63]. Either way, further research is required to determine the role of

telemedicine in sleep-related breathing disorders diagnosis, especially for OSA.

CPAP has shown to wipe out the adverse effect of severe OSA, especially those effects related to cardiovascular diseases. However, the rates of adherence to CPAP are still far of being acceptable. That is way any measure to achieve CPAP adherence is needed, and new ap‐ proaches such as telemedicine seems to be feasible and cost-effective. Compliance to CPAP is a complex process that involves the participation of the device itself, family support, physi‐ cians, health care personal, sleep unit, and government politics [64]. So far, low-quality evidence justifies the use of supportive interventions added to the usual clinical practice to increase CPAP adherence [65] and, similar to previous items, more clinical trials are called for to clear up the role of these interventions, where telemedicine is included. Earlier works presented contradictory results. A statistically significant higher adherence was found in a telemedicine-guided naïve to CPAP patients recently diagnosed with OSA along with greater satisfaction, concluding that telehealth might be cost-effective for CPAP adherence manage‐ ment [66]; while no differences were found in hours of CPAP use, functional status or client satisfaction in another study [67]. It is worth to mention that these two studies followed the

technology and telemedicine to allow real-time remote monitoring.

68 Mobile Health Technologies - Theories and Applications

[Lung transplantation is offered for a great variety on respiratory diseases that have reached their end-stage, where no other treatment would obtain a reasonable survival. They are complex patients who are in need of aggressive immunosuppressive treatment for a lifetime that exposes them to opportunistic infections; so numerous complications are often taking place. By far, the major problem for every lung transplant patient is the allograft dysfunction, either acute or chronic (basically in its form of bronchiolitis obstructive syndrome). Allograft dysfunction is characterized for a functional decline of the implant, which is usually measured by FEV1 [72], and daily home spirometry has been shown to lead to earlier detection and staging of bronchiolitis obstructive syndrome when compared with standard pulmonary function testing [73]. Concerning the need of retrieving daily spirometric data, telemedicine has been studied as a feasible instrument, making some interesting progress conducive to a more efficient follow-up of patients and the prompt recognition of a possible complication.

Earlier works determined the telemonitored spirometry as feasible, valid, reliable, and repeatable, when compared to the regular in-clinic functional testing [74–76]. Although these studies were clearly underpowered due to the small samples included. While on earlier works the objective is to determine the technical aspects of collecting acceptable spirometries, recent works have carried out clinical trials to demonstrate that a computerized rule-based decision support algorithm for nursing triage of potential acute bronchopulmonary events is effective [72, 77], or the identification of these events taking decision rules developed using wavelet analysis of declines in spirometry and increases in respiratory symptoms [78]. In conclusion, the evidence of the increase of quality of life and reduction of hospital admissions seems fairly positive, though we are still in need of more studies [79] and the training process for both medical staff and patients needs to be thorough [80] A different approach was revised by another study where telemedicine was employed in a clinical trial for lung transplant candi‐ dates, and clinical outcome measures were monitoring adherence and level of communication (for monitor acceptability and utilization), hospital length of stay after transplantation and survival at 4 months. However, no significant differences in clinical outcomes between groups were determined [81].

Similar to the previous three respiratory conditions, telemedicine for lung transplant patients is feasible. Still and all, no cost-effectiveness has been demonstrated, thus, larger clinical trials are required to establish the position of these new techniques in lung transplantation.
