In this episode, Irish respiratory fellows Barry and Sandra sit down with Professor Richard Costello to explore the rapidly evolving world of digital asthma care. From eosinophils and T2 inflammation to the future of smart inhalers and precision monitoring, this conversation dives deep into how technology is reshaping diagnosis, adherence, and long-term management.

Professor Richard Costello discusses the challenges of diagnosing a highly variable disease, the limitations of symptom-based tools like the ACT, and why biomarkers and digital home spirometry are essential in modern asthma practice. They cover how digital devices can reveal patient behaviour, uncover hidden comorbidities, and distinguish difficult-to-treat asthma from true severe asthma.

The episode also explores the emerging potential of closed-loop smart inhalers, real-time lung function monitoring, and how personalised dosing may soon become a reality. Along the way, the team unpacks overlooked side effects of chronic inhaled steroids, the importance of steroid stewardship, and how Ireland can move toward a more decentralised, digitally enabled model of asthma care.

Chapters

00:00 – Introduction

00:31 – Episode Overview

01:15 – Rapid-Fire Round: True or False

03:45 – The Importance of Eosinophils & T2 Inflammation
Dr. Costello explains why identifying T2 inflammation is central to diagnosing and managing asthma.

06:15 – Challenges in Diagnosing Asthma
Variability, biomarkers, bronchial responsiveness, and why asthma remains difficult to diagnose in 2025.

09:40 – The Role of Home Spirometry
How home monitoring helps differentiate asthma from mimics and guides treatment decisions.

12:10 – Differentiating Difficult-to-Treat vs Severe Asthma
Using digital adherence data to distinguish true severity from difficult to treat asthma.

14:20 – The Future: Smart, Closed-Loop Inhalers
How inhalers may soon auto-dose based on real-time airflow and physiology.

17:00 – Understanding the User, Not Just the Device
Digital data reveals patient behaviour patterns and barriers to adherence.

20:10 – When Symptoms Aren’t Asthma
Reflux, deconditioning, cardiac disease, and other asthma mimics uncovered through monitoring.

22:20 – Hidden Side Effects of High-Dose Steroids
Adrenal suppression, cataracts, diabetes, and why symptom-based escalation can lead to elevated steroid exposure.

25:00 – The Limitations of the ACT & Symptom Scores
Why subjective questionnaires fall short in a multimorbid population.

27:10 – Ireland’s Future: Digital Home Monitoring & Decentralised Care
How integrated hubs and digital platforms could streamline diagnosis and management.

30:00 – Looking Ahead

31:29 – Closing Remarks

Guest: Professor Richard Costello

Professor Richard Costello is a professor of respiratory medicine at the Royal College of Surgeons in Ireland and a consultant at Beaumont Hospital, Dublin. He trained at RCSI, Beaumont, and Johns Hopkins University. A leading researcher in airways disease and digital respiratory health, he has published over 200 papers, holds several health innovation patents, and founded a company focused on inhaler adherence. He has served as Vice President of the Royal College of Physicians of Ireland and chaired the European Respiratory Society Educational Council, receiving the ERS Educational Award for his contributions to respiratory medicine.

Hosts: Dr Barry Harnedy & Dr Sandra Green

• Dr Barry Harnedy is a respiratory specialist trainee in Ireland. He graduated from National University of Ireland Galway. He is the current Irish Thoracic Society co Educational Officer. He is passionate about digital innovation and airways assessment.
• Dr Sandra Green is a respiratory specialist trainee in Ireland. She is the current Irish Thoracic Society Sustainability Officer. As a founder of Irish Doctors for the Environment she is interested in healthcare sustainability and planetary health.