Air pollution and asthma

[Seasonality in asthma: Impact and treatments]

The role of seasons should be taken into account in the management of asthma. The environment varies between seasons and it is well documented that asthma is modulated by environment. Viruses cause asthma exacerbations peak, in winter, in adults while the peak is present in September in children. Allergens are probably a less powerful source of asthma exacerbation than viruses but pollen involvement in spring and summer and dust mites in autumn are indisputable. Air pollutants, present in summer during the hottest periods, are also highly involved in asthma exacerbations. Indoor air pollution, in winter, is also implicated in asthma disease. All these environmental factors are synergistic and increase the risk of asthma exacerbation. Therapies should be adapted to each season depending on environmental factors potentially involved in the asthma disease.

Environmental and occupational allergies

Airborne allergens are the major cause of allergic rhinitis and asthma. Daily exposure comes from indoor sources, chiefly at home but occasionally at schools or offices. Seasonal exposure to outdoor allergens, pollens, and molds is another important source. Exposure to unusual substances at work causes occupational asthma, accounting for about 5% of asthma in adults. Indoor and outdoor air pollutants trigger airway inflammation and increase the severity of asthma. Diesel exhaust particles increase the production of IgE antibodies. Identification and reduction of exposure to allergens is a very important part of the management of respiratory allergic diseases. The first section of this chapter discusses domestic allergens, arthropods (mites and cockroaches), molds, and mammals (pets and mice). Indoor humidity and water damage are important factors in the production of mite and mold allergens, and discarded human food items are important sources of proliferation of cockroaches and mice. Means of identifying and reducing exposure are presented. The second section discusses outdoor allergens: pollens and molds. The particular plants or molds and the amount of exposure to these allergens is determined by the local climate, and local pollen and mold counts are available to determine the time and amount of exposure. Climate change is already having an important effect on the distribution and amount of outdoor allergens. The third section discusses indoor and outdoor air pollution and methods that individuals can take to reduce indoor pollution in addition to eliminating cigarette smoking. The fourth section discusses the diagnosis and management of occupational asthma.

Climate change and allergic disease

Climate change is potentially the largest global threat to human health ever encountered. The earth is warming, the warming is accelerating, and human actions are largely responsible. If current emissions and land use trends continue unchecked, the next generations will face more injury, disease, and death related to natural disasters and heat waves, higher rates of climate-related infections, and wide-spread malnutrition, as well as more allergic and air pollution-related morbidity and mortality. This review highlights links between global climate change and anticipated increases in prevalence and severity of asthma and related allergic disease mediated through worsening ambient air pollution and altered local and regional pollen production. The pattern of change will vary regionally depending on latitude, altitude, rainfall and storms, land-use patterns, urbanization, transportation, and energy production. The magnitude of climate change and related increases in allergic disease will be affected by how aggressively greenhouse gas mitigation strategies are pursued, but at best an average warming of 1 to 2 degrees C is certain this century. Thus, anticipation of a higher allergic disease burden will affect clinical practice as well as public health planning. A number of practical primary and secondary prevention strategies are suggested at the end of the review to assist in meeting this unprecedented public health challenge.

Dietary oxidized oil influences the levels of type 2 T-helper cell-related antibody and inflammatory mediators in mice

The aim of this present study was to investigate the effect of amount and degree of oxidation of dietary oil on type 2 T-helper cell (TH)-related immune responses. Four groups of BALB/c mice were fed either 50 g soyabean oil/kg (50-S), 50 g oxidized oil/kg (50-O), 150 g soyabean oil/kg (150-S) or 150 g oxidized oil/kg (150-O). After 14 weeks consuming the experimental diets, the mice were immunized with ovalbumin (OVA) plus Al and antigen-specific immunoglobulin (Ig)E, IgG1 and IgG2a, inflammatory mediators such as prostaglandin (PG) E2 and leukotriene (LT)B4 were determined. Higher hepatic microsomal cytochrome P450 was noted in mice fed 150 g oxidized oil/kg compared with those of other groups. OVA-specific IgG1 and IgE were higher in mice fed 150 g oxidized oil/kg compared with those of the other groups. The data suggested the interleukin (IL)-4: interferon (IFN)-γ ratio was higher in mice fed 50 g dietary oxidized oil/kg compared with that of the 50-S group. The IL-5:IFN-γ ratios were higher in the 150-S and 150-O groups than in the 50-S and 50-O groups. PGE2 and LTB4 produced by macrophages stimulated by lipopolysaccharide were highest in mice in the 150 g oxidized oil/kg group. The data suggested that an increased intake of oxidized oil might exert an unfavourable effect on the TH2 response involved in allergic disease.

Thunderstorm-associated bronchial asthma: a forgotten but very present epidemic

Acute episodes of bronchial asthma are associated with specific etiological factors such as air pollutants and meteorological conditions including thunderstorms. Evidence suggests that thunderstorm-associated asthma (TAA) may be a distinct subset of asthmatics, and, epidemics have been reported, but none from Saudi Arabia.The trigger for this review was the TAA epidemic in November 2002, Eastern Saudi Arabia. The bulk of patients were seen in the King Fahd Hospital of the University, Al-Khobar. The steady influx of acute cases were managed effectively and involved all neighboring hospitals, without evoking any "Major Incident Plan".THREE GROUPS OF FACTORS ARE IMPLICATED AS CAUSES OF TAA: pollutants (aerobiologic or chemical) and meteorological conditions. Aerobiological pollutants include air-borne allergens: pollen and spores of molds. Their asthma-inducing effect is augmented during thunderstorms.Chemical pollutants include greenhouse gases, heavy metals, ozone, nitrogen dioxide, sulfur dioxide, fumes from engines and particulate matter. Their relation to rain-associated asthma is mediated by sulfuric and nitric acid.Outbreaks of non-epidemic asthma are associated with high rainfall, drop in maximum air temperature and pressure, lightning strikes and increased humidity. Thunderstorm can cause all of these and it seems to be related to the onset of asthma epidemic.Patients in epidemics of TAA are usually young atopic adults not on prophylaxis steroid inhalers. The epidemic is usually their first known attack. These features are consistent with the hypothesis that TAA is related to both aero-allergens and weather effects. Subjects allergic to pollen who are in the path of thunderstorm can inhale air loaded with pollen allergen and so have acute asthmatic response. TAA runs a benign courseDoctors should be aware of this phenomenon and the potential outbreak of asthma during heavy rains. A & E departments and ICU should be alert for possible rush of asthmatic admissions and reinforce ventilators and requirements of cardio-pulmonary resuscitation. Scientific approach should be adopted to investigate such outbreaks in the future and must include meteorological, bio-aerosole pollutants and chemical pollutant assessment. Regional team work is mandatory.

Cough: occupational and environmental considerations: ACCP evidence-based clinical practice guidelines

OBJECTIVES

This section of the guideline aims to review the role of occupational and environmental factors in causing and contributing to cough. It also aims to indicate when such causes should be considered in a clinical setting, and a general approach to assessment and management.

METHODS

A review was performed of published data between 1985 and 2004 using PubMed. The search terms used included "air pollution," "sick building syndrome," "occupational asthma," "occupational lung disease," "hypersensitivity pneumonitis" (HP), "cigarette smoke," and "asthma." Selected articles were chosen when meeting the objectives, but the extent of articles available and the limited space for this section does not permit a fully comprehensive review of all of these areas, for which the reader is referred to other sections of this clinical practice guideline, the published literature, textbooks of occupational lung disease, or more specific review articles.

RESULTS/CONCLUSIONS

Almost any patient presenting with cough may have an occupational or environmental cause of or contribution to their cough. The importance of this is that recognition and intervention may result in full or partial improvement of the cough, may limit the need for medication/symptomatic treatment, and may improve the long-term prognosis. Nonoccupational environmental contributing factors for upper and lower airway causes of cough include indoor irritant and allergenic agents such as cigarette smoke, cooking fumes, animals, dust mites, fungi, and cockroaches. Causes of HP indoors include birds and fungal antigens. Outdoor pollutants and allergens also contribute to upper and lower airway causes of cough. Occupational exposures can cause hypersensitivity responses leading to rhinitis and upper airway cough syndrome, previously referred to as postnasal drip syndrome, as well as asthma, HP, chronic beryllium disease, and hard metal disease, as well as irritant or toxic responses. The diagnosis is only reached by initially considering possible occupational and environmental factors, and by obtaining an appropriate medical history to determine relevant exposures, followed by objective investigations. This may require referral to a center of expertise.

Prevalence and mechanisms of development of asthma and airway hyperresponsiveness in athletes

A high prevalence of asthma and airway hyperresponsiveness (AHR) has been reported in the athlete population. Factors potentially predisposing athletes to these conditions have not been clearly identified. Although moderate exercise has been shown to be beneficial in patients with asthma, repeated high-intensity exercise could possibly contribute to the development of asthma and AHR. This report provides an overview of the prevalence and possible mechanisms of development of asthma and AHR in the athlete population. The prevalence of asthma and AHR are higher in athletes than in the general population, particularly in swimmers and athletes performing sports in cold air environments. Possible mechanisms involved in the development of asthma in athletes are still uncertain; however, the content and physical characteristics of the inhaled air seem to be important factors, while immune and neurohumoral influences could play a modulatory role. This report stresses the need for further studies to better define the aetiologic factors and mechanisms involved in the development of asthma and AHR in athletes, and proposes relevant preventive and therapeutic measures.

Effect of apocynin on ozone-induced airway hyperresponsiveness to methacholine in asthmatics

Apocynin is an inhibitor of NADPH oxidase present in inflammatory cells such as eosinophils and neutrophils. We investigated the effect of inhaled apocynin on ozone-induced bronchial hyperresponsiveness in vivo. Seven mild atopic asthmatics participated in a placebo-controlled, cross-over study with two exposures to O(3) at 2-week intervals. Apocynin (3 ml of 0.5 mg/ml) was inhaled 2 times before and 6 times after O(3) exposure at hourly intervals. At 36 h before and 16 h after O(3) exposure, methacholine inhalation challenge tests (Mch) were performed, and PC(20) and maximal % fall from baseline (MFEV(1)) were calculated from dose-response curves. O(3)-induced change in PC(20) (Delta PC(20)) after placebo treatment was -1.94 +/- 0.39 DD (mean +/- SEM doubling dose Mch) (p =.001) and apocynin was -0.6 +/- 0.33 DD (p =.17). The difference between apocynin and placebo treatment was 1.3 DD +/- 0.42 (p =.02). O(3)-induced Delta MFEV(1) was 11.9 +/- 1.5% (p =.008) during placebo inhalation and 3.85 +/- 1.8% during apocynin (p =.47). Apocynin reduced the Delta MFEV(1) by 8.05% compared to placebo (p =.025). We conclude that apocynin markedly reduced O(3)-induced hyperreactivity for Mch as well as maximal airway narrowing. The results suggest that apocynin may have a role in preventing ozone-induced exacerbations of asthma.

[Respiratory allergy and environmental pollution in pediatrics]

Allergic disease and pollution effects on children are a subject of worldwide concern. Outdoor pollution is the sum of acid particle (SO2, NO2, PM) and photochemical (ozone) pollution. Experimental studies demonstrated correlation between animals and humans concerning inhalation of pollutants and inflammatory and functional effects. Several studies among children confirmed with variable odds ratios the interaction between air pollution and respiratory health, but other studies showed no clear effect. Physicians should inform parents with children experiencing respiratory disease.

Air pollution and bronchitic symptoms in Southern California children with asthma

The association of air pollution with the prevalence of chronic lower respiratory tract symptoms among children with a history of asthma or related symptoms was examined in a cross-sectional study. Parents of a total of 3,676 fourth, seventh, and tenth graders from classrooms in 12 communities in Southern California completed questionnaires that characterized the children's histories of respiratory illness and associated risk factors. The prevalences of bronchitis, chronic phlegm, and chronic cough were investigated among children with a history of asthma, wheeze without diagnosed asthma, and neither wheeze nor asthma. Average ambient annual exposure to ozone, particulate matter (PM(10) and PM(2.5); [less than/equal to] 10 microm and < 2.5 microm in aerodynamic diameter, respectively), acid vapor, and nitrogen dioxide (NO(2)) was estimated from monitoring stations in each community. Positive associations between air pollution and bronchitis and phlegm were observed only among children with asthma. As PM(10) increased across communities, there was a corresponding increase in the risk per interquartile range of bronchitis [odds ratio (OR) 1.4/19 microg/m(3); 95% confidence interval (CI), 1.1-1.8). Increased prevalence of phlegm was significantly associated with increasing exposure to all ambient pollutants except ozone. The strongest association was for NO(2), based on relative risk per interquartile range in the 12 communities (OR 2.7/24 ppb; CI, 1.4-5.3). The results suggest that children with a prior diagnosis of asthma are more likely to develop persistent lower respiratory tract symptoms when exposed to air pollution in Southern California.

Allergy, asthma and the environment: an introduction

In Europe and the USA the prevalence of certain forms of allergic disease is rising; an increase that can not be reconciled simply on the basis of changes in diagnostic fashion. The changes observed have been too rapid to be explained by alterations in the gene pool and, as a consequence, there has been a growing interest in the possible associations between environmental factors, allergic disease and asthma. Among the environmental influences that have been implicated in modifying the development of respiratory allergy and asthma are the conditions of exposure to allergens themselves, indoor air quality, outdoor air pollution, tobacco smoking, diet and infectious disease. The contributions of some of these factors, acting alone or in concert, to the development of allergic disease are considered.

Analysis of the relationships between environmental factors (aeroallergens, air pollution, and weather) and asthma emergency admissions to a hospital in Mexico City

There have been several studies of the relationships between environmental factors, particularly air pollution, and attacks of asthma. Most of these studies have ignored the potential confounding effects of aeroallergens such as pollens and fungal spores. We report a statistical analysis of the relationships between emergency admissions for asthma to a hospital in Mexico City and daily average airborne concentrations of pollen, fungal spores, air pollutants (O3, NO2, SO2, and particulates) and weather factors. Asthma admissions had a seasonal pattern with more during the wet season (May-October) than the dry season (November-April). There were few statistical associations between asthma admissions and air pollutants for the three age groups studied (children under 15 years, adults, and seniors [adults over 59 years]) in either season. Grass pollen was associated with child and adult admissions for both the wet and dry seasons, and fungal spores were associated with child admissions during both the wet and dry seasons. The analysis was done with environmental data averaged over the day of admission and the 2 previous days. Our results suggest that aeroallergens may be statistically associated more strongly with asthma hospital admissions than air pollutants and may act as confounding factors in epidemiologic studies.

Diesel exhaust enhances allergic airway inflammation and hyperresponsiveness in mice

We previously reported that the intratracheal instillation of diesel exhaust particles enhances allergic airway inflammation and hyperresponsiveness in mice. However, it is not known whether the effects of such instillation differ from those obtained with the daily inhalation of diesel exhaust. We therefore examined whether the inhalation of diesel exhaust would also enhance allergic reactions. Mice were exposed to diesel exhaust or clean air for 5 wk. After the first week, the animals were sensitized to ovalbumin by intraperitoneal injection. At the end of the exposure period, they underwent an ovalbumin challenge. Control animals received saline instead of ovalbumin. Independently of ovalbumin sensitization, diesel exhaust caused an increase in the numbers of neutrophils and macrophages in bronchoalveolar lavage fluid, whereas a significant increase in eosinophil numbers occurred only after antigen challenge combined with diesel exhaust exposure. Furthermore, ovalbumin alone caused an increase in eosinophil numbers in lung tissue, and this was enhanced by diesel exhaust. Exposure to diesel exhaust combined with ovalbumin sensitization, but not diesel exhaust inhalation alone, enhanced the number of goblet cells in lung tissue, respiratory resistance, production of ovalbumin-specific immunoglobulin E and G1 in the serum, and expression of interleukin-5 in lung tissue.

Asthma, type-1 allergy and related conditions in 7- and 8-year-old children in northern Sweden: prevalence rates and risk factor pattern

As a first step in an intervention study of asthma and allergic diseases among school children, a cross-sectional study was performed during Winter 1996 in three towns (Kiruna, Luleå and Piteå) in the northernmost province of Sweden, Norrbotten. The cross-sectional study aimed to measure the prevalence of asthma, type-1 allergy and allergic diseases in order to make it possible to measure the incidence of the diseases, conditions and symptoms related to the diseases. Another aim was to perform a screening for possible risk factors. All children enrolled in the first and second classes at school, 7 and 8 years old, were invited to take part in this study. The ISAAC questionnaire with added questions about symptoms, morbidity, heredity and environment was distributed by the schools to the parents. The response rate was 97%, and 3431 completed questionnaires were returned. The children in two of the municipalities were also invited to skin test, and 2149 (88%) were tested with 10 common airborne allergens. The results showed that 7% of the children were currently using or had used asthma medicines during the last 12 months. Six percent had asthma diagnosed by a physician, and 4% were using inhaled corticosteroids. The prevalence of wheezing during the last 12 months was 12%, rhinitis without colds 14%, and eczema 27%, while 21% had a positive skin test. The respiratory symptoms and conditions were significantly greater in boys and, further, they were most prevalent in Kiruna in the very north, though not significantly. Type-1 allergy and asthma had different risk factor patterns. The main risk factors for asthma were a family history of asthma (OR = 3.2) followed by past or present house dampness (OR = 1.9), male sex (OR = 1.7) and a smoking mother (OR = 1.6). In Kiruna, when none of these three risk factors were present, none of the children had asthma, but when all three were present, 38% of these children were using asthma medicines.

Childhood antecedents of adult respiratory disease

This review examines the relations between early childhood lower respiratory symptoms and adult respiratory disease. The problems associated with investigating potential associations between respiratory disease in children and adults are discussed. Some studies have limitations because they are retrospective and early childhood respiratory symptoms have not been accurately diagnosed. Therefore, in this review, particular attention is paid to longitudinal studies (some from birth) that have used strict diagnostic criteria for respiratory episodes. These studies provide unique insights into the risk factors for the development of childhood respiratory problems and for persistence of symptoms into adulthood. Although cross-sectional studies have indicated that early childhood respiratory disease is more frequent in adults with respiratory disease, evidence from longitudinal studies suggests that respiratory symptoms such as wheezing, are transient in the majority of infants and result from developmentally small airways. These longitudinal investigations have also indicated that persistence of symptoms into later childhood is associated with atopy. The important role of cigarette-smoke exposure as a risk factor for abnormal pulmonary development, persistence of respiratory disease and reduction in lung function is discussed. The discovery of genetic markers associated with respiratory syndromes such as asthma, should facilitate studies that investigate the childhood antecedents of adult respiratory disease. Future longitudinal studies using genetic markers, will allow relations between specific genotypes and phenotypic outcomes to be examined.

Prevalence of asthma and asthma-like symptoms in Athens, Greece

Asthma is a common chronic condition and there is evidence that its prevalence may be rising. The European Respiratory Health Survey (ECRHS) was planned to produce comparable data on asthma epidemiology in Europe. In Greece, in particular, a similar study has not been conducted previously and no epidemiological data are available on adult asthma prevalence. Furthermore, the role of air pollution in the pathogenesis of asthma is currently an issue of debate. Athens is a city with high air pollution, and a study of asthma epidemiology in this city may confirm or refute a possible link with the expression of asthma. A questionnaire developed by the ECRHS was sent to a random sample of 3533 households in Peristeri, an industrialized borough of Athens. Responses were received from 2774 households (response rate 78%). Of all the data on individual subjects, only those from 3325 adults aged 20-44 years were considered, according to the study protocol. The self-reported current prevalence of asthmatic attacks and asthma-like symptoms were as follows: asthma attack 2.4%, use of asthma medication 2.1%, awakening by shortness of breath 5.6%, awakening by cough 17.8%, wheezing 15.8% and nasal allergies 18.4%. It is concluded that the prevalence of asthma and related symptoms in this region of Athens is rather low, despite the high air-pollution levels in the city.

A discussion of the environmental influences on asthma and the role of Environmental Health Officers in combating it

Asthma is a multifactorial disease and environmental influences have long been associated with its everyday symptoms. In recent years it has been proposed that environmental factors can also influence the actual development of the disease. Underlying genetic factors may interact with these common environmental factors. Thus, the environment may be involved in both the aetiology and the symptomatic manifestations of the disease. The discussion is completed by looking at the role of local authority Environmental Health Officers (EHOs) in combating asthma.

Biological effects of diesel exhaust particles (DEP). III. Pathogenesis of asthma like symptoms in mice

Chronic airway inflammation, mucus hypersecretion, reversible airway constriction, and bronchial hyperresponsiveness are important pathogenic features of asthma. We found that diesel exhaust particles (DEP) instilled intratracheally and repeatedly to mice (once/week for 16 weeks) caused marked infiltration of inflammatory cells, proliferation of goblet cells, increased mucus secretion, respiratory resistance, and airway constriction. Eosinophils in the submucosa of the proximal bronchi and medium bronchioles increased eightfold following instillation. Eosinophil infiltration was significantly suppressed by pretreatment with polyethyleneglycol-conjugated superoxide dismutase (PEG-SOD). Bound sialic acid concentrations in bronchial alveolar lavage fluids, an index of mucus secretion, increased with DEP, but were suppressed by pretreatment with PEG-SOD. Goblet cell hyperplasia, airway narrowing, and airway constriction also were observed with DEP. Respiratory resistance in the DEP-group to acetylcholine was 11 times higher than in controls, and the increased resistance was significantly suppressed by PEG-SOD pretreatment. These findings suggest that DEP and/or oxygen radicals derived from DEP cause bronchial asthma in mice.

Air pollution and asthma: molecular mechanisms

Air pollution, in particular that generated by road traffic, is a matter of rising public concern and has been implicated in the worsening of asthma. In this article, the evidence that air pollutants (particularly sulphur dioxide, ozone and nitrogen dioxide) can affect the airways of asthmatic patients is reviewed, and the possible molecular mechanisms that may link air pollution to increased inflammation in the airways are discussed. Airway epithelial cells may respond to oxidant pollutants by the activation of transcription factors, such as nuclear factor kappa B, resulting in increased transcription of genes for certain cytokines, such as interleukin 8 and inflammatory enzymes, such as inducible nitric oxide synthase and cyclo-oxygenase.