Randomized Clinical Trial of Air Cleaners to Improve Indoor Air Quality and Chronic Obstructive Pulmonary Disease Health: Results of the CLEAN AIR Study

Impact of occupational exposures in patients with chronic obstructive pulmonary disease: current understanding and knowledge gaps

PURPOSE OF REVIEW

Chronic obstructive pulmonary disease (COPD) is thought of as a disease caused by tobacco exposure, but numerous occupational exposures have been identified as risk factors for development of disease and exacerbations, although these remain underappreciated and underdiagnosed. We highlight evidence of occupational exposures and how they relate to COPD, while also looking at gaps in how the changing workplace might affect the occupational COPD landscape.

RECENT FINDINGS

Historical exposures linked to COPD included inorganic dusts like coal and silica and organic dusts like cotton and wood. Other data associated agricultural exposures, cleaning agents, air pollution, and construction work with COPD. As the workplace has evolved to include more work from home and growing industries like ridesharing and delivery, items like radon and indoor and outdoor air quality must be factored into the equation as occupational exposures with the potential to cause COPD and increase its morbidity. Despite this, causal conclusions with many risk factors are challenging due to the complex interaction between patient susceptibilities and environmental factors, both occupation-related and nonoccupation related.

SUMMARY

Additional studies are needed, not only to better evaluate occupational exposures and COPD pathogenesis, but also to look at more solution-oriented areas like precision medicine and interventions targeting a healthier workplace.

Goals of chronic obstructive pulmonary disease management: a focused review for clinicians

PURPOSE OF REVIEW

The diagnosis of chronic obstructive pulmonary disease (COPD) encompasses heterogeneous pathophysiological mechanisms which can shape an individual patient's experience. This paper reviews available therapeutic options for the clinician intending to individualize care toward patient goals.

RECENT FINDINGS

The contemporary targeted interventions for COPD include the novel phosphodiesterase inhibitor ensifentrine, the interleukin-4 receptor (IL4R alpha subunit) antibody dupilumab, augmentation therapy for alpha-1 antitrypsin deficiency. Other interventions promoting physical and mental well being include re-envisioned pulmonary rehabilitation, self-management, targeting of comorbidities such as sarcopenia, and virtual health coaching interventions to expand patient access. Opioids did not relieve dyspnea and did not change total step count.

SUMMARY

Advances in precision therapy are complemented by the discovery of novel pathophysiology pathways and behavioral and rehabilitation interventions as a holistic view of COPD management emerges. The management of COPD continues to evolve with new tools including precision medicine and individualized care. Comorbidities remain important determinants of health, yet their prevalence and impact are underestimated.

The Association Between Air Pollution and Lung Function in Sarcoidosis and Implications for Health Disparities

BACKGROUND

Sarcoidosis is a granulomatous disease with varying courses of disease progression. Environmental exposures are thought to be contributors to disease onset. Exposure to air pollutants such as fine particulate matter of 2.5 μm diameter or smaller (PM2.5) and nitrogen dioxide (NO2) have been identified as contributors to health disparities in lung diseases; little is known about these environmental exposures' associations with disease outcomes in sarcoidosis.

RESEARCH QUESTION

Is higher exposure to PM2.5 and NO2 associated with worse lung function in sarcoidosis?

STUDY DESIGN AND METHODS

We conducted a retrospective, cross-sectional study of individuals with pulmonary sarcoidosis seen from 2005 to 2015. Home addresses at the year of enrollment were geocoded, and exposure to PM2.5 and NO2 was modeled using high-resolution 1 km × 1 km annual surface exposure data during the year of enrollment. Racial and sex differences in exposure were determined. Multivariable linear regression models were used to examine the associations between PM2.5 and NO2 and the pulmonary function test measures FVC, FEV1, and diffusing capacity of the lungs for carbon monoxide (Dlco).

RESULTS

Among the 415 individuals in the analysis, Black individuals had significantly higher exposure to PM2.5 and NO2 compared with non-Hispanic White individuals, 12.2 μg/m3 (SD 2.4) vs 11 μg/m3 (SD 2.2) and 6.3 parts per billion (ppb) (SD 1.9) vs 5.0 ppb (SD 2.0), respectively. Every 1 μg/m3 higher exposure to PM2.5 was associated with 1.12% lower Dlco% predicted (95% CI, -1.83 to -0.41; P < .05). Every 1 ppb higher exposure to NO2 was associated with 1.04% lower Dlco% predicted (95% CI, -1.91 to -0.18; P < .05) in fully adjusted models. There were no significant associations between these pollutants and either FVC or FEV1% predicted.

INTERPRETATION

Higher exposure to PM2.5 and NO2 was associated with worse Dlco% predicted. Black individuals with sarcoidosis were exposed to higher PM2.5 and NO2 than non-Hispanic White individuals. Air pollution exposure may be a contributor to reported health disparities in sarcoidosis.

Association between exposure to particulate matter and heart rate variability in vulnerable and susceptible individuals

Particulate matter (PM) exposure can reduce heart rate variability (HRV), a cardiovascular health marker. This study examines PM1.0 (aerodynamic diameters <1 μm), PM2.5 (≥1 μm and <2.5 μm), and PM10 (≥2.5 μm and <10 μm) effects on HRV in patients with environmental diseases as chronic disease groups and vulnerable populations as control groups. PM levels were measured indoors and outdoors for five days in 97 participants, with 24-h HRV monitoring via wearable devices. PM exposure was assessed by categorizing daily cumulative PM concentrations into higher and lower exposure days, while daily average PM concentrations were used for analysis. Results showed significant negative associations between exposure to single and mixtures of different PM metrics and HRV across all groups, particularly in chronic airway disease and higher air pollution exposed groups. These findings highlight that even lower PM levels may reduce HRV, suggesting a need for stricter standards to protect sensitive individuals.

Indoor Environment and Health Effects: Protocol of an Exploratory Panel Study among Young Adults in China (China IEHE Study)

Indoor environment and health have drawn public attention worldwide. However, the joint health effects and mechanisms of exposure to different types of indoor environmental factors remain unclear. We established an exploratory panel study on indoor environment and health effects among young adults in China (the China IEHE Study) to comprehensively investigate 3M issues, including multiple indoor environmental factors, multiple health effects, and multiple omics methods for mechanism exploration. This protocol aims to systematically introduce the entire China IEHE Study. Eighty-one young adults aged 18-28 years from a university adjacent to traffic arteries in Beijing were recruited and followed up four times. Sham/real air purification intervention was simultaneously applied in a randomized crossover order. A broad range of indoor physical, chemical, and biological factors were characterized through real-time monitoring and external and internal exposure analyses. Subclinical health indices reflecting cardiopulmonary, sleep, and cognitive health were repeatedly measured in a prospective order. Various biosamples including fasting venous blood, morning urine, nasal mucosal lining fluid, and exhaled breath condensate were collected to explore the underlying biological mechanisms. The China IEHE Study comes up with an enlightening framework for future prospective studies associated with the exploration of multisystem health effects and underlying biological mechanisms of indoor exposure.

Enhancing indoor air quality and cardiopulmonary health in patients with asthma by photocatalytic oxidation and filters air cleaner

BACKGROUND

Air purifiers can enhance indoor air quality and health outcomes, and studies have primarily focused on filters and particulate matter (PM) in households. Photocatalytic oxidation (PCO) is a promising technique for eliminating gaseous pollutants and bioaerosols. However, no field study was conducted in household. Therefore, this study evaluated the effects of the PCO and PCO + filters intervention on indoor air pollutants and cardiopulmonary endpoints in households.

METHODS

A randomized, double-blind crossover clinical trial was conducted. Indoor air pollutants, including PM, bioaerosols, and gaseous pollutants and cardiopulmonary endpoints including lung function, fractional exhaled nitric oxide (FeNO), respiratory symptoms, and blood pressure were assessed before and after intervention.

FINDINGS

This was the first study to evaluate the effects of PCO and PCO + filters interventions on indoor air pollutants and cardiopulmonary health in households. Indoor total volatile organic compounds (TVOC) and sulfur dioxides (SO2) significantly reduced after PCO intervention, however, we also observed the significant reduction in percentage of predicted values of forced vital capacity (FVC%) and forced expiratory volume in 3 s (FEV3%) and increased in FeNO after 13 days of PCO intervention. The PCO + filters intervention significantly reduced the levels of indoor PM1, PM2.5, PM4, PM10, total suspended particulate matter, ultrafine particles, airborne bacteria, fungi, endotoxin, mites, TVOC, nitrogen dioxide, and SO2, and marginal reduction in carbon monoxide. However, indoor carbon dioxide significantly increased after PCO/PCO + filters intervention. As for cardiopulmonary health, FVC%, and FEV1 % marginally increased 7 days after the PCO + filters intervention.

Accounting for in situ air cleaner utilization and performance to improve interpretation of patient outcomes in real-world indoor air cleaner intervention trials

There is an increasing number of randomized clinical trials intended to assess the effectiveness of indoor air cleaners for improving participant outcomes in real-world settings. In this communication, we synthesize the current state of registered air cleaner intervention trials and call attention to the critical importance of conducting measurements to characterize the performance and in situ utilization of air cleaners in such trials to improve interpretation of exposure measurements and patient outcomes. We draw upon the existing literature and preliminary findings from our ongoing one-year, randomized, single-blind, placebo-controlled case-control trial of stand-alone air filtration in the homes of U.S. military Veterans to inform our recommendations. We demonstrate how to conduct industry-standard performance testing and how to use long-term measurements of air cleaner power draw to assess air cleaner operation. In our analysis of interim data from 53 homes to date with a mean data collection period of 275 days, we found that most air cleaners, whether active or sham, were operated predominantly at low or medium fan speeds, and most participants operated their air cleaner on predominantly one fan speed. In a few homes, air cleaners were mostly off. We estimate that air cleaner operation in these homes is providing a median additional equivalent particle loss rate of ∼0.7/h (ranging ∼0-2.8/h). Accordingly, we recommend that air cleaner intervention trials adopt the steps described herein to account for the amount of clean air delivered in real-world settings and to provide important context alongside indoor exposure measurements and analysis of patient outcomes.

Environment and Public Health: How the Environment Affects Children's Health and Quality of Life

The most well-known health effects of environmental degradation are related to air pollution, water quality, diet, poor sanitation, and hazardous chemicals. Air pollution is the biggest environmental health risk today. It affects the most vulnerable populations and is linked to heart diseases, strokes, lung diseases, lung cancer, and other organ diseases. Also, it affects neurodevelopment and cognitive abilities in children, can trigger childhood asthma and cancer, and can lead to chronic diseases such as heart attacks later in their lives. Indoor air pollution and the combustion of solid fuels lead to a large number of premature deaths from diseases caused by dangerous inhaled particles, especially in children. In addition, improper collection of waste that pollutes the soil, water, and atmosphere has been shown to be directly linked to public health, so the development and implementation of new waste management methods are imperative. With this work, we emphasize that children, in particular, have lifelong impacts on their health, educational prospects, and quality of life from air pollution and environmental degradation, and therefore monitoring, evaluation, and special planning for their health and well-being are required. The information gap needs to be immediately filled by raising awareness in society through educational programs in schools, the community, and the media, as well as by immediately implementing corresponding policies to achieve these goals.

A comprehensive review of ferroptosis in environmental pollutants-induced chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease (COPD) is a common chronic lung disease that impacts hundreds of millions of individuals worldwide. It is principally characterized by irreversible and progressive airflow limitation. Environmental pollutants, including cigarette smoke, air pollution, occupational pollutants, remain predominant risk factors for COPD and play remarkable roles in COPD progression. Despite the availability of treatments to alleviate symptoms of COPD, it continues to exert a serious health and socioeconomic burden. Ferroptosis, a unique form of iron-dependent cell death distinguished by lipid peroxidation, is implicated in various diseases. Recent studies, utilizing COPD patients samples, animal models, and Gene Expression Omnibus (GEO) database, have revealed that ferroptosis is involved in pathogenesis of COPD. Inhibiting ferroptosis signaling pathways halts the progression of COPD. This review consolidates current insights into the mechanisms of ferroptosis in environmental pollutants-induced COPD, which might offer a novel therapeutic strategy for COPD.

Longitudinal anemia status and risk for adverse outcomes in former smokers with COPD

BACKGROUND

Anemia is a prevalent comorbidity in COPD associated with increased morbidity. However, the significance of longitudinal anemia status and variation in anemia status trends over time in COPD are not known. Furthermore, individuals with COPD and smoking history often have multiple comorbidities, in particular cardiovascular disease. The objective of this study was to evaluate the association between longitudinal anemia status and COPD outcomes, accounting for comorbid cardiovascular disease.

METHODS

Serial hemoglobin measures and clinical outcomes were obtained in former smokers with moderate to severe COPD from two clinical studies over a 6-to-9-month period. In the first analysis, the association between repeated measures of time-varying anemia status and outcomes was assessed by generalized estimating equations adjusted for covariates including cardiovascular disease. In the second analysis, each participant's anemia risk profile during the study period was characterized as high versus low anemia risk-growth rate. Mean differences in the progression of COPD outcomes over time between the two groups were assessed using a generalized linear mixed model. Effect modification by baseline coronary artery calcium (CAC) burden was explored.

RESULTS

There were 159 individuals with mean age of 66.5 years (± 8.3) and mean FEV1% predicted of 51.4% (± 17.0), of which 41% were ever-anemic during the study period. Repeated measures of anemia status were associated with higher St. George's Respiratory Questionnaire (SGRQ) scores (β 2.5, 95% CI: 0.1,4.8, p = 0.04), lower 6-minute walk distance (6MWD) (β -38.6, 95% CI: -67.7,-7.4, p = 0.02), and higher rate of moderate-to-severe exacerbations over the prospective follow-up period (IRR 1.8, 95% CI: 1.1,2.8, p = 0.02). There was effect modification by CAC burden such that with higher burden the mean difference in COPD outcome by anemia status was greater for a subset of symptom scores. Participants with profiles of increasing anemia risk had higher estimated rates of decline in the FEV1% predicted and 6MWD and increase in SGRQ scores compared to those with stable or decreasing anemia risk.

CONCLUSIONS

Longitudinal anemia status trends may be predictive of COPD disease trajectory. Anemia status by repeated measures analysis is associated with COPD morbidity with potentially stronger associations in the setting of high CAC burden.

"You can feel the fresh air … " Rural Alaska Native household perceptions of home air purifiers and health

Alaska Native and American Indian children experience frequent respiratory illness. Indoor air quality is associated with the severity and frequency of respiratory infections in children. High efficiency particulate air (HEPA) purifiers effectively improve indoor air quality and may protect respiratory health. In 2019, the Yukon-Kuskokwim Health Corporation implemented a pilot programme that provided education and HEPA purifiers to households of children with chronic lung conditions. The team evaluated HEPA purifier acceptability and use by interviewing representatives from 11 households that participated in the pilot programme. All interviewees reported improvement in their child's health, and some believed that the health of other household members was also improved because of the HEPA purifier. Interviewees reported that the HEPA purifiers were easy to use, quiet, and not expensive to run. Five of 11 households were still using the HEPA purifier at the time of the interview, which was about three years after receipt of the unit. The most common reasons for discontinuing use were equipment failure and lack of replacement filter, suggesting that programme support could increase sustainability. Our evaluation suggests that HEPA purifiers are acceptable and feasible for use in rural Alaska Native households.

Cognitive Benefits of Reducing Indoor Particulate Matter Exposure During Sleep: New Evidence from a Randomized, Double-blind Crossover Trial

There is increasing evidence that particulate matter (PM) pollution may adversely impact cognition. Considering that sleep is critical for cognitive health and occupies about one-third of human life, understanding the cognitive effects of indoor PM exposure during sleep and the potential cognitive benefits of reducing such exposure is crucial, yet currently unknown. This randomized, double-blind crossover intervention trial was conducted among 80 college students with real and sham PM filtration in their dormitories. Real-time indoor PM levels and nocturnal sleep parameters were monitored, followed by quantification of serum neurotransmitter metabolites and cognitive assessments in the mornings. We found that PM exposure during sleep, particularly PM1 and PM2.5, affected immediate and delayed memory, executive function, and global cognition. Reducing PM exposure during sleep resulted in improvements in multiple cognitive domains, with a 0.21 (95% CI: 0.05, 0.36) increase in global cognitive z-score, in which increased sleep oxygen saturation (SpO2) and alterations in dopamine metabolism and histidine metabolism played important roles. Notably, even when indoor PM2.5 levels were below the WHO air quality guidelines, further reducing PM exposure could still improve sleep SpO2 and neurotransmitter metabolism. This study provides a promising strategy to mitigate indoor PM-induced cognitive impairment.

Cleaning indoor air-what works for respiratory health: An updated literature review and recommendations

Indoor air pollution is a growing public health concern globally and is associated with increased respiratory symptoms and morbidity. Individuals spend most of their time indoors, and pollutant-related health effects are often driven by the indoor environment. Understanding effective interventions to improve indoor air quality and their impact on respiratory outcomes is key to decreasing the burden of air pollution for high-risk populations across the life-span. This review applies a hierarchy of interventions framework specific to respiratory health effects and focuses on recent studies of interventions to improve indoor air quality among high-risk populations with chronic respiratory disease published in the past 3 years. While policy and source control interventions are likely the most effective and equitable approaches to improve indoor air quality and benefit population health, these were less extensively investigated. Engineering interventions, such as air cleaner interventions, were the most widely studied. Several studies, including those focused on asthma and chronic obstructive pulmonary disease, demonstrated improvement in symptoms and medication receipt with interventions in both home- and school-based settings. Combined multilevel interventions with engineering and behavioral interventions led to improved respiratory outcomes in some, but not all, studies. Placing the recent work in the context of the broader literature, we identify gaps in research. Further research is needed to understand intervention effectiveness over time and an increased focus on policy and source control interventions that can mitigate risk in vulnerable populations.

Progress for all: addressing disparities in sarcoidosis

PURPOSE OF REVIEW

The impact of healthcare disparities in the treatment, care, and outcomes of patients with sarcoidosis has been described. There is paucity of literature on ways to address these disparities with a goal to improving health outcomes for patients with sarcoidosis.

RECENT FINDINGS

Recent findings in other respiratory and systemic diseases suggest that multifaceted interventions directed at improving care at various levels including individual, family, and larger societal levels have been successful in dismantling some of the social and structural barriers to care and consequently have resulted in a reduction in disparate disease outcomes. We explore what some of these interventions would look like in sarcoidosis.

SUMMARY

The impact of healthcare disparities in the treatment, care, and outcomes of patients with sarcoidosis has been described. We outline various steps and approaches aimed at addressing these health disparities with a goal to improving outcomes for those most impacted by disease.

Adverse Associations of Long-Term Exposure to PM2.5 and Its Components with Platelet Traits among Subway Shift-Workers without Air Purifier Use

Air purifier use, shift work, and long-term exposure to fine particulate matter (PM2.5) are linked to platelet abnormality. However, the role of air purifier use and shift work in the individual or joint associations of PM2.5 and its components with platelet indices are largely unknown. A total of 8772 participants were recruited from a population of subway workers in China. PM2.5 and its component data were obtained from the Tracking Air Pollution in China dataset. The role of air purifier use and shift work in the association between PM2.5 and its components and platelet indices were analyzed. Among shift workers without air purifier use, positive associations of PM2.5 and each component in PM2.5 with the mean platelet volume (MPV) or platelet counts (PLT) were observed, whereas negative associations of PM2.5 and each component in PM2.5 with the platelet distribution width (PDW) were observed. Furthermore, estimated changes (95%CIs) in PLT, MPV, and PDW in response to each 10th percentile increment in the mixture of PM2.5 and its components were 0.8657 (0.2496, 1.4819), 0.0192 (0.0054, 0.0329), and -0.0648 (-0.0945, -0.0351), respectively, and sulfate in PM2.5 was the major contributor to those associations. Long-term exposure to PM2.5 and its components was related to increased platelet disorders among shift workers without air purifier use, and those associations were mainly attributed to sulfate in PM2.5.

Association between exposure to specific PM2.5 constituents and environment, lifestyle, and clinical parameters in patients with COPD

This study investigated the correlation between the individual chemical constituents of particulate matter 2.5 μm (PM2.5) and respiratory parameters as well as the living environment and daily behaviors in patients with chronic obstructive pulmonary disease (COPD). Data were obtained from prospective COPD panel conducted in South Korea. Following collection via a microPEM, 18 metallic elements were determined using energy-dispersive X-ray fluorescence spectroscopy. All participants completed detailed questionnaires on living environments and lifestyle practices. Eighty-nine stable COPD patients (mean age 68.1 years; 94.4% male) were analyzed. Several constituents (titanium, aluminum, bromine, and silicone) were significantly associated with respiratory outcomes. Copper and manganese concentrations were significantly associated with the living environment. Increased ventilation time and air purifier operation were associated with lower concentrations of copper, silicone, barium, and titanium. These findings suggest varying relationships between PM2.5 constituents and clinical parameters in COPD patients, providing a basis for personalized interventions and future research.

Randomized trial in rural Native American homes heated with wood stoves: results from the EldersAIR study

Residential wood burning has both practical and traditional value among many indigenous communities of the United States Mountain West, although household biomass burning also results in emissions that are harmful to health. In a household-level three-arm placebo-controlled randomized trial we tested the efficacy of portable filtration units and education interventions on improving pulmonary function and blood pressure measures among elder participants that use wood stoves for residential heating. A total of 143 participants were assigned to the Education (n=49), Filter (n=47), and Control (n=47) arms. Blood pressure and spirometry measures were collected multiple times during a per-intervention winter period and during a follow-up post-intervention winter period. Despite strong PM2.5 exposure reduction results with the Filter arm (50% lower compared to Control arm), neither this intervention nor the Education intervention translated to improvements in the selected health measures among this population with a mixture of chronic conditions. Intention to treat analysis failed to demonstrate evidence that either of the intervention arms had beneficial effects on the blood pressure or the spirometry measures. Post-hoc evaluation of effect modification for blood pressure and spirometry outcomes did not reveal any interaction influence on the outcomes according to sex, residential smoking, chronic disease history and study area.

Biomass fuels related-PM2.5 promotes lung fibroblast-myofibroblast transition through PI3K/AKT/TRPC1 pathway

Emerging evidence has suggested that exposure to PM2.5 is a significant contributing factor to the development of chronic obstructive pulmonary disease (COPD). However, the underlying biological effects and mechanisms of PM2.5 in COPD pathology remain elusive. In this study, we aimed to investigate the implication and regulatory effect of biomass fuels related-PM2.5 (BRPM2.5) concerning the pathological process of fibroblast-to-myofibroblast transition (FMT) in the context of COPD. In vivo experimentation revealed that exposure to biofuel smoke was associated with airway inflammation in rats. After 4 weeks of exposure, there was inflammation in the small airways, but no significant structural changes in the airway walls. However, after 24 weeks, airway remodeling occurred due to increased collagen deposition, myofibroblast proliferation, and tracheal wall thickness. In vitro, cellular immunofluorescence results showed that with stimulation of BRPM2.5 for 72 h, the cell morphology of fibroblasts changed significantly, most of the cells changed from spindle-shaped to star-shaped irregular, α-SMA stress fibers appeared in the cytoplasm and the synthesis of type I collagen increased. The collagen gel contraction experiment showed that the contractility of fibroblasts was enhanced. The expression level of TRPC1 in fibroblasts was increased. Specific siRNA-TRPC1 blocked BRPM2.5-induced FMT and reduced cell contractility. Additionally, specific siRNA-TRPC1 resulted in a decrease in the augment of intracellular Ca2+ concentration ([Ca2+]i) induced by BRPM2.5. Notably, it was found that the PI3K inhibitor, LY294002, inhibited enhancement of AKT phosphorylation level, FMT occurrence, and elevation of TRPC1 protein expression induced by BRPM2.5. The findings indicated that BRPM2.5 is capable of inducing the FMT, with the possibility of mediation by PI3K/AKT/TRPC1. These results hold potential implications for the understanding of the molecular mechanisms involved in BRPM2.5-induced COPD and may aid in the development of novel therapeutic strategies for pathological conditions characterized by fibrosis.

Association between cooking fuel exposure and respiratory health: Longitudinal evidence from the China Health and Retirement Longitudinal Study (CHARLS)

The epidemiological evidences for the association between cooking fuel exposure and respiratory health were inconsistent, and repeated-measures prospective evaluation of cooking fuel exposure was still lacking. We assessed the longitudinal association of chronic lung disease (CLD) and lung function with cooking fuel types among Chinese adults aged ≥ 40 years. In this prospective, nationwide representative cohort of the China Health and Retirement Longitudinal Study from 2011 to 2018, 9004 participants from 28 provinces in China were included. CLD was identified based on self-reported physician diagnosis in 2018. Lung function was assessed by peak expiratory flow (PEF) in 2011, 2013 and 2015. Multivariable logistic and linear mixed-effects repeated-measures models were conducted to measure the associations of CLD and PEF with cooking fuel types. Three-level mixed-effects model was performed as sensitivity analysis. Among the participants, 3508 and 3548 participants used persistent solid and clean cooking fuels throughout the survey, and 1948 participants who used solid cooking fuels at baseline switched to clean cooking fuels. Use of persistent clean cooking fuels (adjusted odds ratio [aOR] = 0.73, 95 % confidence interval [CI]: 0.61, 0.88) and switch of solid fuels to clean fuels (aOR = 0.81, 95 % CI: 0.67, 0.98) were associated with lower risk of CLD. The use of clean cooking fuels throughout the survey and switch of solid fuels to clean fuels in 2013 were also significantly associated with higher PEF level. Similar results were observed in stratified analyses and different statistical models. The evidence from CHARLS cohort suggested that reducing solid cooking fuel exposure was associated with lower risk of CLD and better lung function. Given the recent evidence, improving household air quality will reduce the burden of chronic lung diseases.

COPD Exposed to Air Pollution: A Path to Understand and Protect a Susceptible Population

TOPIC IMPORTANCE

Air pollution poses a risk to the respiratory health of individuals with COPD. Long- and short-term exposures to higher levels of particulate-rich air pollution are associated with increased COPD exacerbation, hospitalization, and mortality, collectively implicating air pollution as a cause of adverse COPD-related outcomes.

REVIEW FINDINGS

This review summarizes the evidence for COPD as a phenotype that confers susceptibility for adverse health outcomes in the face of common air pollution. We highlight how typical contributors to compromised urban air quality, including that from traffic, wildfire smoke, and indoor biomass combustion, adversely affect the COPD patient population. Evidence underscoring the burden of ongoing air pollution exposure on patients with COPD is discussed. We then detail the detrimental impact of that exposure on COPD pathophysiology, which in turn increases the patient's susceptibility. We specifically propose that indoor air is a particularly rational target for increased monitoring and remediation to protect patients with COPD. Because COPD is a heterogeneous disease with several endotypes, future intervention studies need to better include control populations, to highlight COPD-specific risks and identify subpopulations within patients with COPD who will benefit the most from improved indoor air quality.

SUMMARY

Regulatory efforts must continue to broadly lower emission standards to protect this susceptible population from the negative health impacts of air pollution.

Pulmonary vascular disease, environmental pollution, and climate change

Pollution and climate change constitute a combined, grave and pervasive threat to humans and to the life-support systems on which they depend. Evidence shows a strong association between pollution and climate change on cardiovascular and respiratory diseases, and pulmonary vascular disease (PVD) is no exception. An increasing number of studies has documented the impact of environmental pollution and extreme temperatures on pulmonary circulation and the right heart, on the severity and outcomes of patients with pulmonary arterial hypertension and chronic thromboembolic pulmonary hypertension (PH), on the incidence of pulmonary embolism, and the prevalence and severity of diseases associated with PH. Furthermore, the downstream consequences of climate change impair health care systems' accessibility, which could pose unique obstacles in the case of PVD patients, who require a complex and sophisticated network of health interventions. Patients, caretakers and health care professionals should thus be included in the design of policies aimed at adaptation to and mitigation of current challenges, and prevention of further climate change. The purpose of this review is to summarize the available evidence concerning the impact of environmental pollution and climate change on the pulmonary circulation, and to propose measures at the individual, healthcare and community levels directed at protecting patients with PVD.

Bronchiolitis recovery and the use of High Efficiency Particulate Air (HEPA) Filters (The BREATHE Study): study protocol for a multi-center, parallel, double-blind, randomized controlled clinical trial

BACKGROUND

Acute viral bronchiolitis is the most common reason for hospitalization of infants in the USA. Infants hospitalized for bronchiolitis are at high risk for recurrent respiratory symptoms and wheeze in the subsequent year, and longer-term adverse respiratory outcomes such as persistent childhood asthma. There are no effective secondary prevention strategies. Multiple factors, including air pollutant exposure, contribute to risk of adverse respiratory outcomes in these infants. Improvement in indoor air quality following hospitalization for bronchiolitis may be a prevention opportunity to reduce symptom burden. Use of stand-alone high efficiency particulate air (HEPA) filtration units is a simple method to reduce particulate matter ≤ 2.5 µm in diameter (PM2.5), a common component of household air pollution that is strongly linked to health effects.

METHODS

BREATHE is a multi-center, parallel, double-blind, randomized controlled clinical trial. Two hundred twenty-eight children < 12 months of age hospitalized for the first time with bronchiolitis will participate. Children will be randomized 1:1 to receive a 24-week home intervention with filtration units containing HEPA and carbon filters (in the child's sleep space and a common room) or to a control group with units that do not contain HEPA and carbon filters. The primary objective is to determine if use of HEPA filtration units reduces respiratory symptom burden for 24 weeks compared to use of control units. Secondary objectives are to assess the efficacy of the HEPA intervention relative to control on (1) number of unscheduled healthcare visits for respiratory complaints, (2) child quality of life, and (3) average PM2.5 levels in the home.

DISCUSSION

We propose to test the use of HEPA filtration to improve indoor air quality as a strategy to reduce post-bronchiolitis respiratory symptom burden in at-risk infants with severe bronchiolitis. If the intervention proves successful, this trial will support use of HEPA filtration for children with bronchiolitis to reduce respiratory symptom burden following hospitalization.

TRIAL REGISTRATION

NCT05615870. Registered on November 14, 2022.

The Changing and Predicted Trends in Chronic Obstructive Pulmonary Disease Burden in China, the United States, and India from 1990 to 2030

Background

This study analyzed the burden of chronic obstructive pulmonary disease (COPD) in China, the United States, and India from 1990 to 2019 and projected the trends for the next decade.

Methods

This study utilized the GBD 2019 to compare the age-standardized incidence rate (ASIR), age-standardized mortality rate (ASMR), age-standardized disability-adjusted life years (DALYs) rate, and the proportion attributed to different risk factors in China, the United States, and India. Joinpoint models and autoregressive integrated moving average (ARIMA) models were employed to capture the changing trends in disease burden and forecast outcomes.

Results

From 1990 to 2019, China's age-standardized COPD incidence and mortality rates decreased by 29% and 70%, respectively. In the same period, India's rates decreased by 8% and 33%, while the United States saw an increase of 9% in COPD incidence and a 22% rise in mortality rates. Smoking and ambient particulate matter pollution are the two most significant risk factors for COPD, while household air pollution from solid fuels and low temperatures are the least impactful factors in the United States and India, respectively. The proportion of risk from household air pollution from solid fuels is higher in India than in China and the United States. Predictions for 2030 suggest that the age-standardized DALY rates, ASIR, and ASMR in the United States and India are expected to remain stable or decrease, while China's age-standardized incidence rate is projected to rise.

Conclusion

Over the past three decades, the incidence of COPD has been decreasing in China and India, while showing a slight increase in the United States. Smoking and ambient particulate matter pollution are the primary risk factors for men and women, respectively. The risk of household air pollution from solid fuels in India needs attention.

A systematic review and meta-analysis of field studies of portable air cleaners: Performance, user behavior, and by-product emissions

Indoor air quality is important for the health of building occupants, and public interest in controlling indoor airborne pathogens increased dramatically with the COVID-19 pandemic. Pollutant concentrations can be controlled locally using portable air cleaners (sometimes called air purifiers), which allow occupants to apply air cleaning technology to meet their needs in the location and times that they find appropriate. This paper provides a systematic review of scientific literature that describes field studies of the effectiveness of portable air cleaners. Over 500 papers were considered, and 148 were reviewed in detail, to extract 35 specific research results (e.g., particulate removal performance) or characteristics (e.g., type of building). These were aggregated to provide an overview of results and approaches to this type of research, and to provide meta-analyses of the results. The review includes: descriptions of the geographical location of the research; rate of publications over time; types of buildings and occupants in the field study; types of air cleaner technology being tested; pollutants being measured; resulting pollutant removal effectiveness; patterns of usage and potential barriers to usage by occupants; and the potential for by-product emissions in some air cleaner technologies. An example result is that 83 of the 148 papers measured reductions in fine particulates (PM2.5) and found a mean reduction of 49 % with standard deviation of 20 %. The aggregated results were approximately normally distributed, ranging from finding no significant reduction up to a maximum above 90 % reduction. Sixteen of the 148 papers considered gaseous pollutants, such as volatile organic compounds, nitrogen dioxide, and ozone; 36 papers considered biological pollutants, such as bacteria, viruses, pollen, fungi, etc. An important challenge, common to several studies, is that occupants run the air cleaners for shorter periods and on low airflow rate settings, because of concerns about noise, drafts, and electricity cost, which significantly reduces air cleaning effectiveness.

Indoor particulate matter concentrations and air cleaner intervention association with biomarkers in former smokers with COPD

BACKGROUND

Indoor pollutants have been associated with worse clinical outcomes in chronic obstructive pulmonary disease (COPD). Elevated biomarkers are associated with ambient pollution exposure, however the association with indoor pollution remains unclear.

METHODS

Former smokers with spirometry-confirmed COPD were randomized to portable air cleaner or placebo. Indoor particulate matter (PM2.5, PM10, and ultrafine particles [UFP; PM<0.1]) and biomarkers were measured longitudinally at pre-specified intervals and course PM fraction (PM10-2.5) was calculated. Biomarkers were categorized based on associations with biologic mechanisms: inflammation (white blood cell count, interleukin [IL]-6, IL-8, IL-1β, tumor necrosis factor-α, interferon-γ, serum amyloid A), platelet activation (P-selectin, CD40 ligand [CD40L], 11-dehdydro-thromboxane-B2 [11dTxB2]), endothelial dysfunction (Vascular Cell Adhesion Molecule [VCAM]-1, Intercellular Adhesion Molecule [ICAM]-1), and oxidative stress (thiobarbituric acid reactive substances [TBARS], 8-hydroxydeoxyguanosine, 8-isoprostane). Associations between PM concentrations and each biomarker were analyzed using multivariable linear mixed models. An intention-to-treat analysis was performed to evaluate the air cleaner intervention on the biomarker levels longitudinally.

RESULTS

Fifty-eight participants were randomized to each group. Finer PM was more strongly associated with higher IL-8 (mean difference per doubling: UFP 13.9% [p = 0.02], PM2.5 6.8% [p = 0.002], PM10-2.5 5.0% [p = 0.02]) while interferon-γ was associated with UFP and IL-1β with PM10-2.5. UFP and PM2.5 were associated with elevated levels of the oxidative stress biomarkers TBARS and 8-isoprostane respectively. For platelet activation markers, UFP was associated with higher 11dTxB2 while PM2.5 was associated with higher P-selectin and CD40L. Pollutants were not associated with biomarkers of endothelial dysfunction. In intention-to-treat analysis there was no association of the air cleaner intervention with any of the biomarkers.

DISCUSSION

Among former smokers with COPD, elevated levels of indoor air pollutants, particularly ultrafine particles (PM<0.1), were associated with elevated biomarkers of inflammation, platelet activation, and oxidative stress. However, an air cleaner intervention that reduced PM did not significantly reduce biomarker levels.

Clinical Medicine and Climate Change

The health care system contributes substantially to global greenhouse gas emissions, a driver of climate change. At the same time, climate change has caused disruptions in health care delivery. In this article, the authors describe both how the health care industry contributes to climate change and how climate change affects patient care. The authors also provide clinical recommendations for health care practitioners to counsel patients on health effects of climate change and underscore the need for developing the workforce needed to respond to unique health care delivery challenges resulting from climate-related factors.

Protocol for the air purification for eosinophilic COPD study (APECS): a randomised controlled trial of home air filtration by HEPA

INTRODUCTION

Exposure to particulate matter (PM) pollution has been associated with lower lung function in adults with chronic obstructive pulmonary disease (COPD). Patients with eosinophilic COPD have been found to have higher levels of airway inflammation, greater responsiveness to anti-inflammatory steroid inhalers and a greater lung function response to PM pollution exposure compared with those with lower eosinophil levels. This study will evaluate if reducing home PM exposure by high-efficiency particulate air (HEPA) air filtration improves respiratory health in eosinophilic COPD.

METHODS AND ANALYSIS

The Air Purification for Eosinophilic COPD Study (APECS) is a double-blinded randomised placebo-controlled trial that will enrol 160 participants with eosinophilic COPD living in the area of Boston, Massachusetts. Real and sham air purifiers will be placed in the bedroom and living rooms of the participants in the intervention and control group, respectively, for 12 months. The primary trial outcome will be the change in forced expiratory volume in 1 s (FEV1). Lung function will be assessed twice preintervention and three times during the intervention phase (at 7 days, 6 months and 12 months postrandomisation). Secondary trial outcomes include changes in (1) health status by St. George's Respiratory Questionnaire; (2) respiratory symptoms by Breathlessness, Cough and Sputum Scale (BCSS); and (3) 6-Minute Walk Test (6MWT). Inflammatory mediators were measured in the nasal epithelial lining fluid (NELF). Indoor PM will be measured in the home for the week preceding each study visit. The data will be analysed to contrast changes in outcomes in the intervention and control groups using a repeated measures framework.

ETHICS AND DISSEMINATION

Ethical approval was obtained from the Institutional Review Board of Beth Israel Deaconess Medical Centre (protocol #2019P0001129). The results of the APECS trial will be presented at scientific conferences and published in peer-reviewed journals.

TRIAL REGISTRATION

NCT04252235. Version: October 2023.

Effectiveness of filtering or decontaminating air to reduce or prevent respiratory infections: A systematic review

Installation of technologies to remove or deactivate respiratory pathogens from indoor air is a plausible non-pharmaceutical infectious disease control strategy.

OBJECTIVE

We undertook a systematic review of worldwide observational and experimental studies, published 1970-2022, to synthesise evidence about the effectiveness of suitable indoor air treatment technologies to prevent respiratory or gastrointestinal infections.

METHODS

We searched for data about infection and symptom outcomes for persons who spent minimum 20 h/week in shared indoor spaces subjected to air treatment strategies hypothesised to change risk of respiratory or gastrointestinal infections or symptoms.

RESULTS

Pooled data from 32 included studies suggested no net benefits of air treatment technologies for symptom severity or symptom presence, in absence of confirmed infection. Infection incidence was lower in three cohort studies for persons exposed to high efficiency particulate air filtration (RR 0.4, 95%CI 0.28-0.58, p < 0.001) and in one cohort study that combined ionisers with electrostatic nano filtration (RR 0.08, 95%CI 0.01-0.60, p = 0.01); other types of air treatment technologies and air treatment in other study designs were not strongly linked to fewer infections. The infection outcome data exhibited strong publication bias.

CONCLUSIONS

Although environmental and surface samples are reduced after air treatment by several air treatment strategies, especially germicidal lights and high efficiency particulate air filtration, robust evidence has yet to emerge that these technologies are effective at reducing respiratory or gastrointestinal infections in real world settings. Data from several randomised trials have yet to report and will be welcome to the evidence base.

Systemic inflammation mediates environmental polycyclic aromatic hydrocarbons to increase chronic obstructive pulmonary disease risk in United States adults: a cross-sectional NHANES study

Introduction

This study explored the relationship between environmental polycyclic aromatic hydrocarbons (PAHs) and Chronic obstructive pulmonary disease (COPD), and identified systemic inflammation as a mediator of the increased risk of COPD from PAHs.

Methods

Data were obtained from 60,936 middle-aged and older Americans recruited in the National Health and Nutrition Examination Survey 2005-2016. Environmental PAHs were measured in terms of urinary concentrations of PAHs metabolites (NAP: 1-hydroxynaphthalene, FLU: 2-hydroxyfluorene, PA: 1-hydroxyphenanthrene, and PYR: 1-hydroxypyrene). We used multifactor logical analysis to figure out the link between PAHs and COPD, and the non-linear relationship was examined using Restricted cubic spline. Spearman correlation analysis was utilized to analyze the connection between PAHs and systemic immune-inflammation index (SII).

Results

The results showed that the COPD population had higher NAP (3.550 vs. 3.282, p < 0.001), FLU (2.501 vs. 2.307, p < 0.001), PA (2.155 vs. 2.082, p = 0.005), and PYR (2.013 vs. 1.959, p = 0.008) levels than non-COPD population. In unadjusted logistics analysis, the risk of COPD with log NAP was higher [OR = 1.461, 95% CI (1.258-1.698), p < 0.001]. Upon taking into account, confounders like sex, age, race, and log NAP still increased a possible COPD risk [OR = 1.429, 95% CI (1.224-1.669), p < 0.001]. Similarly, FLU, PA, and PYR significantly increased the risk of COPD (all OR > 1, p < 0.05), both unadjusted and adjusted. Furthermore, Restricted cubic spline demonstrated a strong link between PAHs levels and COPD risk (p < 0.05). Additionally, a Spearman correlation analysis revealed a favorable association between log FLU and log SII (R = 0.43, p = 0.006), while NAP, PA, and PYR levels were not associated with log SII (all p > 0.05). Ultimately, the mediating effect analysis revealed a mediating effect capacity of 5.34% for the SII-mediated association between FLU and COPD.

Conclusion

The findings suggest that the risk of COPD is significantly increased when environmental PAHs exposure is at high levels, and that systemic inflammation may be involved in the process.

Indoor Pollution and Lung Function Decline in Current and Former Smokers: SPIROMICS AIR

Rationale: Indoor pollutants have been associated with chronic obstructive pulmonary disease morbidity, but it is unclear whether they contribute to disease progression. Objectives: We aimed to determine whether indoor particulate matter (PM) and nitrogen dioxide (NO2) are associated with lung function decline among current and former smokers. Methods: Of the 2,382 subjects with a history of smoking in SPIROMICS AIR, 1,208 participants had complete information to estimate indoor PM and NO2, using individual-based prediction models, in relation to measured spirometry at two or more clinic visits. We used a three-way interaction model between time, pollutant, and smoking status and assessed the indoor pollutant-associated difference in FEV1 decline separately using a generalized linear mixed model. Measurements and Main Results: Participants had an average rate of FEV1 decline of 60.3 ml/yr for those currently smoking compared with 35.2 ml/yr for those who quit. The association of indoor PM with FEV1 decline differed by smoking status. Among former smokers, every 10 μg/m3 increase in estimated indoor PM was associated with an additional 10 ml/yr decline in FEV1 (P = 0.044). Among current smokers, FEV1 decline did not differ by indoor PM. The results of indoor NO2 suggest trends similar to those for PM ⩽2.5 μm in aerodynamic diameter. Conclusions: Former smokers with chronic obstructive pulmonary disease who live in homes with high estimated PM have accelerated lung function loss, and those in homes with low PM have lung function loss similar to normal aging. In-home PM exposure may contribute to variability in lung function decline in people who quit smoking and may be a modifiable exposure.

Randomised controlled trial of a behavioural intervention to reduce exposure to PM2.5 in patients with COPD

BACKGROUND

Fine particulate matter (PM2.5) is a well-known risk factor for worse outcomes of chronic obstructive pulmonary disease (COPD). However, evidence-based guidance on effective personal behavioural strategies to minimise the effects of PM2.5 is limited. This study aimed to assess the effectiveness of a behavioural intervention in reducing PM2.5 exposure and improving clinical outcomes in patients with COPD.

MATERIALS AND METHODS

Participants were 1:1 randomised, and the intervention group received a behavioural intervention consisting of five activities, while the control group received usual care. The participants were followed up for 9 months. The primary outcomes were differences in the score of St. George's Respiratory Questionnaire for patients with COPD (SGRQ-C) and COPD assessment test (CAT) from baseline.

RESULTS

A total of 106 participants were enrolled and 102 completed the study. At the end of the study, the intervention group showed significant improvements in the primary outcomes compared to the control group, with a group difference of -5.9 in the reduction of total SGRQ-C (-3.4 vs. 2.5; p = 0.049) and -3.8 in the CAT score (-1.2 vs. 2.7; p = 0.001). Participants with good adherence to the intervention demonstrated a greater extent of improvement in CAT score and lower PM2.5 levels compared to those who had poor adherence or were in the control group. Regular checking of air quality forecasts was significantly associated with a reduction in CAT scores among all the intervention activities.

CONCLUSION

Individual-level behavioural interventions can be an effective strategy for mitigating the health hazards associated with PM2.5.

CLINICALTRIALS

gov Identifier: NCT04878367.

Global Chronic obstructive pulmonary disease burden attributable to air pollution from 1990 to 2019

BACKGROUND

The disease burden attributable to chronic obstructive pulmonary disease (COPD) is significant worldwide. Some studies have linked exposure to air pollution to COPD, but there has been little research on this.

METHODS

We aimed to assess the COPD-related disease burden attributable to air pollution from multiple epidemiological perspectives. This study conducted a three-stage analysis. Firstly, we reported on the burden of disease worldwide in 2019 by different subgroups including sex, age, region, and country. Secondly, we studied the trends in disease burden from 1990 to 2019. Finally, we explored the association of some national indicators with disease burden to look for risk factors.

RESULTS

In 2019, the death number of COPD associated with air pollution accounted for 2.32% of the total global death, and the number of DALY accounted for 1.12% of the global DALY. From 1990 to 2019, the death number of COPD associated with air pollution increased peaked at 1.41 million in 1993, fluctuated, and then declined. We found the same temporal pattern of DALY. The corresponding age-standardized rates had been falling. At the same time, the burden of COPD associated with air pollution was also affected by some national indicators.

CONCLUSIONS

This study indicated that air pollution-related COPD contributed to a significant global disease burden. We called for health policymakers to take action and interventions targeting vulnerable countries and susceptible populations.

Decreased Cardiac Autonomic Function is Associated with Higher Exacerbation Risk and Symptom Burden in Chronic Obstructive Pulmonary Disease

Current measures of chronic obstructive pulmonary disease (COPD) severity, including lung function, do not fully explain symptom burden, and there is a need to identify predictors of exacerbation risk and morbidity. Autonomic dysfunction may be implicated in both cardiovascular and respiratory morbidity in COPD and convey risk for exacerbations. Heart rate variability (HRV) is a marker of cardiac autonomic function that is predictive of cardiovascular health and has promise as a non-invasive COPD biomarker. The CLEAN AIR Heart study provided an opportunity to investigate the association between HRV and COPD morbidity among former smokers with moderate-severe COPD. Eighty-five participants, contributing 305 HRV measurements, underwent repeated clinical assessments over 4 study periods that included a 24-Holter monitoring assessment of HRV. HRV measures of interest were standard deviation of normal-to-normal intervals, (SDNN) (overall HRV) and root-mean-square of successive differences (RMSSD) (parasympathetic function). Exacerbation risk was assessed using negative binomial models, and mixed-effects models analyzed associations between HRV and symptoms. Decreases in SDNN (incidence rate ratio [IRR]1.40; 95% confidence interval [CI] 1.13 to1.74) and RMSSD (IRR 1.60; 95% CI 1.07 to 2.37) were associated with severe exacerbation risk. Decreases in SDNN were associated with higher St George's Respiratory Questionnaire scores, COPD Assessment Test scores, and chronic bronchitis symptoms. Findings demonstrate that HRV is associated with COPD symptom burden and exacerbation risk. HRV may represent an important biomarker with the potential to identify high-risk COPD populations.

Air pollution and COPD: GOLD 2023 committee report

Exposure to air pollution is a major contributor to the pathogenesis of COPD worldwide. Indeed, most recent estimates suggest that 50% of the total attributable risk of COPD may be related to air pollution. In response, the Global Initiative for Chronic Obstructive Lung Disease (GOLD) Scientific Committee performed a comprehensive review on this topic, qualitatively synthesised the evidence to date and proffered recommendations to mitigate the risk. The review found that both gaseous and particulate components of air pollution are likely contributors to COPD. There are no absolutely safe levels of ambient air pollution and the relationship between air pollution levels and respiratory events is supra-linear. Wildfires and extreme weather events such as heat waves, which are becoming more common owing to climate change, are major threats to COPD patients and acutely increase their risk of morbidity and mortality. Exposure to air pollution also impairs lung growth in children and as such may lead to developmental COPD. GOLD recommends strong public health policies around the world to reduce ambient air pollution and for implementation of public warning systems and advisories, including where possible the use of personalised apps, to alert patients when ambient air pollution levels exceed acceptable minimal thresholds. When household particulate content exceeds acceptable thresholds, patients should consider using air cleaners and filters where feasible. Air pollution is a major health threat to patients living with COPD and actions are urgently required to reduce the morbidity and mortality related to poor air quality around the world.

Principal stratification analysis to determine health benefit of indoor air pollution reduction in a randomized environmental intervention in COPD: Results from the CLEAN AIR study

BACKGROUND

Indoor air quality represents a modifiable exposure to Chronic Obstructive Pulmonary Disease (COPD) health. In a randomized controlled trial (CLEAN AIR study), air cleaner assignment had causal effect in improving COPD outcomes. It is unclear, however, what is the treatment effect among those for whom intervention reduced air pollution and whether it was reduction in fine particulate matter (PM2.5) or nitrogen dioxide (NO2) that contributed to such improvement. Because pollution is a posttreatment variable, treatment effect cannot be assessed while controlling for pollution using intention-to-treat (ITT) analysis.

OBJECTIVE

Using principal stratification method, we assess indoor pollutants as the intermediate variable, and determine the causal effect of reducing indoor air pollution on COPD health.

METHOD

In randomized controlled trial, former smokers with COPD received either active or placebo HEPA air cleaners and were followed for 6 months. Saint George's Respiratory Questionnaire (SGRQ) was the primary outcome and secondary measures included SGRQ subscales, COPD assessment test (CAT), dyspnea (mMRC), and breathlessness, cough, and sputum scale (BCSS). Indoor PM2.5 and NO2 were measured. Principal stratification analysis was performed to assess the treatment effect while controlling for pollution reduction.

RESULTS

Among those showing at least 40 % PM2.5 reduction through air cleaners, the intervention showed improvement in respiratory symptoms for the active (vs. placebo), and the size of treatment effect shown for this subgroup was larger than that for the overall sample. In this subgroup, those with active air cleaners (vs. placebo) showed 7.7 points better SGRQ (95%CI: -14.3, -1.1), better CAT (β = -5.5; 95%CI: -9.8, -1.2), mMRC (β = -0.6; 95%CI: -1.1, -0.1), and BCSS (β = -1.8; 95%CI: -3.0, -0.5). Among those showing at least 40 % NO2 reduction through air cleaners, there was no intervention difference in outcomes.

CONCLUSION

Air cleaners caused clinically significant improvement in respiratory health for individuals with COPD through reduction in indoor PM2.5.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT02236858.

Can individual protective measures safeguard cardiopulmonary health from air pollution? A systematic review and meta-analysis

Evidence supporting the effect of individual protective measures (IPMs) on air pollution is relatively scarce. In this study, we performed a systematic review and meta-analysis to investigate the effects of air purifiers, air-purifying respirators, and cookstove changes on cardiopulmonary health outcomes. We searched PubMed, Scopus, and Web of Science until December 31, 2022, 90 articles and 39,760 participants were included. Two authors independently searched and selected the studies, extracted information, and assessed each study's quality and risk of bias. We performed meta-analyses when three or more studies were available for each IPMs, with comparable intervention and health outcome. Systematic review showed that IPMs were beneficial in children and elderly with asthma along with healthy individuals. Meta-analysis results showed a reduction in cardiopulmonary inflammation using air purifiers than in control groups (with sham/no filter) with a decrease in interleukin 6 by -0.247 μg/mL (95% confidence intervals [CI] = -0.413, -0.082). A sub-group analysis for air purifier as an IPMs in developing counties reduced fractional exhaled nitric oxide by -0.208 ppb (95% confidence intervals [CI] = -0.394, -0.022). However, evidence describing the effects of air purifying respirator and cook stove changes on cardiopulmonary outcomes remained insufficient. Therefore, air purifiers can serve as efficient IPMs against air pollution. The beneficial effect of air purifiers is likely to have a greater effect in developing countries than in developed countries.

Indoor Air Pollution and Impaired Cardiac Autonomic Function in Chronic Obstructive Pulmonary Disease

Rationale: Indoor air pollution represents a modifiable risk factor for respiratory morbidity in chronic obstructive pulmonary disease (COPD). The effects of indoor air pollution, as well as the impact of interventions to improve indoor air quality, on cardiovascular morbidity in COPD remain unknown. Objectives: To determine the association between indoor particulate matter (PM) and heart rate variability (HRV), a measure of cardiac autonomic function tied to cardiovascular morbidity and mortality, as well as the impact of household air purifiers on HRV. Methods: Former smokers with moderate-severe COPD were recruited from a 6-month randomized controlled trial of a portable air cleaner intervention to undergo paired assessment of both in-home PM and HRV using 24-hour Holter monitoring at up to five time points. Primary outcomes were HRV measures tied to cardiovascular morbidity (standard deviation of normal-to-normal intervals [SDNN] and root mean square of successive differences between normal-to-normal intervals [RMSSD]). Measurements and Results: Eighty-five participants contributed 317 HRV measurements. A twofold increase in household PM ⩽2.5 µm in aerodynamic diameter was associated with decreases in SDNN (β, -2.98% [95% confidence interval (CI), -5.12 to -0.78]) and RMSSD (β, -4.57% [95% CI, -10.1 to -1.60]). The greatest effects were observed with ultrafine particles (<100 nm) (RMSSD; β, -16.4% [95% CI, -22.3 to -10.1]) and among obese participants. Participants randomized to the active air cleaner saw improvements in RMSSD (β, 25.2% [95% CI, 2.99 to 52.1]), but not SDNN (β, 2.65% [95% CI, -10.8 to 18.1]), compared with the placebo group. Conclusions: This is the first U.S. study to describe the association between household PM and cardiac autonomic function among individuals with COPD, as well as the potential cardiovascular health benefits of household air cleaners.

Contemporary Concise Review 2022: Chronic obstructive pulmonary disease

International respiratory organizations now recommend using lower limit of normal and standardized residuals to diagnose airflow obstruction and COPD though using a fixed ratio <0.7 is simpler and robustly predicts important clinical outcomes. The most common COPD comorbidities are coronary artery calcification, emphysema and bronchiectasis. COPD patients with psychological (high anxiety and depression) and cachectic (underweight and osteoporotic) comorbidity have higher mortality and exacerbate more. Serum eosinophil count remains an important COPD biomarker and we have greater clarity about normal eosinophil levels in COPD and the wider population. Criteria for entry into COPD clinical trials continue to exclude many patients, in particular those at greater risk of exacerbation and death. The effect of hyperinflation on cardiac function impacts COPD mortality and is an important target for successful lung volume reduction procedures.

HEPA filtration intervention in classrooms may improve some students' asthma

OBJECTIVE

The School Inner-City Asthma Intervention Study 2 (SICAS 2) tested interventions to reduce exposures in classrooms of students with asthma. The objective of this post-hoc analysis was limited to evaluating the effect of high-efficiency particulate (HEPA) filtration interventions on mold levels as quantified using the Environmental Relative Moldiness Index (ERMI) and the possible improvement in the students' asthma, as quantified by spirometry testing.

METHODS

Pre-intervention dust samples were collected at the beginning of the school year from classrooms and corresponding homes of students with asthma (n = 150). Follow-up dust samples were collected in the classrooms at the end of the HEPA or Sham intervention. For each dust sample, ERMI values and the Group 1 and Group 2 mold levels (components of the ERMI metric) were quantified. In addition, each student's lung function was evaluated by spirometry testing, specifically the percentage predicted forced expiratory volume at 1 sec (FEV1%), before and at the end of the intervention.

RESULTS

For those students with a higher Group 1 mold level in their pre-intervention classroom than home (n = 94), the FEV1% results for those students was significantly (p < 0.05) inversely correlated with the Group 1 level in their classrooms. After the HEPA intervention, the average Group 1 and ERMI values were significantly lowered, and the average FEV1% test results significantly increased by an average of 4.22% for students in HEPA compared to Sham classrooms.

CONCLUSIONS

HEPA intervention in classrooms reduced Group 1 and ERMI values, which corresponded to improvements in the students' FEV1% test results.

Urine and Plasma Markers of Platelet Activation and Respiratory Symptoms in COPD

Introduction

Antiplatelet therapy has been associated with fewer exacerbations and reduced respiratory symptoms in chronic obstructive pulmonary disease (COPD). Whether platelet activation is associated with respiratory symptoms in COPD is unknown.

Methods

Former smokers with spirometry-confirmed COPD had urine 11-dehydro-thromboxane B2 (11dTxB2), plasma soluble CD40L (sCD40L), and soluble P-selectin (sP-selectin) repeatedly measured during a 6- to 9-month study period. Multivariate mixed-effects models adjusted for demographics, clinical characteristics, and medication use evaluated the association of each biomarker with respiratory symptoms, health status, and quality of life.

Results

Among 169 participants (average age 66.5±8.2 years, 51.5% female, 47.5±31 pack years, forced expiratory volume in 1 second percent predicted 53.8±17.1), a 100% increase in 11dTxB2 was associated with worse respiratory symptoms reflected by higher scores on the COPD Assessment Test (β 0.77, 95% confidence interval [CI]: 0.11-1.4) and Ease of Cough and Sputum Clearance Questionnaire β 0.77, 95%CI: 0.38-1.2, worse health status (Clinical COPD Questionnaire β 0.13, 95%CI: 0.03-0.23) and worse quality of life (St George's Respiratory Questionnaire β 1.9, 95%CI: 0.39-3.4). No statistically significant associations were observed for sCD40L or sP-selectin. There was no consistent statistically significant effect modification of the relationship between urine 11dTxB2 and respiratory outcomes by history of cardiovascular disease, subclinical coronary artery disease, antiplatelet therapy, or COPD severity.

Conclusions

In stable moderate-severe COPD, elevated urinary11dTxB2, a metabolite of the platelet activation product thromboxane A2, was associated with worse respiratory symptoms, health status, and quality of life.

Lung Effects of Household Air Pollution

Biomass fuel smoke, secondhand smoke, and oxides of nitrogen are common causes of household air pollution (HAP). Almost 2.4 billion people worldwide use solid fuels for cooking and heating, mostly in low- and middle-income countries. Wood combustion for household heating is also common in many areas of high-income countries, and minorities are particularly vulnerable. HAP in low- and middle-income countries is associated with asthma, acute respiratory tract infections in adults and children, chronic obstructive pulmonary disease, lung cancer, tuberculosis, and respiratory mortality. Although wood smoke exposure levels in high-income countries are typically lower than in lower-income countries, it is similarly associated with accelerated lung function decline, higher prevalence of airflow obstruction and chronic bronchitis, and higher all-cause and respiratory cause-specific mortality. Household air cleaners with high-efficiency particle filters have mixed effects on asthma and chronic obstructive pulmonary disease outcomes. Biomass fuel interventions in low-income countries include adding chimneys to cookstoves, improving biomass fuel combustion stoves, and switching fuel to liquid petroleum gas. Still, the impact on health outcomes is inconsistent. In high-income countries, strategies for reducing biomass fuel-related HAP are centered on community-level woodstove changeout programs, although the results are again inconsistent. In addition, initiatives to encourage home smoking bans have mixed success in households with children. Environmental solutions to reduce HAP have varying success in reducing pollutants and health problems. Improved understanding of indoor air quality factors and actions that prevent degradation or improve polluted indoor air may lead to enhanced environmental health policies, but health outcomes must be rigorously examined.

Towards the elimination of chronic obstructive pulmonary disease: a Lancet Commission

Despite substantial progress in reducing the global impact of many non-communicable diseases, including heart disease and cancer, morbidity and mortality due to chronic respiratory disease continues to increase. This increase is driven primarily by the growing burden of chronic obstructive pulmonary disease (COPD), and has occurred despite the identification of cigarette smoking as the major risk factor for the disease more than 50 years ago. Many factors have contributed to what must now be considered a public health emergency: failure to limit the sale and consumption of tobacco products, unchecked exposure to environmental pollutants across the life course, and the ageing of the global population (partly as a result of improved outcomes for other conditions). Additionally, despite the heterogeneity of COPD, diagnostic approaches have not changed in decades and rely almost exclusively on post-bronchodilator spirometry, which is insensitive for early pathological changes, underused, often misinterpreted, and not predictive of symptoms. Furthermore, guidelines recommend only simplistic disease classification strategies, resulting in the same therapeutic approach for patients with widely differing conditions that are almost certainly driven by variable pathophysiological mechanisms. And, compared with other diseases with similar or less morbidity and mortality, the investment of financial and intellectual resources from both the public and private sector to advance understanding of COPD, reduce exposure to known risks, and develop new therapeutics has been woefully inadequate.

Patterns and Predictors of Air Cleaner Adherence Among Adults with COPD

Rational

Poor indoor air quality has been associated with worse chronic obstructive pulmonary disease (COPD) morbidity. In-home portable air cleaners reduce indoor pollutants and could improve respiratory health. Factors associated with air cleaner adherence among adults with COPD remains unknown.

Methods

In a 6-month trial of former smokers with COPD, participants (n=116) received active or sham portable air cleaners. Air cleaner adherence was measured by electronic monitors. Potential baseline predictors of adherence included individual factors (demographics, socioeconomic status, smoking history, psychological well-being), COPD disease severity, and housing characteristics. Time and season were also considered. Stepwise logistic regression and longitudinal fixed effect analysis were performed to assess independent predictors of adherence.

Results

A total of 109 participants had an objective measure of adherence, and 76.1% used at least 1 air cleaner 80% of the time (defined a priori as adherent). Higher annual household income ≥$35,000 (odds ratio [OR]=4.4, 95% confidence interval [CI], 1.1-18.0) and use of heat pump/electricity (versus gas) for heating (OR=6.1, 95%CI, 1.7-22.4) were associated with higher odds of adherence. Further, poor quality of life (St George's Respiratory Questionnaire, per 10-point increase) and prior year exacerbations were associated with lower odds of adherence (OR=0.65, 95%CI, 0.4-1.0) and (OR=0.26, 95%CI, 0.1-0.9), respectively. Adherence was highest during the first month and lower during winter compared to other seasons.

Conclusion

These findings suggest that cold weather season, use of gas for home heating, and lower annual income negatively impact adherence. Poor quality of life and worse disease control may also decrease adherence. Addressing factors associated with air cleaner adherence should be considered when designing future environmental studies.

Effect of humidified high-flow nasal cannula oxygen therapy on respiratory function recovery in stable COPD patients

OBJECTIVE

To investigate the effect of humidified high-flow nasal cannula oxygen therapy (HFNC) on the application effect and respiratory functional recovery of stable COPD patients.

METHODS

The data of 116 patients with stable COPD treated in our hospital from March 2019 to January 2021 were analyzed retrospectively. Among them, 54 patients treated with conventional oxygen therapy (COT) were enrolled into the control group (CG), and the remaining 62 treated with HFNC were divided to the experimental group (EG). The clinical efficacy and adverse reactions of both groups were assessed, and the blood gas analysis indexes pH, PaO₂, PaCO₂, respiratory function indexes FEV1, FEV1%, FEV1/FVC, quality of life and motor recovery were compared.

RESULTS

After treatment, compared with the CG, the FEV1, FEV1% and FEV1/FVC in the EG were obviously higher (P<0.05). Besides, the pH and PaO₂ in the EG were markedly higher (P<0.05), while PaCO₂ was lower (P<0.05). The total effective rate, SGRQ scores and 6MWT in the EG were markedly higher than those in the CG (P<0.05), while the incidence of adverse reactions in the EG was lower (P<0.05).

CONCLUSION

HFNC can improve respiratory function and quality of life of stable COPD patients, with higher safety.