Effect of short-term, low-level nitrogen dioxide exposure on bronchial sensitivity of asthmatic patients

Laser-Deposited Carbon Aerogel Derived from Graphene Oxide Enables NO2-Selective Parts-per-Billion Sensing

Laser-deposited carbon aerogel is a low-density porous network of carbon clusters synthesized using a laser process. A one-step synthesis, involving deposition and annealing, results in the formation of a thin porous conductive film which can be applied as a chemiresistor. This material is sensitive to NO₂ compared to ammonia and other volatile organic compounds and is able to detect ultra-low concentrations down to at least 10 parts-per-billion. The sensing mechanism, based on the solubility of NO₂ in the water layer adsorbed on the aerogel, increases the usability of the sensor in practically relevant ambient environments. A heating step, achieved in tandem with a microheater, allows the recovery to the baseline, making it operable in real world environments. This, in combination with its low cost and scalable production, makes it promising for Internet-of-Things air quality monitoring.

Interaction of Copper Phthalocyanine with Nitrogen Dioxide and Ammonia Investigation Using X-ray Absorption Spectroscopy and Chemiresistive Gas Measurements

The interaction site of phthalocyanine (Pc) with nitrogen dioxide (NO₂) has been characterized using different methods and found to be conflicting. By knowing the interaction site, the Pc molecule can be better customized to improve the gas sensitivity. In this article, the interaction sites of copper phthalocyanine (CuPc) with oxidizing NO₂ or with reducing gas (ammonia, NH₃) were identified using in situ X-ray absorption spectroscopy (XAS). The sensitivity of CuPc to sub-ppm levels of the tested gases was established in the CuPc chemoresistive gas sensors. The analyte-sensor interaction sites were identified and validated by monitoring the Cu K-edge XAS before and during gas exposure. From the X-ray absorption near-edge structure and its first derivative, a low or lack of axial coordination on the Cu metal center of CuPc is evident. Using the extended X-ray absorption fine structure with molecular orbital information of the involved molecules, the macrocycle interaction between CuPc and NO₂ or NH₃ was proposed to be the dominant sensing mechanism on CuPc sensors.

Association between gaseous pollutants and emergency ambulance dispatches for asthma in Chengdu, China: a time-stratified case-crossover study

Objectives

The association between concentrations of sulfur dioxide (SO₂), nitrogen dioxide (NO₂), carbon monoxide (CO), ozone (O₃), and emergency ambulance dispatches (EADs) for asthma was explored in the central Sichuan Basin of southwestern China for the first time.

Methods

EADs for asthma were collected from the Chengdu First-Aid Command Center. Pollutant concentrations were collected from 24 municipal environmental monitoring centers and including SO₂, NO₂, CO, daily 8-h mean concentrations of O₃ (O₃-8 h), and particulate matter less than 2.5 μm in aerodynamic diameter (PM_2.5). The climatic data were collected from the Chengdu Municipal Meteorological Bureau. All data were collected from years spanning 2013–2017. A time-stratified case-crossover design was used to analyze the data.

Results

After controlling for temperature, relative humidity, and atmospheric pressure, IQR increases in SO₂ (13 μg/m³), NO₂ (17 μg/m³), and CO (498 μg/m³) were associated with 18.8%, 11.5%, and 3.1% increases in EADs for asthma, respectively. The associations were strongest for EADs and SO₂, NO₂, and CO levels with 3-, 5-, and 1-day lags, respectively.

Conclusions

This study provides additional data to the limited body of literature for potential health risks arising from ambient gaseous pollutants. The results of the study suggest that increased concentrations of SO₂, NO₂, and CO were positively associated with emergency ambulance dispatches for asthma in Chengdu, China. Further studies are needed to investigate the effects of individual air pollutants on asthma.

Exercise-Induced Bronchoconstriction and the Air We Breathe

An association between airway dysfunction and airborne pollutant inhalation exists. Volatilized airborne fluorocarbons in ski wax rooms, particulate matter, and trichloromines in indoor environments are suspect to high prevalence of exercise-induced bronchoconstriction and new-onset asthma in athletes competing in cross-country skiing, ice rink sports, and swimming. Ozone is implicated in acute decreases in lung function and the development of new-onset asthma from exposure during exercise. Mechanisms and genetic links are proposed for pollution-related new-onset asthma. Oxidative stress from airborne pollutant inhalation is a common thread to progression of airway damage. Key pollutants and mechanisms for each are discussed.

The Risk of Nitrogen Dioxide: What have we Learned from Epidemiological and Clinical Studies?

Nitrogen dioxide (NO2) is an oxidant gas which contaminates ambient air in many urban and industrial locations, and indoor air in homes with combustion appliances. The Environmental Protection Agency presently regulates NO2 in ambient air as a “criteria” pollutant. In spite of decades of laboratory, clinical, and epidemiological research, the health effects of NO2 exposure on humans are not well understood. The toxicological evidence suggests that increased susceptibility to infection, functional deficits from effects on airways, and deterioration of the status of persons with chronic respiratory conditions, including asthmatics, are of potential concern. This paper provides a perspective on the present evidence related to human health effects of NO2. It addresses methodological barriers that limit the available data; assesses the adequacy of the data for risk assessment; and proposes a research agenda to obtain needed information on the health effects of NO2.

Does Nitrogen Dioxide Exposure Increase Airways Responsiveness?

A number of reports have suggested that exposure to nitrogen dioxide (NO2) may cause increased airways responsiveness (AR). Twenty studies of asthmatics and five studies of healthy subjects exposed to NO2 were used to test this hypothesis using a simple method of meta-analysis. Individual data were obtained for the above studies and the direction of change in AR was determined for each subject. Only studies with available individual data were used. Subjects from these studies whose directional change in AR could not be determined were excluded. The fraction of positive responses (i.e. increased AR) was determined for all subjects within a group and tested for significance using a sign test. Data were also grouped according to NO2 concentration and by whether the exposure included exercise. There was an overall trend among asthmatics for AR to increase (60%) but this was primarily due to increased AR seen in resting exposures (70%). Among healthy subjects AR also increased with NO2 exposure but only at concentrations above 1.0 ppm. This analysis suggests that NO2 exposure causes increased airway responsiveness in healthy and asthmatic subjects but that exercise during exposure may modify this response in asthmatics.

Do individuals with asthma experience airway hyper-responsiveness after exposure to nitrogen dioxide?

The current 100 ppb short-term National Ambient Air Quality Standard for NO₂, and EPA's determination of a causal association for respiratory effects, are based in part on controlled human exposure studies evaluating airway hyper-responsiveness (AHR). A meta-analysis by Goodman et al. (2009) found increased AHR at 100 ppb NO₂ but no clear concentration-response relationship up to 600 ppb, and an overall lack of an AHR effect for studies involving exercise or exposure to allergens. Several factors have been suggested to explain why effects on AHR are observed while people are at rest, but not during exercise or after exposure to allergens. These include an exercise-induced refractory period; partial reversal of bronchospasm from use of forced expiration maneuvers; and greater airway responsiveness of participants exposed to NO₂ at rest. We reviewed the scientific evidence to determine whether there is biological support for these factors and found that none sufficiently explained the lack of an effect during exercise or after exposure to allergens. In the absence of either a consistent concentration-response or a plausible explanation for the paradoxical AHR findings, the biological significance of these findings is uncertain and provides equivocal support for NO₂ as a causal factor of AHR at these exposure levels.

On the road to recovery: Gasoline content regulations and child health

Gasoline content regulations are designed to curb pollution and improve health, but their impact on health has not been quantified. By exploiting both the timing of regulation and spatial variation in children's exposure to highways, I estimate the effect of gasoline content regulation on pollution and child health. The introduction of cleaner-burning gasoline in California in 1996 reduced asthma admissions by 8% in high exposure areas. Reductions are greatest for areas downwind from highways and heavy traffic areas. Stringent gasoline content regulations can improve child health, and may diminish existing health disparities.

Airborne fine particulate matter causes murine bronchial hyperreactivity via MAPK pathway-mediated M3 muscarinic receptor upregulation

Regarding the human health effects, airborne fine particulate matter 2.5 (PM_2.5 ) is an important environmental risk factor. However, the underlying molecular mechanisms are largely unknown. The present study examined the hypothesis that PM_2.5 causes bronchial hyperreactivity by upregulated muscarinic receptors via the mitogen-activated protein kinase (MAPK) pathway. The isolated rat bronchi segments were cultured with different concentration of PM_2.5 for different time. The contractile response of the bronchi segments were recorded by a sensitive myograph. The mRNA and protein expression levels of M₃ muscarinic receptors were studied by quantitative real-time PCR and immunohistochemistry, respectively. The muscarinic receptors agonist, carbachol induced a remarkable contractile response on fresh and DMSO cultured bronchial segments. Compared with the fresh or DMSO culture groups, 1.0 µg/mL of PM_2.5 cultured for 24 h significantly enhanced muscarinic receptor-mediated contractile responses in bronchi with a markedly increased maximal contraction. In addition, the expression levels of mRNA and protein for M₃ muscarinic receptors in bronchi of PM_2.5 group were higher than that of fresh or DMSO culture groups. SB203580 (p38 inhibitor) and U0126 (MEK1/2 inhibitor) significantly inhibited the PM_2.5 -induced enhanced contraction and increased mRNA and protein expression of muscarinic receptors. However, JNK inhibitor SP600125 had no effect on PM_2.5 -induced muscarinic receptor upregulation and bronchial hyperreactivity. In conclusion, airborne PM_2.5 upregulates muscarinic receptors, which causes subsequently bronchial hyperreactivity shown as enhanced contractility in bronchi. This process may be mediated by p38 and MEK1/2 MAPK pathways. © 2016 Wiley Periodicals, Inc. Environ Toxicol 32: 371-381, 2017.

Biological effects of inhaled nitrogen dioxide in healthy human subjects

PURPOSE

Several epidemiological studies indicate that inhaled nitrogen dioxide (NO2) at low concentrations have been statistically associated with adverse health effects. However, these results are not reflected by exposure studies in humans. The aim of the study was to assess the acute functional and cellular responses to different NO2 concentrations in healthy human subjects with various techniques.

METHODS

Twenty-five subjects were exposed for 3 h to NO2 concentrations 0, 0.1, 0.5, and 1.5 ppm in a randomized crossover study design during 4 consecutive weeks. In each subject, lung function, diffusion capacity and exhaled nitric oxide were measured and inflammation markers were assessed in blood, nasal secretions, induced sputum and exhaled breath condensate.

RESULTS

From all lung function indices under consideration, only intrathoracic gas volume was borderline significantly increased after 0.5 ppm (p = 0.048) compared to 0.1 ppm NO2. Regarding the cellular effect parameters, the macrophage concentration in induced sputum decreased with increasing NO2 concentration, although these changes were only borderline significant (p = 0.05).

CONCLUSION

These results do not suggest a considerable acute adverse response in human subjects after 3 h of exposure to NO2 in the NO2 concentration range investigated in this study.

Nitrogen dioxide exposure and airway responsiveness in individuals with asthma

Controlled human exposure studies evaluating the effect of inhaled nitrogen dioxide (NO2) on the inherent responsiveness of the airways to challenge by broncho-constricting agents have had mixed results. In general, existing meta-analyses show statistically significant effects of NO2 on the airway responsiveness of individuals with asthma. However, no meta-analysis has provided a comprehensive assessment of the clinical relevance of changes in airway responsiveness, the potential for methodological biases in the original papers, and the distribution of responses. This paper provides analyses showing that a statistically significant fraction (i.e. 70% of individuals with asthma exposed to NO2 at rest) experience increases in airway responsiveness following 30-min exposures to NO2 in the range of 200 to 300 ppb and following 60-min exposures to 100 ppb. The distribution of changes in airway responsiveness is log-normally distributed with a median change of 0.75 (provocative dose following NO2 divided by provocative dose following filtered air exposure) and geometric standard deviation of 1.88. About a quarter of the exposed individuals experience a clinically relevant reduction in their provocative dose due to NO2 relative to air exposure. The fraction experiencing an increase in responsiveness was statistically significant and robust to exclusion of individual studies. Results showed minimal change in airway responsiveness for individuals exposed to NO2 during exercise.

Critical review of the human data on short-term nitrogen dioxide (NO2) exposures: evidence for NO2 no-effect levels

Nitrogen dioxide (NO2) is a ubiquitous atmospheric pollutant due to the widespread prevalence of both natural and anthropogenic sources, and it can be a respiratory irritant when inhaled at elevated concentrations. Evidence for health effects of ambient NO2 derives from three types of studies: observational epidemiology, human clinical exposures, and animal toxicology. Our review focuses on the human clinical studies of adverse health effects of short-term NO2 exposures, given the substantial uncertainties and limitations in interpretation of the other lines of evidence. We examined more than 50 experimental studies of humans inhaling NO2, finding notably that the reporting of statistically significant changes in lung function and bronchial sensitivity did not show a consistent trend with increasing NO2 concentrations. Functional changes were generally mild and transient, the reported effects were not uniformly adverse, and they were not usually accompanied by NO2-dependent increases in symptoms. The available human clinical results do not establish a mechanistic pathway leading to adverse health impacts for short-term NO2 exposures at levels typical of maximum 1-h concentrations in the present-day ambient environment (i.e., below 0.2 ppm). Our review of these data indicates that a health-protective, short-term NO2 guideline level for susceptible (and healthy) populations would reflect a policy choice between 0.2 and 0.6 ppm. EXTENDED ABSTRACT: Nitrogen dioxide (NO2) is a ubiquitous atmospheric pollutant due to the widespread prevalence of both natural and anthropogenic sources, and it can be a respiratory irritant when inhaled at elevated concentrations. Natural NO2 sources include volcanic action, forest fires, lightning, and the stratosphere; man-made NO2 emissions derive from fossil fuel combustion and incineration. The current National Ambient Air Quality Standard (NAAQS) for NO2, initially established in 1971, is 0.053 ppm (annual average). Ambient concentrations monitored in urban areas in the United States are approximately 0.015 ppm, as an annual mean, i.e., below the current NAAQS. Short-term (1-h peak) NO2 concentrations outdoors are not likely to exceed 0.2 ppm, and even 1-h periods exceeding 0.1 ppm are infrequent. Inside homes, 1-h NO2 peaks, typically arising from gas cooking, can range between 0.4 and 1.5 ppm. The health effects evidence of relevance to ambient NO2 derives from three lines of investigation: epidemiology studies, human clinical studies, and animal toxicology studies. The NO2 epidemiology remains inconsistent and uncertain due to the potential for exposure misclassification, residual confounding, and co-pollutant effects, whereas animal toxicology findings using high levels of NO2 exposure require extrapolation to humans exposed at low ambient NO2 levels. Given the limitations and uncertainties in the other lines of health effects evidence, our review thus focused on clinical studies where human volunteers (including asthmatics, children, and elderly) inhaled NO2 at levels from 0.1 to 3.5 ppm during short-term ((1/2)-6-h) exposures, often combined with exercise, and occasionally combined with co-pollutants. We examined the reported biological effects and classified them into (a) lung immune responses and inflammation, (b) lung function changes and airway hyperresponsiveness (AHR), and (c) health effects outside the lungs (extrapulmonary). We examined more than 50 experimental studies of humans inhaling NO2, finding that such clinical data on short-term exposure allowed discrimination of NO2 no-effect levels versus lowest-adverse-effects levels. Our conclusions are summarized by these six points: For lung immune responses and inflammation: (1) healthy subjects exposed to NO2 below 1 ppm do not show pulmonary inflammation; (2) at 2 ppm for 4 h, neutrophils and cytokines in lung-lavage fluid can increase, but these changes do not necessarily correlate with significant or sustained changes in lung function; (3) there is no consistent evidence that NO2 concentrations below 2 ppm increase susceptibility to viral infection; (4) for asthmatics and individuals having chronic obstructive pulmonary disease (COPD), NO2-induced lung inflammation is not expected below 0.6 ppm, although one research group reported enhancement of proinflammatory processes at 0.26 ppm. With regard to NO2-induced AHR: (5) studies of responses to specific or nonspecific airway challenges (e.g., ragweed, methacholine) suggest that asthmatic individuals were not affected by NO2 up to about 0.6 ppm, although some sensitive subsets may respond to levels as low as 0.2 ppm. And finally, for extra-pulmonary effects: (6) such effects (e.g., changes in blood chemistry) generally required NO2 concentrations above 1-2 ppm. Overall, our review of data from experiments with humans indicates that a health-protective, short-term-average NO2 guideline level for susceptible populations (and healthy populations) would reflect a policy choice between 0.2 and 0.6 ppm. The available human clinical results do not establish a mechanistic pathway leading to adverse health impacts for short-term NO2 exposures at levels typical of maximum 1-h concentrations in the present-day ambient environment (i.e., below 0.2 ppm).

Effects of nitrogen dioxide on human health: systematic review of experimental and epidemiological studies conducted between 2002 and 2006

In order to assess health effects in humans caused by environmental nitrogen dioxide (NO(2)) a systematic review of studies in humans was conducted. MEDLINE database was searched for epidemiological studies and experiments on adverse effects of NO(2) published between 2002 and 2006. The evidence with regard to NO(2) exposure limits was assessed using the Scottish Intercollegiate Guidelines Network (SIGN) grading system and the modified three star system. Of the 214 articles retrieved 112 fulfilled the inclusion criteria. There was limited evidence that short-term exposure to a 1-h mean value below 200 microg NO(2)/m(3) is associated with adverse health effects provided by only one study on mortality in patients with severe asthma (*2+). The effect remained after adjusting for other air pollutants. There was moderate evidence that short-term exposure below a 24-h mean value of 50 microg NO(2)/m(3) at monitor stations increases hospital admissions and mortality (**2+). Evidence was also moderate when the search was restricted to susceptible populations (children, adolescents, elderly, and asthmatics). There was moderate evidence that long-term exposure to an annual mean below 40 microg NO(2)/m(3) was associated with adverse health effects (respiratory symptoms/diseases, hospital admissions, mortality, and otitis media) provided by generally consistent findings in five well-conducted cohort and case-control studies with some shortcomings in the study quality (**2+). Evidence was also moderate when the search was restricted to studies in susceptible populations (children and adolescents) and for the combination with other air pollutants. The most frequent reasons for decreased study quality were potential misclassification of exposure and selection bias. None of the high-quality observational studies evaluated was informative for the key questions due to the choice of the dose parameter (e.g., 1-week mean) and exposure levels above the limit values. Inclusion of study designs unlisted in the SIGN grading system did not bring additional evidence regarding exposures below the current air quality limit values for NO(2). As several recent studies reported adverse health effects below the current exposure limits for NO(2) particularly among susceptible populations regarding long-term exposure further research is needed. Apart from high-quality epidemiological studies on causality and the interaction of NO(2) with other air pollutants there is a need for double-blinded randomized cross-over studies among susceptible populations for further evaluation of the short-term exposure limits.

Uncontrolled occupational exposure to 1,1-dichloro-1-Fluoroethane (HCFC-141b) is associated with acute pulmonary toxicity

BACKGROUND

The toxicity of 1,1-dichloro-1-fluoroethane (HCFC-141b), a hydrochlorofluorocarbon (HCFC), is low according to animal studies. However, pulmonary manifestations associated with acute HCFC exposure by inhalation have not been reported as yet in man. We evaluated the pulmonary effects of HCFC-141b inhalation, caused by an accident, in previously healthy individuals.

METHODS

The subjects in this study were 15 workers in whom unpleasant symptoms developed after inhaling HCFC-141b at work. Clinical manifestations, radiologic findings, and changes in pulmonary function and airway hyperresponsiveness (AHR) over time were assessed, and BAL fluid analyses findings for four subjects were compared with those of four healthy volunteers (control subjects).

RESULTS

(1) Cough, shortness of breath, and malaise developed in most patients, but only two patients complained of a sore throat. (2) A high-resolution CT scan of the chest revealed bilateral diffuse ground-glass opacities that were predominant in upper lung zones. (3) The mean (+/- SD) FVC was 71.4 +/- 18.86% predicted, and the mean FEV(1)/FVC ratio was 92.9 +/- 4.25%. Eleven patients (73%) showed restrictive ventilatory impairments during the initial tests. FVC gradually improved, and the FEV(1)/FVC ratio gradually decreased with time. (4) AHR was observed in four subjects during the initial tests. (5) BAL fluid samples revealed significantly higher neutrophil counts than those in control subjects.

CONCLUSIONS

Overexposure to HCFC-141b was associated with parenchymal lung injury that was characterized by ground-glass opacities, elevated BAL neutrophil counts, and restrictive ventilatory impairment. Restrictive impairments improved with time after exposure.

The German view: effects of nitrogen dioxide on human health--derivation of health-related short-term and long-term values

The presented overview concerning health relevant effects caused by nitrogen dioxide (NO2) resumes the current state of results from animal experiments and human studies (epidemiology and short-term chambers studies). NO2 concentrations applied in animal experiments were mostly considerably higher than in ambient air. Therefore, short- and long-term limit values were derived from human data. Experimental studies conducted with humans demonstrate effects after short-term exposure to concentrations at or above 400 microg NO2/m3. Effects on patients with light asthma could not be observed after short-term exposure to concentrations below 200 microg/m3. On basis of epidemiological long-term studies a threshold below which no effect on human health is expected could not be specified. Two short-term limit values have been proposed to protect public health: a 1-h value of 100 microg/m3 and a 24-h mean value of 50 microg/m3. Due to the limitations of epidemiological studies to disentangle effects of single pollutants, a long-term limit value cannot be easily derived. However, applying the precautionary principle, it is desirable to adopt an annual mean of 20 microg NO2/m3 as a long-term mean standard to protect public health.

Airway hyperresponsiveness to methacholine at age 6 to 8 years in nonasthmatic patients is not related to increased health-care utilization for asthma in the ensuing 5 years: a longitudinal study of a birth cohort

BACKGROUND

Children with heightened airway responsiveness have a greater tendency to develop asthma symptoms. Many existing studies describing this relationship have relied on self-reported symptoms that may be prone to recall bias. In addition, few studies have examined the relationship of airway hyperresponsiveness (AHR) to indicators of asthma severity such as health-care utilization.

OBJECTIVE

To determine whether a positive response to methacholine challenge in children without current or physician-diagnosed asthma at age 6 to 8 years is predictive of the subsequent onset of asthma requiring medical evaluation or treatment in the ensuing 5 years.

METHODS

Data were obtained from subjects in a population-based birth cohort (n = 835) enrolled from 1987 to 1989, who were members of a large medical group practice component of a health maintenance organization (HMO). We analyzed a subset of subjects (n = 245) who had completed a methacholine challenge at age 6 to 8 years, had no current or physician-diagnosed asthma, and were still served by the same medical group. These children were followed up from the time of methacholine challenge until HMO disenrollment or through June 2001 (ages 11 to 13 years), whichever came first. Pharmacy claims data and diagnostic codes from physician-patient encounters were evaluated for incident asthma. Incident cases of clinical asthma were defined as any child with two outpatient visits or one hospitalization, one emergency department encounter associated with an asthma diagnostic code (ie, 493.XX), or any child filling prescriptions for two bronchodilators or one antiinflammatory asthma medicine. Methacholine responsiveness was interpreted using American Thoracic Society criteria.

RESULTS

Asthma incidence did not differ based on methacholine challenge results for children with normal, borderline, and mild AHR. No child in the study demonstrated moderate-to-severe AHR.

CONCLUSION

Our data suggest that AHR with a borderline or weakly positive result in a methacholine challenge in children 6 to 8 years old without current or physician-diagnosed asthma is not related to increased health-care utilization for asthma in the ensuing 5 years.

Gas stove use and respiratory health among adults with asthma in NHANES III

BACKGROUND

Gas stoves release respiratory irritants, such as nitrogen dioxide and other combustion by-products. Adults with asthma may be susceptible to the effects of gas stove exposure because of their underlying airway hyperresponsiveness, but this association has been difficult to establish.

AIMS

To examine the association between gas stove use and respiratory health.

METHODS

The analysis used data from the US Third National Health and Nutrition Examination Survey among 445 adults with asthma (representing 4.8 million persons with the condition).

RESULTS

Nearly half of the adults with asthma had a gas stove in their home (47.1%). There was no association between gas stove use and FEV1 (mean change 146 ml; 95% CI -50 to 342 ml), FVC (0 ml; 95% CI -151 to 152 ml), or FEF25%-75% (357 ml; 95% CI -7 to 722 ml). There was also no relation between gas stove use and the risk of self reported cough (OR 0.8; 95% CI 0.4 to 1.7), wheeze (OR 1.5; 95% CI 0.7 to 3.2), or other respiratory symptoms. Controlling for sociodemographic, smoking, housing, and geographic factors did not appreciably affect these results.

CONCLUSIONS

Among adults with asthma, there was no apparent impact of gas stove use on pulmonary function or respiratory symptoms. These results should be reassuring to adults with asthma and their health care providers.

The effects of air pollution on acute respiratory conditions

OBJECTIVE

Air pollution and its potential health effects are very important worldwide. It is particularly problematic in densely populated cities of developing countries that suffer from a lack of both short- and long-term programmes for air pollution control. We decided to study the short-term effects of air pollution on lung health by assessing the relationship between the levels of six air pollutants and emergency visits for asthma and COPD exacerbations in Tehran, Iran.

METHODOLOGY

We monitored the daily attendances for acute respiratory conditions (asthma attacks and COPD exacerbations) to the emergency departments of five major hospitals together with the daily concentrations of six major pollutants during a 5-month period in Tehran. The association between these acute respiratory conditions and the levels of air pollutants was determined by multiple stepwise regression.

RESULTS

A correlation was observed between the number of hospital admissions for asthma and the weekly mean concentration of nitrogen dioxide (P < 0.05). The 3-day and 10-day mean concentrations of sulphur dioxide were also found to be directly associated with the number of asthma admissions during this period (P < 0.05). No direct correlation was observed for other variables.

CONCLUSION

This study further emphasizes the deleterious effects of air pollution on respiratory health in major populated cities such as Tehran and suggests that increased attention needs to be given to urgent control of air pollution problems.

Effect of air pollution on peak expiratory flow rate variability

Exposure to air pollution affects pulmonary functions adversely. Effect of exposure to pollution on diurnal variation of peak flow was assessed in healthy students. Three hundred healthy age-matched nonsmoker students were studied. They were categorized into two groups on the basis of their residence: commuters and living on campus. Peak expiratory flow (PEF) recordings were made twice daily for 2 days with the Pink City Flow Meter. The measurement was then used to calculate for each subject the amplitude percentage mean, which is an index for expressing PEF variability for epidemiological purposes (Higgins BG, Britton JR, Chinns Jones TD, Jenkinson D, Burnery PG, Tattersfield AE. Distribution of peak expiratory flow variability in a population sample. Am Rev Respir Dis 1989; 140:1368-1372). Air pollution parameters were quantified by measurement of sulfur dioxide (SO2), oxides of nitrogen (NO2), carbon monoxide (CO), and respirable suspended particulate matter (RSPM) in the ambient air at the campus and on the roadside. The mean values of PEF variability (amplitude percent mean) in the students living on campus and in the commuters were 5.7 +/- 3.2 and 11 +/- 3.6, respectively (P < .05). Among the commuters, maximum number of subjects showed amplitude percentage mean PEFR at the higher end of variability distribution, as compared to the students living on campus, among whom the majority of subjects fell in the lower ranges of variability distribution. The ambient air quality parameters, namely SO2, NO2, CO, and RSPM were significantly lower on the campus. It can be concluded that long-term periodic exposure to air pollution can lead to increased PEF variability even in healthy subjects. Measurement of PEF variability may prove to be a simple test to measure effect of air pollution in healthy subjects.

Exposure to indoor combustion and adult asthma outcomes: environmental tobacco smoke, gas stoves, and woodsmoke

BACKGROUND

Because they have chronic airway inflammation, adults with asthma may be particularly susceptible to indoor air pollution. Despite widespread exposure to environmental tobacco smoke (ETS), gas stoves, and woodsmoke, the impact of these exposures on adult asthma has not been well characterised.

METHODS

Data were used from a prospective cohort study of 349 adults with asthma who underwent structured telephone interviews at baseline and 18 month follow up. The prospective impact of ETS, gas stove, and woodsmoke exposure on health outcomes was examined.

RESULTS

ETS exposure at baseline interview was associated with impaired health status at longitudinal follow up. Compared with respondents with no baseline self-reported exposure to ETS, higher level exposure (>/=7 hours/week) was associated with worse severity of asthma scores at follow up, controlling for baseline asthma severity, age, sex, race, income, and educational attainment (mean score increment 1.5 points; 95% CI 0.4 to 2.6). Higher level baseline exposure to ETS was also related to poorer physical health status (mean decrement -4.9 points; 95% CI -8.4 to -1.3) and asthma specific quality of life (mean increase 4.4 points; 95% CI -0.2 to 9.0) at longitudinal follow up. Higher level baseline ETS exposure was associated with a greater risk of emergency department visits (OR 3.4; 95% CI 1.1 to 10.3) and hospital admissions for asthma at prospective follow up (OR 12.2; 95% CI 1.5 to 102). There was no clear relationship between gas stove use or woodstove exposure and asthma health outcomes.

CONCLUSION

Although gas stove and woodstove exposure do not appear negatively to affect adults with asthma, ETS is associated with a clear impairment in health status.

Hazardous air pollutants and asthma

Asthma has a high prevalence in the United States, and persons with asthma may be at added risk from the adverse effects of hazardous air pollutants (HAPs). Complex mixtures (fine particulate matter and tobacco smoke) have been associated with respiratory symptoms and hospital admissions for asthma. The toxic ingredients of these mixtures are HAPs, but whether ambient HAP exposures can induce asthma remains unclear. Certain HAPs are occupational asthmagens, whereas others may act as adjuncts during sensitization. HAPs may exacerbate asthma because, once sensitized, individuals can respond to remarkably low concentrations, and irritants lower the bronchoconstrictive threshold to respiratory antigens. Adverse responses after ambient exposures to complex mixtures often occur at concentrations below those producing effects in controlled human exposures to a single compound. In addition, certain HAPs that have been associated with asthma in occupational settings may interact with criteria pollutants in ambient air to exacerbate asthma. Based on these observations and past experience with 188 HAPs, a list of 19 compounds that could have the highest impact on the induction or exacerbation of asthma was developed. Nine additional compounds were identified that might exacerbate asthma based on their irritancy, respirability, or ability to react with biological macromolecules. Although the ambient levels of these 28 compounds are largely unknown, estimated exposures from emissions inventories and limited air monitoring suggest that aldehydes (especially acrolein and formaldehyde) and metals (especially nickel and chromium compounds) may have possible health risk indices sufficient for additional attention. Recommendations for research are presented regarding exposure monitoring and evaluation of biologic mechanisms controlling how these substances induce and exacerbate asthma.

Effects of birch pollen and traffic particulate matter on Th2 cytokines, immunoglobulin E levels and bronchial hyper-responsiveness in mice

BACKGROUND

Health effects due to air pollution arising from motor vehicles are a major public and political concern world-wide. Epidemiological studies have shown that the manifestations of asthma are increased by air pollution in already affected individuals.

OBJECTIVE

To investigate the potential role of air-polluted tunnel dust (traffic particulate matter, TPM) or pure carbon core particles in the initiation and persistence of experimental allergic inflammation.

METHODS

BP2 mice were immunized with birch pollen alone (group B) or pollen together with TPM (group A), or with birch pollen and Al(OH)3 (group C), or with birch pollen and carbon core particles (group D). Before methacholine challenge they were challenged intranasally and thereafter bronchial hyper-reactivity (BHR) was evaluated in a whole-body plethysmograph. Levels of Th2 cytokines, fibronectin and lactate dehydrogenase (LDH) were determined, and differential counts were performed in the bronchoalveolar lavage (BAL) fluid. Sera were collected for determination of antibody titres and cytokine levels.

RESULTS

Specific IgE titres, BHR, the number of recruited eosinophils and levels of fibronectin and LDH in BAL were increased in mice immunized and challenged with a mixture of birch pollen and TPM. However, mice immunized with birch pollen alone and challenged intranasally with pollen or a mixture of pollen and TPM demonstrated the highest levels of IL-4 and IL-5.

CONCLUSION

This study highlights the importance of the exposure to a combination of particulate matters and pollen allergens, in the induction of allergic disease in the airways, and we have demonstrated that polluted tunnel dust has an effect on both the inflammatory and immunological components of experimental allergy. Immunization and challenge with carbon core particles together with birch pollen increased neither the BHR nor the specific IgE production significantly. Our results therefore strongly suggest that it is most likely to be the organic phase bound to the carbon core of the diesel exhaust particles that might have an important adjuvant effect in the induction of experimental allergy.

Exposure to carbon monoxide and nitrogen dioxide in enclosed ice arenas

This article summarises the latest information on the adverse cardiorespiratory effects of exposure to carbon monoxide (CO) and nitrogen dioxide (NO(2)) in enclosed ice rinks. Sources of CO and NO(2) emissions are identified, current standards for these agents, as well as methods of controlling the emissions, dispersion, and evacuation of these toxic gases are presented. A detailed literature search involving 72 references in English and French from research conducted in North America and Europe was used. Material was from peer reviewed journals and other appropriate sources. Air pollutants such as carbon monoxide (CO), and nitrogen dioxide (NO(2)) which are present in enclosed skating facilities, may exacerbate a pre-existing pathogenic condition in those people who spend considerable time in these environments. Considering the popularity of ice hockey, short track speed skating, and figure skating, and the hundreds of hours that a sensitive person may spend each year in these environments, it would seem appropriate to seek more definitive answers to this important health problem. From the findings and conclusions of the research reviewed in this paper, 10 recommendations are listed.

Effect of exposure to nitrogen dioxide on alveolar macrophage-mediated immunosuppressive activity in rats

Nitrogen dioxide (NO2), a major component of air pollutants, induces inflammatory responses in the lungs. Resident alveolar macrophages (AM) play an immunosuppressive role in the lungs via suppression of lymphocyte proliferation, and nitric oxide (NO) plays a crucial role in this immunosuppressive activity. Microenvironmental changes within the alveoli during inflammatory responses, however, can inhibit this immunosuppressive activity of AM. The present study was designed to clarify the effect of NO2 exposure on the immunosuppressive activity of and NO production by AM in rats. Wistar rats were exposed to 10 ppm NO2 for 3, 14 or 28 days, after which bronchoalveolar lavage fluid (BALF) was taken as a sample of the alveolar microenvironment. Suppression of concanavalin A-induced lymphocyte proliferation and NO production by AM were markedly inhibited by BALF from NO2-exposed rats (NO2-BALF). The inhibitory effect of NO2-BALF at 28-days exposure was stronger than that of NO2-BALF at 3 or 14 days exposure. In conclusion, AM-mediated immunosuppressive activity was inhibited by the NO2-induced changes of the alveolar microenvironment through the inhibition of NO production.

The pathobiology of acute asthma

Acute bronchial asthma is a common problem with immense medical and economic impacts. It is estimated that this disease affects 12 to 14 million people in the United States with costs in excess of $6 billion per year. Most of the morbidity and all of the mortality of asthma tends to be associated with acute exacerbations, and treatment of these events accounts for the majority of expenditures in money and health care resources. Unfortunately, the factors that contribute to the destabilization of asthma are rarely studied and much of the pathogenesis and pathobiology of acute asthma remains unknown. This article examines these issues and suggests treatment for acute asthma.

Bronchopulmonary inflammation and airway smooth muscle hyperresponsiveness induced by nitrogen dioxide in guinea pigs

We investigated whether acute exposure to nitrogen dioxide (NO2) causes major inflammatory responses (inflammatory cell recruitment, oedema and smooth muscle hyperresponsiveness) in guinea pig airways. Anaesthetised guinea pigs were exposed to 18 ppm NO2 or air for 4 h through a tracheal cannula. Bronchoalveolar lavage was performed and airway microvascular permeability and in vitro bronchial smooth muscle responsiveness were measured. Exposure to NO2 induced a significant increase in eosinophils and neutrophils in bronchoalveolar lavage fluid, microvascular leakage in the trachea and main bronchi (but not in peripheral airways), and a significant in vitro hyperresponsiveness to acetylcholine, electrical field stimulation, and neurokinin A, but not to histamine. Thus, this study shows that in vivo exposure to high concentrations of NO2 induces major inflammatory responses in guinea pig airways that mimic acute bronchitis induced by exposure to irritant gases in man.

Inflammatory response in humans exposed to 2.0 ppm nitrogen dioxide

Nitrogen dioxide (NO2) is a common indoor air pollutant, especially in homes with unvented combustion appliances. Epidemiological studies suggest that children living in homes with unvented heating sources are more prone to respiratory infections than children living in homes with lower levels of NO2. However, experimental studies in which human volunteers were exposed acutely to moderate levels of NO2 (0.5-2.0 ppm) have shown little evidence of lung inflammation or decreased host resistance capacity. In the study reported here, 8 healthy volunteers were exposed to 2.0 ppm NO2 and to filtered air for 4 h while undergoing intermittent moderate exercise. Bronchoalveolar lavage was performed the following morning. The lavage was divided into a predominantly bronchial washing (first 20 ml of lavage; BL) and a predominantly alveolar washing (BAL). In the BL, NO2 exposure caused increases in polymorphonuclear neutrophils (PMNs), interleukin 6 (IL-6), IL-8, alpha1-antitrypsin, and tissue plasminogen activator, and decreases in epithelial cells. In the BAL, there were no NO2-induced changes in either cell numbers or soluble mediators. On the other hand, alveolar macrophages from BAL showed a decrease in the ability to phagocytose unopsonized Candida albicans and a decrease in superoxide production. No difference in susceptibility to virus infection was found between the NO2- and air-exposed macrophages. No changes in lung function were observed, but the aerosol bolus recovery technique revealed a statistically significant (p <.05) decrease in the fraction of aerosol recovered following nitrogen dioxide exposure, which is suggestive of small obstructive changes induced by NO2.

Determinants of nitrogen dioxide concentrations in indoor ice skating rinks

OBJECTIVES

The combination of poor ventilation and fuel-powered ice resurfacers has resulted in elevated nitrogen dioxide (NO2) concentrations in many indoor ice skating rinks. This study examined the factors influencing concentrations and the effects of various engineering controls in ice rinks with different resurfacer fuels.

METHODS

Indoor NO2 concentrations were measured in 19 enclosed ice skating rinks over 3 winters by means of passive samplers, with 1-week average measurements during the first winter pilot study and single-day working-hour measurements in the final 2 winters. Personal exposures to drivers also were assessed during the last winter.

RESULTS

Rinks in which propane-fueled resurfacers were used had a daily mean indoor NO2 concentration of 206 ppb, compared with 132 ppb for gasoline-fueled and 37 ppb for electric-powered resurfacers. Engineering controls, such as increased ventilation and resurfacer tuning, reduced NO2 concentrations by 65% on average, but outcomes varied widely, and concentrations increased in subsequent months.

CONCLUSIONS

Electric ice resurfacers, increased ventilation, or emission control systems are recommended to protect the health of workers and patrons, with surveillance programs proposed to track implementation and maintain an observer effect.

Effects of air pollution and smoking on chronic obstructive pulmonary disease and bronchial asthma

Although both tobacco smoking and air pollution are believed to be environmental factors affecting the prevalence of chronic obstructive pulmonary disease (COPD) and bronchial asthma, the mechanisms by which they induce/aggravate these diseases are still not known in detail. While smoking has been demonstrated to cause and aggravate COPD and bronchial asthma, the influence of air pollution, suspected to have hazardous environmental effects since the historical episodes of severe air pollution such as the London Smog, on the prevalence of airway diseases remains unclear. This is due, in part, to changes over time in the nature of the air pollutants concerned. There have been no consistent findings on the effects on airway diseases of air pollutants at levels currently observed in developed countries. It is believed that cessation of smoking is the most important factor in preventing the development of COPD.

Kinetics of protein depletion in rat bronchoalveolar lavage fluid following in vitro exposure to nitrogen dioxide

Upon inhalation, nitrogen dioxide (NO(2)), a strong oxidizing agent, first comes into contact and reacts with the fluids lining the airways of the respiratory tract. These respiratory tract lining fluids (RTLF) form a barrier between the inhaled toxic pollutant and the epithelium which protects the underlying tissue from inflammation. Proteins, mainly albumin, and antioxidants are the major components of the RTLF. Many studies have utilized human blood plasma to study the interaction of an extracellular fluid with ozone. In this study, we used bronchoalveolar lavage fluids (BALF) as a more specific surrogate for rat RTLF, and we utilized the native fluorescence as a marker to investigate the depletion kinetics of naturally-occurring protein following exposure to NO(2) in a controlled flow reactor system. We also studied the depletion kinetics of albumin in a buffered salt solution. The results indicated that: (1) the decay in fluorescence was linearly dependent on the concentration of NO(2), indicating that protein oxidation was first order with respect to NO(2) concentration in both BALF and in buffered albumin solution; (2) the depletion kinetics of protein in BALF was non-linear with respect to substrate concentration; (3) the rate of protein depletion was much slower in BALF than in a buffered solution of albumin, suggesting that the presence of antioxidants in BALF protected proteins from being oxidized by NO(2); and (4) whereas the addition of ascorbic acid to buffered albumin solution significantly attenuated albumin depletion, the addition of glutathione had no effect. This suggested that the reaction rate constant of ascorbic acid was considerably higher than that of glutathione.

Long-term exposure of adults to outdoor air pollution is associated with increased airway obstruction and higher prevalence of bronchial hyperresponsiveness

The authors studied the association between long-term exposure (i.e., > 10 y) to outdoor air pollution and the severity of obstructive pulmonary disease and prevalence of bronchial hyperreactivity to beta2 agonists in two groups of adult patients who were of similar ages and who had similar smoking habits. The subjects lived in downtown districts or in the outer suburbs of Marseilles, the neighborhood that contained air samplers. The regions were similar with respect to sulfur dioxide levels, but levels of nitric oxides and particulate matter (10 millimeters or less) were higher in the downtown area than the suburbs. The authors assessed airway obstruction, as determined by a decrease in forced expiratory volume in 1 s, mean forced expiratory flow measured between 25% and 75% of vital capacity, and an elevated value of central airway resistance. The authors tested the changes in these variables induced by inhalation of a beta2 agonist. Baseline lung function was altered more significantly in both male and female patients who lived in downtown Marseilles than in those who resided in the suburbs, and the differences persisted regardless of the season during which the study occurred. Prevalence of bronchial hyperreactivity and symptoms of asthma (but not of rhinitis) were higher in the downtown than suburban male subjects. The results of this study suggest that an association exists between actual environmental exposure to outdoor air pollution (i.e., nitrogen oxides and/or particulate matter of 10 millimeters or less) and respiratory effects in sensitive adults represented by patients with chronic obstructive pulmonary disease or asthma.

[Impact of air pollution on the mortality and emergencies of chronic obstructive pulmonary disease and asthma in Barcelona]

OBJECTIVES

Air pollution has been associated with increased mortality according to studies carried out in the US. The APHEA project (Air Pollution on Health: a European Approach) analyzes the short-term effects in 15 european cities. We evaluated the acute relation between air pollution, mortality, and hospital emergency-room visits in Barcelona, one of the cities participating in the APHEA project.

METHODS

Daily variations in total mortality, cardiovascular mortality, respiratory mortality, and emergency-room visits for chronic obstructive pulmonary disease (COPD), and asthma were studied in relation to daily variations in air pollution levels in 1985-1991. Poisson regression was done and temperature, relative humidity, and epidemics of asthma and flu were controlled. Temporal trends and auto-regressive terms were examined.

RESULTS

A reduction of about 50 micrograms/m3 in particles and sulfur dioxide was accompanied by a reduction of about 4% and 6% (p < 0.05), respectively, in daily deaths from respiratory and cardiovascular causes and emergency-room visits for COPD. Oxidant pollutants (nitrogen dioxide and ozone) were related positively with cardiovascular mortality and emergency visits for COPD and asthma. The role of ozone was notable, with a reduction in ozone levels of 50 micrograms/m3 originating a 4% reduction in emergency-room visits for COPD and asthma (p < 0.05).

CONCLUSIONS

Current levels of air pollutants had an epidemiologically measurable impact on mortality and emergency-room visits in Barcelona. These results were consistent with the findings of similar studies in other european and american cities and with previous studies of emergency-room admissions in Barcelona. These studies suggest the possible toxicity of air pollution.

Indoor environment of residential homes in Hong Kong--relevance to asthma and allergic disease

BACKGROUND

The prevalence of asthma and allergic disease has been increasing in Hong Kong and environmental factors are thought to play a major role.

AIM

To define the distribution of common inhaled allergens and air pollutants inside residential homes in Hong Kong.

METHODS

Forty randomly selected residential homes were visited and surveyed. Dust samples were collected from mattress, bedroom floor, lounge room floor and kitchen floor for assays of Der p 1, Fel d 1, and Bla g 2. Nitrogen dioxide (NO2) levels were measured by stationary samplers left in the bedroom, lounge room and kitchen over a 1-week period.

RESULT

All 40 homes were apartments in high-rise buildings and the mean age of the homes was 7.6 +/- 4.8 years. Visible dampness and mould patches were present in 27.5% of homes and the main fuel for cooking was gas (97.5%). Der p 1, Fel d 1 and Bla g 2 were detectable in at least 1 niche in over 85% of homes. In particular, all dust samples from mattress and bedroom floor contained Der p 1, and over 50% had levels > or = 2 microg/g. The (geometric) mean Der p 1 level in mattress dust was 8.8 (0.3-157.8) microg/g. Fel d 1 and Bla g 2 were present in low levels throughout the homes with respective (geometric) means of 0.3 (0-3.7) microg/g and 0.1 (0-1.1) Unit/g in mattress dust. NO2 was readily detected in all niches but the highest level was in the kitchen with mean exposure of 48.7 ppb which was 1.5 times higher than that in the bedroom and lounge room.

CONCLUSION

Major allergens of mite, cat and cockroach, and NO2 are present in varying quantities in residential homes in Hong Kong. Exposure to these environmental factors could be important in the development of asthma and allergic diseases in susceptible individuals.

Acute effects of nitrogen dioxide after accidental release

OBJECTIVES

Following an accidental release of nitrogen dioxide from a railroad tank car containing nitrous tetroxide, the authors undertook a study of the health effects of the release, measuring the association between acute low level exposure and pulmonary symptoms.

METHODS

The authors reviewed the records of three emergency departments, surveyed 80 emergency department patients, 552 community residents, 21 chemical plant workers, and 29 emergency workers, and conducted a case-control study. Pulmonary case status was defined as having an objective pulmonary finding noted on the emergency department record, reporting that the onset of symptoms was subsequent to the release, and being within the city limits at the time of the release. Self-reported case status was defined as reporting one or more symptoms consistent with exposure to nitrogen dioxide in the week after the release and having been within the city limits at the time of the release. Control subjects were survey respondents who reported no symptoms in the week after the release and had been within the city limits at the time of the release. Chemical exposure was characterized by proximity to, direction from, and being outdoors within one hour after the release. Duration of potential exposure was not measured. Logistic regression was used to estimate odds ratios and 95% confidence interval for symptoms by exposure level, adjusted for age, sex, smoking, and preexisting pulmonary conditions.

RESULTS

Local emergency department visits increased fivefold in the week after the release. The most common complaints recorded in a systematic sample of 528 visits in the first 30 hours after the release were headache (31%), burning eyes (30%), and sore throat (24%). Objective pulmonary findings were recorded for 41 (5%) patients in the week before and 165 (4%) in the week after the release. The odds of being a pulmonary case increased by 40% for each quarter-mile increment in proximity to the release (odds ratio [OR] 1.4; 95% confidence interval [CI] 1.1, 1.7), while the odds of being a self-reported case increased by 20% for each quarter-mile increment in proximity (OR 1.2, 95% CI 1.1, 1.4). People who met the pulmonary case definition were 2.5 times (CI 1.3, 4.8) more likely than control subjects to have been outdoors and 6.4 times (CI 3.2, 12.6) more likely to report a preexisting pulmonary condition. Self-reported cases were 2.6 times (95% CI 1.8, 3.8) more likely than control subjects to have been outdoors and 1.9 times (95% CI 1.1, 3.1) more likely to report a preexisting pulmonary condition.

CONCLUSIONS

Emergency department visits increased five-fold, but serious acute health effects were uncommon. People who met the pulmonary case definition were six times more likely to report pulmonary symptoms than those without preexisting conditions. This study was not designed to determine any potential long-term effects of exposure.

Urban air pollution and emergency admissions for asthma in four European cities: the APHEA Project

BACKGROUND

A study was undertaken to assess the combined association between urban air pollution and emergency admissions for asthma during the years 1986-92 in Barcelona, Helsinki, Paris and London.

METHODS

Daily counts were made of asthma admissions and visits to the emergency room in adults (age range 15-64 years) and children (< 15 years). Covariates were short term fluctuations in temperature and humidity, viral epidemics, day of the week effects, and seasonal and secular trends. Estimates from all the cities were obtained for the entire period and separately by warm or cold seasons using Poisson time-series regression models. Combined associations were estimated using meta-analysis techniques.

RESULTS

Daily admissions for asthma in adults increased significantly with increasing ambient levels of nitrogen dioxide (NO2) (relative risk (RR) per 50 micrograms/m3 increase 1.029, 95% CI 1.003 to 1.055) and non-significantly with particles measured as black smoke (RR 1.021, 95% CI 0.985 to 1.059). The association between asthma admissions and ozone (O3) was heterogeneous among cities. In children, daily admissions increased significantly with sulphur dioxide (SO2) (RR 1.075, 95% CI 1.026 to 1.126) and non-significantly with black smoke (RR 1.030, 95% CI 0.979 to 1.084) and NO2, though the latter only in cold seasons (RR 1.080, 95% CI 1.025 to 1.140). No association was observed for O3. The associations between asthma admissions and NO2 in adults and SO2 in children were independent of black smoke.

CONCLUSIONS

The evidence of an association between air pollution at current urban levels and emergency room visits for asthma has been extended to Europe. In addition to particles, NO2 and SO2--by themselves or as a constituent of a pollution mixture--may be important in asthma exacerbations in European cities.

In vitro assessment of environmental toxicology using alveolar cells as target

Biphasic culture of alveolar cells (alveolar macrophages and type II cells) has been widely developed and permits a precise evaluation of the toxic effects of air pollutants. Clearly, in vitro exposure of alveolar cells to high concentrations of oxidant gases is responsible for a loss of cell viability. In contrast, when exposed to realistic concentrations of gases (NO2, O3), cell viability is not altered and various proinflammatory mediators are released. This in vitro model has proved to be sensitive at levels of gas exposure of ambient air quality standards and appears a sensitive biological indicator of air pollutant cell toxicity.

Occupational exposure during nitric oxide inhalational therapy in a pediatric intensive care setting

OBJECTIVE

To determine the amount of occupational exposure to nitric oxide (NO) and nitrogen dioxide (NO2) during NO inhalational therapy.

DESIGN

In a standard pediatric intensive care room, 800 ppm NO was delivered to a high-frequency oscillator and mixed with 100% O2 to obtain 20 ppm NO in the inspiratory gas flow. NO and NO2 concentrations in room air were measured using a chemiluminescence analyzer. Air samples were taken from a height of 150 cm at a horizontal distance of 65 cm from the ventilator in a nonventilated and in a well-ventilated room with and without an expiratory gas exhaust under normal intensive care environmental conditions.

SETTING

Pediatric intensive care unit in a university children's hospital.

MEASUREMENTS AND RESULTS

Maximal concentrations of NO and NO2 were reached after 4 h NO use. Without exhaust, in a nonventilated room, environmental NO and NO2 concentration rose to a maximum of 0.462 and 0.064 ppm, respectively. With the use of an expiratory gas exhaust, NO and NO2 concentrations were 0.176 and 0.042 ppm, respectively. With normal air-conditioning, these values were 0.075 and 0.034 ppm, respectively, without the use of an expiratory gas exhaust. With expiratory gas exhaust added to normal air-conditioning, values for NO and NO2 were 0.035 and 0.030 ppm, respectively.

CONCLUSIONS

The use of 20 ppm NO, even under minimal room ventilation conditions, did not lead to room air levels of NO or NO2 that should be considered toxic to adjacent intensive care patients or staff. Slight increases in NO and NO2 concentrations were measurable but remained within occupational safety limits. The use of an exhaust system and normal room ventilation lowers NO and NO2 concentrations further to almost background levels.

Effect of subchronic in vivo exposure to nitrogen dioxide on lung tissue inflammation, airway microvascular leakage, and in vitro bronchial muscle responsiveness in rats

OBJECTIVES

In a previous study on bronchoalveolar lavage fluid from rats exposed in vivo for seven days to 10 ppm nitrogen dioxide (NO2), it has been shown that there is an influx of macrophages into the airways. The present study investigated the effect of seven day exposure to 10 ppm NO2, on: (a) lung tissue inflammation and morphology; (b) airway microvascular leakage; (c) in vitro contractile response of main bronchi.

METHODS

Lung tissue was studied by light microscopy, after fixing the lungs by inflation with 4% formalin at a pressure of 20 cm H2O. Microvascular leakage was measured by extravasation of Evans blue dye in the larynx, trachea, main bronchi, and intrapulmonary airways. Smooth muscle responsiveness was evaluated by concentration-responses curves to acetylcholine (10(-9)-10(-3) M), serotonin (10(-9)-10(-4) M), and voltage-response curves (12-28 V) to electrical field stimulation.

RESULTS

Histology showed an increased total inflammation at the level of respiratory bronchioles and alveoli. No influx of inflammatory cells was found in the main bronchi. A loss of cilia in the epithelium of small airways and ectasia of alveolar capillaries was also found. By contrast, no alterations to microvascular permeability or modification of bronchial smooth muscle responsiveness was found.

CONCLUSIONS

Subchronic exposure to 10 ppm NO2 causes airway inflammation and structural damage, but does not cause any persistent alteration to microvascular permeability or bronchial smooth muscle responsiveness in rats.

Bronchial hyperresponsiveness following acute severe asthma

OBJECTIVE

To evaluate bronchial hyperresponsiveness (BHR) early after recovery from acute severe asthma (ASA).

DESIGN

Prospective study including all patients admitted to the intensive care unit (ICU) for ASA over a 12-month period.

SETTING

University teaching ICU and pneumonology department.

PATIENTS

41 consecutive patients admitted to the ICU for ASA. Results were compared with those of a control group with stable asthma and no history of ASA or steroid therapy, matched for sex and age.

MEASUREMENT AND RESULTS

Of the 41 patients, 40 completed respiratory function tests 10 days after ICU admission, and the minimal dose of acetylcholine inducing a fall in forced expiratory volume in 1 s (FEV1) of 20% or more (PD AC) could be determined safely by a novel method in 26 patients with an FEV1 above 60% predicted. PD AC (micrograms) was found to be significantly lower in ASA than in control patients. Very severe BHR (PD AC < or = 100 micrograms) was found in 18 ASA patients, but not in the control patients; 5 ASA versus 12 control patients had marked BHR (100 > PD AC < or = 500 micrograms); and 3 ASA versus 14 control patients had moderate BHR (> 500 micrograms). A similar level of BHR was found in ASA patients with progressive or acute worsening. No correlation was found between PD AC and admission PaCO2 value, admission peak expiratory flow (PEF) value, delay in improvement of PEF, delay in PD AC determination, or prechallenge FEV1 value.

CONCLUSION

BHR measurement is safe soon after an episode of ASA if done with caution. At this time, patients who are free of clinical symptoms and have no significant objective bronchial obstruction appear to have severe bronchial hyper-responsiveness.

The incidence of exercise-induced bronchospasm in competitive figure skaters

Pediatric commitment to competitive sports is on the rise. Previous reports of the incidence of exercise-induced bronchospasm (EIB) have investigated high school, college, and Olympic athletes in traditional sports. The purpose of this study was to investigate the incidence of EIB in competitive figure skating, a high-intensity, cold-weather sport performed by young athletes. To investigate the incidence of EIB in skaters, 100 competitive skaters from five Mid-Atlantic rinks completed rinkside pulmonary function tests. Results showed an overall incidence of 30%, signaling the need for education and screening for EIB in youth participating in physically demanding, cold-weather sports.

Short-term association between air pollution and emergency room visits for asthma in Barcelona

BACKGROUND

Several studies have assessed the association between urban air pollutants and hospital admissions or emergency room visits for asthma with inconsistent results. The objective of this study was to assess the relation between levels of black smoke, sulphur dioxide, nitrogen dioxide, and ozone and adult emergency room visits for asthma in Barcelona, Spain during the five year period 1985-9.

METHODS

The daily number of emergency room visits for asthma was obtained from a register of respiratory emergencies designed to study the asthma outbreaks occurring in Barcelona. The association between asthma visits and levels of pollutants was assessed separately for summers and winters with Poisson regression models controlling for meteorological and time related variables.

RESULTS

Black smoke was associated with asthma visits in summer but not in winter. The relative risk (RR) of asthma visits for a 25 micrograms/m3 increase of current day concentrations of black smoke was 1.082 (95% CI 1.011 to 1.157). The mean current and previous three day levels of black smoke led to a stronger association (RR = 1.114 (95% CI 1.010 to 1.160). In addition, nitrogen dioxide was associated with asthma visits in both summer (RR = 1.045, 95% CI 1.009 to 1.081) and winter (RR = 1.056, 95% CI 1.011 to 1.104). These associations were slightly higher for the previous day's level of nitrogen dioxide. No associations were found for sulphur dioxide or for ozone.

CONCLUSIONS

This study provides further evidence of the effect of particulate pollution on asthma, and it suggests that nitrogen dioxide may have a role in the exacerbation of bronchial asthma in adults.

Associations between criteria air pollutants and asthma

The evidence that asthma is increasing in prevalence is becoming increasingly compelling. This trend has been demonstrated not only in the United States, but also in the United Kingdom, New Zealand, Australia, and several other Western countries. In the United States, the increase is largest in the group under 18 years of age. There is mounting evidence that certain environmental air pollutants are involved in exacerbating asthma. This is based primarily on epidemiologic studies and more recent clinical studies. The U.S. Clean Air Act of 1970 provides special consideration to the class of outdoor air pollutants referred to as criteria pollutants, including O3, sulfur dioxide (SO2), particulate matter (PM), NOx, CO, and Pb. Standards for these pollutants are set by the U.S. Environmental Protection Agency with particular concern for populations at risk. Current evidence suggests that asthmatics are more sensitive to the effects of O3, SO2, PM, and NO2, and are therefore at risk. High SO2 and particulate concentrations have been associated with short-term increases in morbidity and mortality in the general population during dramatic air pollution episodes in the past. Controlled exposure studies have clearly shown that asthmatics are sensitive to low levels of SO2. Exercising asthmatics exposed to SO2 develop bronchoconstriction within minutes, even at levels of 0.25 ppm. Responses are modified by air temperature, humidity, and exercise level. Recent epidemiologic studies have suggested that exposure to PM is strongly associated with morbidity and mortality in the general population and that hospital admissions for bronchitis and asthma were associated with PM10 levels. In controlled clinical studies, asthmatics appear to be no more reactive to aerosols than healthy subjects. Consequently, it is difficult to attribute the increased mortality observed in epidemiologic studies to specific effects demonstrated in controlled human studies. Epidemiologic studies of hospital admissions for asthma have implicated O3 as contributing to the exacerbation of asthma; however, most study designs could not separate the O3 effects from the concomitant effects of acid aerosols and SO2. Controlled human clinical studies have suggested that asthmatics have similar changes in spirometry and airway reactivity in response to O3 exposure compared to healthy adults. However, a possible role of O3 in worsening atopic asthma has recently been suggested in studies combining allergen challenge following exposure to O3. Attempts at identification of factors that predispose asthmatics to responsiveness to NO2 has produced inconsistent results and requires further investigation. In summary, asthmatics have been shown to be a sensitive subpopulation relative to several of the criteria pollutants. Further research linking epidemiologic, clinical, and toxicologic approaches is required to better understand and characterize the risk of exposing asthmatics to these pollutants.

Evaluation of a possible association of urban air toxics and asthma

The prevalence of asthma, measured either as the frequency of hospital admissions or number of deaths attributed to asthma, has increased over the last 15 to 20 years. Rapid increases in disease prevalence are more likely to be attributable to environmental than genetic factors. Inferring from past associations between air pollution and asthma, it is feasible that changes in the ambient environment could contribute to this increase in morbidity and mortality. Scientific evaluation of the links between air pollution and the exacerbation of asthma is incomplete, however. Currently, criteria pollutants [SOx, NOx, O3, CO, Pb, particulate matter (PM10)] and other risk factors (exposure to environmental tobacco smoke, volatile organic compounds, etc.) are constantly being evaluated as to their possible contributions to this situation. Data from these studies suggest that increases in respiratory disease are associated with exposures to ambient concentrations of particulate and gaseous pollutants. Similarly, exposure to environmental tobacco smoke, also a mixture of particulate and gaseous air toxics, has been associated with an increase in asthma among children. In addition, current associations of adverse health effects with existing pollution measurements are often noted at concentrations below those that produce effects in controlled animal and human exposures to each pollutant alone. These findings imply that adverse responses are augmented when persons are exposed to irritant mixtures of particles and gases and that current measurements of air pollution are, in part, indirect in that the concentrations of criteria pollutants are acting as surrogates of our exposure to a complex mixture. Other irritant air pollutants, including certain urban air toxics, are associated with asthma in occupational settings and may interact with criteria pollutants in ambient air to exacerbate asthma. An evaluation of dose-response information for urban air toxics and biological feasibility as possible contributors to asthma is therefore needed. However, this evaluation is compounded by a lack of information on the concentrations of these compounds in the ambient air and their effects on asthma morbidity and mortality. Through an initial review of the current toxicological literature, we propose a tentative list of 30 compounds that could have the highest impact on asthma and respiratory health. These compounds were selected based on their ability to induce or exacerbate asthma in occupational and nonoccupational settings, their allergic potential and ability to react with biological macromolecules, and lastly, their ability to irritate the respiratory passages. We recommend better documentation of exposure to these compounds through routine air sampling and evaluation of total exposure and further evaluation of biological mechanisms through laboratory and epidemiological studies directed specifically at the role these substances play in the induction and exacerbation of asthma.

In-vitro exposure of guinea pig main bronchi to 2.5 ppm of nitrogen dioxide does not alter airway smooth muscle response

In order to investigate whether the oxidant airborne pollutant nitrogen dioxide (NO2) affects airway smooth muscle responsiveness, the contractile response of guinea pig main bronchi after in vitro exposure to 2.5 ppm of nitrogen dioxide was studied. Main bronchi were cannulated and exposed for 2 or 4 h to a constant flow of either NO2 or air. After exposure, bronchial rings were obtained and placed in a 37 degrees C jacketed organ bath filled with Krebs-Henseleit solution. Concentration-response curves were performed for acetylcholine (10(-9)-10(-3) M), substance P (10(-9)-10(-4) M), and neurokinin A (10(-10)-10(-5) M), and voltage-response curves (12-28 V) were performed for electrical field stimulation. There was no significant difference in either the smooth muscle maximal contractile response, or sensitivity between the bronchi exposed to NO2 and those exposed to air. We conclude that in vitro exposure to 2.5 ppm of NO2 does not alter airway smooth muscle responsiveness in guinea pigs.

Variability in airway conductance and lung volume in subjects with asthma

Variability in airway conductance (Gaw) and lung volume (TGV) was studied in 26 subjects with moderately severe asthma during a 9-week period. Specific airway conductance (SGaw) was calculated as Gaw:TGV. There was considerable inter-individual variability in airway conductance, and a smaller variability in TGV. Airway conductance (SGaw) showed an eight-fold difference and TGV a three-fold difference between smallest and largest values. The intra-individual variability was less, with a range of +/- 55% (SGaw) and +/- 12% (TGV) of the grand mean, respectively. The error of the method contributed only marginally to the variations in airway conductance. These data for spontaneous variability of conductance facilitate, for example, the assessment of the clinical importance of changes in lung function seen after exposure to air pollutants in chamber studies. Furthermore, the substantial inter-individual variability in conductance argues against comparing samples of asthmatic subjects in polluted and non-polluted areas, and in favour of prospective studies of cohorts of subjects with asthma.