Clean Air & Your Health (Part 1) - David Stukus, MD
D A V I D S T U K U S , M DA S S I S T A N T P R O F E S S O R O F P E D I A T R I C SS E C T I O N O F A L L E R G Y A N D I M M U N O L O G YN A T I O N WI D E C H I L D R E N ‘ S H O S P I T A LHEALTH IMPLICATIONS OFOZONE AND AIR POLLUTION
DISCLOSURES• No financial disclosures or conflicts of interest
OBJECTIVES• Discuss normal function of the respiratory tract• Review the health implications of air pollution• Describe common chronic respiratory ailments andspecific effect from air pollution
RESPIRATORY PHYSIOLOGY: NOSE• Nose serves several purposes• Only means to warm and humidify air into lungs• Primary organ for filtering particles out of air• Provides first line immunologic defense• Nose connects to pharynx (throat), also serves asdraining area for ear canals
RESPIRATORY PHYSIOLOGY: SINUSES• Sinuses are hollow boxes in the bones of the face• Filled with air and lined with a mucus membrane• Tiny hairs called cilia move back and forth to filtermucus into nose• Provide resonance to voice
RESPIRATORY PHYSIOLOGY: LUNGS• Lungs are located inside the chest, protected byribs• Airways that bring air into lungs are made of smoothmuscle and cartilage, which allows them toconstrict and expand• End point are alveoli, which are millions of tiny sacswhere air exchange occurs• Primary purpose of lungs: Gas exchange• Inhale – breathe oxygen in• Exhale – breathe carbon dioxide out
UNIFIED AIRWAY• Nose and lungs are closely inter-related• Pharynx (throat) connects the respiratory tract• Respiratory tract is considered an integrated system• Any process affecting one part will affect the other• Changes in physiology of nose and sinuses can andwill affect lower airways and vice versa
WHAT IS MUCUS?• Sticky, slippery fluid that protects the lining of therespiratory and gastrointestinal tract• 1st line of defense against outside world• Mucus membranes line all surfaces that interfacewith the environment• Mucus helps trap and filter small particles• Dust• Air pollution• Allergens• Bacteria, viruses• Normal mucus is clear• Becomes yellow or green when immune system is activated• Color change does not = bacterial infection
WHAT ARE CILIA?• Billions of microscopic hairs lining the entirerespiratory tract• Function to push mucus along and clear particlesfrom respiratory tract
SAD, BUT TRUE• Two brothers, 4 and 7 years old, both with asthma• Parents involved in custody dispute• Mother primary custodian, boys stayed with fatheron weekends• Father never accompanied to any medicalappointments• Did not believe they had asthma• Would not administer medications• Would not follow treatment plan• Father exposed boys to ‗natural‘ remedy
AIR POLLUTION EFFECTS ON THE BODY• Normal respiratory tract exists for breathing inair, filtering particles, exchange of oxygen• Exposure to air pollution• Increases immune response to foreign particles• Increased mucus production• Mucus becomes more sticky and thick• Unable to flow normally• Becomes stuck inside sinuses, nose, lungs• Cilia become ‗paralyzed‘• Unable to clear mucus and secretions• Nonproductive cough
• Increased inflammatory response• Swollen mucus membranes• Increased irritation from other particles• Impaired ability to protect against bacteria, viruses• Increase in respiratory infectionsAIR POLLUTION EFFECTS ON THE BODY
AIR POLLUTION EFFECTS ON THE BODY• Inflammation, change in mucus, altered immuneresponse trickles down from nose to smaller airwaysinside lungs• Small particles can bypass nose completely• Become trapped in mucus and are unable to be clearedfrom lungs• Areas of scarring can occur
TRICKLE DOWN EFFECT• Ultimate response is impaired oxygen exchange• Lower levels of oxygen inside body• Can affect any organ system• Increase demands on heart and cardiovascular system• Heart needs to pump faster to get less amounts of oxygenthroughout body• Blood vessels start to tighten and constrict• High blood pressure• Pregnant women unable to supply same amount of blood togrowing fetus• Over time, chronic irreversible changes occurthroughout the body
OZONE• Anyone who spends time outdoors during days withhigh ozone levels is at risk• Groups especially vulnerable:• Children and teenagers• Anyone > 65 years of age• People who work outdoors• People with existing lung diseases• People with existing cardiovascular disease
OZONE• Study of healthy lifeguards in Galveston, TX 2008:• Lung function (obstruction) worsened on days when ozonelevels were higher• Led Galveston to become 1st city to install air qualitywarning flag system on the beachJ Occup Environ Med. 2008 Feb;50(2):202-11.
OZONE: EFFECT ON LUNG FUNCTIONJ Occup Environ Med. 2008 Feb;50(2):202-11.
OZONE: HEALTH IMPLICATIONS• Risk of premature death increases in cities withhigher levels of ozone• Low level ozone can cause higher mortality ratesfrom cardiovascular disease, strokes, andrespiratory causes• Effect seen in people with and without pre-existingcardiovascular disease1. JAMA. 2004; 292:2372-2378.2. Am J Respir Crit Care Med. 2004; 170: 1080-1087.3. Epidemiology. 2005; 16:458-468.4. Environ Health Perspect. 2006; 114:120-123.5. Circulation. 2005; 111:563-569.
OZONE: HEALTH IMPLICATIONS• Immediate breathing problems:• Shortness of breath• Wheezing• Coughing• Pre-existing conditions – asthma attacks, respiratoryinfections, need for medical treatment• Can affect cardiovascular health• Increased risk of arrhythmias• Increased risk of heart attacks• Increased emergency department visits and hospitalizations1. Am J Epidemiol. 2006; 163(6):579-588.
EPA & OZONEEPA Concludes Ozone Pollution Poses Serious Health Threats• Causes respiratory harm (e.g. worsened asthma, worsenedCOPD, inflammation)• Likely to cause early death (both short-term and long-term exposure)• Likely to cause cardiovascular harm (e.g. heart attacks, strokes, heartdisease, congestive heart failure)• May cause harm to the central nervous system• May cause reproductive and developmental harm—U.S. Environmental Protection Agency, Integrated Science Assessmentfor Ozone and Related Photochemical Oxidants, 2013. EPA/600/R-10/076F.
PARTICLE POLLUTION• Airborne particles smaller than 10 microns (PM10) canbypass natural respiratory tract barriers/immunity andpermeate lower airways• Anyone who lives near or is exposed to high levels ofparticle pollution is at risk• Highest exposure occurs in urban areas close tohighways• Higher risk similar to ozone• Children and teenagers• Anyone > 65 years of age• People who work outdoors• People with existing lung diseases• People with existing cardiovascular disease
PARTICLE POLLUTION: HEALTHIMPLICATIONS• Peaks in pollution can have immediate or delayedeffects• Affect on lung function• Coughing• Wheezing• Shortness of breath• Asthmatics at high risk for health problems1. Am J Respir Crit Care Med. 2000; 162(3 Pt 1):981-988.
EPA & PARTICLE POLLUTIONEPA Concludes Fine Particle Pollution Poses Serious Health Threats• Causes early death (both short-term and long-term exposure)• Causes cardiovascular harm (e.g. heart attacks, strokes, heartdisease, congestive heart failure)• Likely to cause respiratory harm (e.g. worsened asthma, worsenedCOPD, inflammation)• May cause cancer• May cause reproductive and developmental harm—U.S. Environmental Protection Agency, Integrated ScienceAssessment for Particulate Matter, December 2009. EPA 600/R-08/139F.
DISPARITIES IN IMPACT OF AIRPOLLUTION• Studies show different results between races• Low socioeconomic status more consistently linkedto greater harm from air pollution• Greater exposure• Disadvantages in regards to access to healthcare, employment opportunities, living environment• Pre-existing health conditions1. Am J Epidemiol. 2008; 167:986-997.2. Environ Health Perspect. 2005: 113:693-699.3. Int J Environ Res Public Health. 2011; 8: 1755-1771.
HIGHWAYS• 30-45% of population of North America live next to a‗busy road‘• Areas most affected are within 500 meters (about 5½ football fields)Environ Res. 2011 Nov;111(8):1222-9
Total (excluding 0-1)Asthma Collaborative SitesCCSNCH PCCsChurchesNCH PCC & Asthma Collaborative Site
CHRONIC RHINITIS AND POLLUTION• Exposure to ozone and particulate matter canenhance the inflammatory response to allergens• Patients can experience a multiplied effect• Increase in symptoms• Remember the ―Unified Airway‖• Effects on asthma
ASTHMA• Chronic disease with no cure• Very common in children and also adults (~30% ofpopulation)• Often inherited• Not ‗caused‘ by exposure to anything• Symptoms are not always present, but inflammationnever goes away• Common symptoms• Coughing• Wheezing• Shortness of breath• Difficulty breathing• Respiratory distress
ASTHMA• Treatment• No cure• As needed fast acting inhalers – albuterol; opens airwaysrapidly• Daily controllers• Inhaled steroids decrease inflammation• Long acting bronchodilators• Leukotriene modifiers (singulair)• As needed oral or IV steroids for flare ups• Allergen immunotherapy• Omalizumab (Xolair) – anti IgE molecule• Avoidance of known triggers
ASTHMA• Morbidity• Poor quality of life• Poor sleep• Frequent missed work/school• Difficulty with exercise• Flare ups may result in Emergency Department visit orHospitalization• Mortality• ~5,000 Americans die each year due to asthma• Each death is entirely preventable
ASTHMA AND AIR POLLUTION• Well documented health effects in children andadults with asthma• Both acute and long term exposure• Specific effects:• Increased lower airway inflammation• Increased bronchial constriction and hyper-reactivity• Decline in lung function• Morbidity:• Increased asthma attacks• Increase need for ER visits, hospitalizations• Increase in mortality rates
COPD/EMPHYSEMA• Similar to asthma except caused by exposure tocigarette smoke or pollution/chemicals• Not inherited, and is preventable• Adult disease• Chronic inflammation with fixed airway narrowing• Different from asthma:• Alveoli are destroyed• Fixed airflow limitations• Often leads to need for supplementaloxygen
COPD/EMPHYSEMA• Symptoms are more chronic and progress over time• Common symptoms• Shortness of breath• Difficulty breathing• Coughing• Wheezing• Respiratory distress
COPD/EMPHYSEMA• Treatment• No cure• Bronchodilators• Albuterol; opens airways rapidly• Anticholinergic inhalers - atrovent• Daily controllers• Inhaled steroids decrease inflammation• Long acting bronchodilators• As needed (daily) oral or IV steroids for flare ups• Antibiotics to help treat flares• Need to stop smoking• Will not reverse disease but will still slow progression
COPD/EMPHYSEMA• Morbidity• Very poor quality of life• Poor sleep• Physical intolerance• Missed work• Disability• Mortality• 3rd leading cause of death in United States• Projected to be 4th leading cause of death worldwide by2030
COPD AND AIR POLLUTION• Effects very similar to asthma• Both acute and long term exposure• Specific effects:• Increased lower airway inflammation• Increased bronchial constriction and hyper-reactivity• Decline in lung function• Morbidity:• Increased COPD exacerbations• Increase need for ER visits, hospitalizations• Increase in mortality rates
WHAT CAN BE DONE?• Increased vigilance for high air pollution days toknow when to take precautions• Avoid exercising/exposure to high traffic areas• Avoid exercising outdoors when pollution levels arehigh• Reduce exposure to indoor cigarettesmoke, fireplaces, wood burning stoves• Advocacy and change in legislation
CONCLUSIONS• The normal respiratory tract is a complex, unifiedairway that serves many functions• Respiratory tract is intimately related to ambient airand environment• Air pollution has significant effects on the respiratorytract and other organ systems• People with chronic health conditions are mostaffected by air pollution