DAV I D S T U KU S , M DA S S I S TA N T P R O F E S S O R O F P E D I AT R I C S

S E C T I O N O F A L L E R GY A N D I M M U N O LO GYN AT I O N W I D E C H I L D R E N ’ S H O S P I TA L

HEALTH IMPLICATIONS OF OZONE 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 and specific effect from air pollution

ANATOMY OF THE RESPIRATORY TRACT

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 as draining 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 filter

mucus into nose• Provide resonance to voice

Normal Sinusitis

RESPIRATORY PHYSIOLOGY: LUNGS

• Lungs are located inside the chest, protected by ribs

• Airways that bring air into lungs are made of smooth muscle and cartilage, which allows them to constrict and expand

• End point are alveoli, which are millions of tiny sacs where 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 and will affect lower airways and vice versa

WHAT IS MUCUS?

• Sticky, slippery fluid that protects the lining of the respiratory and gastrointestinal tract• 1st line of defense against outside world

• Mucus membranes line all surfaces that interface with 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 entire respiratory tract

• Function to push mucus along and clear particles from respiratory tract

POLLUTION AND NORMAL 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

father on weekends• Father never accompanied to any medical

appointments• Did not believe they had asthma

• Would not administer medications• Would not follow treatment plan

• Father exposed boys to ‘natural’ remedy

OZONATOR

AIR POLLUTION EFFECTS ON THE BODY

• Normal respiratory tract exists for breathing in air, 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 infections

AIR POLLUTION EFFECTS ON THE BODY

AIR POLLUTION EFFECTS ON THE BODY• Inflammation, change in mucus, altered immune

response trickles down from nose to smaller airways inside lungs

• Small particles can bypass nose completely• Become trapped in mucus and are unable to be cleared

from 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 oxygen throughout body

• Blood vessels start to tighten and constrict• High blood pressure

• Pregnant women unable to supply same amount of blood to growing fetus

• Over time, chronic irreversible changes occur throughout the body

OZONE

• Anyone who spends time outdoors during days with high 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

ozone levels were higher• Led Galveston to become 1st city to install air quality

warning flag system on the beach

J Occup Environ Med. 2008 Feb;50(2):202-11.

OZONE: EFFECT ON LUNG FUNCTION

J Occup Environ Med. 2008 Feb;50(2):202-11.

OZONE: HEALTH IMPLICATIONS

• Risk of premature death increases in cities with higher levels of ozone

• Low level ozone can cause higher mortality rates from cardiovascular disease, strokes, and respiratory causes• Effect seen in people with and without pre-existing

cardiovascular disease

1. 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, respiratory

infections, 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 & OZONE

EPA Concludes Ozone Pollution Poses Serious Health Threats

• Causes respiratory harm (e.g. worsened asthma, worsened COPD, inflammation)

• Likely to cause early death (both short-term and long-term exposure)

• Likely to cause cardiovascular harm (e.g. heart attacks, strokes, heart disease, congestive heart failure)

• May cause harm to the central nervous system • May cause reproductive and developmental harm

—U.S. Environmental Protection Agency, Integrated Science Assessment for Ozone and Related Photochemical Oxidants, 2013. EPA/600/R-10/076F.

PARTICLE POLLUTION

• Airborne particles smaller than 10 microns (PM10) can bypass natural respiratory tract barriers/immunity and permeate lower airways

• Anyone who lives near or is exposed to high levels of particle pollution is at risk

• Highest exposure occurs in urban areas close to highways• 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: HEALTH IMPLICATIONS

• Peaks in pollution can have immediate or delayed effects

• Affect on lung function• Coughing• Wheezing• Shortness of breath• Asthmatics at high risk for health problems

1. 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, heart

disease, congestive heart failure)• Likely to cause respiratory harm (e.g. worsened asthma, worsened

COPD, inflammation)• May cause cancer• May cause reproductive and developmental harm

—U.S. Environmental Protection Agency, Integrated Science Assessment for Particulate Matter, December 2009. EPA 600/R-08/139F.

DISPARITIES IN IMPACT OF AIR POLLUTION

• Studies show different results between races• Low socioeconomic status more consistently

linked to greater harm from air pollution• Greater exposure• Disadvantages in regards to access to health care,

employment opportunities, living environment• Pre-existing health conditions

1. 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

5 ½ football fields)Environ Res. 2011 Nov;111(8):1222-9

Total (excluding 0-1)

Asthma Collaborative Sites

CCS

NCH PCCs

Churches

NCH PCC & Asthma Collaborative Site

COMMON DISORDERS OF THE RESPIRATORY TRACT

• Upper airway• Allergic rhinoconjunctivitis• Nonallergic rhinoconjunctivitis• Chronic sinusitis

• Lower airway• Asthma • Chronic Obstructive Pulmonary Disease• Bronchitis

CHRONIC RHINITIS/SINUSITIS

• Nasal and sinus mucosa is constantly inflamed and irritated

• Symptoms increase with exposure to triggers• Airborne allergens• Viral infections• Chemical aerosols• Pollution

• Symptoms• Nasal congestion and postnasal drip• Runny nose• Sneezing• Itching

CHRONIC RHINITIS/SINUSITIS

• Treatment• Oral antihistamines• Nasal steroid sprays• Allergen immunotherapy• Antibiotics• Avoidance of triggers

• Morbidity• Poor sleep• Poor quality of life• Fatigue• Headaches• Missed work/school

CHRONIC RHINITIS AND POLLUTION

• Exposure to ozone and particulate matter can enhance the inflammatory response to allergens

• Patients can experience a multiplied effect• Increase in symptoms• Remember the “Unified Airway”

• Effects on asthma

ASTHMA

ASTHMA

• Chronic inflammation of lower airways hallmarked by recurrent episodes of reversible bronchospasm

• Airways are very ‘twitchy’ in response to triggers

ASTHMA TRIGGERS

ASTHMA

• Chronic disease with no cure• Very common in children and also adults (~30% of

population)• Often inherited

• Not ‘caused’ by exposure to anything• Symptoms are not always present, but inflammation

never goes away• Common symptoms

• Coughing• Wheezing• Shortness of breath• Difficulty breathing• Respiratory distress

ASTHMA• Treatment

• No cure• As needed fast acting inhalers – albuterol; opens airways

rapidly• 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 or

Hospitalization• 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 and adults 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 to cigarette 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 supplemental oxygen

COPD/EMPHYSEMA

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 by

2030

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 to know when to take precautions

• Avoid exercising/exposure to high traffic areas• Avoid exercising outdoors when pollution levels

are high• Reduce exposure to indoor cigarette smoke,

fireplaces, wood burning stoves

• Advocacy and change in legislation

CONCLUSIONS

• The normal respiratory tract is a complex, unified airway that serves many functions

• Respiratory tract is intimately related to ambient air and environment

• Air pollution has significant effects on the respiratory tract and other organ systems

• People with chronic health conditions are most affected by air pollution

THANK YOU