man wearing mask

EVIDENCE

MANAGEMENT

MANAGEMENT OF AIR POLLUTION EFFECTS ON RESPIRATORY HEALTH

Clean breathing matters to health. Increasing public awareness of air pollution and the burden of disease that it imposes on individuals, families and society is an essential step toward making the changes that will improve public health.

Patients need to be informed about the adverse impacts of air pollution on their respiratory health and how they can protect against and minimise exposure to air pollution. Avoidance of the source of air pollution is commonly reported as the best strategy to help minimise respiratory symptoms related to air pollution.

However, avoidance of exposure to both indoor and outdoor pollutants is challenging in most geographical regions. Along with behavioural changes, protective measures such as nasal filters, masks and dietary supplementation, may help to reduce the effects of air pollution and manage the associated symptoms.

Here, The Clean Breathing Institute discusses strategies to minimise the adverse impacts of air pollution on respiratory health.

 

female doctor

 

The need to raise awareness of the health impacts of air pollution

Despite the well-documented negative effects of air pollution on health,1 there appears to be a lack of public understanding and awareness in this area.2 There is a need for greater understanding of the long-term effects of poor air quality and of the positive action people can take to reduce their exposure to air pollution. A recent US survey found that only 3% of adults with existing respiratory and heart disease had discussed strategies to reduce their exposure to air pollution with a health professional.3 In a companion survey among health professionals in the US, it was found that most respondents were not talking with their at-risk patients about limiting their exposure to air pollution.4

 

The health effects resulting from exposure to air pollution

Though the respiratory system has remarkable resilience to air pollution, long- and even short-term exposure to elevated levels of air pollution can contribute to reduced respiratory function, even in apparently healthy people.5

Pollution levels can be high in the following situations:

  • Near busy roads, in urban areas (especially during rush hour), and in industrial areas 
  • When there is smoke in the air from wood stoves, fireplaces, campfires, or wildfires
  • Hot, sunny, humid days with stagnant air have higher particle concentrations than days when the air is partially ‘scrubbed’ by rain or snow
  • When fine particles outdoors penetrate into homes and buildings – high levels of outdoor particle pollution can elevate particle pollution levels indoors

Exposure to high air pollution levels can:6–11  

  • Cause or worsen symptoms such as coughing, wheezing and shortness of breath
  • Increase the number of hospital admissions for respiratory conditions – an estimated 1% increase for every 10 μg/m3 increase in PM10
  • Increase the risk of death from lung conditions

How does exposure to air pollution compare with smoking?

When communicating the health risks of air pollution to patients, the risks can be compared with those from other sources, such as environmental exposure to tobacco smoke.2,12

Air pollution can be as damaging to respiratory health as passive smoking. Living alongside a major road carries a health risk similar to that associated with passively smoking 10 cigarettes per day.13

However, the risk to health associated with active smoking is greater than for air pollution. Long-term exposure to fine particulate air pollution in a highly polluted city was estimated to reduce average life expectancy by approximately 3 years, compared with an 8-year reduction in life expectancy for a moderate, active smoker.14,15

Strategies to reduce exposure to air pollution

Although we cannot completely avoid exposure to air pollution, taking simple steps to reduce exposure will reduce the severity of lung and systemic adverse health effects in both healthy and at-risk individuals.

Advise patients to:

  • Be aware of the local air quality and ways to check this

Up-to-date information about local air quality and air quality alerts are widely available in many countries, and air quality agencies may issue alerts when pollution levels are high16–19

  • Take steps to reduce exposure when pollution levels are of concern — particularly important for people with lung or cardiovascular disease, for children and the elderly, and for those with symptoms such as cough or sore throat20,21
    • Minimise time spent in traffic-congested areas  — walk along side roads instead of main roads where possible12,21
    • Avoid or reduce strenuous activity outside at times and locations where pollution levels are high12,20,21 — but note that exercise has health benefits, which will often outweigh the risk from air pollution21,22

 

 

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STOP: Avoid exercising outdoors when pollution levels are high

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GET READY: Choose quieter routes and avoid busy roads

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GO: Exercise in green spaces

HOW CAN THE EFFECTS OF AIR POLLUTION BE MANAGED?

The overall goal should be to protect against and minimise exposure to air pollution, rather than simply treating the resultant symptoms.

Protective barriers, including nasal filters and masks, may help to reduce exposure to air pollutants and allergens when avoidance is not possible, for example in large cities. However, their efficacy varies substantially depending on the design and material used23, and there is currently limited evidence to recommend their use.21

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Nasal filters

Nasal filters are effective in reducing the symptoms of allergic rhinitis24,25 and may reduce the effects of air pollution.25 Due to the ability of these products to filter pollen from inspired air, it is reasonable to assume that they could filter pollutants of similar size. However, there is currently a lack of evidence demonstrating a link between filtration capacity of a nasal filter and any subsequent reduction in air pollution-related respiratory symptoms. This is an area for future exploration alongside aspects of filter design. Constraints on the design of nasal filters include the need to be discreet, comfortable to wear, aesthetic and easy to use while conforming to variations in nostril shape to ensure a good fit and seal to enable effective filtration.25

 

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Masks and respirators

Face masks are commonly used in some parts of the world to reduce exposure to air pollutants. Some types of mask are effective for filtering outdoor particulate matter, and may reduce the respiratory and cardiovascular health risks associated with severe pollution.21,26

However, masks must be fully sealed between the face and edge of the mask to be effective;21 a recent study found that many commercially available disposable face masks do not provide adequate protection because of poor facial fit.27 The authors called for more rigorous testing of air pollution masks, similar to that required for workplace masks.

At present, commercially available masks cannot efficiently remove gaseous pollutants.21 Masks can also be uncomfortable to use and breathe through, sometimes leading to overheating, rashes and breathlessness.21,25

 

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Air filters and monitors

Air filters and purifiers, in the form of household systems or portable air cleaners, provide improvements in indoor air quality, reducing exposure to particulate matter and allergens.28,29 Portable air monitors may have a role in notifying at-risk individuals when pollution levels are high.26

 

 

How can symptoms associated with exposure to air pollution be relieved?

There are currently no specific treatments for relieving air pollution-related symptoms; in order to develop effective treatments for relieving these effects, those symptoms must be better characterised and distinguished from general symptoms of infection and allergy.

Current treatments for respiratory conditions are effective and well tolerated; however, specific evidence is needed to support the efficacy of these treatments for the relief of air pollution-related symptoms.

 

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Nose

Nasal irrigation, sprays and saline rinses may provide relief of irritant rhinitis by cleansing the nose of irritant particles and improving mucociliary clearance.30–32

 

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Nose and throat

Decongestants, anticholinergics and antihistamines may relieve congestion, runny nose, itching and sneezing.31,33,34

 

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Throat

Cough suppressants, expectorants, throat sprays and lozenges may help relieve symptoms of cough and dry throat.35–37

 

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DIET

Nutrients such as vitamins A, C and E and polyphenols, found in many types of plant-based foods, may enhance the body’s antioxidant defences, reducing oxidative stress and facilitating detoxification.7,26,38

There is some evidence to suggest that carotenoids, vitamin D and vitamin E may help protect against pollution damage which can trigger asthma, chronic obstructive pulmonary disease and lung cancer initiation. Vitamin C, curcumin, choline, sulforaphane and omega-3 fatty acids may also play a role.21,39

However, it is very difficult to design robust randomised studies to examine the effect of nutrition in protecting against air pollution. This is because of the confounding factors of diet, obesity, co-morbid illness, medication and environmental exposure.

 

 

Other resources for health professionals to learn more about the health effects of air pollution

Resource Information

World Health Organization guidelines.1

 

The World Health Organization sets recommended limits for health-harmful concentrations of key air pollutants both outdoors and inside buildings and homes, based on global synthesis of scientific evidence. 

National Institute for Health and Care Excellence. Air pollution: outdoor air quality and health guideline.40

 

 The guideline covers road traffic-related air pollution and its links to ill health. Published in 2017.

Environmental Protection Agency. Particle pollution and your patients’ health.41

 

An online course by the Environmental

Protection Agency with continuing education credit offered by the Centers for Disease Control and Prevention. Published in 2017.

European Respiratory Society. Air pollution and respiratory e-learning.42

 

 Online module on air pollution and respiratory health with interactive case simulations and engaging case discussions with continuing education credit offered by the European Respiratory Society. Published in 2018.

Thurston GD, et al. A joint ERS/ATS policy statement: what constitutes an adverse health effect of air pollution? An analytical framework. Eur Respir J 2017;49:pii:1600419.43

 

 The report integrates the latest science into a general framework for interpreting the adversity of the human health effects of air pollution. Published in 2017.

Government of India. Steering Committee on Health Related Issues on Air Pollution.44

 

 A report of the steering committee established by the Ministry of Health and Family Welfare, Government of India, which aimed to collate and appraise evidence linking air pollution exposure to adverse health effects at Indian and global levels, and provide recommendations for policy. Published in 2015.

Huang J, et al. Health impact of China's Air Pollution Prevention and Control Action Plan: an analysis of national air quality monitoring and mortality data.45

 

 A review of the effects of the Air Pollution Prevention and Control Action Plan on long-term air quality management and the related health impacts in China. Published in 2018.

Act now to reduce the health impacts of air pollution

Join the TCBI community to keep updated with the latest news and research.

Download our literature review and our advisory meeting summary to find out more about managing the health effects of air pollution and how to minimise exposure to air pollution.

 

  • REFERENCES

    01. World Health Organization. Guidelines. Available at: http://www.who.int/airpollution/guidelines/en/. Last accessed: 22 July 2018.

    02. Powell P, et al. How do you explain the risk of air pollution to your patients? Breathe 2016;12:201–3.

    03. Mirabelli MC, et al. Air quality awareness among U.S. adults with respiratory and heart disease. Am J Prev Med 2018;54:679–87.

    04. Mirabelli MC, et al. Patient–provider discussions about strategies to limit air pollution exposures. Am J Prev Med 2018;55:e49–52.

    05. Paulin L, Hansel N. Particulate air pollution and impaired lung function. Available at: https://f1000research.com/articles/5-201/v1. Last accessed: 25 July 2018.

    06. Atkinson RW, et al. Acute effects of particulate air pollution on respiratory admissions. Am J Respir Crit Care Med 2001;164:1860–6.

    07. Kampa M, Castanas E. Human health effects of air pollution. Environ Pollut 2008;151:362–7.

    08. Peacock JL, et al. Outdoor air pollution and respiratory health in patients with COPD. Thorax 2011;66:591–6.

    09. Shusterman D. The effects of air pollutants and irritants on the upper airway. Proc Am Thorac Soc 2011;8:101–5.

    10. Sacks DS, et al. Particulate matter–induced health effects: who is susceptible? Environ Health Perspect 2011;119:446–54.

    11. Xue X, et al. Temporal trends in respiratory mortality and short-term effects of air pollutants in Shenyang, China. Environ Sci Pollut R 2018;25:11468–79.

    12. Kunzli N, et al. “Breathe clean air”: the role of physicians and healthcare professionals. Breathe 2014;10:214–9.

    13. Van der Zee SC, et al. Air pollution in perspective: health risks of air pollution expressed in equivalent numbers of passively smoked cigarettes. Environ Res 2016;148:475–83.

    14. Dockery DW, Pope CA III. Lost life expectancy due to air pollution in China. Available at: http://institute.swissre.com/research/risk_dialogue/magazine/Cardiovascular_risks_in_HGM/Lost_life_expectancy_due_to_air_pollution_in_China.html. Last accessed: 22 July 2018.

    15. Pope CA III, Dockery DW. Air pollution and life expectancy in China and beyond. Proc Natl Acad Sci USA 2013;110:12861–2.

    16. AirNow. Current Air Quality Index. Available at: https://airnow.gov/index.cfm?action=airnow.main. Last accessed: 22 July 2018.

    17. AirNow-International. International air quality. Available at: https://www.airnow.gov/index.cfm?action=airnow.international. Last accessed: 22 July 2018.

    18. Government of Canada. Air Quality Health Index. Available at: https://weather.gc.ca/airquality/pages/index_e.html. Last accessed: 22 July 2018.

    19. Air Quality in Europe. Forecast. Available at: http://www.airqualitynow.eu/comparing_forecast.php. Last accessed: 22 July 2018.

    20. UK Department for Environment & Rural Affairs. Daily air quality index and recommended actions and health advice. Available at: https://uk-air.defra.gov.uk/air-pollution/daqi. Last accessed: 26 July 2018.

    21. Laumbach R, et al. What can individuals do to reduce personal health risks from air pollution? J Thorac Dis 2015;7:96–107.

    22. De Hartog JJ, et al. Do the Health Benefits of Cycling Outweigh the Risks? Environmental Health Perspectives 2010;118:1109–16.

    23. Patel D, et al. Challenges in evaluating PM concentration levels, commuting exposure, and mask efficacy in reducing PM exposure in growing, urban communities in a developing country. Sci Total Environ 2016;543:416–24.

    24. D'Amato G, et al. Nasal filters in prevention of seasonal rhinitis induced by allergenic pollen grains. Open clinical study. Eur Ann Allergy Clin Immunol 2012;44:83–5.

    25. Sigsgaard T, Tovey ER. Nasal filters: a novel approach to tackling allergic rhinitis. Expert Rev Clin Immunol 2014;10:1133–5.

    26. Guan WJ, et al. Impact of air pollution on the burden of chronic respiratory diseases in China: time for urgent action. Lancet 2016;388:1939–51.

    27. Cherrie JW, et al. Effectiveness of face masks used to protect Beijing residents against particulate air pollution. Occup Environ Med 2018;75:446–52.

    28. Batterman S, et al. Particulate matter concentrations in residences: an intervention study evaluating stand-alone filters and air conditioners. Indoor Air 2012;22:235–52.

    29. Vijayan VK, et al. Enhancing indoor air quality – the air filter advantage. Lung India 2015;32:473–9.

    30. King D, et al. Saline nasal irrigation for acute upper respiratory tract infections. Cochrane Database Syst Rev 2015;4:CD006821.

    31. Macy E. A rhinitis primer for family medicine. Perm J 2012;16:61–6.

    32. Rabago D, Zgierska A. Saline nasal irrigation for upper respiratory conditions. Am Fam Physician 2009;80:1117–9.

    33. Baena–Cagnani CE, et al. The international survey on the management of allergic rhinitis by physicians and patients (ISMAR). World Allergy Organ J 2015;8:10.

    34. Scarupa MD, Kaliner MA. Nonallergic rhinitis, with a focus on vasomotor rhinitis: clinical importance, differential diagnosis, and effective treatment recommendations. World Allergy Organ J 2009;2:20–5.

    35. Farrer F. Sprays and lozenges for sore throats. S Afr Pharm J 2011;78:26–31.

    36. Holzinger F, et al. The diagnosis and treatment of acute cough in adults. Dtsch Arztebl Int 2014;111:356–63.

    37. Rubin BK. Mucolytics, expectorants, and mucokinetic medications. Respir Care 2007;52:859–65.

    38. Gilliland FD. Outdoor air pollution, genetic susceptibility, and asthma management: opportunities for intervention to reduce the burden of asthma. Pediatrics 2009;123(Suppl 3):S168–73.

    39. Whyand T, et al. Pollution and respiratory disease: can diet or supplements help? A review. Respir Res 2018;19:79.

    40. National Institute for Health and Care Excellence. Air pollution: outdoor air quality and health guideline. Available at: https://www.nice.org.uk/guidance/ng70. Last accessed: 22 July 2018.

    41. Environmental Protection Agency. Particle pollution and your patients’ health. Available at: www.epa.gov/particle-pollution-and-your-patients-health. Last accessed: 22 July 2018.

    42. European Respiratory Society. Air pollution and respiratory e-learning. Available at: https://www.ersnet.org/the-society/news/cme-online--air-pollution-and-respiratory-health. Last accessed: 22 July 2018.

    43. Thurston GD, et al. A joint ERS/ATS policy statement: what constitutes an adverse health effect of air pollution? An analytical framework. Eur Respir J 2017;49:pii:1600419.

    44. Government of India. Report of the Steering Committee on Air Pollution and Health Related Issues in India. Available at: https://mohfw.gov.in/sites/default/files/5412023661450432724_0.pdf. Last accessed: 22 July 2018.

    45. Huang J, et al. Health impact of China's Air Pollution Prevention and Control Action Plan: an analysis of national air quality monitoring and mortality data. Available at: https://doi.org/10.1016/S2542-5196(18)30141-4. Last accessed: 22 July 2018.

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