1. D A V I D S T U K U S , M D
A 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 S
S 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 Y
N A T I O N WI D E C H I L D R E N ‘ S H O S P I T A L
HEALTH IMPLICATIONS OF
OZONE AND AIR POLLUTION

2. DISCLOSURES
• No financial disclosures or conflicts of interest

3. 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

4. ANATOMY OF THE RESPIRATORY
TRACT

5. 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

6. 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

7. Normal Sinusitis

8. 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

11. 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

12. 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

14. WHAT ARE CILIA?
• Billions of microscopic hairs lining the entire
respiratory tract
• Function to push mucus along and clear particles
from respiratory tract

15. POLLUTION AND NORMAL
RESPIRATORY TRACT

16. 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

17. OZONATOR

18. 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

19. • 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

20. 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

21. 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

22. 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

23. 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.

24. OZONE: EFFECT ON LUNG FUNCTION
J Occup Environ Med. 2008 Feb;50(2):202-11.

25. 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.

26. 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 hospitalizations
1. Am J Epidemiol. 2006; 163(6):579-588.

27. 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.

28. 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

29. 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.

30. EPA & PARTICLE POLLUTION
EPA 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.

31. 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.

32. 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

33. Total (excluding 0-1)
Asthma Collaborative Sites
CCS
NCH PCCs
Churches
NCH PCC & Asthma Collaborative Site

34. COMMON DISORDERS OF THE
RESPIRATORY TRACT
• Upper airway
• Allergic rhinoconjunctivitis
• Nonallergic rhinoconjunctivitis
• Chronic sinusitis
• Lower airway
• Asthma
• Chronic Obstructive Pulmonary Disease
• Bronchitis

35. 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

37. 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

38. 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

39. ASTHMA

40. ASTHMA
• Chronic inflammation of lower airways hallmarked
by recurrent episodes of reversible bronchospasm
• Airways are very ‗twitchy‘ in response to triggers

41. ASTHMA TRIGGERS

43. 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

44. 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

45. 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

46. 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

47. 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

48. COPD/EMPHYSEMA

49. COPD/EMPHYSEMA
• Symptoms are more chronic and progress over time
• Common symptoms
• Shortness of breath
• Difficulty breathing
• Coughing
• Wheezing
• Respiratory distress

50. 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

51. 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

52. 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

53. 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

55. 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

56. THANK YOU