J. Tod Olin, MD, MSCS

We in the United States can learn from the experience in Australia because wildfires are and presumably will be predictably problematic for the foreseeable future, especially in the western U.S.

One medical message is that laryngeal symptoms, especially cough, are easy to confuse with asthma symptoms and therefore confound how health care providers assess asthma severity in patients who have both asthma and laryngeal hypersensitivity.

I do think health care providers are improving their awareness of laryngeal hypersensitivity. At the same time, we do not have a reliable way to assess the relative contributions of asthma and laryngeal hypersensitivity in patients with both conditions. As you might imagine, this will predictably lead to either overtreating or undertreating asthma in some patients.

I am fairly involved in creating policies related to air quality as it relates to sport. Here is a high-level overview of most of those policies.

Athletic organizations and individuals who work or enjoy recreational activities outdoors are predictably going to have to deal with unhealthy air quality at some point in the future. There have been a few high-profile cases of events getting canceled due to poor air quality, such as New York Yankees baseball games this year and Pac-12 football games in 2018. Most recommendations and policies related to outdoor activities use a publicly available measure called the air quality index to stratify risk for both healthy individuals and those with underlying cardiorespiratory problems.

Regardless of which threshold air quality index number an individual or group uses to change or cancel an activity, it is important to think about risk mitigation plans now because there is usually very little warning before air quality worsens in any given area.

I live in Denver. We woke up in late May this year to very poor air quality one day because wind patterns coming out of Canada changed. The night before, air quality seemed quite good.

I usually start with the following question when organizations ask for advice: “What would you do if the air quality were so bad that no one in their right mind would participate?” Sometimes, there are options that balance both safety and participation, although there are usually drawbacks that prevent a single strategy from working in all situations.

For example, well-fitted N95 masks can limit exposure, but might not be feasible in athletics. Sometimes, moving activities indoors to areas with well-filtered air can limit exposure. Sometimes, especially in areas with poor air quality caused by combustion engines, air quality changes with time of day. Sometimes, relatively small geographic changes make very large differences in terms of exposure.

Then we work backward to come up with contingency plans that work for groups based on the air quality index.

Another thing to keep in mind as it relates to participating in activities in areas with poor air quality is that overall exposure likely matters a lot. If there is a 1-hour activity in that area with suboptimal air quality, participants can help themselves by using the other 23 hours of the day to minimize exposure.

Albert Rizzo, MD, FACP

The findings of this study are not surprising but significant in supporting already recognized detrimental effects of poor air quality on airways, both upper and lower, especially in those with known chronic diseases such as laryngeal hypersensitivity and asthma.

Hypersensitivity of the larynx can be both a cause and a symptom of a variety of laryngeal disorders, including chronic cough, paradoxical vocal fold motion disorder or vocal cord dysfunction, globus sensation, and some instances of muscle tension dysphonia. 

These conditions, when triggered, can mimic both acute and chronic symptoms of poor asthma control as well. Common triggers are found in many of these sensory disorder syndromes and environmental exposures such as PM from, for example, wildfires; allergens; heat, cold and humidity extremes; and odors or perfumes. Strong emotions can cause flares in the condition as well.

Patients with these conditions should be educated in important preventive and ultimately needed treatment modalities. Being aware of air quality on a daily basis should become a habit by checking websites such as airnow.gov and using that information to tailor the day's activities, such as trying to avoid being outdoors on bad air quality days. If being outdoors cannot be avoided, appropriate masks (N95) should be worn.

At home, windows and doors should be shut, air conditioner systems should be set to recirculate to keep the poor outdoor air quality from coming in, and HEPA filters, if available, should be used. Such patients also should be up to date on what their physicians have recommended to treat their chronic conditions. 

Besides drug therapies, many patients with laryngeal hypersensitivity syndrome should be aware of the nonpharmacologic treatments that may have been recommended for them and use them during periods when increased PM or wildfire smoke are prevalent. These patients also should have a good communication channel with their treating health care provider so any symptoms, especially worsening ones, can be addressed by way of phone calls, portal messages or virtual or in-person visits. 

Additionally, policies need to consider the inequitable distribution of the social determinants of health that often exist and strive to improve the situation. At the policy level, several approaches are needed. 

Legislation and administrative action to help support the EPA in setting air quality standards needs advocacy. Policies should be passed to make sure that patients have adequate coverage for needed medications to control their chronic condition and be able to have available rescue medications on hand for flares related to trigger exposures.

Ongoing research should aim to identify more effective therapies, both pharmacologic and nonpharmacologic, to help keep patients with laryngeal hypersensitivity from flaring their condition and bring it back under control as quickly as possible when triggered by such exposures as PM pollution, especially when related to wildfires, which we know, unfortunately, are occurring more frequently.