Climate change poses ‘major threat’ to respiratory health

Key takeaways:

• Increases in heat, wildfires and air pollution, as a result of climate change, lead to negative outcomes for patients with lung diseases.
• Pulmonologists/respiratory specialists can help reduce these events.

The historical climate events of the past summer may have been eye-opening for all, but the health of patients with respiratory diseases and conditions has been particularly threatened due to these exposures.

From the Canadian wildfires and subsequent air quality concerns, to extreme heat, rain and flooding, climate change has had a major impact on this patient population.

“Currently, it is estimated that approximately 35 million Americans have underlying lung disease, most commonly COPD and asthma,” Laurie A. Manka, MD, pulmonologist at National Jewish Health, told Healio. “The consequences of climate change such as elevated ozone levels and poor air quality related to volatile organic compounds from vehicles, wildfire smoke and other particulate matter will likely drive this number higher. These environmental exposures not only affect those who already have underlying lung disease, but also promote the development of lung disease in children who are exposed to these early in life. All of this could place a much larger burden on our health care system.”

In a recent position statement, the European Respiratory Society (ERS) called climate change a “major threat” to patients with lung disorders, with extreme weather events and environmental exposures linked to increases in exacerbations, declines in lung function and new respiratory infections.

Healio spoke with pulmonologists and leaders of clean air efforts to discuss how facets of climate change such as extreme heat, poor air quality and longer pollen seasons are impacting patients with lung conditions; what policy changes are required now to improve conditions; and how these patients and the pulmonology community can prepare for a near future where extreme weather events are more commonplace.

Extreme heat

This past summer proved to be a brutal one for patients with asthma, COPD and other lung conditions as recording-breaking and persistent heatwaves took place worldwide.

Such extreme heat has been linked to greater burdens on the health care system and an increase in hospitalizations.

“Heat and humidity can cause drops in lung function leading to worsening symptoms and increased health care utilization,” Manka told Healio.

For instance, a study published in Thorax found that increasing temperatures during the summertime in England heightened the risk for hospitalization for asthma.

Notably, Konstantinoudis and colleagues found that each additional 1°C in daily mean summer temperature increased risk for asthma hospital admittance by 1.11% (95% CI, 0.88%-1.34%).

Heat exposure increases the likelihood for worsening conditions across patients with lung diseases; however, those living in urban areas tend to face a higher risk for poor outcomes, signaling that health inequities only grow more prevalent with climate change.

“In urban areas, people may live in places that are more at risk for pollution and be closer to the highways, and the heat factor only exacerbates all these things,” Victor Waters, MD, JD, FCLM, chief medical officer at Dignity Health St. Joseph’s Hospital and Medical Center and St. Joseph’s Westgate Medical Center and national spokesperson of the American Lung Association, told Healio. “Further, multigenerational living in small environments can also place individuals at higher risk.”

In terms of access to care, patients may be stuck in their homes during these instances or forced to relocate, both of which can negatively impact their regular treatment.

“A secondary outcome of these severe heatwaves and other extreme weather phenomena can lead to displacement of people from their homes potentially leaving them without lifesaving medications, including inhaled medicines,” Manka said. “Even loss of electricity to one’s home can lead to worsening air quality within the home as well as inability to utilize medical devices such as nebulizer machines and supplemental oxygen.”

Recognizing that extreme heat can pose a threat to even otherwise healthy individuals, the Biden administration in July announced three new efforts that are anticipated to protect both communities and workers from extreme heat. These efforts include:

1. issuing a Hazard Alert for heat that will inform employers on how to protect their workers during that time;
2. investing $7 million to improve weather forecasts; and
3. investing $152 million to increase water storage capacity and pipelines in areas greatly impacted by drought, such as California, Colorado and Washington.

These efforts show promise in improving conditions during periods of extreme heat, but spikes in temperature can also result in harmful changes to the environment, propelling the cycle of climate change even further, experts told Healio.

“The ozone layer is increased during heat waves, which in turn worsens pollution,” Waters said. “Anything that worsens pollution could put our patients with lung diseases at risk for exacerbations, worsened condition and the need to use more medication.”

Heat waves also impact pollen concentrations and wildfire risk.

“Warmer weather promotes longer allergen seasons which doubly impact those with both allergies and lung disease,” Manka said. “Higher temperatures also increase drought conditions, which increases wildfire risk.”

Air quality

The poor air quality experienced this summer on the East Coast from the Canadian wildfires demonstrate that no geographic community is immune from the effects of climate change.

“Smoke from wildfires can be carried for hundreds of miles from the origin of the fire, thereby affecting a large population of people, and burdening health care systems,” Manka told Healio.

The quickly spreading wildfires in Maui, Hawaii, and the devastation that ensued also prompted media attention and may have spread awareness of the growing threat of wildfires.

“Coverage of such weather phenomena sounds the alarm to the general population regarding trends that physicians have been seeing in their offices for a while now,” Manka said. “The downstream medical consequences could be great if climate change continues on its current trajectory.”

Considering how prevalent wildfires are becoming, it is incredibly important that everyone is aware of the risks associated with wildfires and their related pollution, especially clinicians and patients with lung diseases, experts said.

Study data suggest that exposure to wildfire smoke puts individuals at a higher risk for adverse outcomes, including disease and mortality. For instance, in a study published in American Journal of Respiratory and Critical Care Medicine, Linde and colleagues showed that each wildfire-associated event involving particulate matter less than 2.5 µm in diameter (PM_2.5) was linked to 23% increased odds for tuberculosis over 6 months.

Another study, published in the Journal of Hazardous Materials, found each 10 µg/m³ rise in 3-year cumulative concentrations of wildfire-related pollution resulted in a 0.4% increased risk for both all-cause mortality (adjusted HR = 1.004; 95% CI, 1.001-1.006) and nonaccidental mortality (aHR = 1.004; 95% CI, 1.002-1.006), as well as a 0.5% heightened risk for neoplasm death (aHR = 1.005; 95% CI, 1.002-1.008).

Air quality concerns for the pulmonology community extend beyond wildfire exposure.

In a study published in JAMA Internal Medicine, Goobie and colleagues found that PM exposure was linked to increased mortality, poor lung function and faster disease progression among patients with fibrotic ILD. Further, researchers found that high levels of sulfate, ammonium and nitrate elements in the air had the worst harm on this patient population.

Also, in the American Thoracic Society’s “Health of the Air” report, Cromar and colleagues calculated national annual health impacts associated with PM_2.5 and ozone levels above those recommended by ATS. Their results showed 13,900 avoidable deaths associated with PM_2.5 and 7,400 for ozone, 3,000 new cases of lung cancer attributable to PM_2.5, 748,660 cardiovascular and respiratory morbidity events associated with the combined pollutants, and 10,660 adverse birth outcomes.

Risks associated with ozone pollution tend to be similar to those observed with PM exposure. Laura Kate Bender, national assistant vice president of healthy air at the American Lung Association, told Healio short-term exposure to heightened ozone levels can cause shortness of breath, wheezing and coughing, whereas long-term exposure can contribute to premature death, increased respiratory harm and a higher risk for metabolic disorders among others.

“There are a lot of commonalities between the harms of particle pollution and ozone pollution,” Bender told Healio. “In both cases, they can cause immediate harm, particularly to breathing, and long-term harm if you’re exposed day after day.”

Advocating for clean air

Given these risks associated with poor air quality, the American Lung Association is ringing the alarm bells that now is the time to enact policies that aim to clean the air.

In this year’s State of the Air report, containing information from 2019 to 2021, the American Lung Association found that more than one in three U.S. citizens (almost 120 million individuals) are subjected to high fine particulate matter or ozone levels in the area they live.

Notably, the 2023 report highlighted an increase in unhealthy levels of short-term particle pollution and a decrease in ozone pollution exposure compared with the prior year’s report.

“Our main ask with the State of the Air report this year is that the EPA and the Biden administration pick up the pace and get strong air quality standards and regulations finalized,” Katherine Pruitt, BA, national senior director for policy at the American Lung Association and project lead of the report, told Healio when the report was published in April. “The sooner they can get them done, the more lives we can save.”

Currently, there is a lot of opportunity in advocating for clean air efforts due to the Biden administration’s investment in clean air technologies, Pruitt added.

“If we can stay the course, we will be able to strengthen protections for the public with some of the resources and regulatory improvements,” she told Healio.

This year the American Lung Association also published a “Driving to Clean Air” report, in which they discuss the health benefits of switching to zero-emission vehicles and reducing traffic-related pollution.

William Barrett, report author and national senior director of advocacy & clean air for the American Lung Association, told Healio there are several ways to spark change within each level of government.

“Local governments can work toward building out the infrastructure needed to fuel zero-emission vehicles,” Barrett told Healio at the time the report was published. “They can also add their own incentive programs for consumer purchases, as well as really try innovative strategies like zero-emission car share programs and other alternatives to personal vehicle ownership.”

Barrett discussed the state of California as an example, which, under the Clean Air Act, has the ability to set stronger standards than the federal government. Under this act California has adopted the Advanced Clean Cars II (ACC II) program, which dictates that by 2035, every new vehicle sold in the state will be zero-emission. Since 2022, eight additional states have exercised their Clean Air Act authorities to implement the ACC II standards.

“Now, we have eight states in the country with a zero-emission sales standard of 100% by 2035, and one more with a standard of over 80% by 2031,” Barrett told Healio. “Six more states are currently in the process of approving ACC II this year. This demonstrates a growing effort by states to bring, through these policies and standards, more and more zero-emission vehicle options to their communities and to bring public health benefits to their residents.”

The EPA’s proposal to set new emission standards for passenger vehicles is a main focus of policy change at the federal level.

“There’s a disproportionate share of pollution burden in communities nearest major roadways,” Barrett said. “These communities tend to include individuals of lower income, as well as people of color, so reducing pollution from the transportation sector is not only an important overall public health issue but a critical health equity issue.”

Adding to the American Lung Association’s fight for clean air, they recently expressed their disappointment in the EPA’s announcement that it will be conducting a new review of ozone standards, delaying actions to update the current outdated limit of the National Ambient Air Quality Standards for years.

Those standards should be based on science, Bender told Healio at the time of the EPA announcement.

“The science has shown for years that the current ozone standard is not safe to breathe; it allows levels of pollution that are unhealthy and can cause health harms,” Bender told Healio.

“Updating these standards is a real opportunity to promote environmental justice and meet the administration’s goals in terms of ensuring that communities have equitable access to healthy air but, if not, then it perpetuates the injustices that have been in place for too long already,” Bender added.

Pollen, flooding, vulnerable populations

Although extreme heat and poor air quality may be the first aspects of climate change that come to mind when thinking about impacts on patients with lung conditions, exposure to seasonal allergens and flooding also can be detrimental.

Because climate change alters factors related to pollen and aeroallergens, pollen seasons are longer, and there are new allergens floating in the air.

“Warmer weather promotes longer allergen seasons which most certainly can affect those with underlying lung disease, especially if that lung disease is triggered by allergens,” Manka told Healio. “Longer allergen seasons also increase the need for medication use for larger parts of the year.”

In the ERS position statement on climate change, Ana Maria Vicedo-Cabrera, PhD, assistant professor and head of the climate change and health group at the Institute of Social and Preventive Medicine at University of Bern in Switzerland, and colleagues acknowledged that the increase in thunderstorms brought on by climate change can cause allergic asthma outbreaks triggered by exposure to pollens and wet-air fungal spora.

Moreover, more rainfall and flooding as a result of the warming climate could contribute to poorer respiratory health because of the increased possibility for indoor mold.

Although patients with asthma, COPD, ILD and other lung conditions may stand to experience the most immediate harm from climate change, the ERS position statement also noted that such weather events may impact the lung health of vulnerable populations, creating downstream consequences for years to come.

Notably, children and pregnant women are two of the most highly vulnerable populations, according to the position statement. Children in particular stand to be highly affected as their lung and immune systems are immature; they breathe faster than adults and, thus, breathe in more polluted air and aeroallergens; and they spend more time outdoors.

For instance, in a study published this year in American Journal of Respiratory and Critical Medicine, Korsiak and colleagues found that higher levels of metal, sulfur and particulate oxidative potential in the air over a short period of time are linked to respiratory hospitalizations in children.

In the position statement, Vicedo-Cabrera and colleagues noted that such impacts on children can start immediately following conception, with extreme heat known to be associated with poor pregnancy outcomes.

Maternal and newborn exposures to extreme temperatures also impact lung volume in infants, as demonstrated by a study published in JAMA Network Open. Looking at long-term exposure to average temperatures of 24°C (ie, heat exposure) within weeks 20 to 35 of pregnancy and the first 4 weeks following birth against the median of 12°C, researchers found that infant girls had reduced functional residual capacity (–39.7 mL; 95% CI, –68.6 mL to –10.7 mL).

‘Active partners’ in change

There are specific actions health care professions in the pulmonology community can take to help protect current and future patients.

With the current pace of climate change and the growing intensity of the problems it creates for vulnerable individuals and patients with respiratory conditions alike, the ERS position statement calls on health care professionals “to become more active partners in climate change mitigation efforts that would help reduce the rate of warming.”

Respiratory physicians can take specific steps to reduce their greenhouse gas emissions, such as by implementing greener health care systems, prescribing more environmentally friendly inhalers and striving for smoking eradication.

At the end of their statement, Vicedo-Cabrera and colleagues outlined three calls for action.

Firstly, the society endorsed the air pollution limit values of the WHO Air Quality Guidelines and the phasing out of greenhouse gas emissions.

Secondly, the statement emphasizes the importance of zero-emission policies to reduce air pollution levels. Lastly, that statement called on health care professionals to be “role models” and advocates in this fight.

During this year’s ATS International Conference, a keynote session also described how clinicians can play an active part in reducing the harmful effects associated with warming temperatures.

As health care relies heavily on energy, Mary B. Rice, MD, MPH, director of the Institute of Lung Health at Beth Israel Deaconess Medical Center, recommended adopting more sustainable practices, such as renewable energy, in the workplace.

Pollution related to pressurized canisters for patients with asthma also came up during this session and sparked a conversation on the implications changing this form of medication delivery could have on low-income countries.

“In some of these countries, a canister of albuterol, for example, already costs 7 days’ wages,” Juan Carlos Celedón, MD, DrPH, ATSF, professor of medicine, epidemiology and human genetics at University of Pittsburgh, said during the session, highlighting that proposed changes to reduce pollution will impact individuals of all races and social classes across the world who should not be forgotten when fighting for change.

At this year’s CHEST Annual Meeting, in a session titled “Clean Air & Climate Advocacy for the Busy Clinician,” Erika M. Moseson, MD, pulmonary & critical care physician with Legacy Health in Oregon and host of the Air Health Our Health podcast, described how clinicians are well equipped to be clean air advocates despite their full plates.

Clinicians are already well versed in interpreting studies and how to make decisions with “imperfect data,” she said, adding that it is important not to waste time trying to change people’s minds when it comes to politics and climate change but to focus on shared values that are concordant with climate action and clean air in each local community.

“Clinicians are already well-positioned in their communities to both know the local community values and how clean air and a stable climate fit with those values,” she told Healio.

“A little effort goes a long way,” she said. “Anything that is worth doing is worth doing badly. Whatever time you have is enough.”

Following her talk at this year’s CHEST meeting, Moseson released a podcast episode with simple steps to get started for those interested in advocacy.

Future preparations, tips

When preparing for a future where climate change events are more common, awareness and patient-physician relationships are key, Manka told Healio.

“Physicians should be aware that weather phenomena can act as triggers for patients with lung disease, particularly those with asthma,” Manka said. “A discussion between a physician and patient regarding typical triggers for lung disease should occur at regularly scheduled visits and should include weather and environmental exposures such as air quality and ozone, in addition to allergies, irritants and infections.”

Proper education on the consequences of extreme heat, air pollutant and wildfire smoke exposure is also a necessity in trying to reduce the impacts of climate change.

“In preparing for the future with climate changes, there must be a lot more educational drive and making sure patients don’t underestimate their level of heat tolerance,” Waters said.

Moseson agreed that educating the pulmonology community is key to adapt to this changing world.

“We need to advocate for ways to decrease the climate change that is driving these wildland fires and also for resiliency measures,” she told Healio. “For example, we need to ensure that there is access to clean indoor air in the time of wildfires, and we need to know how to talk about HEPA filters with our patients and how to avoid or mitigate other sources of indoor air pollution, such as gas stoves.”

For patients with underlying lung disease, Manka recommends three steps to help preserve health during events resulting from climate change:

1. “Work with your doctor to come up with a plan to keep your underlying lung disease as well controlled as possible on a day-to-day basis.
2. Know your own triggers and monitor their presence in your environment. Be aware of the weather around you and follow local air quality index reports and pollen counts.
3. Avoid excessive time outside when air quality is poor, pollen counts are high or severe weather fronts are moving through.”

Ultimately, such adaptations might become commonplace and part of everyday life as “we have reached a point of no return,” Vicedo-Cabrera and colleagues wrote in the ERS statement.

“As the recent extreme weather events have shown, we need to prepare our community for a much more complex future adapting to the ever-increasing impact of climate-related respiratory disease,” they wrote.

References:

• ATS experts discuss the effects of climate change on health in Monday keynote. https://www.atsconferencenews.org/ats-experts-discuss-the-effects-of-climate-change-on-health-in-monday-keynote/. Published May 23, 2023. Accessed Sept. 26, 2023.
• Cromar K, et al. Ann Am Thorac Soc. 2023;doi:10.1513/AnnalsATS.202305-455OC.
• Driving to Clean Air: Health benefits of zero-emission cars and electricity. https://www.lung.org/getmedia/9e9947ea-d4a6-476c-9c78-cccf7d49ffe2/ala-driving-to-clean-air-report.pdf. Published June 7, 2023. Accessed June 7, 2023.
• EPA initiates new review of the ozone national ambient air quality standards to reflect the latest science. https://www.epa.gov/newsreleases/epa-initiates-new-review-ozone-national-ambient-air-quality-standards-reflect-latest. Published Aug. 21, 2023. Accessed Aug. 24, 2023.
• Fact sheet: President Biden announces new actions to protect workers and communities from extreme heat. https://www.whitehouse.gov/briefing-room/statements-releases/2023/07/27/fact-sheet-president-biden-to-announce-new-actions-to-protect-workers-and-communities-from-extreme-heat/. Published July 27, 2023. Accessed Sept. 26, 2023.
• Gao Y, et al. J Hazard Mater. 2023;doi:10.1016/j.jhazmat.2023.131779.
• Goobie GC, et al. JAMA Intern Med. 2022;doi:10.1001/jamainternmed.2022.4696.
• Guilbert A, et al. JAMA Netw Open. 2023;doi:10.1001/jamanetworkopen.2023.3376.
• Internal medicine physicians applaud white house action on extreme heat to protect workers, communities. https://www.acponline.org/acp-newsroom/internal-medicine-physicians-applaud-white-house-action-on-extreme-heat-to-protect-workers. Published July 28, 2023. Accessed Sept. 26, 2023.
• Konstantinoudis G, et al. Thorax. 2023;doi:10.1136/thorax-2022-219901.
• Korsiak J, et al. Am J Respir Crit Care Med. 2022;doi:10.1164/rccm.202205-0896OC.
• Linde LR, et al. Am J Respir Crit Care Med. 2023;doi:10.1164/rccm.202203-0457OC.
• Moseson E. Climate & clean air advocacy as a full-time clinician. Presented at: CHEST Annual Meeting; Oct. 8-11, 2023; Honolulu.
• State of the Air 2023 report. https://www.lung.org/getmedia/338b0c3c-6bf8-480f-9e6e-b93868c6c476/SOTA-2023.pdf. Published April 19, 2023. Accessed Sept. 26. 2023.
• Vicedo-Cabrera AM, et al. Eur Respir J. 2023;doi:10.1183/13993003.01960-2022.

For more information:

William Barrett can be reached at william.barrett@lung.org.

Laura Kate Bender can be reached at laura.bender@lung.org.

Laurie A. Manka, MD, can be reached at mankal@njhealth.org.

Erika M. Moseson, MD, can be reached at airhealthourhealth@gmail.com.

Katherine Pruitt, BA, can be reached at katherine.pruitt@lung.org.