BPCO e inquinamento atmosfericoCOPD and air pollution

Giovanni Invernizzi

Laboratorio per la Ricerca Ambientale SIMG Società Italiana di Medicina Generale

giovanni.invernizzi.md@gmail.com

BPCO e inquinamento:la letteratura scientifica recente.

COPD and pollution: an update.

Inquinamento e sviluppo dell’apparato respiratorioPollution and lung development

Wright RJ, Brunst KJ. Programming of respiratory health in childhood: influence of outdoorair pollution. Curr Opin Pediatr.2013

Air pollutants may impact anatomy and/or physiological functioning of the lung and interrelatedsystems. Programming effects may result from pollutant-induced shifts in a number of molecular,cellular, and physiological states and their interacting systems. Specific key regulatory systemssusceptible to programming may influence lung development and vulnerability to respiratorydiseases, including both central and peripheral components of neuroendocrine pathways andautonomic nervous system (ANS) functioning which, in turn, influence the immune system. Starting in utero, environmental factors, including air pollutants, may permanently organize thesesystems toward trajectories of enhanced pediatric (e.g., asthma, allergy) as well as adult disease risk(e.g., chronic obstructive pulmonary disease). Evidence supports a central role of oxidative stress in the toxic effects of air pollution. Additionalresearch suggests xenobiotic metabolism and subcellular components, such as mitochondria aretargets of ambient air pollution and play a role in asthma and allergy programming. Mechanisms operating at the level of the placenta are being elucidated.Epigenetic mechanisms may be at the roots of adaptive developmental programming.Optimal coordinated functioning of many complex processes and their networks of interaction arenecessary for normal lung development and the maintenance of respiratory health. Outdoor air pollution may play an important role in early programming of respiratory health and isPotentially amenable to intervention.

L’inquinamento atmosferico è causa di BPCO?Occorrono studi più approfonditi per una conferma, ma…

Is pollution a definte cause of COPD? More studies are needed. However…Schikowski T, et al. Ambient air pollution- a cause for COPD? Eur Respir J.2013

The role of ambient air pollution in the development of chronic obstructive pulmonarydisease (COPD) is considered to be uncertain. We review the evidence in the light of recent studies.Eight morbidity and six mortalitystudies were identified. These were heterogeneous in design, characterization of exposureto air pollution, and methods of outcome definition. Six morbidity studies with objectivelydefined COPD (FEV1/FVC ratio) were cross-sectional analyses.Most studies were based on within communities exposure contrasts which mainly assesstraffic related air pollution. Overall, evidence of chronic effects of air pollution on theprevalence and incidence of COPD among adults was suggestive but not conclusive despiteplausible biologic mechanisms and good evidence that air pollution affects lungdevelopment in childhood and triggers exacerbations in COPD patients. To fully integrate this evidence in the assessment, the life-time course of COPD should bebetter defined. Larger studies with longer follow-up periods, specific definitions of COPD phenotypes, andmore refined and source-specific exposure assessments are needed.

…ma è confermato che l’inquinamento atmosferico è fattore di rischio per di riacutizzazioni e mortalità nella BPCO.

…pollution is a definite cause of COPD exhacerbations. Gan WQ et. al.

Associations of Ambient Air Pollution with Chronic Obstructive Pulmonary Disease Hospitalization and Mortality. Am J Respir Crit Care Med 2013

BACKGROUND. Ambient air pollution has been suggested as a risk factor for chronic obstructive pulmonarydisease (COPD). However, there is a lack of longitudinal studies to support this assertion.AIMS: To investigate the associations of long-term exposure to elevated traffic-related air pollution andwoodsmoke pollution with the risk of COPD hospitalization and mortality.METHODS: This population-based cohort study included a 5-year exposure period and a 4-year follow-up period. Allresidents aged 45-85 years who resided in Metropolitan Vancouver, Canada, during the exposure period and did nothave known COPD at baseline were included in this study (N = 467,994). Residential exposures to traffic-related airpollutants (black carbon, particulate matter < 2.5 µm in aerodynamic diameter, nitrogen dioxide, and nitric oxide) andwoodsmoke were estimated using land-use regression models and integrating changes in residences during theexposure period. COPD hospitalizations and deaths during the follow-up period were identified from provincialhospitalization and death registration databases.MEASUREMENTS AND MAIN RESULTS: An interquartile range elevation in black carbon concentrations (0.97×105/m, equivalent to 0.78 µg/m3 elemental carbon) was associated with a 6% (95% confidence interval, 2-10%) increasein COPD hospitalizations and a 7% (0-13%) increase inCOPD mortality after adjustment for covariates. Exposure tohigher levels of woodsmoke pollution (tertile 3 versus tertile 1) was associated with a 15% (2-29%) increasein COPD hospitalizations. There were positive exposure-response trends For these observed associations.CONCLUSIONS: Ambient air pollution, including traffic-related fine particulate pollution and woodsmoke pollution,is associated with an increased risk of COPD.

L’inquinamento atmosferico è fattore di rischio per di riacutizzazioni nella BPCO: una conferma italiana.

Pollution is a definite cause of COPD exhacerbations: an Italian confirmation Eur Respir J. 2013 Jan 11. [Epub ahead of print]Air pollution and multiple acute respiratory outcomes.Faustini A et al. on behalf of the EPIAIR collaborative Group Regional Health Service, Lazio Region,Rome, Italy.Short-term effects of air pollutants on respiratory mortality and morbidity have been consistentlyreported but usually studied separately.To more completely assess air pollution effects, we studiedhospitalisations for respiratory diseases together with out-of hospital respiratory deaths. A "timestratified" case-crossover study was carried out in six Italian cities from 2001-2005. Associations between daily particulate matter (PM10) and nitrogen dioxide (NO2) andhospitalisations for respiratory diseases (n. 100,690), chronic obstructive pulmonary disease (COPD)(n. 38,577), lower respiratory tract infections (LRTI) among COPD patients (n. 9,886) and out-ofhospital respiratory deaths (n 5,490) were estimated for 35+year-old residents. For 10 μg·m(-3) PM10, we found an immediate 0.59% (lag 0-1) increase in hospitalisations forrespiratory diseases and a 0.67% increase for COPD; the 1.91% increase in LRTI hospitalisationslasted longer (lag 0-3) and the 3.95% increase in respiratory mortality lasted six days. Effects of NO2 were stronger and lasted longer (lag 0-5). Age, gender, and previous ischemic heart disease acted as effect modifiers for different outcomes.Analysing multiple more than single respiratory events shows stronger air pollution effects. The temporal relationship between the pollutants' increases and hospitalizations or mortality forrespiratory diseases differs.

Groneberg DA, Chung KF Models of chronic obstructive pulmonary diseaseRespiratory Res, 2004, 5:18

Groneberg DA, Chung KF Models of chronic obstructive pulmonary diseaseRespiratory Res, 2004, 5:18

Come ridurre l’esposizione all’inquinamentoHow to reduce exposure

• conoscere le situazioni di rischio espositivo•stay informed about sources

• evitare il fumo passivo• avoid second-hand smoke

• in casa at home• in auto inside car• all’aperto outdoors luoghi di svago ad alta frequenza di fumatori (centri storici, stadi)crowded leisure places (historical centers, stadium)

• informarsi sulla qualità dell’aria outdoor• dati ARPA (previsioni/tempo reale)• stay informed on pollution real time data and forecasts (EPA website)

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Time (min)

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Starting smoldering cigarettesor idling diesel engine

Background

PM production from ETS (e) and an ecodiesel engine (d) (three smoldering cigarettes or an idling engine for 30' in a 60m3 garage)

PM

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/m3

Attenzione: le sigarette producono più PM di un motore diesel di ultima generazione!

Beware: cigarettes produce much more particles than a diesel engine!

Invernizzi G, et al. Tobacco Control, 2004.

Results 2.Transportations.1

Smoking in the car exposes to huge PM concentrations.

Invernizzi G, Ruprecht A, Boffi R, et al. Real-time measurement of particulate matter produced by environmental

tobacco smoke: a new way to monitor indoor air quality. Am J Crit Care Med 2003; 167: A500

L’inquinamento da fumo passivo in autoSmoking pollution inside cars.

L’inquinamento outdoor da fumo passivoOutdoor second-hand smoke pollution

Car-free road

High traffic road

Results

• A total of 1396 smokers were counted in Fiorichiari street during the “Promenade time” (20.00 p.m. - 02.00 a.m.)

• A total of 2513 cars crossed Pontaccio Street in the same time-window

PM1 Comparison between Fiorichiari (car free) and Pontaccio Street (open to car traffic) on Saturday night

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Fiorichiari St. Pontaccio St.

FIORICHIARI PM1 CROSSOVER PONTACCIO'S

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Mean excess PM1 1.1 mcg/m3

Durante le ore di maggior afflusso di visitatori la qualità dell’aria è molto peggiore nella zona pedonale rispetto all’adiacente via molto trafficata

During the promenade hours air quality is worse in car-free zone due to SHS

La qualità dell’aria allo stadio di San Siro peggiorava notevolmente durante gli eventi sportivi rispetto all’esterno a causa del fumo passivo (80.000 circa le sigarette fumate durante Inter-Lazio 2011).

Air quality worsened inside the San Siro stadium due to the 80.000 sigarettes smoked during the Inter vs Lazio match, srping2011.

Comparison Nicotine inside/outside

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L’inquinamento da fumo nello stadio di San Siro:le concentrazioni di nicotina ambientale dentro e fuori lo stadio.

Airborn nicotine concentration in- and outside the stadium.

CONFRONTO NICOTINA INTERNO/ESTERNO

1.32

3.43

2.88

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nell'ora prima della partita I° tempo II° tempo nell'ora dopo la partita

L’inquinamento da fumo nello stadio di San Siro:le concentrazioni di nicotina ambientale dentro e fuori lo stadio.

Airborn nicotine concentration in- and outside the stadium.

L’inquinamento da fumo nello stadio di: le concentrazioni di PM2.5.PM2.5 concentrations in- and outside the stadium

Come ridurre l’inquinamento outdoor.How to mitigate outdoor pollution

Gli interventi di limitazione del traffico: l’esperienza di Milano (Ecopass, Area C).

The Milan LEZ (low emission zone)

Area C monitoring campaign, July 2010.

Fixed monitoring stations: 1-7.

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Dane Westerdahl and Giovanni Invernizzi at the black carbon monitoring site in Duomo Square pedestrian zone, Milan, Italy, July 2010.

% BC in PM10 in the different zones

9.8

7.8 7.98.5

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13.211.8

25.324.7

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22.6

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C in

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Pedestrian zone Ecopass zone No restrictions zone

Percentuali di BC / PM10 nelle zone a diversa viabilità nelle tre giornate di monitoraggio, e media delle tre giornate.

La riduzione della % di BC nel PM10 in Aera C è stata del 47%,in zona Duomo del 62%.Black carbon reduction inside the LEZ was 47%, in the car-free zone was 62%.

AIR quality index: a reference to understand exposure risk.EPA's Air Quality Index (AQI) for

Particulate Matter 2.5 (PM 2.5) and Ozone (8-Hr)

Credits

ARIO RUPRECHTLaboratorio di Ricerca Ambientale SIMG, Milano

DANE WESTERDAHLCornell University, Ithaca, NY

COSTANTINOS SIOUTASUniversity of Southern California, LA

NINO KUENZLI

Basel Institute for Social Preventive Medicine