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Near-fatal and fatal asthma and air pollution: are we missing an opportunity to ask key questions?

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We have a responsibility to discuss and record the detrimental health effects of air pollution
Heather J Lambert, Mark J Hayden, Chinthika Piyasena and Stephen W Lord
Published on: 18 July 2024

Published on: 18 July 2024
We have a responsibility to discuss and record the detrimental health effects of air pollution
- Heather J Lambert, Paediatrician and research associate 1. University of Newcastle upon Tyne 2. Ride For Their Lives
- Other Contributors:
  Mark J Hayden, Consultant Paediatric Intensivist
  
  Chinthika Piyasena, Consultant Neonatologist
  
  Stephen W Lord, Consultant Cardiologist and Medical Examiner
Varghese and colleagues draw attention to and argue for better capture of the link between air pollution and fatal or near-fatal asthma at a patient level [1]

Evidence on the detrimental effects of air pollution on health have led to the World Health Organisation proposing stringent targets in guidelines for improving air quality [2,3], which in the UK we fall far short of [4].
There is a clear mismatch: if air pollution is a major risk for 5 million excess deaths per year globally and 30-40 thousand excess deaths in the UK [5], why is that risk rarely discussed in clinical consultations or documented in clinical records? We frequently ask about smoking and pets in the household when taking a clinical history, but not about outdoor air pollution exposure in terms of where children live or how they walk to school in relation to local busy roads.

In 2020 the result of an inquest linked the death of a 9 year old girl, to air pollution based on careful examination of timing of admissions and spikes in air pollution over the preceding years. The coroner rightly criticised many professional groups. This included those responsible for medical education for failing to focus on air pollution and clinicians for failing to warn this girl’s family about the health risks of air pollution [6].

So despite the considerable scientific evidence, air pollution is seldom recorded clinically. It has a code that is rarely used (Exposure to air pollution ICD10 Co...
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Varghese and colleagues draw attention to and argue for better capture of the link between air pollution and fatal or near-fatal asthma at a patient level [1]

Evidence on the detrimental effects of air pollution on health have led to the World Health Organisation proposing stringent targets in guidelines for improving air quality [2,3], which in the UK we fall far short of [4].
There is a clear mismatch: if air pollution is a major risk for 5 million excess deaths per year globally and 30-40 thousand excess deaths in the UK [5], why is that risk rarely discussed in clinical consultations or documented in clinical records? We frequently ask about smoking and pets in the household when taking a clinical history, but not about outdoor air pollution exposure in terms of where children live or how they walk to school in relation to local busy roads.

In 2020 the result of an inquest linked the death of a 9 year old girl, to air pollution based on careful examination of timing of admissions and spikes in air pollution over the preceding years. The coroner rightly criticised many professional groups. This included those responsible for medical education for failing to focus on air pollution and clinicians for failing to warn this girl’s family about the health risks of air pollution [6].

So despite the considerable scientific evidence, air pollution is seldom recorded clinically. It has a code that is rarely used (Exposure to air pollution ICD10 Code Z58.1) and is not being listed as a contributing factor on the medical certificates of death [7]. As Smith et al point out there is government advice on when to include “smoking, alcohol and occupational exposures on death certificates but not when to include air pollution” [7].

Does it matter, and do we clinicians have a role in this?

Clearly the answer has to be yes – if we are not even trying to access information on air pollution at a time of hospital admission how can we begin to discuss it? Clinicians are busy and traditionally have received little in their education about the health effects of air pollution.
One way of alerting and educating clinical staff to a patient’s potential exposure is by automating information relating air quality to home postcode in electronic clinical records. This has been done at Great Ormond Street Hospital NHS Foundation Trust, Guys’ and St Thomas’ NHS Foundation Trust and King’s College Hospital NHS Foundation Trust when a patient lives in an area with levels above the WHO 2021 recommendations [8]. Not only does this alert the clinician to the relevant air quality data for that patient but “hover bubbles” provide an educational component and can be used for communication with primary care and the patient/family. Data collected and appropriately coded may be used for future much needed monitoring and research.

We would argue that air pollution is such an important health issue with effects across the lifespan, that we have a professional responsibility to speak widely about it. Without systems to help educate clinicians, inform patient management, and describe individual adverse clinical outcomes more accurately including in communications, we risk air pollution being continued to be overlooked as an important cause of ill health and death. We also lose the authority to demand infrastructure and policy changes required to clean the air we all breathe.

Yours sincerely,

Dr Heather J Lambert, Paediatrician and Research Associate, University of Newcastle upon Tyne

Dr Mark J Hayden, Consultant Paediatric Intensivist, Great Ormond Street Hospital NHS Foundation Trust

Dr Chinthika Piyasena, Consultant Neonatologist, Guys’ and St Thomas’ NHS Foundation Trust

Ride For Their Lives https://RideForTheirLives.net

Dr Stephen W Lord , Consultant Cardiologist and Medical Examiner
Newcastle upon Tyne Hospitals NHS Foundation Trust and Chair Medical Education Leaders UK

References

1. Varghese D, Clemens T, McMurray A, et al. Near-fatal and fatal asthma and air pollution: are we missing an opportunity to ask key questions?
Arch Dis Child Epub ahead of print: Oct 2023. doi:10.1136/archdischild-2023-325548

2. Taylor L. WHO cuts air pollution limits to save millions of lives. BMJ 2021;374:n2349.

3. WHO global air quality guidelines: particulate matter (PM2.5 and PM10), ozone, nitrogen dioxide, sulfur dioxide and carbon monoxide. 21 Sep 2021. ISBN 9789240034228.

4. PHE publishes air pollution evidence review. 2019. https://www.gov.uk/government/news/public-health-england-publishes-air-p....

5. Lelieveld et al. Air pollution deaths attributable to fossil fuels: observational and modelling study BMJ 2023:383:e077784

6. Barlow P. Regulation 28: Report to prevent future deaths. 2021. https://www.judiciary.uk/wp-content/uploads/2021/04/Ella-Kissi-Debrah-20...

7. Smith LJ, Tomson M, Brown K. Air pollution should be listed on death certificates. BMJ 2023;383:2162.

8. Hayden M, Andersson J, Wilson N, Fecht D. Taking air pollution to the next level – displaying in the patients chart and empowering action. Archives of Disease in Childhood 2023;108:A291-A292.
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Conflict of Interest:
None declared.
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