APRIL 27 , 2014 - enao · WITH EVERY BREATH YOU TAKE Presentation at National Emergency Nurses’ Affiliation Pan-American Conference 2014 Connected by Caring Across the Americas

WITH EVERY BREATH YOU TAKE

Presentation at National Emergency Nurses’ Affiliation Pan-American Conference 2014 Connected by Caring Across the Americas

APRIL 27th, 2014

HILDA SWIRSKY, RN, BScN, MEd, Regional Air Pollution Expert/Spokesperson for College of Family Physicians of

Canada Air Quality Health Index Trainer

Learning Objectives

1.  Air Pollution & Health: what is the evidence linking air pollution with adverse health effects?

2.  AQHI: What is it & how is it used? 3.  Clinical Application of AQHI and ER patients especially with

diabetes, asthmatics, and patients with respiratory and cardiovascular health impairments

4.  Guidelines to using the Air Quality Health Index

•  You assess 26 year-old, Judy, in ER with shortness of breath; worsening of her asthma; 28 weeks pregnant and diabetic

•  PMH: She has had difficulty controlling her asthma; and is on beclazone

•  She does not smoke, and no-one at home smokes

• Her diabetes and accuchecks are stable

Case Study: •The Air Quality Health Index is 7 • Could outdoor air pollution be a trigger that is exacerbating her asthma? • What are the possible triggers for the worsening of her asthma? • What do you advice her to do?

•  Short term exposure to air pollution clearly worsens asthma symptoms

•  AQHI- asthma health care utilization “each unit increase in daily max AQHI is highly and significantly associated with an increase in asthma ED and OP visits”

•  You assess 61 year-old male in ER with atrial fibrillation x 4hrs

•  He also has COPD and has been a smoker for 20 years

•  PMH: Hypertension; on Ramipril 5mg and HCT 12.5mg od;

•  He was outdoors exercising this morning and the AQHI is 7

•  Is air pollution a possible trigger for his arrhythmia?

Air Pollution-Atrial Fibrillation

Link MS. J American Coll Cardiology 2013 62(9)

AQHI: Objectives

•  To create a national, simplified communications tool for measured and forecast air quality of the “air pollution mixture”.

•  To empower individuals to take action to protect their health from air pollution

•  To create advocates for reducing pollution •  To support active living

Certain populations are more susceptible to the effects of air pollution

Factors such as: •  age, •  health status, •  lifestyle, •  genetics •  may influence susceptibility to the acute effects of air pollution

Components of AQHI • There are health effects at low pollutant concentrations • Mix of multiple pollutants

NO2 ozone PM2.5

Health Risk

Air Quality Health Index

Health Messages

At Risk Population* General Population

Low Risk 1 - 3 Enjoy your usual outdoor activities.

Ideal air quality for outdoor activities.

Moderate Risk 4 - 6

Consider reducing or rescheduling strenuous activities outdoors if you are experiencing symptoms.

No need to modify your usual outdoor activities unless you experience symptoms such as coughing and throat irritation.

High Risk 7 - 10

Reduce or reschedule strenuous activities outdoors. Children and the elderly should also take it easy.

Consider reducing or rescheduling strenuous activities outdoors if you experience symptoms such as coughing and throat irritation.

Very High Risk Above 10

Avoid strenuous activities outdoors. Children and the elderly should also avoid outdoor physical exertion.

Reduce or reschedule strenuous activities outdoors, especially if you experience symptoms such as coughing and throat irritation.

A national implementation

Finding out what AQHI value affects you Determine susceptibility (are you at-risk?)

Self Calibrate

Long term exposure

•  ^ Risk CVS mortality

• ? summation of acute effects • ? Incremental due to ^ atherosclerotic development

•  RR long term studies > acute exposures

•  Reductions in PM reduce mortality over a few years

Brook  RD;  Circula/on.    2010  

Short-term exposure

Worsens pre-existing respiratory disease

• Asthma • Chronic Obstructive Pulmonary Disease

Worsens pre-existing Cardiovascular Disease

• Ischemia (inadequate supply of blood to an organ, usually due to a blocked artery) cardiac failure • Arrhythmia (irregular usually rapid heart beats Ischemic stroke

Increased Hospitalization/ ED visits

Where you can find the AQHI TV:

•  The Weather Network

Internet: •  www.airhealth.ca •  www.theweathernetwork.com •  Provincial websites

Technologies •  Widget, Phone apps, E-alerts

Patient handouts •  [email protected] •  Clean Air Champions •  Newspapers

Annual Comparison of Air Pollutants in Toronto 2001-2009

NO2 O3 PM2.5

Average Concentration Average Contribution to

AQHI

Average Concentration

Average Contribution to

AQHI

Average Concentration

Average Contribution to AQHI

2001 24.53 2.08 22.73 1.18 8.89 0.42 2002 22.12 1.86 23.39 1.22 8.73 0.41 2003 22.79 1.93 21.91 1.14 8.83 0.41 2004 20.65 1.75 20.65 1.07 7.94 0.37 2005 21.62 1.83 22.83 1.19 9.04 0.43 2006 19.11 1.62 21.70 1.13 7.65 0.36 2007 18.56 1.57 23.67 1.23 7.78 0.37 2008 17.72 1.50 22.70 1.18 6.98 0.33 2009 16.54 1.40 22.09 1.15 5.80 0.27

Environmental control Exposure to air pollution has been associated with increased morbidity and mortality in individuals with asthma. Efforts to reduce exposure of patients with asthma to air pollution should continue During periods of increased outdoor pollution, patients can minimize exposure by remaining indoors or reducing outdoor exercise or rescheduling strenuous activities Lougheed MD, Lemiere C, Dell S et al. Canadian Thoracic Society Asthma Management Continuum – 2009. Can Respir J 2010

• How and how often to assess asthma control (self-monitoring) • Instructions to maintain good control using controller medication, and making specific environmental changes • Signs and symptoms indicating uncontrolled asthma, with instructions on what to do…….

Does the AQHI have a place in asthma plans?

Lougheed MD, Lemiere C, Dell S et al. Canadian Thoracic Society Asthma Management Continuum – 2009 Consensus Can Respir J 2010: Volume 17(1)

•  All patients with CVD should be educated about the cardiovascular risks posed by air pollution

•  On the basis of the forecast Air Quality Index, prudent recommendations for reducing exposure and limiting activity should be provided based on the patient’s level of risk

•  Awareness of CVD - Air pollution link in at-risk cardiovascular patients: –  Mostly unaware –  Health care practitioner discuss link (7%)

–  H&S Foundation 13%

AHA Scientific Statement Particulate Matter Air Pollution and Cardiovascular Disease

Could we be effective?

Wen XL, J Comm Health 2008

Prof advice received 57%

Prof advice not received 23%

Change in outdoor activity due to media alerts on air quality in asthmatics

Reducing Exposure to Air Pollution •Disease control (asthma controllers; CF) •Traffic

• Commuting / exercising, decreasing vehicle emissions and not exercising near busy roadways

•Indoor air • Intake fraction differs depending on pollutant, tightness of house • Indoor sources

•Cleaning the air indoors • HEPA filters on furnace, stand alone filters** • Central Air Conditioners

Indoor pollutant sources can be significant eg Tobacco smoke, cooking, VOCs from furniture, carpets or cleaning materials, and mould Improve ventilation of cooking spaces; reduce other sources Staying indoors during extreme heat

Other interventions to reduce exposure

•  Disease control (asthma controllers; heart failure control) •  Traffic

•  Driving and exercising •  Indoor air

•  Intake fraction and indoor sources •  Cleaning the air

•  HEPA filters •  Air Conditioning

•  Masks

Pollution Concentrations

Beckerman et al. (2008) Atmos Enviro. 42:275-290; Hudda N. Environ Sci Technol. Sept 2013

•  Average 33% (5.8 to 3.9 µg/m3) reduction of indoor PM2.5

Air Cleaners (Winter, Prince George)

Barn P J Exp Science and Env Epi 2008

Active Transportation: Cycling Routes

• NO2 • PM 2.5 • Ultrafine PM

Interventions to Prevent Disease from Air Pollution

•  Long term exposures •  Point sources •  Transportation •  Urban planning - Sprawl - California law restricting schools near highways –  BC: Hospitals and long term care facilities

Your checklist to protect your vulnerable patients from air pollution

1.  Determine at risk patients

2.  Tune in to the AQHI

3.  Learn & Teach Self calibration

4.  Advice when to reduce or reschedule strenuous activities

5.  Awareness of impact of traffic on vulnerable populations 6. Impact of Heat

References: AHA Scientific Statement Particulate Matter Air Pollution and Cardiovascular Disease Brook RD. Circulation. 2004; 109: 2655-2671 Particulate matter air pollution and cardiovascular disease: An update to the scientific statement from the American Heart Association. Brook, RD. Circulation 2010;121(21):2331-78 New Insights Into Pollution and the Cardiovascular System : 2010 to 2012 Gold DR. Circulation. 2013;127:1903-1913 Abelsohn A, Stieb DM. Health effects of outdoor air pollution. Approach to counseling patients using the Air Quality Health Index. Canadian Family Physician. 2011; 57:881-7 http://www.cfp.ca/content/57/8/881