Chronic Obstructive Pulmonary Disease (COPD) and Air Pollution: A Review

authors:

avatar Noorollah Tahery ORCID 1 , avatar Kourosh Zarea ORCID 2 , avatar Maria Cheraghi ORCID 3 , avatar Nasser Hatamzadeh 4 , avatar Majid Farhadi ORCID 5 , avatar Sina Dobaradarn ORCID 6 , avatar Mohammad Javad Mohammadi ORCID 7 , *

Department of Nursing, School of Nursing, Abadan Faculty of Medical Sciences, Abadan, Iran
Department of Nursing, Nursing Care Research Center in Chronic Diseases, School of Nursing and Midwifery, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
Department of Public Health, Cancer Research Center, School of Health, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
Department of Health Promotion and Education, School of Health, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
Nutrition Health Research Center, Department of Environmental Health, School of Health and Nutrition, Lorestan University of Medical Sciences, Khorramabad, Iran
Systems Environmental Health and Energy Research Center, The Persian Gulf Biomedical Sciences Research Institute, Bushehr University of Medical Sciences, Bushehr, Iran
Department of Environmental Health Engineering, School of Public Health and Social Determinants of Health Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran

how to cite: Tahery N , Zarea K , Cheraghi M , Hatamzadeh N, Farhadi M , et al. Chronic Obstructive Pulmonary Disease (COPD) and Air Pollution: A Review. Jundishapur J Chronic Dis Care. 2021;10(1):e110273. https://doi.org/10.5812/jjcdc.110273.

Abstract

Air pollution exposure is one of the main risk factors for respiratory system diseases, including airway diseases, Chronic Obstructive Pulmonary Disease (COPD), and lung cancer. Few studies have been done concerning Interstitial Lung Disease (ILD) and its relationship with air pollution. Particulate Matter (PM10), sulfur dioxide (SO2), nitrogen dioxide (NO2), ozone (O3), Polyaromatic Hydrocarbons (PAHs), and Heavy Metals (HM) are the most important air pollutants found to exert harmful effects on the human and environment. This review aimed to study the health effects of air pollution on respiratory systems, especially COPD. A narrative review of the literature was done from 1978 to 2020 in various databases, including Google Scholar, Science Direct, Web of Science, Springer, PubMed, NCBI, and BMJ. The results indicated that air pollution exposure could increase respiratory diseases, especially COPD. According to the results, COPD is caused by poor airflow and long-term breathing problems due to disrupted lung tissue. Based on the results, hazardous air pollutants induce destructive effects on the lung and result in COPD. Thus, COPD is a critical public health issue in Iran and the world. To decrease the rate of COPD attributed to air pollutants, we should use policies to decrease pollutant emissions.

1. Context

Nowadays, the rates of morbidity and mortality due to problems in cardiovascular and respiratory systems are increasing because of the increases in air pollutant emissions by vehicles, industries, economic development, and dust storms (1-4). Major sources of pollutants that are harmful to the environment and human health include industries, transportation systems, power plants, and population growth (5-8). A major policy worldwide is to decrease air pollutants because of their different health effects on citizens (9-13). In the world (United States, Europe, and Asia), several studies have reported the effects of air pollution on human health. The results of these studies showed that higher concentrations of PM10, O3, NO2, SO2, metals, and polyaromatic hydrocarbons (PAHs) can increase the risk of morbidity and mortality due to respiratory infections, chronic obstructive pulmonary disease, asthma attacks, coughing, reduced lung function, eye irritation, cardiovascular disease, stroke, respiratory and cardiovascular death) (14-20).

Based on several reported, epidemiological human systems that are sensitive in exposure to air pollutants are nervous, cardiovascular, and respiratory systems. The main organs whose functions are impaired due to short and long-term exposure to air pollutants are the heart, lung, brain, and eyes (19, 21-23). Poor airflow and long-term breathing problems due to disrupted lung tissue are defined as Chronic Obstructive Pulmonary Disease (COPD) (8). It is a disease that makes breathing, walking, or getting dressed become difficult (24, 25). Nowadays, COPD is one of the commonest respiratory diseases worldwide (26). Tobacco smoking, air pollution, and genetic factors are the important factors causing COPD (27). This disease can be prevented by reducing cigarette smoking and improving the air quality (28). Lung function tests by measuring the airflow is a way to diagnose COPD (29). Inhaled bronchodilators, respiratory rehabilitation, vaccination, and smoking cessation are the best ways for COPD treatment (30).

Chronic obstructive pulmonary disease, bronchitis, asthma, repository disease, and lung cancer are the main health effects of air pollution on the repository system (26). This narrative review aimed to evaluate the link between the development and progression of COPD and air pollutants. Moreover, we focused on the current state of knowledge of the association between COPD and air pollution.

2. Evidence Acquisition

In this narrative review study, we used available studies in various databases, including Google Scholar, Science Direct, Web of Science, Springer, PubMed, NCBI, and BMJ (Table 1). The year of publication (1978–2020) and the English language were the main criteria for search limitation.

Table 1.

Search Terms and Query Results

TermGoogle ScholarWeb of ScienceSpringerScience DirectPubMedBMJUnique results
Chronic obstructive pulmonary disease30213751879636295
Respiratory systems23012146707521173
Respiratory diseases1368151536313142
Air pollution and lung97523157509130
Air pollution and respiratory systems8139173146694
Total84643019629833085834

2.1. Data Gathering

‘Chronic obstructive pulmonary disease’, ‘respiratory systems’, ‘respiratory diseases’, ‘air pollution and lung’, and air pollution and respiratory systems. Overall, 62 relevant original and review papers were reviewed to establish the possible link between cardiovascular and respiratory diseases with exposure to air pollution... Duplicate articles from different searches were removed before starting the screening process.

2.2. Ethical Approval

Ethical approval of the present study was acquired from the Ethics Committee of Ahvaz Jundishapur University of Medical Sciences (Code of ethics: IR.AJUMS.REC.1399.700). According to the national guidelines, studies such as the current one do not require individual consent.

3. Results

The results of the narrative review study included six categories: Functional structure and biochemically active compounds for the lung, major airborne pollutants harmful to the lung, the pathophysiology of COPD, and action mechanisms of PM, VOCs, metals, and PAHs on the human respiratory system and air pollution, COPD, and clinical manifestations of the effect of air pollutants on COPD.

3.1. Functional Structure and Biochemically Active Compounds for the Lung

The primary organs of the respiratory system are the lungs, including two lungs. The main role of the lungs is to extract oxygen from the atmosphere, release carbon dioxide from the bloodstream, and provide airflow that makes vocal sounds (31). The respiratory system includes an upper respiratory system (nose and nasal passages, sinuses, and pharynx) and a lower respiratory system (larynx, trachea, bronchi, and bronchioles) (32). The respiratory bronchioles, alveolar ducts, alveolar sacs, and alveoli can be included in the lower respiratory tract (33).

3.2. Major Airborne Pollutants Harmful to the Lung

Gender, age, and exposure duration are the most important factors affecting human health and lung condition, and air toxicants exert harmful effects (34). In the atmosphere, Particulate Matters (PMs) form a complex of small particles and liquid droplets (35). Soil, dust, metals, acids, and organic chemicals are the major sources of PMs (36). Particulate matters are among the most serious air pollutants in Europe (37).

Toxic gaseous pollutants include Volatile Organic Compounds (VOCs), CO2, CO, NO2, SO2, and ground-level ozone. Besides, BTEX (benzene, toluene, and xylene) are important compounds, which play a crucial role in the formation of ground-level ozone. Among metals, lead, cadmium, chromium, nickel, and zinc are the most frequent airborne pollutants (38). There are reports on the considerable toxicity of airborne metals to the lung (39). Polycyclic Aromatic Hydrocarbons (PAHs) are a group of hydrocarbons that are composed of multiple aromatic rings (16). Human exposure to PAHs can cause different health effects (15, 16).

Polycyclic aromatic hydrocarbons that occur in air dust have highly bioaccumulative properties and can bind to cell macromolecules. Air pollutants can induce chronic human health effects and have been recognized as extremely toxic to the lung (40). In fact, contaminated air can contain over 2,000 different chemicals and compounds that can strongly influence the development of serious lung pathologies (41).

3.3. Pathophysiology Chronic Obstructive Pulmonary Disease

Chronic obstructive pulmonary disease is caused by poor airflow and long-term breathing problems due to disrupted lung tissue (42). Bullous emphysema is defined as damage to large focal lung pneumatosis that replaces lung tissue (43, 44). Macrophages and neutrophil granulocytes, two types of white blood cells, are the main inflammatory cells (45). The most important processes that can cusses lung damage are free radicals in tobacco smoke and oxidative stress. (46-49). The most common complications of chronic obstructive pulmonary disease and poor lung function (destruction of lung tissue) are poor airflow, emphysema, poor absorption, and release of respiratory gases (Figure 1) (46-49).

Left: Lungs and airways (normal bronchioles and alveoli). Right: Lungs damaged by COPD (damaged bronchioles and alveoli). Source: Wikimedia Commons.
Left: Lungs and airways (normal bronchioles and alveoli). Right: Lungs damaged by COPD (damaged bronchioles and alveoli). Source: Wikimedia Commons.

3.4. Action Mechanism of PM, VOCs, Metals, and PAHs on Human Respiratory System

The effects of ambient PM, VOCs, metals, and PAHs on mortality have been investigated for decades (50). Several epidemiological studies have reported a robust correlation between PM, VOCs, metals, and PAH pollutants and cardiovascular and respiratory diseases (51-56). There are several proposed mechanisms for the impact of PM, VOCs, metals, and PAHs on human respiratory physiology (50). Chronic inflammation due to the effects of air pollutants exposure on respiratory systems, including the binding of pathogenic antibodies to pro-inflammatory cell receptors, is presented in Figure 2.

Route of the destruction of the human respiratory system after air pollutants exposure. MAPK: mitogen-activated protein kinase; ERK: extracellular regulated protein kinases; STAT-1: Signal transducers and activators of transcription-1 (50)
Route of the destruction of the human respiratory system after air pollutants exposure. MAPK: mitogen-activated protein kinase; ERK: extracellular regulated protein kinases; STAT-1: Signal transducers and activators of transcription-1 (50)

3.5. Air Pollution and Chronic Obstructive Pulmonary Disease

Improved indoor and outdoor air quality may prevent COPD (57). Personal involvement, cultural changes, and public policy changes have the most important efforts on the decreased rate of the incidence of chronic obstructive pulmonary disease (47, 58). One of the best activities that developed countries have successfully done for decreasing health outcomes is the development of regulations regarding air quality (57). Those with COPD may experience fewer symptoms if they stay indoors on days when outdoor air quality is poor (47). Good ventilation at home and better stoves are the keys to decreasing smoke emissions from cooking and heating fuels (47, 58). Based on the results of different studies, improved stoves can improve indoor air quality. Using alternative energy sources such as solar cooking and electrical heating is also effective. Using fuels such as kerosene or coal might be less harmful than traditional biomass such as wood or dung (57). Coal mining, construction, and stonemasonry are the major industries whose workers are at increased risk of COPD due to exposure to pollutants emitted from these industries (57). One of the ways that can reduce COPD and further lung damage in workers is to change their role in the workplace (59).

3.6. Clinical Manifestations of the Effect of Air Pollutants on Chronic Obstructive Pulmonary Disease

Hazardous air pollutants induce destructive effects on the lung and result in chronic obstructive pulmonary disease (37). The permanent production of ROS under the exposure of the lung to air toxins causes the secretion of cytokines and cellular dysfunction. Consequently, the breakdown of the lung is observed, and some abnormal conditions such as chronic obstructive pulmonary disease, inhalation, bronchitis, and lung cancer can be initiated (29, 45).

3.7. Future Research About COPD in Iran

Based on the projection of the World Health Organization (WHO) about chronic obstructive pulmonary disease, this disease will become the third leading cause of death by 2030. Nowadays, one of the most important public health problems in Iran that have an increasing trend is COPD. Demonstrating that prevention and early detection chronic obstructive pulmonary disease should be considered, especially in the age group of 15 to 70 years.

4. Conclusions

The findings of this study can have wide applications for the health effects of air pollution. There is a large and growing body of epidemiological evidence associating the emissions of air pollutants with increased COPD worldwide. Chronic obstructive pulmonary disease is a critical public health issue in Iran and the world. It has had an increasing trend in recent years. The lung as a vital organ of the human body stays in direct and continuous contact with the environment and its pollution. Lung pathologies not only result from internal disturbances in body metabolism and processes. There is considerable evidence that air pollution increases oxidative stress in repository system cells.

Defining policies for decreasing air pollution by using green fuels such as solar and electrical energy, actions to reduce emissions to air in industries and source of dust in neighboring countries, implementing appropriate health measures, and developing green spaces can be effective in reducing chronic obstructive pulmonary disease. Therefore, government authorities at various levels should put legislative frameworks for protecting the residents against the high health risks and other effects of air pollution.

Acknowledgements

References

  • 1.

    Effatpanah M, Effatpanah H, Jalali S, Parseh I, Goudarzi G, Barzegar G, et al. Hospital admission of exposure to air pollution in Ahvaz megacity during 2010–2013. Clin Epidemiol Glob Health. 2020;8(2):550-6. https://doi.org/10.1016/j.cegh.2019.12.001.

  • 2.

    Faraji Ghasemi F, Dobaradaran S, Saeedi R, Nabipour I, Nazmara S, Ranjbar Vakil Abadi D, et al. Levels and ecological and health risk assessment of PM2.5-bound heavy metals in the northern part of the Persian Gulf. Environ Sci Pollut Res Int. 2020;27(5):5305-13. [PubMed ID: 31848967]. https://doi.org/10.1007/s11356-019-07272-7.

  • 3.

    Goudarzi G, Alavi N, Geravandi S, Yari AR, Aslanpour Alamdari F, Dobaradaran S, et al. Ambient particulate matter concentration levels of Ahvaz, Iran, in 2017. Environ Geochem Health. 2019;41(2):841-9. [PubMed ID: 30191444]. https://doi.org/10.1007/s10653-018-0182-0.

  • 4.

    Dastoorpoor M, Sekhavatpour Z, Masoumi K, Mohammadi MJ, Aghababaeian H, Khanjani N, et al. Air pollution and hospital admissions for cardiovascular diseases in Ahvaz, Iran. Sci Total Environ. 2019;652:1318-30. [PubMed ID: 30586817]. https://doi.org/10.1016/j.scitotenv.2018.10.285.

  • 5.

    Davar H, Taghavirad SS, Mohammadi MJ. The investigation of effects of silica on the environment and prevention of release of the silica particles with simulation of gas-solid flow in a gas cyclone. Res J Chem Environ. 2014;18(11):28-30.

  • 6.

    Geravandi S, Sicard P, Khaniabadi YO, De Marco A, Ghomeishi A, Goudarzi G, et al. A comparative study of hospital admissions for respiratory diseases during normal and dusty days in Iran. Environ Sci Pollut Res Int. 2017;24(22):18152-9. [PubMed ID: 28631126]. https://doi.org/10.1007/s11356-017-9270-4.

  • 7.

    Hashemzadeh B, Idani E, Goudarzi G, Ankali KA, Sakhvidi MJZ, Babaei AA, et al. Effects of PM2. 5 and NO2 on the 8-isoprostane and lung function indices of FVC and FEV1 in students of Ahvaz city, Iran. Saudi J Biol Sci. 2019;26(3):473-80.

  • 8.

    Saki H, Goudarzi G, Jalali S, Barzegar G, Farhadi M, Parseh I, et al. Study of relationship between nitrogen dioxide and chronic obstructive pulmonary disease in Bushehr, Iran. Clin Epidemiol Glob Health. 2020;8(2):446-9. https://doi.org/10.1016/j.cegh.2019.10.006.

  • 9.

    Volkamer R, Jimenez JL, San Martini F, Dzepina K, Zhang Q, Salcedo D, et al. Secondary organic aerosol formation from anthropogenic air pollution: Rapid and higher than expected. Geophys Res Lett. 2006;33(17). https://doi.org/10.1029/2006gl026899.

  • 10.

    Gurjar BR, Butler TM, Lawrence MG, Lelieveld J. Evaluation of emissions and air quality in megacities. Atmos Environ. 2008;42(7):1593-606. https://doi.org/10.1016/j.atmosenv.2007.10.048.

  • 11.

    Goudarzi G, Idani E, Alavi N, Salmanzadeh S, Babaei AA, Geravandi S, et al. Association of polycyclic aromatic hydrocarbons of the outdoor air in Ahvaz, southwest Iran during warm-cold season. Toxin Rev. 2017;36(4):282-9. https://doi.org/10.1080/15569543.2017.1304422.

  • 12.

    Khaefi M, Goudarzi G, Yari AR, Geravandi S, Dobaradaran S, Idani E, et al. An association between ambient pollutants and hospital admitted respiratory cases in Ahvaz, Iran. Fresenius Environ Bull. 2016;25(10):3955-61.

  • 13.

    Liang Q, Xue ZJ, Wang F, Sun ZM, Yang ZX, Liu SQ. Contamination and health risks from heavy metals in cultivated soil in Zhangjiakou City of Hebei Province, China. Environ Monit Assess. 2015;187(12):754. [PubMed ID: 26577214]. https://doi.org/10.1007/s10661-015-4955-y.

  • 14.

    Kim KH, Kabir E, Kabir S. A review on the human health impact of airborne particulate matter. Environ Int. 2015;74:136-43. [PubMed ID: 25454230]. https://doi.org/10.1016/j.envint.2014.10.005.

  • 15.

    Goudarzi G, Alavi N, Babaei AA, Geravandi S, Idani E, Salmanzadeh S, et al. Investigation of Ambient Polycyclic Aromatic Hydrocarbons in a Populated Middle Eastern City. Polycycl Aromat Compd. 2020:1-16. https://doi.org/10.1080/10406638.2020.1823857.

  • 16.

    Goudarzi G, Geravandi S, Alavi N, Idani E, Salmanzadeh S, Yari AR, et al. Association between cancer risk and polycyclic aromatic hydrocarbons' exposure in the ambient air of Ahvaz, southwest of Iran. Int J Biometeorol. 2018;62(8):1461-70. [PubMed ID: 29959528]. https://doi.org/10.1007/s00484-018-1543-1.

  • 17.

    Pope CA, Burnett RT, Turner MC, Cohen A, Krewski D, Jerrett M, et al. Lung cancer and cardiovascular disease mortality associated with ambient air pollution and cigarette smoke: shape of the exposure-response relationships. Environ Health Perspect. 2011;119(11):1616-21. [PubMed ID: 21768054]. [PubMed Central ID: PMC3226505]. https://doi.org/10.1289/ehp.1103639.

  • 18.

    Peng RD, Butz AM, Hackstadt AJ, Williams DL, Diette GB, Breysse PN, et al. Estimating the health benefit of reducing indoor air pollution in a randomized environmental intervention. J R Stat Soc Ser A Stat Soc. 2015;178(2):425-43. [PubMed ID: 27695203]. [PubMed Central ID: PMC5042208]. https://doi.org/10.1111/rssa.12073.

  • 19.

    Pride KR, Peel JL, Robinson BF, Busacker A, Grandpre J, Bisgard KM, et al. Association of short-term exposure to ground-level ozone and respiratory outpatient clinic visits in a rural location - Sublette County, Wyoming, 2008-2011. Environ Res. 2015;137:1-7. [PubMed ID: 25483412]. https://doi.org/10.1016/j.envres.2014.10.033.

  • 20.

    Tsai SS, Goggins WB, Chiu HF, Yang CY. Evidence for an association between air pollution and daily stroke admissions in Kaohsiung, Taiwan. Stroke. 2003;34(11):2612-6. [PubMed ID: 14551399]. https://doi.org/10.1161/01.STR.0000095564.33543.64.

  • 21.

    Gschwind B, Lefevre M, Blanc I, Ranchin T, Wyrwa A, Drebszok K, et al. Including the temporal change in PM2.5 concentration in the assessment of human health impact: Illustration with renewable energy scenarios to 2050. Environ Impact Assess Rev. 2015;52:62-8. https://doi.org/10.1016/j.eiar.2014.09.003.

  • 22.

    Taghavirad SS, Davar H, Mohammadi MJ. The a study on concentration of BETX vapors during winter in the department of ports and shipping located in one of the southern cities of Iran. Int J Curr Life Sci. 2014;4(9):5416-20.

  • 23.

    Mandel JH, Wendt C, Lo C, Zhou G, Hertz M, Ramachandran G. Ambient air pollution and lung disease in China: health effects, study design approaches and future research. Front Med. 2015;9(3):392-400. [PubMed ID: 26089192]. https://doi.org/10.1007/s11684-015-0397-8.

  • 24.

    Lopez-Campos JL, Soler-Cataluna JJ, Miravitlles M. Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Lung Disease 2019 Report: Future Challenges. Arch Bronconeumol. 2020;56(2):65-7. [PubMed ID: 31320191]. https://doi.org/10.1016/j.arbres.2019.06.001.

  • 25.

    Mohammadi MJ, Geravandi S, Vosoughi M, Salmanzadeh S, Goudarzi G. An Association between air quality and COPD in Ahvaz, Iran. Jundishapur J Chronic Dis Care. 2015;4(1). https://doi.org/10.5812/jjcdc.26621.

  • 26.

    Khaefi M, Geravandi S, Hassani G, Yari AR, Soltani F, Dobaradaran S, et al. Association of Particulate Matter Impact on Prevalence of Chronic Obstructive Pulmonary Disease in Ahvaz, Southwest Iran during 2009–2013. Aerosol Air Qual Res. 2017;17(1):230-7. https://doi.org/10.4209/aaqr.2015.11.0628.

  • 27.

    Llor C, Moragas A, Hernandez S, Bayona C, Miravitlles M. Efficacy of antibiotic therapy for acute exacerbations of mild to moderate chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 2012;186(8):716-23. [PubMed ID: 22923662]. https://doi.org/10.1164/rccm.201206-0996OC.

  • 28.

    Assad NA, Balmes J, Mehta S, Cheema U, Sood A. Chronic obstructive pulmonary disease secondary to household air pollution. Semin Respir Crit Care Med. 2015;36(3):408-21. [PubMed ID: 26024348]. https://doi.org/10.1055/s-0035-1554846.

  • 29.

    Nathell L, Nathell M, Malmberg P, Larsson K. COPD diagnosis related to different guidelines and spirometry techniques. Respir Res. 2007;8:89. [PubMed ID: 18053200]. [PubMed Central ID: PMC2217523]. https://doi.org/10.1186/1465-9921-8-89.

  • 30.

    Decramer ML, Chapman KR, Dahl R, Frith P, Devouassoux G, Fritscher C, et al. Once-daily indacaterol versus tiotropium for patients with severe chronic obstructive pulmonary disease (INVIGORATE): a randomised, blinded, parallel-group study. Lancet Respir Med. 2013;1(7):524-33. https://doi.org/10.1016/s2213-2600(13)70158-9.

  • 31.

    Fisher AB. Normal and pathologic biochemistry of the lung. Environ Health Perspect. 1976;16:3-9. [PubMed ID: 797566]. [PubMed Central ID: PMC1475232]. https://doi.org/10.1289/ehp.76163.

  • 32.

    Branchett WJ, Lloyd CM. Regulatory cytokine function in the respiratory tract. Mucosal Immunol. 2019;12(3):589-600. [PubMed ID: 30874596]. [PubMed Central ID: PMC7051906]. https://doi.org/10.1038/s41385-019-0158-0.

  • 33.

    Petersen E, Memish ZA, Zumla A, Maani AA. Transmission of respiratory tract infections at mass gathering events. Curr Opin Pulm Med. 2020;26(3):197-202. [PubMed ID: 32149751]. https://doi.org/10.1097/MCP.0000000000000675.

  • 34.

    Parrado C, Mercado-Saenz S, Perez-Davo A, Gilaberte Y, Gonzalez S, Juarranz A. Environmental Stressors on Skin Aging. Mechanistic Insights. Front Pharmacol. 2019;10:759. [PubMed ID: 31354480]. [PubMed Central ID: PMC6629960]. https://doi.org/10.3389/fphar.2019.00759.

  • 35.

    Harrison RM, Yin J. Particulate matter in the atmosphere: which particle properties are important for its effects on health? Sci Total Environ. 2000;249(1-3):85-101. https://doi.org/10.1016/s0048-9697(99)00513-6.

  • 36.

    Donaldson K. Free radical activity associated with the surface of particles: a unifying factor in determining biological activity? Toxicol Lett. 1996;88(1-3):293-8. https://doi.org/10.1016/0378-4274(96)03752-6.

  • 37.

    Cincinelli A, Guerranti C, Martellini T, Scodellini R. Residential wood combustion and its impact on urban air quality in Europe. Curr Opin Environ Sci Health. 2019;8:10-4. https://doi.org/10.1016/j.coesh.2018.12.007.

  • 38.

    Sivulka DJ, Conard BR, Hall GW, Vincent JH. Species-specific inhalable exposures in the nickel industry: a new approach for deriving inhalation occupational exposure limits. Regul Toxicol Pharmacol. 2007;48(1):19-34. [PubMed ID: 17270331]. https://doi.org/10.1016/j.yrtph.2006.12.002.

  • 39.

    Neisi A, Vosoughi M, Shirmardi M, Idani E, Goudarzi G, Hazrati S, et al. Concentration of air pollutants as toxic matter in urban and rural areas of Ahvaz. Toxin Rev. 2017;37(3):243-50. https://doi.org/10.1080/15569543.2017.1337796.

  • 40.

    Uddin MA, Akhter MS, Singh SS, Kubra KT, Schally AV, Jois S, et al. GHRH antagonists support lung endothelial barrier function. Tissue Barriers. 2019;7(4):1669989. [PubMed ID: 31578921]. [PubMed Central ID: PMC6866681]. https://doi.org/10.1080/21688370.2019.1669989.

  • 41.

    Juliano C, Magrini G. Cosmetic Functional Ingredients from Botanical Sources for Anti-Pollution Skincare Products. Cosmetics. 2018;5(1):19. https://doi.org/10.3390/cosmetics5010019.

  • 42.

    Hurst JR, Vestbo J, Anzueto A, Locantore N, Mullerova H, Tal-Singer R, et al. Susceptibility to exacerbation in chronic obstructive pulmonary disease. N Engl J Med. 2010;363(12):1128-38. [PubMed ID: 20843247]. https://doi.org/10.1056/NEJMoa0909883.

  • 43.

    Calverley PM, Koulouris NG. Flow limitation and dynamic hyperinflation: key concepts in modern respiratory physiology. Eur Respir J. 2005;25(1):186-99. [PubMed ID: 15640341]. https://doi.org/10.1183/09031936.04.00113204.

  • 44.

    O'Donnell DE. Hyperinflation, dyspnea, and exercise intolerance in chronic obstructive pulmonary disease. Proc Am Thorac Soc. 2006;3(2):180-4. [PubMed ID: 16565429]. https://doi.org/10.1513/pats.200508-093DO.

  • 45.

    Beasley V, Joshi PV, Singanayagam A, Molyneaux PL, Johnston SL, Mallia P. Lung microbiology and exacerbations in COPD. Int J Chron Obstruct Pulmon Dis. 2012;7:555-69. [PubMed ID: 22969296]. [PubMed Central ID: PMC3437812]. https://doi.org/10.2147/COPD.S28286.

  • 46.

    Rabe KF, Hurd S, Anzueto A, Barnes PJ, Buist SA, Calverley P, et al. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: GOLD executive summary. Am J Respir Crit Care Med. 2007;176(6):532-55. [PubMed ID: 17507545]. https://doi.org/10.1164/rccm.200703-456SO.

  • 47.

    Vestbo J, Hurd SS, Agusti AG, Jones PW, Vogelmeier C, Anzueto A, et al. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: GOLD executive summary. Am J Respir Crit Care Med. 2013;187(4):347-65. [PubMed ID: 22878278]. https://doi.org/10.1164/rccm.201204-0596PP.

  • 48.

    Vogelmeier CF, Criner GJ, Martinez FJ, Anzueto A, Barnes PJ, Bourbeau J, et al. Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Lung Disease 2017 Report. GOLD Executive Summary. Am J Respir Crit Care Med. 2017;195(5):557-82. [PubMed ID: 28128970]. https://doi.org/10.1164/rccm.201701-0218PP.

  • 49.

    Singh D, Agusti A, Anzueto A, Barnes PJ, Bourbeau J, Celli BR, et al. Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Lung Disease: the GOLD science committee report 2019. Eur Respir J. 2019;53(5). [PubMed ID: 30846476]. https://doi.org/10.1183/13993003.00164-2019.

  • 50.

    Li T, Hu R, Chen Z, Li Q, Huang S, Zhu Z, et al. Fine particulate matter (PM2.5): The culprit for chronic lung diseases in China. Chronic Dis Transl Med. 2018;4(3):176-86. [PubMed ID: 30276364]. [PubMed Central ID: PMC6160608]. https://doi.org/10.1016/j.cdtm.2018.07.002.

  • 51.

    Kloog I, Nordio F, Zanobetti A, Coull BA, Koutrakis P, Schwartz JD. Short term effects of particle exposure on hospital admissions in the Mid-Atlantic states: a population estimate. PLoS One. 2014;9(2). e88578. [PubMed ID: 24516670]. [PubMed Central ID: PMC3917892]. https://doi.org/10.1371/journal.pone.0088578.

  • 52.

    Maleki H, Sorooshian A, Goudarzi G, Nikfal A, Baneshi MM. Temporal profile of PM10 and associated health effects in one of the most polluted cities of the world (Ahvaz, Iran) between 2009 and 2014. Aeolian Res. 2016;22:135-40. [PubMed ID: 28491152]. [PubMed Central ID: PMC5422000]. https://doi.org/10.1016/j.aeolia.2016.08.006.

  • 53.

    Mraihi R, Harizi R, Mraihi T, Bouzidi MT. Urban air pollution and urban daily mobility in large Tunisia's cities. Renew Sustain Energy Rev. 2015;43:315-20. https://doi.org/10.1016/j.rser.2014.11.022.

  • 54.

    Raaschou-Nielsen O, Andersen ZJ, Beelen R, Samoli E, Stafoggia M, Weinmayr G, et al. Air pollution and lung cancer incidence in 17 European cohorts: prospective analyses from the European Study of Cohorts for Air Pollution Effects (ESCAPE). Lancet Oncol. 2013;14(9):813-22. https://doi.org/10.1016/s1470-2045(13)70279-1.

  • 55.

    Woerman AL. Air pollution & cardiovascular disease. The George Washington University; 2013.

  • 56.

    Barnett AG, Williams GM, Schwartz J, Best TL, Neller AH, Petroeschevsky AL, et al. The effects of air pollution on hospitalizations for cardiovascular disease in elderly people in Australian and New Zealand cities. Environ Health Perspect. 2006;114(7):1018-23. [PubMed ID: 16835053]. [PubMed Central ID: PMC1513338]. https://doi.org/10.1289/ehp.8674.

  • 57.

    Pirozzi C, Scholand MB. Smoking cessation and environmental hygiene. Med Clin North Am. 2012;96(4):849-67. [PubMed ID: 22793948]. https://doi.org/10.1016/j.mcna.2012.04.014.

  • 58.

    Majeed AJ, Deli FA, Kasim SE. Influence of High resolution computed tomography (HRCT) in reviewing the diagnosis of chronic obstructive pulmonary disease (COPD): A study of 16 male patients. Ann Trop Med Public Health. 2020;23(12). https://doi.org/10.36295/asro.2020.231241.

  • 59.

    George RB. Chest medicine: essentials of pulmonary and critical care medicine. Lippincott Williams & Wilkins; 2005.

Glen Zamiska
2023-01-28 15:34:32
I'm almost 62 and was diagnosed with COPD in 2006 I was extremely short of breath and constantly tired due to my Emphysema, I was introduced to Health Herbs Clinic and their COPD Herbal Protocol. I started on the COPD Treatment last year, my symptoms gradually diminished including my shortness of breath, wheezing and fatigue. Reach them at healthherbsclinic. c om , I no longer carry my portable oxygen cylinder around with me. I am Emphysema free!