Major air pollutants and risk of COPD exacerbations: a systematic review and meta-analysis

Abstract

Background: Short-term exposure to major air pollutants (O₃, CO, NO₂, SO₂, PM₁₀, and PM_2.5) has been associated with respiratory risk. However, evidence on the risk of chronic obstructive pulmonary disease (COPD) exacerbations is still limited. The present study aimed at evaluating the associations between short-term exposure to major air pollutants and the risk of COPD exacerbations.

Methods: After a systematic search up until March 30, 2016, in both English and Chinese electronic databases such as PubMed, EMBASE, and CNKI, the pooled relative risks and 95% confidence intervals were estimated by using the random-effects model. In addition, the population-attributable fractions (PAFs) were also calculated, and a subgroup analysis was conducted. Heterogeneity was assessed by I².

Results: In total, 59 studies were included. In the single-pollutant model, the risks of COPD were calculated by each 10 μg/m³ increase in pollutant concentrations, with the exception of CO (100 μg/m³). There was a significant association between short-term exposure and COPD exacerbation risk for all the gaseous and particulate pollutants. The associations were strongest at lag0 and lag3 for gaseous and particulate air pollutants, respectively. The subgroup analysis not only further confirmed the overall adverse effects but also reduced the heterogeneities obviously. When 100% exposure was assumed, PAFs ranged from 0.60% to 4.31%, depending on the pollutants. The adverse health effects of SO₂ and NO₂ exposure were more significant in low-/middle-income countries than in high-income countries: SO₂, relative risk: 1.012 (95% confidence interval: 1.001, 1.023); and NO₂, relative risk: 1.019 (95% confidence interval: 1.014, 1.024).

Conclusion: Short-term exposure to air pollutants increases the burden of risk of COPD acute exacerbations significantly. Controlling ambient air pollution would provide benefits to COPD patients.

Keywords: COPD exacerbations; acute exposure; air pollution; meta-analysis.

Figure 1

PRISMA flow chart of identified, included, and excluded studies. Abbreviation: COPD, chronic obstructive pulmonary disease.

Figure 2

Associations between gaseous and particular air pollution and COPD risk stratified by time lag (days). Abbreviations: CI, confidence interval; COPD, chronic obstructive pulmonary disease; RR, relative risk.

Figure 3

Subgroup analysis for all gaseous and particulate air pollutants stratified by outcome, location, age, and study design. Abbreviations: CI, confidence interval; COPD, chronic obstructive pulmonary disease; RR, relative risk.

Figure 4

Cartogram identifying associations between sulfur dioxide and nitrogen dioxide short-term exposure and COPD risk stratified by countries of high- and low-/middle-income levels.