Inside the Breathing Zone

Addressing Indoor Air Quality Issues for COPD and Asthma

• By Elisha Bury
• Apr 01, 2009

Many people are familiar with the harmful effects of outdoor air pollution. In metropolitan areas, for example, air quality is color coded to assist those with respiratory sensitivities. Those with allergies and asthma monitor pollen count, and smog is easy to pinpoint.

Unfortunately, few people are familiar with the dangers lurking inside their own homes.

The EPA estimates that the air inside homes has about two to five times more organic pollutants than outdoor air. The figure is alarming for people with a healthy respiratory system, but even more so for people who already have damaged or sensitive airways or lungs.

People with COPD or asthma "are the canaries in the mine," says Allen Rathey, president of The Health House Institute in Bosie, Idaho, which provides consumers with information to make their homes healthier. "They're probably the ones that are letting the rest of us know that there's a problem with our air."

In fact, Rathey says that what people do at home makes a big difference in how they manage their respiratory conditions.

Is indoor air pollution making your respiratory patients sicker? Here's how to help.

Know the Facts

A 2008 survey commissioned by the American College of Allergy, Asthma and Immunology (ACAAI) revealed that more than one-third (41 percent) of people surveyed suffer from allergic rhinitis or allergic asthma. A quarter of allergy sufferers said they often experience allergy symptoms at home. The survey also revealed:

• More than a third said other family members suffer from allergy symptoms at home.
• Allergy sufferers said they do not take steps to reduce indoor allergens because it requires big changes, like restricting pets to certain rooms.
• Nearly a third of allergy sufferers said indoor allergies are an inconvenience.
• An additional 14 percent said indoor allergies are unpleasant or make it difficult to enjoy being at home.

What's more, allergists surveyed expressed a need for more indoor allergy education. In fact, 70 percent of allergists said that their patients ask for advice on how to manage indoor allergens quite a bit or all of the time.

When it comes to pollution, the respiratory system gets hit the hardest. Rathey explains that we inhale about 30 pounds of air per day. By contrast, we only ingest about 4 pounds of water and 2 pounds of food per day. As a result, Rathey says, indoor air pollution “becomes extremely important” in respiratory therapy, especially regarding prevention.

COPD patients also are at risk. In a 2006 study led by Dr. Liesl Osman, senior research fellow, Chest Clinic, Aberdeen Royal Infirmary, Scotland, researchers familiar with the dangers of outdoor air sought to examine indoor air quality and its impact on those with COPD. The scientists studied indoor environmental characteristics of homes of 148 patients with severe COPD in northeast Scotland. What they found was that higher levels of smaller size fractional particles, which are associated with respiratory morbidity and mortality, were significantly higher in homes with smokers and that higher levels of these particles were associated with worsening health status among COPD patients.

In a 2007 editorial in the American Journal of Respiratory and Critical Care Medicine, Dr. Mark Eisner, University of California, San Francisco, concluded that, "Obstructive lung disease appears to predispose to a higher risk of adverse health effects from indoor particulate pollutants, especially SHS (secondhand smoke). Further research is needed to elucidate the prospective effects of indoor pollutants on adults with COPD, including pulmonary function endpoints. Studies that simultaneously consider a broad range of indoor exposures, including allergens and pollutants, would help to fully characterize the health effects of the indoor environment in COPD."

While additional research is still needed, the link between indoor pollutants and respiratory health is becoming increasingly more evident among those in the health industry.

Identify the Pollutants

"On days when the outdoor air quality is not so good, people will seek refuge by going inside," says Dr. Jay Portnoy, ACAAI past president and chief of the Allergy, Asthma & Immunology section at Children's Mercy Hospital, Kansas City, Mo. "The problem with that is that the indoor air quality may be worse than the outdoor air quality and they may not be aware of it."

In today's society, especially, people spend up to 20 hours a day inside, Portnoy says. "If there are things that are generating allergens or irritants in the home, they can adversely affect somebody's respiratory health."

Many sources of indoor air pollutants exist. Some of the common ones include asbestos, mold, cockroach droppings, dust mites, pet dander, ozone, pollen, carbon monoxide, formaldehyde, household cleaners, lead, pesticides, radon, respirable particles, tobacco smoke, and nitrogen dioxide from stoves, fireplaces and chimneys.

The respiratory symptoms of exposure vary depending on the pollutant, but can include rhinitis, epistaxis, pharyngitis, wheezing, dyspnea and severe lung disease.

Volatile Organic Compounds
Volatile organic compounds (VOCs) pose a serious threat to indoor air quality. VOCs include a variety of chemicals and are estimated to be consistently higher indoors (up to 10 times higher) than outdoors, according to the EPA. One of the most well-known VOCs is formaldehyde, which is found in furniture, carpets, cabinets and floor tiles. The health effects of VOCs include eye, nose and throat irritation; headaches, loss of coordination, nausea, and damage to the liver, kidney and central nervous system. Reactions can include nose and throat discomfort, allergic skin reaction, dyspnea and more.

The reason VOCs tend to be higher inside homes has a lot to do with the way homes are constructed. In the 1970s, the energy crisis forced people to take a serious look at their heating and cooling bills. Homes were tightened to reduce cracks in walls, attics, foundations, doors and windows to reduce those expenses. Without proper ventilation, however, people are "like a bug in a jar with a lid on it without holes in it, " Rathey says. The air pollutants get trapped inside the home.

Tobacco Smoke
One of the most dangerous indoor irritants is tobacco smoke. "We know that anybody who's exposed to tobacco smoke is going to have an increased likelihood of respiratory problems," Portnoy says. The problems can be caused by firsthand smoke for smokers, secondhand smoke for those living with smokers and even thirdhand smoke, the smoke that sets into furniture, curtains, carpeting and clothing, he says.

Biologicals
Numerous allergens can affect the functionality of the respiratory tract, including pet dander, dust mites, cockroaches and molds. Humidity or constantly damp surfaces can encourage the growth of certain biologicals, including dust mites and mold.

According to the Asthma and Allergy Foundation of America (AAFA), bedding items such as pillows, comforters and mattress pads, in addition to containing unwanted chemical ingredients and finishes from manufacturing or packaging, accumulate household allergens during everyday use. For this reason, people with asthma and allergies often experience increased symptoms at night, which interrupts sleep.

Combustion Products
Malfunctioning or improperly used stoves, space heaters, furnaces and fireplaces can emit combustion pollutants. The EPA cites possible sources as gas ranges that are malfunctioning or used as heat sources; improperly flued or vented fireplaces, furnaces, wood or coal stoves, gas water heaters and gas clothes dryers; and unvented or otherwise improperly used kerosene or gas space heaters.

The pollutants themselves fall into three major categories: carbon monoxide, nitrogen dioxide and sulfur dioxide.

Clean Up the Air

Fortunately, indoor air can be improved. Rathey says making a home healthy involves three basic principles: eliminate, separate and ventilate.

Eliminate — To eliminate, Rathy says, patients must identify the sources of indoor air pollution and get rid of the ones they can. For example, furniture constructed with particle board can emit formaldehyde gas and should be removed from the house.

Also, take a look at the vacuum cleaner: Is it containing dust? Is the beater brush hitting the carpet and stirring up dust? Do patients smell anything when they turn on the vacuum cleaner? All of these are signs that the vacuum is releasing particles into the air. "One of the first things that (we) recommend is make sure you get a good vacuum that's containing or trying to eliminate the particles of the source," Rathey says.

Portnoy agrees. "We're also looking at the possibility that vacuuming with HEPA, high-efficiency particle air vacuums, as well as cyclonic ones like the Dyson, may be effective in removing allergens enough that it can improve the health of people," he says.

Old cleaning products that have not been made green also should be eliminated. "Convert over to products that have a better indoor environmental profile: lower VOC counts, less stuff that gets airborne that can bother your lungs," Rathey recommends.

If pets are in the home, they should be washed every one to two weeks to cut down on the amount of dander floating in the air. "There are also denaturing solutions, such as tannic acid and Clorox Anywhere, a dilute bleach solution, that denature dog and cat allergens," Portnoy says.

Also, patients should pay attention to what's being brought into the home. Does the new item contain VOCs?

Controlling humidity levels is important to help eliminate biological pollutants, such as mold and mildew. "Lower relative humidity means less growth of mold, decreasing the conditions by which microbes live," Rathey says. "Germs need moisture to live, so if you decrease the moisture in the air, then you lower the chance that you're going to be creating a favorable environment for bugs, for dust mites, for bacteria, for other things that like moisture."

Portnoy says that dust mites grow in places where humidity is above 45-50 percent. He recommends that humidity in the home be kept at 35 percent. Portnoy also says that eliminating dampness, leaking and water-infiltration can cut down on mold growth.

But that's not the only problem with high humidity. Any furnishings that contain formaldehyde, especially particle board and plywood in kitchen cabinets, outgas more in humid environments, according to Rathey.

"The home is really a system; it's like an ecosystem," Rathey says. "When you tweak one variable, for example, change the relative humidity in the air, you affect a lot of other things. A change in humidity... can either make the environment more favorable to dust mites or make it impossible for dust mites to effectively live in your home."

Separate — If you can't eliminate, then separate those sources from the living space, Rathey advises. Insulation is one example. "Obviously, you can't eliminate having insulation in your home, but you can make sure that the walls are properly sealed so that whatever insulation is between the walls doesn't get into the living space and whatever insulation that is in the attic does not somehow inadvertently get pulled into the ventilation system through leaks in the duct work, " Rathey says.

Ventilate — Ventilation means exchanging stale indoor air with fresh outdoor air. "The reason that's important for people (with) respiratory conditions, whether it's bronchitis, emphysema, COPD or asthma or just allergies in general or any other malaise that could be related to indoor air quality, is fresh air is generally a good thing," Rathey says.

Since opening doors and windows won't necessarily create the right air pressure differential, Rathey recommends that people install a heat recovery ventilator (HRV). The system is attached to the existing central ventilation system and mechanically brings in fresh air and pulls out stale air. "The reason it's helpful is that the two air streams — incoming fresh air and the outgoing stale air — pass very closely by each other in an aluminum heat exchanger, and as the air streams pass each other, they transfer heat or cooling energy so you're not losing your heat through outgoing air or your cooling if it's in the summertime," Rathey says. In addition, HRVs can be manually shut off to prevent bringing in outside pollutants, such as pesticides if a neighbor is spraying outdoor plants.

Ventilation also helps control humidity levels by removing excess moisture in the air. Energy Recovery Ventilators, which are related to heat recovery ventilators, especially help to control humidity.

Generally speaking, an HRV that's built into the home's ventilating system can be purchased for around $1,000. Window-mounted units, though less effective, sell for less than $1,000.

Another way to improve ventilation is to install high-quality media filters on furnaces because standard furnace filters are not designed to block fine particles. Doing so, however, means that filters will need to be changed more frequently.

"If you have high-efficiency filters, they tend to slow the air down because it's going to trap more dust," Rathey says. "As it traps more dust, it slows the air down even further. So, you've got to keep those high-efficiency filters clean. There's no free lunch. You really have to do your homework and take care of all of these types of things on a monthly to quarterly basis." If an air cleaner is being used, Rathey says it's important that people are realistic about how much air can be cleaned. "An air cleaner can only clean so much air at one time," He says. "If the indoor air is more polluted than the air cleaner can deal with, then it's not going to be significantly helpful. The air cleaner has to be sized to the home."

According to the EPA, the effectiveness of an air cleaner depends on how well it collects pollutants (expressed as a percentage efficiency rate) and how much air it draws through the cleaning or filtering element (expressed in cubic feet per minute).

For patients looking for signs of indoor air pollution, two dead giveaways are odor and frequent dust accumulations — both of which point to particles in the air. The need for frequent dusting doesn't necessarily mean that those particles are harmful, however. So, patients should pay careful attention to the key physical signs and symptoms of indoor pollution.

"If you're experiencing symptoms of any kind that seem to be accelerated when you're at home and seem to diminish when you're outside, that's an indication that it may be an air quality issue," Rathey says.

Build Green

The Green Home movement is driving awareness of HRVs, according to Rathey. The idea of green building takes into consideration all three steps for preventing and addressing indoor air pollution. First, known pollutants, such as VOCs, are eliminated. More natural resources are used to build cabinets, furniture and flooring.

"In a green home, you're going to tend to want to build with cabinetry that doesn't have formaldehyde in it," Rathey says. "They're going to tend to want to build with flooring that doesn't have toxic finishes. And they're going to tend to put carpeting in that is green-label certified or green-label rated by the Carpet and Rug Institute, which means it's been evaluated for low emissions and certified for having low emissions."

Second, though the homes are built tight to reduce energy needs, the homes include HRVs to properly ventilate the home. Plus, green homes are built with a smaller square footage, which makes ventilation easier while reducing the home's carbon footprint, Rathey says.

"Indeed, the green home movement is definitely helping us become more conscious of good ventilation and how it effects people with respiratory illnesses," Rathey says.

Patients who are looking to build a new home should express concerns regarding indoor air quality to the architect or builder. The American Society of Heating, Refrigeration and Air-Conditioning Engineers (ASHRAE) recommends a ventilation rate of 0.35 ach (air changes per hour) for new homes.

This article originally appeared in the Respiratory Management April 2009 issue of HME Business.