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Mary B. Rice, MD; Aaron S. Bernstein, MD, MPH
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From the Pulmonary and Critical Care Unit (Dr Rice), Massachusetts General Hospital; the Center for Health and the Global Environment (Dr Bernstein), Harvard School of Public Health; and the Division of General Medicine (Dr Bernstein), Boston Children’s Hospital.

Correspondence to: Mary B. Rice, MD, Pulmonary and Critical Care Unit, Massachusetts General Hospital, Bullfinch 148, 55 Fruit St, Boston, MA 02114; e-mail: mrice2@partners.org


Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2013;144(5):1732. doi:10.1378/chest.13-1692
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To the Editor:

We thank Dr Hernàndez-Garduño and colleagues for their close reading and questioning of our recent article.1 We take this opportunity to address their concerns.

There are two comments from the authors with which we agree. The first is that while climate may influence COPD hospitalization rates, it remains unclear which specific indications for COPD hospitalization are most affected. We agree that more research could reveal with greater specificity which pathophysiologic mechanisms are involved. Their second comment relates to how barometric pressure might influence oxygen saturation based on a single small study.2 Long-term changes in barometric pressure have not been considered a major consequence of higher concentrations of greenhouse gases, but there may be more variability in barometric pressure as a result of climate instability, with potential consequences for patients with COPD.

We presented findings that indicate greenhouse gases may worsen air quality by increasing ground-level ozone and promoting forest fires, which release a variety of air pollutants, including particulate matter < 2.5 μm in diameter (PM2.5). Dr Hernàndez-Garduño and colleagues mention the relationship between PM2.5 exposure and cardiorespiratory mortality and argue that air pollutants need to be included in models that assess health effects of climate change. Of the studies we referenced on acute effects of heat waves on respiratory hospitalizations or mortality, both adjusted for ozone3,4; additionally, Monteiro et al4 adjusted for PM2.5. Future studies should continue to consider the complex interplay of air pollution and climate.

Dr Hernàndez-Garduño and colleagues make a further blanket critique of air pollution/climate change and COPD research, stating that there are “too many factors to be considered” and inevitably confounded results. Of a lengthy list of variables they name, including smoking history, obesity, and β-blocker use, almost none are associated with both the exposure (eg, heat waves) and outcome (COPD hospitalization) and as such cannot be confounders. Temperature, humidity, and season of the year are included in almost all models of acute health effects of air pollution and, in climate research, are often the primary exposures of interest. Despite the many challenges of climate and air pollution research, we maintain that their critique underestimates the quality and consistency of the epidemiologic studies in the literature. Although it is true that most studies of COPD hospitalization in relation to air pollution or climate are based on administrative data, we disagree that these studies have poorly adjusted for confounding.

We reiterate that climate change puts at risk the health of millions of people around the world with chronic lung diseases. Physicians are uniquely positioned to understand and communicate the importance of reducing greenhouse gas emissions for the welfare of patients.

References

Bernstein AS, Rice MB. Lungs in a warming world: climate change and respiratory health. Chest. 2013;143(5):1455-1459. [CrossRef] [PubMed]
 
Dockery DW, Pope CA 3rd, Kanner RE, Martin Villegas G, Schwartz J. Daily changes in oxygen saturation and pulse rate associated with particulate air pollution and barometric pressure. Res Rep Health Eff Inst. 1999;;(83):1-19.
 
Lin S, Luo M, Walker RJ, Liu X, Hwang SA, Chinery R. Extreme high temperatures and hospital admissions for respiratory and cardiovascular diseases. Epidemiology. 2009;20(5):738-746. [CrossRef] [PubMed]
 
Monteiro A, Carvalho V, Oliveira T, Sousa C. Excess mortality and morbidity during the July 2006 heat wave in Porto, Portugal. Int J Biometeorol. 2013;57(1):155-167. [CrossRef] [PubMed]
 

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References

Bernstein AS, Rice MB. Lungs in a warming world: climate change and respiratory health. Chest. 2013;143(5):1455-1459. [CrossRef] [PubMed]
 
Dockery DW, Pope CA 3rd, Kanner RE, Martin Villegas G, Schwartz J. Daily changes in oxygen saturation and pulse rate associated with particulate air pollution and barometric pressure. Res Rep Health Eff Inst. 1999;;(83):1-19.
 
Lin S, Luo M, Walker RJ, Liu X, Hwang SA, Chinery R. Extreme high temperatures and hospital admissions for respiratory and cardiovascular diseases. Epidemiology. 2009;20(5):738-746. [CrossRef] [PubMed]
 
Monteiro A, Carvalho V, Oliveira T, Sousa C. Excess mortality and morbidity during the July 2006 heat wave in Porto, Portugal. Int J Biometeorol. 2013;57(1):155-167. [CrossRef] [PubMed]
 
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