Personal exposure to nitrogen dioxide (NO(2)) and the severity of virus-induced asthma in children

BACKGROUND: A link between exposure to the air pollutant nitrogen dioxide (NO(2)) and respiratory disease has been suggested. Viral infections are the major cause of asthma exacerbations. We aimed to assess whether there is a relation between NO(2) exposure and the severity of asthma exacerbations caused by proven respiratory viral infections in children. METHODS: A cohort of 114 asthmatic children aged between 8 and 11 years recorded daily upper and lower respiratory-tract symptoms, peak expiratory flow (PEF), and measured personal NO(2) exposures every week for up to 13 months. We took nasal aspirates during reported episodes of upper respiratory-tract illness and tested for infection by common respiratory viruses and atypical bacteria with RT-PCR assays. We used generalised estimating equations to assess the relation between low (<7·5 μg/m(3)), medium (7·5–14 μg/m(3)), and high (>14 μg/m(3)) tertiles of NO(2) exposure in the week before or after upper respiratory-tract infection and the severity of asthma exacerbation in the week after the start of an infection. FINDINGS: One or more viruses were detected in 78% of reported infection episodes, and the medians of NO(2) exposure were 5 (IQR 3·6–6·3), 10 (8·7–12·0), and 21 μg/m(3) (16·8–42·9) for low, medium, and high tertiles, respectively. There were significant increases in the severity of lower respiratory-tract symptom scores across the three tertiles (0·6 for all viruses [p=0·05] and >2 for respiratory syncytial virus [p=0·01]) and a reduction in PEF of more than 12 L/min for picornavirus (p=0·04) for high compared with low NO(2) exposure before the start of the virus-induced exacerbation. INTERPRETATION: High exposure to NO(2) in the week before the start of a respiratory viral infection, and at levels within current air quality standards, is associated with an increase in the severity of a resulting asthma exacerbation.