Environmental Health and the AJRCCM

This issue of the AJRCCM contains three original articles (1-3) and an accompanying editorial (4) dealing with the health effects of urban air pollution. The articles concern the influence of particulate air pollution on out-of-hospital coronary deaths (1) and on heart rate variability (2, 3). Traditional methods in respiratory epidemiology, such as pulmonary function testing, are conspicuously absent from all three studies. In the articles on heart rate variability, the drug category studied-statins (2)-and the dietary intervention-administration of n-3 polyunsaturated fatty acids (3)-may not be very familiar to pulmonologists and critical care physicians, as they belong to the realm of cardiovascular prevention. Readers may be surprised that these contributions found their way into the premier respiratory journal, because the focus of all three studies lies not on respiratory endpoints, but entirely on cardiac endpoints. The writer of the editorial (4) is a cardiologist.

Why should the AJRCCM publish studies that appear to deal only remotely with respiratory medicine?

A simple, historical reason why respiratory journals contain articles on the adverse effects of air pollution is that many irritants, toxic agents, or carcinogens that are present in the occupational or general environment enter the body by inhalation. Hence, the respiratory tract constitutes the primary target for inhaled pollutants and, consequently, research on the adverse effects of pollutant gases or particulates has been conducted largely by experts in respiratory health. These are either pulmonary physicians who developed an interest in environmental health, or specialists in occupational or environmental health who became experts in pulmonary pathophysiology. So, environmental medicine and pulmonary medicine have naturally become very close friends.

However, there is also a more substantive, mechanistic reason to justify why air pollution research should be at home in respiratory journals, even when the effects studied are seemingly entirely outside the lungs. The justification is that injury to the lungs resonates throughout the body-a notion that has been known for a long time in critical care medicine. This concept now also appears to hold for the effects of air pollution, even when the degree of lung damage is likely to be only minor. Air pollution researchers have realized that the increase in overall mortality and morbidity that occurs during weather-related peaks of air pollution is mainly driven by increases in the number of people who die or are hospitalized from cardiac causes (5). The same appears to be true for the increase in mortality that is associated with long-term exposure to higher levels of urban pollution (6). The mechanisms for these acute and chronic cardiovascular effects of inhaled pollutants have not yet been entirely elucidated, but the lungs are likely to play an important role. The inflammation that occurs in the lungs in response to the deposition of particles may be responsible for alterations in the autonomic nervous control of heart rhythm and/or for the release of proinflammatory mediators in the systemic circulation, thus affecting hemostasis or even the atherogenic process itself (7). In other words, the lungs are not merely a portal of entry for pollutants; they probably also mediate cardiovascular responses to a substantial extent. This is another good reason to consider that air pollution research is intimately linked with pulmonary research.

So, let the AJRCCM be your preferred journal in respiratory, critical care, and environmental medicine!

Conflict of Interest Statement: Neither author has a financial relationship with a commercial entity that has an interest in the subject matter of this manuscript.

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