Air Quality Matters
Air Quality Matters inside our buildings and out.
This Podcast is about Indoor Air Quality, Outdoor Air Quality, Ventilation, and Health in our homes, workplaces, and education settings.
And we already have many of the tools we need to make a difference.
The conversations we have and how we share this knowledge is the key to our success.
We speak with the leaders at the heart of this sector about them and their work, innovation and where this is all going.
Air quality is the single most significant environmental risk we face to our health and wellbeing, and its impacts on us, our friends, our families, and society are profound.
From housing to the workplace, education to healthcare, the quality of the air we breathe matters.
Air Quality Matters
Air Quality Matters
#80 Abigail Whitehouse: When a child can't breathe, everything else stops.
What really happens in a child's body during a severe asthma attack? Dr. Abigail Whitehouse, pediatric respiratory consultant, takes us on a sobering journey through the physiology of asthma, beginning with a paramedic's memory of a late-night emergency.
The conversation reveals the hidden mechanisms of respiratory distress—airways becoming increasingly constricted as immune cells flood lung tissues, creating a life-threatening situation where medication becomes ineffective and oxygen levels plummet. We learn that asthma development involves a complex interplay between genetic predisposition and environmental triggers that "switch" the immune system's response.
Dr. Whitehouse shares insights from her environmental health clinic, where she's pioneering approaches that look beyond medication to address the root causes of respiratory illness. The discussion uncovers disturbing connections between air pollution, poor housing conditions, and asthma mortality rates, revealing how social inequalities create disproportionate health burdens.
Most powerfully, she challenges the acceptance of ongoing symptoms, emphasising that proper asthma management should aim for complete symptom elimination. For parents, healthcare providers, and anyone concerned about respiratory health, this episode offers critical knowledge about warning signs, proper inhaler use, and the environmental factors that could mean the difference between life and death during an asthma emergency.
Abigail Whitehouse - Linkedin
Asthma & Lung UK
Check out the Air Quality Matters website for more information, updates and more. And the YouTube Channel
The Air Quality Matters Podcast is brought to you in partnership with.
Eurovent Farmwood 21 Degrees Aereco Aico Ultra Protect InBiot
The One Take Podcast is brought to you in partnership with.
All great companies that share the podcast's passion for better air quality in the built environment. Supporting them helps support the show.
Welcome back to Air Quality Matters. We already have the tools and knowledge we need to make a difference to the quality of the air we breathe in our built environment. The conversations we have and how we share what we know is the key to our success. Coming up a conversation with Abigail Whitehouse, senior Clinical Lecturer in Children's environmental health and honorary pediatric respiratory consultant, we discussed the impacts of air quality on this podcast, and one of them is asthma. Many of the conversations have turned particularly to the topic of childhood asthma, but we haven't until now really stopped to talk about what it actually is, what a child is going through in an attack and dealing with this illness in general. Abigail is a clinical academic respiratory children's doctor working in East London. She completed her PhD on the immune cell impacts of air pollution exposure on healthy children and she works at the Queen Mary University of London within the Centre for Genomics and Child Health and clinically at the Royal London Hospital. Her research activities have included setting up the new Children's Environmental Health Service at the Royal London and innovative trial work in both preschool wheeze and asthma interventions in primary and secondary care, and her work encompasses all paediatric lung conditions, with a focus on asthma and wheeze. So this is a deep dive about asthma, what it is, how it affects children and their families and what we currently know about it and, in particular, the impacts of our environment on the disease itself. I think this is a really valuable podcast in the context of the broader air quality and ventilation conversation and I hope you enjoy this conversation as much as I did. Please don't forget to check out the sponsors in the show notes and at airqualitymattersnet. This is a conversation with Abigail Whitehouse.
Simon:People that listen to the podcast might actually be aware of my history from my work and actually the very early days from a teenager as a 19 year old to when I was 26. I was actually in the ambulance service in oxford and that was my first real job actually, as it goes, and what a job it was. So, as happens with that kind of a career, you you come away with pictures of situations you've you found yourself in over the time. Some stand out more than others, some bother you, some don't and, interestingly, some you revisit and they change, I think, as you go through life and things mean different things to you at different stages of your career or your life stage, and one of those for me was asthma. Actually, you know, as a paramedic we would have been called out to hundreds and hundreds and hundreds of children with asthma. You know it becomes almost routine in its nature, but then unfortunately, and you're only ever called. It should be said that an ambulance is only ever called when it gets to some kind of crisis level. So it's not, it's nothing, but it's anything but routine for those that are going through it. Um, but every now and then one stands out and there is one particular scenario that's played back, particularly as I've got older and had children myself, and particularly as a father that has stuck with me. And that story was that it was like any other call-out really. We were going to an asthma attack. It was late at night, probably early hours of the morning actually, and we pulled into this close in a housing estate, as we would have done a thousand times over, and you learn to read the room quite well.
Simon:When you're in emergency situations day in, day out, you can see from how people are behaving often that something more serious is going on. So that particular night I was driving and I had a more junior trainee working with me, so their job was to go in first and start assessing. And I got the first red flag, which was a father caught in this awful middle ground of wanting to come and grab us and drag us into the property but not wanting to leave his home. And you could see this kind of individual torn between wanting to be close to his family and wanting to literally come and pull us out of the truck and pull us in. So my red flags had already gone up, so I turned the ambulance around and made ready for a quick escape if we needed to.
Simon:Um, so I came in after my, after my colleague, and, again, nothing particularly unusual about it. Um, this was a serious crisis and you could tell. And when you've seen enough asthma attacks as you have, there's a, a sitting position a child gets into, naturally when they're really struggling to breathe hands on the knees, arched shoulders. It's just awful to see and you could see in a second, this child was fading, starting to run out of steam, was fading, you know, starting to run out of steam. And this story is about running out of tools really, and I knew in an instance we did not have the tools as an ambulance response to sort this child out.
Simon:This was not just a nebulising inhaler of salbutamol. Whatever we were going to give them, we scooped and ran. Sometimes, in some situations, there's only one place for a patient to be and that is in the hospital in A&E. So, without creating a fuss, I picked the child up, grabbed the mum by the arm and said we're leaving. There wasn't time for explanations. It wasn't time for explanations, it wasn't time for niceties. The oxygen bottle was brought with us and we were gone and we got into the back of the ambulance and my colleague jumped in the driver's seat. Um, we were out of there and we left the dad to mop up the scene and come and join us. There wasn't time for any kind of negotiating who was coming with who. We just needed to be in hospital. And that was nothing unusual, really, other than the fact that it was an awful crisis and this child was minutes, an hour from being in real trouble.
Simon:But there was a picture of that father as I drove away, because you see out the window of the back of the ambulance, you know, you see, you see, you see the scene disappearing away from you. And it always struck me later on in life, the the look on that father's face, of a dad who'd run out of tools. You know, and as a father, often with kids, you're the one that fixes everything. You know dad was the one that has a tool for, that knows what to do. Somehow Same with mum, but mum was there doing the job and in this father's face you saw somebody lost, that had no tools, had nothing to give and was probably traumatized by that event. He was utterly helpless and that stuck with me as a father goes to show how something that we talk about very regularly, particularly in the air quality community and asthma can, at a certain point, take all the tools away from people and put a family, and particularly a child and a patient, at a point where it's life and death and life transforming for people.
Simon:Um. So I thought it would be an interesting conversation to have with you, abby, because of your work in asthma care with children, to really dig into what, how we get there. We talk about asthma all the time on this show as a as a as a consequence of poor air quality, but I don't think we've ever stopped and gone. What are we actually talking about In that child in that moment? What was that kid going through physiologically and how did they get to that point. So perhaps could we start there and walk back from the most serious situation what was happening to that young seven-year-old boy? And walk back from the most serious situation. What was happening to that young seven-year-old boy that was minutes or hours away from his body giving up completely? What physiologically is happening to a child at that point?
Abigail:So he was in the middle of what we call a life-threatening asthma attack. Um, and the the fundamental bit of that is that your your airways, so you've got your lungs, and within your lungs you've got your airways that come down from your windpipe and then you have two other tubes that come off those, your main bronchus, and then they go out and they fill and that's how the air moves through your lungs within asthma. What you get in an acute attack is that those, those airways are already inflamed because they've got asthma already, and then they've been exposed to a trigger and that trigger has gone and has caused those airways to get tighter, more full of immune cells, so white blood cells and things that make things irritated, a bit like when you get a rash on the outside, when you have an allergic reaction, similar kind of concept inside, and so you get your trigger and without enough medication to relieve that the, it will just keep getting tighter and tighter. So that position that you're talking about, that kind of almost like tripodting forwards with the arms forward, that's you trying to keep your airway as open as possible and you forcing the air into your airway. The problem with aspirin is that you can get the air in, but then it's really difficult to blow it back out because you're blowing out against this, these much thinner tubes than there should be.
Abigail:When you have an aspirin attack, you take a reliever inhaler most of the people have a blue one, so I'll be small and that one when you breathe that in, it's a bronchodilator. It it acts on cells within those muscles of the airway and it relieves them. It opens them up. Um, the problem is is that you get to a point where it doesn't matter how much of that you give if it's that bad and that far through an asthma attack, it doesn't work in that moment. So you, you scooped and run that that was the best thing to do because while you still need to give those medicines, you need to give oxygen. Nothing at that point potentially would open up the airways enough and that's where you need to get IONI. But that's your. That's an acute attack and unfortunately, in the UK in particular, we have some of the highest rates of kids dying from acute asthma attacks and for various reasons relevant to this. Air pollution exposure is one of them. But that acute asthma attack, that inability of your, your airways, to relax, is one of the key issues.
Simon:And what's the difference between children that are having more typical asthma attacks, so asthma episodes of some description, where they have to pull out the blue inhaler to have a reaction? What differentiates those attacks from ones that end up, where you go beyond this, this line, where it's not retrievable with the, with the home medication?
Abigail:it's probably a combination of things. It's probably that there isn't enough of the preventer medication. So your other inhalers that you take we call them preventers the brown inhalers, purple inhalers, white inhalers and what those inhalers do is they remove the inflammation, they stop the cells from being inflamed, and so that means that when you, when you breathe in a trigger, your cell, even if you tighten a little bit, that doesn't, it doesn't cause as much of an issue because you've relieved and you've removed some of that initial inflammation and swelling. And so either we're not giving them enough of the right medicine or it's just that on that day that trigger was just too much and it pushed the cells into overdrive and that's why they've ended on to have a severe asthma attack.
Simon:That's why they've ended up having a severe asthma attack. So when a patient then comes into A&E in that kind of a crisis, they've probably already been fairly dosed with the standard medication that parents have at home. What are the tools, then, that an A&E department and the specialist that would then descend from the paediatric areas of the hospital in on the child like what? What are the tools that you have then that everybody else doesn't? Then to try and walk this back from this crisis point?
Abigail:so we've got, and by that point, nine times out of ten, most children will have had large amounts of their blue inhaler from home that they will be jittery and triggery because that also puts your heart rate up, and at that point we will give them more salbutamol through a nebulizer which is forcing it in. But the key thing about it being in hospital is it's being forced in with a nebulizer using oxygen, so you're combining the salbutamol with oxygen. So at that point the reason they're unwell, they're not able to get enough oxygen in. So that's one step and then the next is we give them IV medication, so medication into a vein, and they work very similar.
Abigail:They're designed to relax those airway muscles and to open them up and they're kind of the next step that we have. They don't always work and the point after that is when we have to take over breathing. But if we have to do that A, we're really really sick already and B, it's really difficult because the airways are so sticky and clogged up and really difficult to push the air into. It can be really difficult to ventilate, so really difficult to help with the breathing. So I would much rather we find a way to stop anyone getting to a severe asthma attack in the first place.
Simon:At some point do you find yourself then intubating patients and actually physically taking over the breathing? Yeah, okay, and as you say, physiologically they're in real trouble. At that point already, they're already hypoxic. They've used all of their energy reserves. They've got no capacity left to fight. So you're dealing with a seriously compromised chart and children for those that haven't worked with kids that they're very good at maintaining for a while, and then they just fall off a cliff, don't know that.
Abigail:The energy reserves just plummet and they go from surviving to not in a heartbeat incredibly good at compensating yeah um, which is why it can be sometimes really difficult to know how severe an asthma attack is in, particularly in children, because they're just really good at coping until they're not yeah, yeah, and that's the, that's the, the hard one to read.
Simon:Yeah, um, so, so, really, you're treating two things then, at the point where it's that critical emergency One the physiological effects of the asthma attack, the hypoxia, the risk of failures of organs and just the lack of breathing, the impacts of not being able to breathe effectively, right In plain English, not being able to breathe effectively, right in plain English. And then you've physically, medically, got to be able to walk back that inflammation to the point where the breathing is possible to some degree. How quickly when you start to see an impact with these medications, is it a very broad bandwidth? Can it take a very long time to walk a patient back from that crisis point? Or, once you get the right medication in, could it be quite a quick process that a kid is like two hours later sitting up in bed, going what was all the fuss about, kind of thing pretty much.
Abigail:Yeah, it can be one of two extremes, or in the middle ways. Um, we, we see children that respond incredibly well to just that higher level of treatment and they, yeah, two hours later sat up in bed, smiling happy, wouldn't even know something was wrong. Possibly if you remove the medication at that point it would still come back, but it's still. They look really, really well quite quickly. Other children take a lot longer and they're probably children who have got a much more chronic. Their inflammation has been worse, their asthma has been poorly managed or they haven't been taking the medication or they haven't had the right medication to try and prevent the ather attack. So their lungs just take a lot longer to recover.
Simon:So some kids can just be sicker kids from the asthma, the much deeper chronic symptoms and issues with asthma. So they're starting from a much more poorly place and you can also get kids having a severe asthma attack. They're coming from a relatively healthy spot so you can get quite a big difference in what your baseline starting point is. Okay, interesting, is there anything? It's probably an impossible question to answer, but are there warning signs for adults and lay people when they see children having an asthma attack? Because we've all seen kids take an inhaler on the side of a football pitch or having that being a bit wheezy at home and taking an inhaler. At what point should people that aren't parents, that haven't been through this and seen the warning signs and know for other people, other stakeholders that are around kids? Are there key things we should be watching out for? Where you're saying this is beyond ringing your mum. I think we need to be calling an ambulance, kind of situation give reliever medication, it should start to get better relatively quickly.
Abigail:You might have to give quite a lot of it, so you might blue inhaling up to 10 puffs, um, but it it should start to get better now. If it's not, if they're still wheezy after they've taken whatever their reliever amount of medicine is, that's not a. We need to just sit and wait and see. It's a. They need to be seen Two things either it's not enough and they need more, and they should just keep taking it, or that inhaler's empty and that's the other thing.
Simon:Yeah, it's really interesting. It's interesting you say up to 10 puffs. I think a lot of people that are used, you know, have these images of, you know, adrenaline pens and medication on the side of the road, medications as being a kind of a one dose thing. So it's not unusual to see a kid like taking three, four, five, six puffs of their inhaler to try and get an impact.
Abigail:Yeah, but the other. The issue with that is that actually, if you're having a huge asthma attack, even just getting the medicine out of your inhaler and into it, you should be using a spacer. A huge asthma attack, even just getting the medicine out of your inhaler and into you, you should be using a spacer. I'm very specific about this um, but you still might not be able to breathe enough in to be able to make it work. So it's it's about giving the medicine time to work, um, and but also making sure that it is working.
Simon:Yeah and and that spacer thing, that's these kind of plastic, jar type things where the inhaler gets in one side. All it does it just allows the gas to expand in a volume before you breathe it in.
Abigail:So the inhalers that we're all traditionally seeing, they're called metered dose inhalers, so you press on the top of them and you breathe in at the same time. If you're an adult, now ideally I would suggest that any adult that has one of these also has a spacer as well, because it makes it much easier, because otherwise the issue you've got to do is you've got to press down on the button at the same time as taking the breath in to make the medicines go into lungs. So that's not the easiest thing to do when you're feeling unwell or jittery or having an asthma attack. So with kids in particular, in particular, we show them that they should be taking normal tidal breathing through a spacer, because then you know you're getting leadson in there.
Simon:Interesting. And can you see? Can you see a mist in the spacer disappearing into the truck?
Abigail:there's no visual. It's not. No, okay.
Simon:No, the particles are so small that you don't see them interesting, okay, because I think people have this vision of a nebulizer as a, you know, steve steve, which is nice and it's all steam.
Abigail:But yeah, no, with inhalers you don't necessarily know, which is why sometimes kids and adults don't realize that their inhalers are empty.
Simon:Because they can still pssst and not have anything in them.
Abigail:It's still got the propellant in it, it's still got something out, but it's just not got the medicine there as well.
Simon:Okay, so that's a really good bit of advice then, like if you're find yourself with a child or around a child that's got the equipment to use an inhaler, they're struggling with an asthma attack, not to be freaked out if they're doing more than one, that they're trying to get a decent dose into them, to ask if they've got a spacer to help them, if you can help them with it. They're not complicated, oh, you just shove the thing on one end and press, you'll figure it out without any instructions, kind of thing. And not to worry about several doses to try and get a reaction, and the reaction will be within a few minutes of the dose generally.
Abigail:Probably takes about. A proper reaction will take about 15 to 20 minutes, but you'll start to see the signs within a few minutes.
Simon:They're just going okay and so and so if you're not getting that and the kid is feeling anxious and fit, looking worried and struggling and there isn't immediate help around them, that's the time. Then start acting, not to wait, because you don't want to wait 20 minutes to find you're going to wait another 20 minutes for an ambulance. Those are the scenarios where you find yourself not knowing what to do exactly. You know so. They're far better and they're you know.
Simon:I can speak for experience in the ambulance service. Of all the call outs you get. Nobody minds going out to a child having an asthma attack that turns out not to be anything right of all the things that we can get called out to, that don't end up being anything. That's right down the bottom of the list. There's stuff that's going to annoy you, right, yeah, and nobody at the other end of the line is gonna. They'll take it seriously. It'll be right at the top of the list and they'll get a reaction. Yeah, that's really interesting. How does a child start to develop asthma in the first place? What is asthma at its fundamental level Like from a healthy child? How do they end up at the point with these chronic illnesses? Is it all environmental? Is it genes? Is it passed on? Is it food like? I imagine these are all questions you get from parents and first time people with asthma like fundamentally, what is aspir asthma and how do you find yourself with it as a child?
Abigail:So asthma is a chronic medical condition that does have a genetic basis. So we know that there is a family history to it. So we know that if your dad's got it and your mum's got it or your older siblings have got it, you've got a higher risk of having it. It's also known as an atopic illness, so atopy means allergic. So we know that it's the immune system that's not doing its job as it should do and your immune system works, that you get exposed to things and it fights off bacterial infections, viral infections.
Abigail:The problem is is that if you've got a predisposition to asthma through your genetics and there is no, unfortunately no genetic test that will tell you whether you've got asthma or not but if you are, if you've got that predisposition and you get a trigger, um and we traditionally look at kind of a bad viral infection as an infant potentially will trigger your immune system To switch from your immune system just fighting off the stuff that it should fight off to fighting other things that it comes into contact with, such as pollen or air pollution or cats and dogs and all those kind of traditional allergic things. Or cats and dogs and all those kind of traditional allergic things, and basically it's that you're producing too many of these extra immune cells to try and fight off all these things that you're coming into contact with, and then the main place that it acts is within the lungs and on the airways. So once you've got that kind of immune switch, you're then likely to continue to have asthma. Problem is there's no test to prove that.
Simon:So there's no test to prove it. And is it? Is that immune switch predictable in any way? So can you say, if you're, if there's a family history of asthma, are there things that parents can do to try and avoid that switch? That goes from good response to bad response.
Abigail:There's nothing that we can do as parents, unfortunately, to try and stop it happening. One of the key ones that we know increases your risk of using an asthma later in life is if you get an infection called RSV, which is now a vaccination for, but that causes bronchiolitis in babies. So we know that babies that have bad bronchiolitis or chest infections when they're little are more likely to wheeze when they're older, and we think that's probably because the immune system is switched at that point based on that infection, which is why one of the reasons why there is now an evolving vaccination programme towards it because not just that it will stop wheezing, which is a nice side point, but actually it will stop those bad infections in infants as well Interesting.
Simon:So that's one of those known triggers that we can actually include in the range of vaccines.
Abigail:Yeah, but the other things that we know that are probably going to act as that trigger are if you're exposed to things like pollution as you're growing at key points when your lungs are growing okay.
Simon:So the things that trigger an asthmatic reaction, are they the same things that cause that trigger in the first? So if you, if you're allergic to pollen, or can pollen, can pollen cause that trigger? Can cats and dogs cause that? Chiller it just you just don't know so the, the.
Abigail:the immune switch trigger, we're pretty sure is to do with infections and those kind of environmental exposures to things that you would prefer not to be exposed to things like pollution Whereas your sensitization to pollens and things like that is more just a trigger for the actual acute asthma attack Once it's happened.
Simon:So things like pet dander and pollen spores and so on Because moulds often talked about a lot at the moment is exposure to mould, vocs and mould spores and fragments. Is that a potential trigger or is that just one of those things that cause a reaction later on? Do we know anything about?
Abigail:We probably don't have enough evidence to say that it's one of the ones that can potentially switch your immune system or primary immune system I'm. We know that exposures later in life are more likely to exacerbate symptoms that you've already got. But, um, probably the vocs is a possible one. But that kind of. How do you tell the difference between what you've been exposed to over life in terms of particulate matter, vocs, ozone, sulfur dioxide? Sure, how do you split them all up? That's very difficult, but I would lump VOCs in with that. The mould and damp is a bit more difficult.
Simon:Yeah, you know and you say you know, for listeners and academics and people in the field are saying probably and not sure it's, because often there's evidence one way and evidence the other and it's just really not clear. And I think, reading through some of the material, there does appear to be some evidence that prolonged exposure to fairly serious damp and mould could be attributable to perhaps the onset of asthma. But then there are also studies that haven't found those links. It's really, it's potentially there but we just don't know.
Abigail:Yeah, and mainly because how do you know whether someone's been exposed to mould and damp is quite difficult as well. So there's some nice big cohort studies, like the ASPAC cohort from around Bristol and there, which continue to explore what children's exposures were and whether or not they've gone on to develop wheezing and asthma later in life. So there's potential that we will see more information coming from those big cohort studies as well.
Simon:Yeah, I mean to add complexity. I was just reviewing a paper for the midweek podcast there I think it comes out next week where they're even looking at mothers' exposure to pollution during the various trimesters and the onset of asthma in the cohorts, and there's some really interesting links there between PM and sulphur dioxide and nitrogen. It's really complex so we just don't. It's just so complex, it's very hard to know when, but for some reason that trigger happens. So at some point your body gets rewired to react to an irritant. There's some description, the wrong way. It overreacts, the body does something that it shouldn't and that presents as asthma, and this is what you're describing as this inflammation of the airways, the primary airways.
Simon:Yeah, so you now have kids coming into your clinic who have some reason. This switch has happened, I take it. There's a huge range spectrum of severity that you're seeing. Like kids first visits we think this is asthma all the way to kids where you're managing a whole range of severities. Are you diagnosing, as part of those visits and those clinics, causes and effects and trying to root out with people how to eliminate these stresses or the things that are causing asthma, as well as the medication and the actual dealing with the symptoms. Is that part of the work that you do to try and understand why this is coming on, why things happen at certain times, and trying to work with parents to deal with it?
Abigail:Yeah, so we're quite privileged. So at the moment we've got funding for our environment clinic so we are able to do a bit more extra, a bit more extra digging into what might be potentially setting off asthma. I'm but the context. So children will be referred to our secondary and tertiary care clinics from either primary care or our community asthma nurses because they've got asthma and wheezing that isn't being managed or isn't being controlled with kind of first and second level medicines. And then they come to our more specialist clinic and we at that point spend a lot of time addressing the education around why we're using our inhalers because, as I said, sometimes it's that we're just not using our inhalers properly and also making sure that we're aiming for a no symptoms type of management rather than this expectation that you should you've got asthma, you should continue to wheeze, but don't worry about it. As long as you take your inhalers you'll be all right. What we really want is for you to have no asthma symptoms at all. The problem is is that some. We've always traditionally looked for all those different triggers, so we'll address kind of exercise and pollen and cats and dogs and unfortunately tell you to remove your cat and dog from your home if you're properly allergic to them.
Abigail:But the uniqueness of what we're able to do is spend a bit more time looking at whether or not there's other external exposures that might be those triggers. So, is air pollution a trigger? Is your home a trigger? Is there mold and damp in the home? How do we help you work out what to do with the mold and damp? Are there other things that you're being exposed to?
Abigail:Um, and that's more just to give the patient and the family more of an idea of what to do, um, and to try and kind of improve their care, because what we don't want to have to do is keep going up and up and up on medicines which will work. Eventually we will give. Eventually we will find a medicine that dampens down that inflammation to the degree that it needs to, and but that might be something called like a biologic medicine, which is basically an immune-changing medicine. And they're expensive. They're also a bit faffy to use. They're either injections in the hospital or injections at home. To get to that point you have to be having lots of asthma attacks and actually, if we could find a way to remove a trigger that wasn't traditionally seen as a trigger, such as pollution, exposure or anything like that, then that's a really key thing that we're able to do now.
Simon:That's really interesting, and is that a common conversation that's happening at every level of medicine that kids that are we're talking about, about kids here, but obviously adults have asthma too, but you know the focus here is children. Um, is that happening at every level, from the primary care onwards, where it's not just about medical medicine but it's also about environment, that those questions are being asked by gps and asthma nurses and so on? Tell me why your home isn't a good story for the asthma. Is it carpets, wood floors? Have you got cats and dogs? Is there any damp and mold? Is there a lot of pollen around in the house? Do other people suffer from pollen allergies and so on, like is that a common kind of thing where you're trying to treat some of the triggers as part of it, or is the first response often look, here's an inhaler off you go. That probably sorted out we.
Abigail:We have so many children out there and adults with wheezing disorders um, and so limited time across clinics that it isn't happening to the degree that would be ideal for patient care. If you look at any of the reports that come out and the NICE guidance and things like that, they all say we should be having conversations about housing and pollution and exposures and we should be discussing with with our patients. The problem is is that if you were to add everything into an asthma consultation that you need in primary care, it would take 45 minutes instead of a 10 minute appointment. So, and the important bit to start with is to make sure that the medicine is there to remove the inflammation and treat that. But actually, if you've got ongoing symptoms, then we need to investigate further, which is why they quite often end up coming up to hospital clinics.
Abigail:The problem is is that we traditionally in medical education get taught how to take a social history which includes your family history and your birth history and your smoking history, your family history and your birth history and your smoking history. We're not taught still how to take a housing or an environmental exposure history, which we should be doing, particularly for respiratory illnesses and asthma, but actually we should probably do it for most things. Heart attacks, strokes, all of those things are all related to pollution exposure. So actually we should be getting better at having those conversations, but it's all a matter of time and availability of time.
Simon:Yeah, and I suppose at one level those environmental questions are also very useful for things other than asthma and wheezes. So that's on the medical record that can be referred to for all sorts of ailments. You know that could be reflected on over time Because a lot of the symptoms beyond wheezes, a lot of the environmental conditions that people face are so multisystemic. You know almost anything could be caused by an environmental something or other, right? So it's an incredibly difficult thing to pick your way through. But you need the data in the first place. You know it doesn't matter whether you're a gp or you know somebody specializing in a clinic. If you don't have that background information, you're shooting in the dark in a lot of cases. So you can see the value in them.
Simon:But but I picked up on something you said there that I guess, by your tone, that this is a. This is an almost an overwhelming problem in society. Wheezing in kids like this is prolific, like you're seeing this at scale. Is that so? Is that something that has always been the case or is this something we're just more aware of now? Is this something that's getting worse? Like this sounds like a big problem like this is taking us.
Abigail:This is a serious cost to society and health and well-being of people that are suffering from this I think I mean, if you look at the evidence, the the numbers of kids and young people and adults with asthma and wheezing disorders and respiratory conditions and allergic conditions has continued to increase over the last 50 years, even though actually we've made some good progress with improving lots of things and our medicine that we have available to us now are much better at treating them. What we see in hospitals and even what we see in primary care is the tip of the iceberg. There are kids out there who get the odd cough and cold and respiratory infection and probably wheeze. They might see an out-of-hours GP, they might see urgent care, they might see A&E once or twice, but they won't necessarily then be referred on because they look well when they get seen again. But they're they're the ones that worry me. They're the ones that are out there living in moldy, damp homes that have the potential to having a severe wheeze attack, that don't have the medicines because they weren't unwell in between.
Abigail:And we quite often see that with kids, particularly the young preschool wheezes. We call them um. They can be completely well, apart from when they get a viral infection or a trigger um. But as opposed to asthma, where you quite often see symptoms with other things like exercise. So they're the ones that worry me the most, because they're the ones that potentially will have a severe asthma attack or a severe wheeze attack, won't have the medication at home or won't have the understanding about it to seek help early enough. And actually what we need to do is flip, I think, asthma and wheeze care on its head and say this is not about treating you once you've got established wheezing and asthma. It's about finding you before you get there, giving you some education about how to avoid things that might set you off and giving you the education on how to treat it with medication early, because then you're less likely to have a severe attack while I have you, I just want to borrow your attention for a minute to tell you about Errico, a partner of this podcast.
Simon:In fact, I worked for Errico for over 12 years, so I can speak with some authority here. With over 40 years of expertise, errico has undoubtedly established itself as a market leader in DCV technology, that's, demand controlled ventilation. Their mechanical extract systems dynamically adjust airflow rates based on real-time needs, and their MVHR systems further enhance energy savings by recovering heat while delivering fresh, filtered air, both creating comfortable and sustainable environments. Their advanced solutions are tailored for residential, commercial and educational settings, ensuring optimal indoor air quality and energy efficiency. As part of the ALDIS group and based in Paris, france. As part of the Aldis Group and based in Paris, france, errico continues to innovate and set benchmarks for the industry. Their solutions seamlessly integrate into buildings, providing intelligent, efficient and reliable ventilation tailored to the unique demands of each space. With a global footprint, errico, as part of the aldis group, are a powerful partner in securing good indoor environments and are well worth checking out. Links are in the show notes, at air quality mattersnet and, of course, at erico spelt a, e, r e, c o dot, co dot, uk. That's recocouk. Now back to the show, yeah, and like a lot of things with air quality, it keeps bad company.
Simon:So you know, if your body's having a reaction to something in your environment that's getting to the point where your body is wheezing as a result, whether that's because you've got a trigger and the same thing isn't causing a reaction, another you perhaps are the canary in the coal mine that there's an environmental condition in that space that you may actually get away with it through childhood.
Simon:But what foundations are you laying down in your body for long-term health and well-being? You know things like exposure to carcinogens, things endocrine instructor, disrupt, you name it. This grand chemical experiment we all seem to be exposed to. It's a symptom of, often of an environment that's causing a reaction. That should be a red flag that the environment should be considered because that environment is unlikely to change. For many people their environment is their environment for the majority of their lives and it should be a red flag, particularly at a child level, that perhaps this is something that should be considered Because it may never make it onto the higher levels of asthma but that might turn into cardiovascular disease or something else later on in life Because that person we didn't pick up. They were exposed to high levels of particulate matter and mold spores and VOCs because they were in poor housing, as an example.
Abigail:Yeah, and your lung function is a really good marker of that and has been used over the years in lots of studies. So your lung function is a way of seeing how much air you can breathe into your lungs and how much you can blow out, but it's a really good marker of how well your lungs are functioning. We know that your markers of lung function get gradually better until you hit about 20 21 and then it's all downhill and that's just normal aging decline at that point. So your best you get this accelerated decline increase in the numbers when you're kind of in your kind of 5 to 15 and then you hit about 20 and then it's downhill. The problem is is that if you have any impact in that period of time when it's going up so if you live in a mouldy home or you live in the centre of a city with really high pollution levels we know that you never hit what you'd expect to hit.
Simon:Oh, interesting, you kind of set a glass ceiling for your potential.
Abigail:Exactly so. Instead of hitting that level, you're much lower, which means that as you start to decline, you're going to decline further, and then, if you have ongoing exposures, you decline even further. So you're, you've got. You could have bad copd as an adult, and the only thing that you might have had was a little bit of wheezing, but it wasn't too much of an issue when you were a teenager. So actually it's, it's about being able to change. That environment has really far-reaching and long-reaching effects for everybody yeah.
Simon:So we should really be taking this a lot more seriously than we do at a systemic level. But you know, you know, I am sure parents take asthma with their kids very seriously and I imagine a lot of them are very well read by the time they get to you as well, like many of them already got hepa filter hoovers and, you know, hypoallergenic beded lillian and if they can afford. You know, like you know, and again, like we should talk about the equality here as well, I'm sure asthma, like many environmental exposures, does not affect all people equally, and is that reflected in your clinic as well?
Abigail:I mean, I work in northeast London, which is incredibly deprived in areas but also has some of the highest pollution levels, but also has some of the highest pollution levels. We know that the highest pollution areas are the ones that have the most social deprivation. Mainly a lot of it's to do with social mobility, but a lot of it is just to do with how cities work. But we also know that it's not just your deprivation levels, it's also your ethnicity as well and potentially that's to do with your genes as to how you react to what you're exposed to. But actually they all work against you. So if you're growing up in an inner city in fuel poverty, you can't heat your home, you're more likely to have asthma, you're more likely to have a moldy home, and then you walk outside and you're on an a-road and you're being exposed there as well. You've just got all these things working against you.
Simon:Yeah, your school's probably not as well funded. You know you're in more crowded class. Yeah, like it just doesn't end, does it? Yeah, that's really interesting. One thing I did pick up on what you said, which I thought was a kind of light in this very gloomy conversation so far, is that the general goal here, particularly with kids with asthma and wheezes, is for a wheeze-free life. Is that this is a treatable condition in the round? We can't remove the environmental conditions sometimes, but your target isn't just to kind of get them by with a wheeze and a limited life. This is very much a trajectory towards a completely normal life for most kids, is it?
Abigail:Yeah, we know that your risk of a severe asthma attack is much less if it's really well controlled. So what we should be aiming for in everybody is that they don't wheeze regularly. And if you are wheezing regularly, that means either we need to change medications we need to think about what you're being exposed to and give you ideas to change that or we need to give you something stronger. But we just need to work out what's best for each individual. But we need everyone to be aware of that, and the education not only of the public but also healthcare providers, is that we should be aiming for that rather than aiming for. Oh, it's okay if you take your blue inhaler a couple of times a week, Because we know that the long-term effects of that are that if you're continuing to wheeze, then you're probably getting ongoing inflammation then you're probably getting ongoing information.
Simon:Yeah, so you almost consider the need for a reactive medication as a failure in the treatment in some way or an environment that's exacerbated, that's outside of the norm.
Simon:You know like a kid that that is reacts to pet dander that goes and visits auntie and uncle so and so, that has pets and end up. That's fine, that we understand that there'll be a major trigger and then you just have to make a decision about how often you go visit auntie and uncle so and so, that has pets and end up. That's fine, that we understand that there'll be a major trigger and then you just have to make a decision about how often you go visit auntie and uncle so and so. But but in the round it's considered a uh, it should be considered a failure if the, if the blue inhaler is needed, that something's got to a point where we haven't managed this. Yeah, okay, that's interesting and that in the round is very, very possible. This isn't a losing battle. You're fighting there like, generally speaking, you can find a level at which the medication generally works and then there's always another level. You can kick it up a gear if you need to yeah, they are always going to be.
Abigail:There are always going to be patients and and children, young people that are difficult to treat in because they just react more than others. But actually, if we, if we have an end point of we're going to, this is what we're aiming for and we have a shared understanding and, with that, so a shared conversation with the patient and the family, that that's what we're aiming for and that's why you need to take this really annoying inhaler twice a day when you're 15. That's what we're aiming for and that's why you need to take this really annoying inhaler twice a day when you're 15. That's why we're doing this. We're doing this because we know that it will stop you from having an asthma attack yeah it's, and it's that it's that kind of shared decision making and patient-led treatment as well.
Abigail:It it's really about giving everybody the autonomy to be able to make decisions but understand why they need to take the treatment.
Simon:At the end of the day, and in the UK, what's the kind of state of continuity of care for patients in that environment? There's a kind of understanding that certain sectors within the health service seem to be able to really manage certain conditions really well. Others struggle because of funding or the complexity or and potential to build relationships with people in clinics. Or is it bare thread really struggling? You know we're losing skill sets. What's the kind of state of play?
Abigail:We have really good access to all the supportive stuff that we need for asthma care in this country.
Abigail:We've got trained clinicians, we've got trained allied health professionals that work at all levels of healthcare and there's really good kind of education.
Abigail:Trying to maintain education for clinicians and health professionals tier training for asthma that you can have depending on what level of asthma you're treating. So if you're treating difficult asthma in tertiary care pediatrics, like I do, you have to have the highest tier. If you're seeing them in a pharmacist, just in a pharmacy, just to provide the inhalers, you have also have training there and actually you can use those tier training levels to train up other people that aren't just clinicians or aren't just health care professionals. So there is a really wonderful project in the West Midlands where, as part of a wider piece of work around kids and asthma in homes, they have trained up the repair engineers that go in to address mould and damp. They've given them like the basic asthma training because then when they go into a home and they see a four-year-old with lots of inhalers on the side and they're going in to fix some Mould and Damp, they can potentially refer that patient back into healthcare so that they can be seen and so that they don't get lost, and that's wonderful.
Simon:And under things like Howard's Law, obviously that's going to red flag as a vulnerable patient or vulnerable tenant, which means there'll be a different reaction than if they're walking in as a fit and robust 14 year old kind of floating around, and I think that's that's really key.
Abigail:It's about realizing that asthma and wheezing in particular are not necessarily a they're not your high level need to be seen by super specialists all the time. They are managed primarily in primary care. Um, we don't see very many of them in the hospital compared to the amount that's out there.
Simon:Um, so actually it's about there being a global awareness of it and and that will also help with care as well one of the things I'll do after the podcast, by the way, abby, is I'll get some links from you and we'll share them in the podcast notes for people as to some good resources, because there are some fabulous resources, you know, touch wood, nobody in my family has asthma so I haven't needed to access those for a long time, but I know they're there. There's some really really good ones. We've mentioned air quality a couple of times in this conversation so far. Air quality is a broad church. Obviously we're talking about particulates and chemicals and all sorts of things. Is air quality one of the key pillars? Is it in the driver of certainly reactive reactions to asthma? That's a real focus of asthma. Is it air quality?
Abigail:Absolutely, and particularly asthma for children and young people. So there's some really good evidence out there about those different bits of the asthma story that I've talked about and how air quality plays into it. So, like you said, mothers being exposed, that has an end effect on the baby that's growing at the time, probably on their lung function, but also on their immune system there. When you're smaller, if you're exposed, then potentially that's triggering that change in your immune system. When you're older, it's the one that's triggering your asthma attack and it's altering your lung function. It also alters your response to infections as well. So it makes you more likely to get viral and bacterial infections and we've seen that on lots of things.
Simon:Yeah, just on that one before we move on. I assume you know if you've got inflamed lungs they are much more open to absorbing other things you might not want as well.
Abigail:Like any inflammation, bugs are more likely to stick on the airway, so they're more likely to spend more time there, or you're more likely to have more mucus around, so there's more likely for there just to be that extra level of exposure to things yeah, so you're more likely to see infections, so that's another impact that it has on it.
Abigail:Um, so air quality has an impact across the whole of kind of the way that asthma works. Um, there was a report that came out towards the end of last year which is the National Child Mortality Database Report, the NCMD, and that looks at all child deaths and looks at kind of themes around how they occurred, how they happened and they did the report that came out around asthma and anaphylaxis deaths and they delved into all of the reports and within paediatrics we see a lot less people dying than they enough before they're 18, thankfully. So that means that the processes around children dying mean that we spend a lot of time trying to work out what happened, because it shouldn't happen, and with asthma deaths in particular, there's been a lot of effort spent to go in and examine what happened in each of those deaths and what this report brought together. And what the data brought together was that actually a large number of those children that had died from asphalt anaphylaxis had been exposed to either poor housing conditions or significant levels of outdoor air pollution.
Simon:Yeah, and this is the point, we should probably make reference to Ella and the Ella Roberts Foundation, well known in this part of the world of the young girl who died at the age of seven. Actually, wasn't she at the time as a?
Abigail:as a direct result of exposure to air pollution yeah, in and around her home. And she remains the only person in the world that has got air pollution on their death certificate, and that's I attribute to her mother for fighting for that. And I think it often contorts the story around pollution confusing, contributing to deaths, because well, if it's not on everybody's death certificate then it can't possibly have caused that. But actually that's because the death certificate is written normally very soon after someone dies, so you can't to be able to examine it, unless what we were to do and what there are projects potentially looking at is actually, can we code everybody that's got poor air quality on the medical records? So can I? I mean a lot of the patients that come through my clinic.
Abigail:There's a note in their problem list that says exposed to poor air quality or bad pollution levels at home or mould and damp in the home. Bad pollution levels at home or mould and dampen the home. But actually we should be. If we were better at recording this and looking at it then we would have more data that would support that. But there's enough data out there the RCP report that was released last week. The updated report estimated 30,000 deaths per year attributable to yeah, and is that acute?
Simon:and there's always the death is always acute. It's a really bad way of saying it, but is that deaths as a direct result to air pollution or chronic impacts over a lifetime copd?
Abigail:it's a combination of the two things. So it's um. There are very few where you're going to say actually it was a, it was a pollution event, like we have every sore thumb with a sandstorm, um, and that directly caused it. But actually the majority it will be that they've been exposed over a chronic period of time and that their copd is probably due to where they've lived for the whole of their life and anybody that thinks those pollution events don't happen.
Simon:A lot of the air laws that we have are as a result of pollution events that happened decades and even centuries ago. That did cause many, many, many deaths, you know. So a pollution event wildfire smoke is one of the big ones we're dealing with globally at the moment. You know, joseph allen and the big group from harvard and others are doing a lot of work from the california wildfires and there's an enormous amount of air pollution involved with wildfire smoke, both during the event and afterwards that we're only really just starting to learn about, um and like. So these things do happen. You know it's not just a city, small china, india problem. You know this is a. These things are happening all over the world. But that kind of chronic exposure to city, urban pollution, poor housing, that kind of thing this is an air quality problem.
Abigail:And it's one that you don't necessarily see. You certainly don't smell it at the time, you definitely don't see it at the time, but you see it later on and you see the health effects later. See it later on and you see the health effects later. Um, and that's why sometimes it's difficult to put two and two together and say that this is, these things are related to pollution, because you have to have that period of time for it to develop. Problem is by the time those changes have developed.
Simon:Backtracking from that is too difficult yeah, and it's a complex, you know. Is it a home? Is it the home? Is it the trip to school? Is it the classroom? Is it the classroom's exposure? You know there's a lot to it, but the reality is somewhere in there. The combined exposure is causing it. Is there something specific about air quality or lack of it? That is the exacerbator. What's causing the issues? Is it particulate matter? Is it nitrogen dioxide, sulfur dioxide, the classic car pollution type pollutants, industrial pollutants? Is it chemicals and VOCs, bioaerosols? There's a lot to air, isn't there? Are you seeing things popping up as the primary markers?
Abigail:See, the problem with it all is how do you measure how much someone's been exposed to, because then you can measure the health effect from it.
Abigail:So there is lots of good evidence across lots of studies around kind of two ends of the story. So you can do a lab study where you're taking cells from the body, potentially, and you're growing in the lab and you're exposing them to things and you see what happens to them and you can see the immune changes there. There's really good evidence there. You've got another big body of evidence, which is your epidemiological studies. So they're big cohort studies. They're the ones where you've got 30,000 people. They all had they lived in an area that was this polluted and this many have got pollution, this many have got asthma and this many don't. And if you're in this polluted area it's higher and lower. So you can see, and that's normally around particulate matter and nitrogen dioxide exposure, mainly because they are the main things we started to measure to start with. But there's definitely an emerging story around ozone as well and the impacts of ozone exposure.
Simon:Yeah, we'll come back on to ozone, because I know that's an interesting one, but this street light effect that I love talking about in academia that this is where we're looking because this is where we can see effect. So, like you say, a lot of the evidence points to particular matter and nitrogen dioxide and those kind of pollutants, because we've been measuring ambient air pollution and we have those markers Measuring indoor ozone or VOCs.
Abigail:good luck that data set isn't there, so we just don't know, I guess really no, and the other issue is that that all of what we're measuring is what's around us and what's outside and we're theorizing around how much we're breathing in. We're going to say, well, if you're, we know that you've got this condition and you're breathing air that has this much in it. Therefore, this is causing this, the ability to check how much of it you're exposed to. It's getting better so you can do personal mortgaging. That's great. You're still not necessarily seeing how much is making it inside the body.
Abigail:There are tests that you can do, and we've done over the years and Jonathan Greek's body of work around black carbon in macrophages, so the airway cells, and that's great because that shows you like an internal dose of how much black stuff you've been breathing in, and that's carbon more than anything. And there is a merging work where you've seen those particles go all the way through a pregnant mother to the placenta as well. So those particles are everywhere. So we know that you're breathing that in. So that's great because that gives you a marker of how much an individual has been exposed to and that gives you more that fills in that gap between the lab studies and the epidemiological studies. It gives you that real life exposure.
Simon:But interestingly, even something like particulate matter. Particles aren't just one thing. They're a collection of heavy metals and chemicals and bio, all sorts of stuff. So we know that fine particulate matter is getting in, is multisystemic. There isn't an organ in the body that potentially it can't cross and have an impact on, including a child. The challenge is that it's fine knowing which of that composite part and that's just particulate matter. Then you've got the gases and then you've got the chemicals, the VOCs and the bioaerosols as well. So it's a complex mix.
Abigail:And I think it's important to have a focus on trying to decide which bit is the bad bit, but you can never tease it out completely. But I also think there should be a focus on the fact that, yes, we have government and EU and WHO levels and I would like it if we move towards the who levels, um and limits. But there is no safe level and we know that from the studies. So even in areas which have really low pollution exposure, well below who levels, there's still health effects from that. You're still being exposed to it. So there needs to be an understanding that actually we should just be aiming to reduce all of these things as far as we can.
Simon:Yeah, and you know, I think, interestingly, within the built environment, which is the area this podcast tends to focus on, there are only so many levers we can pull in a building anyway anyway. So so often, as as complex as this subject matter is, ultimately what we're talking about is damp and mold-free homes that are well ventilated, that don't have too many off-gassing materials in them, and we elect, we're electrifying the built environment and removing combustion appliances as we go. Like it's just the basics. Really, this stuff isn't rocket science. That the, the air, chemistry and the biology is science, rocket rocket science. And it is hard, no doubt about it.
Simon:But actually the fundamental levers that we have at our disposal as engineers, as people managing homes is limited. It's not actually that complicated, and sometimes it is about just doing the basics, and sometimes it is about just doing the basics. The trouble is having agency over that. There are certain things we can control and we're lucky enough, if we own our own home and have the funds to do that, to be able to affect a better outcome. Because, as you say, there is no safe level of particulate matter pollution, but there's also no risk-free world. So we live in this reality and we've just got to give people as many choices as we can possibly give them and the agency to do something about it yeah, and I think it's about where we there's lots of um education, advice that's given around reducing your individual exposures and things like that.
Abigail:We know that lots of them do reduce your exposure. Um, and there are certain key things that are really important, which is around particularly ventilation, um heating and making sure the heat is the right one, and I've learned lots, considering I'm a lung doctor. I've learned lots over the last couple of years around housing, um ventilation dynamics and heat bridges and things like that and how that affects all these things. Um, but it's about giving the person living within a home, regardless of whether they own it or they rent it or it's provided to them the agency to be able to make that choice for themselves. But we can support by suggesting that we don't put gas in buildings anymore, and that's important, the heat we note but also by teaching people that actually, if you burn toast in your toaster or you burn candles, that's equally not great for you. So we have to be able to give everybody that education, but work out a way that works for people as well yeah, no, totally.
Simon:How did you end up doing this? How did you end up focusing on pediatric asthma and lung disease? It's quite specialist, like yeah, is it just purely back? So you kind of fell down this rabbit hole at some point, or was it by design?
Abigail:I'm a little bit by design, a bit down a rabbit hole. I'm so I I went to medical school and then I'm always had a focus on pediatrics. That's what I was going to do, so I went straight in. As soon as I could, I went into pediatric training. A couple of years into that I um had the opportunity to a PhD um, and I did that with um Prof Jonathan Grigg at um, queen Mary's um, and that was looking at pollution exposure of healthy kids in London um, and in particular I looked at sputum.
Abigail:So a lot of spit and for three years um and at that point realized that actually asthma and wheezing and respiratory conditions was my clinical focus, but but that I particularly found that that academic side of things, that ability to move research into clinical practice, was a key thing that I wanted to do um. And then I went on and was lucky to get some more funding to do some um, some more research towards the end of my peds training and then um, and then I got my post at the university which was designed to support environmental health research, um, and continue to look at that and as part of that, towards the end um, we've applied for the funding for um, the environmental health clinic, because it was quite clear that we needed to find ways to look at these things in more detail and bring all those fancy bits and pieces that we do in the research researcher um into the clinic because that's where it needs to be done. And so pollution exposure and things like that. I hadn't quite twigged that I would then turn into somebody who talked about housing and looked at housing exposures. But it's obvious because I do clinics every week and we talk about more than damp, because we know that that causes issues.
Abigail:But I think I'm the the ability to affect change in this space from a clinician's point of view is quite difficult, because you feel quite um, it's quite difficult to do anything. So you've got all these patients coming to you. If you're not academically, you're not doing research. All these patients are coming, they're telling you what their housing's like and you're like, oh okay, well, I can write you a letter that says that you've got a condition that um is made worse by your housing. I wonder where that letter goes. And most of us know that those letters don't break up to the right place. And I learned quite late on a really sad fact about the awab case in Rochdale that one of the healthcare professionals involved in his care had written a letter that ended up on the wrong person's desk about two weeks before he died, and that kind of.
Simon:That stuff haunts you.
Abigail:Yeah, that galvanises me to go. Actually, you know, we need to work out a different way to do this, which is why I now have conversations with housing providers and the council and really innovative providers of different businesses that are all trying to turn this on its head, so that we can stop things like that happening, but also that we could just improve health generally. It's one of the NHS's priorities now and I really really feel strongly about it is that this is about prevention rather than treatment. It's great that we can make all these medicines and they're really exciting and they will treat everything and we will get there and we will find a treatment for most things, but actually it'd be really nice if we didn't have to treat people with medicines and that we could do something to start with to stop them being exposed, and so I suppose that kind of drives me now so you've kind of got two hats then primarily a clinical hat, that, and then your research, research and teaching.
Simon:You do some teaching as well as well.
Abigail:Yeah, a small amount of teaching, um, so yeah, so half of my time is NHS and I work in North East London as a respiratory consultant and primarily children with asthma and wheezing but also other respiratory conditions. And then my other hat is my academic side, which is leading on kind of environmental health research around children's exposures. We've got some really exciting stuff around playground exposures and we've got some really exciting stuff around playground exposures and lung function that we're doing at the moment, um and then kind of. But my real focus is in how we change things and how we co-design change. So how can we go back to these patients and say, actually, what do you want? What can we do? How can we help?
Simon:yeah, that kind of not citizen science, but that. Yeah, like you say, that code design is kind of yeah kids are amazing for citizen science yeah, aren't they?
Abigail:just for my phd. We were doing um. We'd go out and do sampling in the schools and run a workshop alongside it. And we ended up going back a couple of years later to a couple of the schools and it was wonderful because they were like they told me all the stuff that I taught them two years ago and I'm like, oh, please, let me do. But they also, the schools, used that at the time. We're talking 10 years ago. Now the schools use that as a body of work. So we did a workshop and they then did several weeks of stuff around environment and so that kind of change just in that it's really exciting yeah, we've seen that with things like the Sammy project, you know the the the clean air in schools project, with the citizen science.
Abigail:The engagement of children is just kids are far better teachers than the rest of us?
Simon:yeah, no, totally. And you mentioned the um, the environmental health clear. That sounds great. So that's a practical manifestation of this kind of crossing the divides, of kind of research, clinical practice and, yeah, kind of coalface absolutely um.
Abigail:so it's. It's a funded service, um, designed to sit within the clinical service, and it's been funded by bars charity, which is one of our charitable um grant giving um uh groups that's associated with the hospital um, and they funded it as a health care innovation. So you know, saying that this is something that needs to happen, but isn't necessarily something that's already funded by the NHS, and that it's designed to do those things that we've always talked about, or you've had to be in a research study to have so personal monitoring, or going into people's homes to have a look at and comparing all those things and actually going. You know, what are we going to do with this information? Well, we'll give it back to you and you can make change. And that's kind of the next step.
Abigail:Where, at the moment, is the first round of pollution monitoring? And then we'll go back and we'll go actually look, this is where you've been exposed, this is what you could do about it, and that runs alongside the children coming to their clinic for aspirin wheezing. We expected it to be around outdoor pollution and outdoor exposures and things like that, because we've done work about reducing that, but actually a lot of it now is looking at actually, how much information can we get about the inside of the home? Because what can we change?
Simon:there is, that is that a defined project over a certain period of time. Is it a kind of a never-ending thing? Is it?
Abigail:I'm hoping it's never ending, no sure yeah um, so it was.
Abigail:Um, it's been funded for three years. We were extended into next year now, so we've got about 12 months left. Um, but um, there is a really exciting report coming out tomorrow from the royal college of pediatrics and child health that looked at our clinic and also another clinic up in liverpool by um ian sinner. Um, which again is kind of badged as a clean air clinic, so it's around those exposures and we're the only two clinics in the country that look at the wider exposures as a defined clinic.
Simon:And have you been able to show impact from this yet? Is it something that there's some models that could be replicated and patterned elsewhere that that show a return on like extra effort?
Abigail:so we know. We know that if you give, we know that there's evidence, if we're educating around pollution exposures, that actually they can change things, and lots of research ideas have shown that, and we've we've done some small pilot work before this that looked at black carbon and that you could change that based on it. This is we're at the point now where we're looking at the outputs in terms of this is what we'd like to do elsewhere, and there's lots of. This is not something that could easily be replicated elsewhere, because of the time spent analysing the data from the pollution monitoring particular, but there is scope that this could be something that works on a wider scale, but with slight differences. I mean, one of the simplest things that we add into clinic is a questionnaire that asks about cooking and candles and exposure to roads, and it just gives you that structured tick list or check boxes of things that you can then have a conversation with about with your patients.
Simon:yeah, I don't know expensive it would be to send every child home from an asthma clinic. Certainly the point. They get to you with a air quality monitor to stick in their home and feed data back to the clinician about the exposure.
Abigail:You know I mean that would be really lovely, and there's definitely the. The technology has changed so much over time as well. We've gone from you know um, so black carbon monitors that we used to use um, which were very simplistic but also very technologically advanced and gold standard at time to and really expensive it's several thousand pounds to using um.
Abigail:So we use Atmo tubes in the clinic which give you PM nitrogen dioxide. They give you humidity, they give you temperature, they give you CO2. They give you really good quality data and you've got more than one way of using them. We use them in that we give them out and we analyse the data from them. You can just buy one and have a phone that's connected to it and it tells you what's there yeah, and it's not that you necessarily need to be an expert on air quality to understand that.
Simon:You know there's there's delicacy and nuance in some data around air quality, but sometimes it's just smack in your face this bedroom's at 4 000 parts per million overnight that it's just not well ventilated or this building is just horrendously humid, or you know there are certain environments that you don't need a PhD in air quality to figure out. There's a problem.
Abigail:It's actually about having the conversation and having the time to have that conversation as well, and I think that you know all of the kind of guidance that comes out says we should be talking about this and educating people on pollution. You need to be able to see it. You need to be able to grasp something that shows you what it is. You can't just say, well, you live on a main road and this and your home isn't well ventilated, but you're then telling them that they live on a main road. Then they can't open the window because the outdoor pollution will come in and they can't heat their home because they don't have enough money. So which one do you choose?
Abigail:yeah how do you decide what to do how? How do you weigh that up?
Simon:um, but you don't get to have that conversation unless you, because you can't see the air and people aren't you, so that awareness isn't there, that conversation often doesn't happen. Imagine the questionnaires are very powerful, actually, even just.
Abigail:That, honestly, has given us more that's more visual data than the pollution monitoring. I could tell you what your pollution monitoring is probably going to show you. Just by looking at the home and looking at the road that you live on and where you go to school, you can see where the peaks are going to be Is that questionnaire publicly available.
Simon:It would be an interesting set of questions from an awareness perspective.
Abigail:So we use and it's a variation on um ones that have been used for research studies before. It's not uh where people have. We've shared it but it's not publicly available. But I'm more than happy for people to have a look at it yeah, I might try and produce a um with your permission.
Simon:A one page or something just kind of says these are the kind of questions that you get asked that you might want to consider yourself in your own environment might be an interesting thing. I think those questions can be very powerful and at the end of the day I get, at the end of the day, some of this stuff isn't rocket science. You know, if you've got prolific levels of damp and mold in your home, there's a good chance you've got a problem like. So sometimes stuff is obvious your home. There's a good chance you've got a problem, so sometimes stuff is obvious. It doesn't have to be, you know. It's just a question of being asked sometimes, isn't it?
Abigail:One of the things particularly over the last year, but over the last few years that I've been more and more involved in is that interaction with the housing sector and the amount of data that can potentially be there and be used is really interesting, um, and for the benefit of the people that are living within the social housing sector.
Abigail:Actually, you know what? What benefit? And it has benefit for everybody, because if you can demonstrate that you're picking up homes that are moldy and damp, that either the residents don't want to report it because lots of reasons, um, one being being worried about being kicked out if they've come from private rental before, um, or that they want to fix it themselves. Because that's what you want to do you want to make sure your home's as clean and tidy as possible, and but actually, if the landlords know, or the providers know, that there's some mold and down there, they can go and treat it earlier and then it doesn't get as bad as some of the pictures that I see. And I think that we're a really unique point where actually, by having all these insights brought together, we can do some real good yeah, and those insights, like you say, are often there.
Simon:I was involved, um a few years ago now, in a project called the Thamesmead Condensation, damp and Mould Project and the early phases of that project was a risk assessment that was carried out on this area of Thamesmead. So for people that don't know Thamesmead, it's where they filmed the clockwork orange, so it's a very uh, it's a very fuel poor area, mass concrete, high-rise tenement type buildings that used to be district heated but now privately heated and, as such, many of them are in a poor state. Um, and at the time they did a survey and they they had a very simple matrix in the end and it was the epc of the building, the occupancy level of the building, the vulnerability of the occupants, whether there'd ever been any complaints of damp and mold previously and whether the the the house was on the financial support list for the, for the housing organization, and they set up a weighted scoring system and those houses that were high risk for a combination of those factors. A hundred percent of the time when they went and visited those homes, they found damp and mold, so like sometimes. All the data you need is there because, at the end of the day.
Simon:If a home is fuel poor, it's poor energy performance. They've complained of damp and mold before and it's highly occupied. There's a pretty good chance when you go and visit it it's going to still be the same right? So sometimes this the all the information is there. We just need to care to look and hopefully ab's law and the effort that you've seen from. We're at the housing conference this week and you know there's a lot of stands. There's a lot of attention on damp and mould rightly so. We've got the law coming out soon here in the UK around Arabs law. It is a unique time, isn't it?
Abigail:I think so, and I think at the housing conference today, the panel that I was on was around co-designing and co-creating solutions for um residents. Um, which is not something I would ever expect to to have been sitting on as a panel member, but actually it was really interesting because it's a lot of. It's very similar to the work that we try and do from a research perspective in terms of not doing things to people but doing them, doing things for people and with them, with their support, to create them. So one of the projects and we're looking at the moment from my perspective is how do I give that, this kind of mitigation advice to people that come to the clinic? But I know what I want to say, but actually they have a very different view of what they want to hear and how they want to hear it and also who's the right person to have some of these conversations.
Abigail:So the benefit of things like community champions and link workers and social prescribers and bringing back your village almost around you, because one of the things if you're in social housing is there's the potential that you've been a moved around lots of temporary accommodation, you're far from your family and your friends, you've been moved to somewhere that you don't know and you don't have that support. And one of the interesting parts of the clinic is that the home visits that are done, the places that some of these houses are in that my students going out to look at, are really interesting and really quite worrying. And you're bringing up families and children in these environments. How do you bring back a sense of community within that? And I think that's really key as well.
Simon:Yeah, no, that's really key as well. Yeah, no, that's very true, abby, look, it's been brilliant talking to you this afternoon. I really appreciate you taking time out from the conference. You know travelled all the way up from London to Manchester. Today you were very kind to sit down and talk to me. It's been a fascinating conversation about asthma. I don't think we've spent enough time talking about it, so hopefully it's been useful for people to hear a little bit more detail about it. So thanks a million, really appreciate it.
Abigail:Abby, thank you very much for talking.
Simon:Thanks for listening. Hold on a minute Before you go and shoot off or onto the next podcast. Can I just grab your attention for one minute? If you enjoyed this episode and know someone else you think might be interested in this subject or you think should hear the conversation? You think might be interested in this subject or you think should hear the conversation, please do share it and let's keep building this amazing community. And this podcast would not be possible without the sponsors Ako, errico, ultra, protect, imbiote, 21 Degrees, farmwood and Eurovent. They're not here by accident. They care deeply about the subject too, and your support of them helps them support this show and keep it on the road. Please do check them out in the links under their qualitymattersnet. Also check out the show on YouTube with video versions of the podcast and more. See you next week.
