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The Association Between Personal Air Pollution Exposures and Fractional Exhaled Nitric Oxide (FeNO): A Systematic Review

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Abstract

Purpose of Review

Airway inflammation is a common biological response to many types of environmental exposures and can lead to increased nitric oxide (NO) concentrations in exhaled breath. In recent years, several studies have evaluated airway inflammation using fractional exhaled nitric oxide (FeNO) as a biomarker of exposures to a range of air pollutants. This systematic review aims to summarize the studies that collected personal-level air pollution data to assess the air pollution–induced FeNO responses and to determine if utilizing personal-level data resulted in an improved characterization of the relationship between air pollution exposures and FeNO compared to using only ambient air pollution exposure data.

Recent Findings

Thirty-six eligible studies were identified. Overall, the studies included in this review establish that an increase in personal exposure to particulate and gaseous air pollutants can significantly increase FeNO. Nine out of the 12 studies reported statistically significant FeNO increases with increasing personal PM2.5 exposures, and up to 11.5% increase in FeNO per IQR increase in exposure has also been reported between FeNO and exposure to gas-phase pollutants, such as ozone, NO2, and benzene. Furthermore, factors such as chronic respiratory diseases, allergies, and medication use were found to be effect modifiers for air pollution–induced FeNO responses. About half of the studies that compared the effect estimates using both personal and ambient air pollution exposure methods reported that only personal exposure yielded significant associations with FeNO response.

Summary

The evidence from the reviewed studies confirms that FeNO is a sensitive biomarker for air pollutant-induced airway inflammation. Personal air pollution exposure assessment is recommended to accurately assess the air pollution–induced FeNO responses. Furthermore, comprehensive adjustments for the potential confounding factors including the personal exposures of the co-pollutants, respiratory disease status, allergy status, and usage of medications for asthma and allergies are recommended while assessing the air pollution–induced FeNO responses.

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Data Availability

Data will be available upon request.

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Acknowledgements

E. C. acknowledges the UConn Health Research Program and the UConn Office of Undergraduate Research for their support and resources. The authors thank Ms. Tony Vella for her assistance in reviewing the biological mechanisms of FeNO production.

Funding

M. L. Z. is supported by the National Institute of Environmental Health Sciences of the National Institutes of Health under award number R00ES029116.

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  1. Department of Public Health Sciences, UConn School of Medicine, UConn Health, 263 Farmington Avenue, Farmington, CT, 06030-6325, USA

    Abhay Anand, Elliana Castiglia & Misti Levy Zamora

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A.A. and M.L.Z. wrote the main manuscript text and E.C. prepared Table 1. All authors reviewed the manuscript.

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Correspondence to Misti Levy Zamora.

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Anand, A., Castiglia, E. & Zamora, M.L. The Association Between Personal Air Pollution Exposures and Fractional Exhaled Nitric Oxide (FeNO): A Systematic Review. Curr Envir Health Rpt 11, 210–224 (2024). https://doi.org/10.1007/s40572-024-00430-1

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