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\begin{document}

\title{Outdoor air pollution and near fatal/fatal asthma attacks in children. A
systematic review.}



\author[1]{Deepa Varghese}%
\author[2]{Kathryn Ferris}%
\author[2]{Bohee Lee}%
\author[3]{Jonathan Grigg}%
\author[2]{Hillary Pinnock}%
\author[1]{Steve Cunningham}%
\affil[1]{The University of Edinburgh}%
\affil[2]{Asthma UK Centre for Applied Research}%
\affil[3]{Queen Mary University of London Blizard Institute}%


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  \date{May 24, 2024}


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\begin{abstract}
\textbf{Background}: Globally, observational studies have demonstrated
an association between high levels of air pollution and asthma attacks
in children. It remains unclear whether and to what extent exposure may
be associated with increased near fatal and fatal attacks.
\textbf{Objective}: To systematically review the evidence for an
association between ambient outdoor air pollution and fatal and/or near
fatal asthma (NFA). \textbf{Methods}: Following Cochrane methodology, we
searched MEDLINE, EMBASE, Web of Science, Scopus and Open Grey
electronic databases for studies reporting the association of fatal/NFA
and air pollution (Particulate Matter (PM), sulphur dioxide, nitrogen
dioxide, black carbon and ozone) in children. NFA was defined as
requiring intensive care (ICU) management. \textbf{Results}: Two
reviewers independently screened 1,358 papers. 276 studies identified
asthma attacks related to air pollution, 272 did not meet inclusion
criteria after full text review. Four observational studies described
fatal/NFA, of which 3 addressed NFA. PM2.5 and ozone (22ppb) were
associated with NFA in one study (RR 1.26 CI (1.10-1.44)). PM10 was
associated with ICU admission in the context of thunderstorm asthma.
Elemental carbon was associated equally with NFA that did not require an
ICU admission (p=0.67). Studies of fatal asthma including children did
not demarcate age within analysis. \textbf{Conclusions}: Ozone and PM2.5
have been associated with NFA in children but synthesis is limited by
the paucity of studies and methodological heterogeneity. Poor reporting
of severities of asthma attack does not enable assessment of whether
outdoor air pollution is associated with an increased number of NFA and
fatal attacks in children.%
\end{abstract}%



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