Air Quality, Breathing, and Health

I grew up with pretty bad asthma. This might surprise those of you who know me, since you’ve seen me breathe and I’m not half bad at it. I was one of the lucky people that grew out of my asthma, but not before it subjected me to a life of writing “current medications: Albuterol (as necessary)” on every single patient intake form. 

I’ve been thinking more about lung health, air quality, and breathing recently. A few trends seem to be converging that make me think we might see some changes in the space. Here’s a semi-structured brain dump of thoughts; apologies cause it’s a bit rough.

Climate Change + Outdoor Air

When I was younger and I would travel to India - getting off the plane would almost immediately set off an asthmatic flare. The particulates and smog in the air would immediately start burning my lungs while the food and my hubris would start burning the rest.

Today in the US, wildfire season on the West Coast has now thrown the US into a similar phenomenon. The other day I felt a light version of that lung sensation, and only later discovered that New York’s air quality that day had tanked due to the aftereffects of the West Coast fires. It’s sort of surreal to see AQI (Air Quality Index) now included in the Apple Weather App and it’s something I actually check.

Because of the rapid and visible decline in air quality, we’re starting to see a slew of research coming out on different air quality <> health effects related to the wildfire that builds on a lot of research about the effect of pollution as well. 

• Wildfire smoke exposure during pregnancy increases preterm birth risk, Stanford study finds
• Excess of COVID-19 cases and deaths due to fine particulate matter exposure during the 2020 wildfires in the United States
• Fine Particles in Wildfire Smoke and Pediatric Respiratory Health in California (guess what, turns out it’s not good lol)

This seems to be getting worse. It’s worth thinking about how healthcare might respond to this. 

For one, it seems inevitable that we’ll see more large-scale trials that can be done today that capture data passively and take environmental data into account. Pre-smartphones, these types of studies would be done with participants remembering how they felt, when they had flares, what the weather was like, etc. Today, we can capture this passively with environmental sensors + smart inhalers to get more specific and real-time. This study used Propeller Health’s smart inhaler in Louisville Kentucky and looked for hotspots where people tended to use their inhalers.

My hope is we’ll see similar studies that examine similar hotspots across the areas thanks to the proliferation of these sensors + people’s desire to understand how the very visible air quality decrease around them is affecting them (which should increase enrollment?). Companies like Aclima for instance are working with Google to put tons of hyperlocal sensors to understand AQI changes - showing us things like how AQI gets much better at night for example.

Hopefully this kind of granular data can tell us different subgroups of patients which are at-risk for different triggers (pollution, allergens, etc.) and help them avoid them during peak times or specific areas. It could also inform local governments about hotspots and ways to potentially mitigate the issues. The Propeller study suggested planting trees in certain areas and rerouting truck routes to prevent concentrated diesel emissions. Airly just raised to build these hyperlocal pollution maps while Purple Air and AirNow have been doing it for a bit. BreezoMeter (the company powering Apple’s weather app) even have an entire page for their digital health offering. 

But just because we can track this doesn’t mean anyone is going to do anything. As with anything in healthcare, money talks. It’s possible that this coincides with some evolution on the reimbursement side. 

The first is emerging geographic based reimbursement models for care. Specifically, we can watch the Geographic Direct Contracting Model (though it’s paused right now and might honestly just get killed completely). Conceptually, it would put providers on the hook to manage the care of Medicare beneficiaries in a given region. If providers in this program were at-risk geographically, they’d be more incentivized to care about air quality hot spots in their area that might increase the chance of things like COPD related flares. Even absent of geography, any Medicare focused primary care clinic that’s at-risk for the total cost of care of a patient would want to inform them if the air quality is going to be an issue.

Another development is Medicaid expansion and specifically the push to bring more Medicaid births into some value-based care program. Medicaid covers ~43% of all births in the US and yet the outcomes are terrible (7.4 deaths per 1000 live births in Medicaid vs. 4.3 in private insurance). Improving this is a focal point for the current administration and I would guess you see increased quality payments for Medicaid plans that can improve this + experimentation at the state level in terms of what Medicaid can cover to improve this. Medicaid births are a particularly good testing ground because the feedback loop between intervention and outcome is short, pretty measurable, and expensive. As the evidence between air quality and pregnancy issues grows, we could see plans spend more time trying to help at-risk patients manage their exposure to poor AQI environments. 

That being said, I don’t expect the private sector to invest a ton in these air quality issues. They might become more vocal about specific local hotspot issues and work with companies to alert patients during especially bad times. This problem feels too large for any single company to tackle and it’s really the job of the state/government, especially since they end up footing most of the bill for longer term health costs.

Indoor Air Quality

If outdoor air exposure is something to be concerned about, wouldn’t it make sense that indoor air quality is even more important since we spend so much more time there? Consider asbestos - one of the more notable indoor air quality related diseases. An extremely commonly used material, it was linked to lung issues due to exposure in 1924, and cancer in the 1940s/50s, but only saw significant restrictions in the 1980s followed by mesothelioma incidence falling as well. This led to lots of mesothelioma lawsuit-related commercials from lawyers.

Now COVID has put the spotlight on how disease spreads in the air of rooms that we’re in.

With COVID and wildfires happening, we have an interesting natural experiment being set up. 

• Everyone is staying home much longer than usual
• Offices and commercial buildings are spending a lot of focus on air quality/air circulation to mitigate COVID spread risk
• A large number of people are monitoring the air quality in their homes/purifying it

The relationship between indoor air quality and health is seemingly way less studied than outdoor air quality. This New Yorker piece suggests that in intense cooking sessions indoors, we actually see higher fine-particulate concentrations in the air compared to the most polluted cities. This is why I like to sous-vide everything - I can claim moral superiority from a culinary and health perspective simultaneously. I’ve never sat on a horse so high in my life. 

With a focus on indoor health currently + more sensors + decentralized trials we’ll hopefully learn more about the impact on indoor air quality vs. health. For example - a common trope for people with asthma has been that indoor dust, mites, etc. cause flares. But thanks to the PREPARE at-home asthma study that’s been going on since 2018, we might have discovered that this is less of a risk than we thought as the team tried to discover why pediatric ICU cases for asthma went down during COVID. 

“The answer became clear as the monthly questionnaires started rolling in. The number of attacks the participants suffered at home really was dropping. It fell by 40 percent after the onset of the pandemic. “We know that this isn’t reluctance to go to the emergency room,” Israel said. “This is a true, real decrease.”

In that case, why? Israel and his team didn’t see a clear pattern connected to changes in air pollution. People who normally worked outside the home, however, had bigger decreases in asthma attacks than those who worked at home (65 percent compared with 23 percent), perhaps because they were no longer being exposed to viruses and irritants at work. And people whose type of asthma is driven by environmental triggers also saw bigger improvements than those whose asthma is driven more by underlying inflammation. All of this suggests that people really were able to avoid triggers during the pandemic.

Ordinary respiratory viruses may play a bigger role in asthma attacks than previously thought, Israel said.”

What else will we learn from prolonged indoor air exposure while outdoor variables are avoided? With more sensors in people’s homes, I’m hoping we learn more about that effect longitudinally. 

As we learn more we might see more payer interest - already Medicare Advantage plans can include air purifiers/humidifiers in their supplemental benefits (though I have yet to personally see a plan that actually offers this). You can also use your FSA/HSA to buy one if you get a letter from your doctor because we live in a constant state of high school. 

Indoor air quality at home is one angle, but I wonder what this means for offices. As commercial real estate owners and businesses try to entice workers/customers to come back to the office, they’re paying much more attention to airflow and air quality. If businesses care about reducing things like the flu via flu shots at work, then it would make sense to care about ventilation and filtration at workplaces to also try and reduce spread.

I think about all of the open office startups I’ve worked at which incentivized cross pollination of ideas, bothering people if they didn’t respond to your Slack message, and the spread of disease to anyone in your immediate vicinity if you were sick. Beyond just sickness there’s also research that suggests stale air is making us sluggish and less productive, so there’s that bonus too if we’re monitoring anyway. Why am I more alert in a Vegas casino than my workplace? 

The stakes are much higher in areas with a high density of at-risk elderly people. Assisted living, nursing homes, etc. are already getting more heavily scrutinized and will probably benefit from consistent indoor air monitoring + air flow circulation. Schools are another important area since children are currently unvaccinated and the short-term/long-term effects of COVID are still relatively unknown. Everyone wants kids to get back into the classroom in a way that feels safe. 

I’ve seen some companies like SecureAire trying to attack the airborne pathogen and particle spread but frankly not a ton and have no idea what adoption actually looks like. Companies like Awair are building hardware to monitor different aspects of indoor air quality and see changes in real-time. 

Breathing As The New Wellness

Recently I read the NY Times bestseller book “Breathe”. Okay I didn’t read it, I watched the talk the author gave that gave most of the high level points (sue me, most nonfiction books should be 1/5th the length). The point the author makes is that deep breathing and  breathing through your nose is important for regulating body functions like heart rate, blood pressure, asthma, etc. 

But it’s the meta conversation around this book that’s interesting to me. A lot of my friends in different self-optimization circles (biohacking, weightlifting, general type A optimizers, etc.) have mentioned this book in the last few months. It reminds me of conversations when the Michael Pollan book “How To Change Your Mind” came out, which was very closely followed by a psychedelic mushroom boom and seemingly widespread societal acceptance of them.

After listening to the talk I actually bought some mouth tape to put on when I sleep just to test it out. It’s meant to force myself to breathe through my nose and it’s way harder than I thought. Yes I look like a kidnap victim when wearing it, yes I always suddenly remember I’m thirsty once the tape is on, and no I don’t notice any benefits yet. But let’s see if that changes over time! 

Breathwork and blood oxygenation feels like it could be the next frontier for personalized healthcare/wellness if it isn’t already. Pulse oximeters have now become more ubiquitous in many households due to COVID and many of the wearables now include optical SpO2 sensors to measure blood oxygenation. These sensors are helping better diagnose sleep apnea which has historically been underdiagnosed and causes a host of health issues. But they’re also useful for athletes trying to optimize their workouts and recovery periods since blood oxygenation fluctuates during and after workouts. Based on this patent, Whoop seems to be exploring how blood oxygenation impacts physical performance.

Beyond oxygenation, Strados created a device you stick on that listens to your lung sounds like a stethoscope, and just received FDA clearance. 

I think when you start combining these measurements with the indoor/outdoor air quality readings, you’ll start getting people that treat breathing as quantified self activity. I wonder if we’ll see a similar Levels-esque product that uses some of the sensors I mentioned to help people optimize their breathing. Apple’s Breathe app and Calm/Headspace do a version of this by guiding people through deep breathing already, but what if it was more personalized to you and measured more constantly. I see this as potentially an extension of CBT, mindfulness, etc. that could help the higher-end quantified self types but also a combination intervention for people managing chronic disease as well. Companies like Spire Health are already pitching a home device + respiratory therapists to make it easier for physicians to bill for remote patient monitoring codes to manage COPD and other chronic diseases. VitalFlo has smart Spirometers which honestly I could see myself blowing into while fidgeting during the day just to see how strong my lungs were. Never skip lung day.

Conclusion

We seem to be learning much more about air quality and health nowadays because our lung function has been thrust into the spotlight and the environments we live in are viscerally getting worse. The unfortunate reality is that this problem likely needs to be addressed through a massive public health intervention despite funding to those departments remaining anemic. COVID might be the bump needed to treat air quality as a serious public health issue. 

I’m interested in seeing more companies examining our air quality and breathing from a preventive health and wellness angle. If you see any cool projects or initiatives in this line, let me know!

Thinkboi out,

Nikhil aka. "lil' nebulizer"

Twitter: @nikillinit

IG: @outofpockethealth

Thanks to Samir Khanna, Chris Hogg, and Dean Young for reading drafts of this

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