World Trade Center asthma

More than 40,000 individuals were exposed to particulate matter following the World Trade Center (WTC) attacks. This population has increased rates of asthma and worsening of preexisting asthma. WTC asthma is on the spectrum of disorders ranging from reactive airways dysfunction to irritant-induced asthma. It is a non-immunologic phenomenon, with direct airway epithelial damage causing release of pro-inflammatory mediators. Risk factors for development of WTC asthma relate predominantly to the magnitude of irritant exposure. Symptoms are similar to other asthma patients, with chest tightness, exertional and non-exertional dyspnea, wheezing, and cough. Spirometry is variable, and may be normal, and demonstrate obstruction, or even restriction, with or without air trapping. Chest CT with inspiratory and expiratory imaging can demonstrate air trapping and bronchial wall thickening, which may help support a diagnosis of asthma in cases where clinical symptoms are consistent. Multiple comorbidities can impact asthma presentation, including GERD and rhinosinusitis. Clinical evaluation must include a focused history and physical exam, detailed assessment of clinical symptoms, occupation, and WTC-related exposure history. Treatment is similar to non-WTC asthma and includes inhaled corticosteroid therapy with short-acting beta agonists as rescue medications. Additionally, management involves limiting irritant exposure and addressing the multiple physical and mental health comorbidities that often coexist and can decrease asthma control. Some individuals may respond well to treatment, and others have persistent and often difficult-to-control lower respiratory symptoms. Since the trajectory of lung function decline in WTC asthma over many years is not yet known, continued long-term monitoring is necessary to effectively manage this population.