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Severe asthma has been shown to occur in the combined presence of high pollen and thunderstorm conditions, also known as 'thunderstorm asthma.' First studied as severe epidemic events, recent longitudinal work studied less dramatic but more frequent occurrences. We explore thunderstorm asthma-related emergency department visits in the Minneapolis-St. Paul metropolitan area and evaluated risk differences by sex and age. We define a thunderstorm asthma exposure event as the daily occurrence of 2 or more lightning strikes during high pollen periods, and use daily counts of asthma-related emergency department visits to estimate relative and absolute risk of severe asthma during thunderstorm asthma events for the full population and for sex and age subgroups. The overall population had a 1.06 (95 % CI: 1.02, 1.09) times higher risk of asthma-related ED visits during thunderstorm asthma events compared to days without thunderstorm asthma events. Children under 18 show no higher risk (RR 1.02; 95 % CI: 0.97 1.08), but adults 18-44 years (RR 1.08; 95 % CI: 1.02, 1.13) and 45 and up (RR 1.08; 95 % CI 1.02, 1.15) show higher relative risk. Absolute risk measures show similar patterns to the age and sex results, but age-sex subgroups show more variation in absolute vs relative risk. Our results support an association between ED visits and thunderstorm asthma and provide evidence of varying risks by sex across the life course. These differences in risk have implications for clinical treatment of this allergic type of asthma and for future research into this poorly recognized environmental exposure. Plain Language Summary: Recent research has highlighted the existence of Thunderstorm asthma events, a phenomenon in which pollen grains rupture in the conditions that occur with a thunderstorm, releasing subpollen particles that are capable of triggering severe asthma in susceptible populations. Where severe asthma is a disease that usually impacts children, we find in this study that asthma ED visits associated with thunderstorm asthma events more frequently impact adults, particularly males 18-44 and females 45 and up., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Objectives: Epidemic Thunderstorm asthma (TA) is a serious public health threat with a potential to overwhelm health systems. Being the first documented incidence in Ghana, we sought to determine whether the chronic respiratory risk factors for the development of TA as identified in other countries were similar or different from that in Ghana., Study Design: A matched case-control study involving 41 cases and 82 controls was conducted in two conveniently selected health facilities in the Ashanti Region of Ghana., Methods: Data were collected from pre-existing patient records and included general demography, a history of allergies and a history of asthma. A chi-square and multiple logistic regression analysis were conducted to identify risk factors for the development of TA., Results: Overall, 53.7 % of the TA cases and 7.3 % of controls had a previous history of asthma (AOR = 4.53 p = 0.064, 95 % CI = 0.918-22.365). Also, 29.3 % of the cases and 1.2 % of the controls had a previous history of allergies (AOR = 12.48 p = 0.05, 95 % CI = 0.919-169.305)., Conclusions: A previous history of allergy was a significant risk factor for TA. A previous history of asthma though associated with TA, was not a significant risk factor for its development. The recognition and awareness of risk factors for TA, by clinicians and health managers, is essential for health education, case management and preparation for the surge capacity occasioned by the event., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2024 The Authors.)

Pollen allergies, such as allergic rhinitis, are triggered by exposure to airborne pollen. They are a considerable global health burden, with their numbers expected to rise in the coming decades due to the advent of climate change and air pollution. The relationships that exist between pollens, meteorological, and environmental conditions are complex due to a lack of clarity on the nature and conditions associated with these interactions; therefore, it is challenging to describe their direct impacts on allergenic potential clearly. This article attempts to review evidence pertaining to the possible influence of meteorological factors and air pollutants on the allergic potential of pollen by studying the interactions that pollen undergoes, from its inception to atmospheric traversal to human exposure. This study classifies the evidence based on the nature of these interactions as physical, chemical, source, and biological, thereby simplifying the complexities in describing these interactions. Physical conditions facilitating pollen rupturing for tree, grass, and weed pollen, along with their mechanisms, are studied. The effects of pollen exposure to air pollutants and their impact on pollen allergenic potential are presented along with the possible outcomes following these interactions, such as pollen fragmentation (SPP generation), deposition of particulate matter on pollen exine, and modification of protein levels in-situ of pollen. This study also delves into evidence on plant-based (source and biological) interactions, which could indirectly influence the allergic potential of pollen. The current state of knowledge, open questions, and a brief overview of future research directions are outlined and discussed. We suggest that future studies should utilise a multi-disciplinary approach to better understand this complex system of pollen interactions that occur in nature., Competing Interests: Declaration of competing interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Sudharsun Venkatesan reports administrative support and writing assistance were provided by Deakin University. Svetlana Stevanovic reports a relationship with Deakin University that includes: employment. If there are other authors, they declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024. Published by Elsevier B.V.)

The objective of this article is to review recent literature on the implications of extreme weather events such as thunderstorms, wildfires, tropical cyclones, freshwater flooding, and temperature extremes in relationship to asthma symptoms. Several studies have shown worsening of asthma symptoms with thunderstorms, wildfires, tropical cyclones, freshwater flooding, and temperature extremes. In particular, thunderstorm asthma can be exacerbated by certain factors such as temperature, precipitation, and allergen sensitization. Therefore, it is imperative that the allergy and immunology community be aware of the health effects associated with these extreme weather events in order to educate patients and engage in mitigation strategies., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Climate change is a key environmental factor for allergic respiratory diseases, especially in childhood. This review describes the influences of climate change on childhood asthma considering the factors acting directly, indirectly and with their amplifying interactions. Recent findings on the direct effects of temperature and weather changes, as well as the influences of climate change on air pollution, allergens, biocontaminants and their interplays, are discussed herein. The review also focusses on the impact of climate change on biodiversity loss and on migration status as a model to study environmental effects on childhood asthma onset and progression. Adaptation and mitigation strategies are urgently needed to prevent further respiratory diseases and human health damage in general, especially in younger and future generations., (© 2023 European Academy of Allergy and Clinical Immunology and John Wiley & Sons Ltd.)

Background: There have been 26 epidemic thunderstorm asthma (ETSA) events worldwide, with Melbourne at the epicentre of ETSA with 7 recorded events, and in 2016 experienced the deadliest ETSA event ever recorded. Health services and emergency departments were overwhelmed with thousands requiring medical care for acute asthma and 10 people died., Objectives: This multidisciplinary study was conducted across various health and science departments with the aim of improving our collective understanding of the mechanism behind ETSA., Design: This study involved time-resolved analysis of atmospheric sampling of the air for pollen and fungal spores, and intact and ruptured pollen compared with different weather parameters, pollution levels and clinical asthma presentations., Methods: Time-resolved pollen and fungal spore data collected by Deakin Air WATCH Burwood, underwent 3-h analysis, to better reflect the 'before', 'during' and 'after' ETSA time points, on the days leading up to and following the Melbourne 2016 event. Linear correlations were conducted with atmospheric pollution data provided by the Environment Protection Authority (EPA) of Victoria, weather data sourced from Bureau of Meteorology (BOM) and clinical asthma presentation data from the Victorian Agency for Health Information (VAHI) of Department of Health., Results: Counts of ruptured grass pollen grains increased 250% when the thunderstorm outflow reached Burwood. Increased PM10, high relative humidity, decreased temperature and low ozone concentrations observed in the storm outflow were correlated with increased levels of ruptured grass pollen. In particular, high ozone levels observed 6 h prior to this ETSA event may be a critical early indicator of impending ETSA event, since high ozone levels have been linked to increasing pollen allergen content and reducing pollen integrity, which may in turn contribute to enhanced pollen rupture., Conclusion: The findings presented in this article highlight the importance of including ruptured pollen and time-resolved analysis to forecast ETSA events and thus save lives.

Higher incidences of asthma during thunderstorms can pose a serious health risk. In this study, we estimate the thunderstorm asthma risk using statistical methods, with special focus on Bavaria, Southern Germany. In this approach, a dataset of asthma-related emergency cases for the study region is combined with meteorological variables and aeroallergen data to identify statistical relationships between the occurrence of asthma (predictand) and different environmental parameters (set of predictors). On the one hand, the results provide evidence for a weak but significant relationship between atmospheric stability indices and asthma emergencies in the region, but also show that currently thunderstorm asthma is not a major concern in Bavaria due to overall low incidences. As thunderstorm asthma can have severe consequences for allergic patients, the presented approach can be important for the development of emergency strategies in regions affected by thunderstorm asthma and under present and future climate change conditions.

There is clear evidence that climate change is occurring as there has been an acceleration of global temperatures since the mid-nineteenth century along with rising atmospheric carbon dioxide levels. It has been proposed that one of the most significant consequences of climate change on human health could be the impact on aeroallergens. Evidence from around globe has pointed to longer and more abundant pollen season associated with global warming. Additional studies have also suggested increased pollen allergenicity due to air pollution., Competing Interests: Disclosure “The author has nothing to disclose.”, (Copyright © 2022 Elsevier Inc. All rights reserved.)

Grass pollens have been identified as mediators of respiratory distress, capable of exacerbating respiratory diseases including epidemic thunderstorm asthma (ETSA). It is hypothesised that during thunderstorms, grass pollen grains swell to absorb atmospheric water, rupture, and release internal protein content to the atmosphere. The inhalation of atmospheric grass pollen proteins results in deadly ETSA events. We sought to identify the underlying cellular mechanisms that may contribute towards the severity of ETSA in temperate climates using Timothy grass (Phleum pratense). Respiratory cells exposed to Timothy grass pollen protein extract (PPE) caused cells to undergo hypoxia ultimately triggering the subcellular re-organisation of F-actin from the peri junctional belt to cytoplasmic fibre assembly traversing the cell body. This change in actin configuration coincided with the spatial reorganisation of microtubules and importantly, decreased cell compressibility specifically at the cell centre. Further to this, we find that the pollen-induced reorganisation of the actin cytoskeleton prompting secretion of the pro-inflammatory cytokine, interleukin-8. In addition, the loss of peri-junctional actin following exposure to pollen proteins was accompanied by the release of epithelial transmembrane protein, E-cadherin from cell-cell junctions resulting in a decrease in epithelial barrier integrity. We demonstrate that Timothy grass pollen regulates F-actin dynamics and E-cadherin localisation in respiratory cells to mediate cell-cell junctional integrity highlighting a possible molecular pathway underpinning ETSA events., (© 2021. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Despite making up a significant proportion of airborne allergens, the relationship between fungal spores and asthma is not fully explored. Only 80 taxa of fungi have so far been observed to exacerbate respiratory presentations, with Cladosporium spp., Aspergillus spp., Penicillium spp., and Alternaria spp. found to comprise the predominant allergenic airborne spores. Fungal spores have been found in indoor environments, such as hospitals and housing due to poor ventilation. Meanwhile, outdoor fungal spores exhibit greater diversity, and higher abundance and have been associated with hospitalizations from acute asthma presentations. In addition, fungal spores may be the underlying, and perhaps the "missing link", factor influencing the heightened rate of asthma presentations during epidemic thunderstorm asthma events. To improve our knowledge gap on fungal spores, airborne allergen monitoring must be improved to include not only dominant allergenic fungi but also provide real-time data to accurately and quickly warn the general public. Such data will help prevent future asthma exacerbations and thus save lives. In this review, we examine the health risks of prominent allergenic fungal taxa, the factors influencing spore dispersal and distribution, and why improvements should be made to current sampling methods for public health and wellbeing.

Climate change (CC) is expected to negatively impact respiratory health due to air pollution and increased aeroallergen exposure. Children are among the most vulnerable populations due to high ventilation rates, small peripheral airways, and developing respiratory and immunological systems. To assess the current knowledge among Italian pediatric pulmonologists on the potential effects of CC on pediatric respiratory allergic diseases, a national survey was launched online from February 2020 to February 2021. The members of the Italian Pediatric Respiratory Society (SIMRI) were contacted by email and 117 questionnaires were returned (response rate 16.4%). 72.6% of respondents were females, 53.8% were academic pediatricians, 42.7% had been working >10 years. Most of the participants were aware of the potential health effects of CC and stated that they had noticed an increase in the incidence (90.6%) and severity (67.5%) of allergic respiratory diseases among their patients. About 61% and 41% of participants respectively felt that there had been an increase in the number of children sensitized to pollen and molds. When applying latent class analysis to identify the features characterizing participants with greater awareness and knowledge of CC-related health effects, two classes were identified: almost 60% of the participants were labeled as "poor knowledge" and those with greater awareness were older, had longer work experience, and were those using the Internet to gather information about CC. There is urgent need to increase pediatricians' awareness of the detrimental effects of CC on children's respiratory health and integrate them in the educational programs of healthcare professionals., (© 2022 The Authors. Pediatric Pulmonology published by Wiley Periodicals LLC.)

The climate crisis poses a major challenge to human health as well as the healthcare system and threatens to jeopardize the medical progress made in recent decades. However, addressing climate change may also be the greatest opportunity for global health in the 21st century. The climate crisis and its consequences, such as rising temperatures, forest fires, floods, droughts, and changes in the quality and quantity of food and water, directly and indirectly affect human physical and mental health. More intense and frequent heat waves and declining air quality have been shown to increase all-cause mortality, especially among the most vulnerable. Climate warming alters existing ecosystems and favors biological invasions by species that better tolerate heat and drought. Pathogen profiles are changing, and the transmission and spread of vector-borne diseases are increasing. The spread of neophytes in Europe, such as ragweed, is creating new pollen sources that increase allergen exposure for allergy sufferers. In addition, the overall milder weather, especially in combination with air pollution and increased CO 2 levels, is changing the production and allergenicity of pollen. The phenomenon of thunderstorm asthma is also occurring more frequently. In view of the increasing prevalence of allergic diseases due to climate change, early causal immunomodulatory therapy is therefore all the more important. During a climate consultation, patients can receive individual advice on climate adaptation and resilience and the benefits of CO 2 reduction-for their own and the planet's health. Almost 5% of all greenhouse gas emissions in Europe come from the healthcare sector. It thus has a central responsibility for a climate-neutral and sustainable transformation., Competing Interests: Conflict of interestD. Luschkova, C. Traidl-Hoffmann and A. Ludwig declare that they have no competing interests., (© The Author(s) 2022.)

Thunderstorm asthma is often characterised by a sudden surge in patients presenting with exacerbated symptoms of asthma linked to thunderstorm activity. Here, we describe a large spike in asthma and difficulty breathing symptoms observed across parts of England on 17 June 2021. The number of healthcare presentations during the asthma event was compared to expected levels for the overall population and across specific regions. Across affected geographical areas, emergency department attendances for asthma increased by 560% on 17 June compared to the average number of weekday daily attendances during the previous 4 weeks. General practitioner out of hours contacts increased by 349%, National Health Service (NHS) 111 calls 193%, NHS 111 online assessments 581% and ambulance call outs 54%. Increases were particularly noted in patient age groups 5-14 and 15-44 years. In non-affected regions, increases were small (<10%) or decreased, except for NHS 111 online assessments where there was an increase of 39%. A review of the meteorological conditions showed several localised, weak, or moderate thunderstorms specifically across parts of Southeast England on the night of June 16. In this unprecedented episode of asthma, the links to meteorologically defined thunderstorm activity were not as clear as previous episodes, with less evidence of 'severe' thunderstorm activity in those areas affected, prompting further discussion about the causes of these events and implications for public health management of the risk.

Epidemic thunderstorm asthma (ETSA) occurs following a thunderstorm due to the interaction of environmental and immunologic factors. Whilst first reported in the 1980s, the world's largest event in Melbourne, Australia, on November 21, 2016 has led to a wealth of clinical literature seeking to identify its mechanisms, susceptibility risk factors, and management approaches. Thunderstorm asthma (TA) typically presents during an aeroallergen season in individuals sensitized to perennial rye grass pollen (RGP) in Australia, or fungus in the United Kingdom, in combination with meteorological factors such as thunderstorms and lightning activity. It is now well recognized that large pollen grains, which usually lodge in the upper airway causing seasonal allergic rhinitis (SAR), are ruptured during these events, leading to sub-pollen particles respirable to the lower respiratory tract causing acute asthma. The identified risk factors of aeroallergen sensitization, specifically to RGP in Australians with a history of SAR, and individuals born in Australia of South-East Asian descent as a risk factor for TA has been key in selecting appropriate patients for preventative management. Moreover, severity-determining risk factors for ETSA-related asthma admission or mortality, including pre-existing asthma or prior hospitalization, poor inhaled corticosteroid adherence, and outdoor location at the time of the storm are important in identifying those who may require more aggressive treatment approaches. Basic treatments include optimizing asthma control and adherence to inhaled corticosteroid therapy, treatment of SAR, and education regarding TA to increase recognition of at-risk days. Precision treatment approaches may be more beneficial in select individuals, including the use of allergen immunotherapy and even biologic treatment to mitigate asthma severity. Finally, we discuss the importance of environmental health literacy in the context of concerns surrounding the increased frequency of ETSA due to climate change and its implications for the frequency and severity of future events., Competing Interests: JC and JAT have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript, which includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties. SC reports grants from the Medical Research Future Fund during the conduct of related studies; grants, personal fees and non-financial support from CSL and non-financial support from Sanofi outside the submitted work. AGS reports grants from CSL Ltd, outside the submitted work. JAD has received funding to support this work from the Medical Research Future Fund’s Rapid Applied Research Translation program in conjunction with the Melbourne Academic Centre for Health. In the past 5 years, she has received honoraria for educational presentations from Astra-Zeneca, GSK, Novartis, Alphapharm, Shire, CSL. She has served on advisory boards: Sanofi-Aventis, Novartis, GSK, Astra-Zeneca, Shire, Immunosis, and CSL. She has undertaken contracted or investigator-initiated research on behalf of: GSK, Novartis, Immunosis, AstraZeneca, Sanofi-Aventis, Grifols, CSL, BioCryst, and Equilium. She has a personal superannuation shareholding in CSL. The authors report no other conflicts of interest in this work., (© 2021 Chatelier et al.)

Objectives: To understand the challenges faced by general practice (GP) services in terms of personnel, materials, secondary support services, and discharge and communication obstacles during the thunderstorm asthma (TA) epidemic in 2016., Methods: Qualitative study using semi-structured interviews and focus groups between September and October 2017. Participants were general practitioners (GPs), practice nurses, and administrative staff working on the TA epidemic days in the northern region of Melbourne, Australia., Results: 18 participants contributed to the study from six clinic sites. Both daytime and evening clinics experienced a surge in respiratory patient presentations. After-hours clinics were inundated with asthma patients during the night of the thunderstorm. Consistent themes emerged about the challenges encountered by participants the most significant being limitation of medication, equipment, space, and personnel. The extraordinary influx of patients necessitated participants innovate solutions including recycling equipment, procuring medications from hospitals and community pharmacies, triage, altering management strategies and extending clinic hours. Participants were limited by the paucity of information from local services during the TA epidemic., Conclusion: This study supports the view that GP services made a substantial contribution to the emergency response on the evening of the TA epidemic that occurred in Melbourne in 2016. Demands on resources were considerable during and after the epidemic yet GP staff showed great resilience increasing clinic surge capacity. Our findings indicate significant barriers at an organizational level including resource limitations, inadequate operational information, and the absence of timely communication channels that impaired the response of GP services during a TA event.

Background: The so-called "thunderstorm asthma" (TA) is an uncommon but dramatic outbreak of asthma attacks occurring during a thunderstorm in the pollen and moulds season. Mechanisms which make the pollen able to enter the deeper airways and provoke severe asthma symptoms are still unclear., Objective: To test the hypothesis that sub-pollen particles (SPPs) originated from the rupture by an osmotic shock of pollen associated with TA contain allergens., Methods: After hydration, SPPs released from pollen grains of grass, pellitory, olive, cypress, ragweed and birch were isolated and determined by microscopy. Allergens were determined by in vitro ELISA inhibition tests indirectly using the sera from 10 polyreactive patients. An inhibition <50% was considered as negative, 50%-75% moderate and > 75% complete., Results: The inhibition experiments showed that the SPPs from birch and cypress were unable to inhibit serum IgE reactivity to Bet v 1 and Cup a 1, respectively. Ragweed SPPs inhibited ragweed pollen extract and Amb a 1 by 75.8 ± 0.11% and 81.2 ± 0.15%, respectively. Olive and pellitory SPPs retained almost the whole IgE-binding capability in all cases tested. Grass SPPs inhibited 32 ± 0.06% of Lolium perenne Lol p 1 and 65% of Phleum pratense extracts, but results were highly variable for individual allergens (97.5%-0.03% for Phl p 2, 45.3 ± 0.12% for Phl p 5, 24.7 ± 0.22% for Phl p 6, and 38.3 ± 0.2% for Phl p 1)., Conclusions: Inhibition experiments confirm the hypothesis that SSPs obtained after the osmotic shock of pollen involved in TA, namely grass, pellitory and olive tree pollen, contain allergens and therefore they can induce severe asthma attacks during thunderstorms., (© 2021 John Wiley & Sons Ltd.)

Extreme weather and climate events are likely to increase in frequency and severity as a consequence of global climate change. These are events that can include flooding rains, prolonged heat waves, drought, wildfires, hurricanes, severe thunderstorms, tornadoes, storm surge, and coastal flooding. It is important to consider these events as they are not merely meteorologic occurrences but are linked to our health. We aim to address how these events are interconnected with asthma outcomes associated with thunderstorm asthma, pollen production, mold infestation from flooding events, and poor air quality during wildfires., Competing Interests: Disclosure J.A. Poole reports funding from the National Institutes of Health (ES019325) and National Institute for Occupational Safety and Health (U54OH010162); all unrelated to the present topic. A. Rorie has no relevant disclosures., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Over recent years, Australians have been subject to an unprecedented number of environmental events materially and visibly affecting air quality, including thunderstorm asthma and bushfire smoke. There is increasing evidence that poor air quality adversely affects health with consequences for mortality and morbidity with measured particulates (PM2.5) in January 2019 frequently exceeding World Health Organization standards. Biological factors can also impact air quality with thunderstorm asthma epidemics evidence of a prime example, the 2016 event being associated with severe impacts on health services. Given these events, consideration needs to be given to environmental health literacy which will support individuals with pre-existing illness to recognise and mitigate as far as possible the effects of adverse air quality. Recognising the impact of poor air quality should also urge physicians to advocate for clean air as a necessity for good health., (© 2020 Royal Australasian College of Physicians.)

: Thunderstorm asthma (TA) epidemics have been recognized globally as a rare phenomenon, producing a rapid surge of acute asthma presentations leading to an increased demand on emergency medical services and healthcare resources. General practitioners (GPs) are well placed in the community to contribute to healthcare during TA epidemics and similar disaster events. The aim of this review was to synthesize current evidence of the experiences of GPs during TA epidemics and similar surge events. A comprehensive systematic search of eleven electronic databases, including ancestry searching for peer-reviewed studies and grey literature published in English was conducted. Quantitative and qualitative study designs were included, and a quality assessment conducted. Of the 125 records identified, 16 were included for synthesis. During TA epidemics and surge events, GPs experience an increased demand for services, yet it is not known if general practice clinics experience resource limitations from this patient surge. While GPs express a willingness to help, few structures are in place to liaise, support and provide information to GPs during surge events. Following most surge/disaster events, no GP data is collected so it is not known how to improve coordination and communication between general practice services and emergency services. GPs have well-functioning adaptive management systems, and resources of space, supplies and staff thus the ability to increase surge capacity of their clinics., Competing Interests: The authors declare no conflict of interest.

Purpose of Review: It is well known that combination of sensitization and exposure to inhaled environmental allergens is related to both the development and elicitation of symptoms of asthma and that avoidance of allergens would exert beneficial effects in the prevention and control of the disease. Other important factors include the relevance of other allergens, exposure to sensitizing agents also outside patient's home, exposure to irritants (like chemical air pollutants), and the involvement of the patient with a correct education. It is also likely that clinical phase of allergic airway disease and the degree of airways remodeling represent relevant factors for the clinical outcome of allergen avoidance procedure. We reviewed existing evidence on prevention of asthma through allergen avoidance., Recent Findings: The management of respiratory allergy is a complex strategy (including prevention, drugs, immunological, and educational interventions). In addition, it is difficult in real life to distinguish the efficacy of single interventions. However, a combined strategy is likely to produce clinical results. A combined strategy is likely to produce satisfactory management of asthma. Allergens are an important trigger factor for the development of symptoms of respiratory allergy, and avoidance measures are able to reduce allergen levels. It is likely that clinical phase of allergic airway disease and the degree of airways remodeling represents relevant factors for the clinical outcome of allergen avoidance procedures. Considering the management of respiratory allergy is a complex strategy; it is difficult in real life to distinguish the efficacy of single interventions. However, further studies better quantifying the effects of allergens are needed.

Background: Reports of thunderstorm asthma in the Middle East are few. This study is the first to report on cases of near-fatal and fatal thunderstorm asthma in Kuwait on December 1, 2016., Methods: We conducted a chart review and interview with adult patients admitted to Mubarak Al-Kabir Hospital with near-fatal asthma, defined as an exacerbation requiring intubation and mechanical ventilation or hypercapnia with a PaCO 2 ≥6 kPa. Information, including patient age, gender, occupation, asthma history, medication usage, and clinical outcome, was collected. For fatal asthma cases, patients' data were collected from the Forensic Department at the Kuwait Ministry of Interior., Results: A total of 17 patients were admitted with near-fatal asthma. Fifteen patients (93.8%) had a prior history of asthma, with an average duration of 9 years. Five patients (33.3%) reported receiving a corticosteroid inhaler from their physician. Fifteen patients (93.8%) reported relying on a short-acting β2-agonist alone to manage their asthma. Eleven patients (68.8%) reported being outdoors during the storm. Eleven patients were diagnosed with fatal asthma., Conclusion: The study is the first to report on a thunderstorm-associated asthma epidemic in Kuwait and emphasizes the potential dangers associated with this entity., Competing Interests: There are no conflicts of interest.

Previous studies that described thunderstorm asthma, which is a rare event, are not being well explained. This study was conducted, to describe the patient perspective on their asthma attack experience during Ahvaz post-rain phenomenon. We have interviewed patients present in the Naft clinic of Ahvaz, during 28th October and the first week of November 2015. Recruitment was continued as saturation ensued by 33 participants. An inductive content analysis was used to evaluate the interviews. The key finding indicated a climatic condition, direct or indirect contact with rain, history of allergy, and physical conditions are the main categories. The patient emphasized the importance of dust, humidity, first autumn rainfall, and environmental air pollution in occurrences of the event. When exposed to further rains (third rainfall onward), they were less likely to experience dyspnea or shortness of breath. However, being indoor or out at the time of rainfall reported not to be related to the onset of asthma exacerbation. This study yielded that patients' asthma outbreak is a climate-related health impact and many individual factors triggering this issue. Patients concerns need future investigation and public health emergency planning and response arrangements.

Purpose of Review: There are observations in various geographical areas that thunderstorms occurring during pollen seasons can induce severe asthma attacks in pollinosis patients., Recent Findings: An accredited hypothesis explaining the association between thunderstorms and asthma suggests that storms can concentrate pollen grains at ground level, which may then release allergenic particles of respirable size in the atmosphere after their imbibition of water and rupture by osmotic shock. During the first 20-30 min of a thunderstorm, patients affected by pollen allergy may inhale a high quantity of the allergenic material that is dispersed into the atmosphere as a bioaerosol of allergenic particles, which can induce asthmatic reactions, often severe. Subjects without asthma symptoms, but affected by seasonal rhinitis can also experience an asthma attack. A key message is that all subjects affected by pollen allergy should be alerted to the danger of being outdoors during a thunderstorm in the pollen season, as such events may be an important cause of severe asthma exacerbations. In light of these observations, it is useful to predict thunderstorms and thus minimize thunderstorm-related events. Patients with respiratory allergy induced by pollens and molds need to be informed about a correct therapeutic approach of bronchial asthma by inhalation, including the use of bronchodilators and inhaled corticosteroids. The purpose of this review is to focalize epidemiological, etiopathogenetic, and clinical aspects of thunderstorm-related asthma.

The rising frequency of obstructive respiratory diseases during recent years, in particular allergic asthma, can be partially explained by changes in the environment, with the increasing presence in the atmosphere of chemical triggers (particulate matter and gaseous components such as nitrogen dioxide and ozone) and biologic triggers (aeroallergens). In allergic individuals, aeroallergens stimulate airway sensitization and thus induce symptoms of bronchial asthma. Over the last 50 years, the earth's temperature has risen markedly, likely because of growing concentrations of anthropogenic greenhouse gas. Major atmospheric and climatic changes, including global warming induced by human activity, have a considerable impact on the biosphere and on the human environment. Urbanization and high levels of vehicle emissions induce symptoms of bronchial obstruction (in particular bronchial asthma), more so in people living in urban areas compared than in those who live in rural areas. Measures need to be taken to mitigate the future impact of climate change and global warming. However, while global emissions continue to rise, we must learn to adapt to climate variability.

Thunderstorm asthma and increased childhood leukemia risk near high-voltage power lines (HVPL) are occurrences whose mechanism of effect is not fully understood. This paper proposes and discusses a key similarity: both thunderstorms and HVPL generate a high enough electrical field in the environment to ionize nearby air and air-borne particles. I argue that the repeatedly demonstrated acute asthma response to pollen-laden air during thunderstorms is largely due to ionization of air-borne allergens, which adhere more readily and in greater quantity in the lungs than non-ionized particles. If these bind to mucous or phagocytic cells, it would enhance immune response. A rapid temperature drop and high ozone also seem to be drivers of thunderstorm asthma. This causal nexus provides strong support for the parallel situation of prolonged exposure to ionized particles near HVPL and an increased rate of childhood leukemia. Here, it is proposed that upwind carcinogens are ionized when passing HVPL and then residential and business areas. Published evidence for most steps are presented, but have not previously been published as a coherent whole, nor has it been suggested that the inhaled ionized micro-particle explanation for acute asthma may also explain development of childhood leukemia over time. The demonstrated series of events leading to increased deposition and retention of ionized particles in airways provides support for explaining both adverse health outcomes: acute thunderstorm asthma and increased risk of childhood leukemia near HVPL. Further support for this explanation of both outcomes is provided by effects of on-going proximity to highways.