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The Environment and Cardiopulmonary Physiotherapy

Original Editor - Andrea Miguel Lopes Rodrigues Ribeiro Top Contributors - Vidya Acharya, Andrea Miguel Lopes Rodrigues Ribeiro, Lucinda hampton and Alexandra Stead

Introduction

The relationship between environmental exposures and cardiopulmonary health is a growing focus of clinical research and an increasingly important consideration in physiotherapy practice.[1][2] Air pollution is defined as the presence of harmful substances in the atmosphere at concentrations sufficient to damage health, and is now recognised as one of the most significant preventable threats to global public health.[3] Cardiovascular disease (CVD) and respiratory conditions represent the primary disease categories affected by these exposures, with direct implications for physiotherapy practice worldwide.

Climate change compounds these concerns by increasing the frequency of heatwaves, wildfires, and extreme weather events, all of which carry documented cardiorespiratory consequences.[4][5] Physiotherapists and rehabilitation professionals who manage people with CVD, chro

The Environment and Cardiopulmonary Physiotherapy

nic obstructive pulmonary disease (COPD), asthma, heart failure, and related conditions must therefore understand both the mechanisms by which environmental factors affect health and the evidence-based strategies available to mitigate their impact.

Air Pollution

Epidemiological Significance

Air pollution is a global health concern of profound scale. Ambient particulate matter, particularly fine particulate matter (PM) with an aerodynamic diameter of 2.5 micrometres or less (PM₂.₅), has been identified by the World Health Organisation (WHO) as one of the pollutants posing the greatest risk to public health.[6] In 2019, ambient air pollution caused an estimated 4.2 million deaths worldwide, with 89% of deaths occurring in low- and middle-income countries (LMICs).[7]

Cardiovascular disease is the predominant cause of air pollution-attributable mortality, with ischaemic heart disease, stroke, and cardiac arrhythmias accounting for the largest proportion of premature deaths.[8] An umbrella review of systematic reviews and meta-analyses confirmed associations between ambient PM and nitrogen dioxide (NO₂) and a wide range of CVD outcomes, including ischaemic heart disease, myocardial infarction, heart failure, stroke, arrhythmias, and cardiac arrest.[8]

Key Pollutants and Health Effects

The pollutants with the most consistent and well-documented associations with cardiorespiratory disease include:

  • Particulate Matter (PM₂.₅ and PM₁₀): Fine particles penetrate deeply into the lungs, enter the bloodstream, and reach every organ. Long-term PM₂.₅ exposure is associated with increased risks of hypertension, acute coronary syndrome, myocardial infarction, cardiac arrhythmia, heart failure, and atherosclerosis, and can reduce life expectancy by several years.[9][10]
  • Nitrogen Dioxide (NO₂): Produced by combustion in vehicles and industry. Long-term exposure is associated with increased CVD and respiratory mortality and accelerated lung function decline.[3]
  • Ozone (O₃): A secondary pollutant formed by photochemical reactions. Increased annual ozone levels are associated with elevated diastolic blood pressure and reduced lung function in healthy adults.[11] Ozone is also linked to asthma exacerbations and respiratory hospital admissions.[3]
  • Ultrafine Particles (UFPs): Short-term UFP exposure is associated with increased blood pressure and markers of inflammation; long-term exposure exacerbates these effects.[12]
  • Traffic-Related Air Pollutants (TRAP): Exercising in environments with high TRAP concentrations increases markers of respiratory and systemic inflammation, impairs vascular function, and raises arterial pressure.[13] Different pollution sources, including traffic emissions, coal combustion, and industrial activity, have distinct impacts on cardiopulmonary health, with traffic emissions and coal combustion linked to increased blood pressure and inflammatory biomarkers.[14]

Air pollutants, including PM₂.₅, PM₁₀, and ozone, are also linked to reduced lung function, increased respiratory inflammation, and conditions such as COPD, asthma, and bronchiolitis.[3][11]

Pathophysiological Mechanisms

Air pollution exerts its cardiorespiratory effects through several interacting pathways:[10][9][15]

  • Oxidative stress: Inhaled pollutants stimulate reactive oxygen species production, activating inflammatory cascades that damage endothelial cells and promote atherosclerosis.
  • Systemic inflammation: Pulmonary and systemic inflammatory pathways are activated, with downstream effects on vascular integrity and cardiac function.
  • Endothelial dysfunction: Reduced bioavailability of nitric oxide impairs vascular tone regulation, increasing the risk of hypertension and coronary artery disease.
  • Autonomic nervous system dysregulation: Particulate deposition in the respiratory tract activates sensory nerves, producing heart rate variability reduction and arrhythmogenesis. Increased daily PM-Coarse exposure significantly and adversely affects cardiac autonomic modulation.[11]
  • Prothrombotic effects: Pollution enhances platelet activation, impairs fibrinolysis, and promotes hypercoagulability, increasing the risk of acute myocardial infarction and stroke.[10]

Following acute pollution exposure, the risk of myocardial infarction may increase within six hours and the risk of out-of-hospital cardiac arrest within twelve hours.[8]

Climate Change

Climate change is increasingly recognised for its profound and wide-ranging impacts on cardiorespiratory health. Climate change directly and indirectly increases cardiovascular morbidity and mortality through factors including air pollution, extreme heat, and severe weather patterns.[4]

Scheme of the pathways linking climate change and respiratory health impacts.
Scheme of the pathways linking climate change and respiratory health impacts.

Heat and Heatwaves

Heatwaves are associated with excess morbidity and mortality from cardiovascular disease, impairing blood vessel tone and structure and increasing cardiovascular mortality.[16] People with pre-existing CVD and COPD are particularly vulnerable, as heat exacerbates dyspnoea, cardiovascular strain, and dehydration. Physiotherapists must adapt exercise prescriptions during periods of extreme heat, including reducing intensity, avoiding outdoor sessions during peak heat, and ensuring adequate hydration.[5]

Air Pollution and Respiratory Disease

Climate change exacerbates air pollution by increasing ground-level ozone and particulate matter concentrations, which are linked to respiratory diseases including asthma, COPD, and lung cancer, as well as cardiovascular events such as myocardial infarction and stroke.[17] Extreme temperatures and increased pollution disproportionately affect high-risk populations, including older adults, those with chronic disease, and socioeconomically disadvantaged communities.[17]

Wildfires

Wildfires are increasing in frequency and intensity globally. Wildfire smoke contains high concentrations of PM₂.₅ and other pollutants capable of triggering acute cardiorespiratory events, including asthma exacerbations, COPD hospitalisations, and increased cardiovascular mortality.[7] Rehabilitation professionals in fire-prone regions should develop contingency plans for indoor exercise alternatives and patient self-management support during smoke events.[5]

Strategies in Managing the Effects of Air Pollution on Cardiopulmonary Health

Better knowledge of the effects of environmental exposures, including air pollution and climate change, is of increasing importance for clinicians and cardiopulmonary physiotherapists, as the exposures impact cardiovascular and respiratory health in ways that require interventions capable of benefiting both people and the planet.[18] Respiratory clinicians carry a professional responsibility to educate themselves and their patients about the impacts of climate change on respiratory health and to incorporate this knowledge into clinical practice.[5] Air pollution poses significant risks to cardiopulmonary health, particularly for people with pre-existing conditions such as heart failure and chronic lung disease. Physiotherapy plays a crucial role in mitigating these adverse effects through both environmental modification strategies and targeted clinical interventions.

Environmental and Protective Strategies

  • Respiratory filtration during exercise: The use of respiratory filters significantly reduces the adverse effects of air pollution on exercise capacity in people with heart failure, improving VO₂ and O₂ pulse during physical activity.[19]
  • Indoor air purification: The use of indoor air purifiers produces substantial reductions in indoor PM₂.₅ levels, associated with decreased inflammatory and thrombogenic biomarkers, lower blood pressure, and improved cardiopulmonary health.[20][21]
  • Personal exposure reduction: Evidence-based personal strategies include: limiting outdoor physical exertion on high-pollution days, reducing near-roadway exposure, using air quality alert systems and real-time Air Quality Index (AQI) tools, wearing appropriately fitted facemasks in polluted environments, avoiding exposure to indoor cooking with solid fuels, and using portable air cleaners fitted with high-efficiency particulate air (HEPA) filters.[22][23]

Physiotherapy Interventions

Pulmonary Rehabilitation

Pulmonary rehabilitation (PR) is the most evidence-based non-pharmacological intervention for people with chronic respiratory diseases. It is a comprehensive, multidisciplinary programme encompassing individualised exercise training, education, and psychosocial support. PR is crucial for managing COPD, with evidence demonstrating potential reductions in hospital admissions and readmissions.[24] In the context of environmental pollution, digital and home-based PR programmes represent increasingly viable alternatives when outdoor or centre-based exercise is inadvisable due to poor air quality or extreme weather conditions.[5]

Inspiratory Muscle Training

Inspiratory muscle training (IMT) involves breathing exercises performed using resistive or threshold loading devices to improve inspiratory muscle strength and endurance. IMT, when delivered in isolation, improves dyspnoea, functional exercise capacity, and health-related quality of life in people with COPD.[25]

For people with asthma, IMT significantly improves maximal inspiratory pressure (MIP), with interventions using loads greater than 50% of PImax (peak inspiratory pressure) for more than six weeks associated with improved exercise capacity.[26]

Key IMT prescription parameters supported by the evidence include:[25][26]

  • Training load of at least 30% of MIP (threshold loading), with loads of 50–60% appropriate for individuals with specific inspiratory muscle weakness
  • A minimum frequency of five sessions per week
  • A minimum duration of six weeks, with longer programmes demonstrating superior outcomes
  • Threshold pressure loading devices as the most commonly studied and recommended training mode

Breathing Exercises and Airway Clearance

Breathing exercises, including diaphragmatic breathing, pursed-lips breathing (PLB), and the Active Cycle of Breathing Technique (ACBT) are low-technology, accessible interventions applicable across diverse settings, including those with limited resources. Bronchopulmonary hygiene techniques are effective in increasing sputum production and may reduce exacerbations in COPD and bronchiectasis.[24] These techniques are of particular relevance in individuals with increased mucus production associated with pollution exposure.

Aerobic Exercise Training

Aerobic exercise training remains the most effective intervention for improving cardiorespiratory fitness. In environments with elevated AQI, physiotherapists should prescribe indoor aerobic alternatives, such as cycle ergometry, treadmill walking, and supervised group activity in climate-controlled settings to maintain the benefits of exercise while minimising pollution exposure.[13][5]

Patient Education and Self-Management

Patient education is an integral component of cardiopulmonary physiotherapy. Evidence-based self-management education for people with COPD and asthma should incorporate:[23][5]

  • Recognition of personal pollution triggers and high-risk weather conditions
  • Use of local AQI forecasting tools and real-time air quality applications
  • Action plans for modifying or postponing outdoor exercise on high-pollution days
  • Understanding of the increased cardiorespiratory risk during heatwaves
  • Home-based exercise strategies and telehealth options as alternatives during adverse environmental conditions
  • Advocacy for cleaner indoor environments, including improved ventilation and avoidance of indoor combustion sources

Summary

Air pollution and climate change are established drivers of cardiovascular and respiratory disease, acting through inflammatory and vascular pathways that worsen CVD, COPD, asthma, and heart failure.[3][10] Heatwaves, wildfires, and worsening air quality place people with pre-existing cardiopulmonary conditions at particular risk.[4][5]

Physiotherapists can reduce this harm through practical measures: adapting exercise prescription during high-pollution or extreme-heat periods, promoting protective strategies, and delivering pulmonary rehabilitation and patient education.[5][23] As environmental exposures intensify, embedding this knowledge into routine cardiopulmonary practice is becoming essential rather than optional.[18]

References

  1. ↑ Li LK, Fryer CE, Chi L, Boucaut R. Physiotherapy and planetary health: a scoping review. European Journal of Physiotherapy. 2025 Jan 2;27(1):20-30.
  2. ↑ Chandak JS, Jani HS. The Impact of Air Pollution on Cardiopulmonary Health: Molecular Mechanisms, Preventive Strategies and Role of Physiotherapy.
  3. ↑ 3.0 3.1 3.2 3.3 3.4 Manisalidis I, Stavropoulou E, Stavropoulos A, Bezirtzoglou E. Environmental and health impacts of air pollution: a review. Front Public Health. 2020;8:14.
  4. ↑ 4.0 4.1 4.2 Aitken WW, Brown SC, Comellas AP. Climate change and cardiovascular health. J Am Heart Assoc. 2022;11:e027847.
  5. ↑ 5.0 5.1 5.2 5.3 5.4 5.5 5.6 5.7 5.8 Andersen ZJ, Vicedo-Cabrera AM, Hoffmann B, Melén E. Climate change and respiratory disease: clinical guidance for healthcare professionals. Breathe. 2023;19:220222.
  6. ↑ World Health Organization. WHO global air quality guidelines: particulate matter (PM2.5 and PM10), ozone, nitrogen dioxide, sulfur dioxide and carbon monoxide. Geneva: WHO; 2021.
  7. ↑ 7.0 7.1 Sagheer U, Al-Kindi S, Abohashem S, et al. Environmental pollution and cardiovascular disease. Part 1 of 2: Air pollution. JACC Adv. 2024;3:100805.
  8. ↑ 8.0 8.1 8.2 de Bont J, Jaganathan S, Dahlquist M, Persson Å, Stafoggia M, Ljungman P. Ambient air pollution and cardiovascular diseases: an umbrella review of systematic reviews and meta-analyses. J Intern Med. 2022;291(6):779–800.
  9. ↑ 9.0 9.1 An Z, Jin Y, Li J, Li W, Wu W. Impact of particulate air pollution on cardiovascular health. Curr Allergy Asthma Rep. 2018;18(3):15.
  10. ↑ 10.0 10.1 10.2 10.3 Lederer AM, Fredriksen PM, Nkeh-Chungag BN, et al. Cardiovascular effects of air pollution: current evidence from animal and human studies. Am J Physiol Heart Circ Physiol. 2021;320(4):H1417–39.
  11. ↑ 11.0 11.1 11.2 Cole-Hunter T, de Nazelle A, Donaire-Gonzalez D, et al. Estimated effects of air pollution and space-time-activity on cardiopulmonary outcomes in healthy adults: a repeated measures study. Environ Int. 2018;111:247–59.
  12. ↑ Liu JY, Hsiao TC, Lee KY, Chuang HC, Cheng TJ, Chuang KJ. Association of ultrafine particles with cardiopulmonary health among adult subjects in the urban areas of northern Taiwan. Sci Total Environ. 2018;627:211–5.
  13. ↑ 13.0 13.1 Madureira J, Brancher EA, Costa C, Aurino de Pinho R, Teixeira JP. Cardio-respiratory health effects of exposure to traffic-related air pollutants while exercising outdoors: a systematic review. Environ Res. 2019;178:108647.
  14. ↑ Wu S, Deng F, Wei H, et al. Association of cardiopulmonary health effects with source-appointed ambient fine particulate in Beijing, China: a combined analysis from the Healthy Volunteer Natural Relocation (HVNR) study. Environ Sci Technol. 2014;48(6):3438–48.
  15. ↑ Meo SA, Suraya F. Effect of environmental air pollution on cardiovascular diseases. Eur Rev Med Pharmacol Sci. 2015;19(24):4890–7.
  16. ↑ Gostimirovic M, Novakovic R, Rajkovic J, et al. The influence of climate change on human cardiovascular function. Arch Environ Occup Health. 2020;75(7):406–14.
  17. ↑ 17.0 17.1 Giorgini P, Di Giosia P, Petrarca M, et al. Climate changes and human health: a review of the effect of environmental stressors on cardiovascular diseases across epidemiology and biological mechanisms. Curr Pharm Des. 2017;23(28):4232–41.
  18. ↑ 18.0 18.1 Hadley MB, Vedanthan R, Ebi KL, Fuster V. Climate cardiology. BMJ Glob Health. 2022;7:e008860.
  19. ↑ Vieira JL, Guimaraes GV, de Andre PA, Saldiva PHN, Bocchi EA. Effects of reducing exposure to air pollution on submaximal cardiopulmonary test in patients with heart failure: analysis of the randomized, double-blind and controlled FILTER-HF trial. Int J Cardiol. 2016;215:92–7.
  20. ↑ Chen R, Zhao A, Chen H, et al. Cardiopulmonary benefits of reducing indoor particles of outdoor origin: a randomized, double-blind crossover trial of air purifiers. J Am Coll Cardiol. 2015;65(21):2279–87.
  21. ↑ Zhao Y, Xue L, Chen Q, et al. Cardiorespiratory responses to fine particles during ambient PM2.5 pollution waves: findings from a randomized crossover trial in young healthy adults. Environ Int. 2020;139:105590.
  22. ↑ Newman JD, Bhatt DL, Rajagopalan S, et al. Cardiopulmonary impact of particulate air pollution in high-risk populations. J Am Coll Cardiol. 2020;76(24):2878–94.
  23. ↑ 23.0 23.1 23.2 Carlsten C, Salvi S, Wong GWK, Chung KF. Personal strategies to minimise effects of air pollution on respiratory health: advice for providers, patients and the public. Eur Respir J. 2020;55(6):1902056.
  24. ↑ 24.0 24.1 Garrod R, Lasserson T. Role of physiotherapy in the management of chronic lung diseases: an overview of systematic reviews. Respir Med. 2007;101(12):2429–36.
  25. ↑ 25.0 25.1 Ammous O, Feki W, Lotfi T, et al. Inspiratory muscle training, with or without concomitant pulmonary rehabilitation, for chronic obstructive pulmonary disease (COPD). Cochrane Database Syst Rev. 2023;1:CD013778.
  26. ↑ 26.0 26.1 Lista-Paz A, Cousillas LB, Jácome C, et al. Effect of respiratory muscle training in asthma: a systematic review and meta-analysis. Ann Phys Rehabil Med. 2023;66(1):101674.
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