30001ni2 Nox

EPA600/8-91/049cF
August 1993
Air Quality Criteria for

Oxides of Nitrogen
Volume III of III
Environmental Cntena and Assessment Office

Office of Health and Environmental Assessment
Office of Research and Development
U S Environmental Protection Agency
Research Tnangle Park, NC 27711
@ Prmted on Recycled Paper

DISCLAIMER
TIns document has been revIewed ill accordance wIth U S EnvIronmental ProtectIOn
Agency pohcy and approved for pubhcatIOn Mention of trade names or commercIal
products does not constitute endorsement or recommendatIOn for use
ill-ll
PREFACE
The U S EnvIronmental ProtectiOn Agency (EPA) promulgates the NatiOnal Ambient

AIr QualIty Standards (NAAQS) on the basIs of sCientIfic mformatIOn contaIned ill cntena
documents In 1971, the fIrst arr qualIty cntena document for mtrogen oXIdes (N0X> was
ISSUed by the NatiOnal Air PollutiOn Control AdtnllllstratIOn, a predecessor of EPA On the
basIs of sCientIfic mfonnatIOn contaIned m that document, NAAQS were promulgated for
3
mtrogen dIoXIde (N00 at levels of 0.053 ppm (100 p.g/m ), averaged over 1 year The last
full-scale NOx cntena document reViSion was completed by EPA m 1982, leadmg to an
Agency decision ill 1985 to reaffmn the annual average N02 NAAQS of 0 053 ppm The
present, reVised cntena document, AIr QualIty Cntena for OXIdes of Nitrogen, assesses the
current sCientIfic baSIS for penodic reevaluatiOn of the N02 NAAQS m accordance With the
proVIsIons IdentIfied m SectIOns 108 and 109 of the Clean AIr Act
Key chapters m thIs document evaluate the latest sCIentIfic data on (a) health effects of
NOx measured ill laboratory animals and exposed humall populatIOns and (b) effects of NOx
on agncultural crops, forests, and ecosystems, as well as (c) NOx effects on VISIbility and
nonbIOlogical matenals Other chapters descnbe the nature, sources, dIstnbutiOn,
measurement, and concentratiOns of NOx m the enVIromnent These chapters were prepared
and peer reVIewed by experts from various state and Federal government offices, academIa,
and pnvate mdustry for use by EPA to support decISiOn makIng regardmg potentIal nsks to
pubhc health and the enVIronment Although the document IS not mtended to be an
exhaustIve hterature reVIew, It IS mtended to cover all the pertment hterature through early
1993
The EnVIronmental Cntena and Assessment Office of EPA's Office of Health and
EnVIronmental Assessment acknowledges WIth appreciatIon the contnbutIons proVIded by the
authors and reVIewers and the diligence of ItS staff and contractors m the preparatiOn of thIs
document at the request of EPA's Office of AIr QualIty Planmng and Standards
ID-1ll
Air Quality Criteria for Oxides of Nitrogen
TABLE OF CONTENTS
Volume I Page
1 EXECUTIVE SUMMARY OF AIR QUALITY CRITERIA FOR

OXIDES OF NITROGEN . 1-1
2 INTRODUCTION 2-1
3 GENERAL CHEMICAL AND PHYSICAL PROPERTIES OF

OXIDES OF NITROGEN AND OXIDES OF NITROGEN-DERIVED
POLLUTANTS 3-1
4 AMJ3IENT AND INDOOR SOURCES AND EMISSIONS OF

NITROGEN OXIDES 4-1
5 TRANSPORT AND TRANSFORMATION OF NITROGEN

OXIDES 5-1
6 SAMPUNG AND ANALYSIS FOR NITROGEN OXIDES

AND RELATED SPECIES 6-1
7 AMBIENT AND INDOOR CONCENTRATIONS OF NITROGEN

OXIDES 7-1
8 ASSESSING TOTAL HUMAN EXPOSURE TO NITROGEN

DIOXIDE 8-1
Volume IT
9 EFFECTS OF NITROGEN OXIDES ON VEGETATION 9-1
10 THE EFFECTS OF NITROGEN OXIDES ON NATURAL

ECOSYSTEMS AND THEIR COMPONENTS 10-1
11 EFFECTS OF NITROGEN OXIDES ON VISffiILITY 11-1
12 EFFECTS OF NITROGEN OXIDES ON MATERIALS 12-1
ill-v
- - - - - - - - - -
Air Quality Criteria for Oxides of Nitrogen
TABLE OF CONTENTS (cont'd)
Volumem
13 STUDIES OF THE EFFECTS OF NITROGEN COMPOUNDS

ON ANI1v.fALS 13-1
14. EPIDEMIOLOGY STUDIES OF OXIDES OF NITROGEN 14-1
15. CONTROLLED HUMAN EXPOSURE STUDIES OF NITROGEN

OXIDES 15-1
16 REALTII EFFECTS ASSOCIATED WITH EXPOSURE TO

NITROGEN DIOXIDE 16-1
APPENDIX A' GLOSSARY OF TERMS AND SYMBOLS A-I
ill-v!
TABLE OF CONTEl\TTS
UST OF TABLES ill-xn

UST OF FIGURES . ill-XVll
AUTHORS ill-XIX
CONTRIBUTORS AND REVIEWERS ill-XX!
CLEAN AIR SCIENTIFIC ADVISORY COMMITTEE ill-XXVll
PROJECT TEAM FOR DEVELOPMENT OF AIR QUAUTY CRITERIA
FOR OXIDES OF NITROGEN ill-XXlX
13 STUDIES OF THE EFFECTS OF NITROGEN COMPOUNDS

ON ANllvIALS 13-1
13 ~ INTRODUCTION 13-1
13 2 NITROGEN DIOXIDE 13-1
13 2 1 Resprratory Tract Transport and AbsorptIOn 13-1
13 2 1 1 IntroductIOn 13-1
13 2 1 2 Pnncipies of Gas Uptake and
Dosnnetry Models 13-3
13 2 1 3 Dosnnetry of Nitrogen DIOXIde 13-6
13 2 2 Resprratory Effects 13-13
1322 1 Host Defense Mechamsms 13-13
13 2 2 2 Lung BIochemIstry 13-55
13 2 2 3 Pulmonary FunctIOn 13-78
13 2 2 4 MorphologIC Stuches 13-89
13 2 3 Extrapulmonary Effects 13-124
13 2 3 1 Body WeIght 13-125
1323 2 HematologIc Changes 13-129
13 2 3 3 Hepatic Function 13-137
13 2 3 4 Effects on the KIdney and on Unne
Content 13-142
13 2 3 5 CardIOvascular Effects 13-144
13 23.6 Effects on the Central Nervous System
and BehaVIOral Effects 13-145
13 2 3 7 Reproductive, Developmental, and
Hentable Mutagemc Effects 13-150
1323 8 Potential Carcmogemc or
Cocarcmogemc Effects 13-152
13 3 EFFECTS OF MIXTURES CONTAINING
NITROGEN DIOXIDE 13-163
13 4 NITRIC OXIDE 13-185
13 5 NITRIC ACID AND NITRATES 13-193
13 5 1 NItnc ACId 13-193
13 5 2 NItrates 13-194
136 SUMMARY 13-195
13 6 1 Ammal-to-Human Dosnnetnc ExtrapolatIOn EstImates 13-196
ill-Vll
13 6 2 Blochemtcal and Cellular MechanIsms 13-197

13 6 3 Effects on Host Defenses 13-198
13 6 4 Influence of ConcentratIOn, Duranon, and
Exposure Regunen 13-200
13 6 5 Impact of Exposure Duranon 13-202
13 6 6 Effects of Pollutant MIxtures 13-205
REFERENCES 13-207
14. EPIDEMIOLOGY STUDIES OF OXIDES OF NITROGEN 14-1

141 INTRODUCTION 14-1
14 2 METIIODOLOGICAL CONSIDERATIONS 14-2
14 2 1 Measurement Error 14-2
14 2 2 MisclassIficanon of Health Outcomes 14-4
14.2 3 Adjustments for Covanates 14-4
1424 Selecnon BIas 14-5
1425 Internal ConsIstency 14-5
14.2 6 PlaUSIbility of Effects 14-6
14.3 STUDIES OF RESPIRATORY ILLNESS 14-6
14.3 1 Indoor StudIes 14-10
14311 Umted KIngdom StudIes 14-10
143 1 2 United States SIX CInes StudIes 14-18
143 1 3 Iowa Study 14-23
14 3 1 4 Dutch StudIes 14-24
14 3 1 5 OhIo Study 14-26
143 1 6 TaySIde Study 14-27
143 1 7 Albuquerque Study 14-28
143 1 8 Chestnut Ridge Study 14-33
14 3 1 9 SWISS Study 14-34
143 1 10 Connecticut Study 14-35
14.3 1 11 Maryland Study 14-37
14 3 1 12 German Study 14-37
143 1 13 CanadIan StudIes 14-38
143 114 North Carolma Study 14-38
143 115 Umted States and CanadIan Skatmg
RInk Exposures 14-40
143.2 Outdoor StudIes 14-40
14 3 2 1 SIX CIty StudIes 14-41
14 3.2 2 SWISS Study 14-42
14 3 2 3 German StudIes 14-43
14 3 2 4 Los Angeles Student Nurses Data 14-44
14325 Chestnut Ridge Study 14-45
14 3 2 6 Fmland StudIes 14-45
14327 CalIfornIa Seventh-Day Adventist Study 14-46
llI-vni
14 3 2 8 Chattanooga Studies 14-47

14 3 2 9 Glendora, Cahfonna, Study 14-49
14 4 STUDIES OF PULMONARY FUNCTION 14-49
14 4 1 Indoor Studies 14-50
14 4 2 Outdoor Studies 14-52
145 OUTCOMES RESULTING FROM OCCUPATIONAL
EXPOSURES 14-53
14 6 SYNTHESIS OF THE EVIDENCE 14-55
14 6 1 Health Outcome Measures 14-55
1462 BIOlogically PlaUSible Hypothesis 14-63
14 6 3 PubhcatlOn Bias 14-64
14 6 4 Quantitative AnalYSiS 14-65
14 6 5 Summary of SyntheSiS of EVidence 14-77
147 CONCLUSIONS 14-78
148 SUMMARY 14-79
REFERENCES 14-85
APPENDIX 14A 14-Al
15 CONTROLLED HUMAN EXPOSURE STUDIES OF

NITROGEN OXIDES 15-1
15 1 INTRODUCTION 15-1
15 2 EFFECTS OF NITROGEN OXIDES IN m~THY
SUBffiCTS 15-10
15 2 1 Lung FunctIOn Effects of Nitrogen DIOXIde 15-10
15 2 1 1 ConcentratIOns Above Jl 0 ppm 15-10
15 2 1 2 Concentrations Below 1 0 ppm 15-23
15 2 1 3 RespIratory Symptom and Sensory Effects
of Nitrogen DIOXIde Exposure 15-26
15 2 1 4 Mucociliary Clearance After Nitrogen
DiOXIde Exposure 15-26
15 2 2 Effects of Nitnc OXIde 15-26
15 2 3 Effects of Nitrogen DIOXIde Gas OJ" Gas!Aerosol
MIXtures on Lung Function ill Normal Subjects 15-27
1524 Summary 15-35
15 3 THE EFFECTS OF NITROGEN OXIDE EXPOSURE
IN SENSITIVE SUBffiCTS 15-36
15 3 1 The Effects of Nitrogen DIOXIde on Asthmatics 15-37
15 3 1 1 Effects of NltnC ACId Vapor on
Asthmatics 15-57
15 3 2 Effects of Nitrogen DIOXIde on Patients With
Chromc Obstructive Lung Disease 15-58
15 3 3 Summary 15-62
15 4 EFFECTS OF NITROGEN DIOXIDE EXPOSURE
ON AIRWAY RESPONSIVENESS 15-66
ill-IX
15 4 1 Healthy Subjects 15-67

15 4 2 AsthmatIc Subjects 15-67
15 5 EFFECTS OF NITROGEN DIOXIDE OR NITRIC ACID
EXPOSURE ON BLOOD, URINE, AND
BRONCHOALVEOLAR LAVAGE FLUID BIOCHEMISTRY 15-76
15 5 1 BiochemIcal Effects ill Blood 15-76
15 5 2 Bronchoalveolar Lavage FlUId BIOchemIstry . 15-78
15 5.3 Unne BIOChemIstry 15-79
15 6 EFFECTS OF NITROGEN DIOXIDE OR NITRIC ACID
VAFOR EXPOSURE ON HUMAN PULMONARY HOST
DEFENSE RESPONSES 15-79
15.7 EFFECTS OF NITRATES ON HUMAN LUNG FUNCTION 15-85
15 8 CONCLUSIONS AND DISCUSSION 15-88
REFERENCES. 15-94
16. HEALTH EFFECTS ASSOCIATED WITH EXPOSURE

TO NITROGEN DIOXIDE 16-1
161 INTRODUCTION 16-1
162 KEY HEALTH EFFECTS OF NITROGEN DIOXIDE 16-1
16.2 1 Arrway ResponsIveness ill AsthmatIcs and
Short-Term (One- to Three-Hour) Exposure
to NItrogen DIoXIde 16-1
16 2 2 Resprratory MorbIdIty ill ChIldren ASSOCiated
wIth Exposure to NItrogen DIOXIde 16-4
16 2 3 BIOlogical Bases Relatmg NItrogen DIOXIde Exposure
to Resprratory MorbIdIty Effects of NItrogen
DIOXIde on the Resprratory Host Defense System 16-5
1624 Emphysema and Exposure to NItrogen DIOXIde 16-9
16.3 CONCENTRATION-RESPONSE RELATIONSlllPS HEALTH
EFFECTS OF EXPOSURE TO NITROGEN DIOXIDE 16-11
16 3 1 ClmIcal StudIes 16-11
16 3.2 EpIdemIological StudIes 16-12
16 3 3 Arumal TOXIcologICal StudIes 16-13
16 4 SUBPOPULATIONS POTENTIALLY AT RISK FOR
NITROGEN DIOXIDE HEALTH EFFECTS 16-15
16.5 NITROGEN DIOXIDE LEVELS, EXPOSURES,
AND ESTIMATES 16-19
16 5 1 AmbIent and Indoor NItrogen DIOXIde Levels 16-19
16 5 2 Patterns of PotentIal Exposure to NItrogen
DIOXIde and Related Health Effects 16-22
16 5 2 1 Patterns of Exposure 16-23
16522 Long-Term Exposure EstImates 16-24
ill-x
1653 NItrogen DIOXIde Exposure Estunates 16-28

REFERENCES 16-32
APPENDIX A GLOSSARY OF TERMS AND SYJ\1J30LS A-I
ill-XI
liST OF TABLES
Number Page
13-1 Effects of NItrogen DIOXIde on MucocIhary ACtIVIty 13-18
13-2 Effects of Nitrogen DIOXIde on Alveolar Macrophages 13-24
13-3 Effects of NItrogen DIOXIde on the Immune System 13-35
13-4 InteractIon of NItrogen DIOXIde WIth InfectIous Agents 13-39
13-5 Effects of NItrogen DIOXIde on LIpId Metabohsm 13-56
13-6 Effects of NItrogen DIOXIde on Lung Ammo ACIds, Protems,

and Enzymes 13-63
13-7 Effects of NItrogen DIOXIde on AntIOXidant Metabohsm and

Influence of AntIOXidants 13-72
13-8 Effects of NItrogen DIOXIde on Pulmonary FunctIOn 13-79
13-9 Effects of Acute Exposure to NItrogen DIOXIde on

Lung Morphology 13-90
13-10 Effects of Subehromc Exposure to NItrogen DIOXIde on

13-11 Effects of Chrome Exposure to NItrogen DIOXIde on

13-12 Effects of NItrogen DIOXIde on the Development of Emphysema 13-121
13-13 Extrapulmonary Effects of NItrogen DIOXIde Body WeIght 13-126
13-14 Effects of NItrogen DIOXIde on Red Blood Cells and

Hemoglobm 13-130
13-15 Effects of NItrogen DIOXIde on Leukocytes and Platelets 13-132
13-16 Effects of NItrogen DIOXIde on Red Blood Cell Membranes 13-135
13-17 Effects of NItrogen DIOXIde on Serum Protems and

Chmcal CheIDlstrles 13-138
13-18 Effects of NItrogen DIOXIde on the LIver 13-139
ill-xn
UST OF TABLES (cont' d)
Number Page
13-19 Effects of NItrogen DIOXIde on the KIdney and

on Unne Contents 13-143
13-20 Effects of NItrogen DIOXIde on the Central Nervous

System and BehaVIOr 13-146
13-21 Effects of NItrogen DIOXIde on ReproductIOIl, Development,

and Hentable MutagenesIs 13-151
13-22 Effects of NItrogen DIOXIde on Carcillogenesis or

Cocarcillogenesis 13-153
13-23 TOXIcolOgiC InteractIons to SImple MIXtures Contammg

NItrogen DIOXIde 13-164
13-24 Effect of NItnC OXide on RespIratory Tract J\1orpho10gy 13-187
14-1 RespIratory Symptom Rates of Umted KIngdom ChIldren by

Gender, SOCIal Class, and Cookmg Type 14-12
14-2 Hasselblad et al (1992) Mulnple LogIsnc AnalySIS of Data

from the Meha et al (1977) Study 14-12
14-3 Unadjusted Rates of One or More RespIratory Symptoms Among

Umted KIngdom ChIldren by Gender, SOCIal Class, and
Cookmg Type 14-14
14-4 Hasselblad et al (1992) Mulnple LogIStIC AnalYSIS of Data

from Meha et al (1979) Study 14-14
14-5 Unadjusted Rates of One or More RespIratory Symptoms

Among Umted KIngdom Boys and Grrls by Bedroom Levels of
14-6 Unadjusted Rates of One or More RespIratory Symptoms Among

Umted KIngdom Boys and Grrls by Bedroom Levels of
14-7 NItrogen DIOXIde ConcentratIOns by Season and Stove

Type ill Portage, Wisconsm 14-19
14-8 Odds RatIOS and 95 % Confidence Intervals for the Effect of

an AddItional 0015 ppm NItrogen DIOXIde on the Symptom
Prevalence 14-21
ID-Xlll
LIST OF TABLES (cont'd)
Number Page
14-9 Odds Ratios and 95 % Confidence Intervals for the Effect of

Ordered NItrogen DIoXIde Exposures on the Prevalence of
Lower Resprratory Symptoms 14-22
14-10 Odds Ratios and 95 % Confidence Intervals for the Effect of an

AddItional 0 015 ppm NItrogen DIoXIde on the Prevalence of Lower
Respiratory Symptoms by Samphng LocatIOn and Season 14-23
14-11 AnalYSIS of Iowa CIty School ChIldren Resprratory Symptoms by

Gas Stove Type and Parental Smokmg 14-24
14-12 Dutch Study Estlmated and Measured Personal NItrogen DIoXIde

Exposure for a Smgle Weekly Average 14-25
14-13 Frequency and Prevalence of Reported Resprratory Symptoms for

Different Categones of Mean Indoor NItrogen DIOXIde
Concentrations m a PopulatIOn of 775 Dutch ChIldren
6 to 12 Years Old 14-26
14-14 RegreSSIOn CoefficIents for Multiple Logistic Analyses of

Resprratory Illness m TaySIde ChIldren 14-28
14-15 Odds Ratios for Effect of NItrogen DIOXIde Exposure on

Incidence of Resprratory Illness 14-32
14-16 Effects of Outdoor NItrogen DIOXIde Exposure on

Respiratory DIsease 14-41
14-17 Adjusted Annual Resprratory Symptom DuratIon and

NItrogen DIOXIde Levels by Region 14-43
14-18 Health Outcome and NItrogen DIOXIde Exposure Measures Used

m Selected Indoor NItrogen DIOXIde EpIdemIOlogy StudIes 14-57
14-19 Summary of Odds RatIos from Indoor StudIes of the Effects of

NItrogen DIOXIde Increased by 0 015 ppm 14-71
14-20 United States Envlfonmental Protection Agency Combmed

Analyses of Indoor StudIes on Resprratory Illness Effects
of Nitrogen DIOXIde Increased by 0 015 ppm 14-72
14-21 Covanate Treatment and Other Factors m Selected NItrogen

DiOXIde EpIdemIOlogy StudIes m Meta-AnalysIS 14-74
ill-XIV
liST OF TABLES (cont'd)
Number Page
14-22 Summary of Odds RatIOS of the Effects of NItrogen DIoXIde,

Health Outcome, and Exposure EstImates fOJ Infant
EpIdemIOlogy StudIes 14-76
15-1 Responses of Healthy Subjects to NItrogen DIoXIde Exposure 15-11
15-2 Exposure of Healthy Subjects to NItrogen DIOXIde MIXtures 15-29
15-3 ClassIficatIon of Asthma by Seventy of DIsease 15-38
15-4 Charactenstics of AsthmatIc Subjects Exposed to NItrogen

DIOXIde 15-40
15-5 Exposure CondItlons and Responses ill AsthmatIcs Exposed to

15-6 Subject Charactenstlcs for PatIents WIth Chromc Obstructlve

Pulmonary DIsease Exposed to NItrogen DIO lOde 15-59
15-7 Exposure CondItIOns and Responses ill Chromc Obstructlve

Pulmonary DIsease Patlents Exposed to NItrogen DIOXIde 15-60
15-8 AIrway ReSIstance and Forced ExpIratory Volume ill One Second
Changes ill AsthmatIcs Exposed to NItrogen DIOXIde 15-63
15-9 Changes ill AIrway ResponsIveness Associated WIth NItrogen

DIOXIde Exposure 15-68
15-10 FractIon of NItrogen DIoXide-Exposed Subjects WIth Increased

AIrway ResponSIveness 15-75
15-11 Exposure CondItlons and Responses ill Subjects Exposed to

NItrates 15-86
16-1 Key Human Health Effects of Exposure to Nltrogen

DIOXIde-Clmtcal StudIes 16-12
16-2 Key Human Health Effects of Exposure to Nltrogen

DIOXide-EpIdemIologIcal StudIes 16-14
16-3 Key Ammal TOXicologICal Effects of Exposure to NItrogen

DIOXIde 16-16
ill-xv
liST OF TABLES (cont'd)
Number Page
16-4 Esttmates of the ReSIdent PopulatIOn of Cluldren and Young

Adults of the Umted States, by Age and Sex, July 1, 1989 16-18
16-5 Umted States EnvlIonmental ProtectIOn Agency AnalYSIS of

Vanabillty ill Two-Week AmbIent Averages of One-Hour
NItrogen DIOXIde Data at 10 Selected Locanons 16-26
16-6 Average Annual NItrogen DIOXIde Means and Standard Errors

of Estunates for 40 SItes ill the Umted States by Annual
Average as Denved by the Umted States EnvlIonmental
Protecnon Agency from the Aerometnc InfonnatIOn Retneval
System (1991) 16-27
16-7 Average Annual NItrogen DIOXIde Means and Standard

Errors of Estunates for 100 Homes Based on Data
of Lambert (1991) as Denved by the US EnvlIonmental
Protecnon Agency 16-27
16-8 NItrogen DIOXIde Exposure Esttmates in Parts per MJ1hon

Derived by the Umted States EnvlIonmental ProtectIOn Agency as
Function of Outdoor NItrogen DIOXIde Concentranon and Percent
Tnne Outdoors, Where Indoor/Outdoor Rano Equals 059 and
Assummg a Basebne ConcentratIOn of 0 005 ppm 16-29
16-9 NItrogen DIOXIde Exposure Esttmates ill Parts per MJ1hon

Derived by the Umted States EnvlIonmental Protecnon Agency at
Selected Outdoor NItrogen DIOXIde ConcentratIOns, Indoor/Outdoor
Concentranon RatIOS, and Percentages of Ttme Spent Outdoors,
Compared WIth a NItrogen DIOXIde Exposure of 0 005 ppm 16-31
III-XVI
UST OF FIGURES
Number Page
13-1 Mortahty enhancement for mIce exposed to mtrogen dIoXide

at VarIOUS concentratIons and for VarIOUS duratIOns pnor
to challenge with streptococCI 13-48
14-1 DIstnbutIOn of tIme at nsk by bedroom mtrogen dIoXide

concentratIOn 14-31
14-2 NItrogen dIoXide ambient and Indoor concentJratIons In four

SWISS regIOns wIth 95 % confidence range 14-34
14-3 Total personal exposure to mtrogen dIoXide versus mtrogen

dIOXIde levels In Connecticut resIdences 14-36
14-4 For the Meha et al (1979) study, a graph of the margInal

hkehhood function of the odds ratios for combIned gender
(boys and gIrls) of the respIratory illness outcome measures
developed by the Umted States EnVIronmental ProtectIOn
Agency 14-60
14-5 Umted States EnVIronmental ProtectIOn Agency meta-analysIs of

Indoor epIdemIOlogic studIes of mtrogen dIoxlde exposure effects
on respIratory dIsease In chIldren 5 to 12 years old 14-70
15-1 Percent change (post-air versus post-mtrogen dIOXide) In

forced expIratory volume In one second versus mtrogen dIOXide
dose In parts per mIlhon times hters In asthmatics 15-65
15-2 Percent change (fpost-mtrogen dIOXide - post-arr]/post-arr)

In reSistance versus mtrogen dIOXide dose In parts per
mIlhon tImes hters ill asthmatIcs 15-65
ID-XVll
AUTHORS
Chapter 13 Stuches of the Effects of NItrogen Compounds on Ammals
Ms Beverly Comfort Dr John Overton

EnvIronmental Cntena and Assessment Office Health Effects Research Laboratory
U S EnvIronmental ProtectIon Agency U S EnvIronmental ProtectIOn Agency
Research Tnangle Park, NC 27711 Research Tnangle Park, NC 27711
Dr Donald Gardner Dr RIchard Schlesmger

ManTech EnvIronmental Technology, Inc New YOlk UmversIty
POBox 12313 Long Meadow Road
Research Tnangle Park, NC 27709 Tuxedo, NY 10987
Dr Juchth A Graham Dr Jeffrey L Tepper

EnvIronmental Cntena and Assessment Office ManTech EnvIronmental Technology, Inc
U S EnvIronmental ProtectIOn Agency POBox 12313
Dr Jerry Last Dr Walter S Tyler

Caltforma Pnmate Research Center VM Anatomy
UmversIty of Caltforma UmversIty of Caltforma
DaVIS, CA 95616 DaVIS, CA 95616
Dr Susan Loscutoff
2594 W Ellery Street
Fresno, CA 93711
Chapter 14. EpIdemIOlogy Stuches of OXIdes of NItrogen
Dr VIctor Hasselblad Dr Denms J Kotchmar

Center for Health Pohcy Research EnVIronmental Cntena and Assessment Office
Duke UmversIty Office of Health and EnVIronmental
Durham, NC 27713 Assessment
U S EnVIronmental ProtectIOn Agency
Chapter 15 Controlled Human Exposure Stuches of NItrogen OXIdes
Dr Lawrence J Fohnsbee
Health Effects Research Laboratory
U S EnVIronmental ProtectIon Agency
ill-XIX
AUTHORS (cont'd)
Chapter 16 Health Effects AssOcIated wIth Exposure to NItrogen DIoXIde
Dr. Donald Gardner Dr Lawrence J Fohnsbee

ManTech EnvlIonmental Technology, Inc Health Effects Research Laboratory
P.O Box 12313 U S EnvlIonmental ProtectIOn Agency
Dr. VIctor Hasselblad Dr JudIth A Graham

Center for Health Pohcy Research EnvlIonmental Cntena and Assessment Office
Duke Umversity U S EnvlIonmental ProtectIon Agency
Durham, NC 27713 Research Tnangle Park, NC 27711
Dr. Denms J Kotchmar

EnvlIonmental Critena and Assessment Office
Office of Health and EnvlIonmental
Assessment
U.S. EnvlIonmental ProtectIon Agency
ill-xx
CONTRIBUTORS AND REVIEWERS
Chapters 13-15
Dr Ursula Ackennann-LIebnch Dr Albert Collier

Department of SOCIal and PreventatIve 5:15 Chmcal SCIences Bldg C #7220
MedIcme UmversIty of North Carohna
UrnversIty of Basel Chapel Hill, NC 27599-7220
St Albanvorstadt 19
4052 Basel Dr Steven D Colome
SWItzerland Integrated EnvIronmental ServIces
41-61-21-60-67 UmversIty Towers, SUIte 1090
4] 99 Campus Dnve
Dr Ester Azoulay-DupUIs Irvme, CA 92715
INSERM Urnt 13-HosPItal Claude Bernard
10 Avenue de la Porte Ms Beverly Comfort
D'Aubervilleis EnvIronmental Cntena and Assessment Office
75019 Pans U S EnvIronmental ProtectIOn Agency
France Research Tnangle Park, NC 27711
Dr MIchael A Berry Dr James Crapo

EnvlJonmental Cntena and Assessment Office DllVISIOn of Allegy, CntIcal Care and
U S EnvIronmental ProtectIOn Agency RespIratory MedIcme
Research Tnangle Park, NC 27711 Box 3177
Duke UmversIty MedIcal Center
Dr Irwm H BIlhck Durham, NC 27710
Gas Research InstItute
8600 West Bryn Mawr Avenue Dlr Douglas Dockery
ChIcago, IL 60631 Harvard School of Pubhc Health
Department of EnVIronmental SCIence and
Dr Gary R Burleson PhySIOlogy
Health Effects Research Laboratory 665 HuntIngton Avenue
U S EnVIronmental ProtectIon Agency Boston,:MA 02115
DJ D L Dungworth
Dr Robert Chapman D(~partment of Vetennary Pathology
Health Effects Research Laboratory Umversity of CalIfonna
U S EnVIronmental ProtectIon Agency DaVIS, CA 95616
DJ Lawrence J. Fohnsbee
Mr DaVId Coffm Health Effects Research Laboratory
Health Effects Research Laboratory U S EnVIronmental ProtectIon Agency
U S EnVIronmental ProtectIOn Agency Research Tnangle Park, NC 27711
ill-xxi
CONTRIBUTORS AND REVIEWERS (cont'd)
Dr. Donald Gardner Dr Milan Hazucha

ManTech EnvIronmental Technology, Inc Center for EnVIronmental MedIcme and
P.O. Box 12313 Lung BlOlogy
Research Triangle Park, NC 27709 CB #7310 TraIler #4 MedICal Research
BuIldmg C
Dr JUdIth A Graham Umversity of North Carohna
EnvIronmental Critena and Assessment Office Chapel Hill, NC 27599
U.S. Environmental Protectlon Agency
Research Triangle Park, NC 27711 Dr Donald Horstman
Dr. Lester D Grant U S EnVIronmental ProtectIOn Agency
Environmental Cntena and Assessment Office Research Tnangle Park, NC 27711
U.S. EnvIronmental ProtectlOn Agency
Research Triangle Park, NC 27711 Ms Pamela Johnson
Office of AIr Quahty Plannmg and Standards
Dr Blame Grose U S EnVIronmental ProtectIOn Agency
Health Effects Research Laboratory Research Tnangle Park, NC 27711
U.S. Environmental Protection Agency
Research Triangle Park, NC 27711 Dr Howard Kehrl
Health Effects Research Laboratol"Y.
Dr. Jack Hackney U S EnVIronmental Protectlon Agency
EnvIronmental Health ServIces-Room 51 Research Tnangle Park, NC 27711
Rancho Los Almgos HOSpItal
7601 Imperial HIghway Dr Hillel Koren
Downey, CA 90242 Health Effects Research Laboratory
U S EnVIronmental ProtectlOn Agency
Dr. Victor Hasselblad Research Tnangle Park, NC 27711
Center for Health Pohcy Research
Duke University Dr Denms J Kotchmar
Durham, NC 27713 EnVIronmental Cntena and Assessment Office
U S EnVIronmental ProtectlOn Agency
Dr. Gary Hatch Research Tnangle Park, NC 27711
U.S EnVIronmental Protectlon Agency Dr Paul Kotm
Research Tnangle Park, NC 27711 4505 South YosemIte #339
Denver, CO 80237
Dr Carl Hayes
Health Effects Research Laboratory Dr Jerry Last
U.S. EnVIronmental Protectlon Agency CalIforma PrImate Research Center
Research Tnangle Park, NC 27711 Umversity of CalIforma
DaVIS, CA 95616
ill-XXI1
CONTRIBUTORS AND REVIE~N"ERS (cont'd)
Dr Bnan Leaderer Dr Steven Nesnow

PIerce FoundatIOn Laboratory Ht~althEffects Research Laboratory
Yale Umverslty School of MedlCme U S EnVIronmental ProtectIOn Agency
290 Congress Avenue Research Tnang1e Park, NC 27711
New Haven, CT 06519
Dr John Overton
Dr Thomas Lmdvall Health Effects Research Laboratory
Institute of EnVIronmental Medlcme U S EnVIronmental ProtectIOn Agency
Doktorsnngen 18 Research Tnangle Park, NC 27711
Tomtebodavagen 30
The Karolmska InstItute Dr Nell Roth
S-104 01 Stockholm, Sweden 6115 Executive Boulevard
Rockville, MD 20852
Dr Susan Loscutoff
2594 W. Ellery Street Ms Lon Saltzman
Fresno, CA 93711 US. Consumer Products Safety ComIDlsslon
5401 Westbard Avenue
Dr Joe L Mauderly Room 724
Lovelace InhalatIOn Tmoco1ogy Research Institute Bethesda, MD 20816
POBox 5890
Albuquerque, NM 87185 Dr Jonathan Samet
Umverslty of New MeXICO HOSpItal
Dr Dame1 Menzel Department of Med1cme 7 South
Department of Commumty and EnVIronmental 2211 Lomas N E
Med1cme AJbuquerque, NM 87131
Umverslty of Ca11forma
Irvine, CA 92717 Dr Richard Schlesmger
New York UniverSIty
Dr Fred Miller Long Meadow Road
Box 3177 l\lxedO, NY 10987
Duke Umversity
Department of Med1cme Dr MaryJane Selgrade
Durham, NC 27710 Health Effects Research Laboratory
U S EnVIronmental ProtectIOn Agency
Dr Paul E Morrow R<;~search Tnang1e Park, NC 27711
Umverslty of Rochester MedICal Center
School of Medicme and Dentistry Dlr Carl Shy
BoxEHSC Department of EpIdemIOlogy
Rochester, NY 14642 CB #8050 SUIte 32 NCNB Plaza
Umverslty of North Carolma
Mr Lucas Neas Chapel Hill, NC 27599-8050
Harvard School of Pubhc Health
6555 Huntlngton Avenue
Boston, MA 02115
ill-XXlll
Dr. Jeffrey L Tepper Dr James Ware

ManTech Environmental Technology, Inc Harvard School of Pubhc Health
P.O Box 12313 6555 Huntmgton Avenue
Research Triangle Park, NC 27709 Boston, MA 02115
Dr. Walter S Tyler Dr Ron Wyzga

V.M. Anatomy Electnc Power Research Institute
University of CalIforma 3412 HillVIew Avenue
DavIs, CA 95616 POBox 10412
Palo Alto, CA 94303
Dr Jaro Vostal
General Motors TechnIcal Center
Environmental ActivItIes Staff
30400 Mound Road
Warren,:MI 48090
Chapter 16
Dr. Michael Berry Dr. JudIth Graham

EnvIrOnmental Cntena and Assessment Office EnvIronmental Cntena and Assessment Office
U S. EnvIronmental ProtectIon Agency U S EnvIronmental ProtectIon Agency
Ms Beverly Comfort Dr Lester Grant

EnvIronmental Cntena and Assessment Office EnvIronmental Cntena and Assessment Office
U S EnvIronmental Protection Agency U S EnvIronmental ProtectIOn Agency
Dr. Robert W Elias Dr VIctor Hasselblad

EnvIronmental Cntena and Assessment Office Center for Health Pohcy Research
U.S Environmental ProtectIOn Agency Duke Umversity
Research Tnangle Park, NC 27711 Durham, NC 27713
Dr. Lawrence Folmsbee Dr Donald Horstman

Health Effects Research Laboratory Health Effects Research Laboratory
U.S. Environmental ProtectIOn Agency U S EnVIronmental ProtectIon Agency
Dr. Donald Gardner Dr Hillel Koren

ManTech EnvIronmental Technology, Inc Health Effects Research Laboratory
P.O. Box 12313 U S EnVIrOnmental ProtectIOn Agency
ill-XXIV
Dr Denms J Kotchmar Dr MaryJane Selgrade

Envrronmental Cntena and Assessment Office Health Effects Research Laboratory
U S Envrronmental Protection Agency U S. Envrronmental ProtectIOn Agency
Mr Tom McMullen
Envrronmental Cntena and Assessment Office
U S Envrronmental ProtectIOn Agency
ill-xxv
U S ENVIRONMENTAL PROTBCTION AGENCY
SCIENCE ADVISORY BOARD
CLEAN AIR SCIENTIFIC ADVISORY COMJv.1ITTEE
OXIdes of NItrogen RJeview
Fonner Chamnan ,Chamnan
Dr Roger 0 McClellan Dr George T Wolff

Chemtcal Industry Institute of TOXIcology General Motors Research Laboratones
POBox 12137 Environmental SCIence Department
Research Tnangle Park, NC 27709 'Varren, MI 48090
Members
Dr Glen R Cass Dr Joseph Mauderly

Envrronmental Engmeenng SCIence Inhalation TOXIcology Research InstItute
Department POBox 5890
MatI Code 138-78 .Albuquerque, NM 87185
Caltforma Institute of Technology
Pasadena, CA 91125 Dr Marc B Schenker
DIVISIon of OccupatIOnal and Envrronmental
Dr Jean Ford, Medtcal Drrector Medicme
Harlem HOSpItal Center I E H R BUIldIng
506 Lenox Avenue UniversIty of Caltforma
New York, NY 10037 DaVIS, CA 95616
Dr BenJamm Lm Dr Mark J Utell

Urnversity of Mmnesota Pulmonary Disease Urnt
125 Mechamcal Engmeenng Box 692
111 Church Street, S E Urnversity of Rochester Medtcal Center
Mmneapohs, MN 55455-0111 601 Elmwood Avenue
Rochester, NY 14642
Consultants
Dr WIlliam C Adams Dr John Balmes

Human Perfonnance Laboratory San FranCISCO General HOSpItal
Department of PhYSICal Education Occupational Health Chmc
Urnversity of Cahforma Building 9, Room 109
DaVIS, CA 95616 San FranCISCO, CA 94110
ID-XXVll
CLEAN AIR SCIENTIFIC ADVISORY COMMITIEE (cont'd)
Consultants (cont'd)
Dr. Douglas Dockery Dr John Skelly

Harvard School of Pubhc Health Department of Plant Pathology
Department of EnVIronmental SCIence and 212A Buckhout Laboratory
PhYSIOlogy Pennsylvama State Umversity
665 HuntIngton Avenue Umversity Park, PA 16802
Boston, MA 02115
Dr MIchael J Symons
Dr. James Fenters School of Pubhc Health
ITT Research Institute Room 3104D
10 West 35th Street McGavran Greenberg Hall
Chicago, IL 60616 Umversity of North Carohna at Chapel Hill
Chapel Hill, NC 27599
Dr. Gareth Green
Harvard School of Pubhc Health Dr Warren WhIte
677 Huntmgton Avenue 8840 Waterman Avenue
Boston, MA 02115 St LoUIS, MO 63130
Dr. Robert Mercer

Center for ExtrapolatIon Modehng
Box 3177
Duke UniversIty Medical Center
Department of MedIcme
Durham, NC 27710
DesIgnated Federal OffiCIal Staff Secretary
Mr. Randall C Bond Ms Jamce Jones

U S. EnVIronmental ProtectIon Agency U S EnVIronmental ProtectIOn Agency
Science Advisory Board (A-I01F) SCIence AdVISOry Board (A-101F)
401 M Street, S W 401 M Street, S W
Washmgton, DC 20460 Washmgton, DC 20460
ill-XXVill
PROJECT TEAM FOR DEVELOPMENT OF
AIR QUAliTY CRITERIA FOR OXIDES OF NITROGEN
SCIentrfic Staff
Dr Denms J Kotchmar, Project Manager Dr J H B Garner

EnvIronmental Cntena and Assessment Office EnVIronmental Cnteria and Assessment Office
(MD-52) (MD-52)
U S EnvIronmental ProtectIon Agency U S EnVIronmental ProtectIon Agency
Ms Beverly Comfort Mr Thomas B McMullen

EnvIronmental Cntena and Assessment Office HnvIronmental Cntena and Assessment Office
(MD-52) (MD-52)
U S EnvIronmental ProtectIon Agency U S Environmental ProtectIOn Agency
Research Tnangle Park, NC 27711 ~esearch Tnangle Park, NC 27711
Dr Robert W Ehas M[s Ellie R Speh, Office Manager

EnvIronmental Cntena and Assessment Office EnVIronmental CnterIa and Assessment Office
(MD-52) (MD-5'2)
U S EnvIronmental ProtectIOn Agency U S EnVIronmental ProtectIOn Agency
Mr WIlham G Ewald M,s Beverly Tilton

EnvIronmental Cntena and Assessment Office Envrronmental Cntena and Assessment Office
(MD-52) (MD-52)
U S EnvIronmental ProtectIOn Agency U S EnVIronmental ProtectIOn Agency
Research Tnangle Park, NC 27711 Rlesearch Tnangle Park, NC 27711
Techmcal Support Staff
Mr Douglas B Fennell, TechnIcal Ms DIane H Ray, TechnIcal InformatIOn

InformatIOn Specmhst Manager (Pubhc Comments)
EnVIronmental Cntena and Assessment Office EnVIronmental Cntena and Assessment Office
(MD-52) (MD-52)
U S EnVIronmental ProtectIOn Agency U S EnVIronmental ProtectIOn Agency
Research Tnangle Park, NC 27711 Rlesearch Tnangle Park, NC 27711
Mr Allen G Hoyt, TechnIcal EdItor and Mr Richard N Wilson, Clerk

GraphIc ArtIst EnVIronmental Cntena and Assessment Office
EnVIronmental Cntena and Assessment Office (MD-52)
(MD-52) U S EnVIronmental ProtectIon Agency
U S EnVIronmental ProtectIOn Agency Research Tnangle Park, NC 27711
ill-XXIX
PROJECT TEAM FOR DEVELOPMENT OF
AIR QUALITY CRITERIA FOR OXIDES OF NITROGEN (cont'd)
Document ProductIon Staff
Ms Mananne Barner, Graplnc ArtIst Ms Wendy B Lloyd, Word Processor

ManTech EnvIronmental Technology, Inc ManTech EnVIronmental Technology, Inc
P.O Box 12313 POBox 12313
Mr. John R Barton, Document ProductIOn Mr J Demck Stout, Graplnc Altist

CoordInator ManTech EnVIronmental Technology, Inc
ManTech EnvIronmental Technology, Inc POBox 12313
P.O. Box 12313 Research Tnangle Park, NC 27709
Research Triangle Park, NC 27709
Mr Peter J Wmz, TechnIcal EdItor
Ms Lynette D Cradle, Lead Word ManTech EnVIronmental Technology, Inc
Processor POBox 12313
ManTech Environmental Technology, Inc Research Tnangle Park, NC 27709
P O. Box 12313
Ms Jorja R Followill, Word Processor

ManTech EnvIronmental Technology, Inc
P.O. Box 12313
Research Triangle Park, NC 27709
Technical Reference Staff
Mr. John A Bennett, Blbhograplnc Echtor Ms Deborah L Staves, Blbhograplnc

ManTech EnVIronmental Technology, Inc Echtor
P O. Box 12313 Research InformatIOn Orgamzers
Research Tnangle Park, NC 27709 POBox 13135
Ms. Susan L McDonald, Blbhograplnc
Editor Ms PatnCla R Tierney, BIbhograplnc
Research InformatIOn Orgamzers EdItor
P.O. Box 13135 ManTech EnVIronmental Technology, Inc
Research Tnangle Park, NC 27709 POBox 12313
Ms. Blythe Hatcher, Blbhograplnc Echtor
Research Informatlon Orgamzers
P.O. Box 13135
ill-xxx
13. STUDIES OF TIlE EFFECTS OF NITROGEN
COMPOUNDS ON i\NIMALS
13.1 INTRODUCTION
ThIs chapter dISCUSSes the effects of the oXIdes of mtrogen (NO,J m expenmental
annnals PrevIOus reVIews of the hterature have appeared m a cntena document (U S
EnvIronmental ProtectIon Agency, 1982) A World He~alth OrgarnzatIon summary has also
been pubhshed (World Health OrgarnzatIon, 1977)
Most of the data presented m this chapter relate to the effects of mtrogen dIOXIde (N~)
on expenmental annnals because the vast maJonty of the NOx hterature IS on N02 The
results of the few comparatIve NOx studIes show that N02 appears to be the most tOXIC of
the NOx specIes, but deftmtlve conclusIOns on relatIve quantItatIve potency must aWaIt new
mfonnatlOn on major NOx specIes The maJonty of the hterature descnbes the effects of
N02 on the respIratory tract, however, extrapulmonary effects also have been observed and
are mcluded here A broad range of N02 concentratIOns have been evaluated, but only
studIes conducted at less than 18,800 p,g/m3 (10 ppm) N02 are dISCUSSed, WIth emphaSIS on
3
those studIes at exposure concentratIons of 9,400 p,g/m (5 0 ppm) or less, WIth the exceptIon
of studIes on dOSImetry and emphysema
DISCUSSIons of the avaIlable hterature on the effects of other NOx compounds and
mIXtures contammg N02 are also included m thts chapter These sectIons are short because
of the general lack of mfonnatIon m these areas
13.2 NITROGEN DIOXIDE

13.2.1 Respiratory Tract Transport and Absorption
13.2.1.1 Introduction
DOSImetry refers to measurement or estImatIon of the quantIty of a chemIcal absorbed
by target SItes such as the pulmonary regIon tIssue or, more locally, the tIssue of the.
centnacmar region DOSImetry allows exposure-respons,e data mto be transfonned to dose-
response relatIonshtps However, to quantItatIvely extrapolate ammal data to humans,
13-1
knowledge of dosnnetry and specIes senSItIvIty must both be consIdered Even when two
species receIve an IdentIcal local tIssue/cellular dose, cellular sensItIvIty and reparr/defense
mechamsms determme the extent and type of mJury produced These mechamsms are hkely
to vary among humans and annnals because of dIssnnIlantIes m pharmacokInetIcs, genetIc
makeup, metabohc rates, detoXIficatIon systems, and/or other factors At present, knowledge
of dosimetry IS more advanced than knowledge of specIes senSItIVIty, mhIbItmg quantitatIve
annnal-to-human extrapolatIon of effectIve N02 concentratIOns Nevertheless, knowledge of
interspecies dIfferences and snnIlantIes m dosnnetry alone IS CruCIal to the process of nsk
assessment, as will be dIscussed
The compound most drrectly responSIble for toXiC effects may be the mhaled gas, here
N02, or chemIcal reactIon products or metabohtes Complete IdentIficatIOn of the actual
toXiC agents and theIr mtegratIOn mto dosnnetry IS a complex Issue that has not been fully
resolved Thus, most dosnnetry mvestIgatIons, whIch are dIfficult enough, are concerned
wIth the dose of the pnmary mhaled chemIcal In the context of mter- or mtraspecies
dosimetnc extrapolatIon, a further confoundmg factor can be the umts of dose (e g , mass
retained per breath, mass retamed per breath per body weIght, mass retamed per breath per
respiratory tract surface area) That IS, when comparmg dose between specIes, what IS the
relevant measure of dose? ThIs questIOn, hke the preVIOUS Issue, has not been answered,
umts are often dIctated by the type of expenment and/or by the chOIce of the mvestIgators
Theoretical (modehng) and expenmental studIes are used to obtam InformatIOn on dose
Experiments have been conducted to obtam dIrect measurements of absorbed N02 m the total
respIratory tract, the upper respIratory tract (regIOn proXImal to the tracheal entrance), and m
the lower respIratory tract (regIOn dIstal to tracheal entrance) However, obtammg
experimental absorptIon data for smaller regIOns or locatIOns, such as specIfic arrways or m
the centnacinar regIOn where leSIOns due to N02 occur (see SectIon 13 2 2 4), IS extremely
dIfficult, and may not be pOSSIble m the near future because of techmcallnnitatIons
Nevertheless, expenmentatIOn IS nnportant for determmmg dose, assessmg hypotheses and
concepts, and vahdatmg mathematIcal models that may be of use m predIctmg dose to
specific SItes
Theoretical studIes are based on the use of mathematIcal models developed for the
purposes of snnulatIng the uptake and dIstnbutIOn of gases that are absorbed m the tIssues
13-2
and flUIds of the respIratory tract, usually at the generatlOnallevel Because the factors
affectmg the transport and absorptIOn of gases are generatl to all mammals, a model that uses
appropnate speCIes and/or dIsease-specIfic anatomIcal and ventilatory parameters can be used
to descnbe absorptIOn by dIfferent-sIZed, aged, or dIseased members of the speCIes Models
may also be used to IdentIfy areas needmg addItlonal research, to make mter- and
mtraspecIes dose compansons, to compare and reconcile data from dIfferent expenments, to
predIct dose m condItIOns not pOSSIble or feaSIble expenrnentally, to better understand the
processes mvolved m tOXiC effects, and to deSIgn expenments
The amount of N02 actmg at a gIVen SIte IS dependent on the nearby arrway lummal or
arrspace concentratlon and the transport of the gas to the SIte In the movement of the gas
from the arrway lumen or arrspace to the cellular components of the respIratory tract, N02
:fIrst comes m contact WIth the lIqUId or flUId that hnes the cells or tlssues of the respIratory
tract (mamly consIstmg of mucus and pencmary flmd m the upper respIratory tract and
tracheobronchIal regIOn and of surfactant :film and serous flUId m the pulmonary regIOn)
NItrogen dIOXide reacts chemically WIth the constltuents of flUIds and tlssues The reactIOns
WIth the chemIcal components of the lIqUId hnmg are hkl~ly to reduce the quantlty of the
mhaled gas reachmg the tlssue However, reactlons m the hnmg may also produce products
that, m tum, may mcrease tOXICIty above that produced by the dIrect actlon of N02 alone
13.2.1.2 Principles of Gas Uptake and Dosimetry Models

To further our understandmg of the absorptlon of gases, mathematlcal models have
been developed to SImulate the processes mvolved and to predIct absorptIOn by vanous
regIOns and SItes Withm the respIratory tract
Arumal specIes-specIfic mformation that characterIZes respIratory tract morphology and
anatomy and transport processes, mcludmg chemIcal reactlons, IS needed for mathematlcal
modehng AnatomIcal mformatlon needed mcludes data about the phYSICal dImenSIOns and
geometry of the structural elements of the respIratory tract (e g , airways, alveolI), the lIqUId
hnmgs, the underlymg tlssues, and the capilhary blood system In the arr phase or arr
compartment (arrway lumens and arrspaces), the processes of convectIOn, molecular
dIffuSIOn, turbulence, dIspersIOn, and the loss or gam of gaseous specIes to and from the
respIratory tract walls must be taken mto account Factors to be conSIdered m lung flUIds
13-3
and tissues Include the bIochemIcal constItuents, chemIcal reactIons, solubility, molecular
dIffusion, convectIOn due to mucociliary actIOn, and capillary blood flow A detaued
dISCUSSIon of these factors can be found In Overton (1984) and Ultman (1988)
Although vanatIOns In phySIOlogICal processes and structures occur between speCIes,
laboratory anImals and humans are very slIDuar, enabbng doslIDetry models to be developed
based on the vahd concept of a general mammahan respIratory tract structure and
physiologIcal processes that apply to both humans and laboratory anImals As a result, only
one dosimetry model IS needed for the slIDulatIOn of uptake In several speCIes or subjects
However, specIes- or subject-dependent structural and phYSIOlogICal data m a form useable
,
by such a model IS requITed to slIDulate the absorptIon of N02 by a specIfic anImal or
human
There IS only one reported theoretIcal mvestIgatIon of N02 doslIDetry, It was dISCUSsed
onginally m Miller et al (1982) and later m Overton (1984) The doslIDetry model used for
this investigatIOn was one developed for modebng of ozone (Og) uptake, however, because
N02 , hke 03' is highly reactIve m the respIratory tract tIssues and flmds and IS not very
soluble, this model IS conSIdered to be vahd for N02 (Miller et al ,1982) Because there
are very few N02 doslIDetry modebng results and the pnncipies of Og uptake are general and
apply to N02 , the followmg IS a dISCUSSIOn of the general aspects and the factors that have
been considered for doslIDetry models of Og
For doslIDetry models, lung dImenSIOns and form usually are accounted for by usmg
airway or anatomIcal models based on upper respIratory tract, tracheobroncmal, and
pulmonary region data The upper respIratory tract can be modeled as a senes of segments
along the path through the upper respIratory tract arrways, segment dlIDensIOns (length,
dIameter, surface areas, etc) are often based on cast data (e g , Schreider and Raabe [1981]
for the rat and Patra et al [1986] for a human child) In the lower respIratory tract, the
complex and numerous branch1ng arrways are represented by a sequence of sets of nght
clfcular cylmders (e g , WeIbel [1963] for humans and Yeh et al [1979] for rats) Each set
corresponds to a generatIOn and each cylmder represents an arrway or alveolar duct ThIs
type of lower respiratory tract model slIDplrfies the development of doslIDetry models m that
all paths from the trachea to the last generatIon arrway or duct are assumed IdentIcal Thus,
13-4
a descnptIOn of transport and absorptIOn m one arrway m a given generatIOn IS the same as
any other arrway m that generatIon (Overton, 1984)
Although gas transport m the arrways IS a three-dllnensIOnal problem, the use of the
styhzed anatomIcal models have lead to the development of methods that allow the
descnptIOn of transport m tenns of a one-<hmensIOnal, tIme-dependent partIal dtfferentIal
equatIon (Overton, 1984) The change wIth respect to tune of the average cross-sectIOnal
concentratIon of the mhaled gas m an arrway IS related to axtal dIspersIOn, convectIon, and
wall loses due to phYSICal absorptIOn and chemIcal reactLons Transfer to the hqUld hnmg IS
often descnbed m tenns of mass transfer coefficIents and the hqUld-phase and gas-phase
mterfacial concentratIOns, related by Henry's law constant In resptratory tract flmds and
tIssues, only chemIcal reactIons and transport perpendtcular to the mterfaces between the atf,
hqUld, and tIssue compartments have been taken mto account ChemIcal reactIOns m the
tIssue and flUlds have been modeled m several ways, dependmg on assumptIons about the
type and nature of the reactIons that effecttvely descnbe the reactIOn processes Reacttons
have been modeled as mstantaneous or first-order and tune-dependent or steady state,
dependmg on the mvestIgators and the state of understandmg Dostmetry models also
account for ventilatIOn, whtch plays an tmportant role ill dehvered dose, some models
mc1ude the effects of expansIOn and contractton to accoUlnt for the fact that dtmensIOns vary
dunng the breathmg cycle (Overton et al , 1987)
Postlethwatt and Bidani (1990) exposed ventilated, Isolated rat lungs to 18,800 to
3
118,000 p,g/m (10 to 63 ppm) N02 for up to 1 h and found eVIdence for both hnear and
nonlmear chemIcal reactIon processes N0 2 uptake (mass of N02 retamed) was proportIonal
to mhalatIOn rates from 2 to 14 p,g N02 /rnm, but saturated WIth greater N02 mhalatIon rates
For the lower rates, reactIOns can be modeled as :ftrst order kmettcs EVIdence for hnear
reactIOns was also observed m an m VItro expenment m whtch Postlethwatt et al (1990)
exposed rat bronchoalveolar lavage flUld to N02 « 19,700 p,g/m3 , 105 ppm) How thts
relates to m VIVO condItIons IS not clear The authors suggested that the renewal of
bIOchemIcal compounds plays a role m N02 uptake and that It IS the rate of thts renewal that
IS hmItmg the uptake A further understandmg of the nonlmeat1.ty aspects IS needed to Judge
If hneanty IS a reasonable assumptIOn for envIronmental condItIOns or If nonlmeanty must be
taken mto account (e g , renewal)
13-5
In another m VItro expenment by PostlethwaIt and coworkers (PostlethwaIt et al ,
1991), rat bronchoalveolar lavage flUId was used to explore whether or not unreacted N02
can penetrate the epIthehal hqUId hnmg to underlymg sItes The mvestIgators concluded that
3
inhaled N02 (:::; 18,800 p..g/m , 10 ppm) does not penetrate the epIthehal hqUId hnmg to
underlying sItes In addItIon to Implymg a very hIgh chemIcal reactIvIty m thIs layer, the
mvesngators suggested that CytOtOXICIty IS the result of chemIcal reactIOn products formed m
the liquid hnmg
In hght of the work of PostlethwaIt and coworkers, It IS of mterest to note that for the
theoretical N02 dOSImetry mvestIgatIOn of MIller et al (1982), N02 chemICal reactIons were
modeled as instantaneous and only as occurrmg m the hqUId hnmg Further, a renewal
process was assumed On the other hand, the tIssue was assumed to be very reactIve and
N02 was predIcted to reach and react WIth the tIssue throughout most of the lower
respIratory tract Uptake saturatIon would not have been predIcted by the model and, m
contrast to PostlethWaIt and Bldam (1990) and PostlethwaIt et al (1990), the model predIcted
nonlmear uptakes at low N02 concentratIOns and lmear uptakes at hIgh N02 concentratIons
(Miller et al , 1978)
The word "uptake" IS often used m conjunctIon WIth gas dOSImetry Generally, the
meaning of thIs word depends on context and should be defmed to reduce ambIgUIty, IT the
meaning IS not ObVIOUS Uptake can denote a measure of the quantIty of gas absorbed (e g ,
100 g) m a region or at a specIfic SIte Unless otherwIse stated, the terms "fractIOnal
uptake" and "percent uptake" refer, respectIvely, to the fractIon or the percent of the Inhaled
N02 retamed by the specIfied respIratory tract regIOn
13.2.1.3 Dosimetry of Nitrogen Dioxide

Based on the findmgs of NOTmduced leSIOns m the respIratory tract of expenmental
anImals (SectiOn 13 224), It appears that N02 IS absorbed along the entIre respIratory tract
Upper Respiratory Tract Absorption

The upper respIratory tract uptake of N0 2 has been expenmentally estImated m dogs,
rats, and rabbIts Usmg umdrrectiOnal flow, Yokoyama (1968) measured N02 uptake m the
3
Isolated upper aIrways of dogs and rabbIts exposed to 7,520 to 77,100 p..g/m (4 to 41 ppm)
13-6
The upper resprratory tract of the two SpecIes was obselved to remove 42 1 % (standard
deViatIOn = 149%) of the N02 drawn through the noses The authors dId not discuss the
relative humIdIty of the arr If It were not sufficIently hIgh, the contmuous arrflow would
dehydrate the mucous membrane, possibly affectmg the uptake properties of the upper
resprratory tractCavanagh and Moms (1987) exposed the Isolated upper resprratory tract of
3
naIVe and prevIOusly exposed rats (76,000 p.g/m , 40 4 ppm N02) under umdrrectIOnal flow
and found the uptakes to be 28 and 25 %, respectively The relative humidity of the
"Inhaled" arr was marntamed so as to be eqUivalent to 92 % at 37° C The reported uptake
dIfference between the naive and previously exposed rats may not be sIgmficant because a
multIvanable analysIs of vanance, and not an analysIs of vanance, test should have been
used to analyze the data
3
Klemman and Mautz (1991) exposed SIX tracheostomlZed dogs to 1,880 or 9,400 p.g/m
(1 0 or 5 0 ppm) N0 2 and measured uptake durmg InhalatIOn Ventl1atIOn rates were vaned
from approxnnately 2 to 14 L/mm by addmg carbon dioXide (CO~ to the msprred arr
Durmg mouth breathmg, fractIOnal uptake was not dependent on concentratIOn and the mean
fractIOnal uptake decreased from 65 % to 30 % as the ventIlatIOn rate mcreased for 2 to
3
8 L/mm However, for nasal breathmg, exposure to 1,880 p.g/m N02 resulted in
slgmficantly greater fractIOnal uptake than did exposure to 9,400 p.g/m3 For the lower
exposure concentratIOn, the mean nasal fractIOnal uptake decreased from 55 % to 40 % over
the same ventIlatIOn range Although the mean fractIOnal nasal uptake was larger than oral
uptake, at ventl1atIOn levels correspondmg to moderate t~xercise, there was no statistically
slgmficant dIfference
Lower RespIratory Tract Absorption

Com et al (1976) estlIDated the average mass transfer coeffiCient (K) of N02 m the
lower resprratory tract of cats The values of K measured were associated With the regIOn
between the trachea and a portIOn of the lung assocIated With the "nght lateral thoracIc
regIOn between the fourth and fIfth nb" No dependence of K on N02 concentration changes
or ventl1atory rates was observed Accordmg to Postlethwait and Bidam (1990), the
estlIDated value of K IS unreasonably large Also, a companson of the Com et al (1976)
value of K to theoretical values mferred from Overton et al (1987) for 03 mdlcate that the
13-7
expenmentally detennmed K for N02 IS over 240 tImes as large as those used for modehng
ozone uptake Further work IS needed to detennme mass transfer coefficIents of N02
PostlethwaIt and Mustafa (1981) measured the uptake of N02 by an Isolated ventilated
perfused rat lung The Isolated lungs were exposed for 90 mm to 9,400 p,g/m3 (5 0 ppm)
N02 at a ventilatIon rate of 45 mL/mm ThIrty-SIX percent of the ventilated N02 was
retamed In a later sImIlar expenment wIth the exposure concentratIon rangmg from
7,520 to 37,600 p,g/m3 (4 to 20 ppm) and the mmute volume rangmg from 45 to
130 mUmm for dIfferent groups of lungs, PostlethwaIt and Mustafa (1989) found that the
quantIty of N02 retaIned was related hnearly to the Inhaled quantIty of N02 , the percent
uptake ranged from 60 to 72 % wIth an average of 65 % These results dIffer consIderably
from the fIrst expenment and no reasons for the dIfferences m results were gIven Although
the tidal volumes m these expenments are realIstIc, the breathmg frequencIes are generally
much lower than for rats breathmg nonnally SImilar expenments should be performed
usmg more realIstIc ventilatory parameters
In addItion to measurmg upper respIratory tract uptakes m dogs, Klemman and Mautz
(1991) also measured lower respIratory tract uptake They found that the fractIOnaJl uptake of
N02 by dog lungs ventilated through a tracheostomy was about 90 % of the N02 msprred by
the lungs ThIs fractIOnal uptake was basIcally mdependent of ventilatIOn rates from 3 to
16 Umm, but was somewhat hIgher at lower ventilatIOn rates From 1 to 4 L/mm, some of
their fractIonal uptakes were greater than 100%, whIch IS not possIble The mvesugators
hypothesIZed that the greater than 100 % values were related to an expenmental error m the
dead space correctIon equatIon used for estImatIon of fractIonal uptake How thIs type of
error effects other measurements IS not clear, but the effect of mstrument dead space on
estImates of fractIonal uptake should decrease as tIdal volume mcreases
Results from SImUlatIOns of N02 uptake m the lower respIratory tract were descnbed
by Miller et al (1982) and Overton (1984) The model used for thIs mvestIgatIOn was the
same as the dOSImetry model descnbed m Miller et al (1978) for 03' but wIth the dIffuSIOn
coefficient and Henry's law constant appropnate to N02 , however, values of the latter
constant and the chemIcal reactIOns were conSIdered uncertaIn The mvestIgatIOn was maInly
a sensitIvIty study of the effects of Henry's law constant and reactIOn rates for whIch the
upper lImit of the latter was assumed to be the reactIOn rate of 0 3 For humans, the results
13-8
mdlcate that N02 IS absorbed throughout the lower resp tratory tract, but the major dose to
tIssue would be dehvered m the centnacmar regIOn, tha1 IS, the JunctIon between the
conductmg and respIratory arrways SImUlatIOns also predIcted that peak tIssue levels would
occur m thIs same anatomIcal regIon of the rat, gumea pIg, and rabbIt These fmdmgs are
conSIstent WIth the SIte of morphological effects (SectIOIll 13 224) Beyond thIs regIon there
IS a rapId fall m the N0 2 dose dehvered to tIssue Dependmg on the tracheal concentratIOn
and tIdal volume, the model predIcted that 75 to 95 % oj the N02 entermg the trachea could
be retamed m the lower respIratory tract tIssues and flUIds However, these predIctIOns are
dependent on the mvestIgator's chOIces of values for the uncertam parameters The results
also predict that exerCIse will mcrease the amount of N02 dehvered to and absorbed m the
pulmonary regIOn over that at rest, and will reduce percent uptake m the tracheobronchIal
regIon (Miller et al., 1982, Overton, 1984)
Total Respiratory Tract Abs01ption

Total respIratory tract uptake has been measured ill healthy and dIseased humans
Healthy humans were exposed by Wagner (1970) to a rutnc made (NO)/N02 mIXture
contammg 550 to 13,500 p,g/m3 (029 to 7 2 ppm) N02 for bnef (but unspecIfied) penods
Of the mhaled N02 , 81 to 90% was absorbed during normal respIratIon, thIs mcreased to
91 to 92 % WIth maxImal ventilation Bauer et al (1986) exposed adult asthmatIcs to
3
560 p,g/m (0 3 ppm) N02 for 30 mm The exposed subjects mhaled N02 by mouthpIece for
20 mm at rest, then exerCIsed for 10 mm on a bIcycle elgometer (30 L/mm). The mspIred
and expIred N02 concentratIons were measured, showmg that the average uptake was 72 % at
rest, whereas the average uptake was 87 % durmg exerCIse, a statIstIcally sIgmficant mcrease
The effects of N02 exposure on pulmonary functIOn m humans followmg thIs exposure
regIme are reported m Chapter 15 of thIs document
Russell et al (1991) exposed rats to N02 labeled WIth oxygen-15 (e50]-NO~ and
determmed the dlstnbutIon of thIs compound m the upper and lower respIratory tract They
found that the combmed nasopharynx and larynx contamed 94 % of the radIolabeled N02
retamed by the respIratory tract In the lower resprratory tract, the trachea and the five lung
lobes each contamed from 0 6 to 1 5 % of the retamed [I50 ]-N02
13-9
Kleinman and Mautz (1991) also measured the fractIOnal uptake of the entIre
resprratory tract of female beagle dogs exposed to 9,400 p.,g/m3 (5 0 ppm) whIle ste'U1dmg at
rest or exercismg on a treadmill The dogs were not tracheostllll1zed, but breathed through a
small respiratory mask Durmg rest at the end of exerCIse and durmg contmuous rest, the
fractional uptake of the entIre resprratory tract was measured to be about 78 % The
fractional uptake was 94 % durmg the exerCIse exposures
Effect of Exercise on Respiratory Tract DosImetry

Expenments mdIcate that mcreased ventilation decreases percent uptake m the upper
resprratory tract, and increases the percent uptake m the lower and total resprratory tract
In all cases, the effect of mcreased ventilatIOn IS an mcrease m the quantity of N02 absorbed
by the indIVIdual regIOns The reductIOn of percent uptake m the upper resprratory tract due
to mcreased ventilation results m a greater proportIOn of mhaled N02 bemg dehveled to the
lower resprratory tract Also, the SWItch from oronasal to oral breathmg at hIgh exerCIse
levels IS expected to mcrease the dehvery of N02 to the lower resprratory tract because the
percent of N02 removed by the mouth IS less than that removed by the nasal caVIty
Aharonson et al (1974) predIcted a negative correlation between percent upper
resprratory tract uptake and ventilation usmg a model The model analyzed data from
expenments on the uptake of vapors by the nose The model was based on assumptions of
quasi-steady-state flow, mass balance, that the flux of a trace gas at the aIr-mucus mterface IS
proportional to the gas-phase concentration of the trace gas and a local mass trace gas, and a
local mass transfer coeffiCIent Miller et al (1985) and Overton et al (1987) illustrated the
effects of ventilation on the lower resprratory tract uptake of 0 3 The theoretical work of
Miller et al (1985) on uptake m humans shows that exerCIse has a milllIDal effect m the
tracheobronchIal regIOn on tissue dose (1 e , quantity of 03 absorbed by umt area of tissue
per umt tIme) and a pronounced mcrease m the dose to the pulmonary regIOn tIssues As the
exercise level was increased, the maXImum tissue dose (at the fIrst resprratory bronchIole for
the restIng state) shIfted dIstally several generatIOns and mcreased by a factor of 19 (over that
of the restIng state and at the generatIon of the shIfted maXImum) for the highest SImulated
exerCIse level Furthermore, thIs dose mcrease was more than tWIce the ratio of the exerCIse
to rest minute volumes On the whole, the pulmonary regIOn absorbed 13 tImes as much at
13-10
the hIghest ventilatIOn rate than at the lowest ventilatIOn rate In contrast, the
tracheobronchIal regIOn dose only mcreased by a factor of I 4 for the same ventilatIOn rate
mcrease The snnulatIOn results for rats (Overton et al , 1987) are m agreement wIth these
predIctIOns Because the upper respIratory tract dehvers a greater proportIOn of mhaled N02
to the lower respIratory tract dunng exerCIse than at re&t, the factors quoted above are
expected to be conservative Thus, the modehng results predict that exerCIse (WIth respect to
the restmg state) dehvers a disproportionately greater quantity of the mhaled mass to the
pulmonary regIOn and an even greater disproportIOnate quantity to the more dIStal pulmonary
regIOn surfaces QuahtatlVely, snnilar conclusIOns for N02 are reasonable
Systemzc Dosimetry
Once depOSIted, N02 dIssolves m lung flUIds, and vanous chemIcal reactIOns occur,
gIvmg nse to products that are found m the blood and other body flUIds Svorcova and Kaut
(1971) suggested that mhaled N02 entered the bloodstream based upon estnnates of
radIOlabelled mtrate and mtnte levels m the blood and unne of rabbIts followmg exposure to
45,120 p,g/m3 (24 ppm) N02 for 4 h The lmual transfonnatIOn products followmg N02
absorption have been the subject of some speculatIOn, however
3
The dIstnbution of N02 radIOlabeled wIth mtrogen-13 (560 to 1,710 p,g/m [0 3 to
091 ppm] mhaled for 7 to 9 mm) m rhesus monkeys was mvestIgated by Goldstem et al
(1977b) They concluded that mhaled N02 was dIstnbuted throughout the lungs, and that It
probably reacts wIth the water molecules m the flUIds of the respIratory tract to fonn mtrous
aCId (HONO) and mtnc aCId (HN03), the authors suggested that the aCIds were responSIble
for subsequent tOXiC effects Based upon the absorption of N02 by Isolated ventilated
perfused rat lungs, Postlethwait and Mustafa (1981) proposed that the mam reactIOn of N02
was not wIth lung water, but wIth readily OXidIzable tissue components (e g , protems and
hpIds) to produce mtnte These mvestigators found that 70% of absorbed N02 appeared as
mtnte m perfusate and lung tissue, and that the concentratIOn of mtnte produced mcreased
wIth tIme dunng exposure They also hypotheSIZed that mtnte m the blood may then be
OXidIzed to mtrate by mteractIOn wIth hemoglobm m red blood cells In a snnI1ar
expenment, Postlethwait and Mustafa (1989) exposed Isolated perfused rat lungs, to vanous
concentratIOns (7,520 to 37,600 p,g/m3 , 4 to 20 ppm) and mmute volumes (45 to 130 L/mm)
13-11
and found that the amount of mtnte detected m the perfusate was proportIOnal (56%) to the
amount of N02 retamed by the lung Saul and Archer (1983) provIded support for thIs
pathway using an m VIVO system m whIch rats were exposed for 24 h to N02 concentratIOns
of 2,260 to 16,540 Jtg/m3 (1 2 to 8 8 ppm) They also concluded that the mam reactIon
pathway of absorptIon m the lungs was the reactIon of N02 wIth oXidIZable tIssue
components to produce mtnte ThIs product may then serve as a precursor for other
chemical reactIOns at extrarespIratory SItes
The current data base mdIcates that once N02 IS absorbed m lung flUIds, the subsequent
reactIon products are rapIdly taken up and then translocated Via the bloodstream For
example, intratrachea1ly mstilled mtnte has been shown to be rapIdly absorbed mto blood
from the lungs (parks et al , 1981) Oda et al (1979, 1980b), after exposmg rats to
20,900 to 113,000 Jtg/m3 (11 1 to 59 9 ppm) N02 labeled wIth mtrogen-15 for 05 to
53.9 h, found mcreased levels of labeled mtrogen m the lungs, kidneys, plasma, and unne,
as well as an mcreased level of mtnte m plasma In a later study, Oda et al (1981) noted a
concentratIon-dependent mcrease m both mtnte and mtrate levels m the blood of mIce dunng
1-h exposures to 9,400 to 75,200 Jtg/m3 (5 to 40 ppm) N02 The blood levels of mtnte and
nitrate declmed rapIdly after exposures ended, wIth the decay half-tImes of a few mmutes for
nitnte and about 1 h for mtrate The shorter tIme for the fonner was ascnbed to Its rapId
reaction (oxidatIon) wIth hemoglobm, producmg mtrate and methemoglobm (Oda et al ,
1981; Kosaka et al , 1979, Case et al , 1979), although such measurements were not made
Free nitrate m blood IS generally excreted m unne (Greene and Hiatt, 1954, Hawksworth and
Hill, 1971)
Summary
The Important phYSICal, chemIcal, and bIOlogICal factors mvolved m the uptake of N02
by the respIratory tract were reVIewed These factors must be taken mto account ill order to
interpret and understand expenmental dOSImetry results and to develop models that SImulate
N02 uptake for mterspecies extrapolatIOn purposes WIth respect to dOSImetry, the followmg
has been observed Total respIratory tract uptake m humans ranged from 72 to 92 %
depending on the mvestIgatIon and the breathmg state (Wagner, 1970, Bauer et al , 1986)
The percent total uptake was found to mcrease WIth mcreasmg exerCIse level Upper
13-12
respIratory tract uptakes have been measured m dogs, rabbIts, and rats (Yokoyama, 1968,
Cavanagh and Moms, 1987, Klemman and Mautz, 1991, Russell et al ,1991) Uptake
values ranged from as low as 25 % to as hIgh as 94 % dependmg on the study, specIes, arr
flow rate, and mode of breathmg (nasal or oral) Percent upper respIratory tract uptakes
were found to decrease wIth mcreasmg ventIlatIOn, uptakes VIa nasal breathmg were
determmed to be sIgnrficantly greater than oral breathmg uptakes For the lower respIratory
tract, Klemman and Mautz (1991) found that the fractIOnal uptake of N02 by dog lungs
ventilated through a tracheostomy was about 90 % of the msprred dose Uptake values of
36 and 72 % have been reported for Isolated, ventilated, perfused rat lungs (PostlethwaIt and
Mustafa, 1981, PostlethwaIt and Mustafa, 1989) Experunental eVIdence mdIcated that N02
chemIcally reacted WIth lung tIssue, but dId not penetrate dIrectly to blood However, the
reactIOn products, labeled mtrogen compounds, have bel~n found throughout the body of
expenmental ammals (Oda et al , 1979, 1980b)
There has been very httle modehng of the uptake of N02 The results of the Olily
SImUlatIon study predIcted that the maxImum N02 tIssue dose m humans, rats, gumea pIgS,
and rabbIts occurred m the VIC1lllty of the centnacmar regIOn where morphologIcal lesIOns
are commonly observed (Miller et al , 1982, Overton, 1984) Modehng has been used to
estImate the effect of mcreasmg ventilatIOn on the dIstnbutIon of absorbed 0:" whIch IS
SImilar to N02 , m humans (Miller et al , 1985, Overton et al ,1987) These SImulatIons,
the quahtatIve results of whIch were expected to apply to N02 , predIcted that mcreasmg
ventilatIOn had httle effect on uptake m the tracheobronchIal region, but greatly enhanced
puhnonary regIOn uptake
13.2.2 Respiratory Effects

13.2.2.1 Host Defense Mechanisms
The respIratory tract defenses encompass many mterrelated responses, however, for
SImphCIty, they can be dIVIded mto two major components the phYSICal defense mechamsms
and the cellular defense mechamsms The phYSICal defense mechamsms m the upper and
lower aIrWays (mucocIhary system) begm WIth aerodynamIcs (Newhouse et al , 1976)
There IS a large amount of turbulence expenenced by the mcommg arrstream, causmg the
nasopharyngeal removal of many of the large partIcles (> 10 /-tID) Smaller partIcles can also
13-13
be deposited on the mucociliary escalator of the tracheobronchIal regiOn PartIcles depOSIted
on the mucus layer are removed by ciliary actiOn that dIrects overlymg mucus, partIcles, and
absorbed gases toward the pharynx. where they are swallowed or expectorated (Breeze and
Wheeldon, 1977, Green, 1970, Newhouse et al , 1976, Proctor, 1977) ThIs mucociliary
clearance IS the fIrst lme of defense of the conductmg arrways
The second component of the pulmonary defense system IS the cellular defense
mechanisms (phagocytIc and lffiffiunologlC reactions), whIch operate mostly m the pulmonary
region of the lung Large mononuclear cells, alveolar macrophages (AMs), are the fITst hne
of cellular defense (Hockmg and Golde, 1979) The role of AMs m host defense IS dIverse
and vaned, mcludmg such important actiVIties as detoXlfymg and/or removmg mhaled
particles, mamtammg stenhty agamst mhaled microorgamsms, mteractmg WIth lymphOId
cells m a variety immunologIc reactiOns, and removmg damaged or dymg cells from the
alveoh through phagocytosIS (Fels and Cohn, 1986) Alveolar macrophages mIgrate
throughout the pulmonary regiOn and It IS thIs mechamsm that allows contact WIth foreIgn
material entermg the lungs Once phagocytosIS has occurred, the partIcle IS encased ill a
phagocytic veSICle and fuses WIth lysosomes to form phagolysosomes, the pnme subcellular
compartment for the lallmg of engulfed bactena (Nathan et al , 1980, Silverstem et al ,
1977) Durmg the phagocytosIS process, AMs release oxygen radIcals and enzymes eIther
into the phagosome or mto the external milieu (Johnston et al ,1978) Oxygen radIcals and
enzymes are beheved to be essential for bactenal lallmg by phagocytes Both oXldatiOn and
decarboxylation of bactenal membranes appear to be the major mechamsms by whIch oxygen
radIcals induce bactenallallmg (Klebanoff, 1968, Strauss et al , 1970)
Polymorphonuclear leukocytes (PMNs), another phagocytic cell, are present m a small
percentage m normal lungs In response to a vanety of msults, there can be an mflux of
PMNs from blood mto the lung by chemotaXIs Once recruIted to the lung, PMNs then
ingest and kill opsomzed mIcrobes and other foreIgn substances by mechamsms that are
similar to those descnbed for AMs (SIbille and Reynolds, 1990) In contrast to AMs, PMNs
contam substantial amounts of myeloperoXldase stored m the pnmary granules and,
therefore, are an lffipOrtant source of hydroXlde radIcals, conSIdered to be major bactencidal
agents (Klebanoff, 1982)
13-14
In most cases, optnnal phagocytosIS of microorgamsms by PMNs and AMs requires the
presence of opsonms Opsonms are Immunoglobulms that have the capacIty to enhance
phagocytoSIS of microorgamsms When the phagocytIc response IS not sufficIent to
effectIvely remove partIcles from the resprratory tract, ImmunologIc (humoral and cell-
mediated Immumty) responses are provIded by the lymphocytes The humoral part of thIs
system prImanly mvolves the B cells that functIon m the synthesIs and secretIOn of antIbodies
(Immunoglobulm A [IgA], Immunoglobulm G [IgG], Immunoglobulm M [IgM]) mto the
blood and body flUIds Secretory IgA IS found m the upper resprratory tract and
tracheobronchIal regIOn and ItS prImary role IS to mhIbI1 mIcrobIal attachment to the
conductmg arrway surfaces Immunoglobulm G IS the predommant class of Immunoglobulms
of the lower resprratory tract These Immunoglobulms act to enhance macrophage
functIonmg Immunoglobulm M IS also present m the lower resprratory tract, but m low
concentratIOns The mteractIOns of these defense mechamsms are comphcated and not
completely understood
The cell-mediated component prImanly mvolves T lymphocytes, whIch are the effectors
of cellular defense These cells are responsIble for delayed hypersensItIvIty and defense
agamst vIral, fungal, bactenal, and neoplastIc dIsease Alveolar macrophages may be
responsIble for the 1llltIatIOn of humoral and cellular Immune responses by the mgestIOn of
partIcles or soluble antIgens and the "processmg" and "presentmg" of these antIgens for
specIfic antIgen-reactIve B and T cells ThIs process stImulates the Band T cells to
prohferate and dIfferentIate mto effectors of humoral (arltIbody productIOn) and cell-mediated
(CytOtOXiC lymphocytes) Immumty It IS these responses that are Important m acute and
chromc mfectIons and fonn the baSIS for antnnicrobIalnnmumty (Harada and Repme, 1985)
Alveolar macrophages also secrete alpha, beta, andl gamma mterferon and platelet
actIvatIng factor The mterferons, protem substances produced by vlnIs-mvaded cells that
prevent the rephcatIOn of the vrrus (LefkOWItz et al , 1984, LefkowItz et al , 1983), have
potentIally Important ImphcatIons m modulatmg the antIvIral and Immune actIvItIes of AMs
Recently, AMs were found to release a factor fIrst thought to be related to the mterferon
family and therefore 1llltIally named mterferon beta 2 It was later detennmed to be a
cytokme (Wong and Clark, 1988) Cytokmes are believed to play an Immunoregulatory role
m the resprratory tract defenses, affectIng mflammatory responses and tumoncidal actIvItIes
13-15
(Dinarello et al ,1986) Platelet actIvatmg factors may play an nnportant role m the
inflammatory response and are capable of PMN aggregation and of the release of arachtdomc
aCId metabohtes from PMNs (Braquet and Rola-PleszczynskI, 1987)
Although antIvIral pulmonary Immune functIOns have not been adequately evaluated
after N02 exposure, theIr proper functIonmg IS essential m humoral and cell-medIated
Immunity agamst vIral dIsease These functIOns mc1ude (1) mterferon productIOn m
bronchoalveolar lavage (BAL) flUId, (2) AM functIOn, (3) natural k1ller (NK) actIVIty,
(4) CytotoXiC T lymphocyte actIVIty, and (5) antibody productIon (Burleson, 1987) A host
infected with VlfUS manifests a cascade of nnmune responses, both specIfic and nonspecIfic
Local and circulatmg mterferons (alpha, beta, and gamma) are produced m the first 24 h
after vIral exposure Interferons have antivIral, antitumor, and nnmunoregulatory actiVIties
Interferons serve as an nnmunoregulator to stnnulate the nnmunological actiVIty of both AMs
and lymphocytes exhtbitIng NK actiVIty Interferon, AMs, and NK cells all contnbute to the
nonspecIfic antivIralnnmumty of the host CytotoXiC T lymphocytes are the first specIfic
immunolOgical response agamst VlfUses These cells can be activated by mterferons and
therefore, are most relevant m defense agamst vIral mfectIons and tumors
Mllcociliary Clearance
The effectiveness of the mucocIhary system IS dependent upon the mtegnty of the cilia
and respIratory epitheha, the chemicophysical propertIes of the mucus, and the rate of mucus
transport. V Ira1 and bactenal mfectIons and vanous chemIcals can lead to over or under
secretion of mucus, alterations m mucous flow charactenstIcs, and loss or paralYSIS of the
cilia The cilia can respond to msults m a number of ways changes m beat frequency,
cessation -of ciliary beatmg, and/or development of abnormal forms of cilia Substances that
produce such dIsruptIOn or nnparrment of thts defense system can result m an excess
accumulation of cellular secretions, mcreased acute bactenal and vIral mfectIOns, chromc
bronchttis, and prolonged pulmonary comphcatIons pOSSIbly associated WIth the pathogenesIs
of chronic obstructive pulmonary dIsease or bronchtal cancer through the accumulatIOn of
inhaled carcmogens (Schlesmger et al , 1987a)
There are numerous reports of SIgnIficant loss of cilia and ciliated cells m the
bronchiolar epIthehum A descnptIon of these htstopathological changes can be found m
13-16
SectIOn 13 2 2 4, addressmg the morphological effects of NOz exposure TIns sectIOn and
Table 13-1 only summanze NOz effects on mucociliary activity
Clearance of marker substances deposited m the aIrWays has been used to assess the
effects of NOz on mucociliary clearance TIns method has ment as an mdex of overall
efficiency of mucociliary clearance The mucocl1ary clearance of mhaled tracer particles
depOSited mto the tracheobroncillal tree of rabbits exposed 2 h/day for 2, 7, or 14 days to
0, 560, or 1,880 pg/m3 (0, 0 3, or 1 0 ppm) NO z did not alter the rate of removal
(ScWesmger et al , 1987a) Usmg a duferent approach wscussed later m tills sectIOn,
short-term phYSical clearance of bactena was not affected at concentratIOns up to
27,800 pg/m3 (14 8 ppm) (4 h) (Goldstem et al , 1973, Parkei et al , 1989)
Giordano and Morrow (1972) demonstrated signllicant mlpalrment of tracheobroncillal
clearance rates m rats followmg exposure to 11,280 pg/m3 (60 ppm) NO z for 6 weeks
Tills decrease m ciliary clearance was not accompamed by any observable abnormality of the
arrways A 2-h exposure to 14,100 pg/m3 (7 5 ppm) fmled to alter the tracheal mucus
velOCity m sheep, but exposure to tWice that concentration for 2 h produced a sigmficant
slowmg of mucus movement (Abraham et al , 1980) NItrogen dIOXlde-mduced effects on
arrway clearance appear to be both concentration and duratIOn-dependent, however, It would
take prolonged exposure to illgh concentratIOns to mduce alterations that would have
detnmental health effects Data would mdicate that even a severely damaged arrway
I
epIthehum has the ability to mamtam mucus transport (Abraham, 1984)
A few m VItro experiments have exammed the efft~ct of NOz on Isolated ciliated
epithehum cells and tracheal nngs KIta and Omicm (1974) reported that exposure to NOz at
concentratIOns greater than 9,400 pg/m3 (5.0 ppm) resulted m a decreased rate of ciliary
beatmg SchIff (1977) Isolated and exposed hamster tracheal nng cultures to 3,760 pg/m3
(20 ppm) NO z for 1 5 h/day, 5 days/week for 1 to 4 weeks After 14 days of exposure, the
NOz produced decreased ciliary beatmg
Alveolar Macrophages
The effectiveness of AMs depends on the type, number, and Viability of the cells The
cells must mamtam an mtact membrane, mobility, and phagocytic activIty, and have
functlOnmg enzyme systems EVidence from both m Vi\lO and ill VitrO studies mdicate that
13-17
TABLE 13-1. EFFECTS OF NITROGEN DIOXIDE ON MUCOCILIARY ACTIVITY a
NO z Concentratlon
3 Specles
p.g1m ppm
Exposure Gender Age (Stram) Effects Reference
560 03 2 hlday, M NS Rabblt No effect on tracheobronclnal Schlesmger et al (1987a)
1,880 10 14 days (New clearance
Zealand)
3,760 20 In vltro, NS 2 weeks Hamster After 2-week. exposure, clhary Sclnff (1977)
15 hlday, (Synan beatmg activlty was decreased and
5 days/week, Golden) morphologlCal changes were
1-4 weeks observed
9,400 50 In vltro N/A Decrease m clhary beatmg activlty KIta and OmlCm (1974)
11,280 60 7 days/week, F NS Rat Decrease m mucocl1lary veloclty, GlOrdano and Morrow (1972)
6 weeks (Long Evans) functlOnallmpaUment reversed by
1 week postexposure
14,100 75 2h NS NS Sheep Slowmg of mucus ve10clty at Abrallam et al (1980)
~
YJ
I
28,200 15 (NS) lnghest concentration
~
00 18,000 10 2h M NS Rabblt No effect on bronclnal clearance Schlesmger et al (1987b)
(New rate
Zealand)
~ = Male
NS = Not Stated
F = Female
N02 exposure alters these functIOns, thereby mcreasmg the nsk of the host to dtsease
Human chmcal studtes of AMs are dISCUSSed more fully in SectIOn 15 6
In Vzvo Exposure. Alveolar macrophages Isolated from mIce that had been
3 3
contmuously exposed to 3,760 p.,g/m (20 ppm) N02 for 33 weeks or exposed to 940 p.,g/m
3
(05 ppm) N02 wIth a I-h peak to 3,760 p.,g/m (20 ppm) for 5 days/week for 21 weeks
showed dIstInctiVe morphologIcal changes as compared to controls (AranYI et al , 1976)
Examples of structural changes observed mcluded the loss of surface processes, appearance
of fenestrae, bleb formatIOn, and denuded surface areas Exposure to a lower level (1 e ,
3 3
940 p.,g/m [0 5 ppm] contInuous or 188 p.,g/m [0 1 ppm] contmuous wIth a 3-h peak to
1,880 p.,g/m3 [1 0 ppm]) for penods of up to 24 weeks dId not result m any sIgmficant
IdentIfiable morphologIcal or bIochemIcal changes Such morphologIcal changes would be
expected to mterfere WIth a number of cellular functIOns, such as chemotaxis and
phagocytosIS
3
StudIes have shown that exposure to N02 at concentratIOns greater than 9,400 p.,g/m
(5 0 ppm) causes concentratIOn-related mcreases m the number of AMs (Suzuki et al , 1986,
Rombout et al , 1986, Sherwm et al , 1968) A 12-week exposure to 2,256 or 7,520 p.,g/m3
(1 2 or 4 0 ppm) N0 2 mcreased the AM populatIOn by 310 % over that of controls (MochItate
et al , 1992) Alveolar macrophage accumulatIon has also been reported after 15 weeks of
exposure at lower concentratIOns, such as to eIther 9,400 p.,g/mJ (5 0 ppm) N02 or to
3 3
1,880 p.,g/m (1 0 ppm) WIth two daIly 1 5-h peaks to 9,400 p.,g/m (Gregory et al , 1983)
After a I-day exposure to 5,000 p.,g/m3 (2 7 ppm) N02 , Rombout et al (1986) reported an
mcrease m the number of AMs m the termmal bronchIoles and proXImal alveoh of rats The
mcrease m AMs was aSSOCIated WIth morpholOgical changes m the resprratory tract, as
dISCUSSed m SectIOn 13224 addressmg NOTmduced changes m lung morphology
No effect was seen at 1,000 or 2,500 p.,g/m3 (053 or 1.:13 ppm)
Chang et al (1986) and Crapo et al (1984) studIed the response of l-day-old and
3
6-week-old rats followmg exposure to 0 5 ppm (940 p.,g/m ) N02, 23 h/day for 6 weeks
Another group of 6-week-old rats was exposed to 2 0 ppm (3,760 p.,g/m3 ) for the same
duratIon Two daIly 1-h peaks of three tImes the basehne level (1 e , 2,820 and
11,280 p.,g/m3 , 1 5 and 6 0 ppm) were apphed Monday-J<'nday In these studIes, the older
13-19
rats were more responSIve to N02 than younger animals, showmg a slgmficant mcrease m
both number and volume of AMs The studies conducted by Azoulay-Dupms et al (1983)
also demonstrated that m both the rat and the gumea pIg, newborns were less affected by a
3-day exposure to 3,760 and 18,800 p,g/m3 (2 0 ppm and 10 ppm) N02 than older anImals
based on changes m lung structure and superoxide dismutase actiVIty m Isolated AMs
Mochitate et a1 (1986) reported a slgmficant mcrease m the total number of AMs
Isolated from rats durmg 10 days of exposure to 7,520 p,g/m3 (40 ppm) N02 At tills
exposure concentratIon, AMs accounted for 97 % of the totallavaged cells The number of
PMNs dId not show any slgmficant mcrease over tills exposure penod Alveolar
macrophages from exposed anImals also exmbited mcreased metabohc actiVIty as measured
by the actiVIties of glucose-6-phosphate dehydrogenase, glutatillone peroXidase, and pyruvate
kinase, willch were slgmficantly mcreased by 1 29-fold, 1 17-fold, and 1 2-fold,
respectively Slffiultaneously WIth these effects, the exposed AMs exmbited a slgmficant
mcrease m the rate of synthesIs of protem and DNA All responses peaked on Day 4 and all
values had returned to control levels by the tenth day
SuzukI et al (1986) found that N02 exposure slgmficantly mcreased the number of
AMs m BAL flmd from rats exposed to eIther 7,520 or 15,000 p,g/m3 (40 or 8 0 ppm)
In this study, the exposure contmued for 10 days, but the effect became most slgmficant at
the fIfth day of exposure The VIability of these Isolated cells was decreased on Day 1 and
remained depressed for the remamder of the exposure penod There was no eVIdence that
either exposure caused an mcrease of PMNs However, Schlesmger (1987b) failed to fmd
any signifIcant changes m the number or the VIability of AMs m lung lavage from rabbIts
3
exposed to 1,880 p,g/m (1 0 ppm) N02 , 2 h/day for 13 days
Rose et a1 (1989) reported a concentratIon-dependent decrease m AM phagocytosIS m
the lower resptratory tract of mIce exposed to 1,880 or 9,400 p,g/m3 (1 0 or 5 0 ppm) N0 2
for 6 h on 2 consecutIve days, but the decrease was only slgmficant at 9,400 p,g/m3 MIce
were mtratracheally moculated WIth gold-198 COllOId followmg N02 exposure When the
3
exposure was mcreased to 28,200 p,g/m (15 ppm) N0 2 , further effects on AM phagocytosIS
were not noted The authors suggested that the lack of addItional effects on AM
phagocytosIS with mcreasmg N02 concentratIOns may be due to an mflux of phagocytIc cells
m the lower resptratory tract due to an mflalllffiatory response to the N02 AddItJlonal
13-20
studies at 9,400 p,g/m3 did not show an effect on the mfectlvlty of munne cytomegalovrrus
for AMs
The phagocytic activity of rat AMs was slgmficantly depressed after 5 days of exposure
to 15,000 p,g/m3 (8 0 ppm) (SuzukI et al , 1986) A slmilar suppression was noted followmg
3
exposure to 7,520 p,g/m (40 ppm), but only after 7 dc:'lys of exposure In all cases, the
phagocytic activity of these affected cells recovered to 1he control values at Day 10 of
exposure SuzukI et al (1986) proposed that the suppreSSlOn of phagocytosIs might be due to
the ability of N02 to cause membrane hpld peroXldatlOl1 The study by Dowell et al (1971)
adds support to this hypothesIs As reported m Section 13 2 2 4 on lung morphology,
3
eVidence of mttochondnal damage was noted m AMs flOm dogs exposed to 5,640 p,g/m
3
(3 0 ppm), and became most eVident m dogs exposed to 13,160 p,g/m (70 ppm) N02 The
authors descnbed this effect as a mamfestatlOn of damage to the membrane function The
apparent recovery of the AMs after 10 days of exposurl~ IS thought to be due to the mflux of
new AMs mto the alveoh The morphological changes were also associated With changes m
lung blOchemlstry
Schlesmger (1987b) did not fmd any slgmficant changes m the number or the VIability
of AMs m BAL flUId from rabbits exposed to 560 or 1,880 p,g/m3 (03 or 1 0 ppm) N02 ,
2 h/day for 2, 6, or 13 days Although there were no effects on the numbers of AMs that
phagocytIZed latex spheres, 2 days of exposure to 560 /l,g/m3 decreased the phagocytic
capacity (i e , number of spheres phagocytIZed per cell), the higher level of N02 mcreased
this parameter After 6 or 13 days of exposure, phagocytosIs was nonnal LefkOWitz et al
(1986) failed to fmd any depresslOn m phagocytosIs after mice were exposed for 7 days to
9,400 p,g/m3 (5 0 ppm) N02
Alveolar macrophages Isolated from humans exposed for 3 h to 1,130 p,g/m3 (0 6 ppm)
N02 had a tendency (p < 0 07) to be less able to mactIvate mfluenza vrrus than controls
cells (Frampton et al , 1989) However, when the concentratIOn was reduced to 94 p,g/m3
(005 ppm) N02 With three 15 mm peaks to 3,760 p,g/rn3 (20 ppm) (same product of
concentratlOn and ttme [C x T] as the 1,120 p,g/m3 regtmen), the rate of vtral mactIvatIon
was unchanged Alveolar macrophages from humans exposed for 4 h to 3,760 p,g/m3
(2 0 ppm) exhIbited a decrease m phagocytosIs of Candzda albzcans (Devhn et al , 1992)
See Section 15 6 for a fuller dIscusslOn of these human studies
13-21
Alveolar macrophages obtaIned by lavage from baboons exposed to 3,760 p,g/m3
(20 ppm) N02 for 8 h/day, 5 days/week for 6 mo had sIgmficantly Imparred responsIveness
to mIgratIOn mInbitOry factor produced by sensItIZed lymphocytes (Greene and Sclmeider,
1978) This substance affects the behaVIOr of AMs by mInbItmg free mIgratIOn, whIch m
turn interferes WIth the functIOnal capaCIty of these defense cells The random mobility of
AMs was SIgmficantly depressed ill rabbIts followillg a 2 h/day exposure for 13 days to
560 p,g/m3 (03 ppm) but not at 1,880 p,g/m3 (1 0 ppm) (Schlesmger, 1987b) Such effects
are inlpOrtant in the medIatIon of local ImmUnologIc responses ill the lung and would be
expected to prolong the residence tIme of the multItude of mhaled depOSIted partIcles ill the
deep lung.
Vollmuth et al (1986) studIed the clearance of strontmm-85 tagged polystyrene latex
spheres from the lungs of rabbIts followmg a smgle 2-h exposure to 560, 1,880, 5,600, or
18,800 p,g/m3 (0 3, 1 0, 3 0, or 10 ppm) N02 An acceleratIon ill clearance (decreased daily
retentIOn) was eVIdent illlilledIately after exposure to the two lowest N02 concentratIOns
A sIml1ar effect was observed by Schlesmger and Gearhart (1987) At the hIgher levels of
N02 , an acceleratIon ill clearance was not eVIdent untIl mIdway through the 14-day
3
postexposure penod Repeated exposure to 1,880 or 18,800 p,g/m N02 , 2 h/day for
14 days produced a response sIml1ar to a smgle exposure at the same concentratIon,
mdIcating that, WIth repeat exposures, some attenuatIon may be produced after the illltIal
exposure (Vollmuth et al., 1986) However, ill rats exposed chromcaIly (7 h/day,
5 days/week, 18 to 22 mo) to 17,900 p,g/m3 (9 5 ppm) N02 , there was no effect on long-
ternl clearance of radIolabeled fused alummosilicate partIcles (Mauderly et al , 1990)
Several studIes have reported that N02 exposure sIgmficantly decreases the ability of
AMs to produce superoXlde amon radIcal, whIch may lImIt the antIbactenal actIVIty of these
cells. Amoruso et al (1981) presented eVIdence of such an effect m rats exposed to N02
3
concentrations rangmg from 2,444 to 31,960 p,g/m (1 3 to 17 ppm) The duratIOn of the
N02 exposure, other than a statement that It was an acute exposure, was not gIVen In thIs
study, the author's objectIve was to compare the measured N02 response WIth 03 effects,
and the data were expressed ill terms of ppm-h, makmg It ImpOSSIble to determme the
specific concentratIon and duratIon of exposure that ehcIted the effect SuperoXlde amon
radical reduction began after exposure to 18 3 ppm-h N02 ProductIOn was reduced by 50%
13-22
after 29 1 ppm-h, and at 51 ppm-h, the hIghest exposun:: tested, the productIOn was
decreased by 85 % Devhn et al (1992) also observed a decrease m the release of
3
superoXlde anton from AMs of humans exposed (wIth exercIse) for 4 h to 3,760 p,g/m
(20 ppm) SuzukI et al (1986) reported a marked decrease m the ability of rat AMs to
produce superoXlde anion radIcal followmg a 10-day exposure 1..0 eIther 7,520 or
15,040 p,g/m3 (40 or 8 0 ppm) At the hIghest concentratIOn, the depreSSIOn was sIgmficant
only on exposme Days 3, 5, and 10
A number of ammal studIes have been performed to mduce various structural,
functIonal, and bIochemIcal changes m AMs by exposmg the test ammals to exceedIngly hIgh
concentratIons (1 e , greater than 9,400 p,g/m3 , 5 0 ppm N02). Some of these studIes, along
WIth the studIes conducted at lower exposure concentratIOns, are hsted m Table 13-2 to
familianze the reader WIth the broad spectrum of blOlog1Cal responses that AMs can exhIbIt
followmg N02 exposure
In Vltro Exposure. VOlsm and co-workers (VOlS11l et al , 1977, VOlsm and Aerts,
1984) have shown concentratIOn-related effects after exposure for 30 mm to N02
concentratIons as low as 188 p.g/m3 (0 1 ppm) In thIs system, the AMs, attached to
cellulose acetate fibers, were floated on top of a nutnent medIum that dIffused through the
fIlter, mamtammg cell VIability WIthout submergmg the cells \ These floatmg cells were then
exposed to N02 In these studIes, gumea pIg AMs seemed to be senSItIve to N02 , exhIbItmg
a reductIOn m phagocytIc and normal bactencIdal actIvIty, reduced adenosme tnphosphase
(ATP) content, and major morphologIcal changes The seventy of these changes was related
to the N02 concentratIon (VOlsm et al , 1977) Increasmg eIther the exposure concentratIOn
to 9,400 p.g/m3 (5 0 ppm) or the exposure duratIon to 24 h resulted m complete destructIon
of the cell (VOlsm and Averts, 1984) As descnbed more fully m SectIon 15 6, normal
3
human AMs exposed m VItro to hIgh levels of N02 (9,400, 18,800, or 28,200 p.g/m , 5, 10,
or 15 ppm) fOf 3 h dId not exhIbIt any change m cell VIability or the release of eIther
neutrophIl chemotactIC factor or mterleukm-1 (PInkston et al , 1988)
RobIson et al (1990) exposed AMs from rats to 188, 1,880, 9,400, or 37,600 p.g/m3
(0 1, 1 0, 5 0, or 20 ppm) N02 for 1 h m VItro to detennme If N02-mduced mfIltratIOn of
PMNs m VIVO was m response to the syntheSIS of leukotnene B4 (LTB4) by AMs Alveolar
13-23
TABLE 13-2. EFFECTS OF NITROGEN DIOXIDE ON ALVEOLAR MACROPHAGESA
N02 Concentratton
3 Species
p.g1m ppm Exposure Gender Age (Stram) Effects Reference
94 base + 005 base + 3 h base + NS NS Human No effects at 0 05 ppm N02 wIth peaks, Frampton et a1 (1989)
3,760 peaks 20 peaks three 15-mm trend (p < 0 07) towards AMs losmg
peaks abIlIty to mactIvate mfluenza Virus at
1,130 o 6 ppm
06 3h
188 o1 Ih NS NS Rat At50ppm mcrease m LTB4, RobIson et al (1990)
1,880 10 (Sprague- concentratton-related decrease m SOD
9,400 50 Dawley) production m AMs at ~ 1 0 ppm, mcrease
37,600 20 (m VItrO) m LDH m AMs at 5 0 and 20 ppm
940 05 Contmuous, NS NS Mouse No effects on AM morphology at 05 ppm Aranyl et al (1976)
24 weeks conttnuous or 0 1 ppm base + peak
exposures
to-"
wI 188 base + o 1 base + Conttnuous After 21 weeks of exposure to 2 0 ppm
N 1,880 peak 10 peak base + 3-h conttnuous or 0 5 ppm base + peak,
~ peak, morpholOgical changes were Identified,
5 days/week, such as loss of surface processes,
24 weeks appearance of fenestrae, bleb formation,
and denuded surface areas
3,760 20 Contmuous,
33 weeks
940 base + o 5 base + Contmuous

3,760 peak 20 peak base + I-h
peak,
5 days/week,
33 weeks
.
TABLE 13-2 (cont'd). EFFECTS OF NITROGEN DIOXIDE ON ALVEOLAR MACROPHAGEsa
N02 ConcentratiOn
3 Species
p.g/m ppm Exposure Gender Age (Stram) Effects Reference
560 03 2 hlday, M NS Rabbit Decreased phagocytic abihty of AMs at Schlesmger (1987b)
1,880 10 2,6, 13 days (New Zealand) o 3 ppm after 2 days of exposure, mcreased
at 1 0 ppm after 2 days of exposure, no
effect on cell number or viabihty, random
mobihty reduced at 0 3 ppm only, no
effects after 6 days of exposure
560 03 2 hlday up to M NS Rabbit Increase m alveolar clearance Schlesmger and Gearhart
1,880 10 14 days (New Zealand) (1987)
560 03 2h M NS Rabbit ConcentratiOn-related acceleration m Vollmuth et al (1986)
1,880 10 (New Zealand) clearance of particles from lung With the
5,640 30 greatest mcrease at two lowest
18,800 10 concentrations, effects from repeated
~
exposures sllmlar to those seen after acute
wI 560 10 2 h/day, exposures to same concentrations
N
Ul 1,880 10 14 days
940 base + 05base+ Base M 1 day Rat Trend towards mcrease m number of AMs Crapo et al (1984)
2,820 peak 15 peak 22 hlday, and (Fischer 344) and cell volume m younger ammals, Chang et al (1986)
7 days/week 6 weeks mcrease m number of AMs and cell volume
3,760 base + 20 base + + two I-h m older rats
11,300 peak 6 o peak peaks,
5 days/week,
6 weeks
1,000 05 Contmuous, M 6 weeks Rat Increase m AMs m highest exposed group, Rambout et al (1986)
2,500 13 28 days (WiStar) no effects noted m 2 lowest exposure
5,000 27 groups
1,880 10 6 h/day, NS 4- Mouse Exposure-related decrease m AM Rose et al (1989)
9,400 50 2 days 6 weeks (CD-I) phagocytosis from 1 0-5 0 ppm, decrease
28,200 15 was not further affected by 15 ppm
TABLE 13-2 (cont'd). EFFECTS OF NITROGEN DIOXIDE ON ALVEOLAR MACROPHAGESa
N02 Concentration
3 SpecIes
1,880 10+ 7 h/day, NS NS Rat StImulated clearance of partIcles from Fenn and Leach (1977)
28,200 o 9 ppm NO 5 days/week (Long Evans) lung at lowest concentratton, but
45,120 15 for 11 or decreased clearance rate at two highest
24 22 exposures concentrattons
1,880 10 7 h/day, MIF 14-16 Rat Accumulatton of AMs Supenmposed Gregory et al (1983)
9,400 50 5 days/week weeks (FIscher 344) peak exposures produced changes that
may persIst WIth contmued exposures
Base 7 h/day,
1,880 base + 1 0 base + 5 days/week,
9,400 peaks 50 peaks two 1 5-h
peaks/day,
15 weeks
...... 2,440- 13- NS F NS Rat Decreased productton of superoXlde Amoruso et al (1981)
wI 32,000 17 ("acute") (Sprague- anton radIcal
tv
0\ Dawley)
3,760 20 3 days M/F 5, 10, 21, Gumea pIg Newborns were less affected than adults Azoulay-Dupuis et al (1983)
19,000 10 45,55, (Dunkm when AMs were tested for SOD levels
60, and Hartley)
>60 days Rat
(WIStar)
3,760 20 8 h/day, M/F 3-4 years Baboon Impatred AM responsIveness to Greene and SchneIder (1978)
5 days/week, mtgratton mhtbitory factor
6mo
3,760 20 4h NS NS Human Decreased phagocytosIS and superoXlde Devlm et al (1992)
anton release
5,000 27 24h M 6 weeks Rat Increase m number of AMs Rombout et al (1986)
(WIstar)
5,640- 3- 3h NS NS Dog Enhanced swellmg of AMs Dowell et al (1971)
30,100 16 (Beagle)
TABLE 13-2 (cont'd). EFFECTS OF NITROGEN DIOXIDE ON ALVEOLAR MACROPHAGESa
N02 ConcentratIOn
3 SpecIes
p,g/m ppm Exposure Gender Age (Stram) Effects Reference
6,770 36 1h F NS Rat Enhanced macrophage agglutmatIon wIth Goldstem et al (1977a)
22,700 121 2h (Sprague- concanavalm A at both concentrations
Dawley) tested
(m vItro)
7,520 4 6 hlday, M NS Rat Changes m morphology at all Hooftman et al (1988)
19,000 10 7, 14, or (WIStar) concentrations, mcrease m number of
47,000 25 21 days AMs at ~ 10 ppm, phagocytic capacIty
reduced after 14 and 21 days of exposure
to 25 ppm
7,520 40 10 days M 19-23 Rat Increase m number of AMs, no mcrease Mocmtate et al (1986)
weeks (WIStar) m PMNs, mcreased metabohc activIty,
protem, and DNA synthesIs, all responses
peaked on Day 4 and returned to normal
.-
w on Day 10
~
-....l 7,520 40 Up to NS NS Rat Increase m number of AMs at both Suzukl et al (1986)
15,000 80 10 days (FIscher 344) concentrations, reachmg a peak on Day 3
and 5, no mcrease m number of PMNs,
decrease m AM vlablhty throughout
exposure penod SuppressIOn of
phagocytic activIty after 7 days of
exposure to 4 ppm and after 5 days of
exposure to 8 ppm, returned to nonnal
value at 10 days Decrease m superoXlde
ramcal productIOn, but at 4 ppm, the
effect became sIgnIficant on Days 3, 5,
and 10, at 8 ppm, the effect was
sIgnIficant at all time penods tested
9,400 50 7 days F NS Mouse No effect on phagocytic actiVIty LefkoWItz et al (1986)
(CD-I)
TABLE 13-2 (cont'd). EFFECTS OF NITROGEN DIOXIDE ON ALVEOLAR MACROPHAGESA
NO z Concentration
3 SpecIes
9,400 5 3 h after NS NS RabbIt AMs lost resIstance to challenge wIth Acton and MyrvIk (1972)
28,200 15 mfectlOn WIth (New Zealand) rabbIt pox VU1IS after exposure to 15 ppm
paramfl.uenza
3 VU1IS
9,400 5 3h M NS Humans No change m cell VIabIlIty, release of Pmkston et al (1988)
18,800 10 pb (In VItro neutroplnl chemotactic factor, or
28,200 15 exposure) mterleukm-l
9,400- 5- 3h NS NS RabbIt InhIbItIon of phagocytIc actIvIty Gardner et al (1969)
113,000 60 (New Zealand) Acton and MyrvIk (1972)
13,200 70 24h NS NS RabbIt Increased rosette formatIon m AMs Hadley et al (1977)
treated WIth lIpase
-
l.J,)
N
I
00
17,900
19,000
95
10
7 h1day,
5 days/week,
18-22mo
35 days
M
NS
18
weeks
NS
Rat
(FIscher 344)
Gumeapig
No effect on long-term clearance of
ramolabeled tracer partIcles
63 % mcrease m epIthelIal cells pOSItIve

Mauderly et al (1990)
Sherwm et al (1968)
for macrophage congregation
19,000 10 4h P NS Mouse Increase ill total pulmonary cells m Jakab (1988)
(SWISS) ammals mfected WIth some SpecIes of
bactena
19,000 10 24h M 12-13 Rat Decreased phagocytosIS at 25 ppm only Katz and LaskIn (1976)
47,000 25 weeks (Sprague-
Dawley)
aNS = Not stated

AMs = Alveolar macrophages
LTB4 = Leukotnene B4
LDH = Lactate dehydrogenase
M = Male
F = Female
SOD = SuperoXlde dlsmutase
bPMNs = Polymorphonuclear leukocytes
Only one female used In study
macrophage productiOn of LTB4 was not affected by exposure to 188, 1,880, or
37,600 p..g/m3 , however, levels of LTB4 were elevated followmg exposure to 9,400 p..g/m3
3
N02 Products from AMs exposed to 9,400 or 37,600 p..g/m enhanced PMN chemotaXiS
SuperoXIde productiOn was decreased ill a concentratiOn-related manner, startmg wIth AMs
3
exposed to 1,880 p..g/m N02 It was suggested that the decrease m superoXIde productIon
may be the result of NOTillduced 1JpId peroXIdatiOn processes at the plasma membrane
An NOTmduced decrease m AM VIability was also suggested m the 9,400- and
37,600-p..g/m3 -exposed AMs by changes m cellular lact.ate dehydrogenase (LDH) content
Humoral and Cell-Medzated Immunity

It IS most relevant to assess the effects of Inhaled compounds on cell-medIated and
antIbody responses m the lung Itself, because thIs IS the pnmary SIte of defense agamst
respIratory mfectiOns However, because of technIcal obstacles, whIch ill some cases have
only recently been overcome, many studIes have assesstxl the responses to Inhaled pollutants
or N02 m the spleen or penpheral blood These studIes are more dIfficult to mterpret m
terms of enhanced nsk of respIratory mfectiOn However, the Immune system IS one of the
many potentIal targets of Inhaled pollutants, such as N02 In some cases, the Immune
system can be affected ImmedIately, whereas under dIf£erent condItIons, the changes may be
secondary to the illJUry of other organs or to a general detenoratIon of the host's health
In eIther case, these changes can often senously compromIse the health and well bemg of the
exposed host Such changes can result m a suppressiOn ill Immune functiOn, thereby
decreasmg defenses agamst mfectIous and neoplastIc dIsease Enhanced Immune actIVIty may
result m an exaggerated response to an antIgemc stImulus causmg hypersensItIvIty There
are many examples of such undeSIrable ImmUnologIcal changes that have been assocIated
WIth chemIcal exposure both m laboratory anImals and humans These changes can, under
certam cIrcumstances, tngger a specIfic response ill the Immune system, pOSSIbly leadmg to a
subsequent pathologIcal state that IS more senous than the ongmallesiOns
Because the Immune system IS a multIcomponent, hIghly regulated system, It offers
numerous target SItes for N02 actiOn and there are some studIes that mdIcate that hIgh
concentratIons of N02 (> 9,400 p..g/m3 , 5 0 ppm) can slgmficantly depress the Immune
response, as determmed by one or more tests avaIlable 10 assess the functIonal mtegnty of
13-29
the specific components Unfortunately, there are only a very few studies conducted at near
ambient concentratIOns, and, mdependent of the concentratIOns tested, only a few of the
numerous immune parameters have been evaluated
Exposmg sheep to 9,400 p,g/m3 (5 0 ppm) N02, 1 5 h/day for 10 to 11 days showed
that such mtermlttent, short-term exposure may temporanly alter therr pulmonary nnmune
responsiveness (Joel et al ,1982) One techmque commonly used m determmmg the
productlon of antlbody formmg cells IS to measure the number of plaque-formmg cells
(PFCs) in the spleen or blood of nnmumzed anImals In thls study, the authors assessed
immunolOgical response by momtormg the dally output of PFCs m the efferent lymph of
caudal mediasnnallymph nodes Although the number of sheep used was small and the data
were not analyzed statlStlcally, It would appear that m the anImals that were lillmumzed with
horse red blood cells (a T-cell dependent antlgen) 2 days, but not 4 days, after nntlatlon of
NOz exposure, the output of PFCs was below controls Blastogemc responses of T cells
from the efferent pulmonary lymph and blood also appeared depressed
Hillam et al (1983) exammed the effects of a 24-h exposure to 9,400, 18,800, and
3
48,900 p,g/m (5, 10, and 26 ppm) N02 on cellular lillmumty m rats after mtratracheal
lillffiumzatlon of the lung with sheep red blood cells (SRBCs) Cellular lillmumty was
evaluated by antlgen-specIfic lymphocyte stlmulatlon assays of pooled lymphOid cell
suspenSIOns from either the thoraCIC lymph nodes or the spleen A concentratlon-response
effect With elevated cellular lillmumty was observed
Studies conducted by Fenters et al (1971, 1973) and Ehrhch and Fenters (1973) usmg
squirrel monkeys showed the lillpact of N02 on the humoral lillmune response to
intratracheally dehvered mfluenza vaccme In monkeys exposed for 493 days (16 mo) to
3
1,880 p,g/m (1 0 ppm) N02 and lillmumzed With monkey-adapted vrrus (A/PRl8/34), the
serum neutrahzmg antlbody tlters were signIficantly mcreased earher, and to a greater
degree, than in controls (Fenters et al , 1973, Ehrhch and Fenters, 1973) In monkeys
exposed to 9,400 p,g/m3 (5 0 ppm) N02 for a total of 169 days and lillmumzed With mouse-
adapted influenza vrrus (AlPRl8), serum neutrahzatIOn tlters were nntlally lower than
controls; no signIficant dIfference was observed by 133 days of exposure (Fenters et al ,
1971; Ehrhch and Fenters, 1973) In all of these studies, the hemagglutmatlon mlubltlon
antibody titers were not affected The authors discussed these dliferences, suggestmg that
13-30
the dIfference ill the VIrUS used for lllmuruzatIOn played a role, along wIth exposure
dIfferences The authors also hypothesIZed that exposure to 1,880 p,g/m3 N02 Improved the
estabhshment and SUrvIVal of the monkey-adapted VIrUS Withm the respIratory tract, resultIng
ill an illcrease ill antibody productIOn
The results of Holt et al (1979) suggest that both the nature of and rate of change ill
ImmUnologIcaJl functIOn from N02 exposure can be both concentratIon- and tIme-dependent
Tests were conducted at 7-week illtervals to assess the functIOnmg ability of the Immune
system of mICe exposed to 18,800 p,g/m3 (10 ppm) NO.. , 2 h/dlay for penods of up to
30 weeks (Holt et al , 1979) Chromc exposure exhIbIted a general suppressIOn ill antibody
titers and ability of the T cells to functIOn ill a graft versus host reaction However, the
more acute exposures resulted ill an enhancement of ImmUnologIcal responSIveness
A senes of ImmUnologIcal studIes desIgned to examille the effects of N02 on the
humoral antibody response to SRBCs was reported by FU]Imala and ShllllZU (1981) and
FU]lllakI (1989) They exposed mIce for 12 h to 9,400, 37,600, and 75,200 p,g/m3 (5, 20,
and 40 ppm) N02 and reported a SIgnIficant suppreSSIOl1l ill PFCs (pnmary antibody
response) ill response to SRBCs at the two hIghest levels of exposure When mIce were
exposed to 7,520 p,g/m3 (40 ppm) N02 for 3, 7, 14, OJ 56 days, no suppreSSIOn ill antibody
response was observed·
USillg thIs same model, FU]Imala et al (1982) reported a SImIlar effect in mIce (1 e ,
suppressIOn of pnmary antibody PFC response ill the spleen) after 4 weeks of contilluous
exposure to 752 and 3,000 p,g/m3 (04 and 1 6 ppm) N02 At the hIgher concentratIOn,
there were no SIgnIficant dIfferences observed ill the actLvitIes of the T and B lymphocytes
Secondary antIbody response was not affected at 752 p,g/m3 , but was shghtly enhanced at
3,000 p,g/m3 exposure level However, Mmgetter et al (1978) found that the normal
transformatIOn response of mouse splemc T and B cells to phytohemagglutmm (PHA) and
bactenal hpopolysacchande (LPS), respectively, was suppressed followillg N02 exposure
Mice were exposed to 940 p,g/m3 (05 ppm) N02 , 24 h/day, 7 days/week for up to 1 year or
to a basehne concentratIOn of N02 (188 p,g/m3 , 0 1 ppm) for 24 h/day, 7 days/week WIth 3-h
peaks 5 days/week to eIther 470, 940, or 1,880 p,g/m3 ~O 25, 05, or 1 0 ppm) N02 The
decrease ill mitogemc responses of splemc lymphocytes to PHA and LPS was not
concentratIOn- or duration-dependent ill the base + peak exposure groups The decrease ill
13-31
T-cell mItogenesIs was hnearly related to the mcreased duratIOn of contmuous exposure to
3
940 p.g/m NOz
LefkOWItz et al (1986) employed several methods to measure unmunoactIvity of mIce
exposed to 9,400 p.g/m3 (5 0 ppm) NOz, 24 hlday for 6 days and m]ected wIth SRBCs after
the fIrst day of exposure NItrogen dIOXIde dId not affect hemagglutmatIOn antIbody tIters or
cell-medIated unmumty (blastogenesIs of splemc T cells), but dId sIgmficantly reduce the
number of splemc PFCs to SRBCs The authors stated (data were not shown) that mIce
3
exposed to 2,820 p.g/m (1 5 ppm) NOz for 14 or 21 days also showed a 33 and 50%
decrease, respectively, m the number of PFCs
3
Kosmider et al (1973b) exposed gumea pIgS to 1,880 p.g/m (1 0 ppm) NOz for 6 mo
and reported a sIgmficant reductIOn m all serum unmunoglobuhn fractIons and complement
Decreased levels of these substances may lead to an mcrease m the frequency, duratIOn, and
3
severity of an infectIous dIsease Mice exposed to a basehne of 940 p.g/m (0 5 ppm) plus
peak of 3,760 p.g/m3 (2 0 ppm) NOz for 3 mo had decreased serum levels of IgA and
exhtbited nonspecIfic mcreases m serum IgM, IgG, and IgGz (Ehrhch et al , 1975)
Effects on lymphocyte populatIOns were tested m mIce by RJ.chters and Darn]I (1988)
The percentage of the total T-lymphocyte populatIOn was lower m the spleens of mIce
exposed for 7 weeks (7 hlday, 5 days/week) to 470 p.g/m3 (025 ppm) NOz The
percentages of mature helper/mducer T lymphocytes and T-CytotoXIc/suppressor lymphocytes
were also lower m the spleen of exposed anunals There were no StatIStICally sIgnIficant
changes in the percentages of NK cells or mature T cells MIce exposed to 670 p.g/m3
(035 ppm) for 7 hlday, 5 days/week for 12 weeks also showed a suppressIOn m the
percentage of total matured T lymphocytes, but no statIstIcally sIgmficant effect on any
specific subpopulatIon However, when the exposure was mcreased to 7,520 p.g/m3
(4.0 ppm) for 8 h, the percentage of total T lymphocytes, T-helper/mducer lymphocytes, and
,
T-CytotoXIc/suppressor lymphocytes was sIgmficantly lower m mIce (Dam]I and RJ.chters,
1989). The most susceptIble subpopulatIOn was the large T-cytotoXIc/suppressor
lymphocytes.
Richters and Darn]I (1990) reported sunIlar fmdmgs m mIce exposed to 470 p.,g/m3
(025 ppm) NOz, 7 hlday, 5 days/week when the exposure tune was mcreased to up to
181 days The splemc T-helper/mducer (CD4 +) lymphocytes were reduced, no effects were
13-32
observed on T-cytotmac/suppressor cells Spontaneously developmg lymphomas m
NOTexposed ammals had progressed more slowly than those m control ammals TIns was
attnbuted to the NOTmduced reductIOn m the T-helper/mducer lymphocytes
Conversely, Selgrade et al (1991) reported that exposure to an N02 peak slowly nsmg
3
to 2,820 p,g/m (1 5 ppm) for 6 h/day, 5 days/week, supenmposed on a baselme
3
concentratIon of 940 p,g/m (05 ppm) for 22 h/day, 7 days/week for up to 78 weeks dId not
affect the splemc or crrculatmg T-cell response to mitogens m rats There were also no
NOTrelated effects on the B-cell populatIon There was a tranSIent decrease m splemc NK
cell actIVIty TIns effect was, however, only noted after 3 weeks of exposure
MIce that were vaccmated wIth mfluenza vrrus (A-2/TaIwan/1I64) after 3 mo of
3 3
contInuous exposure to 3,760 p,g/m (20 ppm) or to 940 p,g/m (05 ppm) N02 wIth a I-h
3
daily, 5 day/week peak exposure to 3,760 p,g/m (20 ppm) had mean serum neutrahzmg
antIbody tIters that were fourfold lower than clean arr controls (Ehrlich et al , 1975) The
hemagglutmatIOn mhIbitIOn tIters m these ammals were unchanged TIns agrees wIth the
3
Fenters et al (1971) fmdmgs m sqUIrrel monkeys exposed to 9,400 p,g/m (5 0 ppm) for
1 year and moculated wIth A1PRl8/34 mfluenza vrrus
Immune response to munne cytomegalovrrus was not substantIally affected by N02 ,
even though N0 2 mcreased susceptIbility to mfectIOn (Rose et al , 1989) MIce were
3
exposed to 9,400 p,g/m (5 0 ppm) N02 for 6 h/day on 2 days pnor to vIral mtratracheal
moculatIon and 4 days after moculatIOn Splemc lymphocyte response to PHA or crrculatmg
specIfic antIbody tIters were not changed However, lymphocyte secondary prolIferatIve
response to the vIral antIgen was decreased
Few studIes have been undertaken to assess the effects of N02 on mterferon
productIOn MIce exposed to eIther 9,400 or 47,000 p,g/m3 (5 or 25 ppm) N02 for 3 to
7 days had serum levels of mterferon sImuar to controls (LefkOWItz et al , 1984, LefkOWItz
et al , 1983)
An mcrease m certaIn ImmUnologIcal functIOns may also be detnmental to the host's
health by stImulatmg the Immune system to react agamst the host's own tIssue Balchum
et al (1965) IdentIfied such an effect when gumea pIgS were exposed to 9,400 p,g/m3
3
(5 0 ppm) or 28,200 p,g/m (15 ppm) N02 There was a notIceable mcrease m the tIter of
serum antIbodIes agamst lung tIssue m all test ammals exposed, startmg after 160 h of
13-33
exposure These antlbody tlters contmued to mcrease wIth the mcreases m N02
concentratlon and exposure duratlon
The effects of N02 exposure on the nnmune system appear to be concentratlOn- and
time-dependent Some studIes suggest httle effect, whereas others suggest suppreSSIOn or
actlvation, dependmg not only on concentratlOn, but also on length of exposure, speCIes
tested, and specIfic end pomts measured Table 13-3 summanzes the reported
nnmunological effects followmg exposure to N02
Interaction with Infectious Agents

Different expernnental approaches usmg laboratory annnals have been employed m an
effort to determme the functlOnal efficIency of the host's pulmonary defenses followmg N02
exposure. In the most commonly used mfectlvlty model, annnals are randomly selected for
exposure to eIther a pollutant, m tills case N02 , or filtered arr After exposure, the
treatment groups are combmed and exposed for approxnnately 15 mm to an aerosol of a
viable agent, such as Streptococcus sp , KlebSIella pneumomae, DIplococcus pneumomae,
influenza A2/Talwan virus, or A!PRl8 mfluenza vrrus The annnals are then returned to
clean air for a holdmg penod (usually 15 days) and the mortallty rates m the N02-exposed
and the arr-exposed groups are compared If the normal pulmonary defenses are functlOnmg
properly, the depOSIted vmble microorgamsms will be qUIckly killed and the lungs will
remain stenle, and only a small percentage (tYPICally between 5 to 15 %) of the control
animals will succumb to the laboratory mfectlOn However, 1f host defenses are
compromised by the cheilllcal exposure, mortallty rates will be illgher (Ehrhch, 1963, 1966,
1980; Gardner et al , 1982, Coffm and Gardner, 1972, Henry et al , 1970)
A wide variety of mannnalmn specIes, mc1udmg humans, share an array of defenSIve
mechanisms that are anatoilllcally and phYSIOlogICally mtegrated m the respIratory tract to
prevent and control most mvadmg mfectmus organIsms The mfectlVlty model IS an
excellent indIcator of a weakened host defense system The effects seen m laboratory
animals represent alteratIOns m host defenses StudIes have shown that these responses are
vahd across species, sensItlve to a vanety of chemIcals, supported by mechamstlc studIes,
and capable of epidemIOlogIcal confirmatIOn Snnl1ar alteratlons m these baSIC defense
13-34
TABLE 13-3. EFFECTS OF NITROGEN DIOXIDE ON TIlE IM:.MUNE SYSTEMa
NO z ConcentratIon
3 SpecIes
p,g/m ppm
470 025 7 h/day, F 6 weeks Mouse Reduced percentage of total T-cell populatIon Rtchters and DalDJI (1988)
5 days/week, (AKRIcum) and trend towards reduced percentage of
7 weeks certam T-cell subpopulatIons and NK cells
470 025 7 h/day, F 5 weeks Mouse Reduced percentage of total T-cell populatIon Rtchters and Darn]l (1990)
5 days/week, (AKRIcum) and percentages of T-helper/mducer cells on
181 days Days 37 and 181
670 035 7 h/day, M 6 weeks Mouse Trend towards suppressIOn m total Rtchters and Darn]l (1988)
5 days/week, (C57BL/6J) percentage of T cells Percentages of other
12 weeks T-cell subpopulatIons lower, but not
slgmficantly
752 04 Contmuous, M 7 weeks Mouse Decreased pnmary splemc PFC response at FU]lmakt et al (1982)
3,000 16 4 weeks (BALB/c) both concentratIons, mcreased secondary
antIbody response at 1 6 ppm
.....
t".)
I 940 05 Contmuous, M 10-11 Mouse Lmear decrease m PHA-mduced mltogenesls Margetter et al (1978)
t".)
Ul up to 1 year weeks (CD-I) WIth NOZ duratIon
188 base + o 1 base + 24 h/day, Vanable suppressIOn of splemc T- and B-cell
470,940, or 025,05, or 7 days/week responsIveness to mttogens but not
1,880 peak 10 peak base + concentratIon- or exposure duratIon-related
3 h/day,
5 days/week
peak for up
to 1 year
940 base + o 5 base + 22 h/day, M 10 Rat No effect on splemc or clfculatmg B- and Selgrade et al (1991)
2,820 peak 15 peak 7 days/week weeks (FIscher 344) T-cell response to mttogens, decrease m
base + splemc NK cell actIvIty only after 3 weeks
6 h/day, exposure No hIstologICal changes m
5 days/week lymphOId tIssue
peak for up
to 78 weeks
TABLE 13-3 (cont'd). EFFECTS OF NITROGEN DIOXIDE ON THE IMMUNE SYSTEMa
NOz ConcentratIon
3 SpecIes
p,g/m ppm
940 base + o 5 base + 24 h/day, M 6 Mouse VaccmatIon WIth mfluenza A2/Tatwan VIruS followed exposure EhrlIch et al
3,760 20 peak 5 days/week weeks (CD-I) Decrease m serum neutraltzmg antIbody, hemagglutInatIon (1975)
peak base + 1 h mhtbitIon tIters unchanged, before VIrus challenge, NOz
daIly peaks exposure decreased serum IgA and mcreased IgG 1, IgM, and
for 3 mo IgGz, after VIrus, serum IgA unchanged and IgM mcreased
1,880 10 Contmuous, M NS Monkey Monkeys challenged five tImes WIth monkey-adapted mfluenza Fenters et al
16 mo (SqUIrrel) VIrus durmg NO z exposure HemagglutmatIon mhtbitIon (1973)
antIbody tIters not altered Compared to controls, NO z caused
an earlIer and greater mcrease m serum neutralIzatIon antIbody
tIters to the VIrus
1,880 10 6mo M NS Gumeapig Intranasal challenge with K pneumomae after exposure Kosnnder
(NS) Decreased hemolytIc actIVIty of complement, decrease m all et al (1973b)
-
~
I
~
0\
2,820 15 24 h1day,
7, 14 or
F NS Mouse
(CD-l and
ImmunoelectrophoretIc fractIons
Splemc PFCs reduced on Day 14 and 21 by 33 and 50%,
respectIvely, no effect on cell-medIated Immune system or
LefkOWItz
et al (1986)
21 days C57BL) hemagglutmatIng tIters
7,520 40 Contmuous, M 8-10 Mouse No suppreSSIon of antIbody response to SRBCs FU]Imakt
up to 56 days weeks (BALE/c) (1989)
7,520 40 8h F 6 Mouse AlteratIon m T lymphocyte subpopulatIOn Dam]I and
weeks (C57BL/6cum) Rtchters (1989)
9,400 50 ISh/day, M/F NS Sheep ReductIon m PFCs m lymph, depressed blastogemc response of Joel et al
10-11 days (Dorset) T cell from lymph and blood (1982)
9,400 50 4 or 7 h1day, NS NS Gumeapig Serum antIbodIes agamst lung tIssue mcreased WIth Balchum et al
5 days/week, (New England) concentratIon and duratIon of exposure (1965)
55mo
9,400 50 Contmuous, M NS Monkey Monkeys challenged 4 X WIth mouse-adapted mfluenza VIrus Fenters et al
169 days (SqUIrrel) mtIal depreSSIOn m serum neutralIzatIon tIters WIth return to (1971)
normal by Day 133, no effect on hemagglutm mlnbltIon titer
TABLE 13-3 (cont'd). EFFECTS OF NITROGEN DIOXIDE ON THE IM:MUNE SYSTEMa
N02 Concentration
3 SpecIes
p.g/m ppm
9,400 50 7 days F 8-12 Mouse No effect on serum mterferon levels LefkowItz et a1 (1983,
47,000 250 3 days weeks (C57BL/6) 1984)
9,400 50 24 hlday, F NS Mouse No effect on serum antibody titers m nnce exposed for LefkoWItz et al (1986)
6, 7, or (CD-I, 6 days (only exposure tested), decrease m splemc PFCs
15 days C57BL) was noted m some groups exposed for 7 or 15 days
9,400 50 24h M 24-28 Rat - ConcentratlOn-related elevatIon of cellular lmmumty m Hdlamet al (1983)
18,800 10 weeks (FIscher 344) thoracIc lymph nodes and spleen after lmmumzmg the
48,900 26 lung WIth SRBCs
9,400 50 Contmuous, NS NS Monkey Depressed postvaccmation serum neutrallzmg antibody Ehrhch and Fenters (1973)
6 mo (SqUlrrel) formation
9,400 50 6 hlday, NS 4-6 Mouse MIce mfected WIth murme cytomegalovIrus after Rose et al (1989)
6 days weeks (CD-I) second day of exposure No effect on clfculatmg
I--' specIfic antibody titer to VIruS or splemc lymphocyte
I.J,)
I
I.J,)
response to PHA Decrease m secondary prohferative
......:J response of splemc lymphocytes to VIral antigen
9,400 50 12 h M/F 6-9 Mouse No effect on pnmary and secondary splemc PFC FUJlmakl and Smnnzu
37,600 20 weeks (BALB/c) response at 5 ppm, at mgher levels, suppressIon m (1981)
75,200 40 pnmary antibody response FUJlmakl et al (1981)
Hldekazu and FUJIO (1980)
10,000 53 Contmuous, F NS Gumeaplg No effect on antibody production Antwe111er et al (1975)
19,26, or (BFA-ZH-
33 days Ktsslegg)
18,800 10 2 hlday, F 6-8 Mouse Marked depreSSIon m ablhty of T cells to respond to Holt et al (1979)
30 weeks weeks (BALB/c) nonspecIfic stimuh, reduced ablhty to reject tumors
aF = Female IgM = ImmunoglobuhnM

NK = Natural kIller cells NS = Not stated
M = Male PFCs = Plaque fornung cells
IgA = Immunoglobuhn A SRBCs = Sheep red blood cells
IgG = Immunoglobuhn G
mechamsms that occur mammals could also occur m humans because they have eqUIvalent
pulmonary defenses In the ammal model frequently used, mortalIty IS the sensItIve response
indicator for alteratIons m host defense functIonmg However, WIth today's medIcal care,
few people dIe of bactenal pneumoma, so a better companson m humans would be the
prevalence of resprratory illness m the commumty, as wscussed m Chapter 14 of thts
document (epidemIOlogIcal studIes) Such a companson IS proper because both mortalIty
(animals) and morblwty (humans) result from a loss of pulmonary defenses However,
dIfferent exposure levels, patterns, and duratIons may be requrred to produce alteratIOns to
human host defenses Table 13-4 summanzes the effects of exposure to N02 and InfectIOus
agents.
An enhancement m mortalIty followmg exposure to N02 and a pathogemc
microorgamsm could be due to several factors StudIes by Goldstem et al (1973) showed
decreases m pulmonary bactencldal actIvIty followmg N02 exposure In therr frrst
expenments, mice breathed aerosols of Staphylococcus aureus (S aureus) labeled WIth
radioacnve phosphorus and then were exposed to N02 for 4 h PhySical removal of the
bacteria was not affected by any of the N02 concentrations used up to 27,800 p,g/m3
(14.8 ppm). Concentrations of 13,200, 17,300, and 27,800 p,g/m3 (70, 92, and 14 8 ppm)
NOzlowered bactencldal activIty by 7, 14, and 50%, respectively, when compared to
3
controls Lower N02 concentrations (3,570 and 7,140 p,g/m , 1 9 and 3 8 ppm) had no
sigmficant effect The cause of the alteratIOn was an lffiparrment of the AM's bactencldal
activity and not an lffiparrment of the host's mechamcal clearance system In another
expenment (Goldstem et al , 1973), illlce breathed 1,880, 4,320, and 12,400 (1 0, 2 3, and
6.6 ppm) NO z for 17 h and then were exposed to an aerosol of radlolabeled S aureus Four
hours later, the animals were exammed No duference m the number of bactena lnbaled
was found m the NOz-exposed ammals ConcentratIOns of 4,320 and 12,400 p,g/m3 N02
decreased pulmonary bactencldal activity by 6 and 35 %, respectIvely, compared to controls
3
Exposure to 1,880 p,g/m N02 had no slgmficant effect Goldstem et al (1973)
hypotheSIZed that the decreased bactencldal activIty was due to defects m AM functIon
Jakab (1987, 1988) confrrrned these fmdmgs and reported that the concentratIOn of N02
requITed to suppress normal pulmonary bactencldal activity m mice depends on the speclfic
13-38
TABLE 13-4. INTERACTION OF NITROGEN DIOXIDE WITH INFECTIOUS AGENTS a
N02 Concentration
3 Specles Infective
p.g/m ppm (Stram) Agent Reference
Exposure Gender Age Effects
100 base 005 base Contmuous, F NS Mouse Streptococcus No effect Gardner (1980)
+ 188 +01 base + (CD-I) sp Gardner et al
peak peak twlce/day l~h (1982)
peaks, Graham et al
5 days/week (1987)
for 15 days
940 base 05 base Increased mortallty
+ +
1,880 peak 1 0 peak
2,256 base 1 2 base Increased mortallty
+ 4,700 +
peak 25 peak
...... 376 base 02 base 23 h/day, F 6-8 Mouse Streptococcus Peak plus baselme caused slgmficantly greater Mllier et al (1987)
~
I
~
+ 1,504 + 7 days/week weeks (CD-I) sp mortality than baselme
\0 peak 08 peak base + twlCe
dally l~h
peaks,
5 days/week
for 1 year
564- 03- Contmuous, F 4 Mouse A/PRl8 Hlgh mCldence of adenomatous prohferation of Motolmya et al
940 05 3 mo weeks (ICR JCL) Vlrus penpheral and bronchtal eplthehal cells, N0 2 (1973)
alone and VlruS alone caused less severe
alteratlOns
Contmuous, No enhancement of effect of N0 2 and VlruS
6 mo
TABLE 13-4 (cont'd). INTERACTION OF NITROGEN DIOXIDE WITH INFECTIOUS AGENTS a
N02 ConcentratIon
3 SpecIes InfectIve
p.g1m ppm Exposure Gender Age (Stram) Agent Effects Reference
940 05 Intermtttent, F NS Mouse K. pneumomae Increased mortaltty after 6 mo Ehrbchand
6 or 18 h/day, (SWISS) mtermtttent exposure or after Henry (1968)
up to 12 mo 3, 6, 9, or 12 mo contmuous
exposure, followmg 12 mo
Contmuous, exposure, mcreased mortalIty
90 days was SIgnIficant only m
contmuously exposed mIce
940- 05-10 Contmuous, F NS Mouse AlPR/8 Increased susceptIbIlIty to Ito (1971)
1,880 39 days (lCR, dd) VIruS mfectIon
18,800 10 2 h/day,
1,3, and
.....
~
5 days
~
I
940- 05-28 Vaned F NS Mouse Streptococcus Increased mortabty WIth Gardner et al (1977a,b)
0 52,700 (CD-I) sp mcreased tIme and
concentratIon, concentratiOn IS
more Important than tIme
940 05 3 h/day, F 6-8 Mouse Streptococcus Increase m mortalIty WIth EhrlIch et al (1979)
3mo weeks (CD2F lo sp reductIon m mean survIval
CD-I) tIme
940 05 24 h/day, F NS Mouse K pneumomae SIgnIficant mcrease m McGrath and OyervIdes
1,880 10 7 days/week, (CF-l) mortalIty after 3-day exposure (1985)
2,820 15 3 mo to 5 0 ppm, no effect at other
concentratIons, but control
9,400 50 3 days mortalIty very htgh
940 05 4h M/F 8-10 Mouse Mycoplasma Decrease m mtrapulmonary DaVIS et al (1992)
1,880 10 weeks (C57BL/6N) pulmoms ktllmg only at 5 0 ppm
3,760 20
9,400 50
NOz Concentration
:3 SpecIes Infective
p.g/m ppm
Exposure Gender Age (Stram) Agent Effects Reference
1,880 10 17 h M NS Mouse S aureus No dIfference m number of Goldstem et al
4,324 23 (SWISS) after exposure bactena deposIted, but at the two (1973)
12,408 66 htghest concentratlOns, there was a
decrease m pulmonary bactencidal
actlV1ty of 6 and 35 %,
respectIvely, no effect at 1 0 ppm
1,880 10 4h F NS Mouse S aureus Injection wIth corticosteroIds Jakab (1988)
4,700 25 (SWISS) mcreased NOz-mduced mpatrment
9,400 50 of bactencidal actiVIty at
18,800 100 ~2 5 ppm
1,880 10 48 h M NS Mouse Streptococcus Increased prolIferation of Sherwood et al
--
(SWISS sp Streptococcus m lung of exposed (1981)
Webster) S aureus nnce but no effect WIth
V.>
I
Staphylococcus
.j:>.
1,880 10 3h F 5-6 Mouse Streptococcus ExercIse on contmuously movmg Illmg et al (1980)
5,640 30 weeks (CD-I) sp wheels durmg exposure mcreased
mortalIty at 3 0 ppm
1,880 10 6 h1day, 6 days NS 4-6 Mouse Cytomegalo- Increase m VIruS susceptibIlIty at Rose et al (1988,
4,700 25 weeks (CD-I) VIruS 5 o ppm only 1989)
9,400 50
2,820- 1 5- 2h NS NS Mouse K pneumomae SIgmficant mcreased mortalIty m EhrlIch (1975)
94,000 50 (NS) nnce, hatnSters, and monkeys at
HatnSter NOz concentratlOns of ~3 5,
(NS) ~35, and 50 ppm, respectively
Monkey
(Sqmrrel)
TABLE 13-4 (cont'd). INTERACTION OF NITROGEN DIOXIDE WITH INFECTIOUS AGENTS 2
N02 Concentratlon
3 SpecIes Infectlve
p.g/m ppm (Stram) Agent Effects Reference
Exposure Gender Age
2,820 15 Contlnuous F NS Mouse Streptococcus After 1 week, mortalIty wIth Gardner et al (1979)
or (CD-I) sp contmuous exposure was greater Coffin et al (1977)
mtermxttent, than that for mtermxttent, after
7 hlday, 2 weeks, no sIgnIficant dIfference
7 days/week, between contmuous and
up to 15 days mtermxttent exposure
6,580 35 Increased mortalIty WIth mcreased
duratlon of exposure, no SIgnIficant
difference between contmuous and
mtermxttent exposure, WIth data
adjusted for total difference m
C X T, mortalIty essentIally the
-
wI
+:0-
tv
2,820 base 1 5 base
+ 8,100 +
peak 45 peak
Contlnuous
64 h, then
peak for 1,
F NS Mouse
(CD-I) sp
same
Streptococcus MortalIty mcreased WIth 3 5- and
7-h smgle peak when bactenal
challenge was after an 18-h
Gardner (1980)
Gardner et al (1982)
Graham et al (1987)
35, or 7 h, baselme exposure
then
contlnuous
18 h base
8,100 45 1,35, or 7 h MortalIty proportlonal to duratIon
when bactenal challenge was
Immediate, but not 18 h
postexposure
2,820 15 7 hlday, 4, NS NS Mouse Streptococcus Elevated temperature (32°C) Gardner et al (1982)
5, and 7 days sp mcreased mortalIty after 7 days
3,570 19 4h M NS Mouse S aureus PhYSICal removal of bactena Goldstem et al (1973)
7,140 38 (NS) unchanged by exposure
13,200 70 Bactencidal actIVIty decreased by
17,200 92 7, 14, and 50%, respectIvely, m
27,800 148 three htghest N02-exposed groups
N02 Concentration
3 SpecIes Infective
p.g/m ppm
Exposure Gender Age (Stram) Agent Effects Reference
2,820- 1 5- 3h F 6-10 Mouse Streptococcus Increased mortalIty m nnce exposed to EhrlIch et al (1977)
9,400 50 weeks (CF-l, sp ::::20 ppm EhrlIch (1980)
CD2F 1)
2,820 15 2h NS 6-8 Mouse K pneumonzae No effect at 1 5 or 25 ppm, mcreased PurvIS and EhrlIch
4,700 25 weeks (SWISS mortalIty at 3 5 ppm and above (1963)
6,580 35 Webster) Increase m mortalIty when EhrlIch (1980)
9,400 50 K pneumonzae challenge 1 and 6 h
18,800 10 after 5 or 10 ppm N~ exposure, when
28,200 15 K pneumonzae challenge 27 h
followmg N02 exposure, effect only at
15 ppm
-
3,760 20 15 h/day, NS 2 Hamster AlPRl8/34 Peak VIruS productIOn m tracheal SchIff (1977)
5 days/week weeks (Golden mfluenza explants occurred earlIer
wI for 1, 2, and Synan) VIrus
.j::o.
w 3 weeks (m VItro)
.1.,700 25 4h F NS Mouse S aureus, ConcentratIOn-related decrease m Jakab (1987, 1988)
7,500 40 (SWISS) Proteus bactencIdal activIty at :::: 4 0 ppm WIth
9,400 ,n
J v mzrabzlzs, S aureus wnen N02 exposure after
18,800 10 Pasteurella bactenal challenge, when N02 exposure
28,200 15 pneumotropzca was before challenge, effect at 10 ppm,
N02 concentratIOns > 5 0 ppm reqUIred
to affect bactencIdal activIty for other
tested nncroorgamsms
9,400 50 Contmuous, M NS Monkey K pneumomae Increased vIral-mduced mortalIty (113) Henry et al (1970)
2mo (SqIDrrel) or AlPRl8 Increase m Klebszella-mduced mortalIty
mfluenza VIruS (217), no control deaths
18,800 10 Contmuous, Increased vIrus-mduced mortalIty (6/6)
1 mo WIthIn 2-3 days after mfectIOn, no
control deaths Increase m Klebszella-
mduced mortalIty (114), no control
deaths
N02 Concentratlon
3 SpecIes Infectlve
p.g/m ppm Exposure Gender Age (Stram) Agent Effects Reference
9,400 50 4h M/F 6-10 Mouse Mycoplasma N02 mcreased mCIdence and seventy Parker et al (1989)
18,880 10 weeks (C57Bl/6N, pulmoms of pneumoma lesIons and decreased the
C3H1HeN) number of orgamsms needed to mduce
pneumoma, no effect on physIcal
clearance, decreased mycoplasmal
kIllmg and mcreased growth, no effect
on specIfic IgM m serum, C57Bl/6N
nnce generally more sensItlve than
C3HIHeN nnce At 10 ppm, one
stram (C57B1I6N) of nnce had
mcreased mortalIty
18,800 10 2h M/F NS Monkey K Clearance of bactena from lungs of Henry et al (1969)
28,200 15 (SqUIrrel) pneumomae 10-, 15-, and 35-ppm groups delayed
C; 65,800 35 or prevented All three ammals m
t
I
94,000 50 hIghest exposed group dIed
lip = Female
NS = Not stated
K pneumomae = Klebszella pneumomae
M = Male
S aureus = Staphylococcus aureus
exT = The product of concentralton and time
illvadmg orgamsm For example, exposure to > 7,520 ",g/m3 (4 0 ppm) N02 for 4 h after
bactenal challenge depressed lung bactencidal actIvIty III mIce agamst deposIted S aureus,
3
but It requITed a concentratIOn of 18,800 to 37,600 ",g/m (10 to 20 ppm) before the lung's
ability to kIll Pasteurella and Proteus was Imparred These effects became more sIgmficant
WIth mcreasmg concentratIOns
The combmatIOn of cortIcosterOId (subcutaneous mJectIOn) and N02 exposure (4 h)
sIgmficantly Imparred the illtrapulmonary kI1lmg of staphylocoCCI at concentratIons of
>4,700 ",g/m3 (;;:::25 ppm) (Jakab, 1988) WIthout cortIcosterOIds, bactencidal actIvIty was
3
only decreased at ;;:::9,400 ",g/m No NOT and cortIcosterOId-related effects on
3
mtrapulmonary kI1lmg were noted ill mIce exposed to 1,880 ",g/m (1 0 ppm) N02 These
results would demonstrate that such a pretreated host IS more susceptIble to the effects of
N02 The nnphcatIOn of thIs fmdmg IS the probable eXIstence of a hIgh-nsk populatIOn
(because of ImmunosUppressIOn, chromc lung dIsease, or old age) whose altered host status
makes them more susceptIble to mfectIon followmg N02 exposure (Green, 1970)
Parker et al (1989) made SImIlar observatIOns ill mIce exposed for 4 h to 9,400 or
18,800 ",g/m3 (5 or 10 ppm) N02 and mfected WIth Mycoplasma pulmonzs The hIgher
concentratIon of N02 illcrease mortalIty Both concentratIOns reduced lung bactencidal
actIVIty and illcreased the number of bactena Withm the' lung, producillg an illcrease m the
illcidence and seventy of munne respIratory mycopiasmosis leSIOns There was no effect on
phySICal clearance When N02 exposure was decreased (940, 1,880, or 3,760 ",g/m3 , 0 5,
1.0, or 2 0 ppm), usmg the same exposure model, the bactencidal actIVIty of the lungs was
not affected, although 9,400 ",g/m3 (5 0 ppm) decreased bactericIdal actIVIty (DaVIS et al ,
1992)
DIfferences in specIes susceptIbility to N02 or to a pathogen may playa role ill the
enhancement ill mortalIty seen m expenmentaI anImals An enhancement m mortalIty was
noted ill mIce, hamsters, and monkeys exposed to N02 for 2 h followed by a challenge of
K pneumonzae (Ehrhch, 1975) However, dIfferences ill susceptIbility were noted between
the specIes SqUIrrel monkeys exposed contmuously to N02 levels of 9,400 and
3
18,800 ",g/m (5 0 and 10 ppm) for 2 and 1 mo, respectIvely, showed mcreased mortalIty
followillg a challenge WIth K pneumonzae and reduced lung clearance of VIable bactena
(Henry et al , 1970). Two of seven monkeys exposed to 9,400 ",g/m3 for 2 mo dIed, and the
13-45
rest had bactena m the lungs on autopsy EhrlIch (1975) found that hamsters exlnbited
enhanced mortality after exposure for 2 h to N02 concentratIOns of ~65,800 /l-g/m3
3
(;;::35 ppm), but not at 9,400 to 47,000 /l-g/m (5 to 25 ppm) The mouse was the most
sensitive to N02 exposure, as eVIdenced by enhanced mortahty followmg a 2-h exposure to
3 3
6,580 /l-g/m (3 5 ppm), but not to 2,820 to 4,700 /l-g/m (1 5 to 2 5 ppm) (EhrlIch, 1975)
Purvis and EhrlIch (1963) also reported no effect on mortahty m mIce exposed for 2 h to
2,820 or 4,700 /l-g/m3 (1 5 or 25 ppm), mcrease mortahty occurred at 6,580 /l-g/m 3
(3.5 ppm) and hIgher However, when Streptococcus sp was the mfectIOus agent, a 3-h
exposure to 3,760 /l-g/m 3 (20 ppm) N02 caused an mcreased m mortahty m mIce (EhrlIch
et al., 1977)
SqUIrrel monkeys exposed to 9,400 or 18,800 /l-g/m3 (5 or 10 ppm) N02 for 2 or 1 mo,
respectively, also showed mcreased susceptIbility to a laboratory mduced vrral mfluenza
infection (Henry et al , 1970) All SIX antmals exposed to the hIghest concentratIOn dIed
withIn 2 to 3 days of mfectIOn WIth the mfluenza vrrus At the lower concentratIOn, one of
three monkeys dIed SusceptIbility to vIral mfection was enhanced when the N02 exposure
occurred 24 h after the mfectIous challenge
McGrath and SmIth (1984) mvestIgated whether changes m susceptIbility to bactenal
infections m mIce were related causally to the effects of N02 on resprratIOn Because no
spontaneous changes m resprratory patterns were produced followmg a 3-day exposure to
3
9,400/l-g/m (5 0 ppm) N02 , the authors concluded that any such relatIonshIp was unbkely
Refer to Section 13 2 2 3 on pulmonary functIOn for detaIls of the study
The importance of the test mIcroorgamsm used WIth the mfectIvity models was also
demonstrated by Sherwood et al (1981) These researchers illustrated that exposure to
1,880/l-g/m3 (1.0 ppm) N02 for 48 h mcreased the propenSIty of vrrulent group C
streptOCOCCI, but not S aureus, to prohferate WIthIn the lungs of mIce and cause earlIer
mortality
The relatIOnshIps of concentratIon and tIme to susceptIbility to respIratory mfectIon and
to subsequent mortahty m mfectIOns WIth Streptococcus sp were exammed by Gardner et al
(1977a,b) When N02 concentratIons were vaned from 2,820 to 52,600 /l-g/m3 (1 5 to
28 ppm) and the duratIon of exposure vaned from 0 25 to 4 7 h so that exT equaled a
value of 7 ppm-h, exposure to hIgh concentratIons of N~ for bnef penods of tIme resulted
13-46
m greater mortahty than dId prolonged exposures to lower concentratIOns (Gardner et al ,
1977b) ThIs mdicated that susceptibility to Infection was mfluenced more by the
concentratIOn of N02 than by the duratIOn of the exposure
In the same study (Gardner et al , 1977a,b), a hnear exposure-duration response was
'I
observed m mIce exposed to from 940 to 52,640 p,g/m- (05 to 28 ppm), mdicatmg that
mortahty mcreases wIth mcreasmg length of exposure to a given concentration of N<h
(FIgure 13-1) Mortahty also mcreased wIth mcreasmg concentratIOn of N02 , as mdIcated
by the steeper slopes wIth hIgher concentrations When C x T was held constant, the
relatIOnshIp between concentratIon and tIme produced sIgrnficantly different mortahty
responses At a constant C x T of approXImately 21 ppm-h, a 14-h exposure to
3
2,820 p,g/m (1 5 ppm) N02 mcreased mortahty by 125%, whereas a 1 5-h exposure to
26,300 p,g/m3 (14 ppm) N02 enhanced mortahty by 58 5% These results confrrmed that
concentration IS more Important than tIme m determmmg the degree of mJury mduced by
N02 m thIs model Accordmg to Larsen et al (1979), N02 modehng studIes have shown
that the concentration (c) of N02 expected to cause a certaIn mortahty level (z) as a functIOn
of the hours of exposure (t) can be expressed as c = 9 55 (2 42)zf o 33
Gardner et al (1979) and Coffm et al (1977) also compared the effect of contmuous
versus mtermittent exposure to N02 followed by bactenal challenge WIth Streptococcus sp
MIce were exposed eIther contmuously or mtermittently (7 h/OOy, 7 days/week) to 2,820 or
6,580 p,g/m3 (1 5 or 3 5 ppm) N02 The results of contmuous and mtermittent exposure to
6,580 p,g/m3 (3 5 ppm) for penods up to 15 days mdicated that there was a sIgrnficant
mcrease m mortahty for each of the expenmental groups WIth mcreasmg duration of
exposure When the data were adjusted for the difference m C X T, the mortahty was
essentially the same for the contmuous and mtermittent groups The contmuous exposure of
mIce to 2,820 p,g/m3 N02 mcreased mortahty after 24 111 of exposure Dunng the fIrst week
of exposure, the mortahty was sIgrnficantly hIgher m nllce exposed contmuously to N02 than
m those exposed mtermittently By the 14th day of exposure, the difference between
mtermittent and contmuous exposure became mdIstlngullshable ThIs suggests that fluctuatmg
levels of N02 may ultImately be as toXiC as sustamed high levels (Gardner et al , 1979)
When mICe were exposed contmuously or mtermllttently (6 or 18 h/day) to 940 p,g/m3
(05 ppm) N02 for up to 12 mo, munne reSIstance to K pneumomae InfectIOn was not
13-47
w .... SYMBOL ppm N02
0
:z
w .... <> 280
a: .... 140
&:i'
-0
6 °0 •°
....
6
70
35
15
~~ 6 • 05
~~
ocr
~z
...:z
~
-
ffi
D.
·1
6 15 253035 1
l-mInutes-le
2 3 5 7 14
haulS
24 48 _ 4Ie 7 1416 1
days_Ie 2 3 6
montils~
9 12
TIME
Figure 13-1. Mortality enhancement for mice exposed to nitrogen dioxide at various
concentrations and for various durations prior to challenge with
streptococci. At all concentrations, prolonged exposure results in
enhanced mortality, but the severity of resistance reduction is more
directly related to concentration.
Source Gardner et al (1977b)
affected dunng the :fIrst month of exposure (Ehrhch and Henry, 1968) Those exposed
continuously exhIbited decreased reSIstance to the Infectious agent, as demonstrated by a
sigmficant enhancement m mortahty at 3, 6, 9, and 12 mo In another expenment, a
significant enhancement dId not occur at 3 mo, but was observed after 6 mo of exposure
After 6 mo, mIce exposed mtermittently (6 or 18 h/day) to N02 showed sIgmficant mcreases
in mortality over controls (18%) Only the contmuously exposed anImals showed mcreased
mortahty (23 %) over controls followmg 12 mo of exposure After 12 mo of exposure, mIce
m the three expenmen!al groups showed a reduced capaCIty to clear Viable bactena from
their lung TIns was :fIrst observed after 6 mo m the contmuously exposed groups and after
9 mo in the mtermittently exposed groups These changes, however, were not statiStically
tested for sigmficance Therefore, although It IS not pOSSIble to drrectly compare the results
of the studies usmg Streptococcus sp to those usmg K pneumonzae, the data suggest that as
the concentratIOn of N02 IS decreased, a longer exposure time IS necessary for the
13-48
mtenmttent exposure regtmen to produce a level of effect eqUIvalent to that of a contmuous
exposure
A sIgmficant mcrease m percent mortalIty and a decrease m relatIve mean SUrvIval tIme
3
was noted ill mIce exposed contInuously to 9,400 p.,g/m (5 0 ppm) for 3 days (McGrath and
Oyervides, 1985) However, stmI1ar contmuous exposure for 24 h/day, 7 days/week to 940,
1,880, and 2,820 p.,g/m3 (05, 1 0, and 1 5 ppm) NO z £Dr 3 mo dId not produce a dIfference
m eIther of these parameters These subchromc exposure results do not agree WIth Ehrhch
and Henry (1968), who found excess mortalIty m mIce .:iller contmuous exposure to
940 p.,g/m3 (05 ppm) for 3 mo, but the short-tenn exposure results do agree WIth those of
Gardner et al (1979) and Ehrhch (1980) The mconsislency may also be attnbuted to the
fact that the McGrath and Oyervides (1985) study had 95 % mortalIty m the control groups,
makmg It vIrtually tmpossible to detect a N0z-illduced e:nhancement m mortalIty
PurvIS and Ehrhch (1963) illvestIgated the perSIstence of the effect of NOz usmg the
mfectivity model They found a sIgmficant illcrease m excess mortalIty ill mIce exposed for
2 h to 9,400 p.,g/m3 (50 ppm) NO z , followed by a challenge WIth K pneumonzae They
reported that the mcreased mortalIty occurred when the mfectious challenge was gIven 1 or
6 h postexposure, but was no longer present If the mfec1IOuS challenge was given 27 h after
the antmals were removed from the InhalatIOn chambers
Gardner (1980), Gardner et al (1982), and Graban} et al (1987) reported further
illvestIgatIOns on the response of mIce to arrborne mfectllOns dunng or followmg mtennittent
exposure to NO z These studies mvestIgated the tOXICIty of NO z peak exposures
supenmposed on a lower contInuous background level of NO z Such a regtmen
approXImates the pattern of exposure that humans receIve ill the urban enVIronment MIce
were exposed to NO z peaks of 8,460 p.,g/m3 (45 ppm) for 1, 3 5, or 7 h and then were
challenged WIth Streptococcus sp eIther tmmedmtely or 18 h postexposure MortalIty was
proportIOnal to the duratIon of the peak when the mIce were exposed to bactena tmmedIately
followmg NO z exposure, but mIce had recovered from the exposure by 18 h When a peak
3 3
exposure of 8,460 p.,g/m was supenmposed on a contInuous background of 2,820 p.,g/m
(1 5 ppm) for 64 h precedmg and 18 h followmg the peak, mortalIty was sIgmficantly
enhanced by a peak exposure lastIng 3 5 or 7 h when th~~ mfectious agent was admlllistered
18 h after the peak exposure POSSIble explanatIOns for these dIfferences due to the presence
13-49
or absence of a background exposure are that mIce contmuously exposed are not capable of
recovery or that new AMs or PMNs recruIted to the sIte of mfectIOn are lIDparred by the
continuous exposure to N02 The effect of multIple peaks was exammed by exposmg mIce
3
for 2 weeks to two daIly I-h peaks (mornmg and afternoon) (5 days/week) of 8,460 p,g/m
3
supenmposed on a contmuous background (7 days/week) of 2,820 p,g/m N02 MIce were
exposed to the mfectIous agent eIther lIDmed1ately before or after the mornmg peak exposure
When the mfectIous agent was given before the mornmg peak exposure, the mcrease m
3
mortality illd not closely approach that of a contmuous exposure to 2,820 p,g/m N02
However, in mICe exposed after the mornmg peak, by the second week of exposure, the
mcreased mortahty over controls approached that eqUIvalent to contmuous exposure to
2,820 p,g/m3 N02 These rmdmgs demonstrate that the pattern of exposure determmes the
response and that the response IS not predIctable based on a slIDple C x T relatIOnsmp
Further mvestigatlons mto the effects of N02 on murme antIbactenallung defenses
have been conducted usmg a peak to baselme ratIO of 4 1, wmch IS not uncommon m the
urban environment (Miller et al , 1987) For 1 year, mIce were contmuously exposed
23 h/day, 7 days/week to a baselme of 376 p,g/m3 (02 ppm) or to tms baselme level on
wmch a I-h peak of 1,500 p,g/m3 (0 8 ppm) N02 was supenmposed two tlIDes a day,
5 days/week The anlIDals exposed to the baselme level illd not reveal any sIgmficant
treatment-related effects, however, the mfectIVIty mortahty of the mIce exposed to the
baselme plus peak reglIDen was sIgmficantly greater than that of eIther the N02 background
exposed IDlce or the control mIce ThIS chromc study millcates that short-term peaks of N0 2
can cause detectable effects on antIbactenallung defenses ThIs baselme and peak exposure
also affected pulmonary functIOn (see SectIOn 13 22 3) (Miller et al , 1987)
3
Mice exposed contmuously for 3 mo to 564 to 940 p,g/m (0 3 to 05 ppm) N0 2
followed by a challenge WIth A!PRl8 mfluenza VlfUS showed sIgmficant pulmonary
patholOgical responses (MotoIDlya et al , 1973) A greater mCIdence of adenomatous
proliferatIon of broncmal epIthehal cells resulted from the combmed exposures of VlfUS plus
N02 than with eIther the vIral or N02 exposures alone Contmuous N02 exposure for an
addItIonal 3 mo illd not enhance the effect of N02 or the subsequent VlfUS challenge
Ito (1971) challenged IDlce WIth mfluenza A/PRl8 VlfUS after contmuous exposure to
940 to 1,880 p,g/m3 (05 to 1 0 ppm) N02 for 39 days and to 18,800 p,g/m3 (10 ppm) N0 2 ,
13-50
2 h daily for 1, 3, and 5 days Acute and intermIttent <;:xposure to 18,880 p,g/m3 N02 , as
well as contInuous exposure to 940 to 1,880 p,g/m3 N02 , mcreased the susceptIbility of mIce
to mfluenza VIrUS, as demonstrated by mcreased mortalIty Further, when Isolated hamster
tracheal organ explants were exposed m VItro for 1, 2, and 3 weeks to 3,760 p,g/m3
(2 0 ppm), 1 5 h/day for 5 days/week and then Immediately mfected wIth mfluenza VIrUS
(AlPRl8/34), the maxImum VIrUS tIter reached was the same for both the exposed and
unexposed explants However, N02 exposure caused the peak VIrUS productIon to occur
earher (SchIff, 1977)
The lower resprratory tract of mIce became sigruficantly more susceptIble to murme
cytomegalovlIDs infectIOn after 6-h exposures for 6 days to 9,400 p,g/m3 (5 0 ppm), but not
::::;4,700 p,g/m3 (=:;;25 ppm) N02 (Rose et al , 1988, 1989) Vrral rephcatIon was routmely
mcreased m the lungs of mIce exposed to 9,400 p,g/m3 N02 over that of controls There was
also an mcrease m the mCIdence of lung lesIOns m the N02-exposed mIce The N02-exposed
anImals could be mfected wIth an moculum 100 tunes less than that requIred to mfect arr-
exposed anImals. Further, the NOTexposed anImals were more susceptIble to vrral
remfectIOn, whereas the arr-exposed controls appeared to resIstant to remfectIOn However,
AM antIvrral capacIty lid not appear to be altered Humoral vIrUs-specIfic antIbody tIters
were not affected by N02 , nor were splemc lymphocyte prohferatIve responses to vrral
antIgens
Exposure to a N02 concentration of 9,400 p,g/m3 (5 0 ppm) lid not sigruficantly alter
the course of a paramfluenza (murme sendm VIrUS) mfectIOn m mICe as measured by the
mfectIous pulmonary VIrUS tIters m the lungs However, thIs concentratIOn of N02 , when
combmed wIth the VIrUS exposure, dId mcrease the seventy of the pulmonary dIsease process
(vrral pneumomtIs) (Jakab, 1988)
Only one human chmcal study has exammed the effect of N02 on mfectIVIty rate
(Gomgs et al , 1989) Subjects were exposed to 1,880, 3,760, or 5,640 p,g/m3 (1.0, 2.0, or
3 0 ppm) N0 2 for 3 consecutIve days (2 h/day) and moculated mtranasally wIth attenuated
mfluenza AlKorealreassortment VIrUS on the second of these days No statIstIcally sigruficant
effects were observed, although there was a trend towards an mcrease m mfectIVIty rates
However, thIs study had a low statIstIcal power to detect small changes See Section 15 6
for an expanded dIScussIon of thIs study
13-51
Stress, m addItIon to mfluencmg the lethahty of a partIcular exposure concentratIon, has
been shown to enhance the toXiC effect of N02 MIce placed on contmuously movmg
3 3
exerCIse wheels dunng exposure to 5,640 p.g/m (3 0 ppm) N02 , but not 1,880 p.g/m
(1 0 ppm), for 3 h showed enhanced mortahty over nonexercised N02-exposed mIce USIng
the streptococcal InfectIVIty model (lllmg et al , 1980) The presence of other envIronmental
factors, such as 0 3 (Ehrhch et al , 1977, Gardner, 1980, Gardner et al , 1982, Graham
et al , 1987), elevated temperatures (Gardner et al , 1982), or tobacco smoke (Henry et al ,
1971), also augments the effect of N02 on host resistance to InfectIOn When mIce were
3
stressed by elevated temperature (32°C) and exposed to 2,820 p.g/m (1 5 ppm) N0 2 , there
was a slgmficant enhancement m mortahty rate after 7 days of exposure (Gardner et al ,
1982)
Summary
The host defense system IS one of the many potentIal targets whose functIOn has been
shown to be altered sIgmficantly by exposure to N02 EVIdence would mdIcate that any
breach m these defenses should be conSIdered as a pOSSIble mdicator of an mcreased nsk of
Infectious pulmonary and/or systemIc dIsease
As dIscussed m the sectIon on lung morphology, N02 causes structural alteratIOns In
the ciliated cells of the arrways, however, sIgmficant Imparrment of tracheobronchIal
clearance rates generally were not seen at levels ~ 18,800 p.g/m3 (10 ppm) N02 (SchleSInger
et al , 1987a,b) ThIs would mdicate that even a severely damaged arrway epIthehum (1 e ,
loss of cilia) stl1l has the ability to mamtaIn mucus transport at a nonnal rate, and that the
exposure of expenmental antmals to N02 would have to be to concentratIOns
> 18,800 p.g/m3 to mduce any sIgmficant alteratIons that would have detnmental health
effects.
Withm the pulmon'ary regIOn of the lung, the pnmary cellular defense affected by both
acute and long-tenn exposure to N02 IS the AM NItrogen dIOXide causes a depressIOn of
phagocytIc actIvIty, reduces cell VIability, dIsrupts membrane mtegnty, reduces the total
number of avaIlable cells, produces morphologIcal changes, and decreases bactencidal
activity Although a few of these effects were seen followmg exposure to concentratIOns
< 1,880 p.g/m3 (l 0 ppm) (SchleSInger, 1987b, Rose et al , 1989), most of the studIes
13-52
3
showed effects at concentratIOns between 1,880 and 9,400 p,g/m (1 0 and 5 0 ppm) N02
(Goldstem et al , 1973, Greene and SchneIder, 1978, Hooftman et al , 1988, Dowell et al ,
1971, Suzula et al , 1986, Acton and Myrvik, 1972) EVIdence mdicates that these cells are
no longer capable of Isolatmg, transportmg, detoXIfymg, or clearmg Inhaled substances
The systemIc cell-mediated and humoral Immune system IS also a target for N0 2 , as
eVIdenced by expeflillental anImal studIes The ImmUnologIcal effects reported seem to be
vanable Some studIes show effects and others do not It has been suggested that long-term
exposure may result m a suppressIOn of the vanous humoral and cell-mediated functIOns,
whereas shorter exposures may cause an enhancement of ImmUnologIcal actiVIty The
response seems to be dependent not only on concentratlOn and duratlon of exposure, but also
on anImal specIes and the specIfic ImmUnologIcal end pomt measured Research on the
systemIC Immune system m mIce, gumea pIgS, and monkeys mdicates that subchromc and
chromc exposure at or below 1,880 p,g/m3 (1 0 ppm) can suppress T- and B-cell
responsIveness to mitogens and can decrease the numbeJr of T cells (Rlchters and Dam]I,
1988, 1990, Maigetter et al , 1978) NItrogen dIOXide mfluences the productlon of serum-
neutrahzmg antIbodIes to VIruses and humoral pflillary antlbody response to SRBCs
(Fu]Imala et al , 1982, Ehrhch et al , 1975, Fenters et a1 ,1973) Other ImmUnologIcal
effects attnbuted to N02 mclude an mcrease m IgM and IgG, and a decrease m IgA serum
levels (Ehrhch et al , 1975) The sIgmficance of many of these changes IS uncertam, and
studIes conducted at lower levels of exposure and for longer penods of tIme are needed to
Improve our understandmg of these ImmUnologIcal responses In the absence of adequate
data, one can only speculate that If N02 affects the systemIc Immune system, It IS hkely that
It also would affect the pulmonary Immune system
The consequence of suppressIOn of the vanous hos.t defense mechamsms would
ultlmately lead to mcreased mIcrobial prohferatIOn withm the lung, resultlng m mcreased
mCIdence and seventy of pulmonary InfectIOns Expenmental anImal studies have
demonstrated that both acute and chromc exposures to N02 can sIgmficantly mcrease
susceptIbility to vrral and bactenal Infectlons The exact exposures producmg such effects
are dependent upon the anImal specIes, the mIcrobIal specIes/stram, and the model used
The InfectIVIty model, m whIch arr- and NOTexposed nllce are challenged wIth a vIable
mIcrobIal aerosol and mortallty IS measured, IS the most senSItIve For example, a 39-day
13-53
exposure to 940 p,g/m3 (05 ppm) N02 mcreased mfluenza-mduced mortahty (Ito, 1971), and
a 6-mo exposure to 940 p,g/m3 (05 ppm) N0 2 mcreased bactenal-mduced mortahty (Ehrhch
and Henry, 1968) After an acute exposure, 3,760 p,g/m3 (20 ppm) IS the lowest level
tested to produce slgmficant mortahty for the bactenal model (Ehrhch et al , 1977, Ehrhch,
1980)
The mouse streptococcal mfectIvlty model has been apphed extensively to elUCidate
eXT relationshIps (Gardner et al ,1977a,b) Exposure concentratIOn has a predommant
influence over that of exposure duratIOn In the urban aIr, the typiCal pattern of N02 IS a
low-level basehne exposure on whIch peaks are supenmposed correspondmg to peaks of NOx
mobIle source emiSSIOns When the relatIonshIp of the peak to basehne exposure and of
enhanced susceptIbility to bactenal mfectIOn was mvestIgated, the results mdIcated that no
simphstic eXT relatIOnshIp was present, and that peaks had a major mfluence on the
outcome (Gardner, 1980, Gardner et al , 1982, Graham et al ,1987) When one compares
the effect of a subchromc contmuous one-level exposure to an exposure conslstmg of basehne
and peaks havmg a lower eXT, the effect was roughly eqUIvalent In a I-year chromc
study With the infectIVity model, the effect of a 376 p,g/m3 (0 2 ppm) N02 basehne exposure
(21 h/day, 7 days/week) was compared to basehne plus two daIly I-h peaks of 1,504 p,g/m3
(0.8 ppm) N02 for 5 days/week Only the basehne-plus-peak group exhIbited slgmficant
increased susceptIbility to bactenal mfectIon (Miller et al , 1987)
The effects associated With N02 exposure on the host defense system are dependent on
the concentration of the gas, the duratIOn of the exposure, the anImal species tested, and the
specific end pomt of tOXICity measured As stated earher, baSIC defense mechamsms are
common across mammalIan species Thus, the summatIOn of the effects on a number of host
defense systems may make the mammalIan host more vulnerable to mfectIOUS dIsease
Although the outcome measured m anImals IS mortahty, morbidity would be expected to
occur fIrst or occur at exposures too low to mduce mortahty In humans, espeCially those
under medIcal treatment, such a loss m pulmonary defenses would be expected to result m an
mcreased mcidence of morbidIty, especially m that segment of the populatIOn that may be
more susceptible, such as young chIldren or the elderly In assessmg or predlctmg such
human nsk from expenmentaI anImal data, It IS understood that m humans, dIfferent levels
of exposure to N02 may be requIred to produce effects SImIlar to those seen mammals
13-54
13.2.2.2 Lung Biochemistry
StudIes of lung bIOChemtstry mammals exposed to N02 have focused on eIther the
putative mechamsms of toXiC actIOn of N02 or on detection of mdIcators of NOTmduced
tissue and cell damage One theory to explam N02 tOXICIty IS that N02 IDltIates hpid
peroXIdatIOn m unsaturated fatty aCIds m membranes of target cells (Menzel, 1976) These
changes are thought to cause cell mJury or death, and the symptoms associated wIth N02
mhalatIon An alternate theory IS that N02 oXIdtzes water-soluble, low molecular weIght
reducmg substances and protems, resultmg m a metabohc dysfunction that eVIdences Itself as
the tOXiC symptom (Freeman and Mudd, 1981) NItrogen dIOXide may, m fact, act by both
means and, as a consequence, may affect the mtermediary metabohsm of ammals and therr
growth and maturatIOn Further, gIVen that N02 dIssolves m water to produce HONO and
HN03 , the possIbility of an aCId or a pH effect as a pnmary or secondary mechanIsm of
mJury should also be consIdered
Lzpid Metabolism
Table 13-5 summanzes the effects of N02 on hpIds
Vanous mvestIgators have performed m VItrO expenments on Isolated lung cells or
subcellular components to examme the effects of N02 on OXidatIOn of unsaturated fatty aCIds
In a senes of studIes, Patel and Block (1986a,b) and Patel et al (1988) exammed the effects
of N02 exposure on cultured endothehal cells from eIther pulmonary artenes or aortae of
pIgS After exposmg the cells to 9,400 p,g/m3 (5 0 ppm) N02 for 24 h, they observed
changes m membrane flUidIty, hpid peroXide formatIOn, 5-hydroxytryptamme uptake, release
of LDH (a marker for cell membrane abnormahtIes) and mcreases m GSH reductase and
G-6-P dehydrogenase actIvIties The authors concluded that mJury of endothehal cells by
N02 can be ascnbed to decreased membrane flUidIty secondary to hpid peroxidatIon, and
that the altered phYSICal state of the cell membrane causes unparred functlonahty of the
membrane, leadmg to cellular abnormahtIes of metabohsm and bIochemIstry
Sekharam et al (1991) found that OXidative damage m endothehal cells (from the
pulmonary artery of pIgS) exposed m VItro to 9,400 p,g/m3 (5 0 ppm) for 48 h
Phosphohpase Al actiVIty was mcreased m the cell membrane, but not m the mttochondnal
13-55
TABLE 13-5. EFFECTS OF NITROGEN DIOXIDE ON LIPID :METABOLISMS
N02 ConcentratIon
3 SpecIes
p.g1m ppm
75 004. ContInuous, M 8 Rat Increased lIpId peroXldatIon (TBA method) at 4 0 ppm after Sagax et al (1984)
752 04 9, 18, or 27 mo weeks (Wlstar) 9 mo and at 0 4 and 4 0 ppm after 18 mo, mcreased ethane Ichmose et al (1983)
7,520 40 exhalation at all levels at 9 and 18 mo, ethane exhalatIon
returned to normal levels m hIghest group by 27 mo, no
changes m total lIpId, phospholIpId, total cholesterol, or
tnglycende contents TBA reactants mcreased at 4 ppm
(9 mo) and :s;o 4 ppm (18 mo)
75 004 Contmuous, Increased ethane exhalation after 9 and 18 mo
225 012 6, 9, and 18 mo
752 04
752 04 Contmuous, M 13 Rat Increased ethane exhalation and TBA-reactIve substances Ichmose and Sagal
2,256 12 1, 2, 4, 8, 12, weeks (Wlstar) dunng first week of exposure, returned to normal levels by (1982)
7,520 40 16 weeks fourth week, tendency towards mcrease thereafter Ichmose et al (1983)
752 04 72h M NS GumeapIg No effect at 0 4 ppm, mcrease m lung lIpId content m VItamm Selgrade et al (1981)
1,880 10 (Hartley) C-depleted, but not normal, anImals at 1 0 ppm and above
5,640 30
9,400 50
9,400 50 3h Increased lung lIpId content m Vltamm C-depleted gumea pIgs
752 04 72 h or 1 week No effect on lung lavage flUId composItion m normal or
Vltamm C-depleted anImals
1,000 053 5 h/day, 21 days F NS Rat Increase m lIpId peroXldatIon products Balabaeva and
10,000 53 (NS) Tabakova (1985)
1,880 10 Contmuous, RabbIt Decrease m lecIthm synthesIs after I week, less marked Seto et al (1975)
2 weeks depressIon after 2 weeks
1,880 1 2h M 15-16 RabbIt 1 ppm elevated thromboxane B2 3 ppm depressed Schlesmger et al
5,640 30 weeks (New Zealand) thromboxane B2 10 ppm depressed 6-keto-PGF1/X and (1990)
18,800 10 thromboxane B2, no changes noted m PG~, PG~/X, or
LTB4
TABLE 13-5 (cont'd). EFFECTS OF NITROGEN DIOXIDE ON LIPID :METABOLISMa
N02 ConcentratlOn
3 Species
Jl-g/m ppm Exposure Gender Age Effects Reference
(Stram)
5,450 29 Contmuous, M NS Rat Increase m lung wet weight (12 7 %) and decrease m total Arner and Rhoades (1973)
5 days/week, (Long Evans) hpids (87%), decrease m saturated fatty aCid content of
9mo BAL flUid and tissue, mcrease m surface tenslOn of BAL
flUid
5,640 30 Contmuous, M NS Rat Decrease m ImolelC and lmolemc aCid content of BAL Menzel et al (1972)
17 days (Sprague- flUid
Dawley)
18,800 10 Contmuous, Decrease m polYUllsaturated fatty aCids m BAL and lung
4 weeks tissue
5,640- 3- 1h NS NS Dog Decrease m phosphohpid content of BAL flUid from Dowell et al (1971)
30,080 16 (Beagle) anllnals with N02-mduced mtraalveolar edema, mcrease
°
m unsaturated fatty content of BAL lecithm at ~5 ppm
I-' 7,520 40 3h M/F 21-33 Human Increased hpid peroXidation products m BAL flUid Mohsenm (1991)
wI
years
Ul
-...l 9,400 50 24h NS 6-7 mo Pig In endothehal cells of pulmonary artery and aorta, Patel and Block (1986a,b)
(m Vitro) changes m membrane flUimty, hpid peroXide formatiOn, Patel et al (1988)
release of LDH, and 5-hydroxytryptamme uptake
9,400 50 48 h NS 6-7 mo Pig Lipid alterations m endothehal cells from pulmonary Sekharam et al (1991)
(m Vitro) artery
10,300 55 3 hlday, 7 and M 8 Rat Decrease m lysolecithm acyltransferase m lung Yokoyama et al (1980)
14 days weeks (Wistar) homogenate lmcrosomes
18,800 10 12 h M NS Rat Changes m fatty aCids of BAL phosphohpids Kobayashietal (1984)
(WiStar)
18,800 10 1,3,5,7, M NS Rat Changes m prostaglandms and thromboxane B2 m BAL Kobayashi (1986)
14 days (NS) flUid
~ = Male PGEz = Prostaglandm E2

TBA = Thlobarbltunc aCid PGEz", = Prostaglandm Ez",
NS = Not stated LTB4 = Leukotnene B4
F = Female LDH = Lactate dehydrogenase
6-keto-PGFl", = 6-keto-prostaglandmF i ", BAL = Bronchoalveolar lavage
or ffilcrosomal membranes There was a sIgmficant illcrease m lyso-phosphatIdyl-
ethanolamme and a sIgmficant decrease ill phosphatIdylethanolamme as a result of the
increase in phosphohpase Al actIvIty PhosphatIdylserme content was also mcreased
However, the total phosphohpid content of the plasma membrane was decreased compared to
that of controls The authors suggested a possIble aSSOCiatIOn between the mcreased actiVIty
of phosphohpase Al and the mcrease ill phosphatIdylserme seen m the cell membrane of the
N02-exposed endothehal cells after treatmg endothehal cells wIth exogenous
phosphatidylserme and observmg an 87 % mcrease m phosphohpase Al actiVIty m the cell
membrane
RietJens and co-workers (1986, 1987) exposed cultured rat AMs to N02 or 03 by gas
diffusIOn through a TeflonClil film Based on VarIOUS expenments usmg dIfferent radIcal
scavengers, the authors concluded that N02 and 03 acted by dIfferent mechamsms, whereby
N02 exerted ItS tOXICIty VIa a free radIcal-mediated peroXIdatIve pathway and 03 Via a
pathway involving the formatIOn of hpid ozomdes Both N02 and 03 appear to act at the
level of hpid OXidation ill causmg AM tOXICIty However, IS should be noted that the
chemical reactions of N02 or 03 WIth orgamc compounds m aqueous solutIOns can be very
complex (Glaze, 1986), and predIction of whIch pathway(s) may predommate m complex
biological systems IS by no means straIghtforward For example, N02 or 03 may react WIth
unsaturated fatty aCIds, a component of lung phosphohpIds, but also WIth water-soluble
reducmg substances of low molecular weIght or redUCIble groups on protems A dISCUSSIon
of the functional and structural effects of N02 on AMs appears m Sections 13 2 2 1 and
13.2.24 on host defense mechamsms and morphologIcal effects, respectively
Roehm et al (1971) studIed the m VItro OXidatIOn of unsaturated fatty aCIds by N02 and
03. Both N02 and 03 wtIated the OXidatIOn of unsaturated fatty aCIds through free radIcals
Typically, an induction penod was noted WIth eIther anhydrous thm films or aqueous
3
emulsions of hnolemc aCId exposed to 2,820 p.g/m (1 5 ppm) N02 The addItion of free
radical-scavengmg agents such as vitamill E, butylated hydroxytoluene, or butylated
hydroxyamsol delayed the onset of OXidation m VItro The rate of OXidatIOn of hnolemc aCId
m thm films was proportional to concentratIOns of N02 from 940 to 10,152 p.g/m3 (0 5 to
5.4 ppm) Thill-layer chromatography of the OXidatIOn products of hnolemc aCId showed a
conversion to polar mtrogen-contailllng compounds and to peroXides A suggested
13-58
mechamsm of fonnatIon of these products (Menzel, 1976) mvolves addItion of N02 across a
double bond between two carbon atoms m an unsaturated fatty aCId to fonn a mtro compound
and a carbon-centered free radIcal Such a radIcal can extract an electron from VarIOUS
potential electron donors, thereby wtIatIng the cham reactIOn NitrohydroperoXIdes and fatty
aCId hydroperoXIdes are produced m VItrO from the oXidatIOn of unsaturated fatty aCIds by
N02 Phenohc antiOXidants can prevent the autOXidation of unsaturated fatty aCIds by N0 2
by reactmg wIth both fatty aCId hydroperoxyl free radIcals and mtrohydroperoxyl free
radIcals generated by the addition of N02 to unsaturated fatty aCIds It IS not known whether
thIs sequence of reactIOns IS Important m the lung ill VIVO
Saga! et al (1984) and Ichmose et al (1983) reported an mcrease m thIobarbitunc aCId
(TBA) reactants (an mdIcatIOn of hpid peroXides) ill lung homogenates of rats exposed to
3
7,520 p,g/m (4 0 ppm) N02 contmuously for 9 mo When exposure was mcreased to
18 mo, a concentration-related mcrease m TBA reactants occurred ill rats exposed to 75,
3
752, and 7,520 p,g/m (0 04, 0 4, and 4 0 ppm) N02 , but the illcrease was only slgmficant m
anImals exposed to the two hIghest concentratIOns
Mohsemn (1991) reported the effects of N02 exposure on healthy human subjects
Subjects receIved eIther a placebo or vitamms C (1,500 mg/day) and E (1,200 IU/day) for
4 weeks and were then exposed to 7,520 p,g/m3 (4 0 ppm) for 3 h In BAL flUId, N02
exposure decreased the elastase mhIbitOry capacIty of <Xl-protease mhIbitor, the major plasma
and lung protease mhIbitor of elastase There was also em NOTmduced mcrease m hpid
peroXIdatIon products (pnmanly conjugated dIenes, but some malondIaldehydes) ill the BAL
flUId However, when subjects were supplemented wIth dIetary vitamm C and E, these
effects were prevented
The exhalation of ethane m the breath was measured m assays of m VIVO hpld
peroXIdatIOn (Saga! et al , 1984, Ichmose et al , 1983) In the fIrst senes of studIes, excess
mortalIty m chamber control rats forced the use of room control rats m the statistical
analyses, however, there was no major dIfference between room and chamber control values
At 75, 752, and 7,520 p,g/m3 (004, 04, and 4 0 ppm) N02 , 9 and 18 mo of exposure
mcreased the exhalatIOn of ethane The two lower N02 concentratIOns also illcreased ethane
exhalation after 27 mo of exposure, but ethane was withm the control range ill the
7,520 p,g/m3 -exposed group Pentane exhalation was m~msured to detennme IT the hpid
13-59
------- ~ ~ ~ ~ - - ~ ~
peroXIdatlOn was bactenal m ongm Pentane was only mcreased after 18 mo of exposure to
75 and 752 p.g/m3 N02, supportmg the mterpretatIon of the ethane results In the second
series of expenments, chamber control rats were used and rats were exposed to 75, 225, and
752 p.g/m3 (004, 0 12, and 0 4 ppm) N02 for 6, 9, and 18 mo Mer 6 mo, ethane
exhalation was only mcreased m the 752 p.g/m3 group All N02 concentratlOns mcreased
ethane exhalatIon after 9 and 18 mo of exposure These studIes showed that N02 mcreased
llpid peroXldatIon m a concentratIon- and exposure duratIOn-related manner An mverse
relationshIp WIth lung antIoXldant metabollsm was also found (see later subsection on
antiOXidant metabollsm) Shorter duratIOn exposures also mfluence llpid peroXldatIOn m rats,
as measured by ethane exhalatlOn For example, exposure to > 2,256 p.g/m3 (> 1 2 ppm)
N02 increases ethane exhalation after 1 week of exposure Levels of ethane had returned to
control values after 4 weeks of N02 exposure, at whIch time ethane levels began a slow nse
again over the remamder of the 16-week exposure penod (Ichmose and Saga!, 1982, Ichmose
et al ,1983) Based on therr body of work and other related studIes, Saga! et al (1984)
suggested that the mcreased llpid peroXldatIon may be related to NOTmduced thIckenmg of
alveolar walls, as reported m some lung morphology studIes, and decreased 02 tenSIOn m
artenal blood
An mcrease m lung llpid peroXldatIOn products has also been reported m pregnant rats
exposed to 1,000 p.g/m3 or 10,000 p.g/m3 (0 53 or 5 3 ppm) N02, 5 h/day for 21 days
(Balabaeva and Tabakova, 1985) When the pregnant progeny of thIs group were exposed to
the same N02 exposure regImen, there was an exposure-related mcrease m the lung llpid
peroxides Nitrogen dIoXlde exposure was also reported to have an effect on llpid
peroxidanon m the hver m both pregnant and nonpregnant rats and m the placenta The
f'mdings are discussed later m Section 13 2 3 7
Arner and Rhoades (1973) exposed rats for 9 mo to 5,450 p.g/m3 (29 ppm) N02 for
24 h/day, 5 days/week' The lung wet weIght mcreased by 13% compared to that of
controls. The llpid content of the lung was sIgmficantly depressed by about 9 % The total
saturated fatty aCId content of the lungs was decreased The largest decrease was seen m the
phosphandylethanolamme Smaller decreases were seen m lecithm (phosphatIdylchohne),
phosphatidyhnositol, and phosphatidyisenne Values for specIfic unsaturated fatty aCIds of
blOlogicallIDportance were not reported The lung surface tenslOn extracts were reported as
13-60
mcreased The authors suggested that the mcreased surface tenslOn corresponded to a
decrease m the lung surfactant concentration
Totaliecithm was reduced m lung lavage flUId from beagle dogs wIth NOTmduced
mtraalveolar edema (Dowell et at , 1971) IndivIdual dogs were exposed for 1 h to 13,160
to 30,080 p,g/m3 (7 to 16 ppm) N02 There was a decrease ill total phosphohpIds, as
compared to neutral hpIds, mammals WIth mtraalveolar edema In ammals WIthout
3
mtraalveolar edema, exposed to 5,640 to 22,560 p,g/m (3 to 12 ppm) N02 for 1 h, the
phosphohpid content was shghtly greater than m control ammals There was also an mcrease
m the amount of unsaturated fatty aCIds m the phospholipIds from the lungs of ammals
3
exposed to 9,400 to 30,080 p,g/m (5 to 16 ppm) N02 whether or not mtraalveolar edema
3
was present These changes were not noted m the anImals exposed to 5,640 p,g/m N02
The phYSlOloglCal effects of N02 exposure m these anImals IS discussed m Section 13 2 2 4
on lung morphology
Lecithm synthesIs has also been reported depressed m the lungs of rabbIts exposed to
1,880 p,g/m3 (1 0 ppm) N02 for 2 weeks (Seto et al , 1975) The most marked effect was
observed after 1 week of exposure and appeared to declIne after the second week of
exposure Yokoyama et al (1980) found few changes m hpid metabolism of rats exposed
for 3 h/day for 7 and 14 days to 10,300 p,g/m3 (5 5 ppm) N02 Lysoiecithm acyltransferase
actIVIty m the mIcrosomal fractlOn decreased when an unsaturated aCId (hnoleIc) was used,
but not when a saturated aCId (PalmItIC) was the substrate The supernatant fractlOn of thIs
enzyme was unchanged, phosphohpase Al and A2 actIVItIes were not affected eIther
Products of arachIdomc aCId metabohsm are also affected by N02 The concentratlOn
of thromboxane B2 was elevated m the BAL flUId from rabbIts exposed to 1,880 p,g/m3
(1 0 ppm) N02 for 2 h (Schlesmger et at , 1990) When exposure was mcreased to
5,640 p,g/m3 (3 0 ppm), the concentratIon of thromboxane B2 was depressed Thromboxane
B2 levels were sIgmficantly below those of controls 24 h postexposure m rabbIts exposed to
18,880 p,g/m3 (10 ppm) N02 6-Keto-prostaglandm F lc was also depressed m rabbIts
)!
Prostaglandms ~ and F2 and LTB4 were not affected

3
exposed to 18,880 p,g/m N02
No effects on BAL hpid and protem content were observed m gumea pIgS exposed to
3
752, 1,880, 5,460, or 9,400 p,g/m (04, 1 0, 3 0, or 5 0 ppm) N02 for 72 h (Selgrade
et al , 1981) However, vitamm C-depleted gumea pIgS, havmg an average of 25% of the
13-61
nonnal blood vitamIn C content, had greater BAL protem and hpid content, except for those
gumea pigs exposed to 752 p.g/m3 N02 In ammals exposed to 9,400 p.g/m3 N02 , the
changes m BAL flUid composItion were correlated wIth mortahty (50 %) and alveolar edema
as detennmed by conventional hght mICroscopy
Effects on Lung Amino Aculs, Proteins, and Enzymes

Table 13-6 summanzes the effects of N02 on protems and selected enzymes
NItrogen diOXide can OXIdIZe VarIOUS reducIble ammo aCIds or SIde chams of protems m
aqueous solution (Freeman and Mudd, 1981) Suzuki et al (1988) reported mcreased
amounts of trytophan metabohtes m the urme of rats exposed for 2 weeks to 9,400 p.g/m3
(5 0 ppm) N02 Concentrations of N02 above 9,400 p.g/m3 produce lung edema WIth
concomItant 111fIltratIOn of serum protem and enzymes Also, an mflux of mflammatory cells
(predommantly leukocytes) from blood and alterations m the epIthehal cell types of the lung
may occur Thus, some reports of changes m lung enzyme actIvIty and protem content may
reflect eIther edema, altered mflammatory cell populatIOns, and/or changes m cell types,
rather than direct effects of N02 on lung cell enzymes
As mdIcated earher 111 this sectIOn, Saga! et al (1984) reported a concentratIOn-related
mcrease 111 TBA reactants m the lungs of rats exposed to 75, 752, and 7,520 p.g/m3
(0.04,04, and 40 ppm) N02 contmuously for 18 mo However, total lung protem content
was not affected by the N02 exposure Gelzieichter et al (1992a) mvestIgated the effect of
C X T on total BAL protem, PMNs, and epIthehal cells m rats Expenmental anImals were
3
exposed to 6,770, 13,500, 20,300, or 27,100 p.g/m (3 6, 72, 10 8, or 144 ppm) N02 for
24, 12, 8, or 6 h, respectively, for 3 consecutive days The cumulative C X Twas
3
2592 ppm-h Concentrations > 13,500 p.g/m mcreased BAL protem to a roughly
3
equivalent extent The 24-h exposure to 6,770 p.g/m caused no effects EpIthehal cell
111creases followed a pattern slIDllar to that of protem, but PMNs were only 111creased at the
highest concentration
NItrogen dIOXide has also been reported to mcrease the protem content of lung lavage m
vitamIn C-depleted gu111ea pIgS (Selgrade et al , 1981, Sherwm and Carlson, 1973, Hatch
et al., 1986, Slade et al , 1989) Selgrade et al (1981) found effects as low as 1,880 p.g/m3
13-62
TABLE 13-6. EFFECTS OF NITROGEN DIOXIDE ON LUNG AMINO ACIDS, PROTEINS, AND ENZYMES a
NO z Concentratton
3 SpecIes
",g/m ppm Exposure Gender Age Effects Reference
(Stram)
752 04 72h M NS Gumeapig No effect at 04 ppm, mcrease m BAL Selgrade et al (1981)
1,880 10 (Hartley) protem m Vitamm C-depleted, but not
5,640 30 normal, annuals at 1 0 ppm and above
9,400 50
9,400 50 3h Increased BAL protem m vitamm C-
depleted gumea pIgs 15 h postexposure
752 04 Contmuous, No effect on BAL protem
1 week
752 04 Contmuous, M NS Gumeapig Increased lung protem content of gumea Sherwm and Carlson
1 week (NS) pIgS WIth an unquanttfied vitamm C (1973)
deficIency
752 04 1 to 14 weeks M 22-24 Rat Complex concentratton and duratIOn TakahashI et al (1986)
I-'
!..U 2,256 12 weeks (WIstar) dependence of effects Example at
I
0\
!..U
7,520 40 o 4 ppm, cytochrome P-450 levels
decreased at 2 weeks, returned to control
level by 5 weeks At 12ppm,
cywchrome P-450 levelS aecreasec1
lUlttally, mcreased at 5 weeks, and
decreased at 10 weeks Effects on
succmate-cytochrome c reductase also
752 04 7 days M 10 Rat Decrease m cytochrome P-450 levels at MochItate et al (1984)
2,260 12 weeks (WIstar) 12ppm
7,520 40
845 045 7 h/day, M NS Mouse No changes m lung serotonm levels, Sherwm et al (1986)
4 weeks (SWISS mcrease m bram serotonm and
Webster) 5-hydroxymdoleacettc aCId content
935 047 Contmuous, M NS Mouse Increased content of serum protems m Sherwm and Layfield
10, 12, 14 days (NS) homogemzed whole lung ttssue (1976)
TABLE 13-6 (cont'd). EFFECTS OF NITROGEN DIOXIDE ON LUNG AMINO ACIDS, PROTEINS, AND ENZ'YMES8
N02 Concentratton
3 Species
p.g/m ppm Exposure Gender Age Effects Reference
(Stram)
940 05 6 h/day, M NS Rat 05ppm mcrease m urmary hydroxylysme output startmg Evans et al
1,880 10 5 days/week, (FIscher 344) dunng Week 1, BAL hydroxylysme level, anglotensm- (1989)
4 weeks convertmg enzyme level, and BAL protem content
unchanged
1 o ppm gradual mcrease m urmary hydroxylysme output,
becommg slgmficant the week after exposure ended, BAL
hydroxylysme level lower followmg exposure and 4 weeks
postexposure, anglotensm-converttng enzyme level mcreased
1,880 10 6 h/day, Concentration-dependent mcrease m urmary hydroxylysme
14,100 75 2 days output and BAL hydroxylysme content, but only slgmficant
28,200 15 at ;:::; 7 5 ppm and 15 ppm, respecttvely, anglOtensm-
47,000 25 convertmg enzyme levels and BAL protem mcreased m
56,400 30 hIghest-exposed groups
I-'
~
1,880 10 7 h/day, M/F 14-16 Rat Changes m BAL and tissue levels of enzymes early m Gregory et al
I
0\ 9,400 50 5 days/week, weeks (Fischer 344) exposure, resolved by 15 weeks (1983)
.J:::o.
up to 15 weeks
1,880 base + 10 base + Base 7 h/day,
9,400 peak 50 peak 5 days/week,
2 1 5-h peaks/day
up to 15 weeks
3,760 20 Contmuous, M NS Gumeaplg Increase m number of lDH-posltIve cells With ttme of Sherwm et al
1-3 weeks (NS) exposure Suggests Type 1 cells decrease as Type 2 cells (1973)
mcrease
3,760 20 14 days M 12-24 Rat Increased activity of lung glycolytiC enzymes MochItate et
7,500 40 10 days weeks (Wlstar) al (1985)
18,800 10 7 days
5,640 30 7 days M/F 8 weeks Rat VariOUS changes m lung homogenate protem and DNA Elsllyed and
(Sprague- content and enzyme actlvltles, changes more severe m Mustafa (1982)
Dawley) Vltamm E-deficlent rats
a
TABLE 13-6 (cont'd). EFFECTS OF NITROGEN DIOXIDE ON LUNG AMINO ACIDS, PROTEINS, AND ENZYMES
N02 Concentration
3 SpecIes
p.g/m ppm Gender Age (Stram) Effects Reference
Exposure
6,770 36 24h M 10-12 Rat Increased BAL protem at ;:::: 7 2 ppm GelzlelChter et al (1992a)
13,500 72 12 h weeks (Sprague-
20,300 108 8h Dawley)
27,100 144 6h
7,520 40 10 days M 21-24 Rat mtIal decrease m lung protem content Mochltate et al (1984)
18,800 10 7 days weeks (WIStar) followed by an mcrease, changes m
Inlcrosomal enzyme activIties
7,520 40 6 hlday, M NS Rat Increased gamma-glutamyl transferase on Hooftman et al (1988)
18,800 10 5 days/week, (WIStar) Days 14 and 21, no consIstent effect on
47,000 25 7, 14, and alkalme phosphatase, LDH, or total
21 days protem
8,100 45 16 h M/F NS Gumeaplg Increased lung wet weIght, alteratIOns m Hatch et al (1986)
...... (Hartley) lung antIOXidant levels m vltamm C-
wI
0\ defiCIent ammals
U\
9,020 48 3h M Increased lung lavage flUId protem content
m Vltamm C-deficlent ammals
9,020 48 8 hldaj, M 8 weeks Mouse No slgmficam changes m lUng homogenate Mustafa et al (1984)
7 days (SWISS parameters
Webster)
9,400 50 14-72 h F NS Mouse Increase m lung protem (14 to 58 h) by Csallany (1975)
(NS) radIoactive label mcorporatIon
9,400 50 2 weeks M 5 weeks Rat Increased amounts of the trytophan Suzukt et al (1988)
(FIscher 344) metabohtes and xanthuremc and kynuremc
aCIds excreted m urme durmg Week 2 of
exposure, but had returned to normal
levels by Week 4
9,400 50 6 hlday, NS 4-6 Mouse Modest mcrease m albumm m BAL no Rose et al (1989)
6 days weeks (CD-I) effect on LDH or lysosomal enzyme
perOXidase
TABLE 13-6 (cont'd). EFFECTS OF NITROGEN DIOXIDE ON LUNG AMINO ACIDS, PROTElNS, AND ENZYl\1ESa
N02 ConcentratIon
3 SpecIes
p.g/m ppm Gender (Stram) Effects Reference
Exposure Age
9,400-47,000 50-25 Contmuous, M 10-11 Rat ConcentratIon-related mcrease m rate of Last et al (1983)
7 days weeks (Sprague- collagen syntheSIS, 125 % mcrease m rats
Dawley) exposed to 5 0 ppm
9,400 50 3h NS NS RabbIt Benzo[a]pyrene hydroxylase actIVIty of Palmer et al (1972)
37,600 20 (New Zealand) tracheal mucosa not affected
94,000 50
9,400 50 Contmuous, M NS Rat Increased BAL protem at 3 days (Day 7 Last and Warren (1987)
1, 3, or 7 days (Sprague- not measured), mcreased (120%) collagen
Dawley) synthesIs at 7 days (not measured other
days)
15,000 80 Contmuous, F (NS) Mouse Increase m lung protem Csallany (1975)
14 days (NS)
~
wI 17,900 95 7 h/day, M m utero Rat Increase m BAL alkalme phosphatase, Mauderly et al (1987)
0\ 5 days/week, and 6 (FIscher 344) aCid phosphatase, and LDH m older rats
0\
6mo mo only
17,900 95 7 h/day M 18 Rat Increase m BAL levels of LDH and Mauderly et al (1990)
5 days/week, weeks (FIscher 344) alkalme phosphatase actIVItIes and m
24mo collagenous peptIdes
18,800 10 Contmuous, M 8 weeks Rat Changes m several enzymes m whole lung Sagal et al (1982)
14 days (WIStar) homogenates
18,800 10 4h M NS Rat Increased actIVItIes of vanous enzymes, Guth and MaVIS (1985,
37,600 20 (Long Evans) SialIC aCid, and BAL protem, attenuatIon 1986)
56,400 30 by mgh dietary levels of Vltamm E
75,200 40
~s = Not stated
LTB4 = Leukotnene B4
LDR = Lactate dehydrogenase
M = Male
BAL = Bronchoalveolar lavage
F = Female
(1 0 ppm) after a 72-h exposure, but not after a I-week exposure to 752 p.g/m3 (0 4 ppm)
The results of the I-week exposure apparently conflIct WIth those of Sherwm and Carlson
(1973), who found mcreased protem content of lavage flmd from vltamm C-deficlent gumea
pIgS exposed to 752 p.g/m3 N02 for 1 week DIfferences m exposure techmques, protem
measurement methods, and/or degree of vltamm C deficJLency may explam the dlfference
between the two studIes However, Sherwm and Carlson (1973) also reported mcreases m
lavage flmd protem from normal gumea pIgS exposed to 752 p.g/m3 (0 4 ppm) N02
contmuously over a I-week penod
Hatch et al (1986) found that the NOz-mduced mcrease ill protein m lung lavage flUld
m vltamm C-deficlent gumea pIgS was accompamed by am mcrease m lung content of
nonprotem sulfhydryls and vltamm C and a decrease m vltamm E content The mcreased
susceptIbility to NOz was observed when lung vltamm C was reduced (by met) to levels
below 50 % of normal values A depletlOn of nonprotem sulfhydryls also enhances
susceptlbility to a illgh level of NOz exposure (18,800 p.g/m3 , 10 ppm) (Slade et al , 1989)
Selgrade et al (1981) expanded earher studIes of Sherwm and Carlson (1973) on the effects
of vltamm C defiCIency on N02 tOXlClty Taken together, these mvestlgatlOns support a role
for metary vltamm C m mfluencmg the susceptlbility of NOTexposed animals to mcreased
protem and hPlds m lung lavage Because vltamm C IS readtly oXld1zed and reduced, It
could serve to detoxtfy oXldatlve products formed by N02 or to mamtam the mtracellular
redox potentlal
Utell et a] (1991) and Frampton et al (1989) repoJrted no slgmficant changes m the
content of total protem, albumm, or a2-macroglobuhn, a glycoprotem that may playa role m
the local control of lung protease actIvIty, of BAL flmd from healthy, nonsmokmg volunteers
exposed to 94 p.g/m3 (005 ppm) N02 WIth three 15-mm peak exposures to 3,760 p.g/m3
(2 0 ppm), to 1,128 p.g/m3 (0 6 ppm) contlnuously, or to 2,820 p.g/m3 (1 5 ppm)
contmuously All N02 exposures were for 3 h, and BAT.... flmd was obtamed at 3 5 h
3
(94-p.g/m + 3,760 p.g/m3 peaks and 2,820-p.g/m3 groups) or 18 h (1,128 p.g/m3 -group)
postexposure When BAL was performed 3 5 h after exposure to 1,128 p.g/m3 N02, there
was an mcrease m aTmacroglobuhn that was not seen under the other exposure reglilles
Whether tills mcrease m a2-macroglobuhn was mdlcatlve of an NOTmduced change m the
13-67
protease-antIprotease balance or was a chance observatlOn IS not known (Frampton et al ,
1989). (See Section 15 6 on chmcal studIes for detaJ1s )
A major concern has been the effect of N02 on the structural protems of the lungs
because elastic recoIl IS lost after exposure Kosmider et al (1973a) reported that the
urmary hydroxyprolme and aCId mucopolysacchande content of gumea pIgS exposed to
3
1,880 p,g/m (1 0 ppm) N02 for 6 mo were sIgmficantly mcreased Because the remodelmg
of bone is the major source (> 90 %) of urmary hydroxyprolme m normal anImals and
dietary ascorbate status would affect hydroxyprolme homeostasIs, the sIgmficance of these
observations to lung structure and function remams to be shown
Because hydroxylysme, a modIfied ammo aCid, IS umque to collagen and protems
containmg collagen-Wee sequences, Evans et al (1989) selected thIs compound for study as a
biomarker of lung mJury Durmg a senes of expenments, rats were exposed to 1,880 to
3
56,400 p,g/m (1 to 30 ppm) N02 , 6 h/day for 2 days A concentration-dependent
relanonshIp was noted m the amount of hydroxylysme m the BAL flUId and the urmary
hydroxylysine output The mcreases m hydroxylysme were, however, only SignIficant at
NO z exposure levels of > 14,100 p,g/m3 (75 ppm) for BAL flUId and ~28,200 p,g/m3
(15 ppm) for urmary output The anglOtensm-convertmg enzyme level and the total protem
concentration of BAL flUId were sIgmficantly mcreased m the hIghest N02-concentratIon
groups
When rats were exposed to 940 or 1,880 p,g/m3 (05 or 1 0 ppm) N02 , 6 h/day,
5 days/week for 4 weeks, there was a gradual mcrease m urmary hydroxylysme output that
became Significant the week after exposure ended m the 1,880 p,g/m3 exposed group, but was
significant m the 940 p,g/m3 exposed group startmg durmg the tITst week of exposure (Evans
et al , 1989). The amount of hydroxylysme m the BAL flUId of rats m the 1,880 p,g/m3
group was signIficantly lower than that of controls Immediately followmg exposure and
remamed sigmficantly lower after a 4-week recovery penod, whereas the anglOtensm-
convertmg enzyme level was sIgmficantly mcreased, returnmg to normal values 4 weeks after
exposure ended The hydroxylysme content of lavage flUId and the anglOtensm-convertmg
3
enzyme level were unchanged m the 940-p,g/m exposed group The total protem content of
the BAL fluid was not SIgnificantly altered at eIther exposure level
13-68
Last and co-workers have exammed the effects of N02 on collagen synthesIs rates m
lung mmces from anImals exposed m VIVO for 7 days Tn one study (Last et al , 1983), rats
3
were contmuously exposed to 9,400 to 47,000 p,g/m (5 to 25 ppm) N02 for 7 days The
authors found a lmear concentratIOn-response curve for ]plots of collagen synthesIs rate, wIth
a correlatIOn coefficIent (least squares analysIs) for fit of the data to a straIght lme of 0 92
Lmear extrapolatIOn of the lme to an estimated no-observable-effect level gave a value of
about 1,880 to 5,640 p,g/m3 (1 0 to 3 0 ppm) N02 Last and Warren (1987) confrrmed that
exposure to 9,400 p,g/m3 N02 increased collagen syntheSIS It was assumed by these
workers, although not proven, that the mcreases m lung collagen syntheSIS rate observed
after acute exposure reglffiens are predIctIve of mcreases m total lung collagen (pulmonary
fibroSIS) after longer penods of exposure
Only a modest mcrease ill albumm, millcatlng a mll1d degree of mJury to the pulmonary
capillary membrane, was noted m mIce exposed to 9,400 p,g/m3 (50 ppm) N02 , 6 hlday for
3
6 days or 9,400 p,g/m , 6 hlday for 2 days pnor to vrrall moculatIon and 6 hlday for 4 days
lffimed1ate followmg moculation (Rose et al , 1989) However, only mmnnal
hIstopathologIcal changes were noted m the N02-exposed, vIral-moculated anImals
Lysosomal enzyme peroXidase and lactate dehydrogenase (LDH) actiVIties were not affected
See also SectIOn 13 2 2 1 on host defense mechamsms
Sherwm et al (1972) exposed gumea pIgS to 3,760 p,g/m3 (20 ppm) N02 for 1, 2, or
3 weeks They exammed lung sectIOns hIstochemIcally for LOH WIth thIs techmque, LOH
IS thought to be pnmanly an mdicator of Type 2 cells rather than Type 1 cells The number
of Type 2 cells per alveolus was determmed In control lung sectIOns, a mean value of
1 9 Type 2 cells per alveolus was found, WIth a range of 1 5 to 3 4 Exposure to N02
sIgmficantly mcreased the LOH content of the lower lobes of the lung by mcreasmg the
number of Type 2 cells per alveolus The mcrease was progressIve over the 3-week
exposure penod The authors suggested that the mcrease m lung LOR content was due to
the replacement of Type 1 cells by Type 2 cells, as shown m some of the morphologIcal
studIes
An mcrease m LOR m BAL flUId was reported in rats exposed to 1,880 to
9,400 p,g/m3 (1 0 to 5 0 ppm) N02 , 7 hlday, 5 days/week for 2 7 weeks (Gregory et al ,
1983) By 15 weeks of exposure, LOR had returned to control values, even though
13-69
histological changes persIsted A baselme (1,880 fJ-g/m3 [1 0 ppm]) plus peak (two 1 5-h
peaks to 9,400 fJ-g/m3 [50 ppm]) exposure had no effects Alkalme phosphatase and LDH
actIvIties, as well as collagenous peptIdes were mcreased m BAL flmd of chromcally exposed
rats (17,900 fJ-g/m3, 9 5 ppm, 7 h/day, 5 days/week, 24 mo) (Mauderly et al , 1990)
GlycolytIc pathways are also mcreased by NO z exposure, apparently due to an mcrease
in Type 2 cells (Mocilltate et al , 1985) The most sensItIve enzyme was pyruvate kmase
After a 14-day exposure to 3,760 fJ-g/m3 (20 ppm) N02 , the actIvIty of tills enzyme was
mcreased When the exposure concentratIOn was mcreased to 7,520 and 18,800 fJ-g/m3
(4 and 10 ppm), the pyruvate kmase actIvIty was mcreased by Day 4 and 7, respectively
AlteratIons m lung xenobIOtIc metabohsm follow a complex pattern based on exposure
duration and concentratIOn m rats exposed to 752, 2,260, or 7,520 fJ-g/m3 (04, 1 2, or
4.0 ppm) N02 (Takahasill et al , 1986) At 752 fJ-g/m3, cytochrome P-450 levels had
decreased by the second week of exposure, but returned to normal levels by the fIfth week of
exposure, where they remamed at Week 10 An lilltIal decrease m cytochrome P-450 was
also seen in animals exposed to 2,260 fJ-g/m3 N02, cytochrome P-450 levels returned to
control level by Week 5 and decreased below control levels by Week 10 A slffil1ar pattern
of response occurred m the mghest concentratIOn tested Only 7,520 fJ-g/m3 affected other
mIcrosomal electron-transport systems The actiVIty of succmate-cytochrome c reductase was
decreased by the fourteenth week of exposure to 752 fJ-g/m3 and even sooner at mgher levels
of exposure Mocmtate et al (1984) also found a decrease m cytochrome P-450 levels after
a 7-day exposure of rats to ~2,260 fJ-g/m3 N02
The actiVIty of benzo[a]pyrene hydroxylase m the tracheobroncmal regIOn of the lungs
of rabbits exposed to 9,400, 37,600, or 94,000 fJ-g/m3 (5, 20, or 50 ppm) N0 2 for 3 h was
studied by Palmer et al (1972) No effect was observed Law et al (1975) studIed the
effect of N02 on benzo[a]pyrene hydroxylase, mIcrosomal O-methyl transferase, catechol
O-methyl transferase, and supernatant catechol O-methyl transferase actiVIty m rat lungs
Exposure to 75,200 or 132,000 fJ-g/m3 (40 or 70 ppm) N02 for 2 h had no effects Thus,
the studIes of Palmer et al (1972) and Law et al (1975) agree that N02 exposure does not
effect total benzo[a]pyrene hydroxylase actiVIty of the lung The O-methyl transferase
activity studIed by Law et al (1975) relates to the ability of the lung to metabohze
catecholamine hormones
13-70
Effects on Antioxulant Metabolism and Influence ofAntioxidants
Table 13-7 summanzes the effects of N02 on antIOXidant metabolism and antIOXidants
Menzel (1970) proposed that antIOXidants mIght protect the lung from N02 damage by
mhIbIt1ng lipid peroXIdatIOn Data related to thIs hypothesIs have been reported by Ayaz and
Csallany (1978), Csallany (1975), Fletcher and Tappel (1973), Menzel et al (1972),
Mohsenm (1991), Slade et al (1989), and Thomas et al (1968) Many laboratones have
observed changes m the actIVIty of enzymes m the lungs of NCh-exposed anImals that
regulate levels of glutathIone (GSH), the major water-soluble reductant m the lung's
armamentanum (Tyson et al , 1982), or m lung content of GSH m rodents exposed to N02
ButhIonme sulfoXlffie, an mhIbitor of GSH synthesIs, has also been shown to cause mcreased
3
lung damage m mIce exposed to 1,960 p,g/m (1 0 ppm) 03' suggestmg a role for GSH as a
protectIve agent agamst OXidant gases m VIVO (Sun et al , 1988) Chow and Tappel (1972)
proposed an enzymatIc mechanIsm for the protectIOn of the lung agamst lipId peroXIdatIOn
damage by 03' mvolvmg coupled reactIOns of glucose-6-phosphate dehydrogenase (G-6-P
dehydrogenase) (to produce reduced mcotmamide-adenme dmucleotIde phosphate [NADPH]),
GSH reductase (to regenerate mcotmamIde-adenme dmudeotIde phosphate [NADP]), and
GSH peroXidase (to regenerate GSH) Chow et al (1974) exposed rats to 1,880, 4,330, or
11,600 p,g/m3 (1 0, 2.3, or 62 ppm) N02 contmuously for 4 days to examme the effect on
the GSH peroXidase system by measurmg the actIVItIes of GSH reductase, G-6-P
dehydrogenase, and GSH peroXIdase m the soluble fractIon of exposed rat lungs Lmear
regressIOn analySIS of the correlatIOn between N02 concentratIons and enzymatIc actIVItIes
showed a sIgmficant pOSItIve correlatIOn coeffiCIent of 0 63 for GSH reductase and of
084 for G-6-P dehydrogenase No correlatIOn was found between the GSH peroXidase
aCtIVIty and the N02 exposure concentratIOn The actIvlltIes of GSH reductase and G-6-P
3
dehydrogenase were sIgmficantly increased durmg exposure to 11,600 p,g/m N02 The
pOSSIble role of edema and cellular mflammation m thes,e fmdmgs was not exammed These
researchers concluded that because exposure of rats to N02 had an mSIgmficant effect on
lung GSH perOXidase actIvIty, but dId sIgmficantly mcrease the actIVItIes of GSH reductase
and G-6-P dehydrogenase, It appears that thIs OXidant attacks mamly GSH and NADPH,
13-71
TABLE 13-7. EFFECTS OF NITROGEN DIOXIDE ON ANTIOXIDANT METABOLISM AND
INFLUENCE OF ANTIOXIDANTSa
N02 Concentratton
3 SpecIes
75 004 ContInuous, M 8 weeks Rat NPSHs mcreased at ;=:04 ppm after 9 or 18 mo, Saga! et al (1984)
752 04 9 and 18 mo (Wlstar) GSH perOXidase acttvity decreased at 0 4 ppm Ichmose et al (1983)
7,520 40 after 18 mo and at 4 0 ppm after 9 and 18 mo,
GSH reductase actIVIty mcreased after a 9 mo
exposure to 4 0 ppm, G-6-P dehydrogenase was
mcreased after a 9- and 18-mo exposure to
4 0 ppm, no effects on 6-P-G dehydrogenase,
SOD, or dIsulfide reductase, some GSH
S-transferase had decreased actIVItIes after 18-mo
exposure to ;=:0 4 ppm
-
752 04 Contmuous, M 13 weeks Rat DuratIon-dependent pattern for mcrease m Ichmose and Saga!
2,260 12 4mo (WIstar) actIVitIes of antIOXidant enzymes, mcrease, (1982)
wI 7,520 40 peakmg at Week 4 and then decreasmg
.....:I Concentratton-dependent effects
N
752- o 4- Contmuous, F NS Mouse Growth reduced, Vitamm E (30 or 300 mg/kg Csallany (1975)
940 05 15 years (NS) dIet) Improved growth
940 05 Contmuous, F 4 weeks Mouse At 1 ppm, GSH-peroXIdase actIVIty decreased m Ayaz and Csallany
1,880 10 17 mo (C57BI/6J) VItamm E-deficient mICe, and mcreased m (1978)
VItamm E-supplemented nuce
1,880 10 4 h/day, NS NS Rat VItamm E-supplement reduced lIpId peroXIdatlOn Thomas et al (1967)
6 days (Sprague-
Dawley)
1,880 10 ContInuous, M 8 weeks Rat ActIVItIes of GSH reductase and G-6-P Chow et al (1974)
4,330 23 4 days (Sprague- dehydrogenase mcreased at 6 2 ppm proportIonal
11,600 62 Dawley) to duratIon of exposure, plasma lysozyme and
GSH perOXidase not affected at 6 2 ppm, no
effects at I 0 or 2 3 ppm
TABLE 13-7 (cont'd). EFFECTS OF NITROGEN DIOXIDE ON ANTIOXIDANT METABOLISM AND
N02 ConcentratlOn
3 SpecIes
fJ-g/m ppm Exposure Gender Age (Stram) Effects Reference
2,260 12 Contmuous, M 12 weeks Rat Increases m G-6-P dehydrogenase, IsocItrate Lee et al (1989,
3,380 18 3 days (Sprague-Dawley) dehydrogenase, dIsulfide reductase, and 1990)
NADPH cytochrome c reductase actIvItIes at
18 ppm only
3,760 20 3 days M/F 5->60 Rat Decreased SOD actlVlty m 21-day-old ammals Azoulay-DupUls
18,800 100 days (WIStar) et al (1983)
Gumeaplg
(DUllkm Hartley)
3,760 20 14 days M 12-24 Rat G-6-P dehydrogenase mcreased at ~2 ppm, at Mochltake et al
7,500 40 10 days weeks (WIStar) 2 ppm, 14 days of exposure needed (1985)
18,800 100 7 days
I'-" 5,600 30 7 days M/F 1 day to Rat Increased hPId peroXIdatlOn (TBA-reactIve Sevaman et al
wI
......:J
>8 weeks (Sprague-Dawley) substances) WIth vItamm E defiCIency (1982)
w
5,600 30 4 days M NS Rat No effects on parameters tested Mustafa et al
(Sprague-Dawley) (1979)
13,200 70 4 days Increase m lung weIght, G-6-P dehydrogenase,
GSH reductase, and GSH peroXIdase
actIVItIes
18,800 10 4 days Increase m lung weIght, G-6-P dehydrogenase,

6-P-G dehydrogenase, and GSH reductase
actIVItIes
28,200 15 1-7 days Increase m lung weIght, DNA content, G-6-P

dehydrogenase, 6-P-G dehydrogenase, GSH
reductase, dIsulfide reductase, GSH
perOXIdase, succmate OXIdase, and cytochrome
OXIdase actIVItIes, no effect on lung protem
TABLE 13-7 (cont'd). EFFECTS OF NITROGEN DIOXIDE ON ANTIOXIDANT l\1ETABOLISM AND
N~ Concentration
3 SpecIes
7,520 40 3h M/F 21-33 Human Decreased elastase mhtbItory capacIty Mohsemn (1991)
years and mcreased hpId peroXIdatton
products ill BAL of subjects not
adlntnlstered supplement of VItamm C
and E pnor to NOz exposure
11,000 60 4 h1day, F NS Mouse Increase ill GSH reductase and G-6-P Csallany (1975)
30 days (NS) dehydrogenase acttvIttes
28,000 15 7 days Increase ill GSH levels, and GSH

53,000 28 reductase, G-6-P dehydrogenase, and
GSH perOXIdase acttVIttes
......
wI 17,900 95 7 h1day, M ill Rat Increase ill GSH reductase acttvIty ill Mauderly et al (1987)
~ 5 days/week, utero (FIscher 344) younger rats and GSH perOXIdase
6 rno and acttvIty ill older rats
6rno
17,900 95 7 h1day M 18 Rat Increase ill GSH reductase acttvIty ill Mauderly et al (1990)
5 days/week, weeks (FIscher 344) BAL
24rno
'M = Male
NPSHs = Nonprotem sulfhydryls
GSH = Glutat1uone
G-6-P dehydrogenase = Glucose-6-phosphate dehydrogenase
6-P-G dehydrogenase = 6-phosphosgluconatedehydrogenase
SOD = SuperOlude dlsmutase
F = Female
NS = Not stated
NADP = Nlcotmaffilde-ademne dmucleotIde phosphate
leo = Isocltlate dehydrogenase
NADPH = Nlcotlnaffilde-ademne dmucleotlde phosphate (reduced form)
TBA = ThlObarblwnc aCId
whereas 03 not only InItiates hpid peroXIdatIOn, but also drrectly attacks these reducmg
substances
NItrogen dIoXIde effects on antiOXIdant metabohsm appears to follow a concentratIOn-
and exposure-duratIOn response Lee et al (1990) reported that G-6-P dehydrogenase,
6-phosphogluconate dehydrogenase (6-P-G dehydrogenase), and NADP-specrfic Isocitrate
dehydrogenase were not affected after rats were exposed to 2,260 p.,g/m3 (1 2 ppm) N0 2
contInuously for 3 days When NOz exposure was mcreased from 3 days to 16 weeks, there
was an mcrease m GSH peroXIdase, GSH reductase, G-6-P dehydrogenase, 6-P-G
dehydrogenase, SOD, and dIsulfide reductase actiVIties m rats from the fIrst week of
exposure that reached a maXImum by the fourth week of exposure and thereafter gradually
declmed over the 16-week exposure penod (Ichmose et al , 1983) The mcrease m
antIOXIdant actIVIty was exposure-dependent over the exposure range of 75 to 7,520 p.,g/m3
(0 04 to 4 0 ppm) NOz
Saga! et al (1984) and Ichmose et al (1983) studIed the effects of prolonged (9 and
18 mo) exposures to 75, 752, and 7,520 p.,g/m3 (0 04, 04, and 40 ppm) N02 on rats
Nonprotem sulfhydryl levels were mcreased m the 752- and 7,520-p.,g/m3-exposed groups
after both exposure durations Nme- and 18-mo exposures to 7,520 p,g/m3 caused a decrease
m the actiVIty of GSH peroXIdase and an mcrease m G-6-P dehydrogenase actIVIty
GlutathIone peroXIdase actIVIty was also decreased m rats exposed to 752 p.,g/m3 N02 for
18 mo Three GSH S-transferases were also studIed, two of whIch (aryl S-transferase and
aralkyl S-transferase) exhIbIted decreased actiVIties after 18 mo of exposure to 752 and
3
7,520 p.,g/m N02 No effects were observed on the ac1tJ.vItIes of 6-P-G dehydrogenase,
SOD, or dIsulfide reductase The decreases m antIOXIdant metabohsm were mversely related
to the formatIOn of hpid perOXIdes (see preVIOUS subsectIOn on hpid metabohsm) Shorter
exposures (4 mo) to N02 between 752 and 7,520 p.,g/m3 also cause concentratIOn- and
duratIOn-dependent effects on antiOXidant enzyme actIVIties (Ichmose and Saga!, 1982) For
example, G-6-P dehydrogenase aCtiVIty mcreased, reachmg a peak at 1 mo, and then
decreased towards control Bnefer (2-week) exposures to 752 p.,g/m3 N02 caused no such
effects m rats or gumea pIgS (Ichmose and Saga!, 1989)
3
Age susceptibility to the effects of N02 (17,900 p.,g/m , 9 5 ppm, 7 h/day,
5 days/week) was exammed by Mauderly et al (1987) Rats were exposed for 6 mo,
13-75
begmnmg m utero or at 6 mo of age In the older rats, only GSH peroXIdase was mcreased,
whereas m the younger rats only GSH reductase was mcreased
Malnutnnon of ammals can drastically affect theIr response to tOXIcants, mcludmg
N02 Expenmental mterest m thIs area has mamly focussed on dIetary lIpIds, vitamm E and
other lIpId-soluble antiOXIdants, and vitamm C and other water-soluble antiOXIdants For
example, Sevaman et al. (1982) reported an mcrease m the amount of TBA reactants m lung
homogenate of vItamm E-deficlent rats after 7 days of exposure to 5,640 p.,g/m3 (3 0 ppm)
NO z Ayaz and Csallany (1978) exposed weanlIng mIce contmuously for 17 mo to 940 or
1,880 p.g/m3 (05 or 1 0 ppm) N02 and fed the ammals a basal dIet that was eIther deficIent
m VItamin E or supplemented WIth 30 or 300 mg/kg of dIet Blood, lung, and lIver tissues
3
were assayed for GSH peroXIdase actiVIty Exposure to 1,880 p.,g/m N02 suppressed GSH
perOXIdase acnvity m the blood and lungs A combmatIOn of vItamm E defiCIency and
3
1,880 p.,g/m N02 exposure resulted m the lowest GSH peroXIdase actIVIty m blood and lung
Liver GSH peroXIdase acnvIty was unaffected by eIther vitamm E defiCIency or N02
exposure Other studIes (Hatch et al , 1986, Selgrade et al , 1981, Slade et al , 1989,
Sherwm and Carlson, 1973) have also shown that vItamm C defiCIency mcreases
susceptibility to N02-mduced mcreases m BAL protem
Summary
Studies on the bIOChemIcal effects of N02 on the lung have focused on the mechamsms
of the toxic acnon or mdICators of tissue and cell damage One theory descnbmg the toXIC
action of N02 IS that of lIpId peroXIdatIOn of unsaturated fatty aCIds m target cell membranes
(Menzel, 1976). An alternate theory IS that N02 OXIdIZes water-soluble low molecular
weight reducmg substances and protems (Freeman and Mudd, 1981) StudIes show that
regardless of the tOXIC action, many of the effects are concentratIOn- or exposure duratIon-
dependent
Exposure to 75 p.,g/m3 (004 ppm) N02 mcreased lIpId peroXIdatIon (as mdICated by
increased ethane exhalation) m the lungs of rats exposed for 9 mo or longer Ethane
3
exhalatIOn was also mcreased m rats exposed to 752 p.,g/m for 6 mo, but not m rats exposed
3
to 75 or 225 p.,g/m (004 or 0 12 ppm) over the same time penod (Saga! et al , 1984,
Ichinose et al , 1983) Increases m lIpId peroXIdatIon products have also been reported m
13-76
healthy, nonsmokIng humans exposed to 7,520 p,g/m3 (4 0 ppm) N02 for 3 h (Mohsemn,
1991)
Increases ill lavage flUid and urmary levels of hydlroxylysille were found ill rats exposed
to 1,880 to 56,400 p,g/m3 (1 to 30 ppm) N02 , 6 h/day for 2 days The illcreases were,
however, only sIgmficant at N02 levels;;:: 14,100 p,g/m? (7 5 ppm) for lavage flUid and
> 28,200 p,g/m3 (15 ppm) for urmary output (Evans et al , 1989) Urmary secretIOn of
hydroxyprohne and aCId mucopolysacchandes have been reported ill guillea pIgS exposed to
1,880 p,g/m3 (1 0 ppm) N02 for 6 mo (KosmIder et al 1973a) The sIgmficance of these
observatIOns to lung structure and functIOn IS unknown
No changes ill blood and lung GSH peroXIdase actIvIty were reported ill mIce exposed
to 940 p,g/m3 (0 5 ppm) N02 contilluously for up to 17 mo, however, when the exposure
concentratIOn was illcreased to 1,880 p,g/m3 (1 0 ppm), a suppressIOn o~ GSH peroXIdase
actIvIty was noted (Ayaz and Csallany, 1978) ThIs enzyme actIvIty was not affected ill rats
exposed contInuously to up to 11 ,600 p,g/m3 (6 2 ppm) N02 for 3 or 4 days (Chow et al ,
1974, Lee et al., 1990), but was sIgmficantly decreased ill rats exposed to 752 p,g/m3 for
18 mo (Saga! et al , 1984, Ichmose et al , 1983)
NItrogen dIOXIde effects on antIoXIdant metabohsm appears to be both concentratIon-
and exposure duratIOn-dependent No effect on G-6-P dehydrogenase, 6-P-G dehydrogenase,
and NADP-specrfic IsocItrate dehydrogenase actIvIties was noted ill rats exposed to
2,256 p,g/m3 (1 2 ppm) N02 contInuously for 3 days (Lee et al , 1990) However, an
mcrease ill GSH peroXIdase, GSH reductase, G-6-P dehydrogenase, 6-P-G dehydrogenase,
SOD, and dIsulfide reductase actIVItIes has been reported ill rats exposed to 75 to
7,520 p,g/m3 (0 04 to 4 0 ppm) N02 from the fIrst week of exposure that reached a maxnnum
by the fourth week of exposure and thereafter gradually dechned over the 16 week exposure
penod (Ichmose et a1 , 1983) When exposure was illcleased to 9 to 18 mo, there was an
illcrease ill G-6-P dehydrogenase actIvIty, but only ill rats exposed to 7,520 p,g/m3
No effects were observed on the actIVItIes of 6-P-G dehydrogenase, SOD, or dIsulfide
reductase (Saga! et al , 1984, Ichmose et al ,1983)
13-77
13.2.2.3 Pulmonary Function
The key Issues addressed by mvestIgators evaluatmg the effects of N0 2 on pulmonary
functIon m expenmental annnals were (1) the effects of low-level, long-term exposures to an
urban pattern of N02 , the lowest concentratIOns that stnnulated respIratory reflexes and
nnpaired gas exchange m the lung, and (2) dIfferences m responses between very young and
mature animals Compared wIth humans, rats and hamsters used m expernnental studIes of
N0 2 have very nnmature lungs at bIrth Humans have approxnnately 50 mIlhon alveoh at
birth, whIch multIply rapIdly untIl age 3 years and slowly until about age 8 years, when
alveolar development IS complete Growth contInues until matunty, 16 to 18 years, through
alveolar enlargement Rats and hamsters are born WIth no true alveoh Alveolar
prolIferatIon IS most rapId between 4 and 30 days of age and IS essentIally complete by
40 days of age Although hamster lungs have reached adult volumes and elastIcIty at 40 days
of age, lung growth through alveolar enlargement contmues m rats to 5 mo of age
(Mauderly, 1989) Changes m pulmonary functIon parameters m the expenmental annnals
from exposure N02 are shown m Table 13-8
NItrogen dIOXIde concentratIons m urban areas are not constant, but conSIst of peak
exposures supenmposed on a relatIvely constant background level Miller et al (1987)
evaluated thIs urban pattern of N02 exposure m mIce usmg contmuous 7 day/week, 23 h/day
3
exposures to 376 p,g/m (0 2 ppm) N0 2 WIth two daily (5 days/week) I-h peak exposures to
3
1,500 p,g/m (08 ppm) N02 for 32 and 52 weeks MIce exposed to clean arr and to the
3
constant background concentratIOn of 376 p,g/m served as controls Data from ammals
exammed nnmed.Iately and 30 days followmg both exposure regnnens were combmed for
analysis because there was no statIstIcal dIfference between the groups (1 e, nnmedIately
and 30 days postexposure) Most of the dIfferences m pulmonary functIon were measured
between groups exposed to background concentratIOns WIth dIUrnal peaks and those exposed
to constant background N02 levels, although the same pattern of effects was found when
comparmg peak- and arr-exposed annnals Both end-expIratory volume and VItal capacIty,
the difference ill lung volume between maxnnum mflatIOn and deflatIOn, were sIgmficantly
lower m mIce exposed to N02 WIth dIUrnal peaks than m mIce exposed to the constant level
of N02 • Lung dIstensIbility, measured as respIratory system comphance, also tended to be
lower (p = 0 072) m mIce exposed to dIUrnal peak exposures of N02 compared WIth
13-78
TABLE 13-8. EFFECTS OF NITROGEN DIOXIDE ON PUlMONARY FUNCTIONa
N02 Concentration
3 Species
fl-g/m ppm Exposure Gender Age (Stram) Effects Reference
376 02 23 h/day, F 6-8 Mouse Decreased Vital capacity and respuatory Ml1ler et a1 (1987)
376 base + 02 base + 7 days/week weeks (CD-I) system comphance followmg exposure to
1,504 peak 08 peak base + o 2 ppm + 0 8-ppm peak compared With
two I-h ror-exposed and 0 2-ppm exposed rats
peaks/day,
5 days/week,
32 and
52 weeks
750 04 1,2, and Rat Decreased heart rate followmg I-mo Suzuki et a1 (1981)
2,250 12 3 mo exposure to 1 2 and 4 0 ppm, decreased
7,520 40 body weight and Pa02 followmg 3-mo
exposure to 4 0 ppm N02
I-' 940 base + o 5 base + Contmuous, M 1 day Rat Increased lung volume (at Weeks 3 and 6) Stevens et al (1988)
wI 2,820 peak 15 peak With two and (Fischer 344) and comphance (at Week 3) m neonates
-...l
\0 daily I-h 7 weeks exposed to the two highest exposure
1,880 base + 1 o base + peaks for 1, levels Decreased body weight and lung
5,640 peak 30 peak 3, or 6 weeks comphance m older rats followmg
6 weeks exposure to the highest
3,760 base + 20 base + concentration, older rats recovered by
11,280 peak 60 peak 3 weeks postexposure (younger rats not
tested)
940 05 6 h/day, M NS Rat No effects 10 ppm, mcrease m Vital Evans et al (1989)
1,880 10 5 days/week, (Fischer 344) capaCity immediately followmg exposure
4 weeks and an mcrease m comphance 4 weeks
postexposure at 0 5 ppm FunctiOnal
changes aSSOCiated With changes m mean
lmear mtercept
TABLE 13-8 (cont'd). EFFECTS OF NITROGEN DIOXIDE ON PUlMONARY FUNCTIONa
NOz Concentration
3 SpecIes
p.gfm ppm
(Stram) Reference
Exposure Gender Age Effects
940 (base) + 0 5 (base) + 22 hlday, M 60 days Rat Decreased AFEF25 followmg 78 weeks of NOz Tepper et al (1992)
2,820 (peak) 1 5 (peak) 7 days/week (FIscher 344) exposure, frequency of breathmg decreased
base + 6-h throughout, WIth greatest decrease observed at
peak/day, 78 weeks
5 days/week,
'1, 3, 12, 52,
and 78 weeks
1,880 10 Continuous, M NS Monkey Monkeys challenged With monkey-adapted Fenters et al (1973)
493 days (SquIrrel) mfluenza VIrus Mmor NOz-mduced changes m
tidal volume, mmute volume, and respiration rate
3,760 20 8 hlday, M 8 Hamster Increase m fixed lung volume, but no change m Lafuma et al (1987)
5 days/week, weeks (Golden VItal capaCIty or lung complIance followmg NOz
8 weeks Synan) exposures m both nonnal and elastase-treated
....
wI anImals
00
0 9,400 50 30 mm/day, M NS Gumea pIg Last 5 weeks of NOz exposure followed by 10-mm YoshIda et al (1980b)
twIce/week (NS) exposure to aerosolIzed albumm Increased
for 7 weeks dyspneIc breathIng dunng fourth through seventh
week of NOz-albumm exposure
9,400 50 2 h, resting F 2-9 Dog Statistically SIgnIficant decrease m the ventilatIOn Klemman and Mautz
or exerClsmg years (Beagle) eqUIvalent for 0z m exercIsmg dogs (1991)
9,400 50 Continuous, M NS Monkey Monkeys challenged WIth monkey-adapted Henry et al (1970)

2mo (SqUIrrel) mfluenza VIrus Decreased tIdal volume and
mcreased respiratory rate
9,400 50 24h M 15-16 Mouse Concentration-related decrease m forced sWImmmg Suzuki et al (1982a)
18,800 10 weeks (JCLICR) time ImmedIately followmg exposure, elevated
37,600 20 blood lactIC aCId ImmedIately and 24 h followmg
75,200 40 4-mm forced SWIm at 5 0 ppm
TABLE 13-8 (cont'd). EFFECTS OF NITROGEN DIOXIDE ON PUlMONARY FUNCTIONa
N02 Concentration
3 SpecIes
p.g/m ppm
9,400 50 24h M 15-16 Mouse Concentration-related mcrease m Suzula et al (1982b)
18,800 10 weeks (JCLICR) reSpiratlOn rate, decrease m PaC02 at
37,600 20 5 ppm and ill Pa02 at :==: 10 ppm
9,400 50 Contmuous, F NS Mouse The Irntant response to 8-rom, l00-ppm McGrath and Stmth (1984)
188,000 100 3-day to (CF-l) N02 exposure, typIfied by mcreased
5 o ppm respiratory rate and decreased tidal volume
followed by and romute volume, was lessened by
8 rom to preexposure to 50 ppm N02 for 3 days
100 ppm
10,200 54 3 h/day for M 7-9 Rat NOnSIgnificant tendency toward mcreased Yokoyama et al (1980)
7, 14, or weeks (WIStar) lung volume at low mflatlOn pressures at
30 days 30 days
..... 13,200- 70-146 Ih M/F 5-10 Gumeapig ConcentratlOn-related mcrease m Sdbaugh et al (1981)
wI 275,000 weeks (CRL COBS) senSItivIty to mhaled 1ustamme aerosols
.....
00
10 rom followmg N~ exposure, but not
2 and 19 h followmg exposure,
concentratlOn-related mcrease m
respiratory rate 10 rom followmg exposure
and decrease m tidal volume 10 rom and
2 and 19 h followmg exposure
14,000 75 2h NS NS Sheep Increased pulmonary reSIstance Abraham et al (1980)
28,000 150 2 and 4 h (NS) ImmedIately followmg 4-h exposure to
15 ppm N~, no conSIstent effects of
exposure on atrway reactivIty to mhaled
carbachol, artenal blood gases, and
pulmonary and systematic hemodynanncs
17,900 95 7 h/day, M 18 weeks Rat Increased lung volumes and lung Mauderly et al (1990)
5 days/week, (FIscher 344) comphance and decreased rate of forced
24mo exhalation m N02-exposed rats, no
phySIologICally SIgnificant mteractIon
between N02 and elastase-treatment
TABLE 13-8 (cont'd). EFFECTS OF NITROGEN DIOXIDE ON PUIMONARY FUNCTION a
N02 ConcentratIon
3 SpecIes
p.g/m ppm (Stram)
Exposure Gender Age Effects Reference
17,900 95 7 blday, M utero Rat
ill No substantIve effects of N~ Mauderly et al (1987)
5 days/week, and (FIscher 344)
6mo 6mo
18,800 10 2h M/F NS Monkey Monkeys challenged wIth Klebslella Henry et al (1969)
28,200 15 (SqIDrrel) pneunwma Decreased tIdal volume that
returned to normal or elevated levels
Wlthm 24 h ill most anImals
lip = Female
PaOZ = Artenal oxygen tensIOn
M = Male
NS = Not stated
Ll.FEFZ5 = Change In forced expIratory flow at 25 % of forced VItal capacIty
0z = Oxygen
.....
~
PaCOZ = Artenal carbon dIOXIde tensIon
I
00
N
constant N02 exposure These changes suggest that up to 52 weeks of low-level N02
exposure wIth dIUrnal peaks produces some decrease m Jlung dIstensIbility, resultmg m
decreased resprratory system comphance and VItal capacJlty VItal capacIty was still
decreased 30 days postexposure Lung morphology (by hght mICroscopy) m these mIce
showed no exposure-related leSIOns, however, the absence of observable morphologIc leSIOns
does not preclude the presence of subtle morphologIc changes as dISCUSSed m
SectIOn 13 2 2 4 The decrease m lung dIstensIbility measured m thIs study IS conSIstent
WIth the mcrease m VItro lung collagen synthesIs rates measured m lung mmces from rats
3
exposed m VIVO for 7 days to 9,400 to 47,000 p,g/m (5 to 25 ppm) N02 (Last et al , 1983)
3
Tepper et al (1992) exposed rats to 940 p,g/m (05 ppm) N02 , 22 h/day, 7 days/week,
WIth a 6-h peale slowly nsmg to 2,820 p,g/m3 (1 5 ppm) N02 , 5 days/week for up to
78 weeks EvaluatIOns of pulmonary functIOn conducted at 1, 3, 13, 52, and 78 weeks
revealed a small, but statIStIcally sIgnrficant decrease m the frequency of breathmg that was
paralleled by a trend toward mcreased tIdal volume, exprratory reSIstance, msprratory and
expiratory tIme In general, these vanables were most affected followmg 78 weeks of
exposure Also, at the 78-week evaluatIon, delta flow at 25 % forced VItal capaCIty was
decreased Taken together, these results mIght mdIcate arrway obstructIOn, however, a more
prudent conclUSIOn would be that few, If any, sIgnrfican1 functIOnal effects were observed
that mIght suggest degeneratIve lung dIsease
Effects of exposure to dIUrnal peaks of N02 were also StUdIed by Stevens et al (1988)
These mvestIgators exposed l-day- and 7-week-old rats 10 940, 1,880, or 3,760 /Lg/m3
(05, 1 0, or 2 0 ppm) N02 WIth two dally 1-h peak exposures at three tImes the basehne
concentratIOn for 1, 3, and 7 weeks The effects on rats begmnmg exposure at 1 day and
7 weeks of age were substantIally dIfferent In rats begmnmg exposure at 1 day of age,
respIratory system comphance was mcreased followmg 3 weeks, but not 6 weeks of exposure
to the 1,880 to 3,760 p,g/m3 N02 basehnes WIth peak eJ<posures In rats begmnmg exposure
at 7 weeks of age, resprratory system comphance was decreased followmg 6 weeks of
exposure to the two hIghest levels, and body weIght was, decreased followmg 3 and 6 weeks
3
of exposure to the 3,760 p,g/m basehne WIth peak exposures The decreased comphance m
the older rats SImIlarly exposed to N02 was aSSOCIated WIth morphologIcal changes,
partIcularly m the centnacmar alveolar regIOn (Chang et al , 1986, SectIOn 13 224) In the
13-83
older rats (younger rats not tested), pulmonary functIOn changes returned to normal values by
3 weeks after exposure ceased
Mauderly et al (1987) dId not measure substantive dIfferences m effects on pulmonary
functIOn parameters between rats exposed to 17,900 p,g/m3 (9 5 ppm) N0 2 , 7 h/day,
5 days/week eIther begmnmg exposure at 6 mo of age for 6 mo or begmnmg from the time
of conceptIon untI16 mo after bIrth There was, however, a statiStically sIgmficant mcrease
in mmute volume m the N02 -exposed younger ammals compared to arr-exposed ammals
The mcrease m mmute volume was attnbuted to an mcrease m tidal volume Because there
were no changes m lung volumes, mechamcs, or gas exchange, the mcreased mmute volume
apparently does not reflect a compensatIOn for Imparred lung functIOn No morphologIc or
morphometnc dIfferences were observed eIther DIfferences m the observed effects of N02
between thIs study and that of Stevens et al (1988) may pOSSIbly be attnbuted to drfferences
in exposure schedules (7 h/day, 5 days/week versus 23 h/day WIth dIUrnal peaks), to
drfferences m the stage of lung development at the tIme of sacnfice (alveolar expanSIOn
essentIally complete at 6 mo, but stIll contmumg at 13 weeks), or to some other factor
In adult rats receivmg a longer (24-mo) mtermittent exposure to 17,900 p,g/m3 (9 5 ppm)
N02, lung volumes and comphance were mcreased (Mauderly et al , 1990) The percentage
of forced vital capacity exhaled m 1 S was decreased There were no structural correlates
(hght mIcroscopy) to these changes
Lung volumes and capaCIties were evaluated m anesthetIZed rats after exposure to
3
940 or 1,880 p,g/m (05 or 1 0 ppm) N0 2 , 6 h/day, 5 days/week for 4 weeks (Evans et al ,
1989). No pulmonary functIOn effects were noted m rats exposed to 1,880 p,g/m3 N02
ImmedIately after exposure ended or 4 weeks postexposure There was, however, a
significant mcrease m VItal capaCIty at the end of the 4-week exposure penod, and an
increase m comphance followmg the 4-week recovery penod m the 940-p,g/m3 -exposed
group. The changes m the pulmonary functIon parameters were aSSOCIated WIth changes m
the mean hnear mtercept m the N02-exposed anImals Except for a nonsIgmficant trend for
an increased lung volume at low mfIatIOn pressure, Yokoyama et al (1980) observed no
changes in ventilatory mechamcs of rats exposed for 14 or 30 days (3 h/day) to
3
10,200 p,g/m (5 4 ppm) N02 HIstologICal changes were mmor A dISCUSSIon of the
13-84
bIochemIcal changes and morphologIcal :fmdmgs m the lungs of these exposed anImals
appears m SectIOns 13 2 2 2 and 13 224
Only mmor changes m tIdal volume, mmute volume, and resprratIOn rate were reported
m squIrrel monkeys exposed to 1,880 p.g/m3 (1 0 ppm) N02 contmuously for 493 days
(16 mo) followmg vIral challenge wIth monkey adapted mfluenza A1PRl8/34 vrrus (Fenters
et al ,1973) These changes were not affected by the vIral challenge, although the authors
stated that shght emphysema and thIckenmg bronchIal and bronchIolar epIthehum were noted
m monkeys exposed to N02 and the mfluenza vrrus When mfluenza challenge followed
3
exposure to 9,400 p.g/m (5 0 ppm) for 2 mo, there was. a decrease m tIdal volume and an
mcrease m resprratory rate that had returned to normal values after 4 weeks (Henry et al ,
1970)
Klemman and Mautz (1991) conducted pulmonary function studIes on a group of beagle
dogs exposed to 9,400 p.g/m3 (5 0 ppm) N02 for 2 h while standing at rest or exercIsmg
Restmg dogs developed a shorter breathmg tune and a trend towards an mcrease in VE and
V02 compared to arr-exposed ammals, however, neithel of these responses was slgruficant
The only statistICally sigruficant effect m N02- and arr-exposed exercIsmg dogs was a
decrease m the ventilation eqUIvalent for oxygen (02) Other pulmonary function parameters
exammed mcluded tIdal volume, mmute ventilation, ventilation equivalent for CO2 ,
pulmonary resIstance, and dynamIc comphance
Lafuma et al (1987) exposed 12-week-old hamsters to 3,760 p.g/m3 (2 0 ppm) N02,
8 hlday, 5 days/week for 8 weeks Half the anImals had been pretreated mtratracheally WIth
elastase to produce a condItion of expenmental emphysema FIXed lung volumes (20 cm
water WIth 2 5 % glutaraldehyde) were slgruficantly hIgher m NOTexposed anImals than m
arr-exposed controls, mdependent of elastase treatment VItal capacIty and pulmonary
comphance were not affected by N02 exposure, however, morphometncally, the
emphysematous leSIOn produced by elastase appeared to be aggravated by the N02 exposure
Mauderly et al (1990) exposed rats to hIgher concentrations of N02 (17,900 p.g/m3 ,
95 ppm) for longer times (7 hlday, 5 days/week for 24 mo) and also found no mcreased
susceptibility, related to pulmonary functIOn or morphologIcal changes, to N02 m elastase-
treated anImals Although there was an mteractIOn of N 02 and elastase treatment on forced
exprratory flow at 10% of forced VItal capacIty, the authors attrIbuted thIs response to eIther
13-85
a statIstIcal fluke or a change of httle phySIOloglCal slgmficance See SectIOn 13 2 2 4 for a
further dlscussIOn of structural changes
Suzuki and Tsubone, along wlth therr colleagues, have conducted extenslve studles on
the effects of N02 on resprratory and cardlac functIOn m mlce and rats Because many
cardlovascular effects observed followmg exposure to N02 are most hkely secondary to
pulmonary edema and/or snmulatIOn of sensory receptors m the resprratory tract, these
changes will be dlscussed together
Suzuki et al (1984) reported that the heart rate m unanesthetIzed mlce was lower
3
following 1-mo exposure to 2,260 and 7,520 p,g/m (1 2 and 4 0 ppm) N02, but not
following 2- and 3-mo exposures Artenal 02 tenSIOn (Pa02) was decreased followmg a
3
3-mo exposure to 7,520 p,g/m N02 Resprratory rate was not affected by N02 exposures
Suzuki et al. (1981) also exposed rats for up to 3 mo to between 752 and 7,520 p,g/m3
(0.4 and 4 0 ppm) N02 After 3 mo of exposure to 7,520 p,g/m3 N02, anesthetIzed rats,
artificially ventllated at mgh frequencles, had a slgmficant reductIOn m Pa02
Effects of 24-h exposures to 9,400, 18,800, 37,600, and 75,200 p,g/m3 (5, 10, 20, and
40 ppm) N02 on swimmmg performance m mlce were evaluated by Suzuki et al (1982a)
Blood lactic acid levels measured m mlce after a 4-mm forced SWlID were approXlIDately
50% mgher followmg exposure to 9,400 p,g/m3 N02 compared wlth controls Exposures to
mgher concentratIOns of N02 (;;;:: 18,800 p,g/m3) resulted m a concentratlon-related decrease
in maXlIDum forced SWlIDIDmg tlIDe Changes m blood lactlc aCld levels m the Suzuki et al
(1982a) study mdlcate that although IDlce exposed to 9,400 p,g/m3 N02 were able to SWlID as
long as control mlce, the cardloresprratory system was not able to supply sufficlent 0z to
meet the metabohc demands of sWlIDmmg, and anaeroblc pathways were actlvated producmg
lactlc aCld
Suzuki et al (1982b) evaluated breathmg pattern and gas exchange m mlce followmg
3
exposure to 9,400, 18,800, or 37,600 p,g/m (5, 10, or 20 ppm) NO z for 24 h The rrntant
3
effect of exposure to 9,400 p,g/m N02 resulted m mcreased resprratory rate and an
associated decrease m artenal CO2 tenSIOn (PaCOz), but no effect on PaOz Resprratory
rates were mcreased at the two mghest N02 exposure concentratIOns, but because of
lIDpaired gas exchange associated wlth mcreased lung wet welght and lung water content,
PaC02 was unchanged and Pa02 was decreased followmg exposure The studles of Suzuki
13-86
and Tsubone together have shown that 30-mm to 3-mo exposures of mIce and rats to N02
concentratIOns of 9,400 p.g/m3 N02 and greater stlmulated respIratory reflexes that slow the
heart rate and produce concentratlon-related pulmonary edema, decreasmg blood oxygenatlOn
and lffiparrmg maxlmum exerCIse performance
McGrath and SmIth (1984) found that the rrntant response m mIce to an 8-mm
exposure to 188,000 p.g/m3 (100 ppm) N02 was lessened by a 3-day contmuous preexposure
3
to 9,400 p.g/m3 (5 0 ppm) N02 Considermg both 188,000 p.g/m N02 exposures and
phenyl diguamde mJectlOns as rrntant challenges, 3 to 7 days of exposure to 7,520 to
9,400 p.g/m3 (40 to 5 0 ppm) N02 lessened the response to 188,000 p.g/m3 N02 exposure,
suggestmg the development of a tolerance or attenuated response to N02 (McGrath and
SmIth, 1984), but heightenmg of the response to phenyl diguamde mJectlons (Tsubone and
Suzuki, 1984)
YoshIda et al (1980b) exposed gumea pIgS to 9,400 p.g/m3 N02 (5.0 ppm) After four
prellmmary 30-mm N02 exposures, spread over 2 weeks, anlmals were exposed tWIce a
week for 10 weeks to 30 mm of N02 , followed 20 mm later by a lO-mm exposure to
aerosohzed albumm After 5 weeks of N02 plus albumm exposures (two 30-mm
exposures/week), anlffials were exposed to aerosohzed acetylcholme for 10 mm Results
were evaluated by gradmg the anlmals breathmg pattern on a scale of 1 to 7, WIth
1 representmg normal breathmg and 7 almost total apnea WIth only rare resprratory efforts
Usmg tms relatively subJectlve measure, the authors state that dyspneIC breathmg patterns
were more severe m anlmals exposed to N02 followed by exposure to aerosohzed albumm
compared to alllffials exposed to albumm alone, WIth the greatest dIfferences occurrmg
between the fourth and seventh week of exposure to albumm Ammals preVIously exposed to
N02 plus albumm were also more affected by the fmal exposure to acetylcholme Although
the authors state that the effects they observed are statls11.cally slgmficant, quantltatlve
measures of pulmonary functlOn would allow for much more thorough statlstlcal evaluatlon
and better defimtion of the functIOnal changes occurrmg m the lungs
Summary
Changes ill pulmonary functlon parameters followmg N02 exposure m expenmental
anlmals have shown conSIstent patterns among dIfferent treatment conmtlons and anlmals
13-87
speCIes A sIgmficant mcrease m VItal capacIty has been reported nnmedIately followmg the
exposure of rats to 940 /l-g/m3 (05 ppm) N02, 6 h/day, 5 days/week for 4 weeks (Evans
et al., 1989) When the animals were exammed 4 weeks later, there was an mcrease m
complIance m the N02-exposed annnals The changes m these pulmonary functlon
parameters were associated wIth changes m the mean lInear mtercept Exposures to dIUrnal
peaks of N02 supernnposed on a constant background level, snnulatmg N02 patterns m the
urban envIronment, produced a decrease m lung mstensibility m both mIce and rats (Miller
et al , 1987, Stevens et al , 1988) These changes were very subtle, and m mIce occurred at
concentrations of 376 /l-g/m3 (0 2 ppm) N02 wIth peak exposures of 1,504 /l-g/m3 (0 8 ppm)
after 52 weeks of contlnuous exposure (Miller et al , 1987) Imparred gas exchange was a
predommant feature m mIce followmg several months of exposure 7,520 /l-g/m3 (40 ppm)
N02 and was reflected m decreased Pa02 (Suzuki et al , 1984) When N02 exposure was
mcreased to 9,400 /l-g/m3 (5 0 ppm) for 24 h, mcreased anaerobIC metabohsm, mamfested by
mcreased productlon of lactlc aCId, occurred (Suzuki et al , 1982)
Newborn and older annnals are affected differently by N02 exposures, partIcularly rats
exposed subchromcally to contlnuous background concentratlons WIth dIUrnal peaks
(1,880 and 3,760 /l-g/m3 [1 0 and 2 0 ppm] WIth two daIly I-h peaks at three tlmes the
baseline concentratlon [Stevens et al , 1988]) Lung dIstensIbility was mcreased transIently
m I-day-old rats exposed to N02 for 3 weeks, but was decreased m rats that were 7 weeks
old at the begmmng of exposure When pulmonary functIOn parameters were compared
3
between 6 mo old rats exposed to N02 concentratlons of 17,900 /l-g/m (9 5 ppm) for 6 mo
and rats exposed to the same N02 regnnen begmmng at conceptlon and contmumg untIl 6 mo
of age, there were no substantIve differences noted between the two exposed groups
(Mauderly et al , 1987)
All these stumes taken together demonstrate that N02 produces subtle to major changes
in pulmonary functIon, d'ependmg on the concentratIOn and duratIOn of exposure Lung
distensIbility and gas exchange are the parameters most conSIstently affected by N02
exposure
13-88
13.2.2.4 Morphologic Studies
InhalatlOn of N02 produces morphologICal alteratIOns m the resprratory tract
Tables 13-9, 13-10, and 13-11 provIde an overvIew of results of studIes of resprratory system
morphology followmg acute, subchromc, and chromc exposures to a wIde range of N02
concentratlOns ExammatlOn of the tables shows vanabIhty m responses at sImIlar exposure
levels m dIfferent studies There are several possIble explanatlOns for these differences m
response SpecIes, stram, and age of the experImental annuals and the dIet they were fed
appear to be major factors Although m most recent studies, the authors specIfy that specIfic
pathogen-free anImals were ordered from the suppher, the possIbility of mtercurrent dIsease
acquIred after they were shIpped or dunng the experImental protocol can only be excluded by
serology, mIcrobIal culture, and a complete necropsy at the end of the experIment
Other major factors that mfluence the results reported are the methods and mstmments
used for morphologIcal evaluatIOn Because N02 does not affect the cells and tlssues of the
lungs m a unIform manner (Stephens et al , 1972, Crapo et al , 1984), samphng procedures
are Important to the detectlOn of leslOns Samphng procedures can also mfluence the
Vahdity of the morphometnc data denved usmg stereoiogical procedures The type of
mICroscopy used for morphologIcal observatlOns IS also cntical LIght mICroscopy (IM)
permIts detectlOn of many N02 leslOns and the exammatlOn of much larger areas of lungs
than does transmISSIon electron mIcroscopy (TEM) However, IM provIdes neIther the
magnlficatlOn nor the resolutlon requIred to detect some very sIgnlficant morphological
leslOns that follow acute or low-concentratlon exposures Conversely, mspectlon of small
areas usmg TEM can easIly mISS the lImIted SItes affecte:d by N02 Scanmng electron
mICroscopy (SEM) IS especIally useful for exammmg the many surfaces of lungs at both low
and hIgh magnlficatlon Scanmng electron mICroscopy IS the method of chOIce for mspectmg
arrways for some subtle N02-mduced changes m cell surfaces Although quahtatlve
Judgments of the extent and seventy of leslOns can be made usmg all of the above
mstmments, quantltatlve evaluatlOn requIres morphometrIC methods employmg appropnate
samphng and stereologICal procedures Morphometnc techmques, especIally those usmg
TEM (Chang et al 1986, 1988, Kubota et al 1987), are~ essentlal for evaluatlng subtle
changes resultmg from exposure to low concentratlons or evaluatlng the extent of recovery of
eIther the epIthehum or the underlymg connectlve tlssue mterstltmm
13-89
TABLE 13-9. EFFECTS OF ACUTE EXPOSURE TO NITROGEN DIOXIDE ON LUNG MORPHOLOGya
NO z Concentratton
SpecIes
3
p.g1m ppm Exposure Procedures Gender Age (Stram) Effects Reference
940 05 4h LM M NS Rat Loss of cytoplaslc granules m and Thomas et al (1967)
1,880 10 (Sprague-Dawley) rupture of mast cells at 0 5 ppm;
degranulatton and decreased number of
mast cells at 1 ppm
940 05 Conttnuous, LM M NS Rat Increased number of mast cells m Hayasht et al (1987)
up to 6 days (WIstar) trachea as exposure duration mcreased
3,760 20 3 days LM M/F 5, 10,21, Rat At 2 ppm. no lesIOns observed Azoulay-Dupms et al
18,800 10 TEM 45,55, (Wlstar) At 10 ppm fibnn depOSItion m alveolI, (1983)
~60 days some bronchIolar clha loss
3,760 20 3 days LM Gumea pIg At2 ppm thtckenmg of alveolar walls,
18,800 10 TEM (Dunkm Hartley) edema, mcrease m macrophage number,
-
SEM loss of bronchtolar clha, mflammatton
wI At 10 ppm severe loss of clha m

\0 trachea and bronchtoles, edema,
0
hemorrhage, mflammatton, focal
emphysema (enlarged aIrspaces),
mcreased number of Type 2 cells
5,640- 3-16 Ih LM NS NS Dog Edema at ~ 7 0 ppm, some damage to Dowell et al (1971)
30,100 TEM (Beagle) alveolar cell tmtochondna and cell
membrane at ~ 3 0 ppm
9,400 50 24 h1day, LM M 60-75 days Rat No major morphologIcal changes Messtha et al (1983)
3 days (Sprague-Dawley) observed
20,000 106 6h LM M 6 weeks Rat Clha loss, shortenmg of CIha, focal Rombout et al (1986)
TEM (Wlstar) hypertrophy of bronchtolar eplthehum
SEM
~ = Male LM = LIght ffilcroscopy

F = Female TEM = TransffilsslOn electron ffilcroscopy
NS = Not stated SEM = ScannIng electron ffilCroSCOpy
TABLE 13-10. EFFECTS OF SUBCHRONIC EXPOSURE TO NITROGEN DIOXIDE ON LUNG MORPHOLOGya
NOZ ConcentratlOn
SpecIes
3
p.g/m ppm Exposure Procedures Gender Age (Stram) Effects Reference
207 011 Contmuous, LM F 1,3, Rat Vanous morphometnc changes, dependmg on age Kyono and KaWaI
865 046 1 mo TEM 12, 21 mo (JCL-SD) and exposure level MultIphaSIc pattern (e g , (1982)
5,260 28 decrease m aIr-blood bamer thIckness from
16,500 88 1-12 mo of age, and mcrease at 21 mo old)
640 034 6 h/day, LM M NS Mouse Type 2 cell hypertrophy and hyperplasIa, mcrease Sherwm and RIchters
5 days/week, (SWISS m mean Imear mtercept and aInount of alveolar (1982)
6 weeks Webster) wall area
940 05 23 h/day, LM M 1 day and Rat In prOXImal alveolar regIon 0 5 ppm base + Crapo et al (1984)
base + base + 7 days/week TEM 6 weeks (FIscher 344) peak caused Type 2 cells to become spread over Chang et al (1986,
2,820 15 base, I-h peaks more surface area m neonates and adults, Type 2 1988)
peak peak twIce/day, cell hypertrophy and mcrease m number of AMs
5 days/week m adults, Type 2 cells thmner m neonates,
3,760 20 3X base 2 0 ppm base + peak (only adults studIed) caused
...... base + base + concentratIon, sundar changes plus an mcrease m numbers of
~
I 11,300 60 6 weeks Type 1 cells, whIch were smaller than nonnal
\0
...... peak peak Type 1 cells 0 5 ppm base + peak had mcreased
mterstItIal matnx and fibroblast volume In
tennmal bronchIolar reglOn 0 5 ppm base + peak
caused no effects on percentage dIstnbutlOn of
CIlIated cells and Clara cells m neonates or adults,
but neonates (only) had an mcrease m CIlIated cell
surface area and mean lummal surface area of
Clara cells 2 0 ppm base + peak (only adults
studIed) resulted m fewer CIlIated cells WIth a
reduced surface area and alteratIons m the shape of
Clara cells
TABLE 13-10 (cont'd). EFFECTS OF SUBCHRONIC EXPOSURE TO NITROGEN DIOXIDE ON
LUNG MORPHOLOGya
N02 Concentration
SpecIes
3
1,000 053 Continuous, LM NS NS Gumeapig No leSIons were vlSlble by the technIque used Steadman et al
90 days (NS) (1966)
RabbIt
(New
Zealand)
Dog
(Beagle)
Monkey
(SquIrrel)
Rat
(Sprague-
Dawley)
I-' 1,000 053 Contmuous, LM M 6 weeks Rat At 0 53 and 1 33 ppm no pathology Rombout et al
wI
\0
2,500 133 up to 28 days TEM (WIstar) At 2 7 ppm focal thIckemng of centnacmar septa by (1986)
N 5,000 27 SEM 2 days, progressIve loss of cIlIa and abnonnal cIlIa m
20,000 106 trachea and roam bronchi at ::::: 4 days, hypertrophy of
bronchiolar epIthelIum at ::::: 8 days At Days 16 and 28,
all epIthelIal cells hypertrophied At 10 6 ppm
hypertrophy of CIlIated and Clara cells m tenmnal
bronchioles by 2 days, hyperplaSIa of bronchiolI by
4 days, extensIve shortemng and loss of CIlIa ill trachea
through bronchioles by 4 days, necrOSIS of Type 1 cells,
mcrease m number of Type 2 cells, thIckemng of
prOXimal alveolar septa, mcreased number of
macrophages and accumulation ill bronchioles, alveolar
dIlatatIOn
20,000 106 6 h1day, Delayed onset of changes and changes less severe
up to 28 days
LUNG MORPHOLOGya
N02 Concentration
SpecIes
3
p,g/m ppm Exposure Procedures Gender Age (Stram) Effects Reference
1,320- 07-08 Contmuous, LM F 3 weeks Mouse At exposure end mucous hypersecretiOn, focal NakajIma
1,500 1 mo TEM (JCL ICR) degeneration and desquamatiOn of mucous membrane, et al
termmal bronchIolar epIthelIal hyperplasIa, some alveolar (1980)
1,880- 10-15 enlargement, shortenmg of cIlIa, Type 1 cell edema After
2,820 1 mo postexposure mmtmaileslons persIsted m some
bronchIoles, lymphocytic mfiltration of tracheal and
bronchIal mucosa
3,760 20 8 h/day, LM M 8 weeks Hamster Moderate alveolar enlargement, pnmarIly at bronchIolar- Lafuma
5 days/week, (Golden alveolar duct Junction, mcrease m mean lmear mtercept, et al
8 weeks Synan) decrease mternal surface area of lung, no lesIons m (1987)
bronchIal, bronchIolar, alveolar duct, or alveolar
epIthelIum, no change m macrophage number
~
wI 3,760 20 ContInuous, LM M NS Gumea pIg Type 2 cell hypertrophy at 7 or 21 days SherwIn
\0 7-21 days (NS) et al
w (1973)
3,760 20 ContInuous, LM M 8 weeks Rat EVIdence of Intercurrent dIsease, whIch may mask changes Azoulay
6 weeks TEM (WIst:!.!:) due to N0 2 exposure Some clha loss m termmal et a1
SEM bronchIoles, some dIstended or dISrupted alveolar walls (1978)
7,520 40 6 h/day, LM M NS Rat At 4 ppm no leSiOns In nasal caVIty or lungs At Hooftman
18,800 10 5 days/week, (WIStar) 10 ppm no leSIons In nasal cavIty, Increased cellulanty of et al
47,000 25 up to 21 days walls of bronchIoles, alveolar duct, and adjacent alveolI by (1988)
21 days, hypertrophy or hyperplasIa of small bronchI and
bronchIolar epIthelIum by 7 days At 25 ppm no leSiOns
m nasal cavIty, hypertrophy or hyperplaSIa of small
bronchI or bronchIolar epIthelIum by 7 days, Increase m
cellulanty of walls of respIratory bronchIoles, alveolar
ducts and adjacent alveolI by 7 days, some mononuclear
Infiltration of penbronchIal areas
LUNG MORPHOWGya
N02 ConcentratIon
SpecIes
3
18,880 10 ContInuous, 1M M NS Rat 3 days swellmg and vacuolar degeneratIon of Type 1 HayashI
14 days TEM (Wlstar) cells, swellmg of Type 2 cells, desquamatIon of alveolar et al
cells, mterstItIal edema, goblet cell hyperplasIa m trachea (1987)
and bronchI 7-14 days desquamatIon of Type 1 cells,
hypertrophy and hyperplasIa of Type 2 cells, slIght
thtckenmg of alveolar wall, mterstItlal edema,
desquamatIon of endothelIal cells, swellmg and vacuolar
degeneratIon of noncllIated bronchIolar cells, loss of CIlIa
and desquamatIon of bronchIal epIthelIum
18,800 10 ContInuous, 1M F 1,3, Rat Increased anthmetIc mean thIckness of au-blood barner, Kyono and
1 mo TEM 12,21 mo (JCL SD) mcreased thIckness of both mterstItIal matnx and of cells, KawaI
hyperplastIc fOCI m mIddle and tennmal bronchI (1982)
I-"
wI 18,800 10 Contmuous, TEM M NS Gumea pIg Type 2 cell hyperplaSIa, mcrease m lIpId bomes and Yuen and
\0 6 weeks (NS) lamellae m cells Sherwm
.j::>.
(1971)
~M = Light nucroscopy
TEM = TransnusslOn electron nucroscopy
F = Female
M = Male
NS = Not stated
AMs = Alveolar macrophages
SEM = Scanmng electron nucroscopy
TABLE 13-11. EFFECTS OF CHRONIC EXPOSURE TO NITROGEN DIOXIDE ON LUNG MORPHOLOGya
NO z ConcentratiOn
SpecIes
3
80 004 Contmuous, LM M 8 weeks Rat At 0 04 ppm no SIgnificant change, but some Kubota et al (1987)
750 04 9-27 mo TEM (JCL, tendency towards mcrease m anthmetlc mean tmckness
7,520 40 Wlstar) of au-blood bamer At 0 4 ppm shght mcrease m
anthmetlc mean tmckness of au-blood bamer by
18 mo, becommg SIgnificant by 27 mo, some
mterstltlal edema and shght change m broncmolar and
alveolar eplthehum by 27 mo At 4 ppm
hypertrophy and hyperplasIa of bronchIolar eplthehum
and mcrease m anthmetlc mean tmckness of au-blood
bamer at 9 mo, Clara cell hyperplasIa, mterstltlal
fibrosIs, hypertrophy of Type 1 and Type 2 cells, and
some declme m anthmetlc mean tmckness of au-blood
-
bamer at 27 mo
380 base 02 base 23 h/day, LM F 6-8 Mouse Shght to moderate mterstltlal pneumoma conSIdered to MIller et al (1987)
wI + be due to mtercurrent dIsease rather than NO Z
\0
+ 7 days/week weeks (CD-I)
VI 1,470 078 base + 2 I-h exposure Intercurrent dIsease may have masked
peak peak peaks, effects of N~
5 days/week,
52 Vveeks_
940 05 Contmuous, LM M/F 4 weeks Rat At 0 5 ppm swellmg of termmal broncmolar clha, Yamamoto and
1,880 10 7mo TEM (JCL- hyperplasIa of Type 2 cells At 1 ppm clha loss m Takahasm (1984)
7,520 40 SD) termmal broncmoles, hyperplasIa of Type 2 cells,
mterstltlal edema At 4 ppm clha loss m termmal
broncmoles, hyperplaSIa of Type 2 cells, mterstltlal
edema, decrease m number lamellar bomes m Type 2
cells, lysosomes WIth osnnopmhc lamellar structure m
clhated cells of termmal broncmoles
TABLE 13-11 (cont'd). EFFECTS OF CHRONIC EXPOSURE TO NO z ON LUNG MORPHOLOGY
N02 Concentratlon
SpecIes
3
p.g1rn pprn Exposure Procedures Gender Age (Stram) Effects Reference
940 05 6-24 hlday, LM NS NS Mouse 3 rno pneumomtIs and alveolar SIZe mcrease, loss of clha Blatr et al (1969)
3-12 rno (NS) m respIratory bronchtoles and bronchtolar InflammatIon WIth
24 hlday, 6-12 rno pneumomtls, clha loss, bronchtal and
bronchtolar Inflammation, alveolar SIZe mcrease
940 05 Contlnuous, LM M NS Rat Type 2 cell hypertrophy and mterstItIal edema by 4 mo, Hayasht et al
up to 19 mo, TEM (Wlstar) mcreased thtckness of alveolar septa by 6 mo, fibrous (1987)
pleural thtckenmg by 19 mo
1,500 08 Contmuous, LM NS 4 Rat MlIDmal changes shght enlargement of alveoh and alveolar Freeman et al
hfetIme weeks (Sprague- ducts, some roundmg of bronchtal and bronchtolar eplthehal (1966)
(up to 33 mo) Dawley) cells, Increase In elastIc fibers around alveolar ducts
1,880 10 Contlnuotis, LM M NS Monkey Shght to moderate mterstItlal pneumoma consIdered to be Fenters et al (1973)
16 mo TEM (Sqmrrel) result of Intercurrent dIsease rather than NOz exposure
Intercurrent dIsease may have masked effects of N02
1,880 10 6 hlday, LM M NS Dog At 1 ppm 6 mo no leSIons observed, no pathology, Wagner et al
9,400 50 5 days/week, (Mongrel) 12 mo dIlated alveoh and alveolar ducts, 18 mo dIlated (1965)
up to 18 mo alveoh, edema, thtckenmg alveolar septa by chrome
mflammatory cells No dIfferences between exposed and
control dogs, so mtercurrent dIsease may have been present
Intercurrent dIsease may have masked effects of N02 At
5 ppm 6 mo no pathology, 12 mo dIlated alveoh and
alveolar ducts, 18 mo edema, congestIon, and thtckened
alveolar septa due to Inflammatory cells
1,880 10 6 hlday, LM M NS GUInea EVIdence of mtercurrent dIsease that may have masked N02 Wagner et al
5 days/week, pIg morphologIcal effects (1965)
18 mo (Enghsh)
TABLE 13-11 (cont'd). EFFECTS OF CHRONIC EXPOSURE TO NITROGEN DIOXIDE ON LUNG MORPHOLOGY
NO z ConcentratIon
SpecIes
3
p.g/m ppm Exposure Procedures Gender Age (Stram) Response Reference
1,880 10 7 h/day, LM M/F 14-16 Rat No lesIOns observed Subpleural Gregory et al (1983)
9,400 50 5 days/week, weeks (FIscher 344) accumulatIons of macrophages and focal
15 weeks areas of hypennflatIOn at 5 ppm or base +
peak exposures No change m mean lmear
1,880 10 Base 7 h/day, mtercepts
base + base + 5 days/week,
9,400 50 2 1 5-h peaks/day
peak peak 15 weeks
3,760 20 Contmuous, LM NS 4 weeks Rat Loss of cIha m termmal bronchIoles, Stephens et al
2 years TEM (NS) abnormal cdIOgenesIs, crystalloId (1971a,b)
mc1usIOns m bronchIolar epIthehal cells,
mcreased thIckness of collagen fibnls and
basement membrane m termmal
.- bronchIoles
~
I
\0
3,760 20 Contmuous, up to LM M 4 weeks Rat Loss of Clha by 72 h, decreased number of Stephens et al (1972)
......:J 12mo TEM (Wlstar) cIhated cells by 7 days, hypertrophy and
hyperplasIa of bronchIolar eplthehum and
an "apparent" return to nonnal after
21 days exposure
3,760 20 ContInuous, up to LM M 4 weeks Rat No change m turnover of termmal Evans et al (1972)
360 days (Wlstar) bronchIolar eplthehal cells, mcrease m
turnover of Type 2 cells m penpheral
alveoh by 1 day, but normal by 7 days
3,760 20 Contmuous, LM M/F NS Monkey (Macaca BronchIolar eplthehal hypertrophy, Funosl et al (1973)
14mo speclOsa) especIally adjacent to alveolar ducts,
change to CUbOIdal cells m prOXimal
bronchIolar eplthehum
M NS Rat MIDlmal effect some termmal bronchIolar
(Sprague-Dawley) epIthehal hypertrophy
TABLE 13-11 (cont'd). EFFECTS OF CHRONIC EXPOSURE TO NITROGEN DIOXIDE ON LUNG MORPHOLOGya
N02 Concentration
Species
3 Exposure Procedures Gender Age (Stram) Effects Reference
p.g/m ppm
3,760 20 ContInuous, LM M NS Rat Alveolar distension, especially near alveolar duct Freeman
lIfetIme (up (Sprague- level, mcreased vanabllIty m alveolar Size, et al (1968b)
to 763 days), Dawley) hypertrophy m termmal bronchiolar cells, no
08 ppm for mflammatIon
69 days, then
20ppm
7,520 40 Contmuous, LM M 4 weeks Rat Bronchial epithelIal hyperplasia Haydon et al
16 weeks (Sprague- (1965)
Dawley)
9,400 50 6 h/day, LM M NS Mouse No leSions observed Wagner et al
5 days/week, (C57BL/6, (1965)
14mo Webster)
...... 9,400 50 4-75 h/day, LM NS NS Gumea pig Some dilation of termmal bronchioles, tracheal Balchum
wI
\0 5 days/week, (New mflammatIon, desquamative pneumomtIs et al (1965)
00
55mo England)
17,900 95 7 h/day, LM M m utero Rat No histological changes, no effects on mean lmear Mauderly
5 days/week, and 6 mo (Fischer mtercepts et al (1987)
6mo 344) Mauderly
(1989)
17,900 95 7 h/day, LM M 18 weeks Rat MImmal mflammatory response, rmld hyperplaSia of Mauderly
5 days/week, (Fischer bronchiolar epithelIum extendmg mto proXimal et al (1989,
24mo 344) alveolI SlIght thIckenmg of termmal bronchiolar 1990)
walls No change m mean lmear mtercept
EmphysemIc rats had slrmlar response
aLM = Light tnlcroscopy

TEM = TranStnlSS10n electron tnlcroscopy
M = Male
F = Female
NS = Not stated
The large degree of mterspecles varlability m responsIveness to N02 IS clearly eVIdent
from those few studIes (Table 13-9 and 13-10) where dIfferent specIes were exposed under
Identical conditIOns and exammed usmg the same methods (Wagner et al , 1965; Funosl
et al , 1973, Azoulay-DupUls et al ,1983) Such dlfferences m response may be due to
mherent specIes dlfferences m sensItivIty of cells at target sItes, to dlfferences m effective
dose of N02 reachmg target sItes due to anatoIDlcal and ventllatory drrferences, or to a
combmatlOn of these factors Thus, the chOIce of expenmental antmal affects the magmtude
of changes observed followmg exposure MorphologIcal lesIOns may not be detectable m
some speCIes by less senSItive methods of evaluatIOn However, m most cases, the sItes and
types of morphologIcal lesIOns produced by N02 mhalailon are slIDl1ar m all specIes when
effectlVe concentratIOns are used and appropnate tissues are exammed usmg senSItive
methods In drrect comparlsons, the gumea pIg, hamstel, and monkey all appear to be more
severely affected by eqUlvalent exposure to N02 than IS the rat, whlch IS the most commonly
used expenmental antmal
Sites Affected
The extent of mJury to an mdlvldual cell IS related to both the senSItIvIty of that cell
type and the dose of N02 dehvered to the sIte OCCUpIed by that cell Among cells of a
specIfic type, several factors (e g , the matunty of the cell and ItS antlOXldant capacIty) may
mfluence ItS senSItivIty The dose of N02 to whlch an md1vldual cell IS exposed IS
determmed by the concentratIOn of N02 at the sIte m the respIratory system occupIed by that
mdlvldual cell and the surface area of that cell that IS exposed to that concentration Thus,
senSItivIty of cells and the magmtude of morphologIcally detectable mJury are not the same
In lungs, morphologIcal eVIdence of mJury IS first noted, and IS usually most severe, m
the eplthehum of the centnacmar regIOn (1 e , at the JunctIOn of the conductmg arrways WIth
the gas exchange area) The centnacmar reglOn mcludes. the termmal or respIratory
bronchloles and the lIDmedmtely adjacent alveoh, often called proXlIDal alveoh Wlthm this
reglOn, those cells that are most senSItive to NOrmduced mJury are the ciliated cells of the
bronchlolar eplthehum and the Type 1 cells of the alveolar eplthehum
Ciliated cells located m termmal or respIratory brouchloles lose some or all of therr
cilia or become necrotic and are shed from the eplthehurn Nonsecretory bronchlOlar cells
13-99
(Clara cells m rodents) appear less sensItive to N02 , but they do lose secretory granules and
surface projections With contInued exposure, nonciliated bronchIolar cells mcrease m
number (hyperplaSia) and m sIZe (hypertrophy) These cells are the progemtor cells for
replacement of the ciliated cells that were sloughed from the arrway epIthelIum Followmg
chronic exposure, there IS also mcreased loss of cilia both m bronchIoles and more proXImal
conductmg arrways Remammg cilia may have abnormal structure and locatIOn
In centnacmar (prOXImal) alveolI, but not m alveolI located at the penphery of aC1lll,
short-term (acute) exposure to N02 results m necrosIs and sloughmg of Type 1 alveolar
epithelial cells, whIch leaves the underlymg basallamma bare ThIs IS followed by
prohferation of, and replacement by, Type 2 alveolar epithelIal cells, whIch are progemtor
cells for Type 1 cells Because Type 2 cells have a cubOidal shape, rather than the squamous
shape of Type 1 cells, thIs may result m a few centnacmar alveolI With a thIckened epithelIal
component of the arr-blood bamer
BronchIolar epithelIum was observed m centnacmar alveolI by Mauderly et al (1990)
in rats exposed to 17,900 p..g/m3 (95 ppm) N02 , 7 h/day, 5 days/week for 24 mo
In addition to the usually descnbed mild hyperplaSia of the termmal bronchIolar epithelIum,
they reported an extensIOn of bronchIolar cell types mto centnacmar alveolI, glvmg the
appearance of respIratory bronchIoles whIch was not observed m controls They also
reported a slIght progressIOn of thIs leSIOn, but not of the epithelIal hyperplaSia NettesheIm
et al (1970) descnbed thIs leSIOn as lIalveolar bronchIolIZatIon and reported It m mIce
ll
chromcally exposed to a synthetIC smog Although It may appear to be only a slIght

modIfication of alveolar epithelIal hypertrophy, replacement of one type of epIthelIum by
another (e g , alveolar by bronchIolar), and the progression of the lesion With mcreasmg
length of exposure, may have qUIte dIfferent consequences
Although the centnacmar epithelIal changes have received the most attention, as they
are easily seen and quantitated usmg a vanety methods, there have also been reports of
changes m the centnacmar basallamma and connectIve tissue mterstItmm that underlIe the
epithelIum. In earlIer studies, Freeman et al (1969, 1972) reported prohferatlOn of new
connective tissue at the Junction of tennmal bronchIoles and alveolar ducts from rats exposed
to 28,200 p..g/m3 (15 ppm) N02 These mterstItIal changes perSisted followmg postexposure
"recovery" penods of up to 52 weeks In more recent studies, Kyono and KaWaI (1982)
13-100
reported morphometnc mcreases m the mterstItmm followmg contmuous exposure of
I-mo-old rats to 940, 5,640, and 18,800 jtg/m3 (05, 3 0, and 100 ppm) N02 for 1 mo
Chang et al (1986), m a TEM morphometnc study of centnacmar alveoh from rats exposed
to an urban pattern consIstmg of a basehne of 940 or 3,760 jtg/m3 (05 or 20 ppm) wIth I-h
peaks tWIce a day to 3 tImes these levels N02 , reported an mcrease m mean volume, but not
number, of mterstItIal fibroblasts and m volume of mterstItIal matnx These mterstItIal
changes were statistically sIgmficant m rats exposed to the lower concentratIOn (940 jtg/m3
wIth peaks to 2,820 jtg/m3 ) N02 for 6 weeks In the same study, they also reported
mcreased surface densIty of the basement membrane (basallamma) m the rats exposed to
3 3
3,760 jtg/m (2 0 ppm) basehne wIth peaks to 11,300 p,g/m (6 0 ppm) for 6 weeks Kubota
et al (1987) reported morphometnc mcreases m the mterstItmm of rats exposed to
3 3
752 jtg/m (04 ppm) for 27 mo and to 7,520 jtg/m (40 ppm) for 18 mo These quahtatIve
and quantitative morphologIcal studIes correlate well wIth the mcreased collagen synthesIs
rate m N02-exposed rats discussed m SectIOn 13 2 2 2 on lung bIOchemIstry
Chromc exposures may result m arrspace enlargement charactenstIc of anImal models
of emphysema In most, but not all cases, tissue destructIOn IS not present, so the conditIOn
does not meet the 1985 NatIOnal Heart, Lung and Blood Institute (NHLBI) de:fImtIOn of
human emphysema (National Institutes of Health, 1985) A detaIled diSCUSSIOn of
emphysema m relatIOn to N02 exposure follows the dIScussIon on susceptIbility to NOT
mduced morphologIcal changes
Progression and Regression of Morphologlcal Changes

The temporal progressIOn of early events due to N02 exposure focusmg on centnacmar
epIthehal cells has best been descnbed m the rat (e g , Evans et al , 1972, 1973a, 1974,
1975, 1977, Freeman et al , 1966, 1968b, Stephens et al , 1971a, 1972) The earhest
alteratIons resultmg from exposure to concentratIOns of >3,760 jtg/m3 (20 ppm) are seen
Withm 24 to 72 h of contmuous exposure and mc1ude desquamatIon of the Type 1 cells and
ciliated bronchiolar cells, resultmg m bare basallamma m the centnacmar regIOn and
accumulatIOn of fibnn m small arrways AccumulatIOns of AMs were also reported
EpIthehal reparr by replacement of destroyed cells begms Withm 24 to 48 h of contInuous
exposure The new cells in the bronchioh are denved from nonciliated cells, whereas m the
13-101
alveoh, the damaged Type 1 cells are replaced wIth Type 2 cells Cell renewal, as measured
by mcoxporatIon of tntIated thy1ll1dme eH-thymidme) by Type 2 cells, IS observed WIthIn
12 h after the InItIal N02 exposure Dunng contmued exposure, the number of 3H-thymidme
labeled cells becomes maxImal by about 48 h and decreases to preexposure levels by about
3
6 days (Evans et al ,1975) If exposure levels are very hIgh (> 18,800 p,g/m , 10 ppm),
however, resolutIon and return to normal-appearmg centnacmar epIthehal cells may be
delayed or prevented, and the presence of mcreased numbers of Type 2 cells may be
prolonged or permanent
The resolutIon of N02-mduced morphologIc changes may be complete after the
exposure ends or some leSIOns may remam, dependmg upon details of the exposure regIme,
species of anImal studIed, and the methods of evaluatIOn For example, Rombout et al
3
(1986) exposed rats to 20,000 p,g/m (106 ppm) contmuously for 28 days By LM and
SEM, bronchIolar epIthehal hypexpiasia appeared totally resolved beyond 4 days after
cessation of exposure, and hypertrophy was totally resolved after 16 days of postexposure
recovery After a I-week postexposure penod, all changes seen by LM and SEM appeared
completely recovered However, some abnormal cilia were observed by TEM 4 weeks after
the exposure ended and some remnants of the N02-mduced leSIOns were stIll seen by TEM
56 days after the exposure ended Kubota et al (1987) exammed the tIme course of alveolar
epithehallesIOns m small groups of rats exposed to 7,520 p,g/m3 (40 ppm) N02 , 24 hI day
for up to 27 mo. In the quantItatIve or morphometnc portIOns of thIs study, Kubota et al
(1987) dehberately aVOIded centnacmar or proXImal alveoh, so the changes they descnbe
represent those in the overall gas exchange area rather than only those m the most mvolved
alveoh (I.e, centnacmar or proXImal alveoh), whIch are the only alveoh usually studIed
One phase, whIch lasted for 9 to 18 mo of exposure, conSIsted of a decrease m number and
an increase m cell volume of Type 1 epIthehum, an mcrease m the number and volume of
Type 2 cells, and an mcrease m the relative ratio of Type 2 to Type 1 cells A second
phase, whIch occurred at 18 to 27 mo of exposure, showed some recovery of alveolar
eplthehum Thus, eplthehal changes tend to resolve, at least partIally, dunng contmued
chronic exposure to low concentratIons and to resolve rapIdly dunng postexposure penods
Changes in the mterstItlUm, the basallamma and connectIve tIssues under the
eplthehum, develop much more slowly and resolutIon, If It occurs, IS prolonged In the two
13-102
studIes of eplthehum dISCUSSed above, Rombout et al (1986) reported TEM: observatIOns of
3
mcreased collagen and elastm m the mterstItmm of rats ,exposed to 20,000 p,g/m (10 6 ppm)
for 28 days, and Kubota et al (1987) reported morphometnc mcreases of the mean alveolar
3
arr-blood bamer m rats exposed to 752 p,g/m (0 4 ppm) for 27 mo and m rats exposed to
7,520 p,g/m3 (40 ppm) for 18 mo These authors consIdered the mterstItIal changes
progreSSIve and leadmg to fibroSIS, rather than resolvmg as do eplthehal changes
In summary, epIthehal changes have been the focus of most studIes Eplthehal changes
progress rapIdly and regress rapIdly and relatIvely completely both durmg chromc exposures
and durmg postexposure penods In contrast, changes ill the mterstItmm have been the
subject of fewer studIes, even though sIgmficant mterslltlal changes have been reported
followmg chromc exposure to low concentratIons of N02 InterstItIal changes develop more
slowly, may progress durmg exposure, and regress slowly, If at all, durmg postexposure
penods
Effects of Nitrogen Dioxule as a Function of Exposure Pattern

Although the extent and degree of morphologIC alteratIOns ill the eplthehum and
mterstItmm appear to correspond to N02 exposure concentratIons, httle IS actually known
about effects of other modIfymg factors, such as the exposure duratIon and concentratIOn
relatIOnshIp, short-term peaks m concentratIOn, or cycles of exposure and postexposure
The relative roles of C and T m response to subchromc exposure were exammed by
3
Rombout et al (1986) These researchers exposed rats to 1,000 to 5,000 p,g/m (053 to
3
2 66 ppm) N02 for up to 28 days, or to 20,000 p,g/m (10 6 ppm) for eIther 6 h, 6 h/day for
28 days, or 24 h/day for 28 days They concluded that concentratIon played a more
Important role m mducmg leSIOns than dId exposure duratIOn, as long as the product of
eXT was constant, and that the effect of concentratIon was stronger WIth mtermlttent
exposure than WIth contmuous exposure They also reported that contmuous exposure was
Important to the development of strong AM response These fmdmgs are SImIlar to those
usmg the mfectIVlty model dIscussed m SectIOn 13 2 2 1
AmbIent concentratIons of N02 are often characterIZed by tranSIent peaks supenmposed
upon a lower and relatIvely constant basehne concentratIon, unhke expenmental exposures,
whIch are most commonly at a constant concentratIon The morphologIcal effects of
13-103
exposure patterns mvolvmg transient peaks were exammed m a number of studIes
However, some studIes lacked a group exposed to the constant baselme concentratlon for
companson WIth those exposed to the baselme concentratIon plus tranSIent peaks Thus, the
findings of these studIes do not elUCIdate the relatlve contnbutlons of the baselme and peaks
to the responses
A study that mc1uded a baselme concentratIOn group was that by Gregory et al (1983)
They exposed rats for 7 h/day, 5 days/week for up to 15 weeks to atmospheres consIstmg of
the followmg concentratIons of N02 (1) 1,880 p,g/m3 (1 0 ppm), (2) 9,400 p,g/m3
(5.0 ppm), or (3) 1,880 p,g/m3 (1 0 ppm) WIth two I 5-h peaks of 9,400 p,g/m3 (5 0 ppm)
per day (1 e , animals were exposed to N02 at 1,880 p,g/m3 for 1 5 h, 9,400 p,g/m3 for
1.5 h, 1,880 p,g/m3 for 3 h, 9,400 p,g/m3 for 1 5 h, and 1,880 p,g/m3 for 05 h) No change
in lung weIght was found m any exposure group After 15 weeks of exposure, routlne LM
Instopathology showed mffilffial effects, WIth focal hypennflatIOn and areas of subpleural
accumulahon of macrophages found m some of the ammals exposed eIther to a constant level
of 9,400 p,g/m3 or to 1,880 p,g/m3 WIth the 9,400-p,g/m3 peaks Because the 1,880 p,g/m3
group WIthout peak exposures dId not have these changes, the peak exposures appear to have
contnbuted to mcreased morphologIcal effects Changes were also reported m the lung
biochemIStry of the N02-exposed ammals as dISCUSSed m Sectlon 13 2 2 2
Miller et al (1987) exposed mICe for 1 year-(23 h/day, 7 days/week) eIther to a
contlnuous baselme concentratlon of 380 p,g/m3 (0 2 ppm) N02, or to tins baselme onto
which was supenmposed, for 5 days/week, two I-h peaks (gIVen m the mommg and
afternoon) of 1,470 p,g/m3 (0 78 ppm) MorphologIC exammatlon (LM) performed after
32 and 52 weeks of exposure, and then 1 mo after all exposures had ended, revealed no
treatment-related leSIOns in eIther exposure group, although host defense and pulmonary
funchon changes were noted (Sechons 13 2 2 1 and 13 223)
,
Crapo et al (1984) and Chang et al (1986) reported on the NOTmduced changes m
the centnacinar (proxnnal) alveolar regIOn of I-day and 6-week-old rats exposed for 6 weeks
to a baselme concentrahon of 940 or 3,760 p,g/m3 (05 or 2 0 ppm), 23 h/day for
7 days/week onto whIch were supenmposed two daily I-h peaks of three hmes the baselme
concentrahon for 5 days/week The rats were StudIed usmg TEM morphometnc analyses
In the older rats (6 weeks old at the start of the exposure) at both exposure levels, Type 2
13-104
3
cells mcreased m total volume and mean cell volume, bUlt not in number/mm , and they
occupIed a larger percentage of the basallamma (basement membrane) In the older rats
exposed to 3,760 p,g/m3 , but not 940 p,g/m3 , wIth peaks. Type 1 cells had a larger total
volume and mcreased numbers/mm3 , wIth a smaller mean surface area The percentage of
the basallamma OCCUpIed by Type 1 cells was decreased m older rats of both exposure
groups They also had mcreased total volume and number of AMs, but the mean cell
volume was mcreased only m the 940-p,g/m3 group Thl~ total volume of mterstItIal matnx
and of fibroblasts mcreased m the 940-p,g/m3 older group, but not the 3,760-p,g/m3 older
group The number of mterstItIal fibroblasts dId not change, but theIr mean cell volume
mcreased m the older groups Both age groups of rats reacted m a generally sImIlar manner
Pulmonary functIOn changes m SImiliarIly exposed anIIDaUs were assessed by Stevens et al
(1988), mdlcatmg a correlatIOn between decreased compliance and thIckenmg of the alveolar
mterstitmm (SectIOn 13 2 2 3)
The termmal bronchIolar regIOn of these rats was also exammed morphometncally
(Chang et al., 1988) The lower exposure level caused no effects At the hIgher level, there
was a 19 % decrease m ciliated cells per umt area of the eplthehal basement membrane and a
reductIOn m the mean surface area of 29 % m the remammg cilia m the hIgh exposure group
In the Clara cells, the SIZe of the dome protrusions were decreased, glvmg the bronchIal
eplthehum a flattened appearance
Susceptib,,[zty to Nztrogen Dzoxule-Induced Morphologic:al Changes

Susceptibility to morphologIcal effects may be mflUlenced by many factors Some
factors that have been StudIed mclude age, compromIsed lung functIOn, and acute mfectIOns
Age of the ammal at the tIme of exposure may be responSIble for some of the vanability m
morphological response seen m the same specIes exposed to comparable concentratIOns
Stephens et al (1978) exposed rats from 1 to 40 days of age to 26,320 p,g/m3 (14 ppm) N02
for 24, 48, or 72 h Usmg LM and TEM, they found only mmor mJury and loss of cilia m
termmal bronchIoles of rats exposed before weanmg at 20 days After weanmg, there was a
progreSSIve mcrease m cellular response m both termmal bronchIoles and alveoh, WIth a
plateau reached at about 35 days of age Other mvestIgators expanded on these observations
usmg lower concentratIOns
13-105
Azoulay-Dupms et al (1983) exposed both rats and gumea pIgS aged 5 to ~ 60 days to
3,760 or 18,800 p.,g/m3 (2 or 10 ppm) for 3 days No rats of eIther age dIed dunng the
exposure, but m the gumea pIgS exposed to 18,800 p.,g/m3 (10 ppm), mortahty mcreased wIth
increasing age from 4 % m the 5-day-old group to 60 % m the 55-day-old group and 67 % m
the mothers In both specIes, older anImals showed greater effects of exposure than dId the
newborns. At 3,760 p.,g/m3 (2 0 ppm), no hIstologIcal effects were observed m rats of any
age. Neither dId exposure of gumea pIgS < 45 days old to thIs level produce hIStologICal
effects The 45-day-old gumea pIgS exposed to 3,760 p.,g/m3 had thIckened alveolar walls,
alveolar edema, and mflammatIOn, whereas anImals older than 45 days showed SImilar, but
more frequent, alteratIons that seemed to mcrease WIth age The mother gumea pIgS exposed
to 3,760 p.,g/m3 had focal loss of cilia m bronchIoh At 18,800 p.,g/m3 , only rats ~45 days
old responded, confIrmmg the observatIOns of Stephens et al (1978) Rats m thIs group had
fibrinous depOSItS m alveoh and focal loss of cilia m bronchIoles Gumea pIgS of all ages
were affected by exposure to 18,800 p.,g/m3 All gumea pIgS m that exposure group had loss
of cilia m bronchIoles and the trachea, edema, an mcrease m number of Type 2 cells, and
alveolar mflammatIOn Gumea pIgS greater than 60 days old and mother gumea pIgS exposed
to 18,800 p.,g/m3 had the most severe leSIOns, mcludmg fOCI of mterstItIal pneumoma and
emphysema, presumably enlarged arrspaces ThIs study clearly demonstrated the relatIve
insenSItivIty of newborn rats and gumea pIgS to N02 and the greater senSItIVIty of gumea
pigs compared to rats of the same age The mvestIgators noted that the "lungs of newborn
guinea pIgS at bIrth were more mature than newborn rat lungs," whIch may explam some,
but probably not all, of the specIes dIfferences m response of SImilarly aged rats and gumea
pIgS (See SectIon 13 2 2 1 on host defense mechamsms )
An extenSIve senes of exposures deSIgned to relate morphometnc changes m the arr-
blood barrier to age was performed by Kyono and KaWaI (1982) Rats at 1, 3, 12, and
21 mo of age were exposed contmuously for 1 mo to 207, 865, 5,260, or 16,500 p.,g/m3
(0.11, 0.46, 2 8, or 8 8 ppm) N02 LIght and electron miCroscopIC analyses were used to
evaluate the exposure effects Vanous morphometnc parameters were assessed, mcludmg
anthmetic mean thIckness of the arr-blood bamer (1 e , the thIckness of the tIssue between
the surfaces of the alveolar and capillary lumens) and the volume denSIty of vanous alveolar
wall components Because these mvestIgators were mterested m effects on the overall gas
13-106
exchange area, they dehberately excluded centnacmar alveoh, the sIte of major N02 damage,
from the morphometnc analyses The anthmetIc mean thIckness of the arr-blood bamer
tended to mcrease m an exposure-dependant manner m all age groups The anthmetIc mean
thIckness of the arr-blood bamer was sIgmficantly illcreased m all age groups ill rats exposed
to 16,544 /1-g/m3 or 5,264 /1-g/m3, wIth the exceptIOn of 12-mo-old rats, and m 3-mo-old rats
3
exposed to 207 /1-g/m Response of anthmetic mean thIckness to N02 was greatest ill the
I-mo-old rats, decreased from 1 to 12 mo and illcreased agam at 21 mo The total
illterstItmm (matnx and cells) mcreased wIth N02 concentratIOns over 5,264 /1-g/m3 and was
a major component of the mcrease m volume densIty of alveolar wall tIssue Alveolar
Type 1 and 2 cells showed vanous degrees of response, dependmg on both age at onset of
exposure and exposure concentratIOn In general, the msponse of each lung component dId
not always show a sImple concentratIOn-dependent mcrease or decrease, but suggested a
multIphasIc reactIon pattern The illvestIgators suggested that part of thIs observatIOn may
have been due to varymg stages of Imparrment and reparr Further, they concluded that age-
dependent differences m response to the same concentratIOn of N02 occurred, and that the
degree of response decreased WIth agmg from 1 to 12 mo, after whIch It illcreased at 21 mo
ThIs study by Kyono and Kawau (1982) IS especIally Important, as It IS one of the few
studIes that examilled the mterstItmm, and all studIes of the mterstItmm (Chang et al , 1986,
Kubota et al , 1987) have reported illcreases ill one or both components of the mterstItIum
These morphologIcal studIes correlate well WIth reports of mcreased collagen synthesIs rates
dIscussed ill SectIon 13 2 2 3 on lung bIochemIstry
A pOSSIble concern m assessmg N02 tOXICIty IS the effect on adults from exposure
dunng early hfe, espeCIally dunng the penod of lung development Unfortunately, there are
few data to allow evaluatIOn of thIs Mauderly et al (1987) compared developmg rats
(exposure began ill utero) and 6-mo-old anImals exposed to 17,900 /1-g/m3 (95 ppm) N02 for
7 h/day, 5 days/week for 6 mo Lung development, as detennmed at young adulthood, was
not sIgmficantly affected by earher exposures There was no sIgmficant LM eVIdence of
lung mJury m eIther group of anImals, and there were no exposure-related differences ill the
morphometnc parameters studIed (1 e , alveolar mean lmear mtercept or the mternal surface
area of the lungs) Thus, the avaIlable data base mdIca1es that alveoh of N02-exposed rats
13-107
develop normally, but does not provIde mformatIon concermng other morphologIcal
parameters of lung growth and development
Chang et al (1986, 1988) exposed I-day- or 6-week-old rats for 6 weeks to a baselme
of 940 p,g/m3 (05 ppm) N02 for 23 h/day, 7 days/week, wIth two I-h peaks (gIven m the
monung and afternoon) of 2,820 p,g/m3 (1 5 ppm), 5 days/week, and exammed the proXImal
alveolar and the termmal bronchIolar regIOns The detaIled results are descnbed m the
prevIous sectIon The older anImals had an mcrease m the surface denSity of the alveolar
basement membrane that was not found m the younger anImals Although both age groups
responded in a generally SImIlar manner, the 6-week-old anImals seemed to be generally
more susceptIble to mJury than were the l-day-old anImals, as they had more vanables that
were sigmficantly dIfferent from theIr control groups Although there was no qualItatIve
evidence of morpholOgical mJury m the termmal bronchIoles of the younger rats, there was a
19% mcrease m the average ciliated cell surface that was not eVIdent m the older rats The
authors also reported a 13 % mcrease m the mean lummal surface area of Clara cells m the
younger anImals versus control anImals of the same age
Although the mvestIgators concluded that the 6-week-old rats were as senSItIve or more
sensitive than l-day-old rats, an alternatIve conclUSIOn that the reverse IS true cannot be ruled
out by this study The l-day-old rats were probably not senSItIve to the effects of N02 untIl
they were 20 days old (Stephens et al , 1978, Azoulay-Dupms et al , 1983), after whIch theIr
sensitIVIty would mcrease untIl they were 35 days old Thus, the effects measured m the
I-day-old rats may have resulted OlIly from the last 22 days of exposure rather than the entIre
42 days of effectIve exposures of the older rats If the measured effects were essentIally the
same as the mvestIgators concluded, the l-day-old rats would be more senSItIve than the
older anImals as they responded quantItatIvely SImIlarly to about one half the exposure tIme
as the older anImals Another alternatIve conclUSIOn IS that the l-day-old rats, due to the
20 nonreactIve exposures, were m a dIfferent phase of damage and reparr at the tIme of
exammation The exposure method may also have had an mfluence Pnor to weanmg,
neonates are exposed WIth theIr mother, often on beddmg The resultmg huddlmg behaVIOr
and reactivity of N02 WIth the beddmg could affect exposure of the neonates
In general, It seems that neonates, specIfically pnor to weanmg, are reSIstant to the
morphological effects of N02 , and that responSIveness mcreases WIth age after weanmg untIl
13-108
a plateau IS reached Furthennore, the responsIveness of mature ammals appears to declme
somewhat wIth age, untu an mcrease m responSIVeness occurs at some pomt m senescence
However, the morphologIcal response to N02 mammals of dIfferent ages mvolves
sunuantIes m the cell types affected and m the nature of the damage mcurred Age-related
dIfferences occur m the extent of damage and m the tune requrred for reparr, the latter takmg
longer molder ammals The reasons for age dIfferences m sensItIVIty are not known, but
may mvolve dIfferences m met, vanable senSItIVIty of target cells durmg dIfferent growth
phases, or dIfferences m sIte-specIfic doses
PreeXlstmg resprratory dIsease as a susceptIbility factor has been StudIed rarely m
ammals, however, an ammal model of emphysema (1 e , WIth enlarged arrspaces but not
arrspace wall destructIOn) has been used Lafuma et al (1987) exposed both nonnal and
elastase-mduced emphysematous hamsters to 3,760 p,g/m3 (20 ppm) N02 , 8 h/day,
5 days/week for 8 weeks and analyzed lung tIssue wIth morphometnc assays The
emphysematous lesIOns produced by elastase appeared to be aggravated by subsequent
exposure to N02 When compared to hamsters treated WIth elastase and exposed to clean
arr, elastase-treated hamsters exposed to N02 had mcrea ses m mean lmear mtercept and
pulmonary volume (volume of fixed lung as measured by salme msplacement) and a decrease
m mtemal alveolar surface area The mvestIgators suggested that these results may unplya
role for N02 ill enhancmg preexistmg emphysema However, there no changes m pulmonary
mechamcs of the ammals (SectIOn 13 2 2 3) In a more comprehensIve, longer tenn study,
Mauderly et al (1989, 1990) exposed elastase-treated and control rats to 17,900 p,g/m3
(9 5 ppm) N02 , 7 h/day, 5 days/week for 2 years or to ftltered arr They evaluated
pulmonary functIOn, clearance, lung collagen, BAL, and htstopathology (by LM), mcludmg
quantItatIve methods for alveolar SIZe and mtemal surface area There were no add1tIve
morphologIcal effects of N02 on the emphysematous rat lungs In summary, It appears that
elastase-mduced emphysema m rats does not mcrease susceptIbility to N02 exposure, but that
the sunuar procedures usmg hamsters may result m enhancement of the emphysema
Acute mfectIous lung dIsease before and dunng N02 exposure could also affect
morphologIc responses to N02 exposure Fenters et al (1973) challenged squrrrel monkeys
WIth an mfluenza vrrus at vanous tunes durmg contmuous exposure to 1,880 p,g/m3
(1 0 ppm) N02 for 16 mo, and compared the response to that seen mammals not challenged
13-109
but exposed to NOz Only the vIrus-challenged ammals showed responses to NOz , wInch
included tInckening of broncInal and broncInolar eplthehum The mvestIgators also reported
"slIght emphysema" m vrral-challenged exposed monkeys However, the lungs were not
fixed in a manner appropnate for the diagnosIs of emphysema usmg the current defimtIOn for
human emphysema (NatIonal InstItutes of Health, 1985) See the followmg subsectIOn
addressing NOz-mduced emphysema m expenmental ammals ThIs study suggests that acute
lung dIsease may mcrease responses to NOz The effects of NOz on InfectIvIty due to
challenges WIth microorgamsms are dIscussed m SectIon 13 2 2 1
Emphysema Followzng Nitrogen Dioxide Exposure

In evaluatIng the reports of emphysema followmg NOz exposure, It IS necessary to
consider both the current and preVIOUS defimtIons of emphysema and to try to determme the
morphologIcal lesIOns the mvestIgators observed that led them to the dIagnosIs of
emphysema Several professIOnal groups have presented defimtIOns of emphysema Those
definitions have changed sIgmficantly from those proposed by a group of BntIsh phySICIans
meeting under the auspIces of elba m 1959 (Fletcher et al ,1959) Presumably, both
investIgators who wrote manuscnpts and reVIewers for Journals that publIshed manuscnpts
concerning emphysema m NOz-exposed ammals were aware of, and used, the latest
definition at the time the manuscnpts were wntten and reVIewed Thus, the date of
pubhcation of the reports of effects of NOz mhalatIon relatIve to the dates of pubhcatIon of
the definitIons of emphysema must be consIdered m the diagnosIs of emphysema The most
recent de:fInItion, by NHLBI, DIVISIon of Lung DIseases Workgroup (NatIOnal InstItutes of
Health, 1985), dIfferentIates between emphysema m human lungs and anImal models of
emphysema When reports of emphysema followmg NOz exposures of ammals are to be
extrapolated to potentIal hazards for humans, the de:fInItIon of human emphysema, rather than
that for ammal models of emphysema, must be used Thus, the current de:fInItIons of
emphysema m human lungs and m ammal models are cntIcal to tIns reVIew
The report from the NatIonal InstItutes of Health (1985) first de:fmes resprratory
airspace enlargement "Resprratory arrspace enlargement IS de:fmed as an mcrease m
arrspace sIZe as compared WIth the arrspace sIZe of normal lungs The term apphes to all
vanetIes of arrspace enlargement dIstal to the termmal broncInoles, whether occurrmg WIth
13-110
or wIthout fibroSIS or destructIOn" Emphysema IS one of several forms of aIrspace
enlargement In human lungs, "Emphysema IS dermed as a condItion of the lung
charactenzed by abnormal, permanent enlargement of aIrspaces dIStal to the termmal
bronchIOle, accompamed by destructIOn of theIr walls, and wIthout ObVIOUS fibroSIS "
Destruction IS further dermed "DestructIOn m emphysema IS further dermed as
nonumformity m the pattern of resprratory aIrspace enlrurgement so that the orderly
appearance of the acmus and ItS components IS dIsturbed and may be lost" The report also
mdIcates that "DestructIon may be recogmzed by subgmss exammatIon of an mflation-rlXed
lung shce "Emphysema m anImal models was dermE'd dIfferently The stated reason for
tills dIfference m the deItmtIOns of emphysema m humans and m anImal models was
"In order to foster the development of new knowledge, ammal models of emphysema are
dermed as norurestnctIvely as pOSSIble An anImal model of emphysema IS dermed as an
abnormal state of the lungs m willch there IS enlargement of the aIrspaces dIStal to the
termmal bronchtole Atrspace enlargement should be determmed qualItatively m appropnate
specImens and quantitatively by stereologlC methods" Thus, mammal models of
emphysema, aIrspace wall destructIOn need not be present "Appropnate specImens"
presumably refers to lungs rlXed m the mflated state and IS slffillar to the 1962 Amencan
ThoracIc SOCIety CommIttee's Iequrrement for tissue rlX.ltIon ThIs document states "It IS
stIll not clear whether the aIrspace enlargement of age IS due to age alone or to the
combmatIon of age and envIronmental illstory, but the occurrence of these changes m nearly
all subjects suggests that the changes are normal" (Meneely et al ,1962) Control ammals of
the same age as the expenmental anImals appear necessary to aVOId potentIal confuSIOn due
to age ThIs NatIOnal Institutes of Health commIttee also noted that, to date, anImal models
of emphysema fall mto two general classes "The rIrst class centers on testmg the
pathogemclty of agents suspected of bemg relevant to the geneSIS of emphysema, models
produced by N02 , cadmIUm, and tobacco smoke are examples of tills type The second class
of models IS analytIcal, for testmg specIfic hypotheses of the pathogenesIs of emphysema "
Both classes of studIes are m tills reVIew
These derlllitIons of emphysema m human lungs and of anImal models of emphysema
are sIgmficantly dIfferent from the 1959 Clba derlllitIons (Fletcher et al ,1959) One of the
lastmg benefits of these Clba derlllitIons was the development of the concept that emphysema
13-111
should be defined m tenns of morbId anatomy rather than altered phySIOlogy or clmIcal
observatlOns (Fletcher and Pnde, 1984) The Meneely et al (1962) de:fImtlOn contmued that
concept and expanded on the most useful mstruments for morphologIcal exammatIon of
properly fIXed lungs All of the defimtlOns smce 1959 have requIred that lungs be dIstended
and fIXed before they are cut so the arrspaces can be exammed m the mflated state
Thus, m revIewmg reports of emphysema followmg expenmental N02 exposure,
Important consideratlOns mclude (1) whether the tissue was fIXed m an mflated state,
(2) whether airspaces distal to the tennmal bronchiole were enlarged beyond nonnal and
whether that enlargement was detennmed quantitatively by stereoiogic methods (control
anImals of Identical age as exposed anImals should be used for stereoiogic studies to exclude
the pOSSIbility that arrspace enlargement was due to age), and (3) whether or not arrspace
wall destruction, as defmed by the NHLBI workgroup (NatlOnal Institutes of Health, 1985),
was present. The presence of arrspace wall destructlOn, as defmed by the NHLBI
workgroup, IS cntIcal In pubhshed reports of emphysema followmg N02 exposure,
evidence of arrspace wall destruction can only be obtamed by careful reVIew of the authors'
description of the leslOns or by exammmg the mIcrographs the author selected for
pubhcatIon In reviewmg the research reports, the authors' descnptIons of tissue changes
relative to the defimtIOn of destruction m the NHLBI workgroup document (NatIonal
InstItutes of Health, 1985) are quoted, and all pubhshed mIcrographs were exammed for
eVIdence of destructIon as defmed by this 1985 NHLBI document Because of the changes m
the defimtions of emphysema and m the methods used for evaluatIOn of results of N02
exposures, the studies are reVIewed chronologIcally
Freeman et al (1964) reported emphysema m rats exposed to 47,000 p,g/m3 (25 ppm)
N02 for 32 to 65 days Control rats of the same age were mamtamed m an IdentIcal
chamber They reported that "alveolar ducts and alveoh m expenmental rats are more
,
variable m sIZe and many are much larger than m controls" The methods for fIXatIon of the
lungs are not mentlOned, nor are the methods for evaluatmg sIZe of aIrspaces Although the
size of the lungs from exposed rats was stated to be mcreased, lung weIghts rather than lung
volumes were reported The concluslOn that emphysema was present was presumably based
on the large sIZe of the lungs and the observatlOn of enlarged arrspaces that were vanable m
SIZe, as no eVIdence of destructlOn of arrspace walls was presented In tenns of the 1985
13-112
NHLBI deftmtlOns, these leslOns appear to represent aIrspace enlargement rather than
emphysema of the type seen m human lungs
Wagner et al (1965) exposed dogs, rabbIts, gume.a pIgS, rats, hamsters, and mIce to
3
9,400 p,g/m (5 0 ppm) N02 for up to 18 mo They dId not observe morphologIcal effects
due to the exposure
Haydon et al (1965) reported emphysema m rats exposed for varymg penods from
3
51 to 813 days to 22,600 p,g/m (12 ppm) N02 , but not m other rats exposed to 7,520 or
3
1,500 p,g/m (4 0 or 0 8 ppm) N02 The lungs were fued Via the trachea m the mflated
state The alveoh were descnbed as "qUIte vanable m SIZe, bemg eIther dIlated or
collapsed" The most stnkIng mIcroscopIc abnormalIty was the "persIstent vanatlOn in SIZe
of alveoh" The dIagnosIs of emphysema was based on alveolar SIZe and vanatlOn m SIZe
and on the "grossly dIstended, arr-filled lungs that fali to collapse when removed from the
thorax" They reported "occaslOnal rupture of alveolar walls" In terms of the 1985 NHLBI
defImtlOns, these leslOns appear to be pnmanly arrspace enlargement rather than emphysema
of the type seen m human lungs
Haydon et al (1967) also reported emphysema m rabbIts exposed contmuously
(presumably 24 h/day) for 3 to 4 mo to 15,000 or 22,600 p,g/m3 (8 or 12 ppm) N02 The
lungs were fIXed Via the trachea m an expanded state They reported enlarged lungs that
failed to collapse when the thorax was opened In 100-/u,m thIck sectlOns from formaldehyde-
fIXed dned lungs, they reported "dilated" arrspaces WIth "dIstorted archItecture" In those
and other tissue preparations, they reported that the arrspaces appeared "grossly enlarged and
rrregular, whIch appears to be due to disrupted alveoh and the absence of adjacent alveolar
collapse" Thus, m appropnately fIXed lungs, they reported eVIdence of enlarged aIrspaces
WIth destructive changes m alveolar walls Although no stereology was done, thIs appears to
be emphysema of the type seen m human lungs DaVId&on et al (1967) reported phYSIOlogIC
changes m these rabbIts, but no new observatlOns related to the cntena for emphysema
Unhke theIr prevlOus reports of emphysema m rats exposed to hIgher concentratlOns of
N02 , Freeman et al (l968b) reported that rats exposed contmuously (24 h1day) to
3
3,760 p,g/m (2 0 ppm) N02 for 112 to 763 days had omy eqUIVOCal mcreases m lung weight
and dIstenSIOn of arrspaces These lungs were fIXed m a dIstended state Via the trachea
These N02 exposures dId not result m emphysema
13-113
Freeman et al (1968a) summanzed many of theIr preVIously pubhshed NO z exposures
in a manuscript resultmg from a meetmg (symposIUm) presentatIOn They agam followed the
defInition of emphysema proposed by the 1959 Clba SymposIUm and dId not present new
data relatIve to enlarged arrspaces or destructIon of alveolar walls No new InformatIon
relevant to emphysema followmg NO z exposure was presented
At the same meeting (symposIUm), Klemerman and Cowdrey (1968), reported results of
3
exposures of hamsters to 84,600 to 103,000 Itg/m (45 to 55 ppm) NO z , 22 to 23 h daIly for
10 continuous weeks. Some of the hamsters were held m room air for a 4-week
postexposure penod. The lungs were fIxed m a dIstended state by formaldehyde fumes Via
the trachea FIXed-lung volumes were estImated by water displacement FIXed-lung volumes
of exposed and postexposed hamsters were sIgmfIcantly larger than SImilar-aged controls
Although the size of alveolar spaces appeared enlarged m the exposed anImals, as compared
to sImI1arly fIXed controls, there was no eVIdence of destructIon The authors concluded that
"emphysema had not been produced ill tills expenment" These authors also reported
prevIOusly unpubhshed observatIOns that 21 to 23 h/day exposure of gumea pIgS, rabbIts, and
rats to concentratIOns of NOz resultmg m a mortahty of approXImately 35 % does not result
in emphysema due to the nondestructIve character of the tIssue response They based theIr
conclusIOns on the deflllitIon of emphysema proposed by the 1962 Amencan ThoraCIC
Society and dISCUSSed the neceSSIty for mflatIon fIXatIon of lungs usmg standard technIques
The conclusIOn that emphysema of the type seen m human lungs was not produced appears
appropriate
Gross et al (1968) studied the effects of NOz on control and pneumocomOtIC lungs
usmg hamsters and gumea pIgS Most exposures were for 2 h/day for 5 days/week The
3
NO z concentratIon appears to have been planned for 41,360 Itg/m (22 ppm), but vaned WIth
3
an inItial range of 94,000 to 169,000 Itg/m (50 to 90 ppm) durmg the fITst 4 weeks and then
3
was reduced to ranges of 56,400 to 94,000 Itg/m (30 to 50 ppm) for a total exposure penod
of 12 mo The lungs were fIXed m a distended state Via the trachea WIth formaldehyde
fumes No morphometry of arrspaces was reported The complex expenmental deSIgn and
deaths of animals durmg exposure made mterpretatIOn dIfficult In hamsters, "smce more
animals with emphysema were found m the group not exposed to NO z It can also be
concluded that long-term exposure of hamsters to NO z dId not cause emphysema" In gumea
13-114
pIgS, thts exposure resulted ill "multIple small fOCI of emphysema WIth a prevalence of only
15 % More ammals (gumea pIgS) WIthout pneumocomosls developed thts emphysema than
dId ammals WIth pneumocomosls" Both enlarged arrspaces and destructIOn of alveolar walls
can be seen m some of the pubhshed mIcrographs Although emphysema WIth alveolar wall
destructIOn was present, the relatIonshtp of the emphysema to N02 exposure IS not clear
3
Blarr et al (1969) exposed mIce to 940 p,g/m (0 5 ppm) N0 2 , 6, 18, or 24 h/day for
1 to 12 mo The method of flXatIon of the lungs IS not entrrely clear They were flXed by
lll1merSIOn, presumably by lll1merSIOn of shces of lung, whtch would be collapsed rather than
flXed m a dIstended state as recommended by the Amencan ThoraCIC SOCIety m 1962
(Meneely et al ,1962) It IS possIble that the lungs mIght have been dIstended WIth arr, the
trachea tIed and then lll1mersed ill flXatIve that would dIffuse illtO the lung through the thm
pleura Control unexposed mIce had pneumomtIs Although these mvestIgators made an
attempt to measure alveolar SIZe, they properly conclude that therr measurements "dtd not
represent quantitatively whole lung structure "Thus, the data concemmg enlarged
arrspaces IS not rehable due to the types of lung flXatIOn and alveolar morphometry They
also mentIOned alveolar "septal breakage", but not destruction as defmed by the 1985 NHLBI
deftmtIon, and the septal breakage was not a factor m the illcreased sIZe of alveoh
No eVIdence of emphysema was presented ill thts pubhcatIOn
Buckley and Loosh (1969) studted the effects of 7'5,200 p,g/m3 (40 ppm) N0 2 for 6 or
8 weeks on germ-free mIce Followmg exposure, the nllce were eIther sacnficed and the
lungs were exammed, or the mIce were Infected WIth mIcroorganIsms for addttIOnal studtes
The lungs were flXed by mflatlOn Via the trachea They made no mentIOn of lung or alveolar
sIZe or of the presence or absence of alveolar destruction, even though they CIted two of the
earher studtes of Freeman and Haydon In the pubhshed mIcrographs of control- and NOT
exposed mIce, the arrspaces appear to be the same sIZe and eVIdence of destruction was not
seen No eVIdence of emphysema was presented m thts pubhcatIOn
Freeman et al (1972) exposed rats to 37,600 p,g/m3 (20 ppm) N02 , whtch was reduced
3
durmg the exposure to 28,200 p,g/m (15 ppm) or to 18,800 p,g/m3 (10 ppm) for varymg
penods up to 33 mo Followmg removal at necropsy, the lungs were flXed VIa the trachea at
25 cm of flXatIve pressure Morphometry of lung and alveolar sIZe was performed ill a
SUItable, although unconventional, manner The morphometry mdicated enlargement of
13-115
alveoh and reduction m alveolar surface area They also both reported alveolar destruction
and illustrated alveolar destructIOn m theIr figures They correctly conclude that they have
demonstrated emphysema m theIr N02-exposed rats However, It IS not entIrely clear
whether both experunental groups or only the group exposed to 28,200 p.g/m3 N02 had
emphysema
Ehrhch and Fenters (1973) exposed sqUIrrel monkeys to 9,400 or 18,800 p.g/m3 (5 or
10 ppm) N0 for 3 mo or to 1,880 p.g/m3 (1 0 ppm) N0 for 16 mo and then challenged the
2 2
monkeys with mfluenza VlfUS PIeces of lung were probably fixed m a collapsed condition
by immerSIon, as they state "At autopsy representatIve lung tissues were obtamed for
histopathological exammatIon" NeIther arrspace wall destruction nor morphometry are
mentioned in the article They concluded that "shght emphysema" was present m the
monkeys exposed to the two hIghest exposure levels and to the VlfUS and "shght to moderate
emphysema't was present m those exposed to 1,880 p.g/m3 N02 and to the VlfUS They also
reported emphysema was not present m monkeys exposed to 1,880 p.g/m3 N0 WIthout the
2
viral challenge The morphologIcal methods used preclude useful mformatIOn concernmg
emphysema followmg N02 exposure
Stephens et al (1976), m a long abstract of papers presented at that year's Aspen
conference, stated that "Rats exposed for long penods (3 to 5 mo) to 28,200 p.g/m3 (15 ppm)
N02 or 0.8 ppm 03 develop a disease whIch closely resembles emphysema "Because It IS
only a long abstract and the emphasIs of the paper was cellular mJury, there were no data
relative to alveolar SIZe, nor was there mformatIOn concernmg the presence or absence of
alveolar destmcnon Thus, thIs paper does not proVIde new data relative to the presence of
Port et al (1977) studied experunental and spontaneous emphysema m rat, mouse,
hamster, horse, and human lungs and compared them WIth normal control lungs from the
same species. Only SIX nllce and one rat had been exposed to N02 The mIce were exposed
to 188 p.g/m3 (0 1 ppm) N02 WIth a 2-h peak of 1,880 p.g/m3 (1 0 ppm) N02 daIly for
6 mo Control mIce of the same age were also exammed Only one NOTexposed and one
control rat were studied The exposed rat breathed 28,200 p.g/m3 (15 ppm) N0 from 2
35 days to approximately 5 mo of age, when chmcal illness became apparent The N02 was
then admlIDstered mtermlttently, based on the chmcal SIgns, to permIt SUrvIval for at least
13-116
2 years The control rat was approXImately the same age as the exposed one The lungs
were fIxed m a dIstended condItIon VIa the trachea at a constant pressure The lungs were
exammed by I.l\.1 and SEM The N02-exposed rat had dIstended alveoh and eVIdence of
arrspace wall destructIOn Both dIlated aIrspaces and eVIdence of alveolar wall destructIOn
were reported m the N02-exposed mIce lungs Although arrspace wall destructIon was
demonstrated, the small number of ammals studIed severely hmItS the value of thIs study
Hyde et al (1978) studIed dogs that had been exposed 16 h daIly for 68 mo to eIther
fIltered arr or to 1,210 p,g/m3 (0 6 ppm) N02 wIth 310 fJ~g/m3 (0 16 ppm) NO or to
3 3
270 p,g/m (0 14 ppm) N02 wIth 2,050 p,g/m (1 1 ppm) NO The dogs then breathed clean
arr durmg a 32- to 36-mo postexposure penod The nght lungs were fIxed m a dIstended
state VIa the trachea at 30 cm fIXatIve pressure SemIautomated Image analysIs was used for
morphometry of arrspaces The dogs exposed to 1,210 I-Lg/m3 N02 wIth 310 p,g/m3 NO had
statIstIcally sIgmfIcantly larger lungs wIth enlarged arrspaces and eVIdence of destructIOn of
3
alveolar walls These effects were not observed m dogs exposed to 270 p,g/m N02 wIth
3
2,050 p,g/m NO, Implymg a sIgmfIcant role of the N02 m the productIOn of the lesIOns
The lesIOns m dogs exposed to the hIgher N02 concentratIOn meet the cntena of the 1985
NHLBI workshop for emphysema of the type seen m human lungs
Lam et al (1983) exposed 3- and 21-day-old hamsters to 56,400 to 65,800 p,g/m3
(30 to 35 ppm) N02 , 23 h1day for 7 days The hamsteu. then breathed room arr untIl they
were 1 year old, when they wele killed and exammed The lungs were fIXed VIa the trachea
at 25 cm of fIXative pressure and fIXed lung volumes were determmed by dIsplacement
Appropnate stereologIc methods were used to determme the mean lmear mtercept and
mternal surface area The authors dId not report emphysema or eVIdence of alveolar
destructIOn, nor was emphysema demonstrated m the pubhshed mIcrographs of exposure-
related lesIOns The group exposed startmg at 3 days old, but not those exposed startmg at
21 days old, had longer mean hnear mtercepts, mdIcatmg larger alveoh Although they
mdIcated that these changes were "compatible" wIth "early emphysema", they dId not
spectfIcally conclude that the hamsters had emphysema ThIs conclusIOn IS appropnate as no
eVIdence of emphysema of the type seen m human lungs was presented
Klemerman et al (1985) descnbe the effects followmg exposure of hamsters to
3
56,400 p,g/m (30 ppm) N02 , 22 h1day for 12 mo The authors dId not descnbe the
13-117
methodology used in detaIl A statIstIcally sIgmficant longer mean hnear mtercept was noted
m the exposed hamsters, mdIcatmg larger alveoh However, there was no mdicatIOn that
destructIon was or was not present The authors concluded that "a small defmable degree of
emphysema developed" usmg the 1985 NatIonal InstItutes of Health workgroup's deftmtIon
of emphysema m ammal models EVIdence of emphysema of the type seen m humans was
not presented.
Stavert et al (1986) exposed rats that had receIved a smgle mtratracheal mstillatIon of
3
sterile normal saline to eIther 65,800 J1-g/m (35 ppm) N02 for 6 h/day or to ftltered arr for
25 days The rats were held an addItIOnal 10 weeks and then were exammed The lungs
were fixed by mtratracheal formalm at 25 cm water pressure and morphometry was
performed accordmg to standard, acceptable technIques They reported that,
microscopIcally, the lungs from these two groups appeared IdentIcal The mean hnear
intercepts of these two groups were nearly IdentIcal, mdIcatmg sIml1ar-sIZed alveoh They
dId not report destructIon, nor IS It eVIdent m theIr pubhshed mIcrographs They concluded
that tills exposure regImen "does not brmg about IrreversIble changes m the lungs of rats
willch are conSIstent WIth eIther centrl10bular or panlobular emphysema" Thts conclUSIon IS
appropnate.
Glasgow et al. (1987) exposed rats to 56,400 J1-g/m3 (30 ppm) N0 2 , 24 h/day for up to
140 days. The primary objectIve of tills study was to evaluate neutrophl1 recrUItment and
degranulatIOn from N02-mduced emphysema The lungs were ftxed VIa the trachea m a
appropriate manner and the mean hnear mtercept was determmed by semiautomatIc Image
analysis, willch was compared to manual methods Exposed rats had sIgmficantly longer
mean hnear mtercepts, mdIcatlng larger alveoh and alveolar wall destructIOn The authors
concluded that the exposed rats had emphysema based on the 1985 NatIOnal InstItutes of
Health's workgroup deftmtIon of emphysema m ammal models However, It appears that
they eIther pooled data from several ages of control rats or termmated all of the control rats
at or before the day the exposures were started Thus, controls may have been younger than
the exposed rats In addItIon, there may have been dIfferences m the methods by whtch the
lung tissues were processed, exposed and control rats may not have been processed at the
same tIme For example, m theIr FIgure 1 (the example of alveolar wall destructIOn), the
alveoh m the control lung do not appear to be as fully dIstended, as the alveolar walls are
13-118
less straight than those of the lungs from the exposed rat The figure legend does not
mdIcate the ages of eIther the control or exposed rat Although these problems may not
mfluence the mvestIgators' mam objectIves, they are troublesome wIth respect to the
presence or absence of emphysema The results are mconcluslVe wIth respect to the
productIOn of emphysema of the type seen m human lungs
Blank et al (1978) used N02 to produce an antmal model of emphysema based on the
1985 NatIOnal InstItutes of Health's workgroup defimtIOTIl The objectIve of thIs study was to
determme the effect of beta-ammopropIOmtnle, whIch mTnbits cross-lmkmg of collagen and
3
elastm, on that antmal model They exposed rats to 56,4100 p,g/m (30 ppm) N02 , 24 h/day
for up to 8 weeks The lungs were fixed by appropnate methods, and the mean lmear
mtercept was determmed by semIautomatIc Image analysls Control and exposed rats fed the
usual rat chow were termmated at the same tIme and age They reported longer mean lmear
mtercepts m the exposed rats, mdicatmg larger alveoh They mentIoned that the lungs were
exammed for alveolar wall destructIon, but do not clearly mdicate whether destructIon was
present They properly refer to the NOTmduced lesIOns as "emphysema-hke" rather than
Lafuma et al (1987) studIed the effect of exposure to 3,760 p,g/m3 (20 ppm) N02 ,
8 h/day, 5 days/week for 8 weeks on control hamsters and on hamsters WIth elastase-mduced
emphysema The lungs were fixed VIa the trachea at a constant pressure RelatIve alveolar
SlZes were estnnated usmg standard stereoiogical methods They found statIstIcally
slgmficantly larger lung volumes and mean hnear mtercepts and smaller mtemal surface
areas, mdicatmg larger alveoh m hamsters exposed to N02 alone They dId not state
whether arrspace wall destructIOn was or was not found There IS no eVIdence of
destructIOn m the pubhshed mIcrographs of lungs from that group of hamsters There IS no
eVIdence from thIs pubhcation that N02 alone produced emphysema of the type seen m
human lungs
The study by Mauderly et al (1989, 1990), dISCUSSed m the preVIOUS sectIOn, IS also
relevant to emphysema m that the fmdmgs were negatIve They studIed the mean lmear
mtercept and mtemal surface areas of rats exposed to 17)900 p,g/m3 (95 ppm) N02 ,
7 h/day, 5 days/week for 2 years There was no slgmficant effect on eIther of these
parameters
13-119
Table 13-12 provIdes an overvIew of the results of the studIes dISCUSSed m thIS sectIon
Summary
The anatonuc regIOn most senSItIve to N02 , and Withm whIch mJury IS generally fIrst
noted, is the area that encompasses the termmal conductmg arrways and adjacent alveolar
ducts and alveoh Withm thIs regIOn, those cells most senSItIve to N0 2-mduced mJury are
the ciliated cells of the bronchIolar epIthehum and the Type 1 cells of the alveolar
epithelium There IS, however, a large degree of mterspecies vanability m responSIveness to
N02 exposure, With gumea pIgS, hamsters, and monkeys bemg more severely affected than
the rat when exposed under the same conditIons and exammed usmg the same technIques
(Azoulay-DupUls et al , 1983, Wagner et al , 1965, FunOSI et al ,1973) When effectIve
N02 concentratIOns are used and appropnate tIssues are exammed usmg sensItIve methods,
sinular morphologIcal leSIons are found m all specIes In alveoh, necroSIS and sloughmg of
Type 1 cells, leavmg bare basallamma, IS followed by prohferatIOn of Type 2 cells that
replace damaged Type 1 cells In bronchIoles, ciliated cells lose some or all of theIr cilia
and noncIliated bronchIolar cells (Clara cells m rodents) lose theIr dome-bke lummal surface
projectIons Ciliated cells may become necrotIC and sloughed from the basallamma
NoncIliated bronchIolar cells, progemtor cells for ciliated cells, prohferate and become
larger. Such effects have been reported followmg acute exposure to ~3,760 p,g/m
3
(2.0 ppm) N02 , dependmg on the specIes tested (Azoulay-DupUls et al , 1983, Rombout
et al., 1986) As the exposure duratIOn mcreases, SImIlar effects are noted, but hyperplaSIa
and hypertrophy of Type 2 cells and nonciliated bronchIolar cells are the predommant
eplthehal changes (Sherwm and RlChters, 1982, Rombout et al , 1986, NakajIma et al ,1980,
Sherwin et al , 1973, Yamamoto and TakahashI, 1984) By LM, these changes may appear
to regress dunng an exposure
, to low concentratIOns, or soon after the exposure ends (Kubota
et al ,1987) Increases m the thIckness of the basallamma and mterstItlUm are slower to
develop and probably slower to resolve (Kubota et al , 1987)
Both exposure concentratIon and duratIon are Important factors affectmg response, With
concentration perhaps playmg a more sIgmficant role (Rombout et al ,1986) Age may also
be a factor affecting response, WIth neonates bemg more reSIstant to the morphologIcal
effects of N02 and responSIveness mcreasmg WIth age until weanmg or shortly after weanmg
13-120
TABLE 13-12. EFFECTS OF NITROGEN DIOXIDE ON THE DEVELOPMENT OF El\tIPHYSEMAa
NOz Concentratlon
Species
b
p.g/m3 ppm Exposure Gender Age (Stram) Emphysema Reference
188 with 2-h peaks o 1 with peaks Dally, 6 mo NS 4 weeks Mouse ± Port et a1 (1977)
to 1,880 to 1 0 (NS)
270 plus 2,050 p.g/m3 014 16 hlday, 68 mo F 6mo Dog Hyde et a1 (1978)
NO (Beagle)
1,210 plus 310 p.g/m3 06 +
NO
940 05 6, 18, or 24 hlday, NS NS Mouse Blatr et al (1969)
1-12 mo (NS)
1,504 08 51-813 days M 4 weeks Rat Haydon et a1 (1965)
7,520 40 (Sprague-
Dawley)
--
wI
1,880 10 16 mo, With and
wIthout vual
NS NS Monkey
(SqUIrrel)
± Ehrhch and Fenters (1973)
-
challenge
tv 3,760 20 Contmuous, M NS Rat Freeman et a1 (1968b)
112~763 days (Sprague-
Dawley)
.., I"f£i\
..J,/UV 20 8 hlday, 5 days/week, M 2mo Hamster Lafuma et ai (1987)
8 weeks (Golden Synan)
9,400 50 3 mo NS NS Monkey Ehrhch and Fenters (1973)
18,800 100 (SqUIrrel)
\1 = Male
F = Female
NS = Not stated
bNO = Nltnc OXIde
+ = Emphysema, - = No emphysema, ± = EqUIvocal
Emphysema IS defined accordmgto the 1985 NatIonal Heart, Lung and Blood Institute Workshop cntena for human emphysema Although several of the papers revIewed reported findmg emphysema,
some of these studIes (espeCIally the early studIes) were reported accordmg to preVIOUS, dIfferent cntena, some reports dId not fully descnbe the methods used, and/or the results obtamed were not In
suffiCIent detaIl to allow mdependent confinnatlOn of the presence of emphysema Thus, a "-" (I e , no emphysema) should only be mterpreted as lack of proof of emphysema, because It IS conceIvable
that If the study were repeated WIth current methods and the current cntena were apphed, some results nught be posItIve
(Stephens et al , 1978, Azoulay-Duphs et al ,1983) ResponsIveness m mature ammals
appears to dechne wIth age until an mcrease occurs at some pomt m senescence (Kyono and
KawaI, 1982)
Several groups of mvesngators who expenmentally exposed dIfferent specIes of
laboratory animals to N02 have reported emphysema of the type seen m human lungs as
dermed by the NHLBI workgroup (NatIOnal Insntutes of Health, 1985) In human lungs, the
workgroup dermed emphysema as "a condinon of the lung charactenzed by abnormal,
permanent enlargement of arrspaces dIstal to the termmal bronchIOle, accompamed by
destrucnon of theIr walls, and WIthout ObVIOUS fibroSIS" "Destrucnon m emphysema IS
dermed as nOnUnllOrmity m the pattern of respIratory arrspace enlargement so that the
orderly appearance of the acmus and ItS components IS dIsturbed and may be lost" StudIes
m thIs group include those by Haydon et al (1967), Freeman et al (1972), and Hyde et al
(1978) Results of studIes by several addinonal groups of mvesngators are mconclUSIve
because, although they demonstrated enlargement of arrspaces, they dId not document or
report whether or not destrucnon as dermed by the NHLBI workgroup (NatIOnal Insntutes of
Health, 1985) occurred The latter group mcludes several studIes testmg specIfic hypotheses
of the pathogenesIs of emphysema, whIch, as appropnate to theIr research obJecnves, used
the NHLBI workgroup's defimnon of antmal models of emphysema rather than the defimnon
of emphysema m human lungs The defimtIOn of emphysema mammal models requITes
arrspace enlargement, but not destructIOn Several studIes were conSIdered mconclusive due
to problems WIth control antmals or to msufficient numbers of antmals It IS Important to
3
note that a 2-year exposure of rats to 17,900 p,g/m (9 5 ppm) N02 dId not result m eVIdence
of emphysema, even though Mauderly et al (1987, 1990) used appropnate morphologIC and
morphometnc methods
13.2.3 Extrapulmonary Effects

Exposure to N02 produces a WIde array of health effects beyond the confmes of the
lung. Although the aggregate data are mconcluslve and do not portray any smgle Issue as
paramount, the eVIdence suggests that N02 and/or some of It'S reacnve products penetrate
the lung epIthelial and endothehallayers to enter the blood and produce alteratIOns m blood
13-124
and vanous other organs Effects on the systemIC Immune system are mcluded m
SectIOn 13 2 2 1 (Host Defense Mechanisms)
13.2.3.1 Body Weight

TradItionally, the measurement of body weIght mammal tOXicology studIes has been
consIdered a pnmary and senSItive end pomt However, ItS bIOlogIcal slgmficance and
extrapolatIOn to humans are stIll generally unmterpretable The measurement of body weIght
may be useful m exammmg questIOns related to dIfferences m specIes sensItivIty, age, and
dIfferent exposure scenanos A compilatIOn of the effects of N02 on body weIght can be
found m Table 13-13
The most comprehensIve study was performed by Wagner et al (1965), who exposed
rabbIts, gumea pIgS, rats, hamsters, and four strams of mIce to 1,880, 9,400, or
3 3
47,000 p,g/m (1, 5, or 25 ppm) and dogs to 1,880 or 9,400 p,g/m N02 For all speCIes
exammed, no sIgmficant dIfferences m body weIght were observed after 6, 12, and 18 mo of
exposure SImilarly, a study by Steadman et al (1966) mdIcated that 90 days of contmuous
exposure to between 900 and 21,600 p,g/m3 (048 and 11 5 ppm) N02 resulted m scattered
reductIOns m body weight gam m five speCIes of ammaJls (dogs, rabbits, squrrrel monkeys,
gumea pIgS, and rats) evaluated at three mtervals (30, 60, and 90 days) The authors
concluded that there was no sIgmficant weIght loss, however, no statistical analySIS of the
data was presented Also, mcreased mortalIty was observed at the 9,200-p,g/m3 (49-ppm)
concentratIOn m gumea pIgS and rabbIts, and m all species at 21,600 p,g/m3 (11 5 ppm) N02
The pOSSIbility that newborn mIce were more senSluve to ambIent levels of N02 than
sImI1arly exposed adults was mvestIgated by RIchters et al (1987), who exposed 7-day
graVId mIce to 470 p,g/m3 (0 25 ppm) N02 ExammatllOn of the male offspnng born dunng
N02 exposure and exposed for 12 additional weeks showed less of an mcrease m body
weIght gam after 3 and 12 weeks of exposure than dId c:ur-exposed rats However, at the
6-week measurement mterval, the body weIghts of aIr- and N~ fetally exposed rats were not
statiStically dIfferent Neonates SImilarly exposed to 564 p,g/m3 (03 ppm) N02 dId not show
a reductIon m body weight gam at 3 weeks, but dId after 6 weeks of exposure, whereas adult
mIce exposed to 320 to 1,500 p,g/m3 (0 17 to 0 8 ppm) N02 for penods rangmg from 1 to
12 weeks showed no slgmficant body weIght changes
13-125
TABLE 13-13. EXTRAPULMONARY EFFECTS OF NITROGEN DIOXIDE: BODY WEIGHTa
N02 Concentratlon
SpecIes
3 Gender Age (Stram) Effects Reference
p.g1m ppm Exposure
94 005 90 days NS NS Rat No effect Shalambendze (1969)
320-1,504 o 17-08 8 hlday, M Adult Mouse No effect fuchters et al (1987)
5 days/week, (SwIss Webster)
1-12 weeks
470-564 025-030 8 hlday, M m utero Reduced body weIght gam compared to
5 days/week, controls at 3 and 12 weeks, but not at
3-12 weeks 6 weeks
658 035 8 hlday, M m utero Mouse Reduced body weIght gam m newborns, KUraItls et al (1981)
5 days/week, and older (SWISS Webster) but not older rats
6 weeks mICe
900- 048- Contmuous, NS NS Dog No effect Steadman et al (1966)
21,600 115 90 days (Beagle)
RabbIt
I-'
~ (New Zealand)
I
I-' Gumea pIg
N
0'1 (NS)
Rat
(Sprague-Dawley)
Monkey
(SqUirrel)
940-3,760 05-20 22 hlday base + M 1 day and Rat Reduced body weIght gam m older rats Stevens et al (1988)
base + base + 2 I-h peaks/day, 7 weeks (FIscher 344) after 3 and 6 weeks exposure to 1 0 or
peaks to peaks to 5 days/week, 2 o ppm No effects m younger rats
3 X base 3 X base 1, 3, and 6 weeks
1,300- 07-08 30 days F 8 weeks Mouse No effect NakajIma et al (1969)
1,500 (ICR)
1,504 08 Contmuous, M 4 weeks Rat No effect Freeman et al (1966)
lIfetime (Sprague-Dawley)
1,880 10 8 hlday, M NS Gumeapig Reduced body weIght gam KosmIder et al (1973b)
6 mo (NS)
KUraItIs et al (1981) also reported that the body weIghts of newborn mIce exposed to
658 p.g/m3 (0 35 ppm) N02 for 6 weeks were sIgmficantly less than age-matched controls
No decrease m body weIght was observed when older mIce were exposed Also, NakajIma
et al (1969) found no effects m 8-week-old mICe exposed for 30 days to 1,316 or
3
1,504 p.g/m (0 7 or 0 8 ppm) N02
Only very hIgh exposure concentratIons of N02 have been found to cause reduced body
weights m rats No exposure-related effects were found m rats exposed for 90 days to
3
94 p.g/m (005 ppm) N02 (Shalambendze, 1969) Freeman et al (1966, 1968b) found no
effects on body weIght after lIfetIme exposure to 1,504 or 3,760 p.g/m3 (0 8 or 2 0 ppm)
N02
Although the data m mIce suggest that newborns may be more senSItIve to N02
exposure than older mIce, other eVIdence (see SectIOn 13 224), mcludmg body weIght data,
do not support thIs contentIon for rats In contrast to the effects on body weIght observed m
newborn mIce, Stevens et al (1988) reported that 1-day-old rats were less responSIve to N02
than 7-week-old rats exposed for 6 weeks to baselInes of 940, 1,880, and 3,760 p.g/m3 (05,
1 0, and 20 ppm) N0 2 wIth two 1-h peaks/day (5 days/week) to three tImes the baselIne
concentratIon To sImulate ambIent exposure patterns, the N02 exposure was mcreased to
three tImes the baselIne concentratIon for 1 h tWIce daIly The body weIght of the 7-week-
old rats was less than the control rats after 1 week and slgmficantly less at 3 and 6 weeks
when the baselIne exposure concentratIon was 1,880 or 3,760 p.g/m3 Rats exposed to
3 3
940 p.g/m wIth peaks to 2,820 p.g/m N02 showed a tranSItOry decrease at 3 weeks that was
no longer eVIdent at 6 weeks The I-day-old rats, exposed WIthIn 36 h after bIrth to the
same N02 concentratIOns, showed no changes m body weIght after 1, 3, or 6 weeks of
exposure.
Kosmlder et al (1973a) reported a reductIOn m body weIght gam m gumea pIgS
exposed continuously to 1,'880 p.g/m3 (1 0 ppm) N02 for 6 mo Mitma (1962) exposed
rabbIts to 2,400 and 5,680 p.g/m3 (l 3 and 3 0 ppm) N02 for 15 and 17 weeks and found a
significant reduction m body weIght gam that perSIsted 5 to 7 weeks after the exposure
ended.
13-128
13.2.3.2 Hematologic Changes
AlteratIons of blood constItuents as a result of NOl exposure may be due to a vanety of
causes Drrect effects of N02 , formatiOn of mtntes and mtrates, or secondary effects
emanatmg from other organs such as the lung, hver, heart, kIdneys, and spleen could all
result m alteratiOns of blood content and chemIstry However, the sIgmficance of many of
these hematologIcal changes IS uncertam
Effects on Blood Cell Counts and Hemoglobin

Several authors have shown effects on the number of red blood cells (RBCs) and
hemoglobm concentratiOn, although the results have been mconsIstent. A summary of these
studtes can be found m Table 13-14 In some of these studIes, leukocytes (whtte blood cells
[WBCs]) and platelet counts were also exammed (Table 13-15)
Shalambendze (1969) exposed rats contInuously to 94 p,g/m3 (005 ppm) N02 for
90 days, causmg no change m blood hemoglobm or RBC counts YakImchuk and
Chehkanov (1972) reported that durmg a 3-mo contmuous exposure to 600 p,g/m3 (0 32 ppm)
N02 , rats showed a sIgmficant mcrease m the number oj leukocytes, and a tendency toward
decreased hemoglobm and RBCs However, by the end of exposure, these changes returned
to WIthm the control range Plasma chohnesterase (CbB) was also measured, but no
sIgmficant effects were found
Fenters et al (1973) showed that exposmg maXe squrrrel monkeys to 1,880 p,g/m3
(1 0 ppm) N02 contmuously for 16 mo had no SIgmfiCaIlt effect on hematocnt, hemoglobm,
total protem, globuhns, cWonde, sodIUm, calCIUm, potaSSIUm, glucose, blood urea mtrogen,
glutamIcpyruVIC transammase, LDH, and LDH Isoenzymes Challenge WIth mfluenza
A1PRl8/34 VIruS mcreased the leukocyte number m NOTexposed antmals above the levels m
SImilarly challenged controls A study by Steadman et aX (1966) mdIcated that 90 days of
contmuous exposure to between 900 and 21,600 p,g/m3 (048 and 11 5 ppm) N02 resulted m
no sIgmficant changes m number of WBCs, percent hemoglobm, or percent hematocnt m
five specIes of antmals (dogs, rabbIts, squrrrel monkeys, gumea pIgS, and rats)
Dogs exposed to 1,880 or 9,400 p,g/m3 (l 0 or 50 ppm) N0 2 for 18 mo showed no
sIgmficant change m hemoglobm, hematocnt, WBC count, or serum alkalme phosphatase
13-129
TABLE 13-14. EFFECTS OF NITROGEN DIOXIDE ON RED BWOD CELLS AND HEMOGLOBINa
NOz ConcentratIon
SpecIes
3
94 005 ContInuous, NS NS Rat No effect on blood hemoglobm Shalambendze (1969)
90 days orRBCs
940-1,500 + 05-08+ Contmuous, M/F 4 weeks Mouse AddItIon of 50 ppm CO to NOz NakajIma and Kusumoto (1970)
Ito15mo (lCR JCL) fal1ed to affect carboxyhemo-
globm
1,500 08 Contmuous, M 7 weeks Mouse No effect on methemoglobm NakajIma and Kusumoto (1968)
5 days (lCR)
1,880 10 Contmuous, M NS Monkey No effect on hematocnt or Fenters et al (1973)
16 mo (SqUIrrel) hemoglobm WIth NOZ and
mfluenza exposure
1,880 10 Contmuous, M NS Dog No changes m hemoglobm or Wagner et al (1965)
I--' 9,400 50 18 mo (Mongrel) hematocnt
wI
I--' 1,880-56,400 1-30 18 h NS NS Mouse ConcentratIon-related mcrease m Case et al (1979)
w (NS) methemoglobm and
0
mtrosylhemoglobm
2,400-5,640 13-30 2 h/day, RabbIt Decreased RBCs Mitma (1962)
15 and 17 weeks
3,760 20 Contmuous, M/F NS Monkey WIth or WIthout NaCI Funosl et al (1973)
3
14mo (Macaca (330 p.g/m ) polycythemta with
specwsa) reduced mean corpuscular
M Rat volume and nonnal mean
(Sprague- corpuscular hemoglobm
Dawley)
3,760 20 Contmuous, M 8 weeks Rat No effect on hemoglobm, Azoulay et a1 (1978)
up to 6 weeks (WIstar) hematocnt or RBC count, no
methemoglobm was observed
TABLE 13-14 (cont'd). EFFECTS OF NITROGEN DIOXIDE ON RED BLOOD CELLS AND HEMOGLOBINa
NO z Concentrabon
SpecIes
3
""g/m ppm Exposure Gender Age (Stram) Effects Reference
9,400- 5-40 Ih F 4mo Mouse No mcrease m methemoglobm Oda et a1 (1981)
75,200 (JCLICR) Increased mtnte and especially
mtrate
18,800 10 2 h/day, F 6-8 weeks Mouse Small decrease m hemoglobm Holt et al (1979)
5 days/week, up (BALB/c) and mean corpuscular
to 30 weeks hemoglobm concentratIOn
aNS = Not stated

RBCs = Red blood cells
M = Male
~ F = Female
I CO = Carbon monOlade
~ NaCI = SodIUm chlonde
.....
TABLE 13-15. EFFECTS OF NITROGEN DIOXIDE ON LEUKOCYTES AND PLATELETS2
N02 Concentration
SpecIes
3
600 032 Continuous, M NS Rat Increased leukocytes after YakImchuk and Chehkanov
3mo (NS) 8-10 weeks, no dIfference after (1972)
3 mo of exposure
1,880 10 Contmuous, M NS Monkey Increased leukocyte count m Fenters et al (1973)
16 mo, (SquIrrel) vIral-challenged N02-exposed
fo1l6wed by anImals
VIral challenge
1,880 10 Continuous, M NS Dog No effect on leukocyte count Wagner et al (1965)
9,400 50 18 mo (Mongrel)
2,400-5,640 13-30 2 h/day, RabbIt Increased leukocytes followed by Mitma (1962)
15 and 17 weeks decreased phagocytic actiVIty
......
l.J,)
3,760 20 Contmuous, M/F NS Monkey NeutrophIl/lymphocyte ratio FunoSI et al (1973)
14mo M (Macaca tendency to shIft upwards m both
......
I
l.J,) specwsa) anImal specIes tested

N
Rat
(Sprague-
Dawley)
18,800 10 Contmuous, M 18 weeks Rat Decreased platelets at 1 to KobayashI et al (1983)
14 days (WIStar) 7 days of exposure, but not after
14 days
18,800 10 2 h/day, F 6-8 weeks Mouse Increased leukocytes at 5 weeks, Holt et al (1979)
5 days/week, up (BALB/c) but not at 15 or 30 weeks
to 30 weeks
"M = Male
NS = Not stated
F = Female
and magnesiUm-activated phosphatase activIty (Wagner et al , 1965) RabbItS exposed to
2,400 to 5,680 p,g/m3 (1 3 to 3 0 ppm) N02 for 15 or 17 weeks had a decrease m the
number of RBCs and a sIgmficant mcrease m the number of WBCs (MItma, 1962)
FunOSI et al (1973) exposed rats to 3,760 + 1,880 p,g/m3 (2 0 +
1 0 ppm) N02 for
14 mo and found polycythemIa wIth reduced mean corpuscular volume, but normal mean
corpuscular hemoglobm concentratIOns Exposure to N02 also mcreased the ratIO of PMNs
to lymphocytes Because exposures occurred whIle the rats were m plaStIC cages mSIde the
exposure chamber, the actual concentration of N02 would probably be less than the stated
concentratIOn However, the reported observatIOns are supported by SImIlar :fmdmgs m
monkeys that were SImultaneously exposed m WIre cages
Azoulay et al (1978) reported no effects on rat RBC parameters (hemoglobm,
hematocnt, and RBC count) after a contmuous N02 exposure of 3,760 p,g/m3 (20 ppm)
lastmg between 1 day and 6 weeks Other factors that mdex or potentIally alter oxygen
affInlty to hemoglobm (the partIal oxygen pressure at wInch hemoglobm IS half-saturated
WIth 02' n Hill factor [hemoglobm bmdmg affInlty], pH, oxygen combmmg capaCIty, and
2,3-dIphosphoglycerate [a measure of tIssue deoxygenatIOn]) were not affected
Although not a dIrect measure of RBC content, the number of RBCs m the red pulp of
the spleen of mIce was mcreased by a 6-week, 5-day/week, 8-h/day exposure to 658 p,g/m3
(035 ppm) N02 (KunutIs et al , 1981) TIns :fmdmg could be mterpreted as supportmg the
polycythemIa that was sometImes observed m N02-exposed anImals Spleen weIghts and the
SIZe of spleen lymphOId nodules were also mcreased
Three studIes exammed the productIon of phYSIOlogICally mactIve hemoglobm
(methemoglobm) that mIght be produced If mtntes or mtrates reacted WIth hemoglobm
NakajIma and Kusumoto (1968) found that the amount of methemoglobm was not mcreased
when mIce were exposed to 1,504 p,g/m3 (0 8 ppm) NO~ for 5 days Methemoglobm was
not detected after a 6-week exposure of rats to 3,760 p,g/m3 (02 ppm) (Azoulay et al ,
1978) Oda et al (1981) also found no mcrease m methemoglobm, but mtntes and
espeCIally mtrates were elevated m the blood of mIce eXJPosed for 1 h to between 9,400 and
75,200 p,g/m3 (5 and 40 ppm) N02 In contrast, Case et al (1979) showed that mIce
exposed to 1,880 to 56,400 p,g/m3 N02 (1 to 30 ppm) exlubited a concentratIOn-related
13-133
increase in methemoglobm and mtrosylhemoglobm and decreased fernc catalase and rron
transferrm actlvItIes
Effects on Red Blood Cell Membranes

Several studIes have exammed changes m RBC membranes of rats after N02 exposure
(see Table 13-16) In a prehmmary report, Mersch et al (1973) showed that RBC
D-2,3-dIphosphoglycerate was mcreased m all four gumea pIgS contmuously exposed to
677 p.g/m3 (036 ppm) N02 for 1 week However, as prevIously mentIoned, Azoulay et al
3
(1978) reported no changes m 2,3-dIphosphoglycerate levels after a 3,760-p.g/m (20-ppm)
continuous N02 exposure lastIng between 1 day and 6 weeks The authors attnbute the
difference between therr results and the results of Mersch et al (1973) to therr use of a more
precise enzymatIc assay and to a larger study populatIOn AddItIonally, there may be
specIes-related dIfferences because Azoulay et al (1978) exammed rats and Mersch et al
(1973) exammed gumea pIgS
Changes m the contents of RBC membranes were detected after exposure to
3
7,520 p.g/m (40 ppm) N02 (Kaya et al , 1980) Increased amounts of SIalIC aCId were
noted in rats exposed between 1 and 10 days to 7,520 p.,g/m3 N02 Increased SIalIC aCId, a
glyCOSIdIC reSIdue dIstnbuted on the outer surface of the RBC, IS found m younger RBCs
(Durocher et al., 1975), suggestIng that N02 mhalatIon may have stlmulated renewal of the
RBC populatIon (mcreased population of Immature cells) An mcreased amount of
lyso-phosphatIdylethanolamme, known to mcrease cell membrane fragilIty, was found on
Days 5, 7, and 10 after exposure to 7,520 p.,g/m3 and after 1, 5, and 7 days of exposure to
3
18,800 p.g/m (10 ppm) N0 2 The protem content of RBCs was shghtly decreased at
3
18,800 p.g/m after 1, 5, and 7 days of exposure, but not after 3 days
The possIbility of a younger crrculatmg RBC populatIOn was mvestIgated by Kummoto
et al (1984), who showed that after 1 and 4 days of exposure to 7,520 p.,g/m3 (40 ppm)
N02 , the actiVIty and content of Na+, K+ -ATPase, and the amount of sIahc aCId were
increased in RBC membranes These changes have also been assocIated WIth a younger
population of RBCs (Cohen et al , 1976)
In contrast, Mocmtate and MIUra (1984) found that after 7 days of contmuous exposure
to 7,520 p.g/m3 (40 ppm) N02 , there was a decreased population of younger RBCs
13-134
TABLE 13-16. EFFECTS OF NITROGEN DIOXIDE ON RED BLOOD CELL :MEMBRANESa
N02 Concentration
Specles
3 Reference
p.g/m ppm Exposure Gender Age (Stram) Effects
677 036 Contmuous, NS NS Gumeaplg Increased RBC Mersch et al (1973)
7 days (NS) D-2,3-dlphosphoglycerate
940 05 8 h/day, NS NS Gumea plg Decrease m RBC GSH Menzel et al (1976)

7 days (Hartley) peroXldase
8 h/day, No change m RBC GSH
4mo peroXldase
3,760 20 Contmuous, M 8 weeks Rat No effect on RBC Azoulay et al (1978)
up to 6 weeks (Wlstar) 2,3-dlphosphoglycerate
7,520 40 Contmuous, M 16-21 Rat Increased slahc aCld, Na +, and Kummoto et al (1984a)
1-10 days weeks (JCL Wlstar) K+-ATPase m RBC membranes
assoclated wlth an mcreased
proportlon of younger RBCs
I--'
I,;.)
I 7,520 40 Contmuous, M 16-20 Rat At Day 7, the fractlOn of young Mochttate and MlUra (1984)
I--'
I,;.) 1-10 days weeks (JCL Wlstar) RBCs was reduced and the
UI
fraction of older RBCs mcreased
ActIvltIes of pyruvate kmase and
phosphofructokmase were
mcreased ill young RBCs
7,520 40 Contmuous, M 8-18 weeks Rat Increased arachtdomc aCld m Kaya and MlUra (1982)
10 days (JCL WlStar) membranes and serum Steanc
palmatIc aCId decreased at 10 and
18,800 10 Continuous, 4 ppm m RBC membranes
7 days
7,520-37,780 4-20 Contmuous, M 8-14 weeks Rat Decreased RBC membrane Kaya et al (1980)
1-10 days (JCL Wlstar) protem at Day 1, 5, and 7, but
not 3 Lyso-phosphatIdyl-
ethanolantme, slallC aCld, and
hexose mcreased at 4 and
10 ppm
~s = Not stated M = Male

RBCs = Red blood cells GSH = Glutathione
However, the actIvity of two glycolytIc enzymes (pyruvate kmase and phosphofructokmase)
was elevated m N02 -exposed annnals on Days 5 and 7, but returned to control levels on
Day 10 The authors concluded that there was not a correspondmg reductiOn m the actIvIty
of the glycolytlc pathway wIth the NOTmduced mcrease m the apparent agmg of the RBCs
Kaya and MIUra (1982) mvestIgated the effects of N02 on fatty aCIds m RBCs, sera,
and hver They found a net mcrease m unsaturated fatty aCIds (predommately arachIdomc
aCId) occurred in RBC membranes from rats after exposure to 7,520 p.g/m3 (4 0 ppm) N02
for 10 days.
Effects on Serum and Plasma

As mentIoned in the preVIOUS sectiOn, Kaya and MIUra (1982) showed that arachIdomc
aCId was mcreased m the RBC membrane after exposure to N02 Because de novo synthesIs
of fatty acids IS not pOSSIble ill the mature RBC, composItIon changes m the membrane
usually reflect exchange WIth serum fatty aCIds, probably ongmatmg m the hver In fact,
3
Kaya and MIUra (1982) found that after exposmg rats to 7,520 p.g/m (4 0 ppm) N02 for
10 days, arachIdomc aCId was elevated m serum and m hver homogenates However,
exposure to 18,800 p.g/m3 (10 ppm) N02 for 7 days mcreased RBC and serum arachIdomc
acid, but liver concentratIons were decreased The authors suggested that the rat cannot
completely overcome the consequences of a 18,800-p.g/m3 N02 exposure, but could
metabohcally compensate for the effects of exposure to 7,520 p.g/m3 N02
Menzel et al (1977) demonstrated that acute effects do not necessanly predIct chromc
injury by contrastIng the serum changes of gumea pIgS after short-term (7-day) and long-term
3
(4 mo) contmuous exposure to 940 p.g/m (05 ppm) N02 Plasma CbB was elevated after a
7-day exposure, but was decreased compared to control values WIth a long-term exposure
(4 mo) ThIs depressiOn m CbB IS suggestIve of a hepatIc lesiOn (Moore et al , 1957)
A depression m RBC GSH peroXidase actIVIty was also mItIally observed, but the effect dId
not persist after 4 mo of exposure SImIlarly, several mdices of nonspecIfic tIssue damage
(serum creatIne phosphokmase, LDH, serum glUtamIC oxaloacetIc transammase, and serum
glutamIc pyruVIC transammase) were also mcreased after 7 days, but were not altered by
long-term exposure
13-136
The followmg studIes all mdicate a general decrease m serum protems and hpoprotems
and an mcrease m serum globuhns, thus suggestmg hepatic damage Drozdz et al (1976)
reported decreased serum total protem, albumm, and seromucOld concentrations m gumea
pIgS exposed to 2,000 /l-g/m 3 (1 05 ppm) N02 , 8 h/day for 180 days However, serum
levels of ar and l1-g10buhns were mcreased These authors also found that serum alanme
and aspartate ammotransferase activIty was mcreased m the mItochondrIal fractIOn, but was
decreased m the cytoplasmIc fractIOn In agreement WIth the Menzel et al (1977) subchromc
data, Drozdz et al (1976) also observed decreased plasma ehE levels However, the
meamng of the cytoplasmIc and mitochondnal fraction of serum IS not clear from the
translatIon of the artIcle
Kosmider et al (1973a) reported a general decrease m protem synthesIs eVIdenced by
3
decreased serum protems m gumea pIgS after contmuous exposure to 1,880 /l-g/m (1 0 ppm)
N02 for 6 mo Followmg exposure to 1,000 /l-g/m3 NO x (mamly N02 , =05 ppm), 8 h/day
for 120 days, Kosmider (1975) reported decreased serum cholesterol, total hpIds, 11 (low
denSIty hpIds) and gamma hpoprotems, and sodIUm, and mcreased serum a (hIgh denSIty
hpIds)-hpoprotems m gumea pIgS SImilarly, Mitma (1962), after exposing rabbIts to
3
2,400 to 5,680 p,g/m (1 3 to 3 0 ppm) N02 for 15 and 17 weeks, found reduced amounts of
albumm, but mcreased serum globuhns Table 13-17 summarIZes the data on NOTmduced
changes m serum protems and chmcal chemistnes
13.2.3.3 Hepatic Function

As descnbed m the above sectIOn, changes m serum chemistnes suggest that N02
exposure may affect the hver Several studIes have exarnmed hepatIc functIOn eIther drrectly
or by mdrrect means These studIes are cataloged m Table 13-18
One Important functIOn of the hver IS detmaficatlOIl of xenobIOtIc compounds
Measurement of the duratIOn of barbiturate-mduced sleepmg tIme has been used as an
mdrrect measurement of hepatIc mIXed-functIOn OXidase actiVIty, the enzymes responsIble for
xenobIOtIc metabohsm NItrogen dIOXide has been shown to mcrease pentobarbital-mduced
sleepmg tImes m mIce (Miller et al , 1980, Graham et aJ , 1982) The effect was observed
m female mICe, but not m males, occurred only at specilled tIme mtervals after exposure,
and usually dId not perSIst beyond 1 day postexposure However, the effects rehably
13-137
TABLE 13-17. EFFECTS OF NITROGEN DIOXIDE ON SERUM PROTEINS AND CLINICAL CHEMlSTRIESa
NOZ ConcentratIon
SpecIes
3 Exposure Gender Age (Stram) Effects Reference
p.g/m ppm
600 032 Contmuous, M NS Rat Cholmesterase was not affected Yakunchuk and ChelIkanov
3 mo (NS) (1972)
940 05 8 hlday, NS NS GUInea pIg At 4 days serum LDH, total creatlnme Menzel et a1 (1977)
7 days, (Hartley) phosphokmase, SGOT and SGPT, plasma
8 hlday, cholmesterase, and lysozyme elevated At
4mo 4 mo lysozyme and plasma cholmesterase
depressed
1,000 NOx 05 8 hlday, NS NS Gumeapig Serum cholesterol and total hPIds KosmIder (1975)
(mamly 120 days (NS) depressed
NOJ
1,880 10 Contmuous, NS NS Gumeapig Protem syntheSIS mhIbited, total serum KosmIder et a1 (1973a)
6 mo (NS) protems and Immunoglobulms decreased
1,880 10 Contmuous, M NS Monkey Ammals challenged WIth VIrus No effect Fenters et a1 (1973)
16 mo (SqUlrrel) on clImcal bIOChemIcal parameters
2,000 105 8 hlday, M NS Gumea pIg Plasma changes decreased albumm, Drozdz et al (1976)
180 days (NS) seromucOld, cholme-sterase, alanme, and
aspartate transmmases Increased a I and
(32 globulms
1,880- 1-30 18 h NS NS Mouse Decreased catalase and Iron transferrm Case et al (1979)
56,400 (NS) actiVIty
11,700 62 Contmuous, M 8 weeks Rat No effect on serum lysozyme Chow et al (1974)
8 days (Sprague-
Dawley)
~ = Male
NS = Not stated
SGOT = Serum glutaffilc oxaloacetlc transammase
SGPf = Serum glutaffilC pyruVIC transaffilnase
TABLE 13-18. EFFECTS OF NITROGEN DIOXIDE ON THE LIVERs
N02 Concentration
SpecIes
3 Exposure Gender Age (Stram) Reference
p.g/m ppm Effects
50 003 6 h/day, M/F m utero Rat Increased hexobarbital-mduced sleepmg Tabacova et al (1985)
100 005 7 days/week, (WIStar) tImeatO 5 and 5 o ppm Cytochrome
1,000 05 21 days P-450 level and ammopynne
10,000 53 N-demethylase activIty were decreased,
whereas hPId perOXides and 02
consumptIOn were mcreased at 5 0 ppm
470-9,400 025-50 3 h/day, 1, 2, or M/F 5-7 weeks Mouse Increase m pentobarbital-mduced MIller et al (1980)
3 days (CD-I) sleepmg time m female mICe only,
repeated daily exposures caused no
effect
235 0125 3 h/day, No effect on pentobarbital-mduced
--
wI
w
\0
752
2,256
7,520
04
12
40
1-2 days
Contmuous,
14 weeks
M 22-24
weeks
Rat
(JCL WIStar)
sleepmg tlme
Cytochrome P-450 level decreased
dunng first 8 weeks of exposure, but
remmed to control levels WIth contmued
TakahashI et al (1986)
exposure (4 0 ppm)
752 04 Contmuous, M 23-26 Rat Succmate-cytochrome c reductase Mocmtate et al (1984)
3,260 12 7 days weeks (WIstar) actlvity was reduced at 10 ppm only, on
7,520 40 Days 3 and 5 Cytochrome P-450 level
was reduced at 10, 4 0, and 0 4 ppm but
7,520 40 10 days 21-24 not at 1 2 ppm NADPH-cytochrome c
18,800 10 7 days weeks reductase actlVIty was reduced at
40 ppm only
1,000 NOx 05 8 h/day, NS NS Gumea pIg Depleted hver magneSIUm and zmc, KoslUllder (1975)
(mamlyNO~ 120 days (NS) swollen hver nutochondna
940 05 Connnuous F weanlmg Mouse No effect on hpofusm pIgment m hver Azaz and Csallany (1977, 1978)
1,880 10 17 mo (NS) or other organs Csallany and Ayaz (1978)
TABLE 13-18 (cont'd). EFFECTS OF NITROGEN DIOXIDE ON THE LIVER3
NO z Concentration
SpecIes
3
2,000 105 8 h/day, M NS Gumeapig Decreased hver protem and Drodz et al (1976)
180 days (NS) cytoplasmIC aspartate
transammase activIty, mcreased
mItochondrIal alanme and
aspartate transammase activIties,
mtracellular edema, and
mflammatory and parenchymal
changes observed
7,520 40 Contlnuous, M 4 weeks Rat Cytochrome P-450 level and Takano and MIyazala (1984)
1, 14, or (Wistar) ammopyrme N-demethylase
30 days activIty mcreased and amhne
hydroxylase activIty was
decreased No effect at Day 1
""""
wI
9,400 50 3h F 6-7 weeks Mouse No decrease m cytochrome Graham et al (1982)
""""
.j::o. (CD-I) P-450 levels or mIxed functIOn
0 OXidase actiVIties
'M = Male
F = Female
02 = Oxygen
NADPH = Reduced mcotmaffilde ademne dmucleollde phosphate
NS = Not Stated
occurred after a 3-h exposure to concentratIOns as low as 470 p,g/m3 (025 ppm) N02
No sIgmficant effects were detected after 1- or 2-day e).posure to 235 p,g/m3 (0 125 ppm)
In an attempt to examme the mechanIsm of thIs response, the level of hepatIc cytochrome
P-450 and the activIties of ammopynne N-demethylase, p-mtroamsole O-demethylase, and
anIlme hydroxylase were measured m the hvers of mIce exposed for 3 h to 9,400 p,g/m3
(5 0 ppm) N02, however, no N02-related effects were found (Graham et al , 1982)
Increased hexobarbital-mduced sleepmg tImes have also been reported m the progeny of
maternally exposed rats (Tabacova et al ,1985) ThIs (,ffect was measured m the offspnng
exposed to 10,000 p,g/m3 (5 3 ppm) N02 at 7, 14, and 21 days postexposure AddItIOnally,
hpid peroXides mcreased and 02 consumptIOn decreased m hver homogenates Cytochrome
P-450 content and ammopynne-N-demethylase actIVIty were decreased on Postnatal Day 30
In the anImals exposed to 1,000 p,g/m3 (05 ppm) N02, mcreased hexobarbital-mduced
sleepmg tImes occurred on Days 7 and 21, but not on Day 14 LIver hpid peroXides were
also mcreased on Postnatal Day 30 m thIs exposure group No exposure momtonng method
was CIted and the details of the bIOlOgical methods used were not avaIlable
Components of the rat microsomal electron-transport system, espeCIally cytochrome
P-450, were generally decreased after contmuous exposure to 752 to 7,520 p,g/m3 (04 to
4 0 ppm) NO z dunng the fIrst 8 weeks of exposure, bu1 WIth contmued exposure, the levels
returned to control values (Takahashi et al ,1986) Talrnno and Miyazaki (1984) exposed
rats to 7,520 p,g/m3 N02 for 1, 14, or 30 days After ]l4 days, cytochrome P-450 levels and
ammopynne N-demethylase actIVIty were mcreased, whereas aniline hydroxylase actiVIty was
decreased Arnmopynne N-demethylase actiVIty was also mcreased at 30 days, but none of
the other measures were affected at Day 1 or 30 Modutate et al (1984) also observed a
duratIOn-dependence of effects ReductIOns of succmate-cytochrome c reductase actiVIty m
rat hver homogenates were found dunng the third and fifth day of an 18,800 p,g/m3 (10 ppm)
N02 exposure, but not dunng the fIrst and seventh day, or WIth exposure to 7,520 p,g/m3
(4 0 ppm) NO z Decreases m cytochrome P-450 levels from hver mIcrosomes were also
found after 7 days of exposure to 752 or 7,520 p,g/m3 (0 4 or 4 0 ppm) N02, but not after
exposure to 2,256 /hg/m 3 (1 2 ppm) NOz A reductIOn m NADPH-cytochrome c reductase
actIVIty was found after 5 days of exposure to 7,520 and 18,800 p,g/m3 NO z
13-141
Drozdz et al (1976) found decreased total hver protem and sIahc aCId, but mcreased
protem-bound hexoses m gumea pIgS exposed to 2,000 p.,g/m3 (1 05 ppm) N0 2 , 8 h/day for
180 days LIver alanme and aspartate ammotransferase activIty was mcreased m the
mitochondnal fractIOn In contrast to the effect seen m the cytoplasmIc fractIOn of the
serum, aspartate ammotransferase actiVIty was decreased m the cytoplasmIc fractIOn of the
liver Electron mIcrographs of the hver showed mtracellular edema and mflammatory and
parenchymal degeneratIve changes
Kosmider (1975) reported hver magneSIUm and zmc stores were depleted m gumea pIgS
following exposure to 1,000 p.,g/m3 NOx (mamly N0 2 , ::::::05 ppm), 8 h/day for 120 days
Swollen hver mitochondna were also observed
Ayaz and Csallany (1978) and Csallany and Ayaz (1978) exposed weanhng mIce to
940 or 1,880 p,g/m3 (05 or 1 0 ppm) N0 2 contmuously for 17 mo Ammals were dIVIded
mto three groups recelvmg the basal dIet WIth eIther a nonnal supplement of vitamm E
(30 mg/kg), 300 mg/kg vitamm E, or 30 mg/kg of the synthetic antIOXidant N,N-dIphenyl-
phenylenediamme After 17 mo of exposure, the presence of hpofuscm pIgment m the hver,
lungs, spleen, heart, bram, kidney, and uterus was detennmed No effect could be ascnbed
to N02 exposure
13.2.3.4 Effects on the Kidney and on Urine Content

The dIrect effects of NO z exposure on the kidney and spleen have been descnbed, and
several studIes have explored the compOSItIOn of unne dunng and after exposure These
studIes are summarIZed m Table 13-19 and are dISCUSSed below
TakahashI et al (1986) found that contmuous exposure to 2,256 and 7,520 p.,g/m3
(1 2 and 4 0 ppm) NO z mcreased the amount of cytochrome P-450 and cytochrome bs m the
kidney after 8 weeks of exposure Contmued exposure for 12 weeks resulted m less
substantIal increases m the amount and actiVIty of the mIcrosomal electron-transport
enzymes ThIS IS m contrast to the decreased actIVIty these authors reported for the hver, as
dIscussed m Section 13 2 3 3
YakImchuk and Chehkanov (1972) reported that dunng a 3-mo contmuous exposure to
600 p,g/m3 (0 32 ppm) NO z, rats showed a SIgnIficant mcrease m the unnary excretIOn of
13-142
TABLE 13-19. EFFECTS OF NITROGEN DIOXIDE ON THE KIDNEY AND ON URINE CONTENTS a
N02 ConcentratiOn
SpecIes
p.g/m3 ppm Exposure Gender Age (Stram) Effects Reference
600 032 Contmuous, M NS Rat Increased urmary Yalamchuk and Chebkanov
3 mo (NS) coproporphyrms (1972)
940 05 Contmuous, NS NS GumeapIg Increased urmary protem and Sherwm and Layfield (1974)
7 or 14 days (NS) specIfic graVIty Protems
752 04 charactenstIc of the nephrotIc
syndrome
1,000 ".,05 8 h/day, NS NS Gumea pIg Increased urmary mtnte, mtrate, Koslllider (1975)
120 days (NS) and coproporphyrm
2,260 12 Contmuous, M 22-24 Rat Increased cytochrome P-450 and Takahasm et a1 (1986)
7,520 40 3 mo weeks (JCL Wlstar) b s after 8 weeks of exposure,
less of an effect after 12 weeks
2,260- 1 2- 24h M 6 weeks Rat Increased urmary mtrate, Saul and Archer (1983)
16,500 88 (Sprague- urmary mtnte mcrease appeared
"""'
(,U
I Dawley) to be artIfactual
"""'
.J::>.
(,U
~ = Male
NS = Not stated
coproporphynns Kosmider (1975) also reported mcreased levels of unnary coproporphyrm
m gumea pIgS exposed to 1,000 p,g/m NOx (mamly N02 , ~O 5 ppm), 8 h/day for
3
120 days Increased coproporphynns can mdicate mcreased heme synthesIs, which mIght
occur If an increased number of RBCs were synthesIZed As discussed m SectIOn 13 2 3 2,
N0 2 exposure has been reported to cause polycythemia and an mcrease m the number of
RBCs m the red pulp of the spleen
Increases m urmary protem and specIfic gravIty of the urme were reported by Sherwm
3
and Layfield (1974) m gumea pIgS exposed contmuously to 940 p,g/m (05 ppm) N02 for
14 days Proteinuna was detected m another group of anImals when the exposure was
reduced to 752 p,g/m3 (04 ppm) N02 for 4 h/day DISC electrophoresIS of the urmary
protems demonstrated the presence of albumm and alpha, beta, and gamma globulms The
presence of hIgh molecular weIght protems m urme IS charactenstIc of the nephrotIc
syndrome. DIfferences m water consumptIOn or m the histology of the ktdney were not
found
In a more comprehensIve study of the relatIonship between Inhaled N02 and urmary
mtrite and nitrate, Saul and Archer (1983) exposed rats for 24 h to 2,256 to 16,544 p,g/m3
(1 2 to 8 8 ppm) N02 They demonstrated that mostly mtrate, WIth very httle mtnte, was
excreted m the unne The small amount of unnary mtnte appeared to be an artIfact that
ongmated from an m VItro reactIOn WIth unne The rate and lmeanty of the converSIOn of
N02 to unnary mtrate suggested that N02 does not fonn mtrate by reactmg WIth respIratory
water, but reacts WIth OXidIZable tIssue to fonn mtnte Nitnte IS then further OXIdIZed m the
blood by oxyhemoglobm (Kosaka et al , 1979) to fonn mtrate, which IS excreted m the
3
urine. Nitrite and mtrate were also found m the unne of gumea pIgS exposed to 1,000 p,g/m
NOx (mamly N02 , ~O 5 ppm), 8 h/day for 120 days (Kosmider, 1975)
13.2.3.5 Cardiovascular Effects

Few papers have reported the effects of N02 exposure on the heart PotentIal changes
in hemoglobm and RBCs as well as lung edema could reduce oxygen uptake and affect
cardIovascular perfonnance Because many of the NOTmduced cardIOvascular effects are
secondary to pulmonary edema or stImUlatIOn of sensory receptors m the respIratory tract,
13-144
some of the studIes addressmg effects on the cardIOvasc ular system are addressed m the
diScussIon on pulmonary functIon (see SectIon 13 2 2 3)
3
Suzuki et al (1981) exposed rats for up to 3 mo to between 752 and 7,520 p.,g/m
(0 4 and 4 0 ppm) NO z After 3 rno of exposure to 7,520 p,g/m3 NO z , anesthetIZed rats,
artIficIally ventIlated at hIgh frequencIes, had a sIgmficant reductIOn m PaOz A reductIon m
heart rate was reported m unanesthetIZed mIce exposed to 2,250 or 7,520 p.,g/m3 (1 2 or
40 ppm) NO z for 1 mo (Suzuki et al , 1984)
MessIha et al (1983) exammed rats, whIch prevIously had been mamtamed on 10%
ethanol or drmkIng water as the sole drmkIng flUId, after 3 days of exposure to 9,400 p.,g/rn3
(5 0 ppm) NO z Heart LDH was sIgmficantly elevated m NOz-exposed rats mamtamed on
water, but not m NOz-exposed rats mamtamed on ethanol Because no changes m LDH
were found m hver or serum, the authors suggested that NOz may be responsIble for the
mductIOn of LDH, however, mductIOn by lactate could not be excluded
Tsubone and Suzuki (1984) exammed the effects of NOz exposure on phenyl dIguamde-
mduced cardIOpulmonary changes Rats were preexposed to 18,800 p,g/m3 (10 ppm) NOz
for 24 h, 7,520 p.,g/m3 (40 ppm) for 1 week, or 752 p.,g/m3 (04 ppm) for 4 weeks pnor to
phenyl diguamde mJectIon The cardiopulmonary effects of phenyl diguamde (decreased
heart rate and respIratory rate) were enhanced by exposure to 18,800 p,g/m3 NOz, but not by
lower NO z exposures
Dowell et al (1971) showed decreased cardiac output, blood pressure, PaOz, and pH m
dogs after a I-h exposure to between 13,160 and 30,080 p,g/m3 (7 and 16 ppm) NOz ThIs
IS m contrast to the fmdmgs m an other expenmental anImal specIes exposed to hIgher
concentratIOns of NOz (Abraham et al , 1980) However, exposures m the Dowell et al
(1971) study were dehvered Via an endotracheal tube m anesthetIZed dogs, thereby bypassmg
any scrubbmg effects of the upper arrways
13.2.3.6 Effects on the Central Nervous System and Behavioral Effects

InformatIOn regardmg the effects of NOz on development and annnal behavIOr IS
hmited to a few studIes (see Table 13-20), most of whIch have uncertam relatIonshIps to
humans Shalambendze (1969) exposed rats to 100 p,g/m3 (005 ppm) NO z for 3 mo WIth no
demonstrated effects on the central nervous system Yalamchuk and Chehkanov (1972)
13-145
TABLE 13-20. EFFECTS OF NITROGEN DIOXIDE ON THE CENTRAL NERVOUS SYSTEM AND BEHAVIORa
N02 ConcentratIon
SpecIes
3
50-10,000 003-53 6 h1day, MIF m utero Rat SIgnIficant defects m posture and gaIt were Tabacova et al (1985)
7 days/week (WIStar) detected at 9 and 14 days at 005 ppm,
adchtIonal effects at lugher levels, no
momtonng method was descnbed
100 005 Contmuous, NS NS Rat No effect on CNS Shalambendze (1969)
3 rno
600 032 Contmuous, M NS Rat Decreased condItIoned reflexes to sound and Yalamchuk and
3 mo (NS) lIght Chehkanov (1972)
845 045 7 hlday, M NS Mouse Increased 5-HT, 5-IllAA, and turnover Sherwm et al (1986)
4 weeks (SWISS Webster)
1,000 053 8 hlday, M NS Gumea pIg Decreased malate, sorbItol, LDH, alanme Drozdz et al (1975)
180 days (NS) ammotransferase, ATPase, and
I-" 5'-nucleotIdase homogenate, mcreased
wI
I-" 1,6-diphosphofructose aldolase, Isocitrate,
~ a-hydroxybutyrate dehydrogenase,
0\
phosphocreatme kroase, and cholmesterase
1,880 10 20 mm1day, F 12 weeks Rat More or less constant sWImmmg Tusl et al (1973)
6,580 50 upto6mo (WIStar) perfonnance m only 1 O-ppm group, WIth a
37,600 20 slIght tendency to detenoratIon, decrease of
25 % by fifth and SIxth week of exposure to
5 0 ppm, declmed from first month at
20 ppm
6,580 35 6 hlday, Decreased sWImmmg performance at
8 weeks 35ppm
9,400-75,200 5-40 24 h M 15-16 Mouse Decreased sWlmmmg performance at Suzukt et al (1982a)
weeks (JCL ICR) 10 ppm, mcreased blood lactate compared to
SImIlarly exercIsed controls at 5 0 ppm
TABLE 13-20 (cont'd). EFFECTS OF NITROGEN DIOXIDE ON THE CENTRAL NERVOUS SYSTEM
AND BEHAVIORa
N02 ConcentratlOn
SpecIes
ppm Exposure Gender Age (Stram) Effects Reference
14,000 77 6h NS NS Mouse Decreased voluntary runmng Murphy et al (1964)
activIty, return to normal Withm
24 h postexposure
9,400 50 2 h/day, M NS Gumeapig Depleted total hplds, Faraham and Hasan (1990)
18,800 10 5 weeks (NS) phosphohplds, and cholesterol m
all bram reglOns, except
mcreased cholesterol m spmal
cord, mcreased hPld
peroXldatIon m all bram regIons
9,400 50 2 h/day, M NS Gumeapig Decreased total and protem Faraham and Hasan (1991)
18,800 10 5 weeks (NS) bound sulthydryls, mcreased
nonprotem bound sulthydryls
~ = Male
F = Female
NS = Not stated
CNS = Central nervous system
'i-HT = 5-hydro1(Jfryptaw.lrte
5-HIAA = 5-hydroxymdoleacettc aCId
reported that during a 3-mo contmuous exposure to 600 p,g/m3 (0 32 ppm) N02 , rats
developed an mcreased latency of response to condItioned sound and hght stlIDuh
Exposure of gumea pIgS to 1,000 p,g/m3 (053 ppm) N02 , 8 h/day for 180 days
affected bram enzyme aCtivIty levels (Drozdz et al ,1975) Decreased activIties m bram
protem metabohsm enzymes were seen m bram malate dehydrogenase, alanme
ammotransferase, sorbItol dehydrogenase, LDH, ATPase, 5'-nucleotIdase, and asparagme
ammotransferase Increases m bram glycolytic enzyme activIties were seen m
1,6-diphosphofructose aldolase, ISOcItrate dehydrogenase, alpha-hydroxybutyrate
dehydrogenase, phosphocreatIne kInase, and ebB
A study by Sherwm et al (1986) mdIcated that the bram content of serotonm (5-HT)
and 5-hydroxymdoleacetIc aCId (5-IllAA, the pflIDary metabohte of 5-HT) mcreased m mIce
exposed to 846 p,g/m3 (045 ppm) N02 , 7 h/day for 4 weeks The ratIO of 5-IDAA 5-HT
was also mcreased The authors dId not speculate as to what these observatIOns mean,
however, they noted that increased turnover, as reflected m the mcreased 5-IDAA 5-HT
ratio, have also been observed m tflIDethyltm and chlordecone exposure
Vyskocil et al (1985) measured a vanety of hormone levels and organ weIghts after
continuous exposure to 6,580 p,g/m3 (3 5 ppm) N02 for 1 or 2 mo The only sIgmficant
effect reported was a decrease ill the hypothalamIC concentratIOn of noradrenalme at both
exposure durations
Two recent papers by the same group of authors (Faraham and Hasan, 1990, 1991)
reported neurotoXiC changes m gumea pIgS exposed 2 h/day for 35 days to 9,400 or
3
18,800 p,g/m (5 or 10 ppm) N02 Although the report contams msufficient mformatIOn to
adequately evaluate the exposure and t-tests were used for all compansons, the effects were
substantial, as well as bram regIOn- and concentration-dependent In the fITst study
(Faraham and Hasan, 1990), total hpIds, cholesterol, and phosphohpids were found to be
,
decreased ill a concentratIOn-dependent manner by 4 9 to 41 1 % m three bram regIOns
cerebral hemIsphere, cerebellum, and midbram SlIDllar decrements m hpids were observed
in the spmal cord, except that cholesterol was sIgmficantly mcreased LIpId peroXIdatIon, as
measured by malonaldehyde formatIOn, was mcreased m all four bram regIOns from 7 5 to
46 5 %, agam m a regIOn-dependent and concentratIOn-dependent manner In the second
report (Faraham and Hasan, 1991), usmg the same exposure reglIDen, total nonprotem bound
13-148
(mostly GSH) and protem bound sulfhydryl groups m the same four bram regIOns were
affected by N02 exposure m a concentratIOn-dependent manner Nonprotem bound
3
sulfuydryls sIgmficantly mcreased after 9,440 p.,g/m (5 0 ppm) exposure, whereas protem
bound sulfuydryls decreased m the cerebellum and especIally m the midbram The mcreased
nonprotem sulfuydryls may be a protectIve, compensatory response to the hpid peroXIdatIon
descnbed above, further corroborating that fmdmg, however, the degree of protectIon from
neurotoXIC mJury was not evaluated
As dIscussed m the sectIOn on reproductIve, developmental, and hentable mutagemc
effects (SectIOn 13 2 3 7), Tabacova et al (1985) report1ed sIgmficant postnatal defiCIts m the
onset of normal neuromotor development and reduced open field actIVIty m the progeny of
maternally exposed rats 2 mo after the dams were exposed to 1,000 or 10,000 p.,g/m3 (05 or
5 3 ppm) N02, 6 h/day for 7 days/week Postural and gaIt defects were also reported at
100 p.,g/m3 (005 ppm) No N02 momtormg method was speclfied
Tusl et al (1973) exposed rats to 9,400 p.,g/m3 (5 0 ppm) N02 for 8 weeks The
mfluence of N02 on forced sWilllming endurance tune was measured By the fifth and SIXth
weeks of exposure, SWImmmg performance had decrease,d 25 % In rats exposed to
1,880 p.,g/m3 (1 0 ppm) N02, performance was mamtamed WIth a shght tendency toward
detenoratIOn
A concentratIon-dependent decrease m forced sWilllmmg endurance tIme after a smgle
3
24-h exposure to between 9,400 and 75,200 p.,g/m (5 and 40 ppm) N02 was reported by
SuzukI et al (1982a) SIgmficant decrements m perfornlance were reported at exposure
concentratIOns as low as 18,000 p.,g/m3 (10 ppm) Recovery from exposure reqUITed 5 to
6 days, 7 to 8 days, and over 9 days for the 9,400, 18,800, and 37,600 p.,g/m3 (5, 10, and
20 ppm) groups, respectIvely In an attempt to examme the mechamsm that produced the
decrement m performance, It was observed that as forced SWImmmg endurance tIme
decreased, lung edema mcreased Furthermore, compared to snmlarly exerCIsed control rats,
3
blood lactate concentratIOn was mcreased m rats exposed to 9,400 p.,g/m both ImmedIately
and 24 h after exposure These two fmdmgs suggest that lung edema prevented suffiCIent
02 from entermg the blood durmg exerCIse to meet aerobIC demands See SectIOn 13 2 2 3
on pulmonary functIOn
13-149
13.2.3.7 Reproductive, Developmental, and Heritable Mutagenic Effects
As summanzed m Table 13-21, few studIes have exammed the effects of N02 on
reproductIon and development or the hentable mutagemc potentIal of N0 2 m VIVO Exposure
to 1,880 p..g/m3 (1 °
ppm) N02 , 7 b1day, 5 days/week for 21 days resulted m no alteratIOns
m spermatogenesIs, germmal cells, or mterstItIal cells of the testes m SIX rats (Knpke and
Sherwm, 1984) AddItIonally, the level of vitamm B12 , a coenzyme m folate metabohsm
that IS used for DNA synthesIS, was not affected by N02 exposure SImIlarly, breedmg
studies by Shalambendze and Tsereteh (1971) found that long-term N0 2 exposure had no
effect on fertility However, there was a decrease m htter SIZe and neonatal weIght when
male and female rats exposed to 2,360 p..g/m3 (1 3 ppm) N02 , 12 h/day for 3 mo were bred
In utero death due to N02 exposure resulted m smaller htter SIZes, but no dIrect teratogemc
effects were observed m the offspnng In fact, after several weeks, N02-exposed htters
approached weIghts sImIlar to controls
In the only study that has exammed postnatal development, a SIgnIficant delay m eye
opemng and mCIsor eruptIon was observed m the progeny of maternally exposed Wistar rats
(Tabacova et al ,1985) The dams were exposed to 50, 100, 1,000, or 10,000 p..g/m3 (0 03,
0.05, 05, or 5 3 ppm) N0 2 for 6 b1day, 7 days/week throughout gestatIOn and the offspnng
were studied for 2 mo postexposure SIgnIficant effects were detected m the offspnng of
dams exposed to 1,000 and 10,000 p..g/m3 N02 There were also concentratIOn-related
increases m neurobehavIOral development reported m the offspnng of the maternally exposed
animals These rmdmgs are dIscussed m the sectIon on N02 effects on the central nervous
system and behavior (SectIon 13 236) The method of momtonng N02 was not reported
Balabaeva and Tabakova (1985) exposed pregnant and nonpregnant albmo rats to
1,000 or 10,000 p..g/m3 (05 or 5 3 ppm) N02 , 5 h/day for 21 days and exammed hpid
peroxidation m lung, hver, and placenta Nonpregnant rats had greater hpid peroXldatIOn m
the liver than m the lung, whereas the OppOSIte was true m pregnant rats Even more
surpnsmg was a fourfold mcrease m hpid peroXldatIon m the placenta of 1O,000-p..g/m3
N02-exposed rats compared to unexposed pregnant controls The authors then exammed the
offspring of the pregnant rats The I-mo-old F 1 nonpregnant rats, exposed to arr or the same
concentratIons of N02 , showed sImIlar changes as were observed m theIr mothers
13-150
TABLE 13-21. EFFECTS OF NITROGEN DIOXIDE ON REPRODUCTION, DEVELOPMENT,
AND HERITABLE MUTAGENESISa
N02 Concentration
SpecIes
3
",g/m ppm Exposure Gender Age (Stram) Effects Reference
50 003 6 hlday, M/F m utero Rat ConcentratIon-dependent delay Tabacova et al (1985)
100 005 7 days/week, (Wlstar) m eye openmg and mCIsor
1,000 05 21 days eruptIOn m progeny of dams
10,000 53 exposed to 0 5 or 5 3 ppm
dunng gestation Momtormg
method not descnbed
188 o1 6h M NS Mouse No mcrease m chromatId- or Gooch et al (1977)
1,880 10 (C3H) chromosome-type alterations m
I
9,400 50 leukocytes or pnmary
18,800 10 spennatocytes ImmedIately and
--
1 to 2 weeks postexposure No
mutagemc effects
wI
-
1,880 10 7 hlday, M NS Rat No alteratIOns m Knpke and Sherwm (1984)
VI 5 days/week, (LEW/fmal) spennatogenesls, germma, or
21 days mterstItIal testicular cells, no
effect on VItamm BIz
2360 13 12 hldllY, F NS Rat No effe.ct on fertlhty, but htter Shalambendze and Tsereteh
3 mo (NS) SIze and weIght were decreased (1971)
No teratogemc effects
18,800 10 Contmuous, M/F m utero Rat Decreased htter SIze and Freeman et al (1974b)
from pregnancy (NS) mortahty of neonates up to
to 3 mo after 15 days postdehvery No
dehvery teratogemc effects noted
~:= Male
F := Female
NS = Not stated
However, pregnant F 1 rats, exposed to 1,000 or 10,000 fJ-g/m3, had a 9- or 17-fo1d mcrease
m placental hpid peroXldes, respectively The authors report that mcreased placental
formatlOn of tOXlC hpid peroXldes m the F 1 rats could be due to decreased blood GSH
(no measurements presented) and that such levels of hpid peroXldes could be fetotoXlc
However, the methods of momtormg N02 and hpid peroXldes were not reported, nor were
the statistical methods
Potential mUtagemc effects were mvestIgated by Gooch et al (1977), who reported that
exposure to 188, 1,880, 9,400, and 18,800 fJ-g/m3 (0 1, 1 0, 5 0, and 10 ppm) N02 for
6 h dId not mcrease eIther chromatid or chromosome aberratlOns m the leukocytes of mIce
Blood samples were obtamed Immediately after exposure and 1 and 2 weeks postexposure
SImIlarly, no mcrease m the number of translocatIons m pnmary spermatocytes was detected
Therefore, the authors concluded that N02 exposure dId not mduce mutagenesIs m these
expenments
13.2.3.8 Potential Carcinogenic or Cocarcinogenic Effects

No dIrect eVIdence millcates that tumors may be produced by N0 2 exposure alone
Several stuilles have evaluated the Issue of carcmogenesis and cocarcmogenesIs, but results
are often unclear or confhctmg Insofar as we are aware, there are no pubhshed reports on
stuilles usmg claSSIcal carcmogenesis whole-anImal blOassays An excellent cntIcal reVIew
and illscusslOn of some of the Important theoretical Issues m mterpretmg these types of
studIes was written by WitschI (1988) Table 13-22 summanzes mformatIon on the
carcmogemc or cocarcmogemc potential of N02
Studies of Hyperplasia and Enhanced Retrovzms Expression

HyperplaSia of the lung epIthehum, although a common response to lung mJury, could
...
be construed as suggestmg a potential carcmogemc or cocarcmogemc effect of N02
However, the relatively frequent reports of hyperplaSia, as dISCUSSed m SectlOn 13 2 2 4 on
morpholOgical effects, illd not mclude the observatlOn of any tumors It should be noted that
these studIes were not desIgned to detect tumors, so It IS not surpnsmg that none were found
NakaJIffia et al (1972) found hyperplastic fOCI due to prohferatlOn of epIthehal cells of the
termmal bronchIoles and alveoh m mIce exposed to 940 to 1,504 fJ-g/m3 (0 5 to 0 8 ppm)
13-152
TABLE 13-22. EFFECTS OF NITROGEN DIOXIDE ON CARCINOGENESIS OR COCARCINOGENESISa
N02 Concentration
SpecIes
3
75 004 Contmuous, Rat NOnSIgnIficant mcrease m Ichmose et al (1991)
752 04 17 rno BHPN-mduced tumors WIth
7,520 40 exposure to 4 0 ppm
188 01 o 5-4h M 7 weeks Mouse MIce exposed to DMA had Iqbal et al (1981)
1,880 10 (ICR) whole-body concentratIOn-related
18,800 10 mcrease m DMN
470 025 7 hlday, F 5 weeks mIce Fewer spontaneous lymphomas RIchters and DamJI (1990)
5 days/week, up (AKRIcum) and mcreased survIval time
to 181 days
658 035 7 hlday, M 5 weeks Mouse SIgnIficant mcrease m lung RIchters and RIchters (1989)
5 days/week, (C57BL/6J) tumors m mIce mJected WIth
6 or 12 weeks melanoma cells at 6 weeks
....... 752 04 8 hlday, M NS Mouse Increased lung tumors m mIce RIchters and KuraItIs (1981)
w I
....... 1,504 08 5 days/week, (SWISS Webster, mJected WIth melanoma cells
Ul 10-12 weeks C57BL/6J) after N02 exposure
w
940-1,504 05-08 Contmuous, F 4 weeks Mouse Hyperplastic fOCI Identical to NakajIma et al (1972)
30 days (ICRICL) those observed after exposure to
known carcmogens
1,504 08 8 hlday, M/F 6 and 10 Mouse Enhanced retrOVIrUS expreSSIOn Roy-Burman et al (1982)
5 days/week, weeks (SWISS Webster, m two strams of mIce
18 weeks AKR)
1,800 10 6 hlday, Mouse No effect at 1 0 or 5 0 ppm At AdkIns et al (1986)
9,400 50 5 days/week, (Al) 10 ppm, spontaneous adenomas
18,800 10 6 weeks m stram All mIce mcreased only
when compared to pooled
control group
2,000 11 Contmuous, M/F NS Rat DMA plus N02 dId not produce Benemanskll et al (1981)
3,000 16 lIfetime (NS) tumors Nitroso-DMA, DMA,
and N02 produced excess
tumors
TABLE 13-22. EFFECTS OF NITROGEN DIOXIDE ON CARCINOGENESIS OR COCARCINOGENESIS8
N02 Concentration
Spect.es
3
9,400 50 Contlnuous, NS 5 weeks Rat Hyperplastic fOCI at 3 weeks ReJthar and ReJthar (1975)
up to 11 weeks (NS) Decreased ciliated cells
ExtensIve hyperplasIa, CUbOIdal
metaplasIa by 5 weeks
Decreased broncmolar lumen
and polymorphous eplthehum by
7 weeks Increased cl1lated cells
and decreased eplthehallayers at
9 weeks By 11 weeks, return
to one-layer epithehum
9,400- 5-10 2 h/day, NS NS Mouse 4-Nltroqumolme-l-oXlde durmg Ide and Otsu (1973)
18,800 5 days/week, (NS) NO z exposure had no effect on
50 weeks tumor production
I-"
wI 18,800 10 2 h/day, NS 4 weeks Mouse MIce gIven 4-mtroqumolme-l- Otsu and Ide (1975)
I-" 5 days/week, (NS) oXlde and NO z NO z decreased
VI
,J::.. 50 weeks mCldence of lung tumors
28,200- 15- 1-4 h M NS Mouse MIce gavaged with morpholme Iqbal et al (1980)
94,000 50 (ICR) had concentration-dependent
mcrease m whole-body content
ofNMOR
31,000- 165-205 5-6 h/day, M NS Mouse In VIVO production of NMOR Van Stee et al (1983)
38,500 4 days, plus 3 h (CD-i) when 1 g/kg of morpholme was
on fifth day admmlstered each day pnor to
exposure
aBHPN = N-bls(2-hydroxypropyl) rntrosanune

M = Male
DMA = Dunethylanune
DMN = Dunethylrntrosamme
F = Female
NS = Not stated
NMOR = N-rntrosomorpholme
N02 for 30 days The authors reported that these lesIOns were completely Identical to early
changes that appeared m the development of pulmonary adenomas after admlIllstratIOn of
known carcmogemc chemIcals such as IsomazId, urethane, and 4-mtroqumolme-l-made
(4NQO) However, no adenomas were detected
Rejthar and Rejthar (1975) exposed rats to 9,400 p,g/m3 (5 0 ppm) N02 contmuously
for penods of 3, 5, 7, 9, or 11 weeks After 3 weeks of exposure, the bronchioles had
a umform cubOIdal one-layer epIthehum composed of nonciliated cells The cells showed
vacuohzatIOn, and hyperplastic fOCI appeared m the bronchiolar epIthehum The fOCI were
two- to four-layer pyramIdal formatIOns By 5 weeks, e'xtensive hyperplasia composed of
three to four layers of epIthehal cells was apparent Centers of cubOIdal metaplasia were
found m adjacent alveoh By 7 weeks, hyperplasIa was apparent m all bronchioles, thereby
narrowmg the bronchiolar lumen The polymorphous epIthehum was extenSIve WIth a few
ciliated cells m hyperplastic areas After 9 weeks, the termmal bronchiolar epIthehum
generally showed two or three Irregular layers The number of ciliated cells mcreased, but
cilia were often located atypIcally m mtercellular spaces A return to a smgle layer of
epIthehum WIthout cilia was observed after 11 weeks Seven weeks after exposure to N02 ,
the lungs appeared to be m a state of reparr, movmg towards reversal of the leSIOns
The pOSSIbility that N02 may facilitate the production of tumors has been suggested and
exammed by several authors Endogenous retrovIrUS expressIOn was enhanced m the spleen
of low-expressor SWISS Webster mIce after exposure to 1,500 p,g/m3 (0 8 ppm) N02 ,
8 h/day, 5 days/week for 1 or 18 weeks (Roy-Burman et al ,1982) However,
measurements taken at mtermedIate time pomts were nolt dIfferent from controls Hlgh-
expressor AKR mIce also showed an mcrease m the concentration of vIrUs-specIfic RNA m
the spleen after 8, 12, or 15 weeks of exposure to 564 /-tg/m3 (03 ppm) N02 The authors
suggest that such data may mdIcate mappropnate or illOldmate expressIOn of genes that could
potentially mfluence genetically controlled diseases, such as cancer
Studies with Nitrogen Dioxule Plus Known Carcinogens

Ide and Otsu (1973) StudIed tumor production m conventIOnal mIce receIvmg five
weekly mjectIons of 0 25 mg 4NQO (a lung-tumor-specllfic carcmogen) when the anImals
were exposed from birth to a N0 2 concentratIOn between 9,400 and 18,800 p,g/m3 (5 and
13-155
10 ppm), 2 h/day, 5 days/week for 50 weeks There was no dIfference m the number of
tumors produced by 4NQO alone (6 of 10) and the number produced m combmatIOn wIth
N02 (6 of 13) MIce exposed to N02 alone had a sImIlar number of tumors as the arr
controls Thus, N02 dId not facilitate the productIOn of tumors
One of the goals of a study by Benemansky et al (1981) was to evaluate the potential
of N02 to influence the productIOn of tumors durmg coexposure to a known carcmogen,
nitrosodImethylamme (NDMA) or ItS precursor, dImethylamme (DMA) No excess tumors
were observed m rats durmg a contmuous ltfetIme exposure to the combmatIon 0 07 mg/m3
DMA + 2,000 p.g/m3 (11 ppm) N02 ThIs suggested that N02 dId not convert DMA to
NOMA, which alone was shown to produce tumors However, when the rats were exposed
to NOMA at a concentratIOn that alone dId not produce tumors (006 mg/m3 ), an excess of
tumors, especIally in males, was observed when DMA (0 05 mg/m3 ) plus N02
(3,000 p.g/m3 , 1 6 ppm) was added to the exposure Appropnate statistical techniques and
control groups were not mcorporated mto the deSIgn, and the methods of exposure and
momtoring of N02 were not reported, makmg the study dIfficult to evaluate
In a simIlarly deSIgned study, Ichmose et al (1991) evaluated rats mjected WIth
N-bIs(2-hydroxypropyl) mtrosamme (BHPN) and contmuously exposed to 75, 752, or
3
7,520 p.g/m (004, 04, or 40 ppm) N02 for 17 mo Although theIr data mdicated five
times as many lung adenomas or adenocarcmomas m the rats mjected WIth BHPN and
exposed to 7,520 p.g/m3 (40 ppm) N02 , the results faIled to achieve statIstical sIgmficance
usmg a elu-square test NItrogen dIOXide exposure alone caused no sIgmficant mcrease m
tumors
Facilitation of Metastases
Rlchters and KUraItiS (1981) performed two expenments m which mIce were exposed to
eIther 752 or 1,500 p.g/m3 (04 or 0 8 ppm) N02 , 8 h/day, 5 days/week for 10 or 12 weeks,
respectively After exposures were termmated, the mIce were mjected mtravenously WIth a
cultured-denved melanoma celllme (B16) The first expenment suggested that there was an
increased tumor yIeld If tumors were counted at 21 days postmjectIOn, however, they dId not
observe a sIgmficant mteractIOn or mam tIme effect m the analySIS of vanance For the
second experiment, they chose a 3-week tIme penod to count tumors The results mdicated
13-156
an mcreased number of tumors m the N02 group compared to fIltered chamber and room arr
control groups The authors concluded that N02 mIght facilitate the metastases of tumors,
agam, these conclUSIOns were based on mappropnate statistICS In more recent expenments,
conSIstent effects have not been observed For example, tumor facilitatIon was observed
when mIce were exposed to 564 or 752 p,g/m3 (0 3 or (I 4 ppm) N02 for 12 weeks (RIchters
3
and KUraItIs, 1983) However, when mIce were exposed to 940 p.,g/m (05 ppm) for
3
8 weeks (RIchters and KUraItIs, 1983) or 752 p,g/m (0 4 ppm) for 12 weeks WIth
mtenmttent arr exposures (RIchters and RIchters, 1983), facilitatIOn was not observed
RIchters et al (1985) attempted to extend theIr fmdmgs by showmg that, If allowed, the
mcreased metastases from exposure to 752 p,g/m3 (0 4 ppm) N02 for 12 weeks led to
mcreased mortalIty m the mIce However, theIr post hoc analySIS of the data precludes thIs
conclUSIOn More recently, RIchters and RIchters (1989) exposed mIce to 658 p.,g/m3
(035 ppm) N02 for 6 or 12 weeks, and exammed tumor facilitation or lung mjury after B16
melanoma mJectIon The authors reported mcreased facilitation at 6 weeks (p = 0 04,
t-test), however, no StatiStICal evaluatIOn of the 12-week results were reported The author)
further claIm that N02-mduced mJury to pulmonary endothehum may facilitate the retentIOn
of the mJected melanoma Agam, thIs result (number of microthrombi m lung, p = 0 10)
t-test) was found only after 6 weeks of exposure (not at 12 weeks) and only when exammed
24 h after melanoma mJectIOn (not at 4 h) Pulmonary endothehal mJury from N02 alone
was not exammed Furthermore, the actual expenmental deSIgn used m these studies
probably dId not evaluate metastases formatIOn, as the term IS generally understood, but
more correctly, evaluated colomzatIon of the lung by tumor cells StudIes m a true tumor
metastases model, such as the Lobm WIStar rat, should be performed
An abstract by Wembaum et al (1987) mdICated that N02 could mhIbit metastases
formatIon If exposure occurred after mJectIon of the B16FI0 tumor cell suspensIon Thus,
studIes showmg facilitatIOn of tumor colomzatIOn m the lung after N02 exposure should be
VIewed WIth cautIOn because N02 may InhIbIt metastase,s as well as facilitate theIr
colomzatIOn
13-157
Studies in Animals with Spontaneously High Tumor Rates
A study by Wagner et al (1965) suggested that NOz may accelerate the productIOn of
tumors in CAF1/JAX mIce (a stram that IS genetIcally susceptIble to pulmonary tumors) after
contInuous exposure to 9,400 p.g/m3 (5 0 ppm) NOz At the 12-mo evaluatIOn, 7 of 10 mIce
had tumors ill the exposed group, compared to 4 out of 10 ill the controls The number of
tumors per ammal was not reported At the 14- and 16-mo evaluatIon, no dIfferences ill
tumor productIon were observed A statIstIcal evaluatIon of the data was not presented
The frequency and illCIdence of spontaneously occurnng pulmonary adenomas was
found to illcrease ill stram AlJ mIce after exposure to 18,800 p.g/m3 (10 ppm) NOz for
6 h/day, 5 days/week for 6 mo (AdkIns et al , 1986) These small, but statIstIcally
SIgnIficant, increases were only detectable when the control response from nme groups
(N=400) were pooled Exposure to 1,880 and 9,400 p.g/m3 (1 0 and 5 0 ppm) NO z dId not
increase the number of spontaneous adenomas ill thIs ill VIVO short-term model for predIctmg
carcmogemcity
A study by RIchters and Dam]I (1990) evaluated the effect of exposure to 470 p.g/m3
(0.25 ppm) NOz, 7 h/day, 5 days/week for up to 181 days on the development and
progressIOn of spontaneous T-cell lymphomas m AKRIcum mIce TheIr results mdicated that
control ammals developed lymphomas earher and theIr survIVal tIme was less than NOz-
exposed mIce The reason for the mcreased illCIdence and progressIon of the lymphoma m
control animals over that seen m N0z-exposed ammals was attnbuted to the decrease m
T-helper/mducer (CD4+) lymphocytes, whIch produce growth factors for lymphomas, m the
spleen of NOz-exposed mIce A dISCUSSIOn of NOz-mduced effects on host lymphocyte
populations appears ill SectIon 13 2 2 1 on host defense mechamsms
Production of N-Nztroso Compounds

Because of eVIdence that NOz could produce mtnte and mtrate m the blood, and mtnte
is known to react WIth ammes to produce ammal carcmogens (mtrosammes), the pOSSIbility
that NOz could produce cancer VIa mtrosoamme formatIOn has been illvestIgated
Iqbal et al (1980) was the fIrst to demonstrate a hnear tIme-dependent and
concentratIon-dependent relatIOnshIp m the amount of N-mtrosomorphohne (NMOR), an
animal carcinogen, found ill whole-mouse homogenates after the mIce were gavaged WIth
13-158
2 mg of mOlphohne (an exogenous amme that IS rapIdly mtrosated) and exposed for between
1 and 4 h to 28,200 to 94,000 p.g/m3 (15 to 50 ppm) N0 2 Thus, because NMOR
(a mtrosamme) IS an anImal carcmogen, these studIes ale sometImes used to suggest that
N0 2 exposure could theoretically react wIth ammes m the body to produce tumors
Iqbal et al (1981), usmg DMA, an amme that IS slowly mtrosated to
dlmethylmtrosamme (DMN), found a concentratIOn-related mcrease m bIOsynthesIs of DMN
3
at N02 concentrations as low as 188 p.g/m (0 1 ppm), however, the rate was sIgmficantly
3
greater at concentratIOns above 18,800 p.g/m (10 ppm) N02 Increased length of exposure
also mcreased DMN formation between 0 5 and 2 h, but syntheSIS of DMN was less after
3 and 4 h of exposure than after 0 5 h
MrrviSh et al (1981) concluded that the results of Iqbal et al (1980) were techmcally
flawed Accordmg to these researchers, the Iqbal et al (1980, 1981) method, whIch
mvolved homogemzatIOn of the whole frozen mouse, did not use an adequate stoppmg
solutIOn to prevent m VItro productIOn of mtrosammes Accordmg to MrrviSh et al (1981),
they could venfy the results of Iqbal et al (1981) by ehmmatmg the use of the stoppmg
solutIOn, but found no m VIVO productIOn of NMOR when m vItro productIOn was
ehmmated However, they dId :fmd that m VIVO exposure to N02 could produce a mtrosatmg
agent (NSA) that would mtrosate morphohne when morphohne was added m vItro
Additional expenments showed that NSA was localIZed m the sIan (Mrrvish et al , 1983) and
that mouse sIan cholesterol was a hkely NSA (Mrrvish et al , 1986) It has also been
reported that only very hpid soluble ammes, whIch can penetrate the sIan, would be available
to the NSA Compounds such as morphohne, WhICh IS not hpid-soluble, could only react
wIth N02 when It was pamted drrectly on the sIan (Mrrvish et al , 1988)
Iqbal (1984), respondmg to the cntIcisms of MrrvlSh et al (1981), concluded after the
completIOn of several control expenments that m VItro mtrosatlon could only account for
between 1 to 2 % of the total amount of NMOR collected usmg hIs preVIOUS techmque (Iqbal
et al ,1980). Several control expenments further suggt,sted that the effects m the ongmal
expenments were due to m VIVO mtrosatIOn One expenment showed that mtrosamme
bIOsynthesIs could be mhlbited m VIVO WIth the additIOn of sulfamate, ascorbate, or
a-tocopherol pnor to N02 exposure Another expenment mdicated that the rapId half-hfe of
morphohne (48 to 54 mm) mIght explam why sIgmficalllt levels were not found by MrrviSh
13-159
et al (1981) because they transferred the N02-exposed rats to room arr for 30 mm pnor to
sacnfice In VIVO mtrosatIon was also demonstrated by Norkus et al (1984) after morphohne
admmistratIon and a 2-h exposure to 84,600 p,g/m3 (45 ppm) N02
PostlethwaIt and Mustafa (1983) exammed thIs problem of m VIVO productIOn of
mtrosamines usmg an Isolated perfused rat lung Rat lungs were ventIlated WIth
37,400 p,g/m3 (19.9 ppm) N02 and the perfuSIOn medIa was supplemented WIth 10 mM of
morphohne An excess of NMOR was found m the N02-exposed group when lung tIssue
and perfusate were combmed Control expenments could not exclude the possIbility that
NMOR was produced m the perfusate
Another study (Van Stee et al , 1983) reported that NMOR was produced m mIce
gavaged WIth 1 g of morphohne/kg of body weIght/day and then exposed to 31,020 to
38,540 p,g/m3 (165 to 20 5 ppm) N02 , 5 to 6 h/day for 5 days The smgle SIte contaImng
the greatest amount of NMOR was the gastromtestmal tract Regardless of whether m VIVO
nitrosation can occur, the relatIve sIgmficance of mtnte from N02 compared to mtnte
resulting from food, tobacco, and mtrate-reducmg oral bactena IS questIOnable (Murma
et al , 1982)
Aside from mtrosammes, other eVIdence suggests the pOSSIbility that mhaled N02 may
be involved in the productIon of other potentIally hazardous N-mtroso compounds Protem
and peptIdes may undergo mtrosatIon to produce dIazO denvatlVes, most of whIch are
mutagemc and/or carcmogemc Challis et al (1987) suggested, based on m VIVO stumes,
that dlazopeptIdes could be produced from mhaled N02 that IS absorbed mto the blood
These mazopeptIdes would be relatIvely stable at blood pH so as to allow them to act as
CIrculatIng carcmogens
Summary
Exposure to N02 produce a WIde array of health effects beyond the confmes of the
lung. EVIdence suggests that N02 and/or some of ItS reactIve products penetrate the lung
and enter the blood, producmg alteratIons m the blood and other organs
Confhctmg results have been reported on whether N02 affects body weIght gam m
expenmental anImals One study reported that N02 dId not affect body weIght gam m
rabbits, gumea pIgS, rats, hamsters, and mIce at exposure concentratIons of up to
13-160
47,000 p,g/m3 (25 ppm) and dogs at 9,400 p,g/m3 (5 0 ppm) for up to 18 mo (Wagner et al ,
1965) However, a dechne ill body weIght ill gumea plgS exposed contmuously to
3
1,880 p,g/m (l 0 ppm) for 6 mo (Kosmider et al , 1973b) and ill rabbIts exposed to
2,400 p,g/m3 (1 3 ppm) for 15 to 17 weeks (Mitma, 1962) has been reported Newborn mIce
appear to be more sensItive to N02 exposure than adult mIce (KUraItIs et al , 1981, RIchters
et al , 1987), but based on lImIted data, JuvenIle rats appear to be less sensItIve to the effects
of N02 exposure than young adult rats (Stevens et al , 1988)
NItrogen dioXIde-mduced changes ill blood constituents may result from the drrect effect
of N02 , formation of mtrate and mtnte, or secondary effects emanatmg from other organs
such as the lung, hver, heart, kidneys, and spleen No effect on hematocnt and hemoglobill
have been reported ill squIrrel monkeys exposed to 1,880 p,g/m3 (1 0 ppm) N02 for 16 mo
(Fenters et al , 1973) and m dogs exposed to up to 9,400 p,g/m3 (5 0 ppm) for 18 mo
(Wagner et al , 1965) There was, however, polycythemIa and an mcreased ratIO of PMNs
to lymphocytes found ill rats exposed to 3,760 + 1,880 ~tg/m3 (2 0 + 1 0 ppm) N02 for 14 mo
(Funosl et al , 1973) There have also been reported changes ill the RBC membranes of
expenmental ammals followillg N02 exposure Red blood cell D-2,3-dlphosphoglycerate was
reportedly illcreased ill guillea pIgS exposed to 677 p,g/rn3 (0 36 ppm) N0 for 1 week
2
(Mersch et al , 1973)An illcrease ill RBC SIalIC aCId, illdicative of a younger populatIOn of
RBCs, was reported m rats eXJPosed to 7,520 p,g/m3 (40 ppm) continuously for 1 to 10 days
(Kummoto et al , 1984), but ill another study, exposure to the same concentratIOn of N02
produced a decrease ill RBCs (MochItate and MIUra, 1984)
Decreases m serum protems and hpoproteills and increases m serum globuhns,
illdicatmg N02-illduced hepatic damage, have also been reported (Drozdz et al , 1976,
Menzel et al , 1977, Kosmider et al , 1973a, KosIDIdeI, 1975) NItrogen dIOXide illcreased
pentobarbital-illduced sleepillg times ill female mIce after a 3-h exposure to 470 p,g/m3
(0 25 ppm) (Miller et al , 1980), suggestmg effects on hepatic xenobIOtIc metabohsm The
effects only occurred at specIfied time penods after exposure ended and did not perSIst
beyond 1 day. SImilar effects (mcreased hexobarbital-1l1duced sleepmg tIme) were reported
m the progeny of maternally exposed rats on Postexposure Days 7 and 21, but not on
Day 14, after bemg exposed to 1,000 p,g/m3 (0 5 ppm) N0 (Tabacova et al , 1985)
2
Decreases m cytochrome P-450 levels ill rat hver mICrosomes have been found after 7 days
13-161
of exposure to 752 or 7,520 p,g/m3 (04 or 40 ppm), but not after exposure to 2,260 p,g/m3
(1.2 ppm) N02 (Moclntate et al , 1984)
Contrary to the rmdmg of decreased amounts of cytochrome P-450 m hver homogenate
followmg N02 exposure, cytochrome P-450 and cytochrome bs levels were mcreased m the
kidney of rats after 8 weeks of exposure to both 2,260 and 7,520 p,g/m3 (1 2 and 4 0 ppm)
N02 (Takahashi et al , 1986) NItrogen dIOXide has also been reported to mcrease urmary
concentrations of coproporphyrms, mdicatmg a possIble mcrease m heme syntheSIS, at N02
exposure concentratIOns of 600 p,g/m3 (032 ppm) over a 3-mo penod (YakImchuk and
Chehkanov, 1972) and has mcreased urmary alpha, beta, and gamma globuhns m gumea pIgS
exposed to 752 p,g/m3 (0 4 ppm) N02, 4 h1day for 14 days (Sherwm and Layfield, 1974)
Only limIted mfonnatIOn IS avaIlable on the effect of N02 on the heart NItrogen
dioXIde-mduced effects on cardIac perfonnance are suggested by a slgmficant reductIOn m
Pa02 m rats exposed to 7,520 p,g/m3 (4 0 ppm) N02 for 3 mo When exposure was
decreased to 752 p,g/m3 (0 4 ppm) over the same exposure penod, Pa02 was not affected
(Suzula et al , 1981) Also, a reductIOn m heart rate has been shown m mIce exposed to
both 2,250 and 7,520 p,g/m3 (1 2 and 4 0 ppm) N02 for 1 mo (Suzuki et al , 1984)
However, whether these effects are the dIrect result of N02 exposure or secondary to lung
edema and changes m blood hemoglobm content, IS not known
From the limIted mfonnatIOn avaIlable, It would appear that N02 affects the central
nervous system Decreased actIVIty of protem metabohzmg enzymes, mcreased glycolytIc
enzymes; changes m neurotransmItter levels (5-HT and noradrenahne), and mcreased hPld
peroXIdatIon, accompamed by hpid profile and antIOXidant changes, have been reported
(Farnham and Hasan, 1990, 1991, Sherwm et al , 1986, Drozdz et al , 1975)
Unfortunately, none of these effects have been rephcated and all reports lack suffiCIent
methodolOgical rigor, thus, the ImphcatIOns of these rmdmgs, albeIt Important, are not clear
and require further mvestIgatIon
The available data do not support the pOSSIbility that N02 IS a dIrect actmg carcmogen
The data that suggest that N02 may act as a promoter or facilitator of neoplastic dIsease are
fraught WIth methodologIcal and mterpretive problems The eVIdence suggests that further
study may be warranted
13-162
13.3 EFFECTS OF MIXTURES CONTAINING NITROGEN DIOXIDE
Exposure to pollutant muctures m ambIent aIr provIdes a basIs for possible tOXicologIC
mteractIOns, whereby combmatIOns of pollutants may b~~have dIfferently than would be
expected from consIderatIOn of the actIon of each constItuent separately In many cases, the
study of mIXtures contammg N02 mvolved exposures to only two pollutants, and the role
played by each can be elucIdated WIth the appropnate elCpenmental deSIgn However, there
IS a farrly large data base that mvolves mIXtures of more than two components, often WIth no
smgle pollutant control, so the contnbutIOn of each mdividual agent to overall response IS
often obscure In some cases, the N02 (or NOx) may have vaned between exposure groups,
or N02 was present m one group and not m another, so ItS relatIve mfluence could be
assessed Thts sectIOn focuses on those studIes where the role of N02 (or NOx) can be
elucIdated
Szmple Mixtures Contazning Nitrogen Dzoxzde

Table 13-23 outlmes those studIes m whIch experumental anImals were exposed to
constant levels of an atmosphere contammg N02 WIth only one other pollutant (bmary
mIXtures) The table IS categonzed by pollutants m the mIXture and further subdIVIded by
class of effect By far, the largest data base IS for N02 plus 03 ExaminatIOn of these
studIes mdicates that vanous degrees and types of mternctIon may occur The morphologic
response to an N02/0 3 mIXture, as reported by Freeman et al (1974a) and Yokoyama et al
(1980), was pnmanly that due to 03 alone, although m these studIes, the levels of N02 used
would have produced only small changes (by hght mICroscopy) that would easIly be obscured
by the more potent 03 Acute lethahty and some bIOchemICal responses to N02 /0 3
mIXtures mvolve synergIsm (e g , Diggle and Gage, 19~)5, Mustafa et al , 1984, Sagal and
Ichmose, 1991, Lee et al , 1989), some have ascnbed t11IS mteractIOn to the productIon of
new reactIon products m the exposure atmosphere On the other hand, antagomsm has also
been reported for effects of N02 and 03 m some enzyme systems (TakahashI and MIUra,
1989)
In terms of host antImIcrobIal defense, tOXicologIC mteractIons mvolvmg N02 and
03 are generally addItIve after acute exposures It seems that each pollutant contnbutes to
13-163
TABLE 13-23. TOXICOLOGIC INTERACTIONS TO SIMPLE:MIXTURES CONTAlNING NITROGEN DIOXIDEa
Pollutant Species Response
ConcentratIon Exposure Gender Age (Stram) End Pomts to MIxture InteractIon Remarks Reference
NOZ + 03
NO z (3,390- 4h M NS Rat Mortaltty, Increase SynergistIc InteractIon due to Diggle and
3
30,200 p..g/m , (NS) dyspnea productIon of Gage (1955)
18-475 ppm) mtrogen
+ 03 (11,000-3
pentoXlde
23,300 p..g/m ,
50-10 7 ppm)
3
NO z (4,700 p..g/m , 6 mo M 4 weeks Rat Morphology Hypertrophy of None Lesion due Freeman et al
25 ppm) + 03 (Sprague- alveolar duct pnmarxly to 03 (1974)
3
(490 p,g/m , Dawley) eplthehum
025 ppm)
3
NO z (1,690 p,g/m , 60 days Emphysema None Lesion due
o 9 ppm) + 303 pnmarxly to 03
I-'
wI (1,760 p,g/m ,
I-' 09 ppm)
0\
+:>. 3
NO z (10,300 p..g/m , 3 h/day, M 8 weeks Rat Enzyme actIvity Increase SynergIstIc Yokoyama
5 5 ppm) + 03 14 days (Wlstar) et al (1980)
3
(2,160 p..g/m ,
1 1 ppm)
3
NO Z (10,200 p..g/m 3 h/day, 7 weeks Morphology Increase None or addItIve
5 4 ppm) + 03 14 or pulmonary no change
3
(1,960 p..g/m , 30 days mechamcs
10 ppm)
TABLE 13-23 (cont'd). TOXICOLOGIC INTERACTIONS TO SIMPLE MIXTURES
CONTAINING NITROGEN DIOXIDEa
Pollutant SpecIes Response
Concentration Exposure Gender Age (Stram) End Pomts to MIxture InteractIOn Remarks Reference
N02 + 03
3
NO z (75 p.g/m , NOZ M 7 Rat LipId Increase m lIpId SynergIstic (for NO z or 03 alone Saga! and
o 04 ppm) + 03 contmuous, weeks (WIStar) peroXIdatIOn, peroXides, no peroXides up showed no change Ichmose
(98 p.g/m , 0 05 ppm) 5-22 mo antiOXidants, change m to 9 mo exposure mperoXIdes (1991)
(03 was antioXidant enzyme of only)
mtermtttent) enzyme actiVIty activIty
3
NO z (752 p.g/m , NOZ
04ppm)+03 contmuous,
3
(98 p.g/m , 0 05 ppm) 5-22 mo
(03 was
mtermtttent)
3
NO z (752 p.g/m , 24 h1day for M 10 Rat LIpId perOXide Increased lIpId SynergIstic Relation between Ichmose
~
wI 04ppm)+03 2 weeks weeks (WIstar) productlOn and perOXides only m antioXidant and Saga!
3
~ (784 p.g/m , 0 4 ppm) activIty of gumea pIgS productIon and (1989)
0\
U1 M 10 Gumea pIg antioXidant Increased levels perOXide
weeks (Hartley) enzymes of antiOXidants Synergistic formatIOn
only m rats
j
NO z (2,260 p.g/m , Contmuous, M 3 mo Rat Lung weIght, Increases m None or synergIstiC Synergistic for Lee et al
12 ppm) + 03 3 days (Sprague- activIty of enzyme activIty (end pomt dependent) some end pomts, (1990)
3
(588 p.g/m , 0 3 ppm) Dawley) vanous enzymes and lung weIght additive for
others, same as
03 for others
3
NO z (3,380 p.g/m , Contmuous, M 3 mo Rat Lung enzymes, Increases m Synergistic (for some Lee et al
18ppm) + 03 3 days (Sprague- lung weIght enzyme activIty enzymes, addItive for (1989)
3
(882 p.g/m , Dawley) others, and same as
045 ppm) 03 for lung weIght
and G-6-P
dehydrogenase
activIty)
TABLE 13-23 (cont'd). TOXICOLOGIC INTERACTIONS TO SIMPLE :MIXTURES
Concentration Exposure Gender Age (Stram) End Pomts to MIxture Interaction Remarks Reference
NOz + 03
3
NO z (7,520 p,g/m , Continuous, M 22 weeks Rat XenoblOtIc (see Remarks) AntagomstIc MIxmre WIth Takahasln and
4 o ppm) + 03 1-2 mo (Wlstar) metabohzmg NOZ reduces MIUra (1989)
3
(392 p,g/m , 0 2 ppm) system m lungs any mcreased
metabohsm
produced by ~
alone for
VarIOUS enzyme
activities
NO Z (13,200 and 3 hlday, M 4 weeks Mouse Level of Increase Additive Watanabe et al
3
28,200 p,g/m , 7 and 7 days (lCR JCL) reduced (1980)
15 ppm) + ~ ~80 glutathione m
.....
wI and 1,960 p,g/m , lung
..... o 5 and 1 0 ppm)
0\ 3
0\ NO z (9,020 p,g/m , 8 hlday, M 8 weeks Mouse Lung weight, Increase Synergistic No sIgmficant Mustafa et al
48 ppm) + 03 7 days (SWISS rate of 0z difference seen (1984)
3
(880 p,g/m , Webster) consumption between effects
045 ppm) (m lung of NO z and 03,
homogenate), each alone
sulfhydryl produced no
metabohsmm change
lung, actiVity of
NADP reducmg
enzymes
Lung DNA No change None No effect With

content, nnxture or
lung protem either alone
content
Pollutant Specles Response
Concentratlon Exposure Gender Age (Stram) End Pomts to Mlxture InteractlOn Remarks Reference
N02 + 03
3
NOZ (5,640 p,g/m , 2h M 5mo Rabblt Effects on Increase Synerglstlc Increases m Schlesmger
3 o ppm) + 03 (New aracmdomc aCld PGEz and et al (1990)
3
(588 p,g/m , 0 3 ppm) Zealand) metabohtes PGEza
(Response
dnven by 03)
3
NO z (5,640 p,g/m , 2 h/day, M 5mo Rabblt ProstanOlds m Decrease m None Dependmg on Schlesmger
30 ppm) + 03 up to (New lavage selected prostanOld, and et al (1991)
3
(588 p,g/m , 0 3 ppm) 14 days Zealand) prostanOlds number of days
of exposure
Dllxture was
addltlve or
I--'
wI slDlllar to 03 or
I--' NO z when
0\ glven alone
-....l
NO Z (3,760- 1-2 h NS NS Mouse CreatlIDDe Increase or None Effect due to Vemnga et al
3
18,800 p,g/m , (NS) phosphokmase ill decrease, °3 (1982)
2-10 ppm) + 03 plasma dependmg on
(980 and concentratlon
3
1,960 p,g/m ,05 and
10 ppm)
NO z (6,770- 6-24 h/day, M 10-12 Rat BALprotem, Increased protem Addltlve or Addltlve at low Gelz1elChter
3
27,100 p,g/m , 3 6- 3 days weeks (Sprague- cell types m at ~1O 8 ppm synerglstlc dose-rate et al (1992a)
14 4 ppm) + 03 (392- (dependmg Dawley) BAL NOz + ~06ppm (36 ppmNOZ
3
1,570 p,g/m ,02- on concen- 03, mcreased + 02 ppm 03)
08 ppm) tratlon) epdhehal cells at and synerglstlc
all concentratlons, at mgher dose-
mcrease rate
neutropmls at
~10 8 ppmNOZ
+ ~O 6 ppm 03
TABLE 13-23 (cont'd). TOXICOLOGIC INTERACTIONS TO SIMPLE MlXTURES
ConcentratIon Exposure Gender Age (Stram) EndPomts to MIxture InteractIon Remarks Reference
NOZ + 03
N02 (6,770- 6 hlday, M 10-12 Rat BALprotem, Increased m all AddttIve, For BAL protem Gelzieichter
3
27,100 p.g1m ,36- 3 days weeks (Sprague- cell types endpomts synergIstIc, or andPMNs, et al (1992b)
14 4 ppm) + 03 (392- Dawley) antagomstIc addItIvIty wIth
3
1,570 p.g/m , 0 2- sequentIal
o 8 ppm) (concurrent exposure,
and sequentIal) synergIsm for
concurrent
mIXture For
epIthelIal cells,
03 and then N02
caused addItIvIty,
N02 then 03
caused
antagomsm,
concurrent
lDlxture caused
synergIsm
3
N02 (7,520 p.g/m , Contmuous, M 8-10 Mouse Organ weIghts, Decrease m spleen None AddItIve for FUJImaIa
40ppm) + 03 3, 7, 14, or weeks BALB/c antIbody response weIght and spleen weIght, (1989)
3
(1,568 p.g/m , 56 days to SRBCs and to mcrease m lung sundar to 03 for
08 ppm) DNP-FIcolI weIght, no effect lung weIght,
on response to antIbody response
DNP, but response suntlar to 03
to SRBCs was
depressed WIth
3-14 day exposure
only
ConcentratIOn Exposure Gender Age (Stram) End Pomts to MIXture InteractIon Remarks Reference
N02 + 03
3
N02 (2,820 p,g/m , 4h M NS Mouse Bactencidal Decrease m Bactenal Goldstem et al
15 ppm) + 03 (SWISS actIvIty bactencidal challenge after (1974)
3
(200 p,g/m , 0 1 ppm) albmo) actIvIty when exposure
N02 >40ppm
+ °3
>036 ppm
N02 (2,800- 17 h Decrease m AddItIve Bactenal
3
7,860 p,g/m , 1 49- bactencidal challenge
418 ppm) + 03 actIVIty when before
3
(220-530 p,g/m , N0 2 ~18 ppm exposure
--
wI
0'1
\0
o 11-0 27 ppm)
N02 (2,820-
3
9,400 p,g/m , 1 5-
3h F 6-10
weeks
Mouse
(CF-l,
Bactenal
mfectlVlty
+ °3
~02ppm
Decreased
SurvIVal tIme
AddItIve Bactenal
challenge after
EhrlIch et al
(1977)
5 0 ppm) + 03 (100- CD2F 1) wIth 0 5 ppm exposure
3
980 p,g/m , 0 05- 03 and any
05 ppm) N02, and WIth
01 ppm 03 and
35ppmN02
3
N02 (3,760 p,g/m , 3 h/day, Excess SynergIstIc No effect wIth
2 o ppm) + 03 5 days/week, mortalIty eIther alone,
3
(100 p,g/m , 1-4 weeks at all tImes except for N02
005 ppm) at 2 weeks
TABLE 13-23 (cont'd). TOXICOWGIC INTERACTIONS TO SIMPLE MIXTURES
CONTAINING NITROGEN DIOXIDE3
Concentration Exposure Gender Age (Stram) End Pomts to MIxture Interaction Remarks Reference
NOz + 03
3
N02 (2,260-p.g/m , 15 days F 4-6 Mouse Bactenal Increased SynergIstic N02 and Graham et al
1 2-ppm base wIth baselme, weeks (CD-I) mfectlVlty mfectlVlty 03 alone (1987)
3
4,700-p.g/m , twIce daIly mcreased Gardner et al
2 5 ppm peak) + 03 I-hpeak mfectIvIty (1982)
3
(196-p.g1m , 0 I-ppm Gardner (1980)
3
base wIth 588-p.g/m ,
o 3-ppm peak)
3
N02 (940-p.g/m , SynergIstic N02 alone
OS-ppm base WIth mcreased
3
1,880-p.g1m , mfectIVIty,
1 O-ppm ~eak) + 03 03 alone dId
(98-p.g/m , 0 05-ppm not
3
o I-ppm peak)
3
N02 (94-p.g/m , None N~or
o 05-ppm base wIth 03 alone had
3
188-p.g/m , 0 I-ppm no effect
peak) + 03
3
(98-p.g/m , 0 05-ppm
3
o I-ppm peak)
Concentration Exposure Gender Age (Stralll) End Pomts to MIXture Interaction Remarks Reference
NOZ + SOZ
3
N02 (3,760 p.g/m , Contmuous, NS 8 weeks Rat Morphology No change None No effect of Azoulay et al
20 ppm) + S02 up to (Wlstar) eIther S02 or (1980)
3
(5,240 p.g/m , 13 weeks Blood vanables No change None N02
20 ppm) (oxyHb
dIssocIation
curve, RBC
count, metHb,
enzymes)
N02 (8,000- 24 hlday, F NS Gumea RespIratory No change None No effect of Antweller and
3
11,000 p.g/m , 4 2- 6 days/week, pIg mechamcs eIther S02 or Brockhaus (1976)
58 ppm) + S02 6 mo (BFA- (frequency, flow N02
3
I-' (9,000-11,000 p.g/m , ZH- rate, mmute
~
I
I-' 34-42 ppm) Ktsslegg) volume)
-...l
I-' NOZ + Particles
3
N02 (3,760 p.g/m , Contmuous, M/F NS Monkey Morphology RespIratory None Effect due to Funosl et al
20 ppm) +
AA 3 NaCI 14mo (Macaca bronchlo1~.r Nn~
A _£ (19 7 3)
(330 p.g/m ) speclOsa) epIthehal
hypertrophy
Contmuous, Hematology Polycythelilla None Effect due to
18 mo N02
3
N02 (3,760 p.g/m , Contmuous, M 4 weeks Rat Hematology Polycythelilla None Effect due to Funosl et al
20 ppm) + NaCI 6mo (Sprague- N02 (1973)
3
(330 p.g/m ) Dawley)
TABLE 13-23 (cont'd). TOXICOLOGIC INTERACTIONS TO SIMPLE :MlXTURES
CONTAlNING NITROGEN DIOXIDE
Pollutant
Concentration SpecIes Response
3
(p.g/m , ppm) Exposure Gender Age (Stram) End Pomts to MIxture Interaction Remarks Reference
NOZ + Particles
3
N02 (9,400 p.g/m , 7 days M NS Rat Rate of collagen Increase Synergistic Last and
5 0 ppm) + NaCI (Sprague- synthesIS by lung Warren
3
(1,000 p.g/m , 0 4 p.m) Dawley) mmces (1987)
3
N02 (9,400 p.g/m , 1,3 days Protem content Increase at SynergIstic at
5 0 ppm) + NaCI of lung lavage 1 and 3 days 3 days
3
(1,000 p.g/m , 0 4 p.m) flUId
N02 ~47,000-56,4OO 6 hlday, NS NS Mouse Morphology Focal Carbon acted as Boren (1964)
p.g/m , 25-30 ppm) + 5 days/week, (SWISS parenchymal carner for localIzed
carbon 3 mo albmo) leSIons N02 depOSItIon
--
wI
......:l
tv
N02 ~9,4OO-47,000
p.g/m , 5-25 ppm) +
(NH4h S04
3
(5,000 p.g/m ,0 8-1 p.m
235 hlday,
7 days
M 10-11
weeks
Rat Rate of collagen Increase
(Sprague- syntheSIS by lung
Dawley) mmces
SynergIstIc Last et al
(1983)
MMAD)
N02 (3,760 and 235 hlday, M NS Rat Rate of collagen Increase SynergIstIc Last and
3
9,400 p.g/m , 20 and 7 days (Sprague- syntheSIS by lung Warren
5 0 ppm) + H 2SO4 Dawley) mmces (1987)
3
(890 p.g/m , 0 4 p.m Last (1989)
MMAD)
Pollutant Species Response
Concentration Exposure Gender Age (Stram) End Pomts to Mixture Interaction Remarks Reference
N02 + Particles
NOz (560 and 2 hlday, M 5 mo Rabbit Particle clearance Decrease None at 03 ppm, Schlesmger
3
1,880 p.g/m , 0 3 and 5 days/week, (New from respIratory response due to and Gearhart
1 0 ppm) + HzS04 14 days Zealand) region H zS04 , at (1987)
3
(500 p.g/m , 0 4 p.m 10 ppm, Schlesmger
MMAD) response different et al (1987a)
from both NOZ
and H ZS04
Mucoclhary With 0 3 ppm
clearance NO z ill lIDxture,
clearance faster,
no change with
1 ppmNOZ
NO z (560 and 2 hlday, M 5 mo Rabbit Alveolar Vanable, Additive or Schlesmger
3
1,880 p.g/m , 0 3 and 5 days/week, (New macrophage dependmg on synergistic (1987a)
1 0 ppm) + HZS04 up to 14 days Zealand) function and NO z dependmg on
3
(500 p.g/m , 0 3 p.m numbers concentratIOn NO z
MMAD) and end pomt concentration and
endpomt
M = Male MetHb = Methemoglobm

NS = Not stated NaCI = SodIUm chlonde
NADP = Ntcotmamtde ademne (NH,v2S04 = Ammomum sulfate
PGEz = Prostaglandm Ez MMAD = Mass medtan aerodynamtc dtameter
PGEza = Prostaglandm E2a H2S04 = Sulfunc actd
F = Female G-6-P dehydrogenase = Glucose-6-phosphatedehydrogenase
S02 = Sulfur dloXlde SRBCs = Sheep red blood cells
oxyHb = Oxyhemoglobm BAL = Bronchoalveolar lavage
RBC = Red blood cell
the observed response when Its concentratIOn reaches a level at whIch It would have affected
bacterial resistance when admffilstered alone (Goldstem et al ,1974) The mouse subchromc
infectivity study conducted by Ehrhch et al (1977) proVIded a suggestIOn of synergIsm WIth
exposure to 3,760 p..g/m3 (20 ppm) N02 and 975 p..g/m3 (005 ppm) 03
SImUlatIOn of urban patterns mvolvmg N02 and 03 have also been performed by
exammmg the effects, on bactenal reSIstance, of a contmuous basehne exposure, WIth
superImposed short-term peaks to a hIgher level Ehrhch et al (1979) exposed mIce for 1 to
6 mo (24 h/day, 7 days/week) to a basehne concentratIOn of 0 (alI) or 188 p..g/m3 (0 1 ppm)
3
N02 , upon whIch was superImposed 3-h/day, 5-day/week peak exposures of 940 p,g/m
3
(0.5 ppm) N02 , or a combmatIOn of 940 p,g/m3 N02 and 200 p,g/m 03' bactenal exposure
followed pollutant exposure, and anImals were then observed for 14 days A sIgmficant and
simllar increase m percentage mortalIty was found by 6 mo m all groups, WIth no eVIdence
that exposure to the N02/03 peaks altered the response, there was also no change m SUrvIVal
time. In another experIment, mIce were reexposed for 14 days (after 1- to 3-mo pollutant
exposure and bactenal challenge) to the same pollutant concentrations as above, and
mortahty was exammed dunng thIs tIme AnImals preexposed for a least 2 mo eIther to
N02 /03 peaks over the alI basehne or to N02/03 peaks over the 188 p,g/m3 N02 basehne
showed SIgnIficant reductions m survIval tIme Although no conclUSIOns were drawn as to
the efficacy of the mIXture, the mvestIgators concluded that the sequence of peak exposure
was Important m altenng reSIstance to mfectIon
Ehrhch et al (1979) also exammed the effect of the same basehne and peak exposures
(for 1 to 3 mo) on AMs Cell VIability was decreased after 3 mo of exposure only when the
N02/03 peaks were superImposed on contInuous exposure to clean alI There also was a
general increase m blood enzyme actIvIty, but contInuous exposure to 188 p,g/m3 (0 1 ppm)
N02 with superimposed peaks of N02 and 03 was the most effective m thIs regard
In another study, Ehrhch (1983) exammed the effects of contmuous exposure (24 h/day,
5 days/week) to a basehne level of 376 p,g/m3 (0 2 ppm) N02 , WIth two daIly peaks gIven
5 days/week as follows 1,880 p..g/m3 (1 0 ppm) N02 for 1 h m the mommg and a mIXture
of 200 p..g/m3 (0 1 ppm) 03 plus 1,880 p,g/m3 N02 gIVen for 1 h m the afternoon
Exposures lasted for 9 mo, followed by bactenal challenge Other groups were exposed
continuously to 376 p,g/m3 N02 eIther WIth no peak or WIth a 1,880-p,g/m3 peak gIVen for
13-174
1 h m both the mommg and the afternoon The only group that showed a sIgnIficant
mcrease m mortalIty was that exposed for 9 mo to 376 p,g/m3 N02 wIth daily peaks of N02
m the mommg and N02 and 03 m the afternoon In addItIOn, only thIs group showed a
change (mcrease) m cellular ATP levels m AMs By 8 mo of exposure, thIs group also
showed an mcrease m counts of RBCs, leukocytes, and lymphocytes, and a decrease m mean
hemoglobm concentratIOn The other pollutant exposUIe groups showed mcreases only m
leukocyte count
Gardner et al (1982), Gardner (1980), and Graham et al (1987) exammed bactenal
resIstance m mIce contmuously exposed (15 days, 24 h/day) to a baselme level of an N02/03
mIXture wIth two daily I-h peaks of the mIXture, as follows (1) hIgh exposure level
2,260 p,g/m (1 2 ppm) N02 plus 196 p,g/m (0 1 ppm) 03 basehne wIth 4,700 p,g/m3
3 3
(25 ppm) N02 plus 588 p,g/m3 (03 ppm) 03 peak, (2) mtermedlate exposure level
3
940 p,g/m (05 ppm) N02 plus 98 p,g/m (005 ppm) 03 baselme wIth 1,880 p,g/m3
3
(1 0 ppm) N02 plus 196 p,g/m3 (0 1 ppm) 03 peak, or (3) low exposure level 94 p,g/m3
(005 ppm) N0 plus 100 p,g/m3 (005 ppm) 03 basehne wIth 188 p,g/m3 (0 1 ppm) N0
2 2
3
plus 196 p,g/m (0 1 ppm) 03 peak Annnals were also exposed to the same baselme levels
of eIther N02 or 03 onto whIch were supenmposed tWJlce daily, I-h peaks of eIther N02 or
03 at the concentratIons descnbed above The low COl1lCentratIOns of eIther gIVen alone, or
m combmatIon, dId not SIgnIficantly mcrease mortahty At the mtermediate exposure levels,
the mIXture was synergIstic, whereas N02 alone increased mortahty and 03 had no effect
At the hIgh exposure level, the combmed exposure was agam synergIstIc, exposure to each
pollutant gIven separately also mcreased mortalIty
Saga! et al (1987) exposed mIce, hamsters, gumea pIgS, and rats to a mIXture of
3 3
750 p,g/m (0 4 ppm) N02 and 780 p,g/m (0 4 ppm) 03' 24 h/day for 2 weeks, to assess
effects on hpid peroXIdatIOn m the lungs Although the two gases were not also admlillstered
smgly to allow assessment of effects due to each alone, the study showed specIes dIfferences
m hpid peroXide formatIon followmg exposure that were related to the relatIve content of
antIoXidants and the specIfic composItIOn of phosphohpids and theIr fatty aCIds The gumea
pIg was the most sensItIve anImal and the hamster was the most reSIstant In follow-up
studies, Saga! and Ichmose (1991) exposed rats for 22 mo to mIXtures of N02 and 03 The
13-175
Increase In lIpid permadatIOn was synergIstIc and maxnnal at 9 mo, later eXamInatIOns
revealed no effects
IchInose and Saga! (1989) also observed a speCIes dependence In the InteractIOn of N02
(752 p.g/m3 , 0 4 ppm) and 03 (784 p.g/m3 , 0 4 ppm) after 2 weeks of contInUOUS exposure
Guinea pigs, but not rats, had a synergIstIc Increase In lung lIpId peroXldes, expressed as
'IBA reactants Rats, but not gUInea pIgS, had synergIstIc Increases In nonproteIn
sulfhydryls, VItamIn C, G-6-P dehydrogenase, and GSH peroXldase
DuratIon of exposure can also have an lffipact SchleSInger et al (1990) observed a
synergistic Increase In prostaglandIns ~ and F 2a In the lung lavage of rabbIts exposed for
3 3
2 h to 5,640 p.g/m (3 0 ppm) N02 plus 588 p.g/m (0 3 ppm) 03' the response appeared to
have been dnven by 03 However, WIth 7 of 14 days of repeated 2-h exposures, only
prostaglandIn ~ was decreased, apparently due to N02 , there was no synergIsm (SchleSInger
et al., 1991).
The studIes descnbed above Involved slffiultaneous exposure to both N02 and another
gas However, "real world" exposures to these pollutants tYPICally have temporal patterns,
and exposure to one agent may then alter the response to another subsequently mhaled
Thus, order of exposure to mhaled N02 may be lffipOrtant In tOXlC mteractIOns
Yokoyama et al (1980) exposed rats to eIther N02 or 03 for 3 h or to N02 for 3 h followed
by 0 3 for 3 h, and assessed lung mechamcs In postmortem lungs, lung hlstology, and
enzyme actIvIty ill subcellular fractlons of lung tIssue In one senes of exposures, rats were
3
exposed for 7 or 14 days to N02 and 03 at concentratIOns of 10,300 p.g/m (5 5 ppm) and
3
2,160 p.g/m (1 1 ppm), respectIvely The actIvIty of phosphohpase A2 m the mitochondnal
fraction of lung homogenate was only Increased In those aDlffials exposed to 0 3 after N02 ,
for 14 days A decrease In actlvity of lysolecIthIn acyltransferase In the supernatant fractIOn
was found after 7 and 14 days In all groups of aDlffials In a second study, rats were
, 3
exposed for 14 or 30 consecutIve days to 10,200 p.g/m (5 4 ppm) N02 followed by
3
1,960 p.g/m (1.0 ppm) 03 Pulmonary mechamcs tests perfonned on the postmortem lung
indicated an mcrease m pulmonary flow reSIstance m the Or and sequentIal N02/03-exposed
animals There were no changes m volume-pressure curves In any of the groups
Hlstologically, the lungs of the aDlffials exposed to both N02 and 03 appeared slffil1ar to
those exposed to 0 3 alone However, a shght degree of epIthehal necroSIS In the medmm
13-176
broncht, not found wIth eIther N02 or 03 alone, was seen m the annnals exposed to both
pollutants In addItion, damage at the bronchtoloalveolar JunctIOn appeared to be somewhat
more marked m annnals exposed to both gases than m those exposed to 0 3 alone These
studies suggest that sequential exposures produced responses that were, m most cases, not
greatly dIfferent from those due to 03 alone
Gelzieichter et al (1992b) also evaluated sequential exposure Rats were exposed for
3 days for 6 h/day to 03 (392 to 1,570 p,g/m3, 02 to 0 8 ppm) or N02 (6,770 to
27,100 p,g/m3, 3 6 to 14 4 ppm) or theIr combmatIOns CombmatIons were eIther concurrent
or sequential (03 fIrst and then N02 or VIce versa) For eIther of the sequential exposures,
the mcrease m BAL protem and PMNs was additive, It was synergIStic for the concurrent
mIXture For lavageable epIthehal cells, the 03 then N02 group showed addItivIty, whereas
the N02 then 0 3 group displayed antagomsm, thts end pomt exhtbited synergIsm when the
03 and N02 were concurrent The synergIsms observed were concentratIOn-dependent
Effects on epIthehal cell numbers were most sensItive, showmg synergIsm at 392 p,g/m3
(02 ppm) 0 3 wIth 27,100 p,g/m3 (144 ppm) N02 The authors postulate that the synergIsm
may be due to chemIcal reaCtivIty of 03 and N02 Withm the exposure chamber and the
subsequent formation of mtrogen pentmade
An Important consIderatIOn m exammmg responses to arr pollutants IS the relatIve roles
of exposure C and T on response The roles of C and T m responses to mIXtures of N02
and 03 were exammed by Gelzieichter et al (1992a) Rats were exposed to VarIOUS
concentratIOns of each gas (6,770 to 27,100 p,g/m3 [3 6 to 144 ppm] N02 and 392 to
1,570 p,g/m3 [02 to 0 8 ppm] 03) for VarIOUS durations, such that the product of C x Twas
constant m all cases They found that the response to these mIXtures could not be related to
the product of exT but, rather, seemed to be more dependent upon actual concentratIOn
than exposure duratIOn The responses were disproporWmately greater at the htgher
concentrations of these gases
Some hmited data eXist for combmatIons of N02 wIth gases other than 0 3 In the two
reported studIes wIth sulfur dioXide (SO~, neIther S02 nor N02 gIVen alone, or together,
produced any response The concentratIOns used by Azoulay et al (1980) were qUIte low,
and the respIratory mechamcal end pomts assessed by Antweller and Brockhaus (1976) were
hkely not very sensItive to pollutant-mduced changes
13-177
Trzeciak et al (1977) exposed gumea pIgS to 940 p,g/m3 (05 ppm) N02 plus 61 p,g/m3
(0.05 ppm) NO, or thIs NOx mIXture plus an equal amount of ammoma, for 8 h/day for a
total of 122 days and analyzed lung phosphohpids There was no dIfference m the
phospholipId content, expressed as mIlhgrams per gram of wet tIssue, of exposed versus
control lungs SIgnIficant alteratIOns were found m the mdIvidual phosphohpid classes
Decreases were noted m phosphatIdylethanolamme, sphmgomyehn, phosphatIdylserme,
phosphatIdylglycerol- 3-phosphate, and phosphatIdIc aCId Increases were noted m the lyso-
phosphatidyl-ethanolantme content, whereas the lecithm content remamed constant or was
slightly depressed Such changes could be mdicatIve of changes m the permeability of the
cell wall and subsequently changes m the cell content The presence of ammoma dId not
significantly influence the results
One major interactIon that may occur m ambIent arr IS that between N02 and partIcles
PartIcle contact may result m gas adsorptIon and subsequent transport to target SItes where
the gas normally would not depOSIt m concentrated amounts Boren (1964) adsorbed N02
onto carbon to determme whether thIs carner changed the tOXICIty of the N02 MIce were
exposed 6 h/day, 5 days/week for 3 mo to carbon (38 % of partIcles were < 2 p,m,
16,000 pamcles/cm3) onto whIch 553 mg N02 was adsorbed per gram, the exposure au also
contained 47,000 to 56,400 p,g/m3 (25 to 30 ppm) free N02 as well The exposed ammals
showed focal changes m the lung parenchyma These leSIOns contamed carbon partIcles, and
were charactenzed by enlarged arrspaces and loss of alveolar walls Exposure solely to N02
resulted in edema and mflammatIon, but no parenchymal leSIOns, and no leSIOns were found
due to carbon-only exposure Thus, Boren (1964) concluded that the carbon partIcles served
as a carrier for N02 , dehvermg hIgh concentratIons of N02 to localIzed areas m the lungs
where the carbon depOSIted
The role of adsorbed N0 2 m the tOXICIty of mmeral dusts was addressed by Robertson
et al. (1982). They exammed the effects of N02 adsorptIon on the CytOtOXiCIty of coal,
quartz, or kaolimte on P388D 1 cells exposed m VItro to mmeral dusts for 48 h, vIability and
enzyme release (e g , LDH) were used as end pomts The amount of N0 2 absorbed was 5 to
10 p,g/mg dust. Although a small decrease m CytOtOXiCIty was found after adsorptIon of
N0 2 , the mvestIgators concluded that there was no systematIC or SIgnIficant dIfference m
biochemical measures of tOXICIty from cells exposed to dust WIth or WIthout N02 On the
13-178
other hand, Shevchenko (1971) noted an mcrease m the fibrogemcIty of quartz dust m albmo
rats followmg adsorptIOn of 0 36 Itg N02/mg dust, a lower level than that used by Robertson
et al (1982) These dIfferent results may be due to dIfferences m partIcle reSIdence tIme
Robertson et al (1982) exposed the cells for only 48 h, whereas dust was present m the
lungs m the Shevchenko (1971) study for months, allowmg a greater tIme for gas desorptIOn
Other aerosols, although not necessarIly actmg as carners, may potentIate response to
N02 by producmg local changes m the lungs that enhance the toXIC actIOn of co-Inhaled
N02 Last et al (1983) and Last and Warren (1987) have exammed the effects of InhalatIOn
of aCIdIC sulfate aerosols plus N02 on bIOChemIcal end pomts, usmg mmces prepared from
the lungs of rats after VarIOUS exposure regImes Last et al (1983) exposed rats to 9,400 to
3 3
47,000 Itg/m (5 to 25 ppm) N02 alone, or m combmatLon wIth 5,000 Itg/m (ammomum
sulfate (NH4hS04) (11tm mass medIan aerodynamIC dIameter [MMAD]), for up to 7 days,
and exammed the rate of collagen synthesIs by lung mmces Ammomum sulfate alone
caused no effects AnalYSIS of the slope of the exposure concentratIOn-response curve for
N02 mdIcated an approXImate doublmg of the synthesIS rate when the mIXture was employed
compared to N02 alone, exammatIOn of responses at m<hvIdual N02 concentratIOns showed
that the mIxture clearly began to mcrease the synthesIs rate (above N02 alone) when N02
concentratIOns exceeded 18,800 Itg/m3 (10 ppm) The mvestIgators also noted that there was
a tendency towards a reductIon m lethal concentratIOn for 75 % of the anImals when
exposures were to (NH4hS04 plus N02, compared to that for N0 2 alone On the other
hand, there was no dIfference m the level of pulmonary edema between anImals exposed to
N02 alone or to N02 m combmatIon wIth (NH4hS04
In a later study, Last and Warren (1987) exposed Jrats to 9,400 Itg/m3 (5 0 ppm) N02
alone or m combmatIOn wIth eIther 1,000 Itg/m3 sulfum~ aCId (H2S04) (0 4ltm :MJv.IAD) or
sodIum chlonde (NaCl) (04 /LID :MJv.IAD) for up to 7 days A synergIstIc mteractIon for
collagen syntheSIS rate was found when eIther aerosol was used wIth N02 ReductIOn of the
N02 level to 3,760 /Lg/m3 (20 ppm) also resulted m a ~)ynergIstlc mcrease m the collagen
syntheSIS rate when combmed wIth 1,000 Itg/m3 H 2S04 (Last, 1989) Changes m protem
content of the lavage flUId (an mdex of lung edema) showed eVIdence of synergIsm at 1 day
wIth H 2S04 or 3 days wIth NaCI The mvestIgators suggested that the mteractIon wIth NaCI
was due to the formatIOn of aCIds (e g , hydrogen chlonde, HN03, HONO) from mtrosyl
13-179
chlonde followmg ItS hydrolySIS after deposItIon m the deep lung, the latter may be formed
from a chemIcal reactIon between N02 and NaCI SImilarly, potentIatIOn WIth the aCId
sulfate aerosols was hkely due to localIzed effects followmg theIr depOSItIon It has been
proposed that the aCId aerosols would produce a shIft m local pH Withm the alveolar milieu
This shift would result m a change m the reactIvIty or reSIdence tIme of reactants mvolved m
madant-mduced pulmonary effects (Last et al , 1984)
The effects of exposure to mIXed atmospheres of N02 and H 2S04 on lung host defenses
have been exammed by Schlesmger and Gearhart (1987) and Schlesmger (1987a) In the
former study, rabbIts were exposed for 2 h/day, 5 days/week for 14 days to eIther 564 or
3 3
1,880 p.g/m (0.3 or 1 0 ppm) N02 or 500 p.g/m H 2S04 (0 3 ",m) alone, or to mIXtures of
the low and hIgh N02 concentratIOns WIth the aCId After the rIrst exposure, an mert tracer
aerosol was admInIstered to assess clearance from the respIratory regIOn of the lungs In the
single-pollutant groups, both concentratIOns of N02 accelerated clearance, whereas H 2S04
retarded clearance, compared to arr-exposed controls Exposure to the combmatIOn of
564 p.g/m3 N02 plus H 2S04 resulted m a response that was not dIfferent from that due to the
aCId alone However, exposure to 1,880 ",g/m3 N02 plus H 2S04 resulted m a clearance
pattern that dIffered from that of both N02 and H 2S04 , but was more SImilar to that of the
H 2S04
Schlesmger (1987a) exposed rabbIts to the same N0 2/H 2S04 atmospheres as above, but
then exammed the anImals 24 h after 2, 6, or 13 exposures and recovered cells from the
lungs by bronchopulmonary lavage Exposure to 1,880 ",g/m3 (1 0 ppm) N0 2 WIth aCId
resulted m an mcrease m PMNs at all tIme pomts (not seen WIth eIther pollutant alone), and
an increase m the phagocytIc capaCIty of AMs after two or SIX exposures In contrast,
exposure to 564 p.g/m3 (0 3 ppm) N02 WIth aCId resulted m depressed phagocytIc capaCIty
and mobility A companson of responses due to exposure to the N02/H 2S04 mIXture WIth
those due to either pollucint alone showed that the effects of the combmed atmospheres were
generally eIther addItIve or synergIstIC, dependmg on the specIfic cellular end pomt bemg
examined
Funosl et al (1973) exposed rats and monkeys contmuously to a combmatIon of
3,760 p.g/m3 (2.0 ppm) N02 and 330 ",g/m3 NaCI HIStologICal response after 14 mo of
exposure m monkeys (respiratory bronchIolar epIthehal hypertrophy) was SImilar m groups
13-180
exposed to N02 alone or to N02 wIth NaCI HematologIC changes (polycythemIa) m both
monkeys, after 18 mo, and rats, after 6 mo, were sImilar for groups exposed to N02 wIth or
wIthout NaCI Thus, m thIs study, the NaCI dId not poltentiate response to N02 Perhaps
the end pomts were not sensItive to the effects of any reactIOn products of N02 and NaCI, or
the concentration of NaCI was too low to allow productIOn of sIgmficant amounts of such
products
Complex Mutures Containing NItrogen Dioxide

Although many studIes have exammed the response to N02 wIth only one addItIOnal
pollutant, the atmosphere m most enVIronments IS a complex mIXture of more than two
matenals. A number of studIes have attempted to examme the effects of multicomponent
atmospheres contammg N02 But, as mentIOned, m many cases, the exact role played by
N02 m the observed responses IS not always clear
Klemman et al (1985a,b) exposed rats for 4 h to atmospheres consIstmg of VarIOUS
3 3
combmations of N02 (4,700 p,g/m , 2 5 ppm), 03 (1,180 p,g/m , 0 6 ppm), S02
3
(13,100 p,g/m ; 5 0 ppm), and partIcles The partIcles consIsted of 1 mg/m3 (0 2 p,m
:M:MAD) of eIther H 2S04 or (NH4hS04, laced wIth Iron and manganese sulfates The
metal1Ic salts act as catalysts for the converSIOn of sulfur IV mto sulfur VI and the
mcorporatIOn of gases mto the aerosol droplets The respIratory regIon was exammed for
morphologIcal effects A confoundmg factor m these studIes was the productIOn of HN03 m
°
atmospheres that contamed N02 and 3, and mtrate m atmospheres that contamed 03 and
(NH4hS04, bUlt not N02 Nevertheless, a sIgmficant enhancement of tissue damage was
produced by exposure to atmospheres contammg H 2S04 or HN03, compared to those
contammg (NH4hS04 In addItion, It was suggested that the former atmospheres resulted m
a greater area of the lung becommg mvolved m leSIOns, whIch were charactenzed by a
thIckenmg of alveolar walls, cellular mfI1tratIOn m the mterstitlUm, and an mcrease m free
cells Withm alveolar spaces ExerCIse seemed to potentIate the hIstologIcal response to the
complex mIXtures contammg aCIds (Klemman et al , 1980)
One of the more common complex mIXtures StudIed IS that of combustIOn exhaust
emISSIOns from automobiles In some cases (see below), the exhaust was rrradIated to
produce a reactive mIXture that IS a model for photochemIcal smog Coffm and Blommer
13-181
(1967) exposed mice for 4 h to rrrawated gasohne-engme exhaust to assess the effects on
bactenal resistance Levels of NOx m the atmosphere were as follows N02 , 200 to
1,600 p.g/m3 (0 11 to 0 85 ppm), and NO, 20 to 180 p.g/m3 (0 02 to 0 15 ppm) Exposure
was found to result m an mcrease m bactenal-mduced mortalIty, but the mvesngators were
not able to clearly ascnbe the results to anyone pollutant However, they noted that the
exposure levels of N02 were less than those that were known to alter resistance when N02
was given alone and, thus, they suggested that the effect of the exhaust mIXture was due to
other oxidants, such as 03
Stupfel et al (1973) exposed rats for 6 h/day, 5 days/week for 2 5 mo to 2 years to
gasolme-engme exhaust mIXtures for morphologic analysIs The atmosphere contamed CO2 ,
aldehydes, carbon monmade (CO), and either 0 2 or 23 ppm NO x Only the mIXture with
the higher NOx concentratIOn produced any slgmficant toXiC response, namely a decrease m
body weight and mcrease m spontaneous tumors However, the latter was ascnbed to the
hydrocarbon component of the exhaust mIXture
Cooper et al (1977) exposed rats contmuously for 38 or 88 days to three gasohne-
engine exhaust atmospheres that dIffered m theIr component concentranons, all contamed
H S0 , S02, and CO, as well as NO (8,700 to 13,300 p.g/m3, 7 1 to 10 8 ppm) and N0
2 4 2
(564 to 9,590 p.g/m3, 0 3 to 5 1 ppm) All exposures resulted m a slgmficant depreSSIOn of
spontaneous locomotor acnvlty not seen With exposure to either H 2S04 or CO alone, the
investigators concluded that thIs response was due to either the hydrocarbon or the NOx
components of the mIXture
The results of a long-tenn exposure of dogs to gasohne-engme exhaust emiSSIOns have
been descnbed by several mvesngators (Stara et al ,1980) Annnals were exposed for
68 mo (16 h/day) to vanous atmospheres, whIch mcluded raw exhaust, rrrawated exhaust, or
3
two mIXtures of NOx-one WIth hIgh N02 (1,210 p.g/m , 0 64 ppm) and low NO
3 3
(310 p.g/m ; 0 25 ppm), and one WIth low N02 (270 p.g/m , 0 14 ppm) and hIgh NO
3
(2,050 p.g/m ; 1 67 ppm) Followmg the end of exposure, the antmals were mamtamed for
about 3 years m nonnal mdoor arr Numerous pulmonary funcnon, hematologiC, and
histologic end pomts were exammed after vanous nmes of exposure (LeWIS et al , 1974,
Vaughan et al , 1969, Starn et al , 1980, Bloch et al ,1973) Only results related to NO x
will be descnbed Vaughan et al (1969) reported no alteratIOns m CO-dIffusmg capaCIty,
13-182
dynamIc comphance, or total exprratory resIstance to flow after 18 mo of exposure
However, by 36 mo, a sIgmficant number of ammals exposed to lngh N02/low NO had an
abnormally low CO diffusmg capacIty (as a ratio of total lung capacIty) (LeWIS et al , 1974)
AddItIOnal changes were observed after 61 mo of exposure, m the dogs breathmg low
N0 2/lngh NO or raw auto exhaust, resIdual volume was mcreased compared to ammals
exposed to control or lngh N02/low NO The common treatment factor causmg tlns effect
appeared to be the hIgher concentration of NO A sIgm11cant number of dogs exposed to
lngh N02/low NO had a lower mean CO dIffusmg capacIty/total lung capacIty ratIO, and a
lower peak flow rate, compared to controls The mvestIgators attnbuted the change m
dIffusmg capacIty to an alteratIOn m the alveolocapillary membrane Bloch et al (1973)
reported no sIgmficant change m hematocnt, blood VISCOSIty, or level of methemoglobm due
to any of the exposure atmospheres after 48 mo of exposure
After all exposures were termmated, the ammals were allowed to recover for 2 years
before pulmonary functIOn measurements were made agam (Stara et al ,1980) In all
pollutant-exposed dogs, total lung capacIty was mcreasedl relatIve to the control group of
ammals Those ammals that receIved the N02/NO mIXtures expenenced modest mcreases m
msprratory volume, VItal capacIty, and total lung capacIty
Orthoefer et al (1976) evaluated bIochemIcal alteratIons 2 5 to 3 years after the end of
all exposures In groups exposed to rrradIated exhaust or lngh N02/low NO, there was a
nse m lung propyl hydroxylase, an enzyme mvolved m collagen synthesIs In addItIOn, a
correlation was found between lung weIght and hydroxyprohne content ill ammals exposed to
the NO x atmospheres
Lung morphology of the dogs was evaluated by Hyde et al (1978) 32 to 36 mo after
68 mo of exposure In the hIgh N02/low NO group, there were mcreases ill total lung
capacIty and lung volume, and decreases ill the surface densIty of the alveoh and the
volumetnc densIty of parenchymal tissue Alveoh were enlarged m both the lngh N02 and
lngh NO groups In the lngh N02 , but not the hIgh NO group, there was cilia loss and
hyperplaSia of nonciliated bronchIolar cells In the lngh NO group, there were leSIOns ill the
mteralveolar pores In the most severely affected dogs m the hIgh N02 group,
morphologIcal changes conSIdered to be analogous to centnlobular emphysema were present
(see SectIOn 13 224 dIscussmg NOTillduced emphysema ill expenmental arumals) Because
13-183
these morphologIc measurements were made after a 25- to 3-year holdmg penod mclean
air, it cannot be determmed wIth certamty whether these dIsease processes abated or
progressed dunng thIs tIme However, mdIcatIons were that the long-term exposures
produced perSIstent damage that was mdeed progressIve even after exposures ended
Another complex mIXture mvolvmg N02 IS dIesel-engme exhaust LIke gasolme-engme
exhaust, thIS contams a number of gases and partIcles Numerous tOXIcologIc studIes have
been perfonned wIth acute, subchromc, and chromc exposure protocols (U S EnVIronmental
ProtectIon Agency, 1991) In acute exposures, tOXIC effects appear to be assocIated WIth
high concentratIOns of CO, N02 , and vanous other gases On the other hand, companson of
responses m laboratory anImals repeatedly exposed to whole dIesel exhaust or fIltered
exhaust contaming no partIcles appears to demonstrate that the partIcles are the pnncIpal
etiolOgIC agent of noncancerous health effects resultmg from exposure (U S EnVIronmental
ProtectIon Agency, 1991) Whether these partIcles act addItIvely or synergIstIcally WIth the
gases m the exhaust mIXture cannot, however, be determmed from the deSIgns of the
avaIlable studIes Thus, the dIesel studIes do not proVIde addItIonal mformatIOn concermng
the tOXICIty of N02 over and above that whIch IS already avaIlable m the data base
Summary
Exposures to mIXtures contammg N02 are qUIte common and proVIde a baSIS for
tOXIcologICal interactIons whereby combmatIOns of pollutants may behave dIfferently than
would be expected from conSIderatIOn of the actIOn of each constItuent separately The
largest data base eXIsts for the combmatIOn of N02 and 03 MorphologIC response to
exposure to thIs mIXture IS generally due to 03 (Freeman et al , 1974a, Yokoyama et al ,
1980), but bIochemIcal effects may mvolve synergIsm (Yokoyama et al , 1980, Ichmose and
Sagai, 1989, Saga! and Ichmose, 1991, Mustafa et al , 1984, Schlesmger et al , 1990)
ReactIons of host defenses, specIfically antIbactenal actIvIty, may be addItIve or synergIstIc
(Goldstem et al , 1974, Graham et al , 1987, Ehrhch et al ,1977) MIXtures of N0 2 and
aCId sulfates result m addItIve to synergIstIc effects (Last, 1989, Last et al , 1983, Last and
Warren, 1987, Schlesmger and Gearhart, 1987, Schlesmger, 1987a, Schlesmger et al ,
1987a). Although many studIes exammed responses to SImple mIXtures of N02 WIth one
other matenal, the atmosphere m most enVIronments IS a complex mIX of more than two
13-184
pollutants The effects of complex mlXtures have been exammed to some extent, however,
the exact role played by N02 m the observed responses IS not always clear
13.4 NITRIC OXIDE

The tOXicologIC data base for NO IS not extensIve, except for those studIes exammmg
ItS mteractIOn WIth blood One problem IS that It IS often dIfficult to obtam pure NO m arr
wIthout some contammation wIth N02 In recent years, much research has mcreased the
understandmg of the role of endogenous NO as a medIator of vascular tone, macrophage
CytOtOXiCIty of microorgamsms and tumors, and platelet dIsaggregatIOn (Moncada et al ,
1991) However, this research and fmdmgs are not dm~tly related to NO as an arr
pollutant
LIttle IS actually known about NO absorption m the respIratory tract, and nothIng IS
known on ItS subsequent mtrapulmonary dIstnbutIon Because NO IS less water soluble and
less reactive than N02 , It follows that ItS absorption from Inhaled arr should be less
Yoshida et al (1981) found that < 10% of the NO "Inhaled" by Isolated, perfused lungs of
rabbIts was absorbed On the other hand, absorptIon ill normal breathIng humans m VIVO
was 85 to 92 % for NO concentrations rangmg from 400 to 6,100 p,g/m3 (0 33 to 5 0 ppm)
(Wagner, 1970, Yoshida and Kasama, 1987), values for N02 were 81 to 90% (Wagner,
1970) AbsorptIOn of NO WIth exerCIse was 91 to 93% m humans (Wagner, 1970) Yoshida
et al (1980a) found the percentage of NO absorbed m rats acutely exposed to 169,300 p,g/m3
(138 ppm), 331,300 p,g/m3 (270 ppm), and 1,079,800 p,g/m3 (880 ppm) to be 90%, 60%,
and 20 %, respectively The lower absorptIon at the two highest concentratIOns was ascnbed
to an exposure-mduced decrease m ventuatIOn Vaughan et al (1969) exposed dogs to auto
exhaust mlXtures and found that 73 % of the constituent NO was removed when the mlXture
was passed m through the nose and out through a trache:ostomy tube, this compared to 90 %
removal for N02 Thus, respIratory tract absorptIon of NO has some sImuantIes to that of
N02 m spIte of solubility dIfferences The lower solubJthty of NO may, however, result m
greater amounts reachIng the pulmonary regIon, where It then dIffuses mto blood and reacts
WIth hemoglobm (Yoshida and Kasama, 1987) In fact, exposures m VIVO do seem to
13-185
indIcate that NO has a faster rate of dIffusIon through tissue than does N02 (ChIodi and
Mohler, 1985)
HIgh exposure levels of NO are apparently needed to be lethal Pflesser (1935)
reported that mice exposed to 380,400 p,g/m3 (310 ppm) NO for 8 h showed no mortalIty,
whereas 50% mortalIty was seen dunng SImIlar exposures to 392,600 p,g/m3 (320 ppm),
however, possIble N02 contammation was not accounted for Greenbaum et al (1967)
reported that dogs exposed to 2 % NO (24,540 mg/m3, 20,000 ppm) for 7 to 50 mm all dIed
withm 15 mm after exposures ended, a smgle dog exposed to ° 5% (5,000 ppm) NO also
died Death was due to pulmonary edema No mcrease m death rate over control was found
m mice exposed to 12,270 p,g/m3 (10 ppm) NO for 6 5 mo (Oda et al , 1976), or to
2,940 p,g/m3 (2 4 ppm) NO for theIr lIfetIme (23 to 29 mo) (Oda et al , 1980b)
The few studies that have exammed hIstologIC response to nonlethal levels of NO are
outlmed m Table 13-24 WIth chromc exposure, the morphologIc changes seen are SImIlar
to those discussed m the section on the morphologIcal effects of N02 , except that the NO
levels needed to produce them are hIgher In terms of pulmonary effects WIth hIgh level
acute exposure, NO IS estImated to be approXImately 30 tImes less toXIC than N02 (Stavert
and Lehnert, 1990) AddItionally, Hugod (1979) noted that the absence of NO-mduced
alterations in the alveolar epIthehum suggested that the observed responses occurred after
absorption of NO, that IS, they were not due to dIrect action of deposIted NO Perhaps
hIgher exposure concentratIOns of NO are needed for dIrect tOXIC action (e g , results of Holt
et al., 1979) Some of the effects seen by Oda et al (1976) WIth 12,270 p,g/m3 (10 ppm)
NO may be due to the presence of 1,880 to 2,820 p,g/m3 (1 °to 1 5 ppm) N0 2 m the
exposure atmosphere
Data concermng the phySIOlogIcal effects of mhaled NO are sparse Murphy (1964)
found no changes m respIratory function of gumea pIgS exposed for 4 h to NO at 19,600 or
3
61,300 p,g/m (16 or 50 ppm) YoshIda et al (1980b) reported that gumea pIgS exposed
twice per week (30 rom each) for 7 weeks to 5,900 p,g/m3 (502 ppm) NO and challenged
during exposure to aerosolIzed albumm exhIbIted dyspneIC breathmg patterns and an
mcreased responSIveness to acetylcholme These results were not substantially dIfferent from
13-186
TABLE 13-24. EFFECT OF NITRIC OXIDE ON RESPIRATORY TRACT MORPHOLOGya
NO Concentration
3 SpecIes
p,g/m ppm
Exposure Gender Age (Stram) Effects References
2,460 20 Contmuous, NS 8 weeks Rat Shght emphysema-lIke alteratlOns of Azoulay et al (1977)
(N0z = 008 ppm)b 6 weeks (Wlstar) alveoh
2,950 24 Contmuous, F 12 weeks Mouse No dtfference from control Oda et al (1980a)
(NOz = 001-004 ppm) 23-29 mo (JCL-ICR)
6,150 50 Contmuous, M NS RabbIt Edema, thIckemng of alveolo- Hugod (1979)
(NO z = ~O 1 ppm) 14 days (Damsh) capIllary membrane due to flUId m
illterstitial space, flUId-filled
vacuoles seen m artenolar
endothehal cells and at Junctions of
endothehal cells, no changes ill
alveolar eplthehum, no
illflammation
'w
"I""" 12,300 10 2 hlday, F 6-8 Mouse Enlarged alfspaces ill lung Holt et al (1979)
5 days/week, up weeks (BALB/c) penphery, paraseptal emphysema,
'""""
00
......:J to 30 weeks some hemorrhage, some congestion
ill alveolar septa, mcreased
concentration of goblet cells ill
bronchI
12,300 10 Contmuous, F 12 weeks Mouse BronchIolar eplthehal hyperplasIa, Oda et al (1976)
(NOz = 1-15 ppm) 65 mo (JCL-ICR) hyperemta, congestlOn, enlargement
of alveolar septum, illcrease ill ratio
of lung to body weIght
aNS = Not stated

F = Female
bM = Male
Represents reported NOZ levels measured dunng exposure
those m gumea pIgS exposed to 9,400 p,g/m3 (5 0 ppm) N0 2 (detaIls of the study are
reported in SectIOn 13 2 2 3 addressmg N02 exposure-related effects on pulmonary
functIOn)
The effects of NO on defense functIOn of the lungs has been exammed m two studIes
3
Holt et al. (1979) exammed unmunoiogical end pomts m mIce exposed to 12,270 p,g/m
(10 ppm) NO, 2 h/day, 5 days/week for up to 30 weeks LeukOCytOSIS was eVIdent by
5 weeks of exposure, and a decrease m mean hemoglobm content of RBCs was found by
30 weeks A decrease m RBC count at Week 15 was not found at 30 weeks An
enhancement of the humoral Immune response to SRBCs was seen at 10 weeks, but thIs was
not eVIdent at the end of the exposure senes Spleen cell response to phytohemagglutmm
was decreased after 15 weeks of exposure, but mItogenesIs then recovered and became
greater than control The ability of spleen cells to mount a graft versus host reactIOn was
stnnulated by 20 weeks of exposure, but was suppressed by 26 weeks Fmally, the ability of
mice to reject vrrus-mduced tumors was assessed, only 40 % of the NO-exposed annnals
SUrvIVed tumor challenge, compared WIth 66 % for control annnals ThIs study suggests that
NO exposure may have affected the unmunoiogic competence of exposed annnals
Effects of NO on bactenal defenses were exammed by Azoulay et al (1981) Male and
female mIce were exposed contmuously to 2,450 p,g/m3 (2 0 ppm) NO for 6 h to 4 weeks, to
assess the effect on reSIstance to mfectIOn mduced by a bactenal aerosol (Pasteurella
multocula) admInIstered after each NO exposure Although there appeared to be somewhat
of an mcrease in bactenal-mduced mortalIty m each group of females exposed to NO for at
least 1 week, there was no statIstIcally sIgmficant dIfference for eIther sex LIkeWIse, each
group of females exposed to NO for at least 1 week showed a shght decrease m mean
survival tnne, but thIs change was not statIstIcally sIgmficant, nor was there any observable
difference m males exposed to NO When the data for those groups exposed for 1 to
4 weeks were combmed, NO-exposed females showed a sIgmficant mcrease m percentage
mortalIty and a sIgmficant decrease m SUrvIval tune, thIs was not seen for males Thus, thIs
study suggests some gender-related dIfference m response, at least to the one level of NO
exammed
One pOSSIble mechamsm of tOXIC actIon of NO IS hpId peroXIdatIon The GSH
transferase system serves to protect VItal molecules from peroXIdatIve damage Thus,
13-188
changes m constItuents of tms system may serve as a marker of effects from mhaled NO
3
However, m1ce exposed to 12,300 to 25,800 f,Lg/m (10 to 21 ppm) NO, 3 h/day for 7 days
showed no change m lung tevels of reduced GSH, a cofactor for GSH peroXldase (Watanabe
et al , 1980)
There 1S some eV1dence that NO may alter the actllv1ty of other enzymes A number of
m v1tro stud1es (Arnold et al , 1977, Braughler, 1982, Katsukl et al , 1977) have md1cated
that NO may affect guanylate cyclase, the enzyme that catalyzes the formatlOn of cychc-
guanasme monophosphate and guanosme tnphosphate They have shown, based upon
exposure of punfied enzymes or tIssue mmces from varIOUS organs, that NO mcreases
enzyme actIv1ty m a concentratlOn-dependent fasmon, and that the act1vatIon 1S revers1ble
when NO 1S removed from the preparatIon Although vanable degrees of actIvatlOn were
seen m dlfferent tIssues, lung tIssue showed one of the llnghest degrees of act1vatlOn It 1S,
however, not known whether NO would alter guanylate cyclase actIv1ty w1th m V1VO
exposure
The bulk of the tOXlcolog1c data base for NO blOchem1stry concerns 1tS reactlOn w1th
hemoglobm JInhaled NO that enters the bloodstream through the lungs bmds to hemoglobm,
producmg mtrosylhemoglobm (Oda et al , 1975, 1980a, 1980b, Case et al , 1979, Naka]lma
et al ,1980) Thls may, m fact, be a major mechamsm of action, and m V1tro studies have
suggested that NO may severely reduce the ability of RJBCs to carry 02 These stud1es have
shown that the afflmty of hemoglobm for NO 1S very lngh, much mgher even than that for
02 (G1bson and Roughton, 1957; Moore and G1dson, 1976) In add1tIon, m V1trO
measurements of 0Td1SS0CIatlOn curves for partially NO-hganded human hemoglobm have
shown that NO bmdmg tends to reduce d1sS0CIatIon. of bound O2 on the molecule (Kon et al ,
1977) Fmally, mtrosylhemoglobm 1S easily and rap1dly oXldIzed to methemoglobm m the
presence of 02 (Cmodi and Mohler, 1985, Kon et aI., 1977), further reducmg the ability of
RBCs to transport 02
Followmg m V1VO exposures, a hnear relatlOnsmp was found between the exposure
concentratlOn of NO (24,500 to 98,200 f,Lg/m3 , 20 to 80 ppm) for 1 h m m1ce and blood
content of mtrosylhemoglobm, however, levels of metlmmoglobm were found to mcrease
exponentIally w1th NO concentratIon, result1ng m greater blood levels of methemoglobm than
mtrosylhemoglobm (Oda et al ,1980b) After exposure of m1ce to 49,100 f,Lg/m3 (40 ppm)
13-189
for 1 h, concentratIons of both methemoglobm and mtrosylhemoglobm decreased rapIdly,
with half-tImes of only a few mmutes (Oda et al , 1980b) Thus, the steady-state
concentration of mtrosylhemoglobm durmg NO exposure would be farrly low, whereas that
for methemoglobm would be somewhat hIgher (Maeda et al , 1987)
Studies of anImals exposed to NO m VIVO have shown that the amount of
nitrosylhemoglobm m blood was much less than would be expected from m VItro exposure
3
data (Oda et al , 1980b, 1975) LIfetIme (23 to 29 mo) exposures of mIce to 2,940 p.,g/m
(2.4 ppm) NO resulted m the blood content of mtrosylhemoglobm remammg relatIvely steady
at 0.01 %, whereas the maxImum amount of methemoglobm was 03% (Oda et al , 1980a)
3
Mice exposed to 12,300 p.,g/m (10 ppm) NO for 6 5 mo showed mtrosylhemoglobm at
0.13% and methemoglobm at 02% (Oda et al ,1976) These results suggest that a steady-
state concentratIOn of methemoglobm may be reached WIth exposures to dIfferent
concentratIOns Furthermore, although the results of VarIOUS studIes have shown that the
fmal product of NO reactIOn WIth hemoglobm IS methemoglobm, WIth some persIstent
nitrosylhemoglobm, thIs effect of NO IS not generally lethal because of a number of factors,
these mc1ude the converSIOn of Inhaled NO to N02 m the aIrways, the rapId OXidatIOn of
nitrosylhemoglobm mto methemoglobm, and the subsequent reductIOn of methemoglobm mto
ferrous hemoglobm by methemoglobm reductase, an enzyme present m RBCs (Kon et al ,
1980, Maeda et al , 1984b, 1987) As long as the actiVIty of methemoglobm reductase IS
mamtamed, the converSIOn of mtrosylhemoglobm to methemoglobm should mItigate any
potentially tOXiC effect on hemoglobm due to NO InhalatIOn (Kon et al , 1980) In long-term
3
exposure studies, Oda et al (1976, 1980a) exposed mIce to 4,512 or 18,800 p.,g/m (2 4 or
10 ppm) NO and after exammatIon of organs senSItive to O2 depletion (e g , bram and
heart), found no eVIdence of hypOXiC damage, whIch would have been expected If
methemoglobm levels were substantially mcreased
3
Azoulay et al (1977) exposed rats to 2,450 p.,g/m (2 0 ppm) NO contmuously for
6 weeks to examme VarIOUS hematologIc parameters, mc1udmg blood-02 affImty
No exposure-related changes were found m hemoglobm content, hematocnt, RBC count, red
cell glucose metabohsm, or m the oxyhemoglobm dISSOCiatIOn curve In addItion, no
methemoglobm was detected m eIther exposed or control ammals ThIs showed that low-
level NO exposure dId not alter the blood-02 affImty On the other hand, the same
13-190
mvestIgatIOll reported that m vItro studIes had shown that blood-02 transport was altered by
hIgh levels of NO (> 12,300 p,g/m3 , 10 ppm) m both human and rat blood
In addItIon to mteractIon wIth hemoglobm, exposure to NO may alter other aspects of
blood Case et al (1979) exposed mIce to 11,070 p,g/n'? (90 ppm) NO for 16 h and found a
decrease m the level of rron transferrm MIce exposed to 12,300 p,g/m3 (10 ppm) NO for
6 5 mo showed mcreased WBC counts and an mcrease m the ratIO of PMNs to lymphocytes
(Oda et al , 1976) These mvestIgators noted that 11 % of the RBCs obtamed from NO-
exposed mIce contamed HeInZ bodIes, whereas the control group showed none Coupled
wIth an mcrease m spleen weIght and btlrrubm, the mvestIgators suggested that thIs mdicated
that NO facilitated the destrucoon of RBCs
A slIght mcrease m RBC hemolysIs was seen m rrllce exposed to 2,940 p,g/m3
(24 ppm) NO for therr ltfet1me (Oda et al , 1980a) Rat RBCs exposed to NO m VItro,
showed OXidatIve cross-lmkmg between cell membrane protems and hemoglobm (Maeda
et al , 1984a), an alteratIOn that could change the cells' rheological propertIes However, m
an m VIVO exposure study, no cross-lmkmg of membrane protems was detected m rats
3
exposed to 30 7 to 254 4 mg/m (25 to 200 ppm) NO for 1 h (Maeda et al , 1987), the
mvesogators suggested that thIs may have been due to rapId repaIr mechanIsms operatmg
m VIVO
The pH of blood has been shown to be reduced by NO, but only WIth very hIgh
exposure levels (e g , 0 5 to 2 0%, 5,000 to 20,000 ppm) (Toothtll, 1967, Greenbaum et al ,
1967) Rats exposed to 2,450 p,g/m3 (2 °ppm) NO contmuously for 6 weeks showed no
change m blood pH (Azoulay et al , 1977)
An exammatIOn of the mutagemcity of NO was performed by Arroyo et al (1992)
Salmonella typhzmunum TA1535 was exposed for 30 mm to 6,150 to 110,700 p,g/m3 (5 to
90 ppm) NO, and mutagemc potenoal was assessed usmg a modtfied Ames reverSIon assay
The number of revertant colomes mcreased roughly m proportIOn to the square of the NO
concentratIOn up to 24,600 p,g/m3 (20 ppm), and then remamed relatIvely constant or slIghtly
decreased at > 24,600 p,g/m3 It was also noted that the observed mutagemcity requrred that
the bactena were actIVely divIdmg at the orne of exposure to NO These results suggested
that NO can act as a drrect-actmg mutagen
13-191
A few studIes have exammed the response to mhalatIon of mIXtures of NO plus one
3
other component Watanabe et al (1980) exposed mIce to NO (12,300 Jl-g/m , 10 ppm) plus
3
03 (1,960 Jl-g/m , 1 0 ppm), 3 h/day for 7 days, they observed an mcrease m the level of
lung GSH, but thts was due solely to the 03 Azoulay et al (1980) exposed rats to NO
3
(2,460 Jl-g/m , 2 0 ppm) wIth S02 (5,240 Jl-g/m 3 , 2 0 ppm) for 13 weeks, no change m
blood-02 afftmty, methemoglobm level, RBC count, or lung htstology was noted Fmally, m
an in VItro study, Robertson et al (1982) adsorbed NO onto mmeral dusts (2 to 5 Jl-g NO/mg
dust), no change m the CytotOXiCIty of coal, quartz, or kaohmte to P388D1 cells was found,
compared to dust wIthout adsorbed NO, suggestmg no mteractIOn of NO and dust The
effects of chromc exposures to NO and N02 m dogs were comprehensIvely exammed (Starn
et al , 1980) The results of the study, summanzed m Section 13 3, showed a vanety of
morphologIcal and phYSIOlogICal effects on the lungs However, because there were no
N02- or NO-only groups, the nature of the mteractIOn IS not clear
McFaul and McGrath (1985) exammed the effect of mhalatIon exposure to NO at levels
3
of 184 to 78.6 mg/m (15 to 64 ppm) for up to 38 h on the reduction of methemoglobm
produced 1ll1t1ally m the blood of rats by mJectIOn of sodIUm mtrate They found the
methemoglobm reductIOn was nnparred at all of the NO levels used, and suggested that
exposure to NO may modulate certam reparr processes followmg exposure to other OXidant
pollutants.
Summary
The tmacoiogic data base for NO IS not extensIve, except for ItS mteractIon WIth blood
Farrly high levels, ~2,460 Jl-g/m3 (2 0 ppm), are needed for morphologIc changes m the
lungs followmg subchromc or chromc mhalatIOn (Azoulay et al , 1977, Holt et al , 1979,
Oda et al , 1976) Inhaled NO that IS absorbed mto the bloodstream results m productIon of
nitrosylhemoglobm which, m tum, IS OXIdIZed to methemoglobm (Oda et al , 1975, 1980a,b,
Case et al , 1979, NakaJnna et al , 1980) Thts has the potential to reduce the ability of
RBCs to transport 02 (GIbson and Roughton, 1957, Moore and GIbson, 1976) But as WIth
other effects, very htgh exposure levels are needed for sIgmftcant changes It should be
noted that a number of cell types have recently been shown to produce NO, whIch seems to
13-192
have vanous blOlogiCal functions as an mter- and mtracellular messenger (Curran et al ,
1991)
13.5 NITRIC ACID AND NITRATES

13.5.1 Nitric Acid
There are only a few tmocoiogic studIes of HN03 , wmch eXIsts m ambIent arr
generally as a mghly water soluble vapor In an early study, Diggle and Gage (1954) noted
3
that a smgle exposure to HN03 vapor at 63,000 jJ-g/m (25 ppm) had no "ObVlOUS effect on
rats", exposure duratIon and end pomts exammed were unspecIfied
More recent studies have exammed the mstologIcaJl response to mstllled HN03 (usually
1 %), a procedure used m developmg models of broncmohtIs obhterans m vanous anImals,
namely the dog, rabbIt, and rat (Totten and Moran, 1961, Greenberg et al , 1971, Mmk
et al ,1984) The major changes noted were degeneratIOn of alveolar Type 2 cells and
alveolar cell hyperplasIa In a somewhat slffiuar study, Peters and Hyatt (1986) dehvered
1 % HN03 mto a catheter pOSItioned m the mam bronclut of the dog, however, in tills case,
the aCId was dehvered VIa nebuhzatlOn, alternately (every other day) as eIther a coarse spray
or as a fme mIst, for 2 hiday for 4 weeks Pulmonary function testIng after 4 weeks of
exposure mdicated decreases m expIratory flow rate, dynamIC comphance, total lung
capacIty, and VItal capacIty, and mcreases m pulmonary reSIstance, c10smg capacIty, the ratIO
of functional reSIdual capaCIty to total lung capacity, and phase ill of the smgle breath
mtrogen washout curve HIStologICally, there was WIdespread chromc mflammatlOn of
conductmg arrways, especIally medmm and small ones, penbroncmolar fibrOSIS, focal
hemorrhage, edema, and hyperplaSIa of goblet cells m the trachea and broncm
Gardmer and Schanker (1976) exammed the effect of HNOrmduced damage on drug
absorption from the lungs of rats InstlllatlOn of I % HN03 produced broncmohtIs and
alveohtIs and mcreased the rate of pulmonary absorptIOn of vanous drugs up to 1 6 tlffies
control values Tills change was ascnbed to an mcrease m the penneability of the
alveolocapillary barrIer
Only two studIes were deSIgned specIfically to exarnme the pulmonary response to pure
HN03 vapor Abraham et al (1982) exposed both nonnal sheep and allergIC sheep (1 e ,
13-193
those havmg arrway responses snmlar to that occurrmg ill humans wIth allergIC arrway
3
dIsease) for 4 h to 4,120 p.g/m (1 6 ppm) HN03 vapor The exposure, wruch was
performed usmg a "head-only" chamber, resulted m a decrease ill specIfic pulmonary flow
resistance, compared to preexposure control values, ill both groups of sheep, thIS mdicated
the absence of any bronchoconstnctlOn To assess arrway reactiVIty, pulmonary resIstance
was also measured after challenge wIth a bronchoconstnctor aerosol (carbachol) AllergIC
sheep showed mcreased reactIVIty, both ImmedIately and 24 h after HN03 exposure
Although there was no sIgnrficant change m reactIVIty m the normal groups as a whole, two
of the anImals showed an mcrease m reactIvIty to carbachol after HN03 exposure, accordmg
to the investIgators, trus suggested that some illdiVIduals ill the normal populatIon may be
more senSItive than others
NadzIeJko et al (1992) exposed rats for 4 h to HN03 at eIther 644 p.,g/m3 (0 25 ppm)
3 3
or 2,575 p.g/m (1 mg/m ) Exposures were nose-only, and bronchopulmonary lavage was
perfomled 18 h after the exposure ended Exposure to HN03 had no effect on total number
of cells recovered, numbers of macrophages recovered, or protem content m lavage flUId
Exposure to the lower aCId level dId result m a reductIon ill respIratory burst actiVIty of
macrophages (wruch was not SImIlarly measured at the rugher concentratlOn), and exposure
to the hIgher concentratIon resulted m an illcrease ill the lavage flUId elastase mrubitory
capaCIty
13.5.2 ~itrates
The tOXIcologIC data base for mhaled mtrates IS qUIte sparse EhrlIch (1979) exammed
the effect of mtrates on reSIstance to respIratory mfectlOn MIce were exposed for 3 h to
vanous mtrate salts at maxImal concentratIons as follows lead mtrate, 2,000 p.g/m3 ,
3
calCIUm mtrate, 2,800 p.g/m , NaN03, 3,100 p.g/m3 , potaSSIUm mtrate, 4,300 p.g/m3 ,
3
ammomum mtrate (NH4N03), 4,500 p.g/m and zmc mtrate (Zn[N03h), 1,250 p.g/m3
,
Following exposure, the anImals were challenged WIth a bactenal aerosol, and mortalIty
determmed after 14 days Only the Zn(N03h exposure resulted ill any SIgnIficant mortalIty
mcrease, the extent of wruch seemed to be concentratIon related, the rughest concentration
illcreased mortalIty by :::: 20 % However, Slllce the response was sunIlar to that seen WIth
ZlllC sulfate, the lllvestIgator ascnbed the effect to the ZlllC lon, rather than to the mtrate
13-194
Busch et al (1986) exposed rats and gumea pllgS wIth eIther normal lungs or lungs wIth
3
elastase-mduced emphysema to 1 mg/m NH4 N03 , 6 h/day, 5 days/week for 4 weeks
Usmg both LM and electron mIcroscopy, the mvestIgators concluded that there were no
sIgmficant effects of exposure on lung structure due to the mtrate exposure
Charles and Menzel (1975) exammed the effects 01 mtrate on the release of hIstamme
by gumea pIg lung fragments, response to some pollutal1lts may be a functIOn of theIr ability
to ehcIt hIstamme release Lung fragments were mcubated for 30 mm WIth 20 to 200 mM
NH4N03 HIstamme was released m proportIOn to the concentratIOn of salt present
However, the response was not totally due to mtrate, ammomum IOn was also a possIble
contnbutor
Summary
InhalatIon studIes WIth HN03 are hmIted and no conclusIOns can be reached LIkewIse,
the toxIcologIC data base for Inhaled mtrates IS sparse, WIth no conclusIOns possIble
13.6 SUMMARY
The vast maJonty of ammal tOXIcology studIes of NOx are on N02 , whIch apparently IS
more tOXIC than other mtrogen specIes (NO, HN03 , and partIculate mtrates) that commonly
occur m the ambIent arr However, dIrect comparatIve studIes of NOx speCIes are rare,
more new InformatIOn could challenge assumptIons of relatIve potency GIven the current
weIght of eVIdence, thIs summary will only address NO?, alone and m mIXtures AmbIent
3 3
and mdoor levels of N02 are ordmanly below 1,880 J-tglm (1 0 ppm) acutely and 94 J-tg/m
(0 05 ppm) chromcally, makIng hIgh-concentratIOn ammal studies dIfficult to mterpret for
assessment of ambIent arr Thus, WIth rare exceptIon, only studIes below 9,400 J-tg/m3
(5 0 ppm) are summanzed here Although a WIde array of systemIC effects have been
observed after N02 exposure, theIr mterpretation for nsk assessment IS qUIte dIfficult and
unclear (WIth th~possIble exceptIon of Immune system effects) compared to respIratory tract
effects Thus, for more diSCUSSIOn of systemIC effects, &ee the summanes WIthin the chapter
ThIs summary IS orgamzed to focus attentIon on key Issues pertammg to respIratory tract
effects They mclude ammal-to-human extrapolatllon, mechamsms of effects, effects on
13-195
host defenses, relative mfluences of concentration and tune (duration) of exposure and
exposure patterns, unpact of exposure duration on effects, and effects of pollutant mIXtures
For summaries of each end pomt, see the summanes Withm the mam text
13.6.1 Animal-to-Human Dosimetric Extrapolation Estimates

QualItatIvely, most experts would agree that a class of effects of N02 observed m
several annnal speCIes could also occur m humans, If exposures were adequate to mduce the
effect Such a qualItative extrapolatIOn IS founded on the mterspecIes commonalIty m
molecular mechamsms of tOXICIty and m targets of tOXICIty For example, small laboratory
annnals, nonhuman prnnates, and humans all have AMs WIth susceptible membrane
components However, quantitative extrapolation reqUIres quantitative knowledge of
mterspecies commonalIties and dIfferences m dosunetry and speCIes senSItIvIty Although
some information IS available on these two elements, It IS not yet suffiCIent for quantitative
extrapolatIOn Nevertheless, the state of knowledge facilitates the mterpretatIOn of annnal
studIes m terms of potentIal human nsks
Total N02 respIratory tract uptake m humans depends on the expernnental methods
used, the health status of the subjects, and breathmg state (Wagner, 1970, Bauer et al ,
1986). Total respIratory tract uptake ranged from 81 to 90% m normally breathmg healthy
subjects and increased to 91 to 92 % durmg maXImum respIration (Wagner, 1970) The
average total uptake m restmg asthmatics was 72 %, and as respIration mcreased, the percent
total uptake of N02 mcreased to 87% (Bauer et al ,1986) Roughly sunIlar fmdmgs were
made in dogs (Klemman and Mautz, 1991) At rest, total respIratory tract uptake was 78 %,
durmg exerCIse, It was 94 % ExerCIse obVIously mcreases the total uptake of N02 , but It
also alters the regIOnal dIstnbutIon of dose Generally, mcreased ventIlatIon decreases the
percent uptake m the upper respIratory tract and mcreases the percent uptake m the total and
lower respIratory tract Theoretical models based on 03 predIct that the mcreased dose to
the lower respIratory tract IS predommantly to the pulmonary regIOn (Miller et al , 1985)
A WIder range of lower respIratory tract uptake values has been observed m anunals as
a result of dIfferences m specIes and methods (PostlethwaIt and Mustafa, 1981, 1989,
Klemman and Mautz, 1991) However, mathematical modelmg of lower respIratory tract
uptakes m humans and annnals (rats, gumea pIgS, and rabbIts) revealed that the greatest dose
13-196
IS dehvered to the centnacmar regIOn (1 e , JunctIon between the conductmg arrways and the
gas-exchange regIOn) m all these speCIes (Miller et al , 1982, Overton, 1984) ThIs IS the
sIte where N02-mduced lesIons are observed morphologlcally m annnal speCIes, lendIng
credence to the mathematIcal model Once deposIted and bound, N02 reacts wIth flUIds and
tIssues, formmg other products that can be transported systemIcally Vanous theones and
expenmental fmdmgs are avatlable suggestmg that HONO and HN03 can be produced m the
lung from N02 exposure (Goldstem et al , 1977b) or that mtnte IS produced m the lungs,
enters the bloodstreams, and reacts wIth hemoglobm to form mtrate and methemoglobm
(postlethwatt and Mustafa, 1981, 1989, Saul and Archer, 1983)
13.6.2 Biochemical and Cellular Mechanisms

Acute exposure to N02 at or below 9,400 p.,g/m3 () ppm) can OXIdIZe unsaturated fatty
aCIds m cell membranes as well as functIonal groups of protems (eIther soluble protems m
the cell, such as enzymes, or structural protems, such as components of cell membranes),
producmg cell IDJUry or death and the toXiC symptoms associated WIth N02 InhalatIOn
(Menzel, 1976 Freeman and Mudd, 1981) Such a proposed mechamsm of actIon IS
supported by data showmg an tmtIalmcrease m hpid permadatIOn products and some
protectIve lung antIOXidant enzymes after N0 2 exposure (Sagat et al , 1984), as well as an
mcreased susceptIbility to N02 mammals defiCIent m vIl.amms C and E (Selgrade et al ,
1981, Sevaman et al ,1982) The dIrect CytOtOXiC effect of N02 on epIthehal cell
membranes may be the fundamental mechamsm of edema.genesis m response to N02
exposure, whereas the dIrect CytOtOXiCIty of N02 to membranes of AMs could well be the
mechanIsm underlymg mcreased mfectivity of bactena and VIruses m the lungs of exposed
ammals A large number of studIes have suggested that vanous enzymes m the lung,
mcludmg GSH peroXidase, SOD, and catalase, may also serve to defend the lung agamst
OXidant attack One may speculate that were there to be a threshold level for N02 tOXICIty to
the lung, It would be that concentratIOn of N02 that was able to overwhelm these endogenous
defense systems of the lung
The bIOchemIcal study usmg the lowest concentratlOn of N02 was conducted by
Sagat et al (1984), who reported that 9 and 18 mo of exposure to ?:.75 p.,g/m3 (004 ppm)
N02 mcreased ethane exhalatIon (exhaled ethane IS an ill VIVO mdicator of hpid peroXIdatIon)
13-197
m rats; at 752 p..g/m3 (04 ppm), they observed tlns response at 6 mo Although tlns chromc
study showed increases m hpid permadation wIth mcreasmg concentratIOn and duratIOn of
exposure, a shorter term (4-mo) exposure revealed that ethane exhalatIOn mcreased after
1 week of exposure, decreased to control levels by 4 weeks, and then rose agam (lchmose
and Sagai, 1982) Saga! et al (1984) also observed that hpid permadatIOn had an mverse
relationslnp WIth changes m lung antIoXidant metabohsm
13.6.3 Effects on Host Defenses

Host defenses are a broad category of functIOns, encompassmg defenses agamst
mfectious (bactenal and vIral) dIsease, neoplastIc dIsease, and mhaled partIculate matter
The nnmune system, a major component of host defense, IS compartmentahzed
phySIOlOgically (e g ,pulmonary and systemIC Immune system) Effects of N02 on the
respiratory tract defense mechamsms will be presented fITst, followed by a dISCUSSIon of
systemIc effects
Studies of respiratory tract host defenses have shown that N02 enhances susceptIbIlIty
to bacterial and viral dIsease, probably through effects on AMs and pOSSIble through changes
in the immune system and other defense mechamsms not yet adequately mvestigated The
mucociliary escalator, an Important component of defenses, IS not functIOnally affected In
rabbIts exposed for 14 days (2 h1day) to 1,880 p..g/m3 (1 ppm) or for 2 h to 18,800 p..g/m3
(10 ppm) N02 (Schlesmger et al , 1987a,b), although there are numerous reports of
structural changes In the ciliated epIthehum at levels below 9,400 p..g/m3 (5 ppm)
(Rombout et a1 , 1986, Stephens et al , 1972, Yamamoto and TakahashI, 1984)
Various acute and subchromc exposure regImens, generally> 1,889 p..g/m3 (1 0 ppm)
N02 , increase the number of AMs m the lung (Moclntate et al , 1992, Gregory et al , 1982,
Rombout et al ,1986) Structure, functIon, and metabohc actIVIty of AMs are also affected
by N02 exposure Pulmonary bactencIda1 actIvIty, often Interpreted as representatIve of AM
actiVIty, is decreased m mIce by a 17-h exposure to >4,320 p..g/m3 (2 3 ppm) N02
(Goldstem et al , 1973), however, effects on AM phagocytosIS are complex For example,
exposure to 560 p..g/m3 (0 3 ppm) N02 , 2 h/day for 13 days, lllitIally decreased AM
phagocytosis m rabbIts, whereas AMs exposed to 1,880 p..g/m3 (1 0 ppm) showed an lllitIal
mcrease m phagocytosIS (Schlesmger, 1987b) However, exposure of rabbIts to these N02
13-198
concentrations for 2 h/day for 14 days mcreased alveolar clearance, which also represents
AM functIOn (Schlesmger and Gearhart, 1987, Vollmuth et al ,1986) Acute N02 exposure
decreases supermode amon radIcal productIOn by AMs, cmd longer exposures cause
morphologIcal changes m AM membranes, metabohc ch1mges, an mcrease m AM numbers, a
decreased responsIveness to mIgratIOn mhtbitOry factor, and a decrease m AM random
mobility (MochItate et al , 1986, Aranyl et al , 1976, Greene and SchneIder, 1978, Amoruso
et al , 1981, Schlesmger, 1987b)
One of the most WIdely apphed methods to mvestIgate effects on defenses m
expenmental anImals IS the mfectIvity model Usmg this model, expenmental anImals are
exposed to N02 and then are challenged WIth Viable bac1ena or VIruses, microbial-mduced
mortalIty IS measured The mortalIty reflects the net Imparrment of host defense
mechamsms The senSItivIty of this model to detect N02-mduced changes m host
susceptibility to mfectmus dIsease IS mfluenced sIgmficantly by the mIcrobIal speCIes, the
anImal speCIes, and exposure regImen After acute exposure, the senSItivIty rankmg was
mIce> hamsters> monkeys (Ehrhch, 1975) In mIce exposed for 2 to 3 h, the lowest
concentratIOn that enhanced mortalIty was 6,580 p,g/m3 (3 5 ppm) usmg Klebslella
pneumoma and 3,760 p,g/m3 (20 ppm) usmg Streptococcus sp (Ehrhch, 1975, PurvIS and
Ehrhch, 1963, Ehrhch et al ,1977) Long-term, mtermllttent exposure of mIce to 940 p,g/m3
(05 ppm) has been reported to decrease reSIstance to bactenal mfectIons Withm 6 mo,
however, contmuous exposure decreases reSIstance to bactenal mfections withm 3 mo
(Ehrhch and Henry, 1968) ExtenSIve studIes of eXT relatIOnships observed m the
mfectIvity model are summanzed m SectIon 13 6 4
Few studIes WIth other mICrobes have been conducted, but they show that repeated
exposures can mcrease susceptibility to mfluenza VlfUS or cytomegalovIruS mfection m rmce
and monkeys (Ito, 1971, Henry et al , 1970, Rose et al 1988, 1989) Acute, hIgh-
3
concentratIOn exposure (9,400 p,g/m , 5 0 ppm) of mIce mcreases the mCIdence and seventy
of Mycoplasma pulmonls leSIOns (Parker et al , 1989)
The pulmonary Immune system IS rarely mvestIgat~xl, and N02 reports WIth modem
methods and appropnate expenmental deSIgns and analyses have not appeared SystemIC
Immune responses to antigens dlehvered VIa the respIratory tract are altered by N02
For example, monkeys exposed to 1,880 p,g/m3 (1 0 ppm) N02 for 16 mo or 9,400 p,g/m3
13-199
(5.0 ppm) for 6 mo and nnmumzed wIth mfluenza expenenced alteratIOns m cIrculatmg
antibody tIters (Fenters et al , 1973, EhrlIch and Fenters, 1973) Several other mvestIgations
show that N02 can alter systemIc humoral and cell-medIated nnmumty Usmg examples
from studIes at lower concentratIOns, a 7-week mtenmttent exposure to 470 p,g/m3
(025 ppm) altered percentages of splemc T-cell subpopulatIOns m mIce (Rlchter and DamJl,
1988, 1990), a 4-week exposure to 752 p,g/m3 (04 ppm) decreased splemc pnmary PFC
responses ill mice (FuJmlak1 et al , 1982), and a 12-mo exposure to 940 p,g/m3 (05 ppm)
caused a lmear decrease ill PHA-mduced mitogenesIs of mouse spleen cells with N02
duranon (Malgetter et al , 1978) Selgrade et al (1991) found no effects on splemc or
cIrculatmg lymphocytic responses to B- or T-cell mltogens after up to 78-weeks of exposure
of mice to an urban exposure pattern of N02 (940-p,g/m3 baselme wIth 2,820-p,g/m3 peaks,
0.5 ppm and 1 5 ppm)
13.6.4 Influence of Concentration, Duration, and Exposure Regimen

An extensive body of research on the exposure-response of N02 mdIcates the
importance of understandmg the compleXity of the exposure used ill the study Two classes
of studies have contnbuted to tlns tOPIC C X T exammatIOns and illvestIgatIOn of other
exposure patterns, both of wlnch are discussed here
Studies dIrectly comparmg C x T responses focus on host defenses and, to a Innited
degree, lung morphology and are dIscussed here Other work that allows illterpretatIOn about
the progression of effects wIth exposure duratIon IS summanzed SectIon 13 6 5 Most of the
C X T fmdings descnbed here are a result of usmg the mouse streptococcal mfeCtIvity
model. In one senes of studIes, Gardner et al (1977a,b, 1979), Gardner et al (1982), and
COffill et al (1977) vaned the concentratIon of N02 from 1,880 to 26,320 p,g/m3 (1 to
14 ppm) and the exposure duratIon from 0 5 to 7 h so that the C x T product was 7 ppm-h
The bactenal-mduced mortalIty was enhanced more by concentratIOn than by tnne
An investigatIOn of SlX concentratIOns of N02 , rangmg from 940 to 52,670 p,g/m3 (05 to
28 0 ppm), for vanous duratIons (30 mm at the lnghest concentratIon and 12 mo at the
lowest) showed that bactenal-mduced mortalIty lDcreased lInearly wIth length of exposure,
the slope of the hne was steeper at lngher concentratIons (Gardner et al , 1977) As before,
concentration had more mfluence than tnne m elIcItmg the response For example, at a
13-200
3
constant eXT of 14 ppm-h, a 9 3-h exposure to 2,820 p,g/m (1 5 ppm) mcreased mortalIty
3
by 10 2%, whereas a 1 O-h exposure to 27,300 p,g/m (140 ppm) enhanced mortalIty by
449% IntermIttent (7-h/day) and contmuous (22- to 24-h/day) exposures were also
compared m the streptococcal InfectIvIty model (Gardner et al , 1979) MICe were exposed
to 2,820 or 6,580 p,g/m3 (1 5 or 3 5 ppm) N02 for up to 15 days All exposures mcreasoo
mortalIty At the hIgher concentratIOn, there were no slgmficant dIfferences between the fwo
exposure groups However, when the concentratIOn was reduced, a longer duratIon of
exposure (14 days) was requIred for mtermittent exposure to produce a level of effect
eqUIvalent to contmuous exposure
In mIce exposed to 940 p,g/m3 (05 ppm) for 6 mo, mtermittent exposure (6 or
18 h/day) was eqUIvalent to contmuous exposure (24 h/day) m mcreasmg mortalIty due to
Klebszella pneumonzae However, after 12 mo of exposure, effects were only observed ill
the contmuous exposure As duratIOn mcreased to 12 mo, the decreased bactenal clearance
was eqUIvalent m the two mtermittent and contmuous groups (EhrlIch and Henry, 1968)
Rombout et al (1986) evaluated exT Impacts 011 lung morphology Rats were
exposed from 1,000 to 20,000 p,g/m3 (053 to 106 ppm) for up to 28 days EpIthelIal
changes were more related to exposure concentratIOn than to duratIOn
In ambIent aIr, there IS a low baselIne concentratIOn of N02 on whIch are superImposed
one or two peaks of hIgher concentratIons (prImarIly Monday through Fnday) resultmg from
the mfluence of vehIcular traffic The Impacts of such patterns have been mvestIgated usrng
the InfectIVIty model, puhnonary functIOn, and lung mOIphology/morphometry Usmg the
mouse streptococcal InfectIVIty model, mIce were exposed to a senes of regImens, WIth and
WIthout a contmuous baselIne of 2,820 p,g/m3 (1 5 ppm) and WIth and without peaks (1, 3 5,
or 7 h) of 8,460 p,g/m3 (45 ppm), mIce were challenged WIth bactena ImmedIately or
18 h after the peak exposures, total exposure duratIons vaned between 1 day and 2 weeks
(Graham et al , 1987, Gardner, 1980, Gardner et al , 1982) The baselme exposure alone
caused no effects, whereas peaks alone enhanced mortaltty when the bactenal challenge was
Immediately after the peak exposure WIth both the baselIne and peak exposures, the effect
perSIsted 18 h after the peak exposure When these data were compared to a 2-week
contmuous exposure to 2,800 p,g/m3 (1 5 ppm), there was no apparent trend towards a
exT relatIOnshIp In a I-year exposure study, contmuous exposure to 376 p,g/m3
13-201
(0.2 ppm) dId not affect streptococcal-mduced mortahty (Miller et al , 1987) However,
In mIce exposed to tIns basehne plus two daIly I-h peaks of 1,500 p.g/m3 (0 8 ppm) for
5 days/week, mortahty was enhanced over arr controls and the basehne N02 group
Pulmonary function was also affected (decreased VItal capacIty) more In the basehne-plus-
peak group compared to basehne only and arr-control groups Pulmonary functlOn and
mOIphometnc studies usmg urban patterns of N02 are descnbed further m the next sectIon
(Section 13.6 5).
The body of work comparmg dIfferent exposure reglffiens clearly shows the dependence
of effects on the concentratlOn and duratlOn and the exposure proIl1e, rather that the
cumulative C X T ThIs illustrates the drfficulty of extrapolatmg from a laboratory exposure
to a complex ambient pattern of N02
13.6.5 Impact of Exposure Duration

As exposure duratIOn Increases, generally lower concentrations of N02 are needed to
produce effects, and different types of effects may occur The effects of exposure duration
on increasmg susceptIbility to pulmonary mfectlOn have been descnbed above
(Section 13.6 4) Thus, other chromc studIes that pnncIpally focused on lung
mOIphology/moIphometry will be dISCUSSed here, along WIth supportmg research on
pulmonary function
Although N02 produces mOIphologIcal changes In the respIratory tract, the data base IS
sometimes confusmg due to quantitatIve and quahtatIve vanability m responSIveness between
SpecIes, and even withm the same specIes For example, the rat appears to be relatIvely
reSIstant to N02 , although tIns IS the most commonly used expenmental ammal Involved In
mOIphological assessments of exposure In any case, when effectIve levels are used, the
target site IS the reglOn that mcludes the termInal and/or respIratory bronchIOles, alveolar
ducts, and alveoli SenSItIve cells are the ciliated cells of the bronchlolar epIthelIum and the
Type 1 cells of the alveolar epIthelIum As these cells are sloughed off, they are replaced by
nonciliated bronchiolar (Clara) cells and Type 2 cells, respectIvely
Acute exposures to concentratIons of =::;;9,400 p.g/m3 (5 0 ppm) generally produce
mInimal or no mOIphologIcal effects m the rat, however, slffiI1ar exposures m the gumea pIg
may result m some epIthelIal damage (Azoulay-Dupns et al , 1983) Thus, prolonged
13-202
exposures are of more mterest Longer term exposures result m lesIOns m some specIes WIth
3
N02 concentratIOns as low as 560 to 940 p.,g/m (0 3 to 0 5 ppm) (Sherwm and RIchters,
1982, Kubota et al , 1987, Yamamoto and TakahashI, 1984; HayashI et al ,1987) LeSIOns
are charactenzed by epIthehal damage SImIlar to that descnbed followmg acute exposure to
<9,400 p.,g/m3 (5 0 ppm), but wIth the mvolvement of more proXImal aIrways, the thIckness
of the basallamma and mterstItmm can mcrease Many of these changes, however, will
resolve even wIth contmued exposure, and long-term exposures to levels above about
3,760 p.,g/m3 (2 0 ppm) are requrred for more extensIve and permanent changes m the lungs
Some effects are relatIvely persIstent, for example, bronchIohtIs and collagen deposItIOn,
whereas others, such as epIthehal cell hyperplasia, tend to be reverSIble and hmited even
WIth contmued exposure (Kubota et al , 1987, Yamamoto and TakahasI, 1984) In any case,
It seems that for both acute or longer term exposure reglllles, the response IS more dependent
on concentratIOn than on exposure duration (Rombout et al , 1986)
Results from rats exposed to 940, 1,880, and 3,760 p.,g/m3 (05, 1 0, and 20 ppm)
N02 WIth two daIly I-h peaks at three tImes the basehne concentration provIde an example of
subchromc effects of N02 on pulmonary function and lung morphometry (at the electron
mICroSCOpIC level) (Stevens et al , 1988, Chang et al , 1986, 1988) Pulmonary functIOn
(decreased respIratory system comphance) was only affected by 6 weeks (and not 1 or
3 weeks) or exposure to the hIghest concentration, recovery occurred by 3 weeks after
exposure ceased Morphometnc measurements were only made at 6 weeks of exposure
Annnals exposed to the 940-p.,g/m3 , but not the 3,760-p.,g/m3 , base (plus peaks) had a
thIckenmg of the alveolar mterstItmm m the proXImal alveolar regIOn due to the mcrease m
total volume of fibroblasts At the lowest concentratIOn of N02 , Type 2 cells were spread
over more surface area and exhIbIted hypertrophy, the number of AMs mcreased There
were no effects m the termmal bronchIolar regIOn At the hIghest N02 concentratIOn, the
prOXImal alveolar regIOn had SImIlar changes m Type 2 cells as well as an mcrease m the
number of Type 1 cells, whIch were smaller m SIZe, the termmal bronchIolar regIOn had
fewer ciliated cells and alterations m nonciliated (Clara) cells A study by HayashI et al
(1987) proVIdes an example of chromc effects of rats exposed to 940 p.,g/m3 (05 ppm)
contmuously for up to 19 mo At 4 mo of exposure, Type 2 cell hypertrophy was observed,
13-203
by 6 mo, the thickness of alveolar septa had mcreased, and at the end of exposure, there was
fibrous pleural thIckenmg
One of the major factors determmmg responsIveness WIthm a partIcular specIes IS age
at time of exposure Compared to adults, neonatal ammals seem to be more resIstant to
pulmonary funct10n or structural changes caused by N02, however, mterpretatIOn IS
confounded by dIfficulty m exposmg anImals pnor to weanmg (Stevens et al , 1988, Chang
et al , 1986, 1988, Mauderly et al , 1987, Azoulay-DupUls et al , 1983, Kyono and KaWaI,
1982) Kyono and KaWaI (1982) observed a complex mterrelatIOnslnp between N02
concentrat1on and age that cannot be mterpreted clearly However, for some end pomts
(e g., arr-blood barrIer thIckness), there was a decrease from 1 to 12 mo of age and an
increase in 21-mo-old rats exposed for 1 mo to ~ 207 ",g/m (0 11 ppm)
3
There IS very substantIal eVIdence that long-term exposure of several specIes of

3
laboratory anImals to hIgh concentrat1ons of N02 (> 9,400 ",g/m , 5 0 ppm) results ill
morphologIc lung lesIOns, whIch meet the current NHLBI cntena for an ammal model of
emphysema (National InstItutes of Health, 1985) Those cntena are "An anImal model of
emphysema IS dermed as an abnormal state of the lungs m whIch there IS enlargement of the
airspaces dIstal to the termmal bronchIole AIrspace enlargement should be determmed
qualitat1vely ill appropnate specImens and quantItatIvely by stereologlC methods "
DestructIOn of alveolar walls, an essent1al addItIonal cntenon for human emphysema, has
been rehably reported m lungs from anImals m a lImIted number of studIes (Haydon et al ,
1967, Freeman et al , 1972, Hyde et al , 1978) The only one of these studIes conducted at
3
N02 exposure levels of less than 9,400 ",g/m (5 0 ppm) illvolved coexposure of Beagle dogs
3
to 1,210 ",g/m3 (0 6 ppm) N02 and 310 ",g/m3 (0 16 ppm) NO or to 270 ",g/m (0 14 ppm)
N02 WIth 2,050 ",g/m3 (1 1 ppm) NO (Hyde et al , 1978) AnImals were exposed 16 h/day
for 68 mo and then breathed clean arr dunng a 32- to 36-mo postexposure penod The dogs
exposed to the hIgher level of N02 had emphysema of the type seen ill human lungs
Although the lowest N02 concentratIOn and the shortest exposure duratIOn that will result m
emphysematous lung leSIOns cannot be rehably determmed from these pubhshed studIes, the
N02 concentrations and exposure duratIOns used are far greater than those currently reported
in ambIent arr
13-204
The susceptibility to N02 of ammals wIth expenmentally mduced emphysema has also
been exammed NItrogen dIoXIde (3,760 p.g/m3, 20 ppm, mternllttent, 8 weeks) appeared to
exacerbate emphysema m hamsters usmg morphologIcal methods, pulmonary functIOn was
not affected (Lafuma et al ,1987) However, elastase-mduced emphysema m rats was not
3
affected, even though the exposure was hIgh (17,900 p.g/m , 95 ppm, 7 h/day, 5 days/week,
24 mo, Mauderly et al [1990])
The hterature provIdes no eVIdence that N02 IS a drrect-actmg carcmogen, but no
classIcal chromc InhalatIon bmassays have been reported Other reports that N02 may act as
a promoter or facIhtator of neoplastic dIsease are fraught WIth methodologICal and
mterpretatlVe problems
13.6.6 Effects of Pollutant Mixtures

NItrogen dIOXIde eXIsts m the ambIent arr WIth other pollutants, especIally NO and 03'
wluch are part of the photochemIstry of NOx Annnal tOXIcology research has addressed
complex mIXtures (e g , exposure to ambIent arr cont:all1ung N02, automobile exhaust), but
the contnbutIon of N02 to the mIXtures effect(s) cannot be determmed due to the study
deSIgns used Bmary mIXture studIes pnmanly mclude 03 and, to a lesser extent, H2 S04
Even WIth the numerous studIes available (descnbed m SectIOn 13 3), mterpretatIOn of
mteractIOns IS unclear In bmary mIXtures, N02 eIther makes no contnbutIOn, IS addItive, or
IS synergIstic, dependmg on exposure regImen and end pomt For example, m a 6-mo
exposure study of rats, 4,700 p.g/m3 (2 5 ppm) N02 dull not affect the lung leSIOn mduced by
3
490 p.g/m (0 25 ppm) 03 (Freeman et al ,1974a) Mustafa et al (1984) found no effect of
an 0rN02 mIxture on lung DNA or protem content of mIce exposed for 1 week, however,
the mIXture caused a synergIstic mcrease of oxygen consumptIOn, sulfhydryl metabohsm, and
activIties of NADP-reducmg enzymes Ehrhch et al (1977) reported that a 3-h exposure to
03 plus N02 caused an addItIve response m the mouse mfectIvity model, whereas longer
exposure (4 weeks) appeared to result m synergIsm When mIXtures of N02 and H2S04
were exammed, SclIlesmger and Gearhart (1987) and SclIlesmger (1987a) found addItive or
synergIstic effects on host defense mechamsms, dependmg on the N02 concentratIOn and end
pomt
13-205
The fmdmgs of eIther addItIvIty or synergIsm are of concern because of the UbIqUItous,
cooccurrmg nature of 03 and N02 and the type of effects observed For example, If one of
these pollutants IS causmg a decrease m host defenses, even an addItIve response to the other
pollutant would hkely mcrease the illcldence or seventy of the effect PreCIse mterpretatIOn
of these :fmdmgs to ambIent scenanos IS confounded, however In the ambIent aIr, the
common dIUrnal pattern IS a senes of peaks of the photochemIcal OXidants and theIr
precursors (e g , NO, N02 , 03), there IS some mlXlllg between the peaks Such a
"real-world ll pattern has been approXImated by Ge1zlelchter et al (1992b), who exammed the
effects of 0 3 and N02 ill mIXture and m sequence Acute exposure of rats to the mIXture
caused a synergIstIc mcrease ill lavage flUId protem, PMNs, and eplthehal cells SequentIal
exposures generally caused an addItIve response, WIth one exceptIOn When the sequence
was N02 fIrst and 03 second, there was an antagomstlc response for the number of lavagable
epithelial cells. The body of work WIth N02 and N02-03 mIXtures illustrates the nnportance
of exposure patterns, so extrapolatmg laboratory bmary mIXture study results to ambIent
patterns Ialses concern, but does not allow precIse conclUSIOns
13-206
REFERENCES
Abraham, W M (1984) Effects of Inhaled matenals on aIrway Secl etIons atmosphenc pollutants and cigarette
smoke Semm Resplr Med 5 324-328
Abrahatn, W M, Welker, M , Ohver, W , Jr , Mmgle, M , JanuszlaewlCz, A J , Wanner, A , Sackner, M A

(1980) Cardiopulmonary effects of short-tenn mtrogen dlOX.lde exposure m conscIous sheep Environ
Res 22 61-72
Abraham, W M, Kim, C S, King, M M, Ohver, W , Jr , Yelger, L (1982) Effects of mtnc aCid on

carbachol reactivity of the airways m nonnal and allerglC sheep Arch EnViron Health 37 36-40
Acton, J D , Myrvlk, Q N (1972) Nitrogen dioXide effects on alveolar macrophages Arch EnViron Health
24 48-52
Adkms, B , Jr , Van Stee, E W , Simmons, J E, Eustis, S L (1986) Oncogemc response of stram AlJ lllice
to Inhaled chelllicals J TOXicol EnViron Health 17 311-322
Aharonson, E F, Menkes, H , Gurtner, G , SWift, D L, Proctor, D F (1974) Effect of respiratory airflow

rate on removal of soluble vapors by the nose J Appl PhysiOl 37 654-657
Amoruso, M A, WltZ, G , Goldstem, B D (1981) Decreased superoXide anIon radical production by rat
alveolar macrophages followmg mhalatIon of ozone or mtro,gen diOXide Life SCI 28 2215-2221
Antweder, H , Brockhaus, A (1976) Respiratory frequency, flowrate and mmute volume m non-anaesthetised
gumea-plgs dunng prolonged exposure to low concentration,> of S02 and N0 2 Ann Occup Hyg
19 13-16
Antweder, H , Kompch, K -H , Brockhaus, A (1975) Untersuchungen zur Frage des Emflusses von N02 und
S02 bzw emer KombmatIon belder Gase auf die Bddung praeZlpltIerender Antlkoerper belm
Meerschwemchen [InvestigatiOns on the mfluence of N02 and S02 as well as a combmatIon of the two
gases on the production of preclpltatmg antIbomes m gumea-plgs] Zentralbl Baktenol Parasltenkd
InfektiOnskrankh Hyg Abt lOng Reme B 160 212-224
Aranyl, C, Fenters, J , Erhhch, R , Gardner, D (1976) Scanmng f'lectron lllicroscopy of alveolar macrophages
after exposure to oxygen, mtrogen diOXide, and ozone EnViron Health Perspect 16 180
Arner, E C, Rhoades, R A (1973) Long-tenn mtrogen diOXide exposure effects on lung lipIds and mechanIcal
properties Arch EnViron Health 26 156-160
Arnold, W P, Mlttal, C , Katsukl, S , Murad, F (1977) Nltnc OXIde activates guanylate cyclase and mcreases
guanosme 3' 5-cyclic monophosphate levels m vanous tissue preparations Proc Nat! Acad SCI
USA 74 3203-3207
Arroyo, P L, Hatch-Pigott, V , Mower, H F, Cooney, R V (1992) MutagemClty of mtnc OXide and ItS
mhIbltIon by antiOXidants Mutat Res Mutat Res Lett 281 193-202
Ayaz, K L, Csallany, A S (1978) Long-tenn N02 exposure of mlCe m the presence and absence of Vltamm E
IT Effect of glutatmone perOXidase Arch EnViron Health 33 292-296
Azoulay, E , Soler, P , Blayo, M C, Basset, F (1977) Nltnc OXid(~ effects on lung strucmre and blood oxygen
affImty m rats Bull Eur Physlopathol Resplr 13 629-644
13-207
Azoulay, E , Soler, P , Blayo, M C (1978) The absence of lung damage m rats after chromc exposure to 2 ppm
mtrogen dioXIde Bull Eur PhyslOpathol Respir 14 311-325
Azoulay, E , Soler, P , Moreau, J , Blayo, M -C (1980) Effects of low-concentration NOxSOz gas IDlxtures on
lung structure and blood-oxygen affinIty m rats J EnViron Pathol TOXIcol 4 399-409
Azoulay, E , Bouley, G , Blayo, M C (1981) Effects of mtnc oXIde on resistance to bactenal mfectIon m IDlce
J TOXIcol Environ Health 7 873-882
Azoulay-DupUls, E , Torres, M , Soler, P , Moreau, J (1983) Pulmonary NO z tOXICity m neonate and adult
gumea pigs and rats EnViron Res 30 322-339
Balabaeva, L , Tabakova, S (1985) Lipidnata peroksldatslya v dvye pokolemya zhensla bell plukhove,
mkhahranl s azoten dvuolas [LIpid peroXIdatIon m two progemes of female albmo rats Inhalmg mtrogen
diOXIde] KbJ.g Zdraveopaz 28 41-46
Balchum, 0 J , Buckley, R D, Sherwm, R , Gardner, M (1965) Nitrogen dIOXIde Inhalation and lung
antibodies Arch Environ Health 10 274-277
Bauer, M A, Utell, M J , Morrow, P E, Speers, D M, Glbb, F R (1986) Inhalation of 030 ppm mtrogen
diOXIde potentiates exerclse-mduced bronchospasm m asthmatics Am Rev Respir DIS 134 1203-1208
Benemansky, V V , Prusakov, V M, Leshenko, M E (1981) lzucheme blastomogennogo delstvlya malykh

kontsentratsll mtrozodlmetIlaIDllla dlmettlamma, dimettlaIDllla I dvuolaSI azota [Blastogemc effect of
treatment With low concentratlOns of mtrosodlmethylaIDllle, dimethylaIDllle and mtrogen dlOXIde] Vopr
Onkol 27 56-62
Blalr, W H, Henry, M C, EhrlIch, R (1969) Chromc tOXICIty of mtrogen dIOXIde II effect on hIstopathology
of lung tissue Arch Environ Health 18 186-192
Blank, M L, Dalbey, W , NettesheIm, P , Pnce, J , CreasIa, D , Snyder, F (1978) Sequential changes m

phospholIpId composItion and syntheSIS m lungs exposed to mtrogen diOXIde Am Rev Resplr DIS
117 273-280
Bloch, W N , Jr , LaSSIter, S , Stara, J F, LeWIS, T R (1973) Blood rheology of dogs chromcally exposed to
air pollutants TOXIcol Appl Pharmacol 25 576-581
Boren, H G (1964) Carbon as a carner mechalllsm for Imtant gases Arch EnViron Health 8 119-124
Bmquet, P , Rola-Pleszczynsla, M (1987) Platelet-actIvatmg factor and cellular Immune responses Immunol
Today 8 345-352
Bmughler, J M (1982) Involvement of sulfhydryl groups m the OXIdative modulation of partIculate lung
guanylate cyclase by mtnc OXIde and N-methyl-N'-mtro-N-mtrosoguanidme Blochem Phannacol
31 1239-1244
Breeze, R J , Wheeldon, E B (1977) The cells of the pulmonary aIrways Am Rev Respir DIS
116 705-777
Buckley, R. D , LooslI, C G (1969) Effects of mtrogen dIOXIde Inhalation on gennfree mouse lung Arch
EnvIron Health 18 588-595
13-208
Burleson, G R (1987) AlteratiOn of cellular mteractIons m the llnmune system natural loller actiVIty and
N-Iymphocytes In Mehlman, M A, Elmone, E, eds Advances m modern envIronmental tOXicology
v XIV Prmceton, NJ Prmceton PublIshmg Company, Inc , pp 51-96
Busch, R H, Buschbom, R L, Cannon, W C, Lauhala, K E, MIller, F J , Graham, J A, S.tnlth, L G

(1986) Effects of a.tnInomum mtrate aerosol exposure on lung structure of normal and elastase-ImpaIred
rats and gumea pIgS EnvIron Res 39 237-252
Cabral-Anderson, L J , Evans, M J , Freeman, G (1977) Effects of N02 on the lungs of agmg rats
I morphology Exp Mol Pathol 27 353-365
Case, G D, DIXon, J S, Schooley, J C (1979) Interactions of blood metalloprotems WIth mtrogen OXides and
OXidant aIr pollutants EnVIron Res 20 43-65
Cavanagh, D G, Moms, J B (1987) Mucus protection and airway peroXIdatIon followmg mtrogen diOXide
exposure m the rat J TOXIcol EnVIron Health 22 313-328
ChallIS, B C, Fernandes, M H R, Glover, B R, Latif, F (1987) FormatiOn of diazopeptIdes by mtrogen

OXides In Bartsch, H , O'NeIll, I K, Schulte-Hermann, R ,eds Relevance of N-mtroso compounds to
human cancer exposures and mechamsms proceedmgs of the IXth mternatIonal sympOSIUm on N-mtroso
compounds, September 1986, Baden, Austna Lyon, France International Agency for Research on
Cancer, pp 308-314 (IARC SCIentific publIcations no 84)
Chang, L -Y , Graham, J A, MIller, F J , Ospltal, J J , Crapo, J D (1986) Effects of subchromc Inhalation

of low concentrations of mtrogen dIOXide I The prOXimal alveolar regiOn of Juvemle and adult rats
TOXIcol Appl Pharmacol 83 46-61
Chang, L -Y , Mercer, R R, StockstIll, B L, MIller, F J , Graham, J A, OSpital, J J , Crapo, J D (1988)

Effects of low levels of N02 on tenmnal bronchtolar cells and Its relative tOXICIty compared to 0 3
Charles, J M, Menzel, D B (1975) A.tn1nomum and sulfate Ion release of htsta.tnIne from lung fragments
Arch EnVIron Health 30 314-316
ChtOdI, H , Mohler, J G (1985) Effects of exposure of blood hemoglobm to mtnc OXide EnVIron Res
37 355-363
Chow, C K, Tappel, A L (1972) An enzymatic protective mechamsm agamst lIpId peroXIdatiOn damage to
lungs of ozone-exposed rats LIpIds 7 518-524
Chow, C K, DIllard, C J , Tappel, A L (1974) Glutathtone perOXIdase system and lysozyme m rats exposed
to ozone or mtrogen dIOXide EnVIron Res 7 311-319
Coffin, D L, Blommer, E J (1967) Acute tOXICIty of Irradiated auto exhaust ItS mdlcatIon by enhancement of
mortality from streptococcal pneumoma Arch EnVIron Health 15 36-38
Coffin, D L, Gardner, D E (1972) Interaction of biOlogIcal agents and che.tnlcal aIr pollutants AmI Occup
Hyg 15 219-234
Coffin, D L, Gardner, DE, Sidorenko, G I, PlIDgm, M A (1977) Role of tune as a factor m the tOXICIty
of che.tnlcal compounds m mtenmttent and contmuous exposures Part II Effects of mtenmttent
exposure J TOXIcol EnViron Health 3 821-828
13-209
Cohen, N S, Ekholm, J E, Luthra, M G, Hanahan, D J (1976) BlOchenncai charactenzation of
density-separated human erythrocytes Blocmm Blophys Acta 419 229-242
Cooper, G P, LewkowskI, J P, Hastmgs, L , Malanchuk, M (1977) Catalytically and noncatalytically treated

automobIle exhaust biological effects m rats J TOXlcol EnVIron Health 3 923-934
Com, M , Kotsko, N , Stanton, D (1976) Mass-transfer coeffiCient for sulphur dIOXIde and mtrogen diOXIde
removal m cat upper respIratory tract Ann Occup Hyg 19 1-12
Crapo, J D, Barry, BE, Chang, L -Y , Mercer, R R (1984) Alterations m lung structure caused by
inhalation of OXIdants J TOXlcol EnVIron Health 13 301-321
Csallany, A S (1975) The effect of mtrogen diOXIde on the growth of Vltamtn E defiCient, vltamm E
supplemented and DPPD supplemented nnce Fed Proc Fed Am Soc Exp Bioi 34 913
Csallany, AS, Ayaz, K L (1978) Long-tenn NOz exposure of nnce m the presence and absence of Vltamtn E
I Effect on body weights and IIpofuscm m pigments Arch EnVIron Health 33 285-291
Curran, R D, Ferran, F K, Ktspert, PH, Stadler, J , Stuehr, D J , Simmons, R L, BtllIar, T R (1991)

Nltnc OXIde and mtnc oXlde-generatmg compounds mhtblt hepatocyte protem syntheSIS FASEB J
5 2085-2092
DarnJI, K S, Rtchters, A (1989) Reduction m T lymphocyte subpopulations followmg acute exposure to 4 ppm
mtrogen diOXIde EnVIron Res 49 217-224
DaVidson, J T, LIllmgton, G A, Haydon, G B, Wassennan, K (1967) PhySiologiC changes m the lungs of

rabbits contmuously exposed to mtrogen diOXIde Am Rev RespIr DIS 95 790-796
DaVIS, J K, DaVidson, M K, Schoeb, T R, Lmdsey, J R (1992) Decreased mtrapulmonary kIllIng of

Mycoplasma pulmoms after short-tenn exposure to NOz IS associated With damaged alveolar
macrophages Am Rev RespIr DIS 145 (2 Part 1) 406-411
Devlm, R , Horstman, D , Becker, S, Gemty, T , Madden, M , Koren, H (1992) Inflamtnatory response m

humans exposed to 2 0 ppm NOz Am Rev Respir DIS 145 A456
Diggle, W M, Gage, J e (1954) The tOXICIty of mtrogen pentoXlde Br J Ind Med 11 140-144
Diggle, W M, Gage, J e (1955) The tOXICity of ozone m the presence of OXides of mtrogen Br J Ind Med
12 60-64
Dmarello, e A, Cannon, J G, Mter, J W , BernheIm, H A, LoPreste, G , Lynn, D L, Love, R N ,

Webb; A e, Auron, P E, Reuben, R e, Rich, A , Wolff, S M, Putney, S D (1986) Multiple
biolOgical activities of human recombmant mterIeukm 1 J elm Invest 77 1734-1739
Dowell, A R, KIlburn, K H, Pratt, P e (1971) Short-tenn exposure to mtrogen dIOXIde effects on

pulmonary ultrastructure, complIance, and the surfactant system Arch Intern Med 128 74-80
Drozdz, M , LuClak, M , Kosnnder, S , Molska-Drozdz, T , Ludyga, K , PaslewIcz, J (1975) Znnany

enzymatyczne I morfologIczne w osrodkowym ukladZle nerwowym u swmek morskIch w przewleklym
zatruCIU dwutlenktem azotu [BraIn enzyme activity and morphologIcal changes m the central nervous
system of gumea pigs chromcally mtoXlcated With mtrogen dIOXide] Bromatol Chern Toksykol
8 241-249
13-210
Drozdz, M , Kucharz, E , Ludyga, K , Molska-Drozdz, T (1976) StudIes on the effect of long-term exposure to
mtrogen dIOXIde on serum and hver protems level and enzyml~ activity m gumea pIgs Eur J TOXIcol
9 287-293
Dungworth, D , Goldstem, E , RiccI, P F (1985) Photochemlcal atr pollution part II West J Med
142 523-531
Durocher, J R, Payne, R C, Conrad, M E (1975) Role of SIalIc ,lcId m erythrocyte SUrvIVal Blood
45 11-20
Ehrhch, R (1963) Effect of atr pollutants on respIratory mfection Atch EnVIron Health 6 638-642
Ehrhch, R (1966) Effect of mtrogen dIOXIde on reSIstance to respIratory mfection Bactenol Rev 30 604-614
Ehrhch, R (1975) Interaction between NOz exposure and respIratory mfection In SCIentific semmar on
automotive pollutants, February, Washmgton, DC Washmgton, DC US EnVIronmental ProtectIOn
Agency, Office of Research and Development, EPA report no EPA-6oo/9-75-003
Ehrhch, R (1979) InteractIOn between enVIronmental pollutants and respIratory mfections In Gardner, DE,
Hu, E PC, Grahatn, J A, eds Proceedmgs of the sympOSIUm on expenmental models for pulmonary
research, February, HIlton Head Island, SC Research Tnangle Park, NC US EnVIronmental
Protection Agency, Health Effects Research Laboratory, EPA report no EPA-6oo/9-79-o22, pp
145-163 AvaIlable from NTIS, Spnngfield, VA, PB80-121049
Ehrhch, R (1980) InteractIOn between enVIronmental pollutants and respIratory mfections EnVIron Health
Perspect 35 89-100
Ehrhch, R (1983) Changes m susceptibIhty to respIratory mfectIon caused by exposures to photochemlcal

OXIdant pollutants In Lee, S D, Mustafa, M G, Mehlman, M A, eds International sympOSIUm on
the bIomedIcal effects of ozone and related photochemlcal OXIdants, March 1982, Pmehurst, NC
Pnnceton, NJ Pnnceton SCIentific Pubhshers, Inc ,pp 273-285 (Advances m modem enVIronmental
tOXIcology V 5)
Ehrhch, R , Fenters, J D (1973) Influence of mtrogen dIOXIde on ehpenmental mfluenza m sqUirrel monkeys
In Proceedmgs of the 3rd mtematIOnal clean atr congress, October, Duesseldorf, Federal Repubhc of
Gennany Duesseldorf, Federal Repubhc of Gennany Verem Deutscher Ingemeure, pp Al1-AI3
Ehrhch, R , Henry, M C (1968) Chromc tOXICIty of mtrogen dIOXIde I effect on reSIstance to bactenal
pneumoma Arch EnVIron Health 17 860-865
Ehrhch, R , SIlverstem, E , Matgetter, R , Fenters, J D, qardner,]) (1975) ImmunologIC response m

vaccmated mlce dunng long-term exposure to mtrogen dIOXIde EnVIron Res 10 217-223
Ehrhch, R , Fmdlay, J C, Fenters, J D, Gardner, D E (1977) H:mlth effects of short-term mhalation of

mtrogen dIOXIde and ozone mlxtures EnVIron Res 14 223-231
Ehrhch, R , Fmdlay, J C, Gardner, D E (1979) Effects of repeated exposures to peak concentrations of

mtrogen dIOXIde and ozone on reSIstance to streptococcal pneumoma J TOXIcol EnVIron Health
5 631-642
Elsayed, N M, Mustafa, M G (1982) DIetary antiOXIdants and the bIOchemlcal response to OXIdant mhalation
I mfluence of dIetary vitamm E on the blochemlcal effects of mtrogen dIOXIde exposure m rat lung
13-211
Evans, M J , Stephens, R J , Cabral, L J , Freeman, G (1972) Cell renewal m the lungs of rats exposed to
low levels of NOz Arch EnVIron Health 24 180-188
Evans, M J , Cabral, L J , Stephens, R J , Freeman, G (1973a) Cell diVISion of alveolar macrophages m rat
lung followmg exposure to NOz Am J Pathol 70 199-208
Evans, M J , Cabral, L J , Stephens, R J , Freeman, G (1973b) Renewal of alveolar epithehum m the rat
followmg exposure to NOz Am J Pathol 70 175-190
Evans, M J , Cabral, L C, Stephens, R J , Freeman, G (1974) Acute lanetIc response and renewal of the
alveolar epithehum followmg mJury by mtrogen dioXide Chest 65(suppl) 62S-65S
Evans, M J , Cabral, L J , Stephens, R J , Freeman, G (1975) TransformatIon of alveolar Type 2 cells to

Type 1 cells followmg exposure to NOz Exp Mol Pathol 22 142-150
Evans, M J , Cabral-Anderson, L J , Freeman, G (1977) Effects of NOz on the lungs of agmg rats IT cell
prolIferation Exp Mol Pathol 27 366-376
Evans, M J , Johnson, LV, Stephens, R J , Freeman, G (1976) Renewal of the termmal bronchiolar
epithelIum m the rat followmg exposure to NO z or 0 3 Lab Invest 35 246-257
Evans, J N , Hemenway, DR, Kelley, J (1989) Early markers of lung mJury Cambndge, MA Health
Effects Institute, report no HEI/RR-89/29 Avadable from NTIS, Spnngfield, VA, PB91-171983
Faraltam, H , Hasan, M (1990) Effect of NOz on hpids and hpid peroXidatIon m the CNS of the gumea-pig
Pharmacol TOXicol 66 146-149
Faraltam, H , Hasan, M (1991) Effect of mtrogen dioXide on sulfhydryl groups m the central nervous system of
gumea pigS Pharmacol TOXicol 69 56-59
Fels, A ° S, Cohn, Z A (1986) The alveolar macrophage J Appl PhyslOl 60 353-369
Fenters, J D, Ehrhch, R , Fmdlay, J , Spangler, J , Tolkacz, V (1971) SerologiC response m sqUirrel monkeys
exposed to mtrogen dioXide and mfluenza ViruS Am Rev RespIr DiS 104 448-451
Fenters, J D, Fmdlay, J C, Port, CD, Ehrhch, R , Coffin, D L (1973) Chromc exposure to mtrogen
dioXide lmmunologic, phySiologiC, and pathologic effects m Virus-challenged sqUirrel monkeys Arch
EnVIron Health 27 85-89
Fenn, J , Leach, L J (1977) The effects of selected air pollutants on clearance of tItanic OXide partIcles from
the lungs of rats In Walton, W H, ed Inhaled partIcles IV proceedmgs of an mternatIonal sympOSiUm
orgamzed by the Bntlsh OccupatIonal Hygiene SOCiety, part 1, September 1975, Edmburgh, Umted
Kmgdom New York, NY Pergamon Press, pp 333-341
Fletcher, B L, Tappel, A L (1973) ProtectIve effects of dietary a-tocopherol m rats exposed to tOXiC levels of
ozone and mtrogen diOXide EnVIron Res 6 165-175
Fletcher, C M, Pnde, N B (1984) DefimtIons of emphysema, chromc bronchitis, asthma, and aIrflow
obstruction 25 years on from the Ciba sympOSiUm Thorax 39 81-85
Fletcher, C M, Gdson, J G, Hugh-Jones, P , Scaddmg, J G (1959) Termmology, defimtlOns, and

clasSificatIon of chromc pulmonary emphysema and related conditIons a report of the concluslOns of a
CIBA guest sympOSiUm Thorax 14 286-299
13-212
Frampton, M W , Smeglm, AM, Roberts, N J , Jr , Fmkelstem, J N , Morrow, P E, Utell, M J (1989)
NItrogen dIoXide exposure m VIVO and human alveolar macrophage mactIvatIon of mfluenza VIruS m
vItro EnViron Res 48 179-192
Freeman, G , Haydon, G B (1964) Emphysema after low-level exposure to N02 Arch EnViron Health
8 125-128
Freeman, B A, Mudd, J B (1981) ReactlOn of ozone WIth sulthydryls of human erythrocytes Arch BlOchem
BlOphys 208 212-220
Freeman, G , Funosl, N J , Haydon, G B (1966) Effects of contllluous exposure of 0 8 ppm N02 on

respiration of rats Arch EnViron Health 13 454-456
Freeman, G , Crane, S C, Stephens, R J , Funosl, N J (1968a) PathogenesIs of the mtrogen dloXIde-mduced

leslOn m the rat lung a reVIew and presentation of new observations Am Rev Resplr DIS
98 429-443
Freeman, G, Stephens, R J , Crane, S C, Funosl, N J (1968b) LeslOn of the lung m rats contmuously
exposed to two parts per lllilhon of mtrogen dlOXIde Arch EnViron Health 17 181-192
Freeman, G , Crane, S C, Funosl, N J (1969) Heahng m rat lung after subacute exposure to mtrogen dlOXIde
Am Rev RespIr DIS 100 662-676
Freeman, G, Crane, S C, Funosl, N J , Stephens, R J , Evans, M J , Moore, W D (1972) Covert

reduction m ventilatory surface m rats dunng prolonged exposure to subacute mtrogen dIOXide Am Rev
RespIr DIS 106 563-579
Freeman, G , Juhos, L T, Funosl, N J, Mussenden, R , Stephen'>, R J , Evans, M J (1974) Pathology of

pulmonary dIsease from exposure to mterdependent ambIent gases (mtrogen dlOXIde and ozone) Arch
EnViron Health 29 203-210
FUjlmakl, H (1989) Impamnent of humoral Immune responses m miCe exposed to mtrogen dIOXide and ozone
lllixtures EnViron Res 48 211-217
FUjlmak1, H , Sh1llliZU, F (1981) Effects of acute exposure to mtrogen dIOXide on pnmary antibody response
Arch EnViron Health 36 114-119
FUjlmak1, H , Sh1llliZU, F , Kubota, K (1982) Effect of subacute exposure to N0 2 on lymphocytes reqmred for
antibody responses EnViron Res 29 280-286
Funosl, N J , Crane, S C, Freeman, G (1973) MIXed sodmm chlonde aerosol and mtrogen dIOXide m air
blOlogICal effects on monkeys and rats Arch EnViron Health 27 405-408
Gardmer, T H, Schanker, L S (1976) Effect of oxygen tOXICIty and mtnc aCld-mduced lung damage on drug
absorption from the rat lung Res Commun Chern Pathol Phannacol 15 107-120
Gardner, D E (1980) Influence of exposure patterns of mtrogen dIOXide on susceptIblhty to mfectIous

respiratory dIsease In Lee, S D, ed NItrogen OXides and their effects on health Ann Arbor, MI Ann
Arbor SCIence Pubhshers, Inc ,pp 267-288
Gardner, DE, Holzman, R S, Coffm, D L (1969) Effects of mtrogen dIOXide on pulmonary cell population
J Bactenol 98 1041-1043
13-213
Gardner, DE, Coffin, D L, PlDlgm, M A, Sidorenko, G I (1977a) Role of time as a factor m the tOXICIty
of chemIcal compounds m mtermIttent and contmuous exposures Part I Effects of contmuous exposure
J TOXIcol Environ Health 3 811-820
Gardner, DE, MIller, F J , Blommer, E J , Coffin, D L (1977b) Relationships between mtrogen dIOXide
concentration, tIme, and level of effect usmg an anImal mfectivity model In DimItnades, B ,
ed International conference on photochemIcal OXidant pollution and Its control proceedmgs, v I,
September 1976, RaleIgh, NC Research Tnangle Park, NC US EnVironmental Protection Agency,
EnVIronmental SCIences Research Laboratory, pp 513-525, EPA report no EPA-600/3-77-Q01a
AvaIlable from NTIS, Spnngfield, V A, PB-264232 (EcologiCal research senes)
Gardner, DE, Miller, F J , Blommer, E J , Coffin, D L (1979) Influence of exposure mode on the tOXICIty
of NOz Environ Health Perspect 30 23-29
Gardner, DE, MIller, F J , Illmg, J W , Graham, J A (1982) Non-respiratory function of the lungs host
defenses agamst mfection In SchneIder, T, Grant, L, eds Air pollution by mtrogen OXides
proceedmgs of the US-Dutch mternational sympOSIUm, May, Maastncht, The Netherlands Ainsterdam,
The Netherlands ElsevIer SCIentific PublIshmg Company, pp 401-415 (StudIes m enVIronmental SCIence
21)
Gelzleichter, T R, WitschI, H , Last, J A (1992a) SynergIstic mteraction of mtrogen dIOXide and ozone on rat
lungs acute responses TOXIcol Appl Pharmacol 116 1-9
Gelzleichter, T R, WitschI, H , Last, J A (1992b) Concentration-response relationships of rat lungs to

exposure to OXidant air pollutants a cntical test of Haber's Law for ozone and mtrogen dIOXide TOXIcol
Appl Pharmacol 112 73-80
GIbson, Q H, Roughton, F J W (1957) The kmetics and eqUllIbna of the reactions of mtnc OXide WIth sheep
hemoglobm J PhySlOl (London) 136 507-526
GIordano, AM, Jr , Morrow, P E (1972) Chromc low-level mtrogen dIOXide exposure and mucocIlmry
clearance Arch EnViron Health 25 443-449
Glasgow, J E, Pletra, G G, Abrams, W R, Blank:, J , OppenheIm, D M, Wembaum, G (1987) Neutrophil

recruItment and degranulation dunng mduction of emphysema m the rat by mtrogen dIOXide Am Rev
Respir DIS 135 1129-1136
Glaze, W H (1986) Reaction products of ozone a reVIew EnViron Health Perspect 69 151-157
Gomgs, S A J , Kulle, T J , Bascom, R , Sauder, L R , Green, D J , Hebel, J R, Clements, M L (1989)

Effect of mtrogen dIOXide exposure on susceptibIlity to mfluenza A VIrus mfection m healthy adults Am
Rev RespIr DIS 139 1075-1081
Goldstem, E , Eagle, M C, Hoepnch, P D (1973) Effect of mtrogen dIOXide on pulmonary bactenal defense
mechanISms Arch EnViron Health 26 202-204
Goldstem, E , Warshauer, D , LIppert, W , Tarkmgton, B (1974) Ozone and mtrogen dIOXide exposure munne
pulmonary defense mechanISms Arch EnVIron Health 28 85-90
Goldstem, B D, Hamburger, S J , Falk, G W , Amoruso, M A (1977a) Effect of ozone and mtrogen dIOXide
on the agglutmation of rat alveolar macrophages by concanavalm A LIfe SCI 21 1637-1644
Goldstem, E , Peek, N F, Parks, N J , Hmes, H H, Steffey, E P, Tarkmgton, B (1977b) Fate and

dIstnbution of mhaled mtrogen dIOXide m rhesus monkeys Am Rev Respir DIS 115 403-412
13-214
Gooch, PC, LUlppold, HE, Creasia, D A, Brewen, J G (1977) Observations on mouse chromosomes
followmg mtrogen dioXide mhalation Mutat Res 48 117-119
Graham, J A, Miller, F J , Gardner, DE, Ward, R , Menzel, D B (1982) Influence of ozone and mtrogen
diOXide on hepatic lllicrosomal enzymes m lllice J TOXicol Environ Health 9 849-856
Graham, J A, Gardner, DE, Blommer, E J , House, DE, Menache, M G, Miller, F J (1987) Influence
of exposure patterns of mtrogen dioxide and modifications by ozone on susceptibihty to bactenal
mfectious disease m lllice J TOXicol Environ Health 21 113-125
Green, G M (1970) The J Bums Amberson lecture - m defense of the lung Am Rev Respir DiS
102 691-703
Greenbaum, R, Bay, J ,Hargreaves, M D, Kam, M L, Kelman, G R, Nunn, J F, Prys-Roberts, C,

Siebold, K (1967) Effects of Ingher OXides of mtrogen on the anaesthetized dog Br J Anaesth
39 393-404
Greenberg, S D, Gyorkey, F , Jenkms, DE, Gyorkey, P (1971) Alveolar epithehal cells followmg exposure
to mtnc aCid electron lllicroscopiC study m rats Arch EnViron Health 22 655-662
Greene, I, Hiatt, E P (1954) BehavlOr of the mtrate ion m the dog Am J PhyslOl 176 463-467
Greene, N D, Schneider, S L (1978) Effects of NOz on the response of baboon alveolar macrophages to
llligratlOn mhlbitory factor J TOXicol EnViron Health 4 869-880
Gregory, R E, Pickrell, J A, Hahn, F F , Hobbs, C H (1983) Pulmonary effects of mtenmttent subacute

exposure to low-level mtrogen dioXide J TOXicol EnViron Health 11 405-414
Gross, P , deTreville, R T P, Babyak, M A, Kaschak, M , Tolker, E B (1968) Expenmental emphysema

effect of chromc mtrogen dlOXide exposure and papam on nonnal and pneumocomotic lungs Arch
Guth, D J , MaViS, R D (1985) BlOchelllical assessment of acute mtrogen dlOXide tOXiCity m rat lung TOXicol
Appl Phannacol 81 128-138
Guth, D J , MaViS, R D (1986) The effect of lung a-tocopherol content on the acute tOXiCity of mtrogen
dioXide TOXicol Appl Phannacol 84 304-314
Hadley, J G , Gardner, DE, Coffin, D L, Menzel, D B (1977) Effects of ozone and mtrogen dioXide
exposure of rabbits on the bmdmg of autologous red cells to alveolar macrophages In Dilllitnades, B ,
ed International conference on photochelllical OXidant pollution and itS control proceedmgs, V I,
September 1976, Raleigh, NC Research Tnangle Park, NC US EnVironmental Protection Agency,
EnVironmental SCiences Research Laboratory, pp 505-512, EPA report no EPA-600/3-77-QOla
Available from NTIS, Spnngfield, VA, PB-264232
Harada, R N , Repme, J E (1985) Pulmonary host defense mechamsms Chest 87 247-252
Hatch, G E, Slade, R , Selgrade, M K, Stead, A G (1986) Nitiogen dioXide exposure and lung antiOXidants
m ascorbiC aCid-deficient gumea pigS TOXicol Appl Pharmacol 82 351-359
Hawksworth, G M, Hill, M J (1971) Bactena and the N-mtrosatJon of secondary ammes Br J Cancer
25 520-526
13-215
Hayasht, Y , Kohno, T , Ohwada, H (1987) MorphologIcal effects of mtrogen dIOXlde on the rat lung EnVIron
Health Perspect 73 135-145
Haydon, G B, Freeman, G, FunosI, N J (1965) Covert pathogeneSIS of NOz mduced emphysema m the rat
Haydon, G B, DaVIdson, J T, Ldlmgton, G A, Wassennan, K (1967) NItrogen dIOXlde-mduced emphysema

m rabbIts Am Rev Respir DIS 95 797-805
Henry, M C, EhrlIch, R , Blarr, W H (1969) Effect ofmtrogen dIOXlde on reSIstance of sqUirrel monkeys to
KlebSIella pneumomae mfection Arch EnVIron Health 18 580-587
Henry, M C, Fmdlay, J , Spangler, J , EhrlIch, R (1970) Chromc tOXlCIty of NOz m squmel monkeys
III effect on resIstance to bactenal and VIral mfection Arch EnVIron Health 20 566-570
Henry, M C, Spangler, J , Fmdlay, J , EhrlIch, R (1971) Effects of mtrogen dIoXlde and tobacco smoke on
retention of mhaled bactena In Walton, W H, ed Inhaled particles III, V 1 proceedmgs of an
mtemational symposIUm orgamzed by the Bntish OccupatIOnal HygIene SOCIety, September 1970,
London, Umted Kmgdom Surrey, Umted Kmgdom Unwm Brothers, Ltd ,pp 527-533
Hdlam, R P, BIce, DE, Hahn, F F, Schmzlem, C T (1983) Effects of acute mtrogen dIOXlde exposure on
cellular Immurnty after lung Immumzation EnVIron Res 31 201-211
Hockmg, W G, Golde, D W (1979) The pulmonary-alveolar macrophage N Engl J Med 301 580-587
Holt, P G, Fmlay-Jones, L M, Keast, D , Papadllmtrou, J M (1979) ImmunologIcal function m lllice

chromcally exposed to mtrogen oXldes (NOJ EnVIron Res 19 154-162
Hooftman, R N , Kuper, C F, Appelman, L M (1988) Comparative senSItiVIty of htsto-pathology and specIfic

lung parameters m the detection of lung mJury J Appl TOXlcol 8 59-65
Hugod, C (1979) Effect of exposure to 43 ppm mtnc oXlde and 3 6 ppm mtrogen dIoXlde on rabbIt lung a lIght
and electron lllicroscopiC study Int Arch Occup EnVIron Health 42 159-167
Hyde, D , Orthoefer, J , Dungworth, D , Tyler, W , Carter, R , Lum, H (1978) Morphometnc and

morpholOgiC evaluation of pulmonary lesIOns m beagle dogs chromcally exposed to lugh ambIent levels of
arr pollutants Lab Invest 38 455-469
Ichmose, T , Sagar, M (1982) StudIes on bIOchelllical effects of mtrogen dIoXlde III changes of the
antIoXldative protective systems m rat lungs and of lIpId peroXldatIon by chromc exposure TOXlcol
Appl Pharmacol 66 1-8
Ichmose, T , Sagar, M (1989) BIOchelllical effects of combmed gases of mtrogen dIoXlde and ozone
III Synergistic effects on lIpId peroXldation and antioXldative protective systems m the lungs of rats and
gumea pigs TOXlcology 59 259-270
Ichmose, T , Sagar, M , Kubota, K (1983) [Changes of lIpId peroXldatIon and antioXldatIve protective systems m
lungs of rats exposed acutely, subacutely and chromcally to mtrogen dIOXlde] Tarkt Osen Gakkaisht
18 132-146
Ichmose, T , FUJll, K , Sagar, M (1991) Expenmental studies on tumor promotion by mtrogen dIOXIde
TOXlcology 67 211-225
13-216
Ide, G , Otsu, H (1973) Tatla osen busshttsu no hatsugan sayo m kansuru kenkyu [StudIes on carcmogemc
actions of air pollutants] In 1972 mvestIgatIon of air and water pollution on human health Chtba,
Japan Chtba Prefectural Government, Department of HygIene, pp 99-100
Illmg, J W , MIller, F J , Gardner, D E (1980) Decreased resIstance to mfectIon m exercIsed nnce exposed to
N02 and 0 3 J TOXIcol EnvIron Health 6 843-851
Iqbal, Z M (1984) In-VIvo mtrosatIon of atmnes m nnce by mhaled mtrogen dIoXide and mhtbitIon of
bIosynthesIs of N-mtrosatmnes In O'NeIll, I K, Von Borstei, R C, MIller, C T, Long, J ,
Bartsch, H ,eds N-mtroso compounds occurrence, bIologICal effects and relevance to human cancer
proceedmgs of the VIIIth mternatIonal symposIUm on N-mtroso compounds, September 1983, Banff,
Canada Lyon, France International Agency for Research on Cancer, pp 291-300 (lARC sCIentific
publIcations no 57)
Iqbal, Z M, Dahl, K , Epstem, S S (1980) Role of mtrogen dIoXide m the bIosynthesIS of mtrosammes m
nnce SCIence (Washmgton, DC) 207 1475-1477
Iqbal, Z M, Dahl, K , Epstem, S S (1981) BIosynthesIs of dlmethylmtrosamme m dlmethylatmne-treated nnce

after exposure to mtrogen dIOXide JNCI J Nat! Cancer Inst 67 137-141
Ito, K (1971) [Effect of mtrogen dIOXide mhalatIon on mfluenza VIruS mfectIon m nnce] NIppon Eiselgaku
Zassht 26 304-314
Jakab, G J (1987) Modulation of pulmonary defense mechamsms by acute exposures to mtrogen dIOXide
EnVIron Res 42 215-228
Jakab, G J (1988) Modulation of pulmonary defense mechamsms agamst VIral and bactenal mfectIons by acute
exposures to mtrogen dIOXide Cambndge, MA Health Effects Institute, research report no 20
Joel, D D, Chandra, P , Chanana, A D (1982) Effects of N02 on unmune responses m pulmonary lymph of
sheep J TOXIcol EnVIron Health 10 341-348
Johnston, R B, Jr , Godztk, C A, Cohn, Z A (1978) Increased superoXIde amon production by

ImmunologIcally activated and chenncally ehclted macrophag(~s J Exp Med 148 115-127
Katsukt, S , Arnold, W , Mlttal, C , Murad, F (1977) Stimulation of guanylate cyclase by sodIUm mtroprusslde,
mtroglycenn and mtnc oXide m vanous tissue preparations and companson to the effects of sodIUm aztde
and hydroxylamme J CyclIc Nucleotide Res 3 23-35
Katz, G V , Laskm, S (1976) Pulmonary macrophage response to lIntant gases In Aharonson, E F,

Ben-DaVId, A , Klmgberg, M A, Kaye, M ,eds Air pollution and the lung proceedmgs of the
twentieth annual "Oholo" bIOlogICal conference, March 1975, Ma'alot, Israel New York, NY John
WIley & Sons, pp 83-100
Kaya, K , MIUra, T (1982) Effects of mtrogen dIOXide on fatty aCId composItions of red cell membranes, sera,
and lIvers m rats EnVIron Res 27 24-35
Kaya, K , MIUra, T , Kubota, K (1980) Effects of mtrogen dIOXide on red blood cells of rats changes m
components of red cell membranes dunng m VIVO exposure to N02 EnVIron Res 23 397-409
KIta, H , Onncht, S (1974) [Effects of aIr pollutants on clhal movement m airway] NIppon Eiselgaku Zassht
29 100
13-217
Klebanoff, S J (1968) MyeloperoXIdase-halIde-hydrogen peroxIde antIbactenal system J Bactenol
95 2131-2138
Klebanoff, S J (1982) Oxygen-dependent CytOtoXIC mechanIsms of phagocytes In Gallm, J I, FaUCI, AS,

eds Phagocytic cells New York, NY Raven Press, pp 111-162 (Advances m host defense
mechanIsms v 1)
Klemerman, J , Cowdrey, C R (1968) The effects of contmuous hIgh level mtrogen dIOXIde on hamsters Yale
J BIOi Med 40 579-585
Klemerman, J , Ip, M PC, Gordon, R E (1985) The reaction of the respIratory tract to chromc NOz
exposure In ScarpellI, D G, Craighead, J E, Kaufman, N , eds The pathologIst and the
enVIronment Baltimore, MD WillIams and WIlkms, pp 200-210 (international Academy of Pathology
monograph no 26)
Klemman, M T, Mautz, W J (1987) The effects of exerCIse on respIratory tract dOSImetry for mhaled gaseous
pollutants Presented at 80th annual meetmg of the AIr Pollution Control ASSOCIation, June, New York,
NY PIttsburgh, PA AIr Pollution Control ASSOCIation, paper no 87-33 5
Klemman, M T, Mautz, W J (1991) The effects of exerCIse on dose and dose dlstnbutIon of mhaled
automotive pollutants Cambndge, MA Health Effects Institute, research report number 45
Klemman, M T, LInn, W S, Bailey, R M, Jones, M P, Hackney, J D (1980) Effect of ammomum mtrate

aerosol on human respIratory function and symptoms EnVIron Res 21 317-326
Klemman, M T, Mautz, W J , McClure, T R, Manmx, R , Phalen, R F (1985a) Comparative effects of

aCIdIC and non-acIdIC multIcomponent atmospheres on the lungs of rats exposed by mhalatIon Presented
at 78th annual meetmg of the Air PollutIOn Control ASSOCIation, June, DetrOIt, MI PIttsburgh, PA AIr
Pollution Control ASSOCIation, paper no 85-29 3
Klemman, M T, McClure, T R, Mautz, W J , Phalen, R F (1985b) The mteractIon of ozone and

atmosphenc aCIds on the formation of lung leSIons m rats In Lee, S D, ed Evaluation of the SCIentific
basis for ozone/OXIdants standards proceedmgs of an APCA mternatIonal specIalty conference,
November 1984, Houston, TX PIttsburgh, PA Air Pollution Control ASSOCIation, pp 357-365 (APCA
publIcation no TR-4)
KobayashI, T (1986) Effects of mtrogen dIOXIde exposure on the contents of prostaglandms and thromboxane
B2 m broncho alveolar lavage Prostaglandms 31 469-475
KobayashI, T , NoguchI, T , KIkuno, M , Kubota, K (1984) Effect of acute mtrogen dIOXIde exposure on the
compOSItion of fatty aCId aSSOCIated WIth phospholIpIds m alveolar lavage Chemosphere 13 101-105
Kon, K , Maeda, N , ShIga, T (1977) Effect of mtnc OXIde on the oxygen transport of human erythrocytes
J TOXIcol EnVIron Health 2 1109-1113
Kon, K , Maeda, N , Suda, T , ShIga, T (1980) Reaction between mtrosylhemoglobm and

oxygen-methemoglobm formation and hemoglobm degradation TaIkI Osen GakkaIShi 15 401-411
Kosaka, H , ImaIzumI, K , ImaI, K , Tyuma, I (1979) StOIchIometry of the reaction of oxyhemoglobm WIth
nitnte BiochIm BIOphys Acta 581 184-188
KosmIder, S (1975) Electrolytes and lIpId dIsturbances m chromc mtoXIcatIon WIth mtrogen OXIdes Int Arch
Occup Environ Health 35 217-232
13-218
KoslDlder, S , LUClak, M , ZaJusz, K, MISIeWICZ, A , Szygula, J I 1973a) Badama nad rozedmotworczym
dztalamem tlenkow azotu [StudIes on emphysogemc action of mtrogen oXIdes] Patol Pol 24 107-125
KoslDlder, S T, MIsIewIcz, A , Felus, E , Drozdz, M , Ludyga, K (1973b) Expenmentelle und khmsche

Untersuchungen ueber den Emfluss der StIckstoffoxyde auf dIe Immumtaet [Expenmental and clImcal
studIes on the effects of mtrogen oXIdes on Immumty] Int Arch Arbeltsmed 31 9-23
Knpke, B J , Sherwm, R P (1984) NItrogen dIoXIde exposure - mfluence on rat testes Anesth Analg (NY)
63 526-528
Kubota, K , MurakalDl, M , Takenaka, S , KaWai, K , Kyono, H (1987) Effects of long-term mtrogen dIOXIde
exposure on rat lung morphologIcal observations EnVIron Health Perspect 73 157-169
Kummoto, M , MochItate, K , Kaya, K , MIUra, T , Kubota, K (1984) Effects of mtrogen dIOXIde on red blood
cells of rats alterations of cell membrane components and populatIOnal changes of red blood cells dunng
m VIVO exposure to NO z EnVIron Res 33 361-369
KuraitIs, K V , Rtchters, A, Sherwm, R P (1981) Spleen changes mammals mhalmg atnblent levels of
mtrogen dIoXIde J TOXIcol EnVIron Health 7 851-859
Kyono, H , KawaI, K (1982) Morphometnc study on age-dependent pulmonary lesIOns m rats exposed to
mtrogen dIoXIde Ind Health 20 73-99
Lafuma, C , Harf, A, Lange, F , BOZZI, L, Poncy, J L, Bignon, J (1987) Effect of low-level NOz chromc
exposure on elastase-mduced emphysema EnVIron Res 43 75-84
LaIn, C , Kattan, M , Collms, A , Klemerman, J (1983) Long-term sequelae of bronchIolItis mduced by

mtrogen dIoXIde m hatnSters Am Rev RespIr DIS 128 1020-1023
Larsen, R I, Gardner, DE, Coffin, D L (1979) An air qualIty data analySIS system for mterrelatmg effects,
standards, and needed source reductions Part 5 NOz mortality m lDlce J AIr Pollut Control Assoc
29 133-137
Last, J A (1989) Effects of mhaled aCIds on lung biochelDlstry EnVIron Health Perspect 79 115-119
Last, J A, Warren, D L (1987) SynergIstic mteractIon between mtrogen dIOXIde and respIrable aerosols of
sulfunc aCId or sodIUm chlonde on rat lungs TOXIcol Appl Pharmacol 90 34-42
Last, J A, Gernets, J E, Hyde, D M (1983) SynergIstic effects on rat lungs of lDlxtures of OXIdant air
pollutants (ozone or mtrogen dIOXIde) and respIrable aerosol,; Am Rev RespIr DIS 128 539-544
Last, J A, Hyde, D M, Chang, D P Y (1984) A mechamsm 01 synergIstic lung damage by ozone and a
respIrable aerosol Exp Lung Res 7 223-235
Law, F C P, Drach, J C, Smsheimer, J E (1975) Effects ofmtrogen dIOXIde and 3-methylcholanthrene on

pulmonary enzymes J Pharm SCI 64 1421-1422
Lee, J -S , Afifi, A A, Mustafa, M G (1989) Effects of short-tenn, smgle and combmed exposure of rats to
NO z and 0 3 on lung tissue enzyme activIties Inhalation ToxlCol 1 21-35
Lee, J -S , Mustafa, M G, Afifi, A A (1990) Effects of short-tenn, smgle and combmed exposure to low-level
NO z and 0 3 on lung tissue enzyme activIties m rats J TOXI('ol EnVIron Health 29 293-305
13-219
Lefkowitz, S S, McGrath, J J , LefkOWitz, D L (1983) Effects of NOz on mterferon productIon m mICe
In Lee, S D, Mustafa, M G, Mehlman, M A, eds InternatIonal sympOSIUm on the biomedical
effects of ozone and related photochelDlcal OXIdants, v 5, March 1982, Pmehurst, NC Prmceton, NJ
Prmceton SCientIfic PublIshers, Inc ,pp 469-474 (Advances m modern envIronmental tOXIcology)
Lefkowitz, S S, McGrath, J J , LefkOWitz, D L, Spicer, J B (1984) Interferon productIon followmg NOz

exposure Int J IInmunopharmacol 6 275-278
LefkOWitz, S S, McGrath, J J , LefkOWitz, D L (1986) Effects of NOz on IInmune responses J TOXIcol

LeWIS, T R, Moorman, W J , Yang, Y -y , Stara, J F (1974) Long-term exposure to auto exhaust and other
pollutant nnxtures effects on pulmonary functIOn m the beagle Arch EnVIron Health 29 102-106
Maeda, N , ImaIzulDl, K , Kon, K , ShIga, T (1984a) [Effect of mtnc OXIde exposure on the red cell rheology -
m relatIon to OXIdatIve crosslInlang of membrane protems] TaI1a Osen GakkalshI 19 283-291
Maeda, N , Kon, K , ImaIzulDl, K , ShIga, T (1984b) [KInetIc study on mtrosylhemoglobm and methemoglobm
formatIon m the blood of rat exposed to mtnc OXIde] TaI1a Osen GakkaIshI 19 239-246
Maeda, N , IlDaIzulDl, K , Kon, K , ShIga, T (1987) A lanetIc study on functIonal Impairment of mtnc
OXIde-exposed rat erythrocytes EnVIron Health Perspect 73 171-177
MaIgetter, R Z, Fenters, J D, Fmdlay, J C, EhrlIch, R , Gardner, D E (1978) Effect of exposure to

mtrogen diOXIde on T and B cells m mouse spleens TOXIcol Lett 2 157-161
Mauderly, J L (1989) SusceptIbilIty of young and agmg lungs to Inhaled pollutants In Utell, M J , Frank, R ,
eds SusceptIbilIty to Inhaled pollutants PhIladelphIa, PA Amencan Society for Testmg and Matenals,
pp 148-161, ASTM special techmcal publIcatIon no 1024
Mauderly, J L, Blce, DE, Carpenter, R L, Gillett, N A, Henderson, R F, Pickrell, J A, Wolff, R K

(1987) Effects of Inhaled mtrogen diOXIde and diesel exhaust on developmg lung Catnbndge, MA
Health Effects InstItute, research report no 8
Mauderly, J L, Blce, DE, Cheng, Y S, GIllett, N A, Henderson, R F, Pickrell, J A, Wolff, R K

(1989) Influence of expenmental pulmonary emphysema on tOXIcological effects from Inhaled mtrogen
diOXIde and diesel exhaust Catnbndge, MA Health Effects InstItute, report no HEI-RR-89/30
AVaIlable from NTIS, Sprmgfield, VA, PB9O-247347
Mauderly, J L, Cheng, Y S, GIllett, N A, Gnffith, W C, Henderson, R F, PIckrell, J A, Wolff, R K

(1990) Influence of preeXIstmg pulmonary emphysema on susceptIbilIty of rats to chromc InhalatIon
exposure to mtrogen diOXIde InhalatIon TOXIcol 2 129-150
McFaul, S J, McGrath, J J (1985) Nltnc OXIde ImpaIrs methemoglobm reductIon J EnVIron SCI Health Part
A 20 305-314
McGrath, J J , Oyervldes, J (1985) Effects of mtrogen diOXIde on resistance to KlebSiella pneumomae In nnce
J Am ColI TOXIcol 4 227-231
McGrath, J J , Snnth, D L (1984) RespIratory responses to mtrogen diOXIde InhalatIon SubtItle mtrogen
diOXIde J EnvIron SCI Health Part A 19 417-431
13-220
Meneely, G R, RenzettI, AD, Jr , Steele, J D, Wyatt, J P, Hams, H W (1962) Chromc bronclutIs,
asthma, and pulmonary emphysema a statement by the COIDlTIlttee on DiagnostIc Standards for
Nontuberculous RespIratory Diseases Am Rev Resplr DIs 85 762-768
Menzel, D B (1970) TOXICity of ozone, oxygen, and radiatIon AmlU Rev Pharmacol 10 379-394
Menzel, D B (1976) The role of free radicals m the tOXICIty of aIr pollutants (mtrogen oXIdes and ozone)
In Pryor, W A, ed Free radicals m bIOlogy v IT New York, NY AcadelTIlc Press, Inc ,
pp 181-202
Menzel, DB, Roehm, J N , Lee, S D (1972) Vitamm E the bwlogiCal and envIronmental antIOXIdant
J Agnc Food Chern 20 481-486
Menzel, DB, Abou-Doma, M B, Roe, C R, EhrlIch, R , Gardner, DE, Coffin, D L (1977) BIOchelTIlcal
mdlces of mtrogen diOXIde mtoXIcatIon of gumea pIgS followmg low level long-tenn exposure
In DilTIltnades, B ,ed International conference on photochelTIlcal OXIdant pollutIon and ItS control
proceedmgs, v IT, September 1976, Raleigh, NC Research Tnangle Park, NC U S EnvIronmental
ProtectIOn Agency, EnvIronmental SCIences Research Laboratory, pp 577-587, EPA report no
EPA-600/3-77-DOlb AvaIlable from NTIS, Spnngfield, VA, PB-264233
Mersch, J , Dyce, B J , Haverback, B J, Sherwm, R P (1973) Dlphosphoglycerate content of red blood cells
measurements m gumea pigs exposed to 0 4 ppm mtrogen diOXIde Arch EnVIron Health 27 94-95
Messilia, F S, McGrath, J , Early, J , Hughes, M J , Rector, D F (1983) Blochetnlcal and morphologIcal

aspects of mtrogen dIoXIde tOXICIty and the effect of ethanol mtake J EnViron SCI Health Part A
18 571-581
MIller, F J , Menzel, DB, Coffin, D L (1978) Sllmlanty between man and laboratory ammals m regIOnal
pulmonary depOSItIon of ozone EnVIron Res 17 84-101
MIller, F J , Graham, J A, Illmg, J W , Gardner, D E (1980) Extrapulmonary effects of NOz as reflected

by pentobarbital-mduced sleepmg tIme m lllice TOXIcol Lett 6 267-274
MIller, F J , Overton, J H , Myers, E T, Graham, J A (1982) Pulmonary dOSImetry of mtrogen diOXIde m

ammals and man In SchneIder, T, Grant, L, eds AIr pollutIon by mtrogen OXIdes proceedmgs of the
US-Dutch mternatIonal symposIUm, May, Maastncht, The NI~therlands Amsterdam, The Netherlands
Elsevier SCIentIfic PublIshmg Company, pp 377-386 (Studies m envIronmental sCience 21)
MIller, F J , Overton, J H, Jr , Jaskot, R H, Menzel, D B (1985) A model of the regIOnal uptake of

gaseous pollutants m the lung I the senSItIVIty of the uptake of ozone m the human lung to lower
respIratory tract secretIons and exerCIse TOXIcol Appl Pharmacol 79 11-27
MIller, F J , Graham, J A, Raub, J A, Illmg, J W , Menache, M G, House, DE, Gardner, D E (1987)

Evaluatmg the tOXICity of urban patterns of OXIdant gases IT Effects m tnlce from chromc exposure to
mtrogen diOXIde J TOXIcol EnVIron Health 21 99-112
Mmk, S N , Coalson, J J , Wlutley, L , GrevIlle, H , Jadue, C (1984) Pulmonary functIOn tests m the
detectIon of small airway obstructIon m a camne model of broncluolItIs oblIterans Am Rev Respir DIS
130 1125-1133
13-221
Mtrvlsh, S S, Issenberg, P , Sams, J P (1981) N-mtrosomorpholme synthesIs m rodents exposed to mtrogen
diOXide and morpholme In Scanlan, R A, Tannenbaum, S R, eds N-mtroso compounds based on a
symposIUm cosponsored by the DIVISions of Agncultural and Food ChemIstry and Pesticide ChemIstry at
the 181st meetmg of the Amencan ChemIcal SOCiety, March-Apnl, Atlanta, GA Washmgton, DC
Amencan ChemIcal SOCiety, pp 181-191 (ACS symposIUm senes 174)
MlrvlSh, S S, Sams, J P, Issenberg, P (1983) The mtrosatmg agent m mIce exposed to mtrogen diOXide
Improved extraction method and 10cahzatIon m the skm Cancer Res 43 2550-2554
MlrvlSh, S S, Babcook, D M, Deshpande, AD, Nagel, D L (1986) IdentificatIOn of cholesterol as a

mouse skm hpld that reacts With mtrogen diOXide to yield a mtrosatmg agent, and of cholesteryl mtnte as
the mtrosatmg agent produced m a chemIcal system from cholesterol Cancer Lett 31 97-104
Mlrvlsh, S S, Ramm, M D, Sams, J P, Babcook, D M (1988) NitrOSamIne formation from ammes apphed
to the skm of mIce after and before exposure to mtrogen diOXide Cancer Res 48 1095-1099
Mitma, L S (1962) [The combmed effect of small concentrations of mtrogen diOXide and sulfur diOXide gases]
Gig Samt 27 3-8
MochItate, K., Miura, T (1984) In VIVO effect of mtrogen dIOXide on the activIties of glycolytic enzymes m red
blood cells of rats TOXicol Lett 22 315-321
MochItate, K , Kaya, K , Miura, T , Kubota, K (1984) In VIVO effects of mtrogen diOXide on membrane
constituents m lung and hver of rats EnVIron Res 33 17-28
MochItate, K , Miura, T , Kubota, K (1985) An mcrease m the activIties of glycolytic enzymes m rat lungs
produced by mtrogen diOXide J TOXicol EnVIron Health 15 323-331
MochItate, K , TakahashI, Y , OhsumI, T , MIUra, T (1986) ActivatIOn and mcrement of alveolar macrophages
mduced by mtrogen diOXide J TOXicol EnVIron Health 17 229-239
MochItate, K , IshIda, K , OhsumI, T , MIUra, T (1992) Long-term effects of ozone and mtrogen dIOXide on the
metabohsm and population of alveolar macrophages J TOXicol EnVIron Health 35 247-260
Mohsenm, V (1991) Lipid peroXidatlOn and antIelastase activity m the lung under OXidant stress role of
antiOXidant defenses J Appl PhyslOl 70 1456-1462
Moncada, S , Palmer, R M J , Higgs, E A (1991) Nltnc OXide phySiology, pathophySIOlogy, and

pharmacology Pharmacol Rev 43 109-142
Moore, E G, Gibson, Q H (1976) CooperatIvlty m the diSSOCiation of mtnc OXide from hemoglobm J Bioi
Chern 251 2788-2794
Moore, C B, Birchall, R , Horack, H M, Batson, H M (1957) Changes m serum pseudo-cholmesterase

levels m patients With diseases of the heart, hver or musculoskeletal systems Am J Med SCI
234 538-546
MotomIya, K , Ito, K , YoshIda, A ,Idewara, S , Otsu, Y , NakaJima, Y (1973) [The effects of exposure to
NOz gas on the mfectIon of mfluenza ViruS of mouse - long term expenment m low concentration]
Kankyo Kagaku Kenkyu Hokoku (ChIba DaIgaku) 1 27-33
Murdia, U S., Mehta, F J , BhIde, S V (1982) Nitrate reductase activity and mtnte levels m the saliva of
habitual users of vanous tobacco products Food Chern TOXicol 20 269-272
13-222
Murphy, S D (1964) A reView of effects on ammals of exposure to auto exhaust and some of its components
J Au Pollut Control Assoc 14 303-308
Mustafa, M G, Elsayed, N , Lim, J S T, Postlethwmt, E , Lee, S D (1979) Effects of mtrogen dioXide on

lung metabohsm In Grosjean, D ,ed Nitrogenous mr pollutants chelllical and biologlcalimphcations
Ann Arbor, MI Ann Arbor SCience Pubhshers, Inc, pp 165-178
Mustafa, M G, Elsayed, N M, Von DoWen, F M, Hassett, C M, PostlethwaIt, EM, QUInn, C L,

Grahatn, J A, Gardner, D E (1984) A companson of biochelllical effects of mtrogen dlOXide, ozone,
and their combmatlOn m mouse lung I mteflllittent eXpOSUlf'S TOXicol Appl Phannacol 72 82-90
NadZlejko, C E, Nansen, L , Manmx, R C, Klemman, M T, Phalen, R F (1992) The effect of mtnc aCId
vapor on the response to mhaled ozone Inhalation TOXicol m press
Nakajuna, T , Kusumoto, S (1968) [Effect of mtrogen dlOXide expo'>ure on the contents of reduced glutathione
m mouse lung] Osaka-funtsu Koshu Eisel Kenkyusho Kenkyu Hokoku Rodo Eisei Hen 6 17-21
Nakajima, T , Kusumoto, S , Chen, C , Okatnoto, K (1969) [Effects of prolonged contmuous exposure to

mtrogen dioXide on the quantity of reduced glutathione m lUDlgs of lllice and their histopathological
changes AppendIX effects of mtnte and mtrate on the glutathione reductase] Osaka-funtsu Koshu Eisei
Kenkyusho Kenkyu Hokoku Rodo Eisel Hen 7 35-41
Nakajima, T , Hatton, S , Tateism, R , Horm, T (1972) [MorphologlCal changes m the bronchial alveolar
system of lllice followmg contmuous exposure to low concentrations of mtrogen dlOXide and carbon
monOXide] Nthon Kyobu Shtkkan Gakkm Zasshi 10 16-22
Nakajima, T , Oda, H , Kusumoto, S , Nogatm, H (1980) BiologlCal effects of mtrogen dlOXide and mtnc
OXide In Lee, S D, ed Nitrogen OXides and their effects on health Ann Arbor, MI Ann Arbor
SCience Pubhshers, Inc ,pp 121-141
Nathan, C F, Murray, H W , Cohn, Z A (1980) The macrophage as an effector cell N Engl J Med
303 622-626
National Institutes of Health (1985) The deftmtion of emphysema report of a National Heart, Lung, and Blood
Institute, DiVISion of Lung Diseases workshop Am Rev Respir DiS 132 182-185
Nettesheim, P et al (1970) Effects of chromc exposure to air pollutants on the respuatory tracts of lllice
histologICal ftndmgs In Nettesheim, P , Hatma, M G, Jr , Deatherage, J W , Jr ,eds Morphology of
expenmental respuatory carcmogenesis Oak Ridge, TN AtollliC Energy COmllliSSlOn, DivlslOn of
Techmcal InfonnatlOn and Education, pp 437-448 (ABC symposmm senes 21)
Newhouse, M , Sanchis, J , Blenenstock, J (1976) Lung defense mechamsms N Engl J Med 295 990-998
Norkus, E P, Boyle, S , Kuenztg, W , Mergens, W J (1984) Formation of N-mtrosomorpholme m lllice

treated With morpholme and exposed to mtrogen dlOXide Carcmogenesis (London) 5 549-554
Oda, H , Kusumoto, S , Nakajima, T (1975) Nitrosyl-hemoglobm fonnation m the blood of ammals exposed to
mtnc OXide Arch Envuon Health 30 453-456
Oda, H , Nogallli, H , Kusumoto, S , Nakajima, T , Kurata, A , Inla.1, K (1976) [Long-tenn exposure to mtnc
OXide m lllice] Talkt Osen Kenkyu 11 150-160
Oda, H , Nogallli, H , Nakajima, T (1979) Alteration of hemoglobm reacted With mtrogen OXides m Vitro
J TOXicol SCI 4 299-300
13-223
Oda, H , Nogann, H , Kusumoto, S , Nakajima, T , Kurata, A (l980a) Lifetime exposure to 2 4 ppm mtnc
oXide m mice Envlfon Res 22 254-263
Oda, H , Nogann, H , Nakajima, T (1980b) Reaction of hemoglobm with mtnc oXide and mtrogen dioXide m
mice J TOXicol Envlfon Health 6 673-678
Oda, H , Tsubone, H , Suzula, A , Ichmose, T , Kubota, K (1981) Alterations of mtnte and mtrate
concentrations m the blood of mice exposed to mtrogen diOXide EnVlfon Res 25 294-301
Orthoefer, J G, Bhatnagar, R S, Rahman, A , Yang, Y Y , Lee, S D, Stara, J F (1976) Collagen and

prolyl hydroxylase levels m lungs of beagles exposed to air pollutants Envlfon Res 12 299-305
Overton, J H, Jr (1984) PhySicochemical processes and the fonnulation of dOSimetry models In Miller, F J ,
Menzel, DB, eds Fundamentals of extrapolatiOn modelmg of mhaled tOXicants ozone and mtrogen
diOXide Washmgton, DC Hemisphere Pubhshmg CorporatiOn, pp 93-114
Overton, J H , Jr , Graham, R C, Miller, F J (1987a) Mathematical modelmg of ozone absorption m the

lower resplfatory tract In PharmacokInetics m nsk assessment v 8, dnnlang water and health
Washmgton, DC National Academy Press, pp 302-311
Overton, J H, Graham, R C, Miller, F J (1987b) A model of the regiOnal uptake of gaseous pollutants m the
lung II the sensitivity of ozone uptake m laboratory ammallungs to anatomical and ventilatory
parameters TOXicol Appl Pharmacol 88 418-432
Palmer, M S, Exley, R W , Coffin, D L (1972) Influence of pollutant gases on benzpyrene hydroxylase

actiVity Arch Envlfon Health 25 439-442
Parker, R F, DaVIS, J K, Cassell, G H, WhIte, H , DZiedZiC, D , Blalock, D K, Thorp, R B, Simecka,

J W (1989) Short-term exposure to mtrogen diOXide enhances susceptibility to munne respiratory
mycoplasmosls and decreases mtrapulmonary lallmg of Mycoplasma pulmoms Am Rev Resplf DIS
140 502-512
Parks, N J , Krohn, K A, MathIs, C A, Chasko, J H, Geiger, K R, Gregor, ME, Peek, N F (1981)

Nitrogen-13-labeled mtnte and mtrate distnbution and metabohsm after illtratracheal admImstration
SCience (Washmgton, DC) 212 58-61
Patel, J M, Block, E R (1986a) Nitrogen dloXide-mduced changes m cell membrane flUidity and function
Am Rev Resplr DIS 134 1196-1202
Patel, J M, Block, E R (1986b) Effect of N02 exposure on antiOXidant defense of endothehal cells
TOXicology 41 343-352
Patel, J M, Edwards, D A, Block, E R, RaIzada, M K (1988) Effect of mtrogen diOXide on surface

membrane flUidity and msuhn receptor bmdmg of pulmonary endothelIal cells BiOchem Pharmacol
37 1497-1507
Patra, A L, Gooya, A , Menache, M G (1986) A morphometnc companson of the nasopharyngeal aIrway of

laboratory ammals and humans Auat Rec 215 42-50
Peters, S. G , Hyatt, R E (1986) A canme model of bronchIal illjUry mduced by mtnc aCId lung mechamcs and
morphologiC features Am Rev Resplr DIS 133 1049-1054
13-224
Pflesser, G (1935) Die Bedeutung des StIckstoffmonoxyds bei der Vergiftung durch mtroso Gase [The
importance of mtrogen monOXide m cases of mtoXicatIon caused by mtrous gases] Naunyn
Schmledebergs Arch Exp Pathol Pharmakol 179 545-557
Pmkston, P , Smeglm, A , Roberts, N J , Jr , Gibb, F R, Morrow, P E, Utell, M J (1988) Effects of m

vitro exposure to mtrogen dioXide on human alveolar macrophage release of neutrophil chemotactic factor
and mterleukm-l EnViron Res 47 48-58
Port, CD, Ketels, K V , Coffin, D L, Kane, P (1977) A comparative study of expenmental and
spontaneous emphysema J TOXicol EnvIron Health 2 589-604
Postlethwait, EM, Bidam, A (1990) Reactive uptake governs the pulmonary aIr space removal of mhaled
mtrogen diOXide J Appl PhyslOl 68 594-603
PostlethWait, EM, Mustafa, M G (1981) Fate of mhaled mtrogen diOXide m isolated perfused rat lung
J TOXicol EnvIron Health 7 861-872
PostlethWait, EM, Mustafa, M G (1983) FonnatIon of N-mtrosomorpholme m isolated rat lungs dunng
mtrogen diOXide ventdatIon Carcmogenesis (London) 4 777-778
PostlethWait, EM, Mustafa, M G (1989) Effect of altered dose late on NO z uptake and transfonnatIon m
isolated lungs J TOXicol EnViron Health 26 497-507
PostlethWait, EM, BlOam, A, Evans, M J (1990) The effect of NO z exposure on perfusate distnbutIon m
isolated rat lungs pulmonary versus bronchial CIrculation TOXicol Appl Phannacol 106 456-461
PostlethWait, EM, Langford, S D, Bidam, A (1991) Transfer of NOz through pulmonary epithehallmmg
flUid Toxicol Appl Pharmacol 109 464-471
Proctor, D F (1977) The upper airways I nasal phySiology and defense of the lungs Am Rev Respir DiS
115 97-129
PurviS, M R, Ehrhch, R (1963) Effect of atmosphenc pollutants on susceptIbihty to respIratory mfectIon

IT effect of mtrogen diOXide J Infect DiS 113 72-76
Re]thar, L , Re]thar, A (1975) HiStologiCal changes of termmal bronchioles m rats dunng the exposure to
mtrogen diOXide Exp Pathol 10 245-250
Rtchters, A, Dam]i, K S (1988) Changes m T-Iymphocyte subpopulatlOns and natural kdler cells followmg
exposure to mnbient levels ofmtrogen diOXide J TOXicol EnVIron Health 25 247-256
Rtchters, A , Dam]i, K S (1990) The relationship between mhalatlOn of mtrogen dioXid,e, the immune system,
and progresslOn of a spontaneously occurrmg lymphoma m AKR lllice J EnVlfon Pathol TOXicol
Oncol 10 225-230
Rtchters, A , KuraItIs, K (1981) Inhalation of NOz and blood borne cancer cell spread to the lungs Arch
Richters, A , Kuraitis, K (1983) Air pollutants and the facihtation of cancer metastaSiS Envlfon Health
Perspect 52 165-168
Rtchters, A , Rtchters, V (1983) A new relationship between air pollutant mhalatIon and cancer Arch EnVlfon
Health 38 69-75
13-225
Richters, A , RIchters, V (1989) Nitrogen dlOXlde (N0:z) mhalatIon formation of lDlcrothrombl m lungs and
cancer metastasIs J Environ Pathol TOXlcol Oncol 9 45-51
RIchters, A , RIchters, V , Alley, W P (1985) The mortality rate from lung metastases m animals mhalmg
mtrogen dloXlde (N0:z) J Surg Oncol 28 63-66
RIchters, A , RIchters, V , Sherwm, R P (1987) Influence of ambient level NOz exposure on newborn and adult
lDlce body weights J EnViron Pathol TOXlcol Oncol 7 65-72
RIetjens, I M C M, Poelen, M C M, Hempemus, R A, GIJbels, M J J , Almk, G M (1986) TOXlcIty

of ozone and mtrogen dloXlde to alveolar macrophages comparative study revealmg differences m their
mechanism of toXlC action J TOXlcol EnViron Health 19 555-568
RIetjens, I M C M, Van Tilburg, CAM, Coenen, T M M, Almk, G M, Konmgs, A W T (1987)

Influence of polyunsaturated fatty aCid supplementation and membrane flUIdity on ozone and mtrogen
dloXlde sensitivity of rat alveolar macrophages J TOXlcol EnViron Health 21 45-56
Robertson, A , Dodgson, J , Gormley, I P, Collmgs, P (1982) An mvestIgatIon of the adsorption of oXldes of

mtrogen on respirable mmeral dusts and the effects on their cytOtOXlClty AmI Occup Hyg 26 607-624
Robison, T W , Duncan, D P, Forman, H J (1990) Chemoattractant and leukotnene B4 production from rat
alveolar macrophages exposed to mtrogen dlOXlde Am J Resplr Cell Mol BlOl 3 21-26
Roehm, J N , Hadley, J G, Menzel, D B (1971) OXldatlOn of unsaturated fatty aCids by ozone and mtrogen
dloXlde a common mechanism of action Arch EnViron Health 23 142-148
Rombout, P J A, Dormans, JAM A, Marra, M , Van Esch, G J (1986) Influence of exposure regimen
on mtrogen dloXlde-mduced morphological changes m the rat lung EnViron Res 41 466-480
Rose, R M, Fuglestad, J M, Skomlk, W A, Hammer, S M, Wolfthal, SF, Beck, B D, Bram, J D

(1988) The pathophyslOlogy of enhanced susceptIblhty to munne cytomegalovirus respiratory mfectIon
dunng short-term exposure to 5 ppm mtrogen dloXlde Am Rev Resplr DIS 137 912-917
Rose, R M, Pmkston, P , Skomlk, W A (1989) Altered susceptIblhty to Viral respiratory mfectIon dunng
short-term exposure to mtrogen dloXlde Cambndge, MA Health Effects Institute, research report
no 24 Avallable from NTIS, Spnngfield, VA, PB90-111139
Roy-Burman, P , Pattengale, P K, Sherwm, R P (1982) Effect of low levels of mtrogen dloXlde mhalatIon on
endogenous retrovirus gene expresslOn Exp Mol Pathol 36 144-155
Russell, M L, Need, J L, Mercer, R R, Miller, F J , Crapo, J D (1991) DlstnbutlOn of mhaled

[oxygen-15]-N02 m the upper and lower respiratory tracts of rats [abstract] Am Rev Resplr DIS
143 (4 Part 2) A704
Sagat, M , Ichmose, T (1991) BlOchelDlcal effects of combmed gases of mtrogen dlOXlde and ozone
IV Changes of hPld peroXldatIon and antIoXldatIve protective systems m rat lungs upon hfe span
exposure TOXlcology 66 121-132
Sagat, M , Ichmose, T , Oda, H , Kubota, K (1982) Studies on blOchelDlcal effects of mtrogen dloXlde
n Changes of the protective systems m rat lungs and of hPld peroXldatIon by acute exposure J TmClcol
Environ Health 9 153-164
13-226
SagaJ, M , Ichmose, T , Kubota, K (1984) StudIes on the blOchetnlcal effects of mtrogen dlOXide IV RelatlOn
between the change of hPld peroXidatlOn and the antioXidative protective system m rat lungs upon hfe
span exposure to low levels of N02 TOXicol Appl Pharmacol 73 444-456
SagaJ, M , Arakawa, K , Ichmose, T , ShimoJo, N (1987) BlOchetnlcal effects on combmed gases of mtrogen
dIOXide and ozone I SpecIes dIfferences of hPld peroXides and phosphohplds m lungs TOXicology
46 251-265
Samet, J M, Tager, I B, Spelzer, F E (1983) The relatlOnship between respiratory ulness m childhood and
chromc aJr-flow obstructlOn m adulthood Am Rev Respir DIS 127 508-523
,
Saul, R L, Archer, M C (1983) NItrate formation m rats exposed to mtrogen dIOXide TOXicol Appl
Pharmacol 67 284-291
Schiff, L J (1977) Effect of mtrogen dlOXide on mfluenza VIruS mfection m haJnSter trachea organ culture Proc
Soc Exp BIOI Med 156 546-549
Schlesmger, R B (1987a) Effects of mtertmttent Inhalation exposures to tnlxed atmospheres of N02 and ~S04
on rabbit alveolar macrophages J TOXicol EnViron Health 22 301-312
Schlesmger, R B (1987b) Intertmttent Inhalation of mtrogen dIOXide effects on rabbIt alveolar macrophages
J TOXicol EnViron Health 21 127-139
Schlesmger, R B, Gearhart, J M (1987) Intertmttent exposures to .mIxed atmospheres of mtrogen dIOXide and
sulfunc aCId effect on particle clearance from the respIratory regIon of rabbIt lungs TOXicology
44 309-319
Schlesmger, R B, Dnscoll, K E, Vollmuth, T A (1987a) Effect of repeated exposures to mtrogen dlOXide

and sulfunc aCId tnlst alone or m combmation on mucoclhary clearance from the lungs of rabbIts
EnViron Res 44 294-301
Schlesmger, R B, Dnscoll, K E, Naumann, B D, Vollmuth, T A (1987b) PartIcle clearance from the

lungs assessment of effects due to Inhaled lmtants Ann Occup Hyg m press
Schlesmger, R B, Dnscoll, K E, Gunmson, A F, Zehkoff, J T (1990) Pulmonary arachidomc aCId

metabohsm followmg acute exposures to ozone and mtrogen <hoXide J TOXicol EnViron Health
31 275-290
Schlesmger, R B, WeIdeman, P A, Zehkoff, J T (1991) Effects of repeated exposures to ozone and mtrogen
dIOXide on respIratory tract prostanOlds Inhalation TOXicol 3 27-36
Schrelder, J P, Raabe,
Rec 200 195-205
°
G (1981) Anatomy of the nasal-pharyngeal aIrway of expenmental ammals Anat
Sekharam, K M, Patel, J M, Block, E R (1991) Plasma membrane-specIfic phosphohpase-Al activation by

mtrogen diOXide m pulmonary artery endothelIal cells TOXicol Appl Pharmacol 107 545-554
Selgrade, M K, Mole, M L, MIller, F J , Hatch, G E, Gardner DE, Hu, P C (1981) Effect of N02
mhalation and Vltamm C defiCIency on protem and hpld accumulation m the lung EnViron Res
26 422-437
Selgrade, M K, Damels, M J , Grose, E C (1991) Evaluation of ImmunotoXiclty of an urban profile of

mtrogen dIOXide acute, subchromc, and chromc studIes Inhalation TOXicol 3 389-403
13-227
Seto, K , Kon, M , KawakamI, M , Yaglshtta, S , SUglta, K , Shtshtdo, M (1975) [Influence of mtrogen dioXide
Inhalation on the formatIon of protem m the lung] Igaku to Selbutsugaku 90 103-106
Sevaruan, A , Hacker, AD, Elsayed, N (1982) Influence of vItamIn E and mtrogen diOXide on hpld
peroXidatIon m rat lung and hver mIcrosomes Lipids 17 269-277
Shalambendze, 0 P (1969) [The Jomt actIon of small concentrations of sulfur diOXide and mtrogen diOXide
gases under conditIons of a chromc test] Gig Sarut 4 10-14
Shalambendze, 0 P, Tsereteh, N T (1971) Effect of low concentratIons of sulfur and mtrogen diOXides on the
estrual cycle and reproductIve functIons of expenmental arumals Hyg Sarut (USSR) 36 178-182
Sherwm, R P, Carlson, D A (1973) Protem content of lung lavage flUId of gumea pigs exposed to 0 4 ppm
mtrogen diOXide disc-gel electrophoresIs for amount and types Arch EnVIron Health 27 90-93
Sherwm, R P, Layfield, L J (1974) Protemuna m gumea pigs exposed to 05 ppm mtrogen dIOXide Arch
Sherwm, R P, Layfield, L J (1976) Protem leakage m the lungs of mIce exposed to 05 ppm mtrogen diOXide
a fluorescence assay for protem Arch EnVIron Health 31 116-118
Sherwm, R P, RIchters, V (1982) HyperplaSia of type 2 pneumocytes followmg 0 34 ppm mtrogen dIOXide
exposure quantItatIon by Image analysIs Arch EnVIron Health 37 306-315
Sherwm, R P, RIchters, V , Brooks, M , Buckley, R D (1968) The phenomenon of macrophage congregatIOn

m vitro and Its relatIonshtp to m VIVO NOz exposure of gumea pigs Lab Invest 18 269-277
Sherwm, R P, Dibble, J , Werner, J (1972) Alveolar wall cells of the gumea pig mcrease m response to
2 ppm mtrogen diOXide Arch EnVIron Health 24 43-47
Sherwm, R P, Margohck, J B, Azen, S P (1973) Hypertrophy of alveolar wall cells secondary to an air
pollutant a semI-automated quantItatIon Arch EnVIron Health 26 297-299
Sherwm, R P, Shth, J C, Lee, J D , Ransom, R (1986) Serotonm content of the lungs, brams, and blood of
mIce exposed to 0 45 ppm mtrogen diOXide J Am ColI TOXicol 5 583-588
Sherwood, R L, Lippert, WE, Goldstem, E , Tarkmgton, B (1981) Effect of ferrous sulfate aerosols and
mtrogen diOXide on munne pulmonary defense Arch EnVIron Health 36 130-135
Shevchenko, A M (1971) The role of some phySICal and chemIcal propertIes of mme dust m the development of
pneumocomosls In Walton, W H, ed Inhaled particles ill proceedmgs of an mtematIonal symposIUm
orgaruzed by the BntIsh OccupatIonal Hygiene SOCiety, V 1, September 1970, London, Umted Kmgdom
Surrey, Umted Kmgdom Unwm Brothers LImIted, pp 561-570
SibIlle, Y , Reynolds, H Y (1990) Macrophages and polymorphonuclear neutrophtls m lung defense and mJury
SIlbaugh, SA, Mauderly, J L, Macken, C A (1981) Effects of sulfunc aCid and mtrogen diOXide on airway
responSiveness of the gumea pig J TOXicol EnVIron Health 8 31-45
SIlverstem, S C, Stemman, R M, Cohn, Z A (1977) EndocytOSIs Annu Rev Blochem 46 669-722
Slade, R , Highfill, J W , Hatch, G E (1989) Effects of depletIon of ascorbiC aCid or nonprotem sulthydryls on
the acute InhalatIon toXiCity of mtrogen diOXide, ozone, and phosgene InhalatIOn TOXicol 1 261-271
13-228
Spelzer, FE, Ferns, B , Jr , BIshop, Y M M, Spengler, J (1980) Respiratory dIsease rates and pulmonary
function m children assocIated wIth NO z exposure Am Rev Resplr DIS 121 3-10
Stara, J F, Dungworth, D L, Orthoefer, J G, Tyler, W S, ed-, (1980) Long-term effects of aIr pollutants
m canme specIes CmcmnatI, OH U S Environmental Protection Agency, Office of Health and
Environmental Assessment, EnvIronmental Cntena and Assessment Office, EPA report no
EPA-600/8-80-Q14 AVailable from NTIS, Spnngfield, VA, PB81-144875
Stavert, D M, Lehnert, B E (1990) Nltnc OXide and mtrogen diOXide as mducers of acute pulmonary mJury
when mhaled at relatively high concentrations for bnef penods InhalatiOn TOXicol 2 53-67
Stavert, D M, Archuleta, DC, Holland, L M, Lehnert, B E (1986) NItrogen diOXide exposure and
development of pulmonary emphysema J TOXicol EnViron Health 17 249-267
Steadman, B L, Jones, R A, Rector, DE, SIegel, J (1966) Ef1ects on expenmental ammals of long-term
contmuous mhalatiOn of mtrogen dIOXide TOXicol Appl Pharmacol 9 160-170
Stephens, R J , Freeman, G, Crane, S C, FunosI, N J (1971a) Ultrastructural changes m the termmal

bronchiOle of the rat dunng contmuous, low-level exposure to mtrogen dIOXide Exp Mol Pathol
14 1-19
Stephens, R J , Freeman, G , Evans, M J (1971b) Ultrastructural changes m connective tissue m lungs of rats
exposed to NOz Arch Intern Med 127 873-883
Stephens, R J , Freeman, G , Evans, M J (1972) Early response of lungs to low levels of mtrogen dIOXide
hght and electron nncroscopy Arch EnViron Health 24 160-179
Stephens, R J , Sloan, M F, Groth, D G (1976) Effects of long-term, low-level exposure of NOz or 0 3 on rat
lungs EnVIron Health Perspect 16 178-179
Stephens, R J , Sloan, M F , Groth, D G, NegI, D S, Lunan, K D (1978) CytologIc response of postnatal

rat lungs to 0 3 or NO z exposure Am J Pathol 93 183-200
Stephens, R J , Tallent, C , Hart, C , NegI, D S (1982) Postnatal tolerance to NOz tOXiCIty Exp Mol Pathol
37 1-14
Stevens, M A, Menache, M G, Crapo, J D, MIller, F J , Graham, J A (1988) Pulmonary function m

Juvemle and young adult rats exposed to low-level NOz WIth dIUrnal spIkes J TOXicol EnVIron Health
23 229-240
Strauss, R R, Paul, B B, Jacobs, A A, Sbarra, A J (1970) Role of the phagocyte m host-parasIte

mteractIons XXII HzOz-dependent decarboxylation and dearmnatIon by myeloperoXidase and ItS
relationship to antInncrobial activIty RES J RetIculendothel Soc 7 754-761
Stupfel, M , Magmer, M , Romary, F , Tran, M -H , Moutet, J -P (1973) LIfelong exposure of SPF rats to
automotive exhaust gas dtlutIon contatmng 20 ppm of mtrogen OXides Arch EnViron Health
26 264-269
Sun, J D, PIckrell, J A, Harkema, J R, McLaughlm, S I, Haltn, F F, Henderson, R F (1988) Effects of

buthtonme sulfoXimme on the development of ozone-mduced pulmonary fibrosIs Exp Mol Pathol
49 254-266
Suzuki, A K, Tsubone, H , Ichmose, T , Oda, H , Kubota, K (1981) [Effects of subchromc mtrogen dIOXide
exposure on artenal blood pHa, PaCOz and PaOz m rats] NIppon Eiselgaku Zasshi 36 816-823
13-229
Suzuki, A K; IchInose, T , Tsubone, H , Oda, H , Kubota, K (1982a) Effects of acute mtrogen dioXIde
exposure on swunmmg performance of Illlce J TOXIcol Environ Health 9 165-172
Suzukt, A K, Tsubone, H , Kubota, K (1982b) Changes of gaseous exchange 10 the lung of Illlce acutely
exposed to mtrogen diOXIde TOXIcol Lett 10 327-335
Suzukt, T , Terada, N , Ikeda, S , Ohsawa, M , Endo, K , Mizogucht, I (1984) [Effect of NO z exposure on the
actIVity of angiotensm convert1Og enzyme 10 lung] Kenkyu Nenpo Tokyo-tontsu Eisei Kenkyusho
35 279-285
Suzula, T , Ikeda, S , Kanoh, T , Mizogucht, I (1986) Decreased phagocytosis and superoXIde amon productIon
10 alveolar macrophages of rats exposed to mtrogen diOXIde Arch Environ Contam TOXIcol
15 733-739
Suzula, T , Kanoh, T , Mtzogucht, I (1988) Increased unnary excretion of tryptophan metabohtes 10 rats
exposed to mtrogen diOXIde Bull Environ Contam TOXIcol 40 139-146
Svorcova, S , Kaut, V (1971) Artenovenozm rozdily V koncentraci dusitanoveho a dusicnanoveho iOntu u krahku
po vdechovam kyshcmku duslku [Arteno-venous differences 10 the mtnte and mtrate ion concentratiOns m
rabbits after mhalatIon ofmtrogen OXIde] Cesk Hyg 16 71-76
Tabacova, S , NJ1a.forov, B , Balabaeva, L (1985) Postnatal effects of maternal exposure to mtrogen diOXIde
Neurobehav TOXIcol Teratol 7 785-789
Takahasht, Y , MIUra, T (1989) Effects of mtrogen diOXIde and ozone 10 comb1OatIon on xenobiOtIc
metabolizmg actIVIties of rat lungs TOXIcology 56 253-262
Takahashi, Y , Mochitate, K , MiUra, T (1986) Subacute effects of mtrogen diOXIde on membrane constituents
oflung, hver, and kidney of rats Environ Res 41 184-194
Takano, T , Miyazaki, Y (1984) Combmed effect of mtrogen diOXIde and cold stress on the actiVity of the
hepatic cytochrome P-450 system m rats TOXIcology 33 239-244
Tepper, J S, Costa, D L, Wmsett, D W , Stevens, M A, Doerfler, D L (1992) Near-lifetime exposure of

the rat to a Simulated urban profile of mtrogen diOXIde pulmonary functiOn evaluation TOXIcol Appl
Pharmacol accepted for pubhcatiOn
Thomas, H V , Mueller, P K, Wnght, R (1967) Response of rat lung mast cells to mtrogen diOXide
mhalatIon J AIr Pollut Control Assoc 17 33-35
Thomas, H V , Mueller, P K, Lyman, R L (1968) LipoperoXIdation of lung hpids m rats exposed to mtrogen
diOXIde SCience (WashIngton, DC) 159 532-534
Toothtll, C (1967) The cheIlllstry of the m ViVO reaction between haemoglobm and vanous OXIdes of mtrogen
Br J Anaesth 39 405-412
Totten, R S, Moran, T J (1961) Cortisone and atypical pulmonary "epithehal" hyperplaSia effects of
pretreahnent With cortisone on repair of cheIlllcally damaged rabbit lungs Am J Pathol 38 575-586
TrzecIak, HI, KosIlllder, S , Kryk, K, Kryk, A (1977) The effects of mtrogen OXIdes and theIr neutrahzatiOn
products WIth ammoma on the lung phosphohpids of gumea pIgs EnViron Res 14 87-91
Tsubone, H , Suzuki, A K (1984) Reflex cardiOpulmonary responses by stimulation to type J receptors 10 rats
exposed to NO z J TOXIcol EnViron Health 13 905-917
13-230
Tusl, M , Stolm, V , Wagner, M (1973) PhYSICal exertIOn (swnllmmg) m rats under the effect of chemICal
agents In Horvath, M , Frantlk, E ,eds Proceedmgs of the International ASSOCIation of Occupational
Health Study Group on FunctIOnal TOXICIty vi, adverse effects of environmental chell1lcals and
psychotropIc drugs quantitative mterpretation of functional tc~sts New York, NY ElseVIer SCIence
PublIshers, pp 155-160
Tyson, C A, Lunan, K D, Stephens, R J (1982) Age related differences m glutatmone shuttle enzymes m
NOz - or 0 3 - exposed rat lungs Arch EnViron Health 37 166-176
US Congress (1991) Identifymg and controllmg ImmunotoXIc substances background paper Washmgton, DC
Office of Technology Assessment, report no OTA-BP-BA-7'), pp 1-77
U S EnVironmental ProtectIOn Agency (1982) Air qualIty cntena for OXides of mtrogen Research Tnangle
Park, NC Office of Health and EnVironmental Assessment, lEnvIronmental Cntena and Assessment
Office, EPA report no EPA-600/8-82-o26 AVaIlable from NTIS, Spnngfield, VA, PB83-131011
Ultlnan, J S (1988) Transport and uptake of mhaled gases In Wat',on, A Y, Bates, R R, Kennedy, D , eds
Air pollution, the automobl1e, and publIc health Washmgton, DC National Academy Press,
pp 323-366
Utell, M J , Frampton, M W , Roberts, N J , Jr , Fmkelstem, J N , Cox, C , Morrow, P E (1991)

Mechamsms of mtrogen dIOXide tOXICIty m humans Cambndge, MA Health Effects Institute, report
no HEI/RR-91/43 AVaIlable from NTIS, Spnngfield, VA, PB92-191261/XAB
Van Stee, E W , Sloane, R A, SImmons, J E, Brunnell1aD1l, K D (1983) In VIVO fonnation of

N-mtrosomorpholme m CD-l ll1lce exposed by mhalation to mtrogen dIOXide and by gavage to
morpholme JNCI J Natl Cancer Inst 70 375-379
Vaughan, T R, Jr , Jennelle, L F, LeWIS, T R (1969) Long-temi exposure to low levels of aIr pollutants
effects on pulmonary functIOn m the beagle Arch EnViron Health 19 45-50
Venmga, T , Hoeksma, E , Lemstra, W , Wagenaar, J (1982) Companson of bIOlogICal effects of NOz' 0 3 and
combmations of both OXidants In SchneIder, T , Grant, L ,eds Air pollutIOn by mtrogen OXides
proceedmgs of the US-Dutch mternational sympOSIUm, May, Maastncht, The Netherlands Alnsterdam,
The Netherlands ElseVIer SCIentific PublIshmg Company, pp 441-445 (StudIes m environmental SCIence
21)
VOlsm, C , Aerts, C (1984) Le macrophage alveolaIre en culture en phase gazeuse, mdicateur bIOlogIque en
tOXIcologie des gaz applIcation a l'etude de la cytotoXIcite dUl blOxyde d'azote (NOJ [Alveolar
macrophage culture m gas phase, as a bIOlogICal mdicator m gas tOXicology applIcation to mtrogen
diOXide cytOtOXiCIty] Bull Acad Natl Med (pans) 168 755-760
VOlsm, C , Aerts, C , Jakubczak, E , Houdret, J L, Tonnel, A B (1977) Effets du bIoxyde d'azote sur les
macrophages alveolaIres en survie en phase gazeuse Un nouveau modele expenmental pour l'etude m
Vitro de la cytotoXIClre des gaz nocifs [Effects of mtrogen diOXide on alveolar macrophages survivmg m
the gas phase A new expenmental model for the study of m VItro cytotOXiCIty of toXiC gases] Bull Eur
PhysIOpathol Respir 13 137-144
Vollmuth, T A, Dnscoll, K E, Schlesmger, R B (1986) Changes. m early alveolar particle clearance due to
smgle and iepeated mtrogen diOXide exposures m the rabbit r TOXIcol Environ Health 19 255-266
Vyskocl1, A , Tusl, M , Zaydlar, K (1985) The effect of chromc exposure to 35 ppm NOz on honnone levels
and organ weIghts m rats J Appl TOXIcol 5 357-359
13-231
Wagner, H -M (1970) Absorption von NO und N02 m MIK- und MAK-Konzentrationen bei der InhalatiOn
[Absorption of NO and N02 m nuk- and mak-concentrations dUrIng Inhalation] Staub Remhalt Luft
30 380-381
Wagner, W D, Duncan, B R, Wnght, P G, Stokmger, H E (1965) Expenmental study of threshold hIDlt of

N02 Arch EnViron Health 10 455-466
Watanabe, H , Fukase, °,
Isomura, K (1980) Combmed effects of mtrogen oXides and ozone on IDlce In Lee,
S D, ed Nitrogen oXides and their effects on health Ann Arbor, MI Ann Arbor SCience Pubhshers,
Inc ,pp 181-189
Weibel, E R (1963) Morphometry of the human lung New York, NY AcadeIDlc Press Inc , Pubhshers
Wembaum, G , Oppenhetm, D , Arai, K (1987) Stimulation of pulmonary metastasis by exposure to mtrogen

dioXide Am Rev Respir DiS 135(suppl) A141
Witschi, H (1988) Ozone, mtrogen dioXide and lung cancer a reView of some recent issues and problems
TOXicology 48 1-20
Wong, G G, Clark, S C (1988) Multiple actions of mterleukm 6 WithIn a cytokme network Immunol Today
9 137-139
World Health Orgamzation (1977) OXides of mtrogen Geneva, SWitzerland World Health Organization
(Envuonmental health cntena 4)
Yaklmchuk, P P, Chehkanov, K N (1972) Data for a samtary baSiS of the mean dally IDaXlmum penmssible
concentration of mtrogen dioXide m atmosphenc air In Nuttonson, MY, ed AlCE survey of USSR
air pollutiOn hterature v xvn A fourth compllation of techmcal reports on the biOlogical effects and
the pubhc health aspects of atmosphenc pollutants WashIngton, DC U S Envuonmental Protection
Agency, Office of Au ProgratnS, pp 17-23, report no AlCE-AIR-72-17
Yamamoto, I , Takahashi, M (1984) Ultrastructural observatiOns of rat lung exposed to mtrogen diOXide for
7 months Kitasato Arch Exp Med 57 57-65
Yeh, H C, Schum, G M, Duggan, M T (1979) AnatoIDlc models of the tracheobronchial and pulmonary
regiOns of the rat Anat Rec 195 483-492
Yokoyama, E (1968) Uptake of S02 and N02 by the isolated upper airways Bull Inst Pubhc Health (Tokyo)
17 302-306
Yokoyama, E , Iclukawa, I , KaWai, K (1980) Does mtrogen diOXide modify the respuatory effects of ozone?
In Lee, S D, ed Nitrogen OXides and theu effects on health Ann Arbor, MI Ann Arbor SCience
Pubhshers, Inc, pp 217-229
Yoshida, K , Kasama, K (1987) Biotransfonnation ofmtnc OXide Envuon Health Perspect 73 201-206
Yoshida, K , Kasama, K , Kitabatake, M , Okuda, M , lmat, M (1980a) Metabohc fate of mtnc OXide Int
Arch Occup Envuon Health 46 71-77
Yoshtda, K, Kitabatake, M , lmat, M , Kasama, K (1980b) The effects of exposure to NO or N02 and an
antigen on the breathIng curve pattern m gumea pigs Envuon Res 21 458-466
13-232
Yoshtda, K , Kasama, K, Kttabatake, M , Wakabayasht, K, Itnal,]\I[ (1981) Changmg ofmtnc oXIde m the
aIrway expenment wIth model-aIrway and perfused lung Rept EnvIron SCI 6 57-61
Yuen, T G H, Sherwm, R P (1971) HyperplasIa of type 2 pneumocytes and mtrogen dIoXIde (10 ppm)
exposure a quantitatIon based on electron photoImcrographs Arch EnVIron Health 22 178-188
13-233
14. EPIDEMIOLOG1{ STUDIES
OF OXIDES OF NI'fROGEN
14.1 INTRODUCTION
ThIs chapter dIscusses the epIdemIOlogIcal eVIdence for the effects of mtrogen OXides
(N0x) on human health Major emphasIs IS placed on dISCUSSIon of the effects of mtrogen
diOXide (NOz) because It IS the NOx compound measur('"d m most epIdemIOlogIcal studIes and
because It IS the NOx compound currently of greatest concern from a pubhc health
perspective Human health effects associated WIth exposure to NOz have been the subject of
several hterature reVIews smce 1970 NatIOnal Research CouncIl (1971, 1977), World
Health OrganIZatIOn (1977), Samet et al (1987, 1988), and Graham et al (1990) OXides of
mtrogen have also been reVIewed prevIously by the U S EnVIronmental Protection Agency
(1982a), wmch presented a comprehensIve reVIew of studIes conducted up to 1980 ThIs
chapter focuses mamly on studies conducted smce 1980, whIle also utIhzmg some key
informatIOn from earher hterature
Studies discussed m the chapter text are those thalC prOVIde useful quantItatIve
InformatIOn on exposure-effect relatIOnsmps for health effects assocIated WIth ambIent arr
levels of N02 hkely to be encountered m the Umted States In additIOn, some studieS that do
not provIde quantitatIve InformatIOn are bnefly discussed m the mam text as appropnate to
help elucIdate particular pomts concermng NOz health effects Both the quantitative studIes
dIscussed m the mam text and the addItional qualItative studIes evaluated here but found to
be of hmited usefulness for present cntena development purposes are conCIsely summanzed
m AppendIX 14A.
The present chapter IS organIZed as follows FIrst, studIes of respIratory symptoms and
Illnesses that meet cntena (see SectIOn 14 6 4) for use m a quantitative analySIS are
dIscussed, followed by studies that prOVIde qualItative mformatIOn The resprratory Illness
sectIon IS dIVIded mto mdoor and outdoor subsections Next, studIes are descnbed that
examme effects of NOz exposure on pulmonary functIOn Then, a short dISCUSSIon of
occupatIOnal studIes IS proVIded Fmally, a quantItatIv,e analySIS IS presented that syntheSIZes
the avaIlable evidence on respIratory Illness
14-1
In U S. EnvIronmental ProtectiOn Agency (1982a), a group of studies exammmg the
relatlonsillp between resprratory illness and exposure m the home to gas (cooking fuel)
combustion products, notably mcludmg N02 , were evaluated At that time, those studies
inferred the presence of N02 by the presence of gas combustiOn emiSSion sources Smce
then, new studies and updates of earher ones have been conducted Many of these studies
provide data on N02 concentratiOns and estlffiates of human exposure
14.2 METHODOLOGICAL CONSIDERATIONS

Studies assessed here were evaluated for several factors noted earher by Hill (1965) and
U.S Environmental ProtectiOn Agency (1982b) to be of lffiportance for mterpretmg
epIdemiologIcal studies Factors considered here m evaluatmg epidemiOlogical studies of the
health effects of N02 mclude (1) exposure measurement errors, (2) misclassmcation of health
outcomes, (3) adjustments for covanates, (4) selectiOn biaS, (5) mtemal consIstency, and
(6) plaUSibility of observed effects, based on other eVidence Because these factors are
common to the evaluation of all epidemiOlogy studies, a bnef diSCUSSion follows
14.2.1 Measurement Error

Measurement error m exposure is potentlally one of the most lffiportant methodological
problems m epIdemiOlogical studies of N02 Ideally, personal momtors would be placed on
all subjects for the entrre penod of a study Even then, some error associated With the
momtormg deVIce itself would remam Such mtensive personal momtonng IS not feasible
Even personal momtoring, because of the mtegrated multlday samplmg, does not adequately
measure short-term peaks nor long-term chromc exposures Instead, N02 exposure may be
estlmated by source descnptiOn, personal momtors, m-home momtors, and fixed-Site outdoor
momtors. In most of the early studies, gas stove presence was related to health outcomes
WIthout any drrect exposure estlmates AdditiOnally, a by-product of mtrogen dioxide,
nitrous aCId (HONO), may be a factor contnbutmg to observed effects, however, very
limIted aerometnc or health effects data are available that examme tills possibility
The effect of exposure measurement error on estlffiatiOn has been studied by several
authors, mcludmg Shy et al (1978), Gladen and Rogan (1979), Clark (1982), Stefanski and
14-2
Carroll (1985), Walker and Blettner (1985), Fuller (1987), Lebret (1987), Schafer (1987),
Wlnttemore and Keller (1988), Samet and Utell (1990), and Yoslnmura (1990) In general,
exposure measurement error that IS mdependent of the health outcome results m estImated
effects bemg biased towards the null For example, WhIttemore and Keller (1988)
specIfically consIder the data of Mella et al (1980) as descnbed by Florey et al (1979) and
show that a 20 % nnsclassIficatlOn rate of the exposure category would result m an
underestImate of the lOgIStiC regreSSIOn coefficIent by as much as 50% Also, StefanskI and
Carroll (1985) have shown that even WIthout the mdependence of error related to outcome,
the biaS IS towards the null m SItuatIOns where the probabilitIes of response are not extremely
close to 0 or 1 The use of the presence of a gas stove as a surrogate for an actual N02
exposure can mtroduce measurement misclassIficatIon etTOr Clark (1982) studIed the effect
of measurement error, whtch was towards the null m lOgIStiC regreSSIOn when that error was
sampled from a normal or lOgIStiC regreSSIOn, and also found biaS towards the null for certam
multIple lOgIStiC models
If the observed health effects (see Chapter 13 and SectIOn 14 3) result from peaks
(1-h or less) generated dunng source use rather than longer term averages, then the use of
estImated averages creates another source of exposure measurement error However,
madequate data are aVailable to adequately evaluate the relatIve contnbutIOns of personal
exposures to peak versus average N02 values to health effects studIed m epIdemIOlogy
studIes Peak levels m bedrooms and other locations are not as htgh as m kItchens (see
Chapter 7), and most mdoor actiVIty occurs m locatIOns other than the kItchens (see
Chapter 8) Harlos et al (1987) state that N02 concentratIOns m the kItchen are dIfferent for
each cookIng event m a 12- or 24-h penod To Improve exposure measurement estImates,
N02 concentratIOns dunng room occupancy are needed The average bedroom N02
concentration already contaIns most of the tIme-location Information by vIrtue of bemg a
pnmary daIly locatIOn, especially for Infants In most homes, peak values may be related to
average values such that reducmg peaks reduces the average concentration Average values
may serve as surrogates for the peaks, however, IT effects are aSSOCiated WIth the peaks, then
the use of averages will mcrease measurement error
14-3
14.2.2 Misclassification of Health Outcomes
MIsclassIficatIon of the health outcome can occur whether the outcome IS, contmuous,
such as a measure of puhnonary functIon, or dIchotomous, such as the presence or absence
of resprratory symptoms Lung functIon IS tYPICally measured WIth spIrometry, a well
standardIZed (Ferns, 1978) technIque The measurement errors of the mstruments collectmg
the data have also been carefully estImated, and random errors will SImply add to the error
vanance On the other hand, resprratory symptoms and dIsease are usually measured by a
questIonnaIre Responses to symptom questIOns are typICally pOSItIvely correlated and
depend on the mterpretatIon of the respondent As noted later m the chapter, a specIfic
resprratory dIsease IS bkely to be reflected by reportIng of a constellatIOn of symptoms, It IS
therefore appropnate to conSIder aggregate rather than, or as well as, smgle specIfic
symptom reports ObvIously, questIonnaIre measurements that depend on recent recall are
better than those based on recall of events that occurred several years m the past
QuestionnaIres for cough and phlegm productIon have been standardIZed, such as the BntIsh
MedIcal Research Council (BMRC) questIOnnaIre (Amencan ThoraCIC SOCIety, 1969) and
reVISIons of the BMRC queshonnaIre (Ferns, 1978, Samet, 1978) These questIonnaIres and
modIficatIOns of them have been used extenSIvely
14.2.3 Adjustments for Covariates

It is common when analyzmg a data set to dIscover that one or more key covanates for
the analySIS were not measured Schenker et al (1983) dISCUSS SOCIOeconomIC status (SES),
paSSIve smokmg, and gender as Important covanates m chIldhood resprratory dIsease studIes
Other covanates mclude age, humIdIty, and pollutants, such as partIculate matter The
concern IS that, had an OmItted covanate been measured, then the estImate of the regreSSIOn
coefficient for a dependent vanable of mterest would have been SIgnIficantly dIfferent
Although the problem IS faced by many mvestIgators, the hterature on the field IS relatIvely
sparse For example, Kupper (1984) shows that hIgh correlatIOns between the vanables Just
descnbed will result m "unrehable parameter estImates WIth large vanances" Gail (1985)
conSIdered the specIal case of omIttmg a balanced covanate from the analySIS of a cohort
study and concluded that "In pnnciple, the biaS may be eIther toward of away from zero,
though m typICal examples-the bIas IS toward zero In apphcatIons WIth addItIve or
14-4
multIphcatIve regressIOn, there IS no bias" NeIther paper provIded InformatIOn on how to
attempt to correct for the bias or on approaches for InvestIgatIng the possIble bias In a gIven
sItuatIOn
Most studIes of resprratory dIsease and N02 exposures dIscussed here measured
Important covanates such as age, SOCIoeconomIC level of the parents, gender, and parental
smokIng habIts The estimated effect (regressIOn coefficIent of dIsease on N02 exposure)
will be overestnnated If a mIssmg covanate IS posItIvely (or negatIvely) correlated wIth both
exposure and outcome The estImated effect will be underestImated If posItIvely correlated
WIth eIther exposure or outcome and negatIvely correlated WIth the other Ware et al
(1984), for example, found that parents WIth some college educatIOn were more hkely to
report resprratory symptoms and were less hkely to use a gas stove, leadmg to an
underestImate of the health effect If educatIOn were left out of the analySIS
14.2.4 Selection Bias

The pOSSIbility of selectIOn biaS, although a concem of every study, seems very low for
the epIdemIOlogic studIes of N0 2 SelectIon biaS would reqUIre selectIon of partICIpants
based on exposure (e g , use of gas stove) and also health outcome Because most
epIdemIOlOgiC studIes of these exposures are populatIOn based, there IS httle pOSSIbility of
selectIon based on health end POInts Nevertheless, the loss of subjects by attntIon aSSOCiated
WIth both exposure and health studIes must be conSIdered
14.2.5 Internal Consistency

Internal conSIstency IS always a check on the valIdIty of a study, but often the authors
do not report suffiCIent detail by whIch to check for such conSIstency For known nsk
factors for resprratory effects, a study should proVIde eVIdence of expected aSSOCiatIOns
(e g , between paSSIve smokIng and Increased resprratOIy illness among exposed coworkers
or children or more wheeze In exposed asthmatIc children) Furthermore, certam patterns of
age or gender relatIonshIps to observed health outcomes should be expected On the other
hand, study results suggestmg a sIgmficant benefiCIal effect of N02 amId other deletenous
effects must be VIewed WIth extreme cautIOn In the absence of mdependent anImal tOXicologIC
14-5
or other types of eVIdence for plausIble mechamsms to account for such effects ConSIstency
between studies proVIdes a further mdicatIOn of the overall strength of the total data base
14.2.6 Plausibility of Effects

Health outcomes measured should be ones for which there are plaUSIble bases to suspect
that they could be affected by N02 exposure Two health outcome measures have been most
extensively conSIdered m the N02 epidemIOlogtc studIes reVIewed here lung functIon
measurements and resprratory illness occurrence Human chmcal and ammal tOXicologICal
studIes have not mdicated a demonstrated effect on lung functIon at ambIent levels m normal
subjects (see Chapters 13 and 15) However, m contrast, antrnal tOXicologICal studIes m
Chapter 13 have shown that N02 exposure can lffiparr components of the respIratory host
defense system, resuItmg m the host bemg more susceptIble to resprratory mfectIOn Thus
observed mcreases m resprratory symptoms and dIsease among chIldren m epIdemIOlogIC
studIes of N02 exposure may be more plausIbly hypotheSIZed to be the result of an mcrease
in resprratory mfectIon
SpecIal attentIOn IS accorded to considermg all of the above factors m evaluatmg the
studIes reVIewed below Those studIes that address these factors most appropnately proVIde
a stronger baSIS for acceptmg conclUSIOns based on therr results
14.3 STUDIES OF RESPIRATORY ILLNESS

Resprratory illness and the factors determmmg occurrence and seventy are lffipOrtant
pubhc health concerns ThIs sectIon discusses epIdemIOlogIcal findmgs relatmg estlffiates of
N02 exposure to resprratory illness ThIs effect IS of pubhc health lffiportance because of the
WIdespread potentIal for exposure to N02 and because the occurrence of childhood
resprratory illness IS common (Samet et al , 1983, Samet and Utell, 1990) ThIs takes on
added Importance because recurrent chIldhood respIratory illness (mdependent of N02) may
be a nsk factor for later susceptIbility to lung damage (Glezen, 1989, Samet et al , 1983,
Gold et al., 1989)
The N02 studIes used standard resprratory questIonnarres that evaluated resprratory
health by askmg questIOns about each chIld's resprratory dIsease and symptom expenence
14-6
The reported symptoms and dIseases (typICally based on parental recall) charactenze lower
respIratory morbIdIty m the cohorts StudIed A bnef dIscussIOn of aspects of epIdemIology
of lower resprratory morbIdIty m chIldren provIdes a background for studIes exammmg N0 2
exposure m relatIOn to lower respIratory health Lower respIratory morbIdIty m chIldren
typICally mcludes asthma, bronchItis, croup, tracheobronchItis, bronchIolItis, and pneumoma
Asthma and bronchItis are bnefly dIscussed mdividually below, and the latter four are
dIscussed together as part of lower respIratory Illness syndromes
Asthma IS charactenzed by reversIble arrway obs1ructIOn, arrway mflammatIOn, and
mcreased aIrway responsIveness to stImulI (NatIOnal Institutes of Health, 1991) Schenker
et al (1983) report a prevalence of approXimately 3 51100 for M D -dIagnosed asthma m
chIldren 5 to 9 years of age The Centers for DIsease Control (1990) mdicate that, for those
less than 20 years of age, the prevalence of asthma mcreased from approXImately 3 51100
persons m 1980 to 5 0/100 persons m 1987 Asthma patIents develop such chmcal
symptoms as wheezmg and dyspnea after exposure to allergens, envrronmental rrntants, vITal
Infections, cold arr, or exerCIse ExacerbatIOns of asthma are acute or subacute epIsodes of
progressIvely worsenmg shortness of breath, cough, wheezmg, chest tightness, or some
combmation of these symptoms Although vITal resprratory tract InfectIons are common
asthma tnggers, especIally m young chIldren (NatIOnal Institutes of Health, 1991), symptoms
such as wheezmg may occur wIthout an Infectious cause
Chromc bronchItis IS de:fmed m adults as a chmcal dIsorder charactenzed by exceSSIve
mucous secretIon m the bronchIal tube WIth an assocIated chromc productive cough on most
days for a mInImum of 3 mo of the year for not less than 2 succeSSIve years (Amencan
ThoracIc SocIety, 1962) The dIagnosIs can only be made after excludmg other dIsorders
WIth SImIlar symptoms In contrast, Morgan and TaussIg (1984) state that a clear de:fmItIOn
and etIOlogy of chromc bronchItis m chIldhood have not yet been descnbed They
charactenze chromc bronchItis ill chIldren as a symptom complex consIstIng of a chromc or
recurrent "wet" cough, mcreased phlegm productIOn, and wheezmg that may be assocIated
WIth eVIdence of arrway mflammatIon A rational appIOach would be to VIew It as a chmcal
presentatIOn of chromc or recurrent arrway dIsease
Symptoms and :fmdIngs observed m chIldren WIth phySICIan-dIagnosed chrome
bronchItis commonly mclude recurrent resprratory mfectIons and wheezmg, WIth chromc
14-7
phlegm productlOn and chromc cough bemg less prevalent (Burrows and LebOWItz, 1975)
Schenker et al (1983) report a prevalence of approxnnately 22/100 for M D -dIagnosed
bronchitis m ch11dren 5 to 9 years of age Resprratory syncytial VlnlS (RSV) and
paramfluenza VlnlS are Isolated m cases of bronchItls (Chanock and Parrott, 1965), but
symptoms of bronchitis may occur WIthout an mfectlOus cause
Lower resprratory illnesses are generally classIfied mto one of four chmcal syndromes
croup (laryngotracheobronchItls), tracheobronchitis, bronchIohtls, and pneumoma (Glezen
and Denny, 1973, Wnght et al , 1989, McConnochIe et al ,1988) In a study m Tucson,
the most common diagnOSIS durmg the fIrst year of hfe was bronchIohtls, which accounts for
60% of al110wer resprratory illness (Wnght et al ,1989) The most common SIgns and
symptoms aSSOCIated WIth lower resprratory illnesses were wet cough (85%), wheeze (77%),
tachypnea (48%), fever (54%), and croupy cough (38%) as reported by Wnght et al (1989)
A few mfectIous agents are presumed to cause the ma]onty of ch11dhood lower resprratory
illness Bactena are not thought to be common causes of lower respITatory illness m
nonhospitalized mfants m the Umted States (Wnght et al ,1989) Seventy-fIve percent of
the Isolated ffilcrobes were one of four types RSV, paramfluenza VlnlS types 1 and 3, and
Mycoplasma pneumomae (Glezen and Denny, 1973, McConnochIe et al ,1988) Resprratory
syncytial VlnlS IS partIcularly hkely to cause lower resprratory illness durmg the fITst 2 years
of hfe. More than half of all illnesses diagnosed as bronchIohtIs, for which an agent was
IdentIfied, were posiuve for RSV (Wnght et al ,1989) Wnght et al (1989) noted that
studIes that rely on parental reports of symptoms may underesumate illness AskIng parents
about illnesses at the end of the fITst year of hfe revealed that one-thrrd of them failed to
report illnesses diagnosed by ped1atncians and evaluated by study nurses
Vanous stuilles of lower resprratory illness have reported rates based on VISIts to
phySIcians rangmg from about 20 to 30 illnesses/lOO ch11dren m the fITst year of hfe (Glezen
and Denny, 1973, Wnght et al , 1989, Denny and Clyde, 1986, McConnochIe et al , 1988)
Glezen and Denny (1973) reported that the rate for lower resprratory illnesses ranged from
24/100 person-years m mfants under 1 year of age and decreased steadily each year through
the preschool years, tendmg to level off m school ch11dren (age 12 to 14 years) to about
7 5 illnesses/lOO person-years Several factors affect the rate of lower resprratory illness m
children, mcludmg age, lffimunoiogic status, pnor VITal mfectlOns, level of health, SES
14-8
(Chanock et al , 1989), day care attendance, home dampness and hUll11dIty, envrronmental
tobacco smoke, N02 , partIculate matter, and other pollutants Rates also depend on method
of illness ascertaInment StudIes m the Umted States (Wnght et al , 1989, Denny and Clyde,
1986, McConnochIe et al , 1988) mdicated that the overall pattern and mCIdence of lower
resprratory illness IS conSIstent m dIfferent geographIc legIOns dunng the two decades
covered by the studIes, suggestmg that diagnosIs and mfectious agents have changed httle m
that tIme penod In summary, lower resprratory illness remams one of the major causes of
chIldhood morbIdity m the Umted States (McConnochIe et ai, 1988)
A large number of factors affect the susceptibility of children and, thus, the subsequent
occurrence of resprratory symptoms SpeCIal attentIOn IS drrected at vrral lower resprratory
morbIdIty m the fIrst 2 years of hie, because the hIghest mCIdence and rate of hospItalIzation
for lower respIratory illnesses are found at thIs time and because of the nsk of chromc
sequelae from lower resprratory morbIdIty m early childhood There IS an Immunologic
basIs for mcreased susceptibility of the neonate to mfectIOn (Wilson, 1986) Full-term
mfants are Immune-deficIent (as compared wIth older cluldren and adults) m essentially all
measured ImmUnologIc parameters due to lack of prior exposure and subsequent development
of Immumty, thus rendenng them susceptible to senous mfectIOns (Bernbaum et al , 1984,
Kibler et al , 1986)
The occurrence of lower reSpIratory morbIdIty m early childhood may be associated
WIth Imparred lung functIOn and growth that appears to perSIst throug~ adolescence Early
msult from VIrUS mfectIOn m the lower respIratory tract may be an essential element m the
development of chromc and perSIstent lung functIOn ImpaIrment (Glezen, 1989, Gold et al ,
1989) Bntten et al (1987) reported that the extensIOn to age 36 of the earher work of
BMRC's National Survey of Health and Development of the 1946 Great Bntam Cohort
mdicates that there can be httle doubt m thIs cohort of the eXistence of an aSSOCiatIOn
between childhood resprratory expenence and adult resprratory morbIdIty They comment
that therr study, coupled WIth eVIdence from Colley et al (1976), lends support to the model
of acqurred lung damage pred1sposmg mdividuals to mcreased resprratory dIseases dunng
adulthood, WIth genetIC susceptibility to respIratory dIsease bemg less of a factor Denny
and Clyde (1986) stated that It IS now recognIZed that lIUectIOns, reactive arrways, and
Inhaled pollutants (mostly CIgarette smoke) are the mos1 Important nsk factors m the
14-9
development of chromc lung dIsease Thus, factors such as the presence of N02 (which
mcreases the nsk for resprratory symptoms and related resprratory morbIdIty) are Important
because of aSSOCIated pubhc health concern wIth regard to both the Immediate symptoms
produced and the longer term potential for mcreases m the development of chromc lung
dIsease
The rest of this sectIOn exammes epIdemIOlogIcal studies relatmg N0 2 exposures to
resprratory illness The resprratory illness studIes ill this sectIOn are dIVIded mto mdoor and
outdoor subsections
14.3.1 Indoor Studies

In this section, studies that meet cntena (see SectIOn 14 6) for use ill a quantitative
analySIS are presented. StudIes conducted by Meha and colleagues m Great Bntam are
discussed fIrst Next, two large studIes conducted ill SIX Umted States CIties are exammed
Then, other quantitatIve studIes are presented that were conducted by dIfferent authors m
vanous locations These are followed by a quantItative study of Infants m Albuquerque,
NM Fmally, a diSCUSSIOn of selective studIes that proVIde useful Information concernmg
N02 relatIOnships to resprratory illness IS presented
Many mdoor studIes report the results of theIr analyses as odds ratios The odds ratio
IS dermed as [Pt (1 - Pc)]/[Pc (1 - pJ], where Pt IS the probability of dIsease m the exposed
group, and Pc IS the probability of dIsease m the control group For small probabilities, the
odds ratIO approaches the relative nsk, plpc Odds ratIOS or relatIve nsks greater than one
suggest an adverse effect of the exposure Although the odds ratio IS more dIfficult to
mterpret than the relatIve nsk, It IS a natural measure resultmg from many epIdemIOlogIcal
analyses
14.3.1.1 United Kingdom Studies

Results of several BntIsh studIes have been reported by Meha et al (1977, 1978, 1979,
1980, 1982, 1985, 1988), Goldstem et al (1979, 1981), and Florey et al (1979, 1982)
Aspects of these studIes were reVIewed preVIOusly (U S EnVIronmental ProtectIOn Agency,
1982a), but theIr Importance requIres a further, more complete dISCUSSIon of them here
14-10
The mItIal study, reported by Mella et al (1977), was based on a survey of 5,658
clnldren (excludes asthmatIcs, thus 100 less than the number reported), aged 6 to 11 years,
WIth suffiCIent questIOnnarre mformatIOn m 28 randomly selected areas of England and
Scotland The study mcluded a self-adm1ll1stered questwnnarre (completed by a parent) that
obtamed mformatIOn on the presence of mornmg cough day or mght cough, colds gomg to
chest, chest sounds of wheezmg or wmsthng, and attacks of bronchItIs The questIonnarre
was dIstnbuted m 1973 and asked about symptoms dunng the preVIOUS 12 mo Colds gomg
to the chest accounted for the ma]onty of the symptoms reported InformatIOn about cookmg
fuel (gas or electnc), age, gender, and SOCIal class (manual versus nonmanuallabor) was
obtamed, but InformatIOn on parental smokmg was not Meha et al (1977) note that,
although they could not mclude famlly smokmg habIts m the analYSIS, the known relatIOn
between smokmg and SOCIal class (Tobacco Research Councll, 1976) allowed them to aVOId
at least some of the potentIal bIaS from thIs source It seemed unhke1y to the authors that
WIthm the SOCIal class groups there was a hIgher prevalence of smokmg m homes where gas
was used for cookmg No measurements of N02 , eIther mdoors or outdoors, were gIven
The authors presented the results m the form of a contmgency table for nonasthmatIcs
WIth complete covanate mfonnatIOn Table 14-11S a summary of that data for nonasthmatIc
clnldren The authors mdIcated that there was a trend for mcreased symptoms m homes WIth
gas stoves, but the mcrease was only sIgmficant fm grr1s m urban areas The authors gave
no measures of mcreased nsk
Hasselblad et al (1992) reanalyzed the data m Table 14-1 usmg a multIple lOgIStIC
model, WIth the results as shown m Table 14-2 Because It had been suggested that gender
had an effect on the relatIOnshIp WIth "gas cooker", mteractIOn terms for gender were
mcluded m the ongmal model None of these proved to be sIgmficant, and they were
subsequently dropped from the model When separate terms for each gender were used for
the effect of "gas cooker", an estImated odds ratIo of 1 25 was obtamed for boys and an
odds ratIo of 1 39 was obtamed for girls The combmed odds ratIo for both genders was
1 31 (95 % confidence hmItS of 1 16 and 1 48) and was statIstIcally sIgmficant (p < 0 0001)
The other mam effects of gender, SES, and age were ali statIstIcally sIgmficant ThIs
reanalySIS suggests that gas stove use m thIs study IS assocIated WIth an estImated 31 %
mcrease m the odds for clnldren of havmg respIratory lllness symptoms
14-11
TABLE 14-1. RESPIRATORY SYMPTOM RATES OF UNITED KINGDOM
CHILDREN BY GENDER, SOCIAL CLASS, AND COOKING TYPEa
Social Classes I-ill Social Classes ill-V
(Nonmanual) (Manual)
Age < 8 years Electnc Gas Electnc Gas
Boys 256% 261% 299% 375%
(203) (88) (375) (309)
Girls 222% 304% 31 8% 335%
(171) (112) (393) (337)
Age > 8 years
Boys 208% 233% 250% 290%
(365) (189) (675) (654)
Girls 18 1% 192% 178% 278%
(303) (187) (674) (623)
8Numbers m parentheses refer to number of subjects
Source Mella et al (1977)
TABLE 14-2. HASSELBLAD ET AL. (1992) MULTIPLE LOGISTIC ANALYSIS

OF DATA FROM THE MELIA ET AL. (1977) STUDY
RegresslOn Standard Ltkehhood RatIO
Factora COeffiCIent Error Cln-Square p-Value
SES and age
by gender mteractlOns (2 d f ) 246 02922
Gas by gender mteractlOn (1 d f ) 072 03953
Gas cooker 02733 00616 1978 <00001
Gender (female) -0 1531 00612 629 00121
SES (manual) 02730 00702 1548 00001
Age « 8 years) 03864 00626 3777 <0 0001
8SES = SOCIoeconOmIC status

df = Degrees of freedom
14-12
Meha et al (1979) report further results of the natIOnal survey covenng a new cohort
of 4,827 boys and gIrls, aged 5 to 10 years, from 27 randomly selected areas that were
exammed m 1977 The 1977 study collected mformatlOn on the number of smokers m the
home In the 1977 cross-sectIOnal study, only the prevalence of day or mght cough m boys
(p :::::: 0 02) and colds gomg to the chest m girls (p < 0 05) were found to be sIgmficantly
hIgher m chIldren from homes where gas was used for cookmg compared wIth chIldren from
homes where electncity was used Groupmg responses accordmg to the SIX respIratory
questIOns mto (a) none or (b) one or more symptoms or dIseases yIelded a prevalence hIgher
m chIldren from homes where gas was used for cookmg than m those from homes where
electncity was used (p :::::: 001 m boys, p = 007 m guls) The results of thIs analysIs are
presented m Table 14-3 The effects of gender, SOCIal class, use of pilot hghts, and number
of smokers m the house were exammed
The reanalysIs of the data m Table 14-3 by Hasselblad et al (1992), applymg a
multiple lOgIstIC model, IS gIven m Table 14-4 ThIs model contamed the same terms as the
analySIS m Table 14-2 As m the prevIOUS analySIS, none of the mteractIOn terms proved to
be sIgmficant, and they were subsequently dropped from the model When separate terms
for each gender were used for the effect of "gas cooker", an estunated odds ratIo of 1 29 was
obtamed for boys and an odds ratio of 1 19 was obtamed for gIrls The combmed odds ratio
for both genders was 1 24 (95 % confidence hmitS of 1 09 and 1 42) ThIs effect was
statIstIcally sIgmficant (p < 00002) The other mam effects of-gender, SES, and age were
all statistically sIgmficant ThIs reanalysis suggests that gas stove use m thIs study IS
associated wIth an estunated 24 % mcrease m the odds of havmg symptoms
ThIs study was followed by a study m 1978 of 808 schoolchIldren (Meha et al , 1980),
aged 6 to 7 years, m Middiesborough, an urban area of northern England RespIratory
illness was defmed m the same manner as m the prevIOUS study Weekly mdoor N02
measurements were collected from 66 % of the homes, wIth the remammg 34 % refusmg to
partIcIpate NItrogen dIOXide was measured weekly by tnethanolamme dilfusIOn tubes
(palmes tubes) attached to walls m the kitchen area and m the children's bedrooms
In homes WIth gas stoves, weekly levels of N02 m kitchens ranged from 0 005 to 0 317 ppm
(10 to 596 p,g/m3 ) WIth a mean of 0 112 ppm (211 p,g/m3), and levels m bedrooms ranged
3 3
from 0 004 to 0 169 ppm (8 to 318 p,g/m ) WIth a mean of 0031 ppm (56 p,g/m ) In homes
14-13
TABLE 14-3. UNADJUSTED RATES OF ONE OR MORE RESPIRATORY
SYMPTOMS AMONG UNITED KINGDOM CHILDREN BY GENDER,
SOCIAL CLASS, AND COOKING TYPE3
SOCIal Classes I-ill SOCIal Classes III-V
(Nonmanual) (Manual)
Age < 8 years Electnc Gas Electnc Gas
Boys 274% 31 7% 328% 367%
(277) (145) (485) (313)
Girls 244% 276% 278% 363%
(291) (134) (497) (336)
Age ~ 8 years
Boys 192% 283% 236% 269%
(286) (113) (501) (338)
Girls 148% 186% 215% 185%
(243) (118) (437) (313)
tlNumbers m parentheses refer to number of subjects
Source Mella et al (1979)
TABLE 14-4. HASSELBLAD ET AL. (1992) MULTIPLE LOGISTIC ANALYSIS OF

DATA FROM MELIA ET AL. (1979) STUDY
RegreSSIOn Standard L:tkebhood Ratio
a
Factor CoeffiCIent Error Cln-Square p-Value
SES and Age
by gender mteractlons (2 d f ) 111 05749
Gas by gender mteractIOn (1 d f ) 035 05566
Gas cooker 02183 00674 10 43 00012
Gender (female) -0 1970 00664 8 81 00030
SES (manual) 02225 00764 860 00034
Age « 8 years) 05253 00675 61 48 <00001
tlSES = SOCIoeconOmIC status

d f = Degrees of freedom
14-14
wIth electnc stoves, weekly levels of N02 m kItchens ranged from 0 006 to 0 188 ppm
(11 to 353 p.,g/m3 ) wIth a mean of 0 018 ppm (34 p.,g/m3 ), and levels m bedrooms ranged
from 0 003 to 0 037 ppm (6 to 70 p.,g/m3 ) wIth a mean of 0014 ppm (26 p.,g/m3 ) Outdoor
levels of N02 were determmed usmg dIffusIOn tubes systematically located throughout the
area, and the weekly average ranged from 0 014 to 0 024 ppm (26 to 45 p.,g/m3 )
One analysIs by the authors was restncted to those 103 chIldren m homes where gas
stoves were present and where bedroom N02 exposure was measured, the data are shown m
Table 14-5 A lmear regreSSIOn model was fit to the lOgIStiC transformation of the symptom
or illness rates CookIng fuel was found to be assocIated wIth respIratory illness,
mdependent of SOCIal class, age, gender, or presence of a smoker m the house (p = 006)
However, when SOCial class was excluded from the regH~ssIon, the aSSOCiatIOn was weaker
(p = 0 11) For the 6- to 7-year-01d chIldren hvmg m gas stove homes, there appeared to
be an mcrease of respIratory illness WIth mcreasmg leveJls of N02 m theIr bedrooms
(p = 0 10), but no sIgmficant relatIOnslup was found between respIratory symptoms m those
chIldren or therr sIblmgs or parents and levels of N02 In kItchens
TABLE 14-5. UNADJUSTED RATES OF ONE: OR MORE RESPIRATORY

SYMPTOMS AMONG UNITED KINGDOM BOYS AND GIRLS BY
BEDROOM LEVELS OF NITROGEN DIOXIDE3
Bedroom Levels of N02 (ppm)
<0020 0020-0039 >0039 Total
Boys 435% 579% 692% 545%
(23) (19) (13) (55)
GIrls 440% 600% 750% 542%
(25) (15) (8) (48)
TOTAL 437% 588% 714% 544%
(48) (34) (21) (103)
aNumbers m parentheses refer to number of subjects
Source Mella et a1 (1980)
14-15
Because no concentrallon-response estunates were gIven by the authors, a multiple
lOgIStiC model was fitted by Hasselblad et al (1992) to the data m Table 14-5, usmg a lmear
slope for NO z and separate intercepts for boys and gIrls NItrogen dIoXIde levels for the
groups were estunated by fittmg a lognormal dIstnbullon to the grouped NO z data, and the
average exposures Withm each mterval were estunated (see Hasselblad et al ,1980) The
estimated lOgistic regressIon coefficIent for NO z (m p.,g/m3 ) was 0 015 WIth a standard error
of 0 007 The hkehhood ratIO test for NO z yIelded a chI-square of 4 94 WIth one degree of
freedom, with a correspondIng p-value of 0 03
The study was repeated m January to March of 1980 by Meha et al (1982a) ThIs
tune, chIldren aged 5 to 6 years were sampled from the same neIghborhood as the prevIOUS
study, but only families WIth gas stoves were recrUited EnVIronmental measurements were
made and covanate data were collected m a manner sltnilar to the preVIOUS study (Meha
et al ,1980) Measurements of NO z were avaIlable for 54 % of the homes The unadjusted
rates of one or more symptoms by gender and exposure level are shown m Table 14-6 The
authors concluded that II no relation was found between the prevalence of respIratory
illness and levels of NO z II The reanalySIS by Hasselblad et al (1992) of the data m
Table 14-6 was made usmg a multiple IOgIsllc model sltnilar to the one used for the preVIOUS
study (Meha et al ,1980) The model mcluded a lmear slope for NO z and separate
intercepts for boys and gIrls NItrogen dIOXIde levels for the groups were estltnated by
fittmg a lognormal dIstnbullon to the grouped bedroom NO z data The estltnated IOgIsllc
regresSIon coeffiCIent for NO z (m p.,g/m3) was 0 0037 WIth a standard error of 0 0052 The
hkehhood ratio test for the effect of NO z gave a chI-square of 051 WIth one degree of
freedom (p = 0.48)
Meha et al (1982b) report an aSSOCiatIOn between the prevalence of respIratory
symptoms m chIldren and relative hutnldity m bedrooms Florey et al (1979) had
hypotheSIZed that the respIratory health effects seen at the observed NOzlevels may be a
proxy for some other factor such as temperature or humIdIty Mter further study, these
researchers (Meha et al , 1982b) conclude that thIs study dId not support the hypotheSIS that
high hUtnldity or low temperature are associated WIth levels of NOz Withm homes WIth a gas
cooker and state that these two enVIronmental vanables are thus unhkely to explam theIr
ongmal observation of an aSSOCiation between respIratory illness among pnrnary school
14-16
TABLE 14-6. UNADJUSTED RATES OF ONE OR MORE RESPIRATORY
SYl\!lPTOMS AMONG UNITED KINGDOM BOYS AND GIRLS BY
BEDROOM LEVELS OF NITROGEN DIOXIDEa
Bedroom levels of N0 2 (ppm)
< 0 020 0 020-0 039 > 0 039 Total
Boys 564% 676% 720% 644%
(39) (37) (25) (101)
GIrls 600% 41 0% 522% 494%
(25) (39) (23) (87)
aNumbers m parentheses refer to number of subjects
Source MelIa et al (1982a)
chtldren and N02 Also, Meha et al (1982b) note that, contrary to theIr ongmal hypothesIs,
homes wIth an electnc cooker tended to have shghtly hlgher relative humIdIty than homes
wIth a gas cooker Arundel et al (1986) comment m general that the maJonty of health
effects related to relatIve humIdIty would be milllffilZed by mamtammg mdoor levels between
40 and 60 % and that thIs would requIre humIdIficatIOn dunng wmter because mdoor relative
humIdItIes below 40 % are wIdespread m wmter
Meha et al (1983) mvesngated the aSSOCiatIOn belween gas cooking m the home and
resprratory illness m a study of 390 Infants born between 1975 and 1978 When the child
reached 1 year of age, the mother was mterviewed by a tramed field worker to complete a
questionnaire The mother was asked whether the chtlcl usually expenenced mommg cough,
day or mght cough, wheeze, or colds gomg to the chest, and whether the chtld had
expenenced bronchItis, asthma, or pneumoma dunng the past 12 mo No relatIOnshIp was
found between type of fuel used for cooking at home and the prevalence of respIratory
symptoms and dIseases recalled by the mother after allowmg for the effects of gender, SOCIal
class, and parental smoking The authors reported prevalence rates for chtldren havmg at
least one symptom by gas stove use and gender The combmed odds ratIO for presence of
symptoms by gas stove use was 0 63 WIth 95 % confidence mterval of 0 36 to I 10
Meha et al (1988) studIed factors affectmg resprratory morbIdIty m 1,964 pnmary
school chtldren hvmg m 20 Inner CIty areas of England m 1983 as part of a natIOnal study of
health and growth Data on age, gender, resprratory Illness, cooking fuels, mother's
14-17
educatlon, and sIZe of family were obtaIned by questionnaIre SmokIng was not StudIed
The same resprratory questlons were asked as m the preVIOUS studIes Meha et al (1990)
reported mdoor levels of N02 associated wIth gas stoves m Inner CIty areas of England m
1987. The mean weekly N0 2 levei measured m 22 bedrooms of homes wIth gas stoves was
0.0241 ± 0013 ppm The mean weekly N02 levei measured m four bedrooms of homes
without gas stoves was 00207 + 00118 ppm Meha et al (1988) reported a relative nsk of
1.06 (95% confidence mterval of 094 to 1 17) for one or more resprratory condItIOns
relatIve to nsk m whIte boys aged 8 years wIth mothers educated up to secondary school
level, one child m famI1y, two-parent family, and no gas or kerosene fuel used m the home
14.3.1.2 United States Six Cities Studies

Several authors (Spengler et al , 1979, SpelZer et al , 1980, Ferns et al , 1983,
Spengler et al , 1986, Berkey et al , 1986, Ware et al , 1984, Quackenboss et al , 1986,
Dockery et al , 1989a, Neas et al , 1990, Neas et al , 1991) have reported on two cohorts of
children studIed m SIX dIfferent U S CIties (Watertown, MA, KIngston and Hamman, TN,
southeast St LoUIs, MO, Steubenville, OH, Portage, WI, and Topeka, KS) The SIX CIties
were selected to represent a range of aIr quahty based on theIr hIstonc levels of outdoor
pollutIOn In each commumty durmg the penod 1974 through 1977, approXImately
1,000 frrst- and second-grade schoolchildren were enrolled m the frrst year and an addItional
500 frrst graders were enrolled durmg the followmg year (Ferns et al ,1979) Families
reported the number of persons hvmg m the home and therr smoking habIts, parental
occupatIOn and educatIOnal background, and the fuels used for cookIng and heatmg Outdoor
pollutIon was measured at fIxed SItes m the commumtIes as well as at selected households
Indoor pollution, mc1udmg N02 , was measured m several rooms of selected households
Spengler et al (1979) show that a stnkmg dIfference m N02 levels eXists between homes
With gas versus electnc cookIng Later results of momtormg m Portage, WI, venfy the fact
that the presence of a gas stove contnbutes to the mdoor N02 levels Table 14-7 IS taken
from Quackenboss et al (1986) based on data collected m 1981 and 1982 These results
clearly show that gas stoves mcrease mdoor concentratIOns and therefore also mcrease the
personal exposures of children
14-18
TABLE 14-7. NITROGEN DIOXIDE CONCENTRATIONS (ppm) BY SEASON
AND STOVE TYPE IN PORTAGE, WISCONSIN
Indoor Outdoor Personal
Std Std Std
Season Stove Mean Dev Mean Dev Mean Dev
Summer Gas 0016 0006 0006 0003 0014 0004
Electnc 0007 0003 0008 0003 0009 0003
Wmter Gas 0027 0013 0008 0003 0023 0009
Electnc 0005 0003 0009 0003 0008 0003
Source Quackenboss et a1 (1986)
SpeIZer et al (1980) fIrst reported on results from the SIX cIties studIes, based on
evaluations of 8,120 chIldren (aged 6 to 10 years) who had been followed for 1 to 3 years
Health end pomts were measured by a standard resprratory questIOnnaIre, completed by the
parents of the chIldren The authors used log-lmear models to estImate the effect of current
gas stoves versus electnc stoves on the rates of senous 1esprratory illness before age 2 The
analysIs gave an odds ratIO of 1 12 (95 % confIdence llmts of 1 00 and 1 26) for gas stove
use The results were adjusted for the presence of adult smokers, presence of arr
condItIonmg, and SES of the family
Ware et al (1984) later reported results from a larger cohort of 10,160 whIte chIldren,
aged 6 to 9 years, m the same SIX commumtIes over a longer penod (1974 to 1979)
Drrectly standardIZed rates of reported illnesses and symptoms dId not show any consIstent
pattern of mcreased nsk for chIldren from homes wIth gas stoves LogIStiC regreSSIOn
analyses controlling for age, gender, CIty, and maternal smokIng level gave estImated odds
ratIOS for the effect of gas stoves rangmg from 093 to 1 07 for bronchItis, chromc cough,
persIstent wheeze, lower respIratory illness mdex, and illness for the last year The lower
resprratory illness mdex mdIcated the presence of bronclutIs, restnctIOn of activIty due to
chest illness, or chromc cough dunng the past year None of these symptom-specIfIc odds
ratIOS were statiStically dIfferent from 1 Oilly two odds ratios approached statistical
sIgmftcance (1) hIstory of bronchItis (odds ratio = 0 86, 95% confIdence mterval 0 74 to
1 00) and (2) respIratory illness before age 2 (odds ratIO = 1 13, 95% confidence
mterval 0 99 to 1 28) When the odds ratio for resprratory illness before age 2 was adjusted
14-19
for parental education, the odds ratio was 1 11 wIth 95 % confidence htmts of 0 97 and 1 27
(p = 0 14). Thus, the study suggests an mcrease of about 11 % m respIratory illness before
age 2 years, whIch is nearly the same as that reported by SpelZer et al (1980), although the
increase was not statistically sIgmficant at the p < 0 05 level The end pomt m the Ware
et al (1984) study most SImilar to that of the Meha studIes was the lower respIratory illness
index. The authors gave the unadjusted prevalence, and from those data, an estImated odds
ratio of I 08 WIth 95 % confidence hmitS of 0 97 and I 19 was calculated by Hasselblad
et al (1992) ThIs rate was not adjusted for other covanates The analysIs of Ware et al
(1984) on the other end pomts found that the effect of adjustment for covanates was
mInimal
Durmg the penod 1983 through 1986, a new cohort of approXImately 1,000 second-
through fIfth-grade schoolchIldren m each commumty were enrolled and gIven an mitial
symptom questIonnarre Dockery et al (1989a) evaluated reported respIratory symptoms on
a subsequent symptom questIOnnarre (second annual) for 5,338 whIte chIldren who were aged
7 to 11 years at the tIme of enrollment The end pomts of chromc cough, bronchItis,
restriction of actiVIty due to chest illness, and perSIstent wheeze were not found to be
associated WIth gas stove use m the home But the health end pomt of doctor-diagnosed
respIratory illness pnor to age 2, yIelded an odds ratIO of 1 15 WIth 95 % confidence hmitS of
o 96 and 1 37 The odds ratIO for chromc cough was 1 15 WIth 95 % confidence hmitS of
o 89 and 1.91 and was adjusted for age, sex, parental education, CIty of reSIdence, and use
of unvented kerosene heaters
Neas et al (1990, 1991) StudIed a stratIfied one-thrrd random sample of the chIldren
that were part of the Dockery et al (1989a) analySIS The sample was restncted to
1,286 whIte chIldren 7 to 11 years of age at enrollment havmg complete covanate
information and at least one vahd mdoor measurement of both NOz and respIrable partIcles
Methods for measurmg mdoor pollutants were descnbed by Spengler et al (1986) Indoor
pollutants were measured m each chIld's home for 2 weeks durmg the heatmg season and
2 weeks durmg the coohng season NItrogen dIOXide was measured by Palmes paSSIve
diffuSIOn tubes at three locatIOns kitchen, actiVIty room, and the chIld's bedroom
Brunekreef et al (1989) exammed chIldren StudIed m the SIX CItIes studIes and
concluded that home dampness IS a strong predIctor of respIratory symptoms among 8- to
14-20
12-year-old cluldren Dampness was determmed by response to these three questIOns on a
questIOnnarre (1) Does water ever collect on the basement floor? (2) Has there ever been
water damage to the bmldmg? and (3) Has there ever been mold or mildew on any surface
mSide the home? Brunekreef et al (1989) comment that relative humidity of the mdoor arr
is less lillportant for the growth of mites and fungi than the dampness of specIfic surfaces or
parts of the buildmg structure Dampness illd not confound the gas stove (Dockery et al ,
1989a) nor the N02 aSSOCiation (Neas et al , 1991)
The analyses by Neas et a1 (1990, 1991) were based on the fmal symptom
questionnarre (thrrd annual), which was completed by parents followmg the mdoor
measurements The questIOnnarre reported symptoms durmg the prevIOus year, mc1udmg
attacks of shortness of breath With wheeze, persistent wheeze, chromc cough, chromc
phlegm, and bronchitis The authors used a multiple logistic model With separate City
mtercepts, mdicator vanables for gender and age, parental history of chromc obstructive
pulmonary disease, parental history of asthma, parental educatIOn, and smgle parent family
3
status. The mcreases m symptoms were estlillated for an additIOnal 0015 ppm (28 3 p,g/m )
N02 exposure Table 14-8 shows the odds ratios for the five separate symptoms associated
With the mcrease m N02 exposure All of these odds ratios are conSistent With the SiZe of
effect seen m the other analyses of the SIX City data and the analyses of the Bntish studies
TABLE 14-8. ODDS RATIOS AND 95% CONFIDENCE INTERVALS FOR THE
EFFECT OF AN ADDITIONAL 0.015 ppm NITROGEN DIOXIDE ON THE
SYMPTOM PREVALENCE
Symptom Odds Ratio 95 % Confidence Interval
Shortness of breath 1 23 093 to 1 61
PerSistent wheeze 1 16 089 to 1 52
Chromc cough 118 087 to 1 60
Chromc phlegm 125 094 to 1 66
Bronchitis 105 075 to 1 47
Source Neas et al (1991)
14-21
Neas et al (1990, 1991) defmed a combmed symptom measure, wluch was the
presence of any of the above-noted symptoms A multiple lOgIStiC regressIOn of tlus
combmed lower resprratory symptom measure, eqUIvalent to the smgle response regressIOns,
gave an estimated odds ratio of 1 40 WIth a 95 % confidence mterval of 1 14 to 1 72 The
odds ratio for the combmed symptom score was shghtly lugher than m other studIes, but IS
not inconsistent WIth those results The reference category for the symptom-specIfic odds
ratios included some cluldren WIth the other lower resprratory symptoms, whereas the
children m the reference category for combmed lower resprratory symptoms were free of any
of these symptoms When spht by gender, the odds ratIO was lugher m grrls, and, when
split by smoking versus nonsmokmg homes, the odds ratio was lugher m smokmg homes
When separate lOgistic analyses were performed for each commumty, the adjusted odds ratIOS
ranged from 1 26 for Topeka, KS, to 1 86 for Portage, WI When the cohort was restncted
to the 495 children ill homes WIth a gas stove, the adjusted odds ratio was 1 37 WIth a 95 %
confidence mterval of 1 02 to 1 84 Table 14-9 proVIdes the adjusted odds ratios for
combmed lower resprratory symptoms across ordered N02 exposure categones The
associanon IS statistically sIgmficant for the upper exposure category, and the lower exposure
categories are conSIstent WIth a hnear dose-response relatIOnslup between N0 2 and lower
resprratory symptoms m cluldren
TABLE 14-9. ODDS RATIOS AND 95% CONFIDENCE INTERVALS FOR

THE EFFECT OF ORDERED NITROGEN DIOXIDE EXPOSURES
ON THE PREVALENCE OF LOWER RESPIRATORY SYMPTOMS
N02 Level (ppm)
Number of 95%
Range Mean Cluldren Odds Ratio Confidence Interval
o to 0 0049 00037 263 100
0.0050 to 0.0099 00073 360 106 071 to 1 58
0.0100 to 0 0199 00144 317 1 36 089 to 2 08
o 0200 to 0 0782 00310 346 1 65 1 03 to 263
14-22
Neas et al (1992) reported that the estunated effect of exposure to an addItional
o 015 ppm (28 3 p,g/m3 ) NOz on lower respIratory symptoms was conSIstent across the
seasons and samplmg locatIOns Table 14-10 proVIdes 1he odds ratios and 95 % confidence
mtervals for thIs aSSOCiatIon by season and sampler locatIOn
The NOz levels measured by
the actiVIty room and bedroom sampler were more strongly assocIated wIth lower respIratory
symptoms than those m the latchen The NOz measurements m the latchen were suggested
to be mfluenced more by the tranSIent peak levels aSSOCIated WIth meal preparation on gas
stoves, whereas the other samplmg locatIOns were more reflectIve of the chIld's long-term
average exposures to NOz m the home Spengler et al (1992) ill<hcated that chIldren spend
relatively httle tune (0 5 hours per day) m the latchen when the range IS operatmg
TABLE 14-10. ODDS RATIOS AND 95% CONFlDENCE INTERVALS FOR THE
EFFECT OF AN ADDITIONAL 0.015 ppm NITROGEN DIOXIDE
ON THE PREVALENCE OF LOWER RESPIRATORY
SYMPTOMS BY SAMPLING LOCATION AND SEASON
Mean DIfference 95 % Confidence
Sampler LocatIOn and Season Gas vs Electnc Odds Ratio Interval
Household annual average 0016 ppm 140 1 14 to 1 72
Household wmter average 0018 ppm 1 16 1 04 to 1 29
Household summer average 0014 ppm 146 1 13 to 1 89
KItchen annual average 0022 ppm 1 23 105to144
ACtiVIty room annual average 0014 ppm 150 1 20 to 1 87
Bedroom annual average 0013 ppm 147 1 17 to 1 85
14.3.1.3 Iowa Study

Ekwo et al (1983) surveyed 1,355 chIldren 6 to 12 years of age for respIratory
symptoms and lung functIOn m the Iowa CIty School DIstnct Parents of the school chIldren
completed a questIonnarre that was a modIficatIOn of the questionnaire developed by the
Amencan ThoraCIC SOCIety The chIldren were a random sample from those families whose
parents had completed the questIOnnarre EIght dIfferent measures of respIratory illness were
14-23
reported by the authors, but only two of those were snmlar to the end pomts used m the
BntIsh stuches and the SIX CIty stuches Parental smokIng was also measured and used as a
covanate m the analyses The results of the analyses are presented m Table 14-11, and are
based on 1,138 chIldren No measurements of N02 exposure, eIther mSIde or outside the
homes, were reported
TABLE 14-11. ANALYSIS OF IOWA CITY SCHOOL CHILDREN RESPIRATORY

SYl\1PTOMS BY GAS STOVE TYPE AND PARENTAL SMOKING
HospItabzatlon for Chest Chest CongestIon and
illness Before Age Two Phlegm WIth Colds
Factor Odds RatiO SEa Odds RatiO SEa
Gas stove use 246 0684 11 0 188
Smoking effects
Father alone smokes 23 b 0856 10 0213
Mother alone smokes 29b 1 239 13 0363
Both smoke 16 0859 12 0383
SSE = Standard error of the odds ratlo

bIndlcates statistical slgmficance at the 0 05 probabIllty level
Source Ekwo et al (1983)
14.3.1.4 Dutch Studies

In the Netherlands, HouthUlJs et al (1987), Brunekreef et al (1987), and DIJkstra et al
(1990) studIed the effect of mdoor factors on respIratory health m chtldren The populatIOn
consisted of 6- to 9-year-old chtldren from 10 pnmary schools m five nonmdustnal
commumtles m the southeast regIOn of the Netherlands ConcentratIOns of N0 2 m the home
and personal exposures to N02 were measured An lffipOrtant N02 emIssion/exposure source
m these homes were geysers, whIch are unvented, gas-fired, hot water sources at the water
tap. Exposure to tobacco smoke was assessed WIth a questlonnalfe that also reported
symptom mfonnatlon The study used Palmes dIffuSIon tubes to measure a smgle weekly
average personal N02 exposure In January and February of 1985, the homes of
593 chtldren who had not moved m the last 4 years were measured for 1 week for N02
14-24
Personal exposure was also estImated from tIme budgets and room momtonng EstImated
and measured exposures to N02 are gIven m Table 14-12
TABLE 14-12. DUTCH STUDY ESTIMATED AND MEASURED PERSONAL

NITROGEN DIOXIDE EXPOSURE (ppm) FOR
A SINGLE WEEKLY AVERAGE3
EstImated Measured
N02 Source Number Anth Mean SD Anth Mean SD
No geyser 370 0012 0004 0012 0005
Vented geyser 112 0015 0005 0016 0006
Unvented geyser 111 0021 0005 0022 0006
aAnth Mean = AnthmetIc mean

S D = Standard devIatIon
Source HouthulJS et a1 (1987)
Three measures of health were obtamed from the questtonnarre, which was a modIfied
form of the World Health Orgarnzation questtonnarre rrhe dIfferent Items were combmed to
create three categones cough, wheeze, and asthma Asthma was defmed as attacks of
shortness of breath wIth wheezmg ill the last year The presence of any of the three
symptoms was used as a combmatIOn vanable The results are presented m Table 14-13
A lOgIStiC regreSSIOn model was used to fit the combma1Ion vanable by Hasselblad et al
(1992) Exposure was estImated by fittmg a lognormal dIstnbution to the grouped data and
the mean exposure values for each group were estimated by a maXImum hkehhood technIque
(Hasselblad et al ,1980) The estImated lOgIStiC regreSSIOn coeffiCIent was -0 002,
correspondmg to an odds ratio of 0 94 for an mcrease of 0 015 ppm (28 3 p,g/m3) m N02 ,
wIth 95 % confidence mterval of 0 70 to 1 27 Thus, the Dutch studIes dId not demonstrate
an mcrease in resprratory dIsease wIth mcreasmg N02 exposure, but the range of uncertamty
IS qUIte large and the rates were not adjusted for covandtes such as parental smokmg and age
of the chIld
Of several potential explanations for the negative findmgs of the study WIth respect to
N02 exposure offered by the authors, one conSIderatIOn was that the power of the study to
14-25
TABLE 14-13. FREQUENCY AND PREVALENCE OF REPORTED
RESPIRATORY SYMPTOMS FOR DIFFERENT CATEGORIES OF MEAN
INDOOR NITROGEN DIOXIDE CONCENTRATIONS IN A POPULATION
OF 775 DUTCH CHILDREN 6 TO 12 YEARS OLD
Frequency and Prevalence m Category of Indoor N02
0-0011 ppm 0011-0021 ppm o 021-0 032 ppm >0032 ppm
Symptom (n = 336) (n = 267) (n = 93) (n = 79)
Cough 16 48% 12 45% 7 75% 3 38%
Wheeze 30 89% 18 67% 3 32% 7 89%
Asthma 22 66% 12 45% 2 22% 3 38%
One or more
symptoms 36 10 7% 24 90% 8 86% 8 10 1%
Source DIJkstra et al (1990)
detect health effects may have been reduced by the smaller sample SIZe of the measured N02
data compared to the categoncal data (e g , geyser versus no geyser) They could not
estimate whether they gamed more prec1s1on by measured N02 than was lost by the
reductlOn m the sample SIZe HouthUl]s et al (1987) report m an earher analys1s that the
presence of an unvented geyser m the latchen 1S associated w1th a hlgher prevalence of
respiratory symptoms and that the dlfference between no geyser present and an unvented
geyser 1S about 0010 ppm
14.3.1.5 Ohio Study

Keller et al (1979a) and M1tchell et al (1975) conducted a 12-mo study of resprratory
illness and pulmonary functlOn m families m Columbus, OH, pnor to 1978 The sample
included 441 families dIv1ded mto two groups those usmg gas and those usmg electnc
coolang Pamc1patmg households were glVen d1anes to record resprratory illnesses for
2-week penods Resprratory illnesses mc1uded colds, sore throat, hoarseness, earache,
phlegm, and cough Only the fIrst mC1dent of illness per person per 2-week penod was
recorded
The study measured N02 exposure by both Jacobs-Hochhe1ser and contmuous
cheml1ummescence methods The electnc stove users averaged 0 020 ppm (38 p,g/m3) N02
14-26
exposure, whereas the gas stove users averaged 0 050 ppm (94 p,g/m3) The paper does not
report WhICh rooms were measured m order to get tms average
The analysIs of mCIdence rates was done usmg the "AutomatIc InteractIon Detector"
No dlfferences were found m any of the illness rates for fathers, mothers, or clnldren
No analyses were done usmg multIple lOgIStIC regressIon or POIsson regreSSIOn (these
methods were relatIvely new at the tIme) No estImates were made that can be conSIdered
comparable to the odds ratIOS reported m the other studIes The authors dId show a bar
graph of all respIratory illness for clnldren under 12 The rates were 389 (per 100 person-
years) for electnc stove use and 377 for gas stove use These rates were not sIgrnficantly
dIfferent even after adjustment for covanates, mc1udmg family SIZe, age, gender, length of
reSIdence, and father's educatIon No mentIon was made of adjustments for smokmg status
or smokmg exposure for the clnldren
In a second, related study (Keller et al , 1979b), 580 persons drawn from households
that partICIpated m the earher study were exammed to confmn the reports and to determme
the frequency dIstnbutIon of reported symptoms among parents and clnldren m gas or
electnc cookmg homes A nurse-epIdemIOlogist exammed selected persons reported ill and
obtamed throat cultures Unfortunately these rates were not adjusted for other covanates
The percent of clnldren havmg respIratory illnesses m homes WIth a gas stove was 85 1 %
(n = 87) versus 88 8 % (n = 89) m homes WIth electnc stoves Although the dlfference IS
not statIstIcally sIgrnficant, these rates gIve an estImated odds ratIO of 0 72 WIth 95 %
confidence mterval of 030 to 1 74 Neas et al (1991) commented that Keller's model
controls for a senes of vanables that speclfy the clnld's pnor illness mstory and that IT
chronic exposure to N02 IS a nsk factor for pnor illnesses, controlling for the clnld's illness
mstory would substantIally reduce the estImated effect of current N02 exposure
14.3.1.6 Tayside Study

Ogston et al. (1985) studIed mfant mortahty and morbidIty m the TaySIde regIOn of
northern Scotland The subjects were 1,565 mfants bom to mothers who were hvmg m
TaySIde m 1980 EpIsodes of respIratory illness were recorded dunng the first year of Me
The mformatIon was supplemented by observatIOns made by a health VISItor and scrutilllZed
by a ped1atncmn who checked dIagnostIc cntena and vahdity One health end pomt assessed
14-27
was defmed as the presence of any resprratory chsease durmg the year ThIs end pomt was
analyzed usmg a mulnple 10gIsnc regressIOn model that mcluded terms for parental smokIng,
age of mother, and presence of a gas stove The results of thIs analysIs are shown m
Table 14-14
TABLE 14-14. REGRESSION COEFFICIENTS FOR MULTIPLE LOGISTIC

ANALYSES OF RESPIRATORY ILLNESS IN TAYSIDE CHILDREN
Factor Regres Coeff a Odds Rano 95 % Confidence LImItS
Parental smokIng 0429 1 54
Age (in 5-year groups) -0094 NAb
Presence of gas stove 0130 114 o 86, 1 50
ftRegres Coeff = RegressIOn coeffiCIent
bNA = Not aVaIlable
Source Ogston et al (1985)
Only the coeffiCIent for parental smokIng was stanstIcally sIgmficant (p < 001)
A test for the sIgmficance for the coeffiCIent for gas stove use gIves a p-value of 0 14 The
study chd not give measured N02 exposure values, but referenced the other Meha studieS
conducted elsewhere in the Umted KIngdom for exposure estImates
14.3.1.7 Albuquerque Study

Samet et al. (1993, 1992), Lambert et al (1993), and Samet and Spengler (1989)
reported prehmInary results of a prospectIve cohort study of resprratory illness durmg the
fIrst 18 mo of hie m relatIOnshIp to estImates of N02 exposure m Albuquerque, NM
Exposure estImates were based on Palmes tube and activIty data The study mcluded
standardIZed ascertamment of illness and assessment of potential confoundmg factors
Samet et al (1993) conducted a prospective cohort study between January 1988 and
June 1990 to test the hypothesIs that exposure to N02 mcreases the mCIdence and seventy of
resprratory illness durmg the fIrst 18 mo of hie A total of 1,315 Infants were enrolled mto
the study at bIrth m Albuquerque, NM The subjects were healthy mfants from homes
14-28
wIthout smokers and who spent less than 20 h per week m day care Illness expenence was
momtored by a daIly darry of symptoms completed by the mother and a telephone mtervIew
conducted every two weeks For a sample of the ill chIldren, a nurse practItIOner made a
home VISIt to conduct a standardIZed hIstory and physIca,1 assessment Exposure to N02 was
estImated by a two-week average concentratIOn measured m the subjects' bedrooms WIth
passIve samplers EstImates of exposure based on bedroom concentratIon were tIghtly
correlated WIth estImates of exposures calculated as tIme-weIghted averages of the
concentratIOns m the kItchen, bedroom, and actIvIty room Twenty-sIX percent of resIdences
had electnc cookmg ranges, 44% of homes had gas ranges WIth contmuously burmng pilot
hghts, and 30 % of homes had gas ranges WIth electromc IgmtIOn or burners that were ht
WIth matches In homes WIth gas stoves, the subjects' bedrooms were momtored every
2 weeks, year round In homes WIth electnc stoves, the chUd's bedroom was momtored
year-round dunng every other 2-week cycle ExtensIve mternal and external quahty
assurance and control procedures were Implemented
Samet et al (1993) defme illness events as the occurrence of at least two consecutIve
days of any of the followmg runny or stuffy nose, wet cough, dry cough, wheezmg, or
trouble WIth breathIng Wheezmg was defmed as a hIgh-pItched mUSIcal sound audIble
dunng breathmg, and trouble WIth breathmg as the parent's perceptIon of rapId or labored
breathmg Illness events ended WIth two consecutIve symptom-free days More specIfic
defImtIOns were determmed as follows "upper respIratory tract" was defmed as at least
2 consecutIve days of any combmatIOn of runny or stuffy nose, dry cough, and trouble
breathmg, "lower respIratory tract" as at least 2 consecutIve days of any of the upper
respIratory symptoms plus wet cough or wheezmg or both bemg reported on at least I day,
"lower respIratory tract, wet cough" as any illness meetmg the cntena for lower respIratory
tract but WIthout wheezmg at any tIme, and "lower respIratory tract, wheezmg" as any illness
meetmg the cntena for lower respIratory tract WIth wheezmg reported for at least I day
The analysIs was hmIted to the 1,205 subjects completmg at least 1 month of
observatIOn, of these, 823 completed the full protocol MultIvanate methods were used to
control for potential confoundmg factors and to test for effect modIficatIon In analyses of
determmants of mCIdent illnesses, the outcome vanable was the occurrence of illness dunng
2 week mtervals of days at nsk The mdependent vanables consIdered m the multivanate
14-29
analyses mcluded the fixed factors of bIrth order (fITst born versus other), gender, ethmclty
(Hispamc versus non-HIspamc), parental asthma and atopIC status (consIdered posItive If hay
fever or desensItIZatIon shots were reported), household mcome (less than $10,000, $10,000
to $40,000, or greater than $40,000), and maternal educatIOn (12 years or less, 13 to
15 years, or 16 years or more) Other vanables consIdered were the temporally varymg
factors of age (6 mo or less, 7 to 12 mo, or 13 to 18 mo), calendar month, day-care
attendance (none, 1 to 4 h, or 5 or more hours per week), and breast feedmg (none, partIal,
or full). PotentIal confoundmg and effect modIficatIOn by CIgarette smokmg were controlled
by excluding subjects from households WIth smokers
The overall dIstnbutlon of tIme at nsk by level of bedroom N02 level was skewed
toward lower contnbutlons, WIth 22 % of the total concentratIOn above 0 02 ppm
(FIgure 14-1) Lambert et al (1993) reports that dunng the summer, bedroom N02
concentratlons in homes WIth gas stoves averaged 0 014 ppm (standard deViatIOn [SD] =
0.01 ppm) In the bedrooms of homes WIth electnc stoves, the summer average
concentratlons was 0 007 ppm (SD = 0 006 ppm) Dunng the wmter, bedroom
concentratIons m homes WIth gas stoves averaged 0 021 ppm (SD = 0 022 ppm)
In bedrooms of homes WIth electnc stoves, wmter concentratIOns averaged 0 007 ppm
(SD = 0 006 ppm) The exposure estImates were stratIfied mto three classes low (0 to
o 02 ppm), medIum (0 02 to 0 04 ppm), and hIgh (greater than 0 04 ppm) For these
exposure strata, personal exposures based on bedroom measurements were not substantially
dIfferent from those denved usmg the mlcroenvrronmental model ApproXImately 77 % of
the bedroom NO z observatlons were less than 0 02 ppm, only 5 % were greater than
0.04 ppm The 10th and 90th percentIles of the weekly measured concentratlons were
0.005 and 0 050 ppm N02 , respectively, m bedrooms
Samet et al (1993) performed the analySIS usmg the generahzed estimated equatlons
descnbed by Zeger and LIang (1986) ThIs takes mto account the correlatIOn structure when
estimatIng regression coeffiCIents and therr standard errors The multIvanate models
exammed the effects of the unlagged N02 exposures, lagged N02 exposures, and stove type
(Table 14-15) None of the odds ratIOS was SIgnIficantly dIfferent from umty, the value for
the reference category of 0 through 0 02 ppm AddItionally, the odds ratios dId not tend to
increase consIstently from the mIddle category of exposure to the hIghest category Also,
14-30
50..------------------·---------------.,
40
30
20
10
o 0-0 01 0 01-0.02 0 02-0 03 0 03-0.04 0.04-0 05 0 06-0.06 0 06-0.07 0.07-0.08 0 08+

Bedroom N02 (ppm)
Figure 14-1. Distribution of time at risk by bedroom N02 concentration.
Source Samet et al (1993)
exposure to NOz and the dura1JLons of the four illness categones were not associated The
authors added NOz exposure to the model as a contmUOlJS vanable, wlule controllmg for the
same covanates mcluded m Table 14-15 For each of the five illness vanables, the estnnated
multIpher of the odds ratIo per 0 001 ppm mcrement of NOz was 0 999, wIth confidence
hmItS extendmg from approxnnately 0.995 to 1 002
Health Effects Institute Health RevIew CommIttee (1993) noted that although exposure
to NOz levels m excess of those encountered m thIs study may be causally related to the
mCIdence or seventy of respIratory illness m cluldren, other data mdIcate that an effect, If It
eXIsts, IS subtle and may be dIfficult to dIstmgmsh from other envIronmental nsk factors,
espeCIally envIronmental tobacco smoke
14-31
TABLE 14-15. ODDS RATIOS a FOR EFFECT OF NITROGEN DIOXIDE
EXPOSURE ON INCIDENCE OF RESPIRATORY ILLNESS
Lower, Lower,
All lllnesses All Lower Wet Cough Wheezmg
Odd Odd Odd Odd
N0 2 Exposure b b b b
Ratio 95% Cl Ratio 95% Cl Ratio 95% Cl Ratio 95% Cl
Unlaggedc
002-004 ppm 104 096-1 12 098 089-109 100 089-1 12 092073-115
>004 ppm 094 081-108 093 076-1 13 094 077-116 088 056-137
C
Lagged
0.02-0 04 ppm 101 093-1 10 097 087-108 097 087-109 095 075-1 19
>004 ppm 092 077-1 10 091 072-1 15 089 068-1 16 098 066-148
d
Gas Stove 098 090-107 091 081-104 094 082-107 084 064-109
aObtamed by generahzed estlmatmg equatiOn method Adjusted for season, age, gender, ethmclty, blfth order,
day care, mcome, maternal educatiOn, breast feedmg, parental atopy and asthma, and maternallllstory of
b~P':~:fisr=;~o:erval
cReference category IS 0-0 02 ppm N02
dReference category IS electnc stove
Source Samet et al (1993)
Health Effects Institute Health ReVIew CommIttee (1993) commented that perlonnmg
the muluvanate Generahzed EstImated EquatIOn analyses wIthout so many covanates bemg
conSIdered SImultaneously wIth an mvestIgatIOn of the separate and combmed vanables may
be mfonnatIve In the present analyses, at least 11 vanables were entered mto the
multivariate analyses These mclude season, age, gender, ethmcIty, birth order, day-care
status, mcome, maternal educatIOn, breast feedmg, parental atopy and asthma, and a
maternal symptom report These analyses are unable to sort out the effects of the vanous
variables
The advantage of restnctIons m the study population IS that the effect of N02 exposure
could be evaluated m a relatively homogeneous sample of Infants The dIsadvantages are
that the results cannot be generahzed to the potentIally more susceptible portIOns of the
population, such as Infants WIth parents or care gIvers who smoke, and Infants who attend
day care (Health Effects Institute Health ReVIew CommIttee, 1993)
The study deSign and ImplementatIOn represent an effective reduction of
mlsclassmcatIon and potential biaS The exposure estImates are a good representative
14-32
estImate of N02 exposure for the subjects over the tIme penod of the study The prospectIve
assessment of illness mCIdence hmlts potential bIas of retrospectIve ascertamment of illness
The fmdmgs mdlcate that m a populatIOn of healthy mf.mts (0 to 18 mo of age), no
sIgmficant assocIatIOns between N02 exposure estImates (m the range of 0 to 0 04 ppm) and
resprratory illness were found when precautIon was taken to make an accurate assessment of
exposures, to vahdate the measurements of resprratory lllness, to ehmmate potentially
confoundmg vanables, and to adjust for key vanables
14.3.1.8 Chestnut Ridge Study

Schenker et al (1983) reported a large resprratory dIsease study of 4,071 cMdren aged
5 to 14 years m the Chestnut Ridge regIon of western Pennsylvania The regIon IS
predommately rural, and there are numerous underground coal mmes and four large coal-
fired electnclty-generatmg plants Wlthm the area The standardized ATS-DLD-78-C
chIldren's questIonnarre (Ferns, 1978) was sent to parents of all chIldren m grades 1 through
6 m targeted schools An SES scale was denved from the parent's occupation and educatIOn
and dIVIded mto qumtIles to proVIde SES strata V (lowe~st) through I (hIghest)
Important confoundmg factors were evaluated to lllclude gender, SES, and maternal
smokIng PerSIstent wheeze and chromc cough were the most commonly reported symptoms
No relatIonshIp was found between perSIstent wheeze, chromc phlegm, or chest illness m the
past year and SES SIgmficant inverse trends WIth SES were present for chromc cough and
severe chest illness before 2 years of age, whereas phySICIan-dIagnosed bronchItis showed
sIgmficant trends of mcreased prevalence WIth hIgher SJES
SIgmficant hnear aSSOCiatIOns were reported to be present only between the number of
parent smokers and the prevalence of chest illness m the past year, and of senous chest
illness before 2 years of age, but not WIth chromc respuatory symptoms Smokmg
questIOnnarres were completed by 1,906 chIldren m grades 4 through 6 Only 53 (2 7%)
said that they had ever smoked five or more CIgarettes, and currently smoked
A sIgmficant mverse relatIOnshIp was observed between gas cookmg stove use and SES
When gas cookIng stove use was tested m the multiple lOgIStiC model, a sIgmficant
aSSOCiation was not found between gas stove use and any of the respIratory or Illness
vanables after adJustmg for SES No odds ratIos or other numencal data were reported
14-33
14.3.1.9 Swiss Study
Braun-Fahrlaender et al (1989, 1992) and RutIshauser et al (1990a,b) studIed the
incIdence and duratIon of common arrway symptoms m children up to 5 years old The
study was conducted over a I-year penod m a rural, a suburban, and two urban areas of
SWItzerland Parents were asked to record theIr child's respIratory symptoms (from a hst)
on a diary form daily over a 6-week penod AdditIonally, covanates mcludmg family SIZe,
parental educatIon, hvmg conditIons, health status of the child, parents' respIratory health,
and smokmg habIts of the family were assessed by questIonnarre
NItrogen dIOXide was measured weekly dunng the same 6-week penod usmg Palmes
tubes, both mSIde and outSIde the home of the partICIpants MeteorologIcal data were
obtamed from local momtonng statIOns, but addItIonal air quahty data from fIXed momtonng
sites were only available for the two urban study areas FIgure 14-2 shows the average N02
concentratIon outSIde and mdoors and makes It clear that N02 concentratIOns mSIde the home
were on average lower than the levels m the outSIde arr Indoor N02 levels for Basel,
Zurich, WetzIkon, and Rufzerfeld were 33 8, 28 4, 205, and 11 2 p,g/m3 (00179, 00151,
0.0109, and 0 0059 ppm), respectIvely The mdoor N02 concentratIon depended to some
extent on the concentratIon of the outSIde arr
0030 - . - - - - - - - - - - - - - - - - - - - - - - - - - - - - ,
0025
0020
E'
,S; 0015
0'
z
0010
0005
o
Basel ZurICh Wetzlkon Rafzerfeld
_ Outside AJr [~ Room Air
Figure 14-2. Nitrogen dioxide ambient and indoor concentrations in four Swiss regions
with 95% confidence range.
Source Braun-FahrIaender et a1 (1989)
14-34
The analysIs was restncted to the 1,063 SWISS natlonals (from a total of 1,225
partlclpatmg families) For all four study areas, regIOnal mean InCIdence rates of upper
resprratory illness, cough, breathIng drfficultIes, and total respIratory illness, adjusted for
mdlvldual covanates and weather data, were regressed (usmg POisson regression) agamst
regIOnal differences m annual mean N02 concentrations All the relative nsks were
computed for a 0 0106-ppm (20-/-tg/m3 ) Increase In pollutIOn concentratIOn Nitrogen diOXide
by Indoor passive sampler was predictive of the duration of any episode (relative duratIOn of
1 16, 95 % confidence mterval of 1 12 to 1 21), upper respIratory episodes (relative duratIOn
of 1 18, 95 % confidence mterval of 1 01 to 1 38), and coughIng episodes (relative
duratIOn of 1 15, 95 % confidence Interval of 1 03 to 1 29) A diScussIon of aSSOCiatIOns
With outdoor levels IS presented m Section 14 3 2
14.3.1.10 Connecticut Study

Berwick (1987), BerwIck et al (1984, 1987, 1989), and Leaderer et al (1986) reported
on a 12-week study (SIX 2-week tIme penods) of lower and upper resprratory symptoms In
159 women and 121 chIldren (aged 12 or less) hVIng In Connecticut Nitrogen diOXide levels
were measured m 91 % of the homes, 57 of winch had kerosene heaters and 62 of winch did
not AmbIent N02 levels ranged from 9 to 19 /-tg/m3 (0005 to 0 01 ppm) for the SIX 2-week
time penods Two-week average Indoor N02 levels m homes of momtored chIldren were
Inghest for homes With kerosene heaters and gas stoves (91/-tg/m3 , 005 ppm, n = 8),
second highest for kerosene only (36 /-tg/m 3 , 002 ppm, n = 45), thIrd Inghest for gas stoves
only (32 /-tg/m3 , 0 02 ppm, n = 13), and lowest for no sources (6 /-tg/m 3 , 0 003 ppm,
n = 43) Indoor levels did not fluctuate greatly over tune, as mdlcated by the 2-week
averages A companson of personal N02 exposures, as measured by Palmes' diffuSIOn
tubes, and N02 exposures measured In reSidences had a correlatIOn of 094 for a subsample
of 23 IndIVIduals Results of tins companson are depicted In Figure 14-3 and show an
excellent correlatIon between average household exposure and measured personal exposure
The study de:fmed lower respiratory illness as the presence of at least two of the followmg
fever, chest pam, productive cough, wheeze, chest cold phySIcian-diagnosed bronclntIs,
phySICIan-diagnosed pneumoma, or asthma Upper resprratory illness was defmed as the
presence of two of the followmg fever, sore throat, nasal congestion, dry cough, croup, or
14-35
0070 - , - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - ,
o 060 • Kerosene Heaters and Gas Stoves

• NoSource
0050
f::. GasStoves
'Y Kerosene Heaters
I
~ 0040
•
sa
l!!
i;l 0030
!
";l
•
c
~ 0020
~
0010
O~--,--__.__-.___-,__-._______,-___.-__r-____r-___._-_,_-_,_---,--____j
o 0010 0020 0030 0040 0050 0060 0070

Average N02 /House (ppm)
Figure 14-3. Total personal exposure to nitrogen dioxide versus nitrogen dioxide levels
in Connecticut residences.
Source Leaderer et al (1986)
head cold Although both upper and lower respIratory illness were mvestIgated, the major
outcome of mterest was lower respIratory symptoms The study obtamed mformatIon on
many potentIal covanates, wInch mcluded SES, age, gender, and exposure to envIronmental
tobacco smoke The covanates havmg the largest effect were age of the cInld, SES of the
family, and Instory of respIratory illness MultIple lOgIStIC analysIs was used to allow for the
vanous factors
When controllmg for SES and Instory of respIratory illness, clnldren under the age of
7 exposed to 30 p,g/m3 (0016 ppm) N02 or more were found to have an mcreased nsk of
lower respIratory symptoms 2 25 tImes that of clnldren who were not exposed
(95 % confidence hmlts of 1 69 and 4 79) They also had an mcreased nsk of upper
resprratory symptoms of 1 33 (95 % confidence hmitS of 1 19 and 1 49) Older clnldren and
adults showed no mcreased nsk
14-36
Although the BerwIck study had relatIvely extensIve mformatIOn on exposure, several
problems are eVIdent The 3-year age-specIfic relatIve asks for lower respIratory dIsease are
very unstable, possIbly due to the small sample SIZes The rates do not appear to be
conSIstent WIth the rates for ages 0 to 6 and 7 and above, and It IS not clear why a cut-off of
7 years of age was used The analyses may be senSItIve to the adjustment for SES, whIch
can be correlated WIth exposure ThIs IS less of a prohiem ill studIes WIth larger sample
SIZes (e g , Meha et al , 1977, 1979), but may be cntIcal ill the BerwIck study Also, Neas
et al (1991) note that the BerwIck study controls for pnor Illnesses, as dId the Keller study,
whIch would reduce the estImated effect of current N02 exposure
14.3.1.11 Maryland Study

Helsmg et al (1982) analyzed the records of 708 nonsmokmg whIte adult reSIdents of
Maryland to evaluate the effects of exposure to envIronmental tobacco smoke at home and
use of gas as a cookmg fuel The frequency of cough and/or phlegm among these
nonsmokers showed a nonsIgnrficant aSSOCiatIOn WIth the presence of CIgarette smokers m the
household Persons whose households had gas as a cookmg fuel reported sIgnrficantly more
chromc cough (relatIve nsk of 2 1) and chromc cough and phlegm (relatIve nsk of 2 2) than
those m households usmg electncity for cookmg The author noted that although gas
cookmg has been conSIdered by some as SImply another mdicator of poor SOCIal condItIOns,
the multIple adjustments for factors such as years of schoohng and persons per room should
fully compensate for vanatIOns m SOCIOeconomIc level They also noted that all the
mdependent vanables combmed m the analySIS accounted for only 5 to 10 % of the vanatIOns
m symptomatology Resprratory ventilatIon functIOn tests gave conSIstent results WIth
symptom reportmg, WIth those usmg gas cookmg showung Imparred pulmonary functIOn
14.3.1.12 Gennan Study

Kuehr et al (1991) conducted a cross-sectIOnal study on the prevalence of asthma ill
childhood m relatIOn to N02 levels ill the CIty of Frelburg and two Black Forest
commumtIes A study group of 704 children aged 7 to 16 years took part m a standardIZed
mterview and medIcal exammatIOn Indoor and outdoOI exposure mformatIOn was taken mto
14-37
account Passive smokIng exposures were assessed Stoves used as heatmg devIces carned a
4.8-fold relatIve nsk for asthma compared to other types of heatmg
14.3.1.13 Canadian Studies

In a case-control study carned out ill Montreal, Quebec, Canada, between 1988 and
1990, N02 levels measured by paSSIve N0 2 momtormg badge were studIed m relatIOn to the
incidence of asthma among 3- and 4-year-old chIldren (Infante-RIvard, 1993) MultIvanate
uncondItIOnal lOgIStIC regreSSIOn was earned out for the 140 subjects who had N02
measurements, the analySIS mcluded N02 and the vanables retamed m the fmal condItIOnal
model that illcludes SES and parental smokIng The odds ratIos for the N0 2 categones
(defined as >00005 to 0 010, >0010 to 0 015, and >0015 ppm, m companson wIth a
zero level) were 0 95 (95 % confidence mterval of 0 31 to 2 95), 3 85 (95 % confidence
mterval of 092 to 1609), and 19 87 (95% confidence mterval of 475 to 83 03),
respectIvely
Dekker et al (1991) StudIed asthma and wheezmg syndromes as part of a questIonnaIre-
based study of 17,962 CanadIan school chIldren The questIOnnarre was developed from the
1978 Amencan ThoraCIC SocIety questIonnarre, whIch was the same one used m the Harvard
SIX CIties Study For analySIS, chIldren were restncted to ages 5 through 8 years and those
with CYStIC fibrOSIS as well as those hvmg m mobIle homes, tents, vans, traIlers, and boats
were excluded The authors calculated odds ratIos adjusted for age, race, gender, parental
educatIon, gender of the respondent, regIOn of reSIdence, crowdmg, dampness, and
environmental tobacco smoke The adjusted odds ratIo of asthma as a functIon of gas
cooking was 1 95 WIth 95 % confidence hmItS of 1 41 and 2 68 The adjusted odds ratIo of
wheezmg as a functIOn of gas cookIng was 1 04 WIth 95 % confidence hmIts of 0 77 and
1 42 The authors note that thIs fmdmg must be treated WIth cautIon, however, because of
the few subjects WIth asthma m the study who were exposed (n = 60)
14.3.1.14 North Carolina Study

Margohs et al (1992) studIed the prevalence of perSIstent respIratory symptoms ill
393 Infants of dIfferent SES by analyzmg data from a commumty-based cohort study of
respIratory illness ill the fIrst year of lIfe m central North Carohna between 1986 and 1988
14-38
Infants were hImted to those weIghmg more than 2,000 g and who dId not requrre neonatal
care outsIde the normal newborn nursery Of those ehgible, 47% were enrolled, and of
these, 77 % completed the study and were mcluded m the analysIs Compared wIth the
1,241 mfants from famihes refusmg enrollment, the 1,091 ehgible study mfants were more
hkely to be of hIgh SES and were more often black S1udy mfants were less hkely to have
mothers who smoked
The presence of persIstent resprratory symptoms was measured at the 12-mo home
mterview usmg an Amencan ThoracIc SOCIety chIldren questIOnnarre (modIfied for mfants)
for studIes of resprratory illness Infants who were reported to "usually cough" or
"occasIOnally wheeze" were classIfied as havmg persIstent resprratory symptoms The
Infant's SES was classIfied mto three levels accordmg to the hIghest level of educatIon
achIeved by the head of the household Each mfant's exposure to tobacco smoke was
measured as the number of cIgarettes smoked m the mfcffits presence durmg the week pnor to
the 12-mo home VISIt
Margohs et al (1992) used lOgIStIC regressiOn to analyze to what extent the relatIonshIp
between SES and persIstent resprratory symptoms could be accounted for by SImultaneously
considermg mteractIons between SES and other nsk factors for lower resprratory illness and
confoundmg by other nsk factors The relatIonshIp between the prevalence of persIstent
resprratory symptoms and SES for mfants ill the study at low SES was 39 %, whereas 14 %
had persIstent symptoms m the hIgh-SES group Infants m the low-SES group were 2 9
(95 % confidence mterval of 1 9 to 4 5) tImes more hkely than mfants of hIgh SES to have
persIstent resprratory symptoms ApproXImately 224 of the 393 infants m the study were
exposed to tobacco smokers Control for tobacco smoke exposure reduced the relatIve nsk
of persIstent symptoms among mfants of low SES compared WIth hIgh SES from 2 9 to 2 3
After accountmg for all the nsk factors, the effect of SES remamed SIgnIficant only for
mfants not m day care
Of the 393 mfants that Margohs et al (1992) mcluded m therr study, approXImately
41 hved m homes WIth the envrronmental nsk factor of gas cookmg The relatIve nsk of
perSIstent respIratory symptoms among mfants exposed to gas cookmg unadjusted for any
covanates was 1 12 (95 % confidence mterval of 0 63 to 2 04)
14-39
14.3.1.15 United States and Canadian Skating Rink Exposures
Hedberg et al (1989) reported that cough, shortness of breath, and other symptoms
among players and spectators of two hIgh school hockey games played at an mdoor Ice arena
m MInnesota were related to emISSIons from a malfunctIonmg engme of the Ice resurfacer
Although the exact levels of N02 were not known at the time of the hockey game, levels of
3
4 ppm (7,500 ftg/m ) were detected 2 days later WIth the ventilatIOn system workmg,
suggesting that levels dunng the games were hIgher Other pollutant levels such as PM lO
may have also been elevated Hedberg et al (1989, 1990) reported that pulmonary function
testmg performed on members of one hockey team WIth a smgle exposure demonstrated no
decrease m lung functIOn parameters at either 10 days or 2 mo after exposure Dewailly
et al (1988) reported another mCIdent m a skatmg nnk m Quebec, Canada, m 1988
mvolvmg referees and employees reportmg resprratory symptoms such as coughmg, dyspnea,
and a suffocatmg feelmg FIve days after the mCIdent, NOzlevels had come down to 3 ppm
(5,600 ftg/m3), suggestIng much hIgher levels dunng the mCIdent
In another skatmg rmk study, SmIth et al (1992) report the outcome of a questionnaIre
admilllstered to all students from two hIgh schools on February 25, 1992, 3 days after
11 students pamcipatmg m a Wlsconsm mdoor Ice hockey tournament had been treated m
emergency rooms for acute resprratory symptoms (1 e , cough, hemoptysIs, chest pam, and
dyspnea) The game had been attended by 131 students, 57 of whom reported symptoms
A SImulation test on February 24 proVIded levels of NOz at 1 5 ppm (2,800 ftg/m 3) m the aIr
over the nnk after use of the Ice resurfacmg machme HIgher levels may have been reached
the rught of the game There are more than 800 Ice arenas m the Uruted States
14.3.2 Outdoor Studies

Several studIes exammed relationshIps between estImates of ambIent NO z levels and
respIratory health measures Those studIes that proVIde a quantitative estImate of effect are
presented m Table 14-16 Health outcome measures mclude vanous resprratory
symptomoiogies
14-40
TABLE 14-16. EFFECTS OF OUTDOOR NITR'OGEN DIOXIDE EXPOSURE
ON RESPIRATORY DISEASE
Odds Odds
RatIO or RatIO Conf
Study Health End Pomt N02 Levels (ppm)/Penoda Estimate Interval
Dockery et al Bronchitis 00065-0 0226/annual average 17 05 to 5 5
(1989b) Chromc cough 00065-0 0226/annual average 16 03to105
Chest illness 00065-0 0226/annual average 12 03t048
Wheeze 00065-0 0226/annual average 08 04to16
Asthma 00065-0 0226/annual average 06 03to09
Braun-Fahrlaender DuratIOn of Change of 0 0106/6-week 111 1 07 to 1 16
et al 1992) respIratory average
epIsodes
DuratIOn of Change of 0 0106/6-week 109 097 to 1 22
coughing epIsodes average
Schwartz et al Croup 0.0053-0 03711daIly average 1 28 1 07 to 1 54
(1991)
Schwartz and Phlegm o 0911daIly I-h maxunum 1 08 1 01 to 1 15
Zeger (1990) mcrease
Jaakkola et al Upper respiratory Contrasted polluted versus 16 I1t021
(1991) mfectIOn less polluted areas by
companson of atmuallevels
aMeasurement penod over whIch stated mtrogen diOXIde (N0 2) level averaged
14.3.2.1 Six City Studies

As part of the SIX CIty StudIes, Dockery et al (1989b) obtaIned respIratory illness and
symptom data from questionnarres dIstnbuted from September 1980 to Apnl1981 Indoor
arr aspects of this study (Dockery et al , 1989a) were de!lcnbed above, m the sectIon on
mdoor studIes The questIOnnarres obtamed mformatIOn on bronchitis, cough, chest illness,
wheeze, and asthma A centrally located aIr momtormg statIOn was estabhshed m 1974
where N02, sulfur dIOXide (S02), ozone (03)' total suspended partIculate (TSP), and
meteorological vanables were measured The authors used multIple lOgIStiC regressIOn
analySIS m order to adjust for covanates of gender, age, maternal smokIng, gas stove use,
and separate mtercepts for each CIty Although the strongest aSSOCiatIOns were found
between respIratory symptoms and partIculate matter, there were also mcreased odds ratios
for respIratory symptoms WIth ambIent N02 These were not statistically sIgnrficant, but the
14-41
directIon for broncmtIs, chromc cough, and chest illness was consIstent WIth the studIes of
mdoor exposure The odds ratios for vanous health end pomts for an mcrease m N02 from
3
the lowest exposure CIty to the mghest exposure CIty (00065 to 0 0226 ppm, 12 to 43 p,g/m )
are noted m Table 14-16
14.3.2.2 Swiss Study

Braun-Fahrlaender et al (1992) stumed the mCldence and duratIOn of common aIrway
symptoms in chIldren up !O 5 years old ThIs study IS also dISCUSSed m the earher section on
mdoor studies The study was conducted over a I-year penod m a rural, a suburban, and
two urban areas of SWItzerland Parents were asked to record theIr chIld's respIratory
symptoms (from a hst) on a mary form daily over a 6-week penod AdmtIOnally, covanates
includ1ng family SIZe, parental educatIOn, hvmg condItions, health status of the chIld,
parents' respiratory health, and smokmg habIts of the faml1y were assessed by questIOnnarre
Nitrogen mOXlde was measured weekly dunng the same 6-week penod usmg Palmes tubes,
both inSIde and outsIde the home of the partIcIpants MeteorologIcal data were obtamed
from local momtonng statIOns, but admtIOnal arr quahty data from fIxed momtonng SItes
were only avaIlable for the two urban study areas
The analySIS was restncted to the 1,063 SWISS nationals (from a total of
1,225 participatmg families) For all four study areas, regIOnal mean mCldence rates of
upper respiratory illness, cough, breathmg dIffIculties, and total respiratory illness, adjusted
for mdIvldual covanates and weather data, were regressed (usmg POIsson regressIOn) agamst
regional dIfferences m annual mean N02 concentratIOns There was no aSSOCIatIOn between
long-term dIfferences m N02 levels by regIOn and mean annual rates of respiratory
inCidence
The adjusted annual mean symptom duratIOn (m days) by regIOn and the correspondmg
NO z levels (measured by paSSIve samplers to produce 6-week averages) are shown m
Table 14-17 A second-stage regreSSIOn of the adjusted natura1loganthm of regIOnal mean
duratIOn on N02 levels yields sIgmfIcant aSSOCiations between outdoor N02 levels (6-week
averages) and the average duratIOn (m days) of any respiratory epIsode (relative duratIOn of
1.11, 95% confIdence mterval of 1 07 to 1 16) and upper respIratory epIsodes (relative
duration of 1 14, 95 % confIdence mterval of 1 03 to 1 25) A posItive trend for the duratIOn
14-42
TABLE 14-17. ADJUSTED ANNUAL RESPIRA~TORY SYMPTOM DURATION
(DAYS) AND NITROGEN DIOXIDE LEVELS BY REGION (n = 1,063)
Any Symptom URI Cough Bre athmg DIfficulty N02 In N02 Out
a
RegIOn DuratIon DuratIon DuratIon DuratIon (ppm) (ppm)
Basel 450 199 232 155 00166 00272
Zunch 421 1 85 201 172 00118 00248
WetZlkon 400 162 210 347 00103 00173
Rafzerfeld 388 172 202 125 00059 00133
aURI = Upper respIratory Illness
Source Braun-Fahrlaender et al (1992)
of coughIng epIsodes was also seen (relatIve duratIon of 1 09, 95 % confidence mterval of
097 to 1 22) No aSSOCIatIon was seen WIth the duration of breathIng dIfficultIes All the
'I
relatIve nsks are computed for a 0 0106-ppm (20-l-tg/m ) mcrease m pollutIOn concentratIOn
In the suburban and rural areas, N02 was the only arr qualIty measure CorrelatIOn between
outdoor paSSIve N02 sampler and TSP measurements m the two urban study areas was qUIte
hIgh (0 52) The hIgh correlatIon between N02 and TSP suggests that thIs N02 aSSOCIatIOn
may reflect confoundIng WIth TSP Unfortunately, the lack of TSP data for the other two
regIOns precludes ehmmatIng TSP as a pOSSIble confounder m thIs analySIS
Although the aSSOCIatIon WIth symptom duratIOn In Zunch and Basel may well be due
to confoundmg WIth TSP, the cross-sectIonal aSSOCIatIon across the four regIOns supports a
pOSSIble contnbutIOn of N02 The authors state that, thus, the aSSOCIatIon between medIUm
and long-term N02 exposure and symptom duratIon deserves conSIderatIon as to a pOSSIble
causal relatIOnshIp
14.3.2.3 German Studies

Schwartz et al (1991) StudIed resprratory Illness In five German commumtIes
ChIldren's hOSpItalS, pedIatncs departments of general hOSpItalS, and pedIatncIans reported
daily the numbers of cases of croup A dIagnOSIS of croup was based on symptoms of
hoarseness and barkmg cough, mspIratory stndor, and dyspnea, and a sudden onset The
most Important factors m croup etIology are paramfluenza VlfUses The croup counts were
modeled usmg POIsson regreSSIOn WIth adjustments for weather, season, temperature,
14-43
humidIty, and autoregressIve lag StatIstIcally sIgmficant effects of both ambIent partIculate
matter and NO z were found on the counts of resprratory illnesses A relatIOnshIp between
short-term fluctuatIons ill arr pollutIOn and short-term fluctuatIons ill medIcal VISItS for croup
symptoms was found ill thIs study The estImated relatIve nsk was 1 28 WIth 95 %
confidence lImItS of 1 07 and 1 54 for an illcrease from 0 0053 to 0 0371 ppm (10 to
70 p.g/m3 ) of N02 The N02 results may be confounded WIth effects of partIcle levels
Rebmann et al (1991) StudIed 875 cases of croup ill Baden-Wurttemberg ill relatIOn to
ambIent N02 levels over a 2-year penod StatIstIcal regreSSIOn methods mdicated weak but
statIstIcally sIgmficant mfluences of the dally ambIent N02 mean on the occurrence of croup
VrrologIc testmg was conducted on 205 cases that yIelded pOSItIve results (mcludmg mfluenza
A and B, paramfluenza I-III, and RSV) ill 34 cases
14.3.2.4 Los Angeles Student Nurses Data

Hammer et al. (1974) reported a daily dIary study of morbimty symptoms m student
nurses ill Los Angeles DIanes on morbIdIty symptoms were collected weekly from October
1961 to June 1964 InItIally, 110 student nurses (over 90% of the class) agreed to
partiCIpate, but the class sIZe decreased over the 3-year penod of the study so that by the end
of the thrrd year, the cohort conSIsted of 30 student nurses Schwartz and Zeger (1990) and
Schwartz et al (1988) reported later analyses of the data They reexamilled the ongmal
dlanes from the study, whIch contamed smokmg and allergy mstones as well as symptom
reports. Ambient arr pollutIOn (N02, S02, carbon monOXIde [CO], and photochemIcal
oxidants) was measured at a momtonng locatIOn approXImately 2 5 mlles from the
dormItory Pack-years of CIgarettes were predIctIve of the number of epIsodes of coughmg
and bnngmg up phlegm A daily I-h maXImum N02 level of 0091 ppm (170 p.g/m3 ) was
assocIated WIth mcreased nsk of phlegm (odds ratIo of 1 08, 95 % confidence mterval of
1. 015 to 1.15) and sore throat (odds ratIO of 1 26, 95 % confidence mterval of 1 18 to 1 35)
Schwartz and Zeger (1990) note that although the use of only outdoor N02 measurements
decreases senSItIvIty, the use of daily manes should be more senSItIve to detect effects of
N02 than annual questIonnarres Smokmg, allergIes, temperature, other pollutants, and
senal correlatIon were controlled for No partIculate measurements were available The
14-44
3
mean of daIly I-h maxunum N02 levels over the study penod was 0 13 ppm (245 Itg/m )
3
wIth 25 and 75% levels of 006 and 0 17 ppm (113 andl320 Itg/m ), respectIvely
14.3.2.5 Chestnut Ridge Study

In the Fall of 1980, Vedal et al (1987) conducted a panel study on 351 chIldren
selected from the 1979 Chestnut RIdge study Parents clnd chIldren were mstructed at the
begmnmg of the school year m completmg dally dIarIeS of resprratory symptoms, whIch were
used to derme symptom outcomes Lower resplIatory Illness was dermed as wheeze, pam on
breathmg, or phlegm productIOn Of the 351 subjects selected for the 8 mo of follow-up,
128 partICIpated m the completIOn of dIarIeS Three subgroups were estabhshed one
wIthout resprratory symptoms, one wIth symptoms of perSIstent wheeze, and one wIth cough
or phlegm productIOn but wIthout perSIstent wheeze NItrogen dIOXIde was measured at a
smgle momtonng SIte m the study regIon MaxImum hourly levels for each 24-h penod
were used to reflect the dally pollutant level Dunng the penod September 1980 to Apnl
1981, the mean N02 maxunum daIly I-h level was 40 ~I Itg/m3 (0021 ppm) wIth a range of
12 to 79 Itg/m3 (0 006 to 0 042 ppm) RegressIOn models could not be fit for subjects who
never had symptoms, thus only 55 subjects were mcluded m the analysIs of lower resplIatory
illness NItrogen dIOXIde levels were not predIctIVe of any symptom outcome
14.3.2.6 Finland Studies

Jaakkola et al (1991) studIed the effects of low-level alI pollutIOn m three FInland
CItIes by comparmg the frequency of upper resprratory mfectIOns over a 12-mo penod m
1982 as reported by parents of chIldren ages 14 through 18 mo (n = 679) and 6 years
(n = 759) Pollutants studIed mcluded ambIent levels of N02 WIth an annual mean of
15 Itg/m 3 (0 008 ppm) Other pollutants momtored weIe S02, hydrogen sulfide (H2S), and
partIculate matter (measured as Itg/m3) PaSSIve smokrng and SES were taken mto account
The authors report a sIgmficant aSSOCIatIOn between the occurrence of upper resplIatory
InfectIons and hvmg m an alI-polluted area for both age groups StudIed, both between and
Wlthm CItIes The adjusted odds ratIO was 1 6 (95 % confidence mterval of lito 2 1) m the
6-year-old age group The authors conclude that the combmed effect of S02, partIculate
matter, N02, H 2S, and other pollutants may be a contnbutmg factor m the study results
14-45
Ponka (1991) studIed the effects of ambIent arr pollutIOn and mmnnum temperature on
the number of patIents who had asthma attacks and who were admItted to hospItal In HelSInkI
from 1987 to 1989 Durmg the 3-year penod, 4,209 hospItahzatIOns for asthma occurred, an
average of 3 84 admISSions a day The number of admiSSions Increased durmg cold weather,
rangmg from -370 to +264 °C, WIth a 3-year mean of 47°C Mter standardIZatIOn for
minunum temperature, the multIple-regreSSIOn analySiS Indicated that N02 and CO were
SIgnificantly related to asthma admiSSion The annual N02 levels averaged 38 6 Jl-g/m3
3
(0.02 ppm) for the 3-year penod Durmg the penod of mgh N02 (dally mean 45 8 Jl-g/m
[0.024 ppm]) levels, the mean number of all admiSSions was 29% greater than durmg the
penod of lower pollutIon (28 1 Jl-g/m3 [0015 ppm]) Indoor N02 levels or cookIng fuel use
were not discussed The observed aSSOCiatIOn of InCIdence of asthma attacks With relatIvely
low levels of pollutants and cold weather accounted for an explanatory power of
approXlffiately 14% In the regreSSIOn analySiS Other factors that may playa role In the
mcidence of asthma attacks were not discussed
14.3.2.7 California Seventh-Day Adventist Study

In a Callforma study, Euler et al (1988) assessed the nsk of chromc resprratory disease
symptoms due to long-term exposure to ambient levels of TSP, OXidants, S02, and N02
Symptoms were ascertamed USIng the NatIOnal Heart, Lung, and Blood InstItute questIOnnarre
on 8,572 Southern Callforma Seventh-Day AdventIsts (nonsmokers-25 years and older) who
had lived 11 years or longer In therr 1977 reSidential area Tobacco smoke (actIve and
passive) and occupatIOnal exposures were assessed by questIOnnarres, as were hfestyle
charactenstIcs relative to pollutIOn exposure, such as tIme spent outSide and reSidence
hIStOry For each of the 7,336 partiCipants who responded and qualified for analySiS,
cumulative exposures to each pollutant were estImated USIng monthly reSidence Zip code
histones and interpolated exposures from state arr momtormg statIons
MultIple logistIc regreSSIOn analyses were conducted for pollutants IndiVidually and
together With eIght covanables, IncludIng envrronmental tobacco smoke exposure at home
and at work, past smokIng, occupatIOnal exposure, sex, age, race, and educatIOn
StatistIcally sigmficant aSSOCiatIons With chromc respiratory symptoms were seen for
(1) S02 (p = 0 03), relatIve nsk of 1 18 for 13 % of the study populatIon With 500 h/year of
14-46
exposure above 0 04 ppm, (2) oXIdants (p < 0 004) relative nsk of 1 20 for 18 % wIth
750 h/year above 0 1 ppm, and (3) TSP (p < 0 00001), relative nsk of 1 22 for 25 % wIth
750 h/year above 200 p.,g/m3 When these pollutant exposures were analyzed together, TSP
was the only one shoWillg statIStICal sIgruficance (p < 0 01) NItrogen dIOXIde exposure
levels ill thIs populatIOn were not lmked to chromc resprratory dIsease symptoms
IndIvIduals workmg wIth smokers for 10 years had relative nsks of 1 11 and those hVillg
wIth a smoker for 10 years had relatIve nsks of 1 07
14.3.2.8 Chattanooga Studies

Several studIes were conducted ill the greater Chattanooga area dunng the late 1960s
and early 1970s Although these studIes were dIscussed ill detaIl prevIously
(U S EnvIronmental ProtectIOn Agency, 1982a), there are at least two addItIOnal POilltS that
need to be made FIrst, there were many measurements made ill the area by methods other
than the Jacobs-Hochhelser method (e g ,chemllumillescence) ReevaluatIon of the Jacobs-
Hochhelser method at a later tIme quesuoned Its accurac y for use ill the studIes to estImate
quanutatIve exposure-effect relatIOnshIps Second, much of the pollutIOn may have been ill
the form of mtnc aCId (HN03 ), and pOSSIble health effec ts may be related to HN03 exposure
rather than N02 Itself The source of pollutIOn was a large tnmtrotoluene (TNT) plant,
located northeast of Chattanooga, whIch produced a substantIal proportIOn of all TNT made
ill the Umted States dunng World War II and the Korean War The plant was reopened ill
Apnl1966 to supply mumtIOns for use ill VIetnam Annual averages of N02 reached
286 p.,g/m3 (0 152 ppm) near the arsenal (as measured by the Saltzman method), and mtrate
fractIon levels reached 4 1 p.,g/m3 at the downtown post office It IS lIkely that the elevated
N02 levels were accompamed by elevated HN03 levels, although no drrect measurements
were made The U S EnVIronmental ProtectIOn Agency (1971) measured several factors
related to ambIent aIr pollutIOn illcludmg corrOSIOn of zmc, steel, and nylon The corrOSIon
levels ill Chattanooga ill 1967 and 1968 were among the hIghest ill U S CItIes, and ill the
case of nylon, were 10 to 100 times the levels of most olher CItIes Accordmg to the report,
the arsenal was known to emIt aCId gases AddIuonally, Warner and Stevens (1973, 1975)
gIve other eVIdence suggestIng the presence of sulfunc aod and HN03 Thus, It IS pOSSIble
that any adverse health effects seen ill Chattanooga dunn'g thIs tIme penod were assocIated
14-47
with combmed exposure to HN03 and N02 rather than wIth N02 alone However, no
conclusIon IS possIble because the health effects of HN03 are poorly understood (see
Chapter 13)
Pearlman et al (1971) reported the results of a respIratory dIsease survey conducted m
the Chattanooga area m 1969 The study reported illness rates m cluldren for the penod
June 1966 to June 1969 HIgher rates of bronchitIs m school-aged cluldren were found m
both the mtemledIate- and high-exposure areas, as compared WIth the low-exposure area
The results were not completely conSIstent WIth the exposure gradIent because the rate of
bronchitis m the mtennedIate area was Just as high as m the high-pollutIOn area
Shy and co-workers (Shy, 1970, Shy et al , 1970a,b, 1973) studIed the effects of
commumty exposure to N02 m reSIdentIal areas of Chattanooga on respIratory illness rates m
famIlIes. The mCIdence of acute respIratory dIsease was assessed at 2-week mtervals dunng
the 1968-69 school year and the respIratory illness rates (adjusted for group dIfferences m
family SIZe and compOSItIOn) were reported to be SIgnIficantly higher for each family segment
(mothers, fathers, cluldren) m the hIgh-N02 exposure neIghborhood than m the mtermedIate-
and low-N02 areas Although mdIvidual area pollutIon estImates are not available, one part
of the high pollutIOn area had an annual average N02 level of 286 p.,g/m3 (0 152 ppm)
Areas more dIStant from the major N02 source (TNT plant) had lower levels
Love et al (1982) StudIed acute respIratory dIsease m the same area dunng the years
1972-73 Fathers, mothers, school cluldren, and preschool cluldren all showed sIgnIficantly
higher illness rates m the area deSIgnated as the high-pollutIon area dunng the begmnmg of
1972 There were almost no SIgnIficant dIfferences m illness rates dunng the penods
September to December 1972 and January to AprI11973 Dunng the penod January to June
1972, N02 levels (as measured by the contInuous chemilummescent method) ranged from
60 2 p,g/m3 (0 032 ppm) m the high area to 28 9 p.,g/m3 (0 015 ppm) m the low area
However, by the second half of 1972, the exposures m all areas were qUIte comparable
because of reduced emISSIons Thus, the results of the study tend to confIrm the effect of
N02 or ItS by-products on acute respIratory dIsease
14-48
14.3.2.9 Glendora, California, Study
In another Cahforma study, Detels et al (1979, 1981a,b) and Rokaw et al (1980)
studIed chromc respIratory dIsease symptoms and lung functIOn m two areas of Los Angeles
County The low-exposure area was Lancaster, a CIty ill the hIgh desert country about
113 Ian from downtown Los Angeles, whIch was studIed from November 1973 to October
1974 The hIgh-exposure area was Glendora, an area m the Los Angeles basm, whIch was
studIed from Apnl1977 to March 1978 The aeromet11.C exposures for Glendora were
estimated from a statIOn m Azuza, about 5 Ian away Pollutants measured mcluded total
oXIdant (ultravIolet absorptIOn method), NOx (Saltzman method), CO (nondispersive mfrared
spectrosc?py method), S02 (conductImetnc method), hydrocarbons (flame IOnIZation
detectIOn method), and partIcles (hIgh-volume TSP method) The 5-year averages were
computed for those pollutants WIth suffiCIent data Comparmg Lancaster to Glendora, the
N02 levels were 0 033 versus 0 114 ppm, the total OXIdant levels were 6 5 versus 11 6 ppm,
and the hydrocarbons were 2 9 versus 4 8 ppm Comparable dIfferences eXIsted for S02,
partIcles, and sulfate fractIOn of partIcles, but the data were only complete for the year 1977
The authors evaluated symptom prevalence of cough, sputum production, wheezmg, and
frequent chest illness All symptoms except frequent chest illness showed sIgmficantly
hIgher rates m Glendora for both sexes and all three smokIng categones
The two pnmary weaknesses of the study are (1) the two areas (Lancaster and
Glendora) were measured at dIfferent tImes (1974 versus 1977), and (2) the areas are qUIte
dIfferent WIth respect to clImate, commutmg patterns, ,utItude, SES, season, and general
llfestyle No specIfic analyses related to N02 levels were dIscussed The effects of smokIng
habIts were carefully controlled and should not be comadered as a senous confounder The
authors also dId attempt to control for vanability m m(~asurement methods and techmclans,
and results of thIs are reported by Tashkm et al (1979)
14.4 STUDIES OF PULMONARY FUNCTION

Pulmonary functIOn studIes are part of a comprehensIve mvestIgatIOn of the pOSSIble
effects of any arr pollutant Measurements can be made m the field, they are nonmvaSlVe,
and theIr reproducIbility has been well documented Age, heIght, gender, and presence of
14-49
resprratory symptoms are nnportant determmants of lung function In addItion, changes m
pulmonary function have been assocIated wIth envIronmental tobacco smoke
(Hasselblad et al , 1981), WIth partIculate matter m combmatIOn WIth S02 (Dockery et al ,
1982, Dassen et al , 1986), and WIth other factors
The rest of thIs section exammes epIdemIOlogIcal studIes relatmg N0 2 exposure to
pulmonary function The pulmonary function studIes m thIs sectIOn are dIVIded mto mdoor
and outdoor subsectIOns
14.4.1 Indoor Studies

Several of the studIes dIscussed earher WIth regard to resprratory dIsease symptoms
also mc1uded evaluatIOns of pulmonary functIOn Ware et al (1984), reportmg on the SIX
CIty Study, descnbed analyses of lung functIOn values usmg multiple hnear regressIOn on the
loganthm of the lung functIon measures Covanates mcluded sex, heIght, age, weIght,
smokmg status of each parent, and educatIonal attamment of the parents Forced expIratory
volume m 1 s (FEV1) values were sIgmficantly lower for chIldren of current smokers than
for chIldren of nonsmokers at both exammatIOns and were hIghest for chlldren of
ex-smokers Forced VItal capacIty (FVC) values were lower for chIldren of nonsmokers than
for children of current smokers at both exammatIons, but the dIfference was statIstIcally
sIgmficant only at the fIrst exammatIOn Both the mcrease m mean FVC and the decrease m
mean FEV 1 among chIldren of current smokers were hnearly related to dally CIgarette
consumptIon Exposure to gas stoves was assocIated WIth reductIons of 0 7 % m mean FEV1
and 0 6% m mean FVC at the fIrst exammatIOn (p < 001), and reductIons of 03% at the
second exammatIon (not sIgmficant) The estnnated effect of exposure to gas stoves was
reduced by approxnnately 30 % after adjustment for parental educatIon The authors state
that the adjustment for parental educatIOn may be an over-adjustment, and may partIally
represent gas stove use because of aSSOCIatIon between parental educatIon and type of stove
Hasabelnaby et al (1989) proVIde estnnatIon formulas for hnear regressIOn models that
mcorporate errors m exposure vanables usmg thIs data set as an example
Berkey et al (1986) used the SIX CIty Study data from chIldren seen at two to fIve
annual VIsits to evaluate factors affectmg pulmonary functIOn growth ChIldren whose
mothers smoked one pack of CIgarettes per day had levels of FEV1 at age 8 years that were
14-50
approxImately 0 81 % lower than chIldren of nonsmokmg mothers (p < 00001) and had
FEV l growth rates approxImately 0 17% per year lower (p = 005) The same data
provIded no eVIdence for an effect of gas stove exposure on growth rate
Neas et al (1991), dIscussed earher, also reported that mdoor N02 levels were not
sIgmficantly assocIated wIth a dechne m chIldren's pulmonary functIOn levels on eIther of
two exammatlOns conducted pnor to the mdoor momtormg The ratIO between FEVland
FVC was actually mcreased m both boys and gIrls on both exammatIOns
Goldstem et al (1988) reported prehmmary data exammmg effects of acute exposure to
N02 m mner-cIty apartments wIth gas cookmg stoves Olll pulmonary functIOn Eleven
asthmatIc and 12 nonasthmatIc women and chIldren were momtored for 5 days wIth a
portable contmuous N02 momtonng mstrument held at breathmg level that prOVIded 5-mm
average N02 levels The average levels observed over the 48-h samphng penod were over
100 p,g/m3 (0 053 ppm) N02 m latchens and over 70 /hg/m 3 (0 037 ppm) N02 m bedrooms,
wIth peak levels sIgmficantly hIgher Pulmonary functIOn (FEV b FVC, functIonal
expIratory volume at 25 to 75% of VItal capaCIty [FEV25-75 %], and peak flow), as well as
tracmgs of the entIre flow curve, were momtored at several dIfferent pomts dunng the
exposure Although the data are hmIted, m thIs pilot study It seemed that at 5-mm average
N02 exposures below 0 3 ppm (564 p,g/m3 ), FVC and peak expIratory flow (PEF) were as
lIkely to be mcreased as decreased, whereas at exposure above 03 ppm, FVC and PEF
mamly decreased for the adult asthmatIc subjects
Ekwo et al (1983), dIscussed earher, obtamed pulmonary functIOn measurements from
89 chIldren whose parents dId not smoke and 94 chIldren whose parents smoked, and
reported no dIfferences m lung functIon assocIated WIth gas stove use m a cohort of Iowa
chIldren 6 to 12 years of age DIJkstra et al (1990) exammed pulmonary functIOns m Dutch
chIldren m a study dIscussed earher Lung functIOn was measured at the schools There
was a weak, negatIve aSSOCIatIOn between maXImal mIdexpIratory flow (MMEF) and
exposure to N02 Forced expIratory volume mIs, PEF, and :M1v.lEF were all negatIvely
assocIated WIth exposure to tobacco smoke The authOIs concluded that the study failed to
document clear aSSOCIatIOns between mdoor exposure to N02 and lung functIOn m Dutch
chIldren 6 to 12 years of age
14-51
LebOWItz et al (1985) studIed a cluster sample of 117 mIddle-class households m
Tucson, AZ. Symptom dIanes and peak flows were obtamed over a 2-year penod Outdoor
samphng of 03' TSP, CO, and N02 was measured m or near the clusters Indoor samphng
of 03' TSP, respIrable suspended partIcles, and CO was measured m a subsample of the
homes Additional informatIOn, such as the presence of a gas stove or smokmg, also was
obtamed The presence of a gas stove was used as a surrogate for mdoor NO x exposure
because It was not measured drrectly The relatIOnshIp of chIldren's peak flow and gas stove
use was of borderhne sIgmficance (p = 0 066) for an analySIS excludmg TSP, and was not
close to sigm:ficance wIth TSP mcluded m the analySIS For asthmatIc subjects, gas stove use
was sigmficantly assocIated wIth peak flow decrements (p < 0001) ThIs was true across
smoking groups, but the dIfference was greatest for smokers Peak flow m adults was also
related to gas stove use, but the level of sIgmficance was not gIVen
14.4.2 Outdoor Studies

Schwartz (1989) StudIed the effect of arr pollutIOn on lung functIOn m U S chIldren and
youths aged 6 to 24 years Forced expIratory volume, FEV l' and peak flow measurements
taken as part of the NatIonal Health and NutntIOn ExammatIon Survey IT Study were
examined after controllmg for age, heIght, race, gender, body mass, CIgarette smokmg, and
respiratory symptoms AIr pollutIOn measurements were taken from all populatIOn-onented
momtors m the U S EnVIronmental ProtectIOn Agency's (EPA's) SAROADS data base
Each person was assIgned the average value of each arr pollutant for the 365 days precedmg
the spirogram HIghly sIgmficant negatIve regreSSIOn coeffiCIents were found for three
pollutants (TSP, N02 , and 03) WIth the three lung functIOn measurements For an mcrease
of N02 exposure of 0015 ppm (28 3 p.g/m3 ), an estImated decrease of about 0 045 L was
seen in both PVC and FEV1
Vedal et al (1987) conducted a panel study on 351 chIldren selected from the 1979
Chestnut Ridge cross-sectIonal study of Pennsylvama elementary school-aged chIldren (mean
age = 95 years) Peak expIratory flow rate (PEFR) was measured daIly m 144 chIldren for
9 consecutIve weeks and was regressed agamst daIly maxImum hourly ambIent concentratIOns
of N02, 03' S02' and coeffiCIent of haze No aIr pollutant was strongly assocIated WIth
level of PEFR All pollutant levels were relatIvely low, daIly maxImum hourly N02 levels
14-52
ranged from 0 006 to 0 042 ppm (12 to 79 p,g/m3 ) No mdoor measurements were made,
nor were any surrogates for mdoor pollutIOn mc1uded ill the analysIs
As part of the SIX CIty StudIes, Dockery et al (1989b) obtamed pulmonary functIOn
data durmg the 1980 to 1981 school year Resprratory illness and symptom data results were
dIscussed for this study m the earher studIes of respIratory illness sectlon Only TSP
concentratIon was conSIstently aSSOCIated wIth estImated lower levels of pulmonary functIOn
There was httle eVIdence for an assoclatlon between lower pulmonary functIOn level and the
annual mean concentratIOn of N02 or any other pollutant
In a study dIscussed earher, Detels et al (1979, 1981a,b) and Rokaw et al (1980)
studIed lung functIOn m adults m two areas of Los Angt~les County Lancaster, the low
NOTexposure area, and GlendIJra, the hIgh NOTexposure area The authors found
sIgnIficantly lower peak flow values m Glendora when compared WIth Lancaster, and these
dIfferences were sIgnIficant across all smokmg categone s and both sexes The percent of
subjects WIth FEV! or FVC below 50% of expected was also sIgnIficantly hIgher m
Glendora Other lung functIon measurements showed less sIgnIficant dIfferences, but the
trend was always toward lower values m Glendora The pnmary weaknesses of the study
were dIscussed earher
14.5 OUTCOMES RESULTING FROM OCCUPATIONAL EXPOSURES

Gamble et al (1987) studIed 232 workers m four dIesel bus garages for the effects of
N02 on acute resprratory illness and pulmonary functIOn Effects were assessed by an acute
resprratory questIonnarre and before- and after-shIft spIrometry Measurements of N0 2 over
the 6- to 7-h shrft (usmg paSSIve Palmes tube samplers) were made for each worker and were
collected on the same day as the pulmonary functIOn tests and questlonnaIres Other rrntant
gases were measured and were well below federal standards Mean N02 levels over a shIft
ranged from 0 56 (SD= 038) ppm N02 m the hIghest garage to 0 13 (SD = 006) ppm
N02 m the lowest garage Short-term N02 measurements mdIcated levels above 1 ppm as
bemg common The authors report that the prevalence of acute resprratory symptoms were
elevated above expected m the hIgh-exposure (> 0 3 ppm) group only No reductIOn m
pulmonary functIon was assocIated WIth exposure
14-53
Gamble et al (1983) exammed chromc resprratory effects m 259 sodIUm cWonde
miners. The Mechcal Research CouncJ1 resprratory symptom questIOnnarre contammg
smokmg lnstory was admilllstered by tramed mterviewers A chest X ray and spIrometry
were also conducted Personal samples of N02 and respIrable particles for Jobs m each mme
were used to estnnate cumulative exposure The cumulative mean exposure ranged from a
low of 02 (SD = 0 1) ppm N02 to a hIgh of 25 (SD = 1 3) ppm N02 DIesel emISSIons
were the pnncipal N02 source The author reported that although cough was associated wIth
age and smokmg and dyspnea was associated wIth age, neIther symptom was assocIated WIth
mdices of arr pollution exposure (1 e , years worked, estnnated cumulatIve N02 or
resprratory particle exposure) Reduced pulmonary function showed no aSSOCiation WIth N02
exposure
Robertson et al (1984) reported on a 4-year study of lung functIOn m 560 BntIsh coal
miners. Overall mean work slnft average N02 levels at nme coal mme sItes ranged from
0.02 to 0 06 ppm (38 to 113 p,g/m3), and mtnc OXide (NO) levels ranged from 0 13 to
1 19 ppm No relatIOnslnp was found between exposure and declme m FEV l or respIratory
symptoms Jacobsen et al (1988) conducted a more extenSIve mvestIgatIOn on nearly
20,000 mmers at the same nme BntIsh coal mmes to examme whether long-term exposure to
low concentration of N02 and NO were associated WIth mcreased susceptibility to respIratory
mfectIOns The NOx source conSIsted of dIesel emISSIons and blastmg Work-slnft medIan
levels were 0 2 ppm NO and 0 03 ppm N02 ThIs complete and mtensive study had
problems WIth misclassmcatIOn of exposure and outcome that are not uncommon when
existmg data are used for purposes that were not foreseen when the data were collected The
authors concluded that the long-term exposure to the levels above do not detectably mcrease
the chance that mmers will absent themselves from work because of a chest mfectIon
Douglas et al (1989) report data between 1955 and 1987 on 17 patients exammed at the
Mayo Clmlc for sJ1o-:filler's dIsease shortly after exposure to sJ10 gas (N02 levels ranged
from 200 to 2,000 ppm) Health outcomes evaluated mcluded hypoxemia, tranSIent
ObstructIOn of the arrways, and death Meulenbelt and Sangster (1990) mdicate that after a
symptom-free epIsode nnmedlately followmg exposure to N02, a severe respIratory faJ1ure
can develop several hours later The pnncipal symptom, breathlessness, may become
manliest 6 or more hours followmg exposure as a result of adult respIratory dIstress
14-54
syndrome Epler (1989) notes that prevention IS essential for ehmmatIOn of silo-filler's
dIsease
Other studIes on illgh exposures (Lowry and Schuman, 1956, Grayson, 1956, Gregory
et al , 1969, Yockey et al , 1980) are revIewed m U S EnvIronmental ProtectIOn Agency
(1982a) Levels above 300 ppm m occupational settmgs are lIkely to result m rapId death,
whereas levels of 150 to 200 ppm may lead to death 2 to 3 weeks after exposure Levels
between 25 and 100 ppm are usually, but not always, followed by essentially complete
recovery
14.6 SYNTHESIS OF THE EVIDENCE

The weIght of the eVIdence does not mmcate that N02 exposure at levels reported m
the stumes revIewed here has any consIstent effect on pulmonary functIOn of a bIOlogICally
sIgmficant magmtude Many of the illdoor studIes, however, do suggest an mcrease m
respIratory mOrbimty ill children from exposure to N02 levels measured ill these studIes,
although the effects reported dId not reach statistical sIgmficance (p < 0 05) ill the maJonty
of the studIes The conSIstency of results across the mdoor studIes IS exammed and the
eVIdence IS syntheSIZed ill a quantitative analySIS presented below
In order to compare available stumes on respIratory effects of N02 , a common end
pomt for a health outcome effect was defmed, and then each mdoor study was compared WIth
tills standard end pomt The end pomt chosen was the presence of lower respIratory
symptoms and illness ill children aged 5 to 12 years Pill attempt was made to mclude as
many mdoor studIes as possIble The requIrements fm illclusIOn were (1) the health end
pomt measured must be reasonably close to the standard end pomt, (2) sIgmficant exposure
dIfferences between subjects must eXist and some estImate of exposure must be available, and
(3) an odds ratIo for a specIfied exposure estImate must have been calculated, or data must
be presented so that an odds ratio can be calculated
14.6.1 Health Outcome Measures

One major concern ill attemptmg to mterpret these studIes IS that the respIratory
morbidIty vanables measured m the vanous studIes may represent dufenng health outcomes
14-55
that may have dIfferent mechamsms of causatIon related to N02 exposure estImates For
example, the ongm of cough may be dIfferent than that of wheeze (1 e , the agents that cause
them may be dIfferent) Vanous dIsease syndromes were evaluated In dIfferent studIes
croup, bronchItIs, bronchIohtIs, asthma, and pneumoma The Instruments measurmg health
outcomes m the studIes are also dIfferent If the sImIlanty between the outcome measures
between and Withm the studIes IS not adequate, the potentIal mterpretatIon of a quantItatIve
analYSIS may be lImIted Are the resprratory morbIdIty measures m these studIes of chIldren
a relatively simIlar outcome measure m both a statIstIcal sense and as a bIologIcal end pomt
across the studIes? ThIs dIscussIOn consIders thIs questIOn by evaluatIng outcome measures
used in the vanous N02 studIes, slllI1antIes m outcome measures In lower resprratory illness
StudIes in chIldren, the use of questIonnarres as mstruments to measure lower resprratory
morbIdity, and, m general, measures of lower resprratory morbIdIty
The studies In the quantItatIve analySIS that follows used health outcome measures that
provide an mdlCatIon of the state of resprratory health of vanous samples of chIldren aged
5 to 12 years old The N02 studIes utilized standard questIOnnarres to evaluate lower
resprratory health In chIldren DIagnoses of specIfic respIratory dIseases such as
bronchlOhtis or asthma were not made The factor of Importance here IS that an attempt was
made to measure some aspect of lower resprratory morbIdIty Table 14-18 hsts the health
outcome measures for each study consIdered Whereas specIfic measures such as colds gOIng
to chest (Melia et a1 , 1977), chest congestIon, and phlegm WIth colds (Ekwo et al , 1983)
are used to provIde measures of lower resprratory morbIdIty, other measures use Indexes,
grouped responses, or combmed IndIcators of lower resprratory morbIdIty, some of whIch
include measures such as colds gOIng to chest
In the Meha et a1 (1977, 1979, 1980, 1982a) studIes, a self-admImstered questIOnnarre
was completed by parents of chIldren m the study QuestIons were asked about each chIld's
resprratory dIsease epIsodes and symptoms durmg the preVIOUS 12 mo The resprratory
symptoms and dIseases surveyed mc1uded asthma In the last year, wheeze, bronchItIs m the
last year, cough (mght or day), and colds gomg to chest Irwig et a1 (1975) examIned the
assocIatIon of these reported questIons WIth objectIvely measured reduced peak flow rates In
a sample of the chIldren exammed In 1973 Because the answers to the morbIdIty questIOns
were related to the reduced adjusted mean peak flow rates (an IndIcator of decreased
14-56
TABLE 14-18. HEALTH OUTCOME AND NITROGEN DIOXIDE EXPOSURE MEASURES USED IN
SELECTED INDOOR NITROGEN DIOXIDE EPIDEMIOLOGY STUDIES
NOz Exposure
Measure Used Age Sample
a b
Reference Health Outcome Used m Meta-AnalysIs Method mAnalysis (years) SIze Where/When
MelIa et al (1977) Colds gomg to chest showed a prevalence Symptoms durmg past Gas stove vs 6-11 5,658 28 Areas of
of 268-198% 12 mo recalled by electnc stove England and
chtld's parent m Scotland (1973)
completmg respIratory
symptoms
questIOnnaire
MelIa et al (1979) Responses to respIratory questIOns As above Gas stove vs 5-10 4,827 27 areas of
grouped mto (a) none or (b) one or more electnc stove England and
symptoms or dIsease types Colds gomg Scotland (1977)
to chest (26 4-19 6%) showed the htghest
-
prevalence, followed by wheeze
(10 1-62%), cough, and epIsodes of
.j::o.
I
asthma or bronchttIs m last year
VI
.....:J MelIa et al (1980) Group response to respIratory questIOns As above N02 measured WIth 6-7 103 Middiesborough,
Florey et al (1979) as above Palmes tubes Gas England (1978)
Goldstem et al (1979) stove homes only
Mella et al (1982a) As above As above N02 measured WIth 5-6 188 Middiesborough,
Palmes tubes Gas England (1980)
stove homes only
Ware et al (1984) Lower respIratory Illness mdex (mdex of QuestIOnnaire (Ferns, Gas vs electnc 6-10 8,240 SIX U S CItIes
respIratory health) mdicatmg dunng past 1978) completed by (1974-1979)
year the presence of (a) bronchtns, parent for symptoms
(b) respIratory Illness that kept the chtld dunng preVIous 12 mo
home 3 days or more, or (c) perSIstent
cough for 3 mo of the year
TABLE 14-18 (cont'd). HEALTH OUTCOME AND NITROGEN DIOXIDE EXPOSURE :MEASURES USED IN
SELECTED INDOOR NITROGEN DIOXIDE EPIDEMIOLOGY STUDIES
NO z Exposure
Measure Used Age Sample
a
Reference Health Outcome Used m Meta-AnalysIS Method m AnalYSlsb (years) SIze WherelWhen
Neas et al (1990, 1991) Combmed mdlCator of one or more lower Symptom questionnarre NOz measured WIth 7-11 1,286 SIX U S CIties
respIratory symptoms as defined The completed by parent for Palmes tubes Gas (1983-1986)
highest prevalences were for chromc the year dunng which and electnc stoves
phlegm and wheeze The other measurements ofN~
symptoms m the mdex are shortness of were taken
breath, chromc cough, and bronchItis
Chest l1lness reflects a restnction of the
chtld's activIties for 3 or more days
Ekwo et al (1983) Chest congestlOn and phlegm WIth colds Questionnaire (ATS) Gas stove vs 6-12 1,138 Iowa City, Iowa
completed by parent electnc stove
I--' DtJkstra et al (1990) RespIratory l1lness combmation vanable QuestlOIDlalre (WHO) NO z measured With 6-12 775 Netherlands
.j::o.
I
VI
Brunekreef et al (1987) of presence of one or more of cough, completed by parent Palmes tubes Gas (1986)
00 wheeze, or asthma and electnc
apphances
Keller et al (1979a,b) RespIratory l1lness Telephone mterview by Gas stove vs <12 176 Columbus, Ohio
nurse epldetmologlst electnc stove (1978)
a
ATS = Amencan ThoraCIC SOCIety
WHO = World Health OrgalllZatlOn
b
NO z = NItrogen wOXlde
respIratory functIOn), thts suggested that the questIOns may be mdicators of lower respIratory
morbIdIty (whereas others such as earache or hospIta1lzatIOn for upper respIratory dIsease m
the last 12 mo may not) Thus, the more subjective morbIdIty measurements by the
questIOnnarres were supported to some extent by more dIrect objective lung functIOn
measurements Meha et al (1977) mdIcated that the htghest prevalence was for colds gomg
to the chest (approXImately 25 %), followed by wheeze (approXImately 10%) BronchttIs and
asthma epIsodes m the past year had respective prevalences of less than 6 % and 3 % The
1977 studIes showed very sImilar prevalences (Meha et al , 1979) to the 1973 data, wIth the
prevalence of asthma and bronchttis epIsodes both under 4 % and colds gomg to chest at
approXImately 25% m 1977
For these Meha studIes, two mdIcators, colds gomg to chest and wheeze, proVIde the
major contnbutIon to the combmed mdIcator for lower respIratory health DIsease mdicators
such as asthma and bronchttIs epIsodes m the past year, although measures of lower
respIratory dIsease, may playa smaller role The Meha et al (1979) study prOVIdes data
that allow the development of graphs of the margmal Wcehhood functIOns (see FIgure 14-4)
of the odds ratIOS for symptoms and dIseases and any respIratory illness for the combmed
mdIcator of boys and gIrls The odds ratIo for colds to chest IS 1 21 (SD of the log [OR] =
o 0675) and for any respIratory illness IS 1 24 (SD of the log [OR] = 0 0703) Tills
demonstrates the sImilanty of these two outcome measures More specIfically, It shows how
colds gomg to the chest represent an Important component of Meha's respIratory mdex
In the quantitative analySIS, the outcome measure used IS colds gomg to chest for the Meha
et al (1977) study and the lower respIratory mdex for the other Meha studIes
Other N02 studIes use dIfferent mdexes or combmatIOns that mc1ude symptoms such as
chromc phlegm and wheeze, perSIstent cough, respIratory illness, and asthma and bronchttIs
(Ware et al , 1984, Neas et al , 1990, 1991, Dljkstra et al , 1990, Keller et al , 1979b)
These symptoms m the mdexes are all mdicators of mvolvement of the lower respIratory
tract and, as such, form a measure of lower respIratory health In most cases, chest colds
and wheeze, or SImilar mdicators, are the promment symptoms m the mdex Use of the
same mdex m several of the N02 studIes and SImilar mdexes m the other N02 studIes
proVIdes conSIstency m the outcome measurements of the studIes
14-59
- - - - - - - - --- -
f\
\ Combmed Indicators
\
V Lower Respiratory
Illness
I
\I
,,
I
, I
\
I
I
I
I
\
\,
,, Day or Night
. / Cough
/ Mormng
Cough
o 05 1 15 2
Odds RatiO
Figure 14-4. For the Melia et aI. (1979) study, a graph of the marginal likelihood
function of the odds ratios for combined gender (boys and girls) of the
respiratory illness outcome measures developed by EPA.
How do the outcome measures m the N02 studIes compare wIth mdicators of lower
reSpIratory health status done m other studIes? The studIes of lower resprratory illness
(unrelated to N02 exposures) dIscussed m SectIOn 143 were based on VISItS to physIcIans
The SIgns and symptoms that were most common m those studIes, wet cough and wheeze,
are SImIlar to the most common end pomts m the N02 studIes, that IS, colds gomg to chest
and wheeze Thus, to an extent, the N02 respIratory studIes are provIdmg a measure of
lower respIratory health somewhat eqUIvalent to these other studIes SpecIfic pedmtnc
dIseases and agents such as bronchIOhtls and RSV are mvestlgated m these other studIes and
not m the N02 respIratory studIes The overall pattern and mCIdence of lower respIratory
14-60
Illness are cons1dered to be cons1stent m drfferent geographlc reglOns over tune (Wnght
et al , 1989, Denny and Clyde, 1986, McConnochle et al , 1988)
Lower resprratory Illness 1S an entlty commonly defmed by cntena for chmcal
magnOS1S (Wnght et al ,1989) Key stumes (Monto et al , 1971, Tauss1g et al , 1989,
Glezen et al , 1971, Gardner et al , 1984, and Maletzky et al., 1971) cons1der the
classIficatlOn of lower resprratory msease and surveillance methods
I
Standardlzed and
umformly accepted chmcal cntena have not been developed for the Illnesses cons1dered to
make up lower resprratory Illness, that 1S, for croup, tracheobronchlt1s, bronchloht1s, and
pneumonia The extent to which the magnostlc cntena for lower resprratory Illness were
documented vanes m these stud1es The charactenstlc S1gnS and symptoms are wheeze,
phlegm from chest, and deep cough These are bas1c resprratory symptoms md1catlve of
lower resprratory mvolvement Samet et al (1992) classIfied Illnesses as lower resprratory
tract illness IT wet cough or wheeze occurred at any tmle dunng the illness exposure Bates
et al (1990) note that dlfferentlatlon among "acute bronchltls", "acute bronchlohtls", and
acute exacerbation of "asthma" 1S chmcally chfficult, therefore, 1t 1S unrealistlc to expect
flmte and noncontrovers1al dlfferentlatlOn among these conmtlons
For the purpose of analys1s of Illness rates, ch11men w1th lower resprratory morb1d1ty
may be cons1dered to belong to a smgle populatlOn W1tllt a slIDl1ar illness. Although drfferent
mseases are grouped together as lower resprratory Illness (such as croup, bronchlohtls, and
pneumoma), the lower resplIatory Illness syndrome des1gnatlon (Monto et al , 1971) 1S a
means of groupmg these Illnesses of slIDl1ar pattern for analytIc purposes It 1S relatlvely
easy to classtfy Illnesses on the bas1s of anatom1C area of mvolvement Graham (1990) states
that classIficatlOn by anatom1C s1te remams the preferred system for most phys1c1ans and 1S
compatible wIth the IntematlOnal ClassIficatlon of D1seases system Such a classIficatlOn 1S
often a good mmcatlOn of the seventy of Illness
The resprratory questlonnarres used m the N02 stud1es determmed the state of lower
resprratory health m the subjects by tabulatlng responses to questlons on resprratory
symptoms such as cough and wheeze and on resplIatory Illnesses such as asthma and
bronchltls Symptom reportlng prov1des subJectlve eV1dence of resprratory mfectlOn and
mseases such as bronchltls D1seases are charactenzed by groups of symptoms D1sease end
pomts such as asthma and bronchlohtls may have SlIDllar defmmg symptoms Lower
14-61
respiratory morblChty reflects a broader groupmg, WIthm winch the ability to drfferentIate
between the wheeze of asthma and wheeze related to other causes or mfectIOns m the
pediatnc age group may not be readIly possIble Wnght et a1 (1989) note that wheeze IS
recorded as occurnng for several dIagnoses to mclude croup, bronclnohtIs, bronclntIs, and
pneumoma QuestIons of asthma ill the past year may not represent a dlsease-defmmg
measure as much as a measure of wheeze AddItIonally, asthma may be related to the
occurrence of mfection as a precIpItatmg cause, thus further confusmg dIfferences between
symptoms and dIsease
The N02 studIes of lower respIratory health are Implemented by use of StandardIZed
questionnarres filled out by the parent for illness and symptoms dunng the past 12 mo The
purpose of a respIratory symptom questIonnarre IS to compare prevalence of symptoms
(Fairbarrn et al., 1959) and to follow theIr rate of progressIOn m populatIOns ThIs facilitates
the quantitatIve companson between groups ThIs, however, contrasts fundamentally wIth
the usual objectIve of chmcal medIcme, that IS, a decISIon about an mdIvIdual provIdmg an
accurate diagnOSIS of the patIent's condItion to detennme the correct treatment or prognOSIS
In surveys of prevalence, vahd compansons can be made wIth less accurate data, provIdmg
that a sufficIent populatIon IS studIed and that maccuraCIes of reportmg are randomly
dIstnbuted between the groups bemg compared StandardIZed questIOnnarres permIt
meamngful compansons of the results of prevalence surveys (Samet, 1978) MItchell et al
(1976) note that the mformatIOn obtamed from the subjects m a respIratory health study that
used a questionnarre are probably an accurate reflectIOn of the lung dIsease expenenced by
the total populatIon of these commumtIes
Childhood lower respIratory morbIdIty IS characterIZed by a groupmg of SImIlar
symptoms and dIseases that reflect changes located anatomIcally m the lower respIratory
tract. This charactenzatIon represents an mdIcatIOn of seventy of the respIratory morbIdIty
status of the clnldren and IS a multIfaceted approach to respIratory health m a populatIOn
livmg under natural condItIons Lower respIratory morbIdIty IS the combmatIon of drfferent
respIratory effects that have m common an evaluatIon of the morbIdIty status of the lower
respiratory tract. The measure of effect on the lower respIratory tract vaned among the
studIes; the indIcators, however, are conventIOnal symptom and illness outcomes The
symptoms are tabulated from SImIlar standardIZed questIOnnarres (Ferns, 1978) and are
14-62
drrected at ehcItmg the same basIc data-an mchcatIOn of the presence of illness or InfectIOn
m the lower respIratory tract
Although the use of IdentIcal health outcome measures would be most desIrable, the
level of sImI1anty and common elements between the outcome measures m the N02 studIes
provIde some confidence m theIr use m the quantItatlve analysIs However, the symptoms
and illnesses combmed are to some extent chfferent and could mdeed reflect chfferent
underlymg processes Thus, cautIOn IS necessary m mtetpretIng the analysIs ThIs concern
IS addressed further later in this section as part of the sltatlstIcal aspects of the random-effects
model
14.6.2 Biologically Plausible Hypothesis

The human chmcal and animal tOXicological stuches m Chapters 13 and 15 that
exammed N02 effects on aspects of the respIratory host defense system provIde a
bIOlogICally plausIble hypotheSIS compatIble WIth the relatIOnshIp seen between respIratory
symptoms and morbIdity and N02 exposure m epIdemIOlOgiC stuches However, research
gaps m both anImal tOXicologICal and chmcal stuches eXIst, mdicatmg the need for further
research efforts A bnef diScussIon IS presented here.
The lung IS one of the SItes of mIcrobIal InfectIOn Although many types of
microorgamsms are Imphcated m respIratory InfectIOn, vrruses represent a major cause of
respIratory disease, particularly for Infants and chIldren In a vIral respIratory InfectIOn,
vIral rephcatIOn produces mJury and, thus, the SIgnS and symptoms of respiratory illness
(Douglas, 1986) The respIratory system has several defense mechamsms agamst Inhaled
Infectious and chemIcal agents Host defense mechanISms conSIst of nonspecIfic and specIfic
components The nonspecIfic aspects mclude mucociliary clearance and alveolar
macrophages, whereas humoral and cellular Immumty offer specIfic defenses The Immune
system functions through a sequence of events, startmg WIth the nonspecIfic components
followed by responses by the specIfic components Thle Immune system IS a pnncipal factor
m the host's mteractIon WIth Infectious agents such as vrruses and m the host's ability to
contam and/or eradicate the estabhshment of InfectIOn To some extent, an mcrease of
reported resprratory symptoms m some epIdemIology studies may be an mdicatIon of the
ability of the respIratory host-defense mechamsm to eIther overcome an Infection or to hmit
14-63
its severity. Nitrogen dIoXIde may affect the unmune system m such a way that one or
several aspects of the unmune system do not functIOn at a level sufficIent to Innit the extent
or occurrence of infectIon NItrogen dIoXIde may to some degree mfluence resprratory
symptom rates by drrect tOXIC mechanIsms Meulenbelt and Sangster (1990) note that N02
may cause drrect epithebal damage that could mcrease susceptIbility to mfectIOn
The evidence from animal tOXIcological and human cbmcal studIes of host defenses
provIde a ratIonale for mvestIgatlng the relatIon between exposure to N02 and an mcrease m
frequency and seventy of resprratory symptoms and/or mfectIons m humans When
microorganIsms attack a lung that has been exposed to N02 , host defense mechanIsms altered
by the N02 exposure may result m mcreased seventy or rate of resprratory illness Although
the host defense system reacts both very specIfically and generally to the challenge, the
overall response ill humans IS expressed as a generalIzed demonstratIOn of SIgns and
symptoms that may be aSSOcIated WIth a SIte such as the lower resprratory tract and also may
be reported or objectIvely dIscerned as a general outcome such as a chest cold, cough, or an
incident of asthma or bronchItIs
14.6.3 Publication Bias

Pubbcation bIas, also known as the "rile drawer problem" (Rosenthal, 1979), IS the
result of the mcreased bkebhood of pubbcatIOn of studIes that have pOSItIve results, leadmg
to a bias in the bterature reVIewed towards pOSItIve results There are two factors that make
this bias less bkely for epIdemIOlOgical studIes FIrst, the studIes are expensIve, well
pubbcized, and the results are usually pubbshed m order to gIve credIt to the researchers
involved. Second, many of the studIes mcluded m thIs sectIon dId not produce statIStIcally
signIficant rmdmgs, indIcatmg that there was not a problem m pubbshmg negatIve studIes
However, some studIes are necessarily excluded because they provIde msufficient
information. Although thIs can lead to bIaS, there IS bttle that can be done to correct for thIs
problem This problem is not normally referred to as pubbcatIon bIas, but It IS a sunilar
problem.
14-64
14.6.4 Quantitative Analysis
In order to compare avatlable mdoor studies on resprratory effects of N02 , a common
end pomt for a health outcome effect was defmed, and then each study was compared with
tills standard end pomt The end pomt chosen was the presence of lower resprratory
symptoms and illness m ch11dren aged 5 to 12 years .An assumptiOn has been made that the
relative odds of developmg tills lower resprratory morblwty outcome is slIDl1ar across tills
age range as a function of N02 exposure, even though 1he actual rates may not be (This is
a common assumptiOn m many analyses)
An attempt was made to mc1ude as many mdoor stuwes as pOSSible The requrrements
for mc1usion were (1) the health end pomt measured must be reasonably close to the standard
end pomt, (2) signrficant exposure illfferences between subjects must eXist and some estimate
of exposure must be avatlable, and (3) an odds ratiO fOl a specIfied exposure estlIDate must
have been calculated, or data must be presented so that an odds ratio can be calculated All
studies that met the cntena for mc1usiOn were mc1uded Quahty scores were not aSSigned to
the studies There is no eVidence that the use of qualIty scores lIDproves estimates (see
Emerson et al ,1990) Separate analyses for studies that had specIfic features that might be
conSidered m quahty scores, such as measured N02 mstead of surrogate estimates, are
exammed later as part of the analYSiS
The tenn "exposure" is lllSed to denote the pattern of concentrations of a pollutant m arr
through willch an mwvidual passes dunng a fiXed penod of tlIDe The term "exposure
estimate" will be used for any measure that estlIDates some function of that pattern, such as
the anthmetic average Exposure estimates mc1ude both personal momtors used for some
fraction of the total exposure time as well as fiXed momtors located m rooms known to be
OCCUpied by mWVlduals for some fractiOn of the tlIDe Some estlIDates may be based on
averages from Sites With slIDl1ar exposure charactenstics, such as presence of a gas stove
Thus, exposure estlIDates are defmed as an estlIDate based on some data of the exposure of
the group bemg stuwed Such an estimate cannot perfectly charactenze true exposure See
Section 7 3 for a more detailed diSCUSSiOn on exposure to N02
The goal was to estimate the odds ratio correspondmg to an mcrease m concentration
3
level of 0015 ppm (28 3 p,g/m ) as an estlIDate of N02 exposure Stuwes With N02
exposure measures used 1- to 2-week mtegrated mdoor measurements by Palmes paSSive
14-65
dtffusion tubes that provIde an estnnate for chromc exposure StudIes that charactenzed N02
exposure by chfferences between gas stove and electnc stove use estunated a value for tills
chfference Four studIes measured N02 levels FIve studIes estunated exposure to N02
based on the presence or absence of a gas stove as a surrogate for N02 measurements
Exposure measurement error related to use of a surrogate was dISCUSSed earher To use
these studies m the meta-analysIs, numencal values of exposure estunates must be
detennined Three of the studIes were conducted m the Umted States (Ware et al , 1984,
Ekwo et al , 1983, and Keller et al , 1979a,b) and two m Great Bntam (Meha et al , 1977,
1979).
Limited data are avaIlable from willch to estnnate N02 exposure values Appropnate
estnnates Ideally would be country specIfic, current wIth the studIes m locatIOn and tune, and
denved from a representatIve sample that appropnately charactenzes the exposure The
Neas et al. (1991) study may be an appropnate source to estnnate a value for the three
United States studIes Tills study had a large sample SIZe, measured levels dunng two
seasons, and was conducted m the same Umted States CItIes as Ware et al (1984) was Neas
et al. (1991) reported a housewide average difference of 00173 ppm (32 5 p,g/m3) N02
between homes WIth electnc stoves and homes WIth gas stoves WIth pilot hghts In two
British studIes (Meha et al , 1980, 1982a,b) conducted by the same authors that conducted
Melia et al (1977, 1979), data on the difference m levels between homes WIth electnc stoves
and homes WIth gas stoves IS proVIded Meha et al (1980, 1982a,b) proVIde data that
indIcate 0.0165 ppm (31 1 p,g/m3) as an estunate of tills difference m average N02
concentratIOns m bedrooms of homes m Bntam
The effects studIed may be related to peak exposures, average exposures, or a
combination of the two To the extent that health effects depend on peak exposures rather
than average exposures, the above exposure estnnates mtroduce exposure measurement error
These studies cannot dIStinguISh between the relative contnbutIons of peak and average
exposures and therr relationship WIth the observed health effects AddItIOnally, a by-product
of N02 , HONO, may be a factor m observed effects, however, hmited health and aerometnc
data are avaIlable that examine such pOSSIbilities
The above factors are used when evaluating each study The BntIsh studIes prOVIde
several estnnates of the subject odds ratio Meha et al (1977) studIed children aged 6 to
14-66
11 years and developed an mdIcator of the presence of at least one of a group of symptoms
mcludmg cough, colds gomg to the chest, and broncIntm The symptom reported most often
was llcolds gomg to chest II , winch was used as an mdIcator of lower resprratory morbIdity
ThIs study dId not measure N02 exposure, and so the assumption was made that the mcrease
m N02 exposure from gas stove use m England was rea.sonably sllD.l1ar to that m the other
British studIes that measured N02 , that is, an mcrease of 00165 ppm (31 1 p.g/m3 ) The
esumated odds ratio was 1 31, WIth 95 % confidence htmts of 1 16 and 1 48 After adjusting
to a standard mcrease of 0015 ppm (28 3 p.g/m3 ), the odds ratiO became 1 28 WIth
95% confidence hmits of 114 and 1 43 No adjustment was made for parental smolang m
tIns study
The cross-sectiOnal data reported by Meha et al (Jl979) on clnldren aged 5 to 10 years
also was employed to esumate an odds ratio, although no exposure estnnates were made
The presence or absence of a gas stove was used as a surrogate as m the Meha et al (1977)
study The estnnated odds ratIO was 1 24, wIth 95 % confidence hmlts of 1 09 and 1 42
After adjust1ng to a standard N02 mcrease of 0015 ppm (28 3 p.g/m3 ), the odds ratio
became 1 22 wIth 95% confidence hmitS of 1 08 and 1.37
Meha et al (1980) studIed clnldren aged 6 to 7 years and measured bedroom N02
levels for the exposure estnnate ThIs study apphed the same combmed health end pomt as
the previOus study The esumated odds ratio for an N02 increase of 0 015 ppm
3
(283 p.g/m ) was 1 49 wIth 95% confidence hmlts of 1 04 and 2 14
Meha et al (1982a) studIed clnldren aged 5 to 6 years, measured N02 exposure m the
bedroom, and also apphed the same combmed health end pomt The 10th and 90th
percentIles of the weekly measured concentrations were 0 009 and 0 065 ppm N~,
respectively, ill bedrooms (Meha et al , 1982b) The esumated odds ratiO for an N0 2
mcrease of 0015 ppm was 1 11, WIth 95% confidence llnmts of 0 84 and 1 46
In the fIrst SIX CIty study cohort, Ware et al (1984) reported an mdex of resprratory
illness Exposure to N02 was based on the presence or absence of a gas stove (0 0173 ppm
[32 5 p.g/m3 ]) The esumated odds ratio was 1 08 WIth 95 % confidence hmlts of 0 97 and
1.19 After adjusting to a standard N02 mcrease of 0015 ppm (28 3 p.g/m3 ), the odds ratios
became 1 07 WIth 95 % confidence hmlts of 0 98 and 1 17
14-67
A second cohort of subjects m the SlX CIty study was InItIally reported on by Dockery
et al. (1989a). Thts cohort of clnldren aged 7 to 11 years was then remterviewed after
indoor N02 measurements were made, and the results of tbts analySIS were reported by Neas
et al. (1990, 1991). The 10th and 90th percentIles of the weekly measured concentrations
were 0.008 and 0033 ppm N02 , respectively m bedrooms (Neas et al ,1991) The
estimated odds ratio for an mcrease m the presence of any respIratory symptom resultrng
from an increase in N02 exposure of 0 015 ppm (28 3 p.,g/m3 ) was 1 40, wIth 95 %
confidence Innits of 1 14 and 1 72
Ekwo et al (1983) studIed several respIratory Illness end pomts from clnldren surveyed
at ages 6 to 12 years No exposure measurements were obtamed, and the exposure was
based on the presence or absence of a gas stove (0.0173 ppm [325 p.,g/m3 ]) None of the
end points matched the end pomt of mterest closely The two most SImtlar end pomts were
hospItalIzation for chest illness before age 2 and chest congestion and phlegm WIth colds
The estImated odds ratio for hospItalIzation was 2 40. The estImated confidence lImIts for
cough and phlegm WIth colds was 1 09, WIth 95 % confidence lImIts of 0 82 and 1 45 Thts
last symptom appears to be most SImtlar to the end pornt of mterest, and so It was mcluded
m the synthesis
The data presented by DIJkstra et al (1990) on the study m the Netherlands were
analyzed and gave an estImated odds ratio of 0 94 for an mcrease of 0 015 ppm (28 3 p.,g/m3 )
in N02 exposure The 95 % confidence lImIts were 0 70 and 1.27. The study had measured
N02 exposure data, but the EPA analySIS dId not adjust for covanates because the covanates
were not included in the tables that mcluded N02 exposure
Keller et al (1979b) dId not frnd any statistically sIgmfi.cant changes m respIratory
disease associated with gas stove use, but the unadjusted estImated odds ratio for lower
respiratory illness was 072, with 95% confidence lImIts of 030 and 1 74. Assummg that
3
the N02 exposure mcrease was 0.0173 ppm (32 5 p.,g/m ), the odds ratiO was adjusted to an
exposure of 0.015 ppm (28.3 p.,g/m3 ) Thts resulted m an odds ratio of 075 WIth 95%
confidence Innits of 0 35 and 1 62
Three studies WIth suffiCIent Information for analYSiS were excluded from the syntheSiS
The Berwick et al (1989) analySiS has been cnticIZed for ItS lack of conSistency across age
groups, which may have resulted from the very small sample SIZes The SWISS study
14-68
(Braun-Fahrlaender et al , 1989, 1992) exammed end pomts that mIght not be consIdered as
sImIlar to the other studIes, such as upper resprratory dIsease, breathmg dJ.fficultIes, and
duratIOn of vanous resprratory measures The Meha et a1 (1988, 1990) study dId not
demonstrate sIgmficant estImated N0 2 exposure dJ.fferences between the two groups
3
contrasted (00034 ppm [64 !-'g/m ]) These dJ.fferences estImated m exposure were much
smaller than those seen for any other study of gas stove exposure ThIS may reflect use of
gas ranges wIthout pilot hghts and changes m cookmg practIces such as mcreased use of
mIcrowave ranges (see SectIon 7-3) If the relatIve nsk were adjusted for an mcrease of
0015 ppm (28 3 !-'g/m3 ), the relatIve nsk would be about 1 29, whIch IS comparable to the
odds ratIos seen m the other studies Because the dJ.ffenmce m exposure groups was so
small, requmng a very large adjustment, It was deCIded not to combme thIs study wIth the
other studIes For these reasons, the above studIes were not mcluded m the synthesIs
These studies, however, qualItatIvely support the results of the synthesIs
Graphs of the odds ratIo from each mdoor study mcluded m the quantItatIve analySIS
are depIcted m FIgure 14-5 Each curve can be gIven one of three mterpretatIons (1) the
normal approXImatIOn to the margmal hkehhood of the loganthm of the odds ratIO,
(2) a dIstnbutIOn such that the 2 5 percentIle and the 97 5 percentIle pomts of the dIstnbutIon
are the 95 % confidence hmitS of the estImated odds ratIo, and (3) the postenor for the odds
ratIO for a partIcular study gIven a flat pnor on the log-odds ratIo The basIc InformatIOn for
each curve IS proVIded m Table 14-19
SyntheslZmg eVIdence (often referred to as meta-analysIs) IS not new, havmg been used
as early as 1904 (Pearson, 1904) Sacks et al (1987) defmes meta-analysIs as a disciphne
that cntIcally reVIews and statIstIcally combmes the results of preVIOUS research Meta-
analyses are bemg used much more frequently now, as mdicated by Mann (1990) For
example, the NatIOnal Research CouncIl (1986) combmed eVIdence on the effect of
envIronmental tobacco smoke on lung cancer usmg Peto's method as descnbed by Yusuf
et al (1985) Also, several methods for combmmg chmcal tnals were dIscussed by Larrd
and Mosteller (1990) The eVIdence to be combmed m thIs sectIOn comes from
epIdemIOlogIcal studIes and, as a result, some of the methods used for chmcal tnals are not
appropnate for thIs sectIon
14-69
/ Combined (fixed)
-c
o
o
J::
=c:
~.Q
=0
lJ)c:
;::.2 mbined (random)
oS-,=,
1U~
C:lJ)
Q-c
8.~ Ware et at (1984)""" jMelia et al (1979)
e.o
c.~
-fIlO...
EC.
-Mella et al (1977)
Cl
~ Dljkstra et at (1990\
/ Neas et ai (1991)
Ekwo et al (1983)
Mella et 81 (1980)
Keller et aJ (1979b)
o 05 1 15 2
Odds Ratio
Figure 14-5. U.S. Environmental Protection Agency meta-analysis of indoor

epidemiologic studies of nitrogen dioxide exposure effects on respiratory
disease in children 5 to 12 years old. Each curve can be treated as a
likelihood function or posterior probability distribution. If treated as a
likelihood function, the 95% confidence limits for the odds ratio can be
calculated as those two points on the horizontal axis for which 95% of the
area under the curve is contained between the two points. If treated as a
posterior probability distrIbution, then the area under the curve between
any two points is the probability that the odds ratio lies between those two
points.
Two basIc models are employed m order to combme eVIdence (Hasselblad et al , 1992)
The first model assumes that each study estImates the same fixed, but unknown, parameter
Most methods of combmmg eVIdence make tills assumptIOn One of the earhest attempts to
combine data usmg a fIXed-effects model was gIVen by Brrge (1932) HIS method weIghts
the estImates mversely by therr vanances and produces a combmed estImate and assocIated
confidence lImItS Other methods mclude the Mantel-Haenszel method (Mantel and
Haenszel, 1959), willch IS used to combme contmgency tables Recently, BayeSIan methods
14-70
TABLE 14-19. SUM:MARY OF ODDS RATIOS FROM INDOOR STUDIES OF THE
EFJFECTS OF NITROGEN DIOXIDE INCREASED BY 0.015 ppm
2 5 and 97 5 PercentIles
Authors Estnnated Odds Ratio (Confidence Interval)
Mella et al (1977) 128 1 14 to 1 43

Mella et al (1979) 122 108 to 1 37
Mella et al (1980) 149 104 to 214
MelIa et al (1982a) 111 084 to 1 46
Ware et al (1984) 107 098 to 1 17
Neas et al (1991) 140 1 14 to 1 72
Ekwo et al (1983) 109 082 to 145
DIJkstra et al (1990) 094 070 to 1 27
Keller et al (1979b) 075 035 to 1 62
have been used to combme eVIdence, and methods partIcularly appropnate to these kInds of
studIes were descnbed by Eddy (1989) and Eddy et al (l990a,b) BayeSian analyses requITe
the chOIce of a pnor distnbutlOn for the parameter of illIterest, WhICh IS often a
nonmformatIve pnor A nonmformatIve pnor IS one that, pnor to seemg the eVIdence,
favors no value of the parameter over any other The mterestmg fact about use of these
methods IS that, for the data sets conSIdered m Table 14-19, the results of the computations
were nearly Identical ThIs IS because the (margmal) hkehhood for the odds ratio IS closely
approxnnated by a lognormal curve The mteIpretatIons of these curves are dIfferent, as
descnbed earher
The second baSIC model assumes that the parameter of mterest IS not fIxed, but IS Itself
a random vanable from a dIstnbutlOn The value of thIs random vanable IS dIfferent for
each study, but each study gIves some mformatlOn abou1 the mean of the mstnbutlOn These
models go by several names, mcludmg random-effects models, miXed models, two-stage
models, or hIerarchIcal models The pUIpose of a random-effects model IS to relax the
assumptlOn that each study IS estImatmg exactly the same parameter ThIs Idea IS not new,
havmg been dIscussed by Cochran (1937) For a mSCUSSlOn of the mteIpretatIon of random-
effects models m chmcal tnals and several methods of estImatmg the parameters of these
models, see DerSImoman and Laird (1986) If the studIes bemg combmed tend to estImate
the same parameter, then the results usmg a random-effects model will approach the results
usmg a fiXed-effects model On the other hand, If the studIes are estImatmg very dIfferent
14-71
parameters, then the confidence lnmts will tend to be much broader than those obtamed from
a fixed-effects model
The mne mdoor studIes descnbed earher (Tables 14-18 and 14-19) were combmed
usmg both kmds of models The results usmg a fixed-effects model are labeled "flXed", and
results of the random-effects model are labeled "random" (see FIgure 14-5) Methods for
estlmatmg the parameters of a random-effects model were descnbed by DerSlffioman and
Larrd (1986) and Eddy et al (1992) The results of the analyses are provIded m
Table 14-20
TABLE 14-20. U.S. ENVIRONl\tIENTAL PROTECTION AGENCY COMBINED

ANALYSES OF INDOOR STUDIES ON RESPIRATORY ILLNESS EFFECTS OF
NITROGEN DIOXIDE INCREASED BY 0.015 ppm
FIxed-Effects Model Random-Effects Model
Number of Odds Confidence Odds Confidence
Groupa StudIes Ratio Interval Ratio Interval
All 9 1 17 I11to123 1 18 108 to 1 28
Umted States 4 111 102to120 1 13 097 to 132
BntIsh 4 125 1 15 to 135 125 1 13 to 1 37
Measured N02 4 123 108 to 1 41 122 099 to 1 50
Gas stove surrogate 5 1 15 109to123 1 16 103 to 1 30
SES adjusted 3 127 1 17 to 1 37 127 1 15 to 1 41
SES not adjusted 6 107 100 to 1 16 108 097 to 1 21
Smokmg adjusted 2 128 109 to 1 52 125 092 to 1 71
Smokmg not adjusted 7 1 15 109to122 1 16 104 to 1 28
Gender adjusted 5 126 1 18 to 1 36 127 1 16 to 1 39
Gender not adjusted 4 105 097 to 1 14 105 096 to 1 15
aN02 = Nitrogen dIOXide

SES = SocloeconOlmc status
The first hne of Table 14-20 shows the results of combmmg all mne mdoor studIes
usmg a flXed model The estlffiated odds ratio IS 1 17 and the 95 % confidence hmitS are
1.11 and 1 23 The analySIS was made assummg that the parameters were the same
(homogeneous), and tills can be tested The chI-square test for homogeneIty for the mne
studies was 12 32 for 8 degrees of freedom, willch has a p-value of 0 1375 Thus, there IS
some eVIdence that the parameters from each study are not Identical The estlffiates for the
random-effects model (also shown on the first hne of Table 14-20) are slffil1ar to the
estimates for the ['lXed model, but the confidence hmitS are shghtly broader The conclUSIOn
14-72
from both models IS the same, namely that the odds ratio IS estimated to be about 1 2 wIth
95 % confidence mtervals rangmg from about lito 1 3 (Hasselblad et al ,1992) Many
researchers have suggested that the random-effects model IS the more appropnate model
because It does not assume that all studIes estImate the same parameter Furthermore, the
random-effects estimates will approach the ftxed-effects estImates when studies gIve sImilar
estlmates
These studIes mclude results from North Amenca and Europe Meta-analyses of
studIes from dIfferent countnes are common For example, Canner (1987), Littenberg
(1988), and Jaeschke et al (1990) all combmed studIes done m both North Amenca and
Europe and dId not adjust for geographIc dIfferences The mdoor N02 studIes were
compared by country Four of them were done m Great Bntam (Meha studIes), and four m
the Umted States (Ware et al , Neas et al , Ekwo et al , Keller et al) The BntIsh studIes
proVIde the hIghest estImated odds ratio (random-effects model), 1 25, the U S studIes gIve
a combmed estlmate of 1 13
Four of the nme mdoor studIes used measured NO z values, whereas the other five dId
not The use of a surrogate for exposure should tend to reduce the estImate of the effect (see
Samet and Utell, 1990) The measured N02 studIes ga\le an estimated odds ratIo (random-
effects model) of 1 22, whereas the others gave an estimate of 1 16, whIch IS conSIstent WIth
a measurement error effect
Table 14-21 hsts the Important covarrntes conSIdered m these nme studIes and shows If
the covanate was used m the study and the meta-analysIs Study deSIgn and exposure
measurement source are also presented The effect of havmg adjusted for vanous covanates
can be seen m Table 14-20 In general, those studIes that adjusted for a partIcular covanate
found larger odds ratIos as compared WIth those that dId not
Although there may be reasons to weIght certam studIes or groups of studIes more
heavily than others, the fmal conclusIon has to be that there IS an mcrease m the odds of
respIratory dIsease of children exposed to N02 , especmUy those of elementary school age
Subject to assumptions made for the combmed analySIS, the mam conclUSIOn from that
analySIS was that an mcreased nsk of about 20 % for respIratory symptoms and dIsease
corresponded to each mcrease of 0 015 ppm (28 3 p,g/m 3) m estlmated 2-week average N0 2
exposure, where mean weekly concentratIOns m bedrooms m studIes reportmg N02 levels
14-73
TABLE 14-21. COVARIATE TREATMENT AND OTHER FACTORS IN SELECTED
NITROGEN DIOXIDE EPIDEMIOLOGY STUDIES IN META-ANALYSIS
a
Covanates
Parental l3xposure ~easureOlent
Reference sm SOlOkmg Gender DesIgn Source
~elia et al (1977) A NM A Cross- Gas stove vs electnc
sectIOnal stove b
Meha et al (1979) A ~ A Cross- Gas stove vs electnc
sectIonal stove b
Meha et al (1980) ~ ~ A Cross- N02 Oleasured wIth PalOles
sectIOnal tubes Gas stove haOles
only
Meha et al (1982a) M ~ A Cross- N02 Oleasured WIth PalOles
sectIOnal tubes Gas stove haOles
only
Ware et al (1984) M M ~ Cross- Gas stove vs electnc
sectIOnal stove C
Neas et al (1991) A A A Cross- N02 Oleasured WIth PalO1es
sectIonal tubes Gas and electnc
stove haOles
:Ekwo et al (1983) NM A ~ Cross- Gas stove vs electnc
sectIonal stove C
DIJkstra et al (1990) ~ M M Cross- N02 Oleasured WIth PalO1es
sectIOnal tubes NOz eOlISSIOns
sources m haOles
Keller et al (1979b) M NM ~ ProspectIve Gas stove vs electnc
stove C
aSES = SoclOeconoIDlc status

A = Covanate mcluded m study and meta-analysIs
NM = Not measured m study
M = Measured m study but data not aVailable for meta-analysIs
bEsttmate of exposure denved from assumptIon of gas stove versus electnc stove levels m bedrooms m
England from data m MelIa et al (1980, 1982a,b) of approXImately 0 0165 ppm
cEstImate of exposure denved from assumptIon of gas stove WIth pIlot lIght versus electnc stove
levels averaged m the home m the Umtes States m Neas et al (1991) of apprOXImately 0 0173 ppm
were predoOlmately between 0 008 and 0 065 ppOl N02 (Hasselblad et al ,1992) The
studIes usmg Oleasured N0 2 gIVe a shghtly hIgher est101ate of the odds ratIo The est101ates
are not senSItIve to the assuOlptIOn that each study IS est101atmg the SaOle paraOleter as
mdIcated by the randoOl-effects Olodel In fact, the fmdIng of mcreased nsk across a WIde
14-74
vanety of study condItions suggests that the effects seen are not an artIfact of anyone
partIcular study
These results are not sensItive to the mclusIOn or eKclusIOn of anyone study It would
have been possIble to mclude the hospItabzatIOn results of Ekwo et al. (1983), the analysIs of
the SWISS study, or the BerwIck et al (1989) study None of these studies would have made
any real change m the estimated odds ratIOs or therr 95 % confidence lnmts
Vanous researchers have conducted studies of Infants less than 2 years of age (see
Table 14-22) A major difference for tms group of studJes IS that the health outcome
measures are less unIform than the studies of older chIldren For purposes of comparability,
a meta-analysIs snmlar to the one for older chIldren was calculated
The seven studies of Infants shown m Table 14-22 show mIXed results A test of
homogeneIty of the odds ratIOs gIves a cm-squared value of 22 66 for 6 degrees of freedom,
wmch has a p-value of 0 0009 that nnphes that the studIes are not homogenous The
vanatIon m results could be due to several factors, mcludmg dIfferent health outcome
measures and other factors Dockery et al (1989a) note that the aSSOCiatIOns dIscussed m
Ware et al (1984) and Dockery et al (1989a) must be VIewed WIth caution because they
compare recalled resprratory events early m the chIld's life Because of the heterogeneIty,
the studIes were combmed usmg a random effects model Subject to the assumptions made
for the meta-analysIs, the combmed odds ratIO for the mcrease m resprratory disease per
mcrease of 0 015 ppm N02 was 1 09 WIth a 95 % confidence mterval of 0 95 to 1 26, where
mean weekly concentrations m bedrooms were predommantly between 0 005 and 0 050 ppm
N02 m studIes reportmg levels Thus, although the overall combmed estnnate IS pOSItIve, It
clearly contams the no-effect value of 1 0 (1 e, IS not statistically sIgnIficant), and so we
cannot conclude that the eVIdence suggests an effect m :mfants comparable to that seen m
older children
There IS always the concern that the studIes descnbed m tms document are not the
complete hst of studies, but contam pnmarIly the pOSItive studIes because these are the
studIes most Wcely to get pubhshed Alternatively, nonSIgnIficant results may not be
reported WIth suffiCIent quantitative detail to permIt then mclusIOn Both of these effects can
be conSIdered as "pubhcatIOn biaS 1/ There are two reasons to be less concerned WIth
14-75
TABLE 14-22. SlJMlV£ARY OF ODDS RATIOS OF THE EFFECTS OF NITROGEN DIOXIDE, HEALTH OUTCOME,
AND EXPOSURE ESTIMATES FOR INFANT «2 years) EPIDEMIOLOGY STUDIES
Estunated 2 5 and 97 5 PercenttIes N02 Exposure
Reference Odds RatIo (Confidence Interval) Health Outcome Estunate (ppm) Age Where/When
11
Melta et al. (1983) 063 036-110 RespIratory Illness 00165 <1 year England (1978)
mCIdence
Ekwo et al (1983) 24 106-374 HospitaltzatIon for chest o 0173b <2 years Iowa
Illness before age 2
Ware et al (1984) 111 097-127 RespIratory Illness before o 0173b <2 years SIX. U S CItIes
age 2 (1974-1979)
Ogston et al (1985) 114 086-150 RespIratory Illness o 0165a <1 years Scotland (1980)
mCIdence
Dockery et al (1989a) 1 15 096-1 37 RespIratory I1lness before o 015 c <2 years SIX. U S CItIes
age 2 (1983-1986)
Margolts et al (1992) 112 063-204 PerSIstent lower o 0105 d < 1 year North Carolma
respIratory symptoms (1986-1988)
e
I-"
,J::.
Samet et al (1993) o 985e 0935-1038 Lower respIratory Illness o 015f <18 mo Albuquerque
I mCIdence (1988-1990)
.....:l
0'1
aEstllnate of exposure denved from assumptIOn of gas stove versus electnc stove levels m bedrooms m England from data m Melta et al (1980, 1982) of
approxllnately 0 0165 ppm
bEstllnate of exposure denved from assumptIon of gas stove WIth pIlot ltght versus electnc stove levels averaged m the home m the Umtes States m Neas et al
(1991) of approXimately 0 0173 ppm
~stImate of exposure denved from assumptIon of gas stove versus electnc stove levels averaged m the home m Umted States m Neas et al (1991) of
apprOXimately 0015 ppm
dEstImate of exposure denved from assumptIon of gas stove versus electnc stove levels averaged m the home m the Albuquerque study (Samet et al , 1993) of
apprOXimately 0 0105 ppm
eComputed from logIstIc regreSSIOn coeffiCIent denved from Samet et al (1993)
fExposure level used to convert logIstIc regreSSIon to an odds ratIO
pubhcatIOn bias m thts particular sItuatIOn FIrst, epIdemIOlogIcal studIes are very expenSIve
and reqUIre the work of many mdIvIduals The desIgns of studIes are usually descnbed to
the sCIentIfic commumty before the results are even known. Second, most of the studIes
CIted,m thts section were reported as negatIve studIes by the authors themselves, mdIcating
that there was no dIfficulty pubhshmg negatIve results However, some studIes are
necessanly excluded because they proVIde msufficlent mformatIOn Although thts can lead to
bIas, there IS little that can be done to correct for thts problem ThIs problem IS not
normally referred to as pubhcatIOn bIas, but It IS a SImIlar problem
14.6.5 Summary of Synthesis of Evidence

The eVIdence from mdIvIdual studIes of the effect of N02 on lower resprratory
symptoms and dIsease IS somewhat mIXed Most of the mdoor studIes used m the synthesIs
showed mcreased resprratory dIsease rates assocIated WJlth mcreased exposure A few of the
mdIvIdual studies were StatiStICally sIgmficant Combrnmg the mdoor studIes gIvmg
quantItatIve estImates of effects tend to show mcreases of lower resprratory morbIdIty m
chIldren assocIated WIth long-term exposure to N02 Combmmg the mdoor studIes as If the
end pomts were sImuar gIves an estImated odds ratIo of 1 2 (95 % confidence lImItS of
1 1 and 1 3) for the effect per 0 015 ppm mcrease of N02 on lower resprratory morbIdIty
(Hasselblad et al ,1992) ThIs suggests that subject to assumptions made for the combmed
analySIS, the mam conclUSIOn from that analySIS was that an mcrease of about 20 % m the
odds of lower resprratory symptoms and dIsease corresponded to each mcrease of 0 015 ppm
(28 3 p.g/m3 ) ill estImated 2-week average N02 exposme, where mean weekly concentratIOns
m bedrooms ill studIes reporting N02 levels were predomrnately between 0 008 and
0065 ppm N02 (Hasselblad et al ,1992) Thus, the combmed eVIdence IS SUpportIve for the
effects of estImated exposure to N02 on lower resprratory symptoms and dIsease m chtldren
aged 5 to 12 years
In the mdIvIdual mdoor studIes of mfants 2 years of age and younger, no conSIstent
relatIonshtp was found between estImates of N02 exposure and the prevalence of resprratory
symptoms and dIsease Based on a meta-analyses of these mdoor mfant studIes, subject to
the assumptIOns made for the meta-analysIs, the combmed odds ratIo for the mcrease m
resprratory dIsease per mcrease of 0 015 ppm N02 was 1 09 WIth a 95 % confidence rnterval
14-77
of 0.95 to 1 26, where mean weekly concentratIons In bedrooms were predomInately between
0.005 and 0 050 ppm N02 In stuches reportIng levels Thus, although the overall combIned
estunate IS posItIve, it clearly contaIns the no-effect value of 1 0, (1 e , IS not statIstIcally
slgmficant), and so we cannot conclude that the eVIdence suggests an effect In Infants
comparable to that seen In older chIldren
Several uncertaIntIes need to be consIdered In InterpretIng the above studIes and results
of the EPA meta-analysIs Measurement error In exposure IS potentIally one of the most
important methodologICal problems In epIdemIOlogIcal studIes of N02 Thus, measured N02
concentrations are not exposure values per se, rather, estunatlng actual exposure requrres
knowledge of both pollutant levels and related human actIVIty patterns The effects studIed
may be related to peak exposures, average exposures, or a combmatIon of the two To the
extent that health effects depend on peak exposures rather than average exposures, the
exposure estImates used In the above stuches and meta-analyses Introduce exposure
measurement error These stuches cannot chstmgUlsh between the relatIve contnbutIons of
peak and average exposures and therr relatIOnshIp wIth the observed health effects
AdchtIonally, a by-product of N02 , HONO, may be a factor In observed effects However,
only very limIted health and aerometnc data are avaIlable that examme such pOSSIbilitIes
Also, although the level of sImIlanty and common elements between the outcome measures
the N02 stuches proVIde some confidence In therr use In the quantItatIve analySIS, the
ill
symptoms and illnesses combIned are to some extent chfferent and could Indeed reflect
chfferent underlymg processes Thus, cautIon IS necessary In mterpretmg the meta-analysIs
results
14.7 CONCLUSIONS
Although there IS eVIdence that suggests that Increased estunated N02 exposure IS
assocIated wIth Increased respIratory symptoms In chIldren aged 5 to 12 years, the exposure
estimated may be madequate to determIne a quantItatIve relatIOnshIp between estunates of
exposure and symptoms The studIes wIth measured N02 exposure chd so only for penods
of 1 to 2 weeks and reported the values as averages None of the studIes attempted to relate
14-78
the effects seen to the pattern of exposure, such as short-tenn peaks Furthennore, the
extrapolatIon to possIble patterns of ambIent exposure IS dIfficult
Several researchers studied a dIfferent populatIon group that consIsted of mfants 2 years
of age and younger In the mdividual studIes of mfants. 2 years of age and younger, no
consIstent relatIonsmp was found between estnnates of N02 exposure and the prevalence of
respIratory symptoms and disease Based on a meta-analyses of these mfant studIes, the
overall combmed estnnate IS posItIve, however, It clearJly contams the no-effect value of 1 0,
(1 e , IS not statIstIcally sIgmficant); and so we cannot conclude that the eVIdence suggests an
effect m mfants.
Several studIes attempted to relate some measure of mdoor and outdoor N02 exposure
to long-tenn changes m pulmonary functIOn These ch~mges were margmally sIgmficant
No short-tenn studIes had mdoor exposures Most studIes did not fmd any effects, wmch IS
consIstent WIth results from controlled human exposure studIes (see Chapter 15) However,
the basIc conclusIOn IS that there IS msufficient epidemmiogical eVIdence to make any
conclusIOn about the long- or short-tenn effects of N02 on pulmonary functIon
14.8 SUMMARY
ThIs chapter dIscusses the epIdemIOlogIcal eVIdence for the effects of NOx on human
health The major emphaSIS IS on the effects of N0 2 because It IS the NOx compound
StudIed m most epIdemIOlogICal studies and because It IS the NO x compound currently of
greatest concern from a pubhc health perspectIve The results from the vanous
epIdemIOlogIcal studIes of N02 exposure effects on human health outcomes are summanzed
m AppendIX 14A
The studIes consIdered m th1s chapter were evaluated for several key factors, mcludmg
(l) measurement error m exposure, (2) misclasslficatIOIl of the health outcome,
(3) adjustment for covanates, (4) selectIOn bIas, (5) mternal consIstency, and (6) plaUSIbility
of the effect based on other eVIdence The health outcome should be an outcome for wmch
there IS good reason to suspect that N02 exposure has em effect Two health outcome
measures are generally conSIdered lung functIOn measuremen.ts and respIratory illness
Each study IS revIewed WIth specIal attentIOn gIVen to the factors Just dISCUSSed Those
14-79
studies that address these factors more appropnately provIde a stronger basIs for the
conclusIOns that they draw
Resprratory Illness and factors that affect ItS rate and/or seventy are illlpOrtant pubhc
health concerns TIns chapter discussed epIdemIologIcal fmdmgs relatmg N02 exposure to
resprratory Illness TIns effect IS of pubhc health illlportance because of the potential for
exposure to N02 and because childhood resprratory Illness IS common (Samet et al , 1983,
Samet and Utell, 1990) TIns takes on added illlportance because recurrent chIldhood
respiratory Illness may be a nsk factor for later mcreased susceptibility to lung damage
(Glezen, 1989)
AnImal tOXicologICal studies m Chapter 13 suggest that N02 exposure can illlpa:tr
components of the resprratory host defense system The observed mcrease m resprratory
symptoms and disease among chIldren m epIdemIologIc studies of N02 exposure may be the
result of an imparred resprratory host defense system The bIOlogICal plaUSIbility of thIs
hypotheSIs IS supported by the anilllal tOXicology data, but the hypotheSIS reqUITes further
testing.
Several of the mdoor epIdemIologIcal studies gave some eVIdence that repeated N02
exposure mcreases resprratory Illness m chIldren, although many were not statistically
significant Meha et al (1977) fIrst reported on a survey of chIldren m randomly selected
areas of England and Scotland usmg the presence of a gas stove as a measure of N02
exposure A reanalySIS of those data yIelds an estImated odds ratIO of 1 31 for the presence
of resprratory symptoms The cross-sectional study of Meha et al (1979) also found that the
presence of a gas stove was associated WIth mcreased nsk of resprratory disease The odds
ratio was 1 24 WIth 95 % confIdence hmIts of 1 09 and 1 42 Meha et al (1980) descnbed
the results of a thIrd study of resprratory symptoms m chIldren aged 6 to 7 years m northern
England. Multiple lOgistic regreSSIOn analySIS of the data presented by Meha et al (1980)
showed a sigmfIcant increase m symptoms as a functIOn of bedroom N02 levels
Melia et al (1982a) reported on a fourth study of chIldren m England Multiple lOgIStiC
regresSIOn analysIs of these data was not statistically sIgmfIcant, although the symptoms were
pOSItively related to N02 exposure The analySIS by Hasselblad et al (1992) suggests that an
increase of 0015 ppm (28 3 p.g/m3) m bedroom N02 levels yIelds an 11 % mcrease m the
odds of resprratory Illness
14-80
The analysIs of the SIX CIty studIes by Ware et al (1984) estnnated an unadjusted odds
ratIo of 1 08 (95 % confidence hmItS of 0 97 and 1 19) for a lower resprratory illness mdex
assocIated wIth gas stove use Other mdIcators such as bronchItIs, cough, and wheeze dId
not show any mcreased mCIdence Neas et al (1990, 1991) analyzed a dIfferent SIX CIty
Study cohort enrolled later, used a dIfferent symptom questIonnarre, and made mdoor N0 2
measurements for all subjects They found mcreased resprratory dIsease and gave an
estnnated odds ratIo of 1 40 (95 % confidence hmIts of JL 14 and 1 72) at an exposure of
o 015 ppm (28 3 p,g/m )3
Ekwo et al (1983) studIed resprratory symptoms in relatIon to gas stove use m Iowa
CIty, IA Gas stove use proVIded m an odds ratIo of 2 4 for hospItaltzatIOn for chest illness
before age 2, and 1 1 for chest congestIOn and phlegm wIth colds DIJkstra et al (1990)
studIed the effect of mdoor factors on resprratory health m chIldren m the Netherlands
A lOgIStIC regressIon analysIs (Hasselblad et al , 1992) yIelded an odds ratIo of 0 94 WIth
95 % confidence hmitS of 0 66 and 1 33, thus showmg no eVIdence of an mcrease m
resprratory dIsease WIth mcreasmg N02 exposure Keller et al (1979b) dId not fmd any
statistIcally sIgmficant changes m resprratory dIsease assocIated WIth gas stove use,the
unadjusted estnnated odds ratIO for resprratory illness was 0 72, WIth 95 % confidence hmitS
of 0 30 and 1 74
Samet et al (1993) report prelnnmary results of a prospectIve cohort study of
respIratory illness dunng the fIrst 18 mo of hfe m reiattonslup to estnnates of N02 exposure
m Albuquerque, NM The fmdmgs mdicated that ill a populatIon of healthy Infants, no
sIgmficant aSSOCIatIOn between N02 exposure estnnate 311ld resprratory illness were found
Other studIes dId not proVIde suffiCIent Infonnatton to denve any quantItatIve estnnates
of the effect of N02 or gas stove use on resprratory dIsease Several other studIes contam
InformatIon about the effects of N02 on resprratory illnl~SS, but most of the studIes eIther
used very dIfferent health end pomts or dId not proVIde quantItatIve estnnates of the effects
In Meha et al (1983), Infants under 1 year of age were exammed No relatIon was found
between type of fuel used for cookmg and the prevalence of resprratory symptoms Ogston
et al (1985) studIed resprratory dIsease m l-year-olds 111 the TaySIde regIOn of northern
Scotland The presence of a gas stove yIelded an mcrease m upper resprratory illness
Schenker et al (1983) StudIed chIldren m Chestnut RIdge, PA, but dId not report any
14-81
quantitative data of any relatIonshIp between datly resprratory symptoms and N02 levels
Braun-Fahr1aender et al (1992) found mdoor N02 levels predIctIve of duratIOn of resprratory
disease episodes. The study of BerwIck (1987) showed mcreased relatIve nsk of resprratory
disease m some age groups, but not m others Dekker et al (1991) reported an mcrease m
asthma m chIldren aged 5 to 8 years (n = 60) m relatIOn to the presence of a gas stove m
Canadian homes Hedberg et al (1989) and S1TI1th et al (1992) reported resprratory
symptoms in relatIon to N02 exposures greater than 1 5 ppm (2,800 p,g/m3) m skatmg nnks
Several studies exammed the relatIOnshIp between estlillates of ambIent N02 levels and
respIratory health measures Dockery et al (1989b) exammed relatIOnshIps between vanous
resprratory symptoms and ambIent N02 leveis Braun-Fahrlaender et a1 (1992) reported
associatIons between outdoor long-term measures of N02 and duratIOn of resprratory
episodes Schwartz et al (1991) showed a relatIOnshIp between short-term fluctuatIOns m arr
pollutIon and short-term fluctuatIons m medical VISItS for croup symptoms Rebmann et a1
(1991) reported a relatIonshIp between croup wIth posItIve vrroiogic testIng and N02 levels
Several of the mdoor studies suggest an mcrease m resprratory symptoms m chIldren
aged 5 to 12 years from estImated exposure to N02 The aSSOCiatIOns m the maJonty of the
studies do not reach statIstIcal sIgmficance The conSIstency of these studIes was exammed
and the eVIdence was synthesIZed m a quantItatIve analySIS The studies descnbed used
dIfferent indIcators to study health end pomts In order to compare these mdoor studies, a
standard end pomt was defmed, and then each study was compared wIth thIs standard end
pomt. The end point chosen was the presence of lower resprratory symptoms and dIsease m
children aged 5 to 12 years It was assumed that the relatIve odds of developmg lower
resprratory symptoms and disease are slilll1ar across thIs age range as a functIon of N02
exposure, even though the actual rates may not be (ThIs IS a common assumptIOn m many
analyses) The goal was to estlillate the odds ratIO correspondIng to each mcrease of
0.015 ppm (28 3 p,g/m3) m N02 exposure (Hasselblad et al , 1992)
An attempt was made to mclude as many mdoor studIes as pOSSIble The requrrements
for mclusIOn were (1) the health end pomt measured must be reasonably close to the standard
end point, (2) exposure dIfferences between subjects must eXist and some estlillate of
exposure must be avaIlable, and (3) an odds ratIo for a specIfied exposure estlillate must have
14-82
been calculated, or data must be presented so that It can be calculated (Hasselblad et al ,
1992)
Two models for combmmg eVIdence were employed (Hasselblad et al ,1992) The
fIrst was a fIxed-effects model, whIch assumed that every study was estImatmg the same
parameter The second basIc model assumed that the parameter of mterest was not fIxed, but
was Itself a random vanable from a dIstnbutIon ThIs kmd of model IS desIgnated by several
names, mcludmg random-effects models or hIerarchIcal models The purpose of a random-
effects model IS to relax the assumptIon that each study IS estImatillg exactly the same
parameter DerSImoman and Larrd (1986) dIscuss the lrandom-effects model Many
researchers have suggested that the random-effects model IS the more appropnate model
because It does not assume that all studIes estImate the same parameter Furthermore, the
random-effects estImates will approach the fIxed-effects estImates when studIes gIve sImIlar
estImates
Subject to assumptIons made for the combmed analysIs, the mam conclusIOn from that
analysIs was that an mcreased nsk of about 20 % for resprratory symptoms and dIsease
corresponded to each mcrease of 0 015 ppm (28 3 p.,g/m3) m estImated 2-week average N02
exposure, where mean weekly concentratIOns m bedrooms m studIes reportmg N02 levels
were predommately between 0008 and 0065 ppm NO? (Hasselblad et al ,1992) The
measured N02 studIes gave an estImated odds ratIo (random-effects model) of 1 22, whereas
the others yIeld an estImate of 1 16, whIch IS consIstent WIth a measurement error effect
The effect of havmg adjusted for covanates such as SES, smokIng, and gender was that those
studIes that adjusted for a partIcular covanate found larger odds ratIOS as compared WIth
those that dId not
Several uncertamtIes need to be consIdered m mterpretIng the above studIes and results
of the EPA meta-analysIs Measurement error m exposure IS potentIally one of the most
Important methodologIcal problems m epIdemIOlogIcal studIes of N02 Thus measured N02
concentratIons are not exposure values per se, rather, estImatmg actual exposure reqUITes
knowledge of both pollutant levels and related human actIvIty patterns The effects studIed
may be related to peak exposures, average exposures, or a combmatIOn of the two To the
extent that health effects depend on peak exposures rather than average exposures, the
exposure estnnates used m the above studIes and meta-analyses mtroduce exposure
14-83
- --------
measurement error These stuches cannot dlstmgmsh between the relative contnbutlons of
peak and average exposures and theIr relatIOnship wIth the observed health effects
AddItionally, a by-product of N02 , HONO, may be a factor m observed effects However,
only very hmlted health and aerometnc data are available that examme such pOSSIbilities
Also, although the level of snrulanty and common elements between the outcome measures
in the N02 stuches proVIde some confidence m theIr use m the quantitatIve analySIS, the
symptoms and illnesses combmed are to some extent dIfferent and could mdeed reflect
dIfferent underlymg processes Thus, cautIOn IS necessary m mterpretmg the meta-analysIs
results.
Although there IS eVIdence that suggests that mcreased estImated N02 exposure IS
associated WIth mcreased respIratory symptoms m children aged 5 to 12 years, the exposure
estImated may be madequate to determme a quantitative relationship between estImates of
exposure and symptoms The studIes WIth measured N02 exposure chd so only for penods
of 1 to 2 weeks and reported the values as averages None of the stuches attempted to relate
the effects seen to the pattern of exposure such as short-term peaks Furthermore, the
extrapolatIon to pOSSIble patterns of ambIent exposure IS dIfficult
Several researchers StudIed a dIfferent populatIOn group that conSIsted of Infants 2 years
of age and younger In the mdtvldual studIes of Infants 2 years of age and younger, no
consistent relationship was found between estImates of N02 exposure and the prevalence of
respIratory symptoms and dIsease Based on a meta-analyses of these Infant studIes, the
overall combmed estImate IS pOSItive, however, It clearly contams the no-effect value of 1 0,
(I.e., is not statistICally slgmficant), and so we cannot conclude that the eVIdence suggests an
effect m Infants
The Harvard SIX CIty study (Ware et al , 1984, Berkey et al , 1986, Neas et al , 1991)
attempted to relate some measure of mdoor and outdoor N02 exposure to long-term changes
in pulmonary function These changes were margmallY slgmficant Most stuches dId not
fmd any effects, which IS conSIstent WIth controlled human exposure study data (see
Chapter 15) However, the baSIC conclUSIon IS that there IS msufficlent epIdemIOlogICal
eVIdence to make any conclUSIOn about the long- or short-term effects of N02 on pulmonary
functIon
14-84
REFERENCES
Amencan ThoracIc SOCIety (1962) DefImtIons and classIfIcatIon of chromc bronchItIs, asthma, and pulmonary
emphysema Am Rev Respir DIS 85 762-768
Amencan ThoracIc SOCIety COmID1ttee on Standards for EpidennologlC Surveys m Chromc RespIratory DIsease
(1969) Standards for epidennoiogic surveys m chromc Iespuatory dIsease New York, NY NatIonal
TuberculosIs and RespIratory DIsease AssociatIon
Anto, J M, Sunyer, J , PlasencIa, A (1986) NItrogen dIoXide and asthma outbreaks Lancet (8515)
1,096-1,097
Anto, J M , Sunyer, J , Rodnguez-ROlsm, R , Suarez-Cervera, M, Vazquez, L, the TmC1coepidennologlCal

COmID1ttee (1989) Commumty outbreaks of asthma assocIated wIth InhalatIon of soybean dust N Engl
J Med 320 1,097-1,102
Arundel, A V , Sterlmg, EM, Biggm, J H , Sterlmg, T D (1986) IndIrect health effects of relatIve hunndity
m mdoor enVIronments EnvIron Health Perspect 65 351-361
Bates, D V , Baker-Anderson, M , SIzto, R (1990) Asthma attack penodicity a study of hOSpItal emergency
VISItS m Vancouver EnVIron Res 51 51-70
Berkey, C S, Ware, J H, Dockery, D W , Ferns, B G, Jr , Speizer, F E (1986) Indoor air pollution and
pulmonary function growth m preadolescent chIldren Am J Epidennol 123 250-260
Bernbaum, J , Anolik, R , Polm, R A , Douglas, S D (1984) Development of the premature mfant's host
defense system and ItS relatIonshIp to routme ImmumzatIOns Clm Pennatol 11 73-84
BerwIck, M (1987) Lower respIratory symptoms m chIldren associated WIth mtrogen dIOXide exposure
[dIssertatIOn] New Haven, CT Yale Umversity AVailable flOm Umversity MIcrofilms, Ann Arbor,
MI, pubhcatIon no 87-29,173
BerwIck, M , Zagraruskl, R T, Leaderer, B P, StolwI]k, J A J (1984) RespIratory Illness m chIldren

exposed to unvented combustIOn sources In Berglund, B , Lmdvall, T , Sundell, J , eds Indoor aIr
proceedmgs of the 3rd mtematIOnal conference on mdoor aIr quahty and chmate, V 2, radon, paSSIve
smokmg, partIculates and housmg epidennology, August, Stockholm, Sweden Stockholm, Sweden
SwedIsh CouncIl for BUlldmg Research, pp 255-260
BerwIck, M , Leaderer, B P, StOIWI]k, J A J , Zagraruskl, R T (1987) ASSOCIatIon between nItrogen dIOXide

levels and lower respIratory symptoms m chIldren exposed to unvented combustIOn sources
In SeIfert, B , Esdom, H , FIscher, M , Rueden, H , Wegn("r, J , eds Indoor aIr '87 proceedmgs of
the 4th mtematIonal conference on mdoor aIr quahty and chmate, v 1, volatile orgaruc compounds,
combustIon gases, partIcles and fIbres, nncrobIOlogical agent'" August, Berlm, Federal Repubhc of
Germany Berlm, Federal Repubhc of Germany Institute for Water, SoIl and AIr HygIene, pp 298-303
BerwIck, M , Leaderer, B P, StOIWI]k, J A, Zagraruskl, R T (1989) Lower respIratory symptoms m chIldren

exposed to nItrogen dIOXide from unvented combustIOn sourc€~ EnVIron Int 15 369-373
BIrge, R T (1932) The calculation of errors by the method of least squares Phys Rev 30 207-227
Braun-FalIrlaender, Ch , AckermamI-LIebnch, U , WamIer, H -U , RutIshauser, M , Gnehm, HE, Mmder,

Ch E (1989) AuswIrkungen von Luftschadstoffen auf dIe Alemwege von Klemkmdem [Effects of air
pollutants on the respIratory tract m young chIldren] SchweI,~ Med Wochenschr 119 1,424-1,433
14-85
Braun-Fahrlaender, Ch, Ackennann-Llebnch, U , Schwartz, J , Gnehm, H P, Rutishauser, M , Wanner,
H -U (1992) Air pollution and respuatory symptoms m preschool children Am Rev Resplr DIs
145 42-47
Bntten, N , Davies, J M C, Colley, J R T (1987) Early respuatory expenence and subsequent cough and
peak expiratory flow rate m 36 year old men and women Br Med J 294 1,317-1,320
Bronekreef, B , FIscher, P , HouthUljs, D , Remtjn, B , Bolelj, J (1987) Health effects of mdoor NOz pollutIOn
In Seifert, B , Esdorn, H , FIscher, M , Rueden, H , Wegner, J ,eds Indoor atr '87 proceedmgs of
the 4th mternational conference on mdoor atr quality and clImate, vi, volatile organtc compounds,
combustIon gases, particles and fibres, mtCrobIOlogical agents, August, BerlIn, Federal RepublIc of
Germany Berlm, Federal RepublIc of Germany InstItute for Water, Soil and Au HygIene, pp 304-308
Bronekreef, B , Dockery, D W , Spelzer, FE, Ware, J H, Spengler, J D, Ferns, B G (1989) Home

dampness and respuatory morbIdity m chIldren Am Rev Respu DIS 140 1,363-1,367
Bronekreef, B , HouthUljs, D , Dljkstra, L , Bolelj, J S M (1990) Indoor mtrogen dIOXIde exposure and
chIldren's pulmonary function J Air Waste Manage Assoc 40 1,252-1,256
Burrows, B , LebOWItz, M D (1975) Charactenstics of chromc bronchItis m a warm, dry regIOn Am Rev
Resplr DIS 112 365-370
Canner, P L (1987) An overvIew of SIX chmcal tnals of aspmn m coronary heart disease Stat Med
6 255-263
Centers for DIsease Control (1990) Asthma-Umted States, 1980-1987 Morb Mortal Wkly Rep 39 493-497
Chanock, R M, Parrott, R H (1965) Acute respuatory disease m mfancy and chIldhood present understandmg
and prospects for prevention Pedlatncs 36 21-39
Chanock, R M, McIntosh, K , Murphy, B R, Parrott, R H (1989) Respuatory syncytial VIruS In Evans,

AS, ed Viral mfections of humans epldemtology and control 3rd ed New York, NY Plenum
PublIshIng Corporation, pp 525-544
Clark, R R (1982) The error-m-vanables problem m the logistic regreSSIOn model [dissertatIOn] Chapel HIll,
NC Umverslty of North Carolma
Cochratl, W G (1937) Problems ansmg m the analySIS of a senes of slmtlar expenments J R Stat Soc
Suppl 4 102-118
Cochran, W G (1954) The combmation of estimates from different expenments Blometncs 10 101-129
Cohen, C A, Hudson, A R, Clausen, J L, Knelson, J H (1972) Respuatory symptoms, spuometry, and

OXIdant atr pollutIOn m nonsmokmg adults Am Rev Resplr DIS 105 251-261
Colley, J R T, Holland, W W , Leeder, S R, Corkhtll, R T (1976) Respuatory functIOn of mfants m

relatIOn to subsequent respIratory disease an epidelU1010gical study Bull Eur Physlopathol Resplr
12 651-657
Comstock, G W, Meyer, M B , Helsmg, K J , Tockman, M S (1981) Respiratory effects of household

exposures to tobacco smoke and gas cookmg Am Rev Resplr DIS 124 143-148
14-86
Dassen, W , Brunekreef, B , Hoek, G , Hofschreuder, P , Staatsen, B , De Groot, H , Schouten, E ,
Blersteker, K (1986) Declme m chIldren's pulmonary functIOn dunng an aIr pollutIOn epIsode J AIr
Pollut Control Assoc 36 1,223-1,227
Dekker, C, Dales, R , Bartlett, S , Brunekreef, B , Zwanenburg, H (1991) ChIldhood asthma and the mdoor
enVIronment Chest 100 922-926
Denny, F W , Clyde, W A (1986) Acute lower respIratory tract mfectIOns m nonhospitalIzed chIldren
J PedIatr (St LoUIS) 108 635-646
DerSImoman, R , LaIrd, N (1986) Meta-analysIs m clImcal tnals Controlled Clm Tnals 7 177-188
Detels, R , Rokaw, S N , Coulson, A H, Tashkm, D P, Sayre, J W , Massey, F J ,Jr (1979) The UCLA
populatIon studIes of chromc obstructive respIratory dIsease I Methodology and companson of lung
functIOn m areas of hIgh and low pollutIOn Am J Epldemwl 109 33-58
Detels, R , Sayre, J W, Coulson, A H, Rokaw, S N , Massey, F J , Jr , Tashkm, D P, Wu, M -M

(1981a) RespIratory effect of longtenn exposure to two llllxe<, of aIr pollutants m Los Angeles County
Chest 80(suppl) 27S-29S
Detels, R , Sayre, J W , Coulson, A H, Rokaw, S N , Massey, F J , Jr , Tashkm, D P, Wu, M -M

(1981b) The UCLA populatIOn studIes of chromc obstructive respIratory dIsease IV respIratory effect of
long-tenn exposure to photochellllcal oXidants, mtrogen dIOXide, and sulfates on current and never
smokers Am Rev Resplr DIS 124 673-680
Detels, R ,Tashkm, D P, Sayre, J W , Rokaw, S N ,Massey, F J ,Jr , Coulson, A H , Wegman, D H

(1991) The UCLA population studIes of CORD X a cohort study of changes m respIratory functIOn
aSSOCIated WIth chromc exposure to sax, NOx, and hydrocarbons Am J PublIc Health 81 350-359
DewaIlly, E , AllaIre, S , Nantel, A (1988) NItrogen dIOXide pOlsonmg at a skatmg nnk-Quebec Can DIS
Wkly Rep 14(15) 61-62
DI]kstra, L , HouthUI]S, D , Brunekreef, B , Akkerman, I , BoleI], J S M (1990) RespIratory health effects of

the mdoor enVIronment m a populatIOn of Dutch chIldren Am Rev RespIr DIS 142 1,172-1,178
Dockery, D W, Ware, J H, Ferns, B G, Jr , SpeIzer, FE, Cook, N R, Herman, S M (1982) Change

m pulmonary functIon m chIldien aSSOCIated WIth aIr pollutIon epIsodes J AIr Pollut Control Assoc
32 937-942
Dockery, D W , Spengler, J D, Neas, L M, Spelzer, FE, Ferns, B G, Jr , Ware, J H, Brunekreef, B

(1989a) An epidellllologlC study of respIratory health status and mdlCators of mdoor aIr pollutIon from
combustIon sources In Harper, J P, ed CombustIon processes and the qualIty of the mdoor
enVIronment transactIOns of an mtematIOnal speCIalty conference, September 1988, Niagara Falls, NY
Pittsburgh, PA AIr & Waste Management ASSOCiatIon, pp ~'62-271 (A&WMA transactIOns senes
TR-15)
Dockery, D W, Speizer, FE, Stram, DO, Ware, J H , Spengler, J D, Ferns, B G, Jr (1989b) Effects
of Inhalable partIcles on respIratory health of chIldren Am Rev Resplr DIS 139 587-594
Douglas, R G, Jr (1986) Pathogenetic mechamsms m VIral respIratory tract mfectIOns In Sande, M A,

Hudson, L D, Root, R K, eds RespIratory mfectIons New York, NY ChurchIll Llvmgstone, Inc,
pp 25-46
Douglas, W W , Hepper, N G G, Colby, T V (1989) Silo-filler's dIsease Mayo Clm Proc 64 291-304
14-87
Eddy, D M (1989) The confidence profile method a Bayesian method for assessmg health technologies Oper
Res 37 210-228
Eddy, D M, Hasselblad, V , Shachter, R (1990a) An mtroductIon to a Bayesian method for meta-analySIS the
confidence profile method Med DecISion MakIng 10 15-23
Eddy, D M, Hasselblad, V , Shachter, R (1990b) A Bayesian method for syntheslZlDg eVidence the confidence
profile method Int J Technol Assess Health Care 6 31-55
Eddy, D M, Hasselblad, V , Shachter, R (1992) Meta-analysIs by the confidence profile method the statistical
syntheSIS of eVidence Boston, MA AcademIc Press, Inc
Ekwo, E E., Wemberger, M M, Lachenbruch, P A, Huntley, W H (1983) RelationshIp of parental smokIng

and gas cookIng to respIratory disease m chIldren Chest 84 662-668
Emerson, J D, Burdick, E, Hoaglm, DC, Mosteller, F , Chalmers, T C (1990) An empmcal study of the
possible relation of treatment differences to quahty scores m controlled randOmIzed chmcal tnal'l
Controlled Clm Tnals 11 339-352
Epler, G R (1989) SIlo-filler's disease a new perspective Mayo Clm Proc 64 368-370
Euler, G L, Abbey, DE, HodgkIn, J E, Magie, A R (1988) Chromc obstructive pulmonary disease
symptom effects of long-term cumulative exposure to ambient levels of total OXidants and mtrogen
dioXide m Callforma Seventh-day Adventist reSidents Arch EnVIron Health 43 279-285
FaIrblUm, AS, Wood, C H, Fletcher, C M (1959) VanabIllty m answers to a questlOnnlUre on respIratory

symptoms Br J Prev Soc Med 13 175-193
Ferns, B G (1978) EpidemIology standardizatIOn project Am Rev RespIr DIS 118 1-120
Ferns, B G, Jr , Spelzer, FE, spengler, J D , Dockery, D , BiShop, Y M M, Wolfson, M , Humble, C

(1979) Effects of sulfur OXides and respIrable particles on human health Methodology and demography
of populations m study Am Rev RespIr DIS 120 767-779
Ferns, B G, Jr , Dockery, D W, Ware, J H, Spelzer, FE, SpIrO, R ,ill (1983) The SIX-City study
examples of problems m analysIs of the data EnViron Health Perspect 52 115-123
Fischer, P, RemIjn, B , Brunekreef, B , Van der Lende, R , Schouten, J , Quanjer, P (1985) Indoor aIr
pollution and ItS effect on pulmonary function of adult non-smokIng women IT associations between
mtrogen diOXide and pulmonary function Int J EpldemIol 14 221-226
Fischer, P , RemIjn, B , Brunekreef, B , Blersteker, K, Bolelj, J S M, Van der Lende, R , Schouten, J P,

Quanjer, P H (1986) ASSOCIations between mdoor exposure to NO z and tobacco smoke and pulmonary
functIon m adult smokIng and non-smokIng women EnVIron Int 12 11-15
Florey, C du V , MelIa, R J W , ChInn, S , Goldstem, B D, Brooks, A G F, John, H H, CrlUghead,

I B, Webster, X (1979) The relation between respIratory Ilh1ess m pnmary schoolchIldren and the use
of gas for cookIng ill-mtrogen dIOXide, respIratory Ilh1ess and lung mfectIon Int J EpldemIol
8 347-353
14-88
Florey, C du V , Mella, R , Goldstem, B , Moms, R , John, H H, Clark, D (1982) StIckstoffdiOXId 1m
Innenraum-EpidemIologische AuswIrkungen 1m VerelDlgten Koemgrelch [The epIdemIology of mdoor
mtrogen dIoXIde m the UK] In Aurand, K , SeIfert, B , Wegner, J ,eds Luftqualltaet m
Innenraeumen [Indoor aIr qualIty] Stuttgart, Federal RepublIc of Germany Gustav FIscher Verlag,
pp 209-218 (SchnftenreIhe des Verems fuer Wasser-, Boden- und Lufthyglene no 53)
Fuller, W A (1987) A smgle explanatory vanable In Measurement error models New York, NY John WIley
& Sons, pp 1-9, 13-20
GaIl, M H (1985) Adjusting for covanates that have the same dlstnbutIon m exposed and unexposed cohorts
In Moolgavkar, S H, Prentice, R L, eds Modem statistIc al methods m chromc dIsease epidemIology
New York, NY John WIley and Sons, pp 3-18
Gamble, J , Jones, W , Hudak, J (1983) An epidemIological study of salt mIners m dIesel and nondlesel mmes
Am J Ind Med 4 435-458
Gamble, J , Jones, W , Mmshall, S (1987) EpidemIological-envIrorunental study of diesel bus garage workers
acute effects of NOz and respIrable particulate on the respIratory system EnVIron Res 42 201-214
Gardner, G , Frank, A L, Taber, L H (1984) Effects of SOCIal and famIly factors on VIral respIratory mfectIon
and Illness m the first year of lIfe J EpidemIol Commun Health 38 42-48
Gladen, B , Rogan, W J (1979) MisclassificatIon and the deSign of envIronmental studies Am J EpidemIol
109 607-616
Glezen, W P (1989) Antecedents of chromc and recurrent lung dIsease childhood respIratory trouble
Am Rev Respir DiS 140 873-874
Glezen, W P, Denny, F W (1973) EpidemIology of acute lower respiratory disease m children N Engl
J Med 288 498-505
Glezen, W P, Loda, FA, Clyde, W A, Jr , Semor, R J , Shea1fer, C I; Conley, W G, Denny, F W

(1971) EpidemIologIc patterns of acute lower respIratory dIsease of children m a pedlatnc group practice
J Pedlatr (St LoUiS) 78 397-406
Gold, DR, Tager, I B , WeISS, S T, Tosteson, T D, Spelzer, F E (1989) Acute lower respIratory Illness
m childhood as a predIctor of lung function and chromc respIratory symptoms Am Rev Resplr DIS
140 877-884
Goldstem, B D, Mella, R J W , Chinn, S , Florey, C du V , Clark, D , John, H H (1979) The relation

between respIratory Illness m pnmary schoolchildren and the use of gas for cookmg II Factors affectmg
mtrogen diOXIde levels m the home Int J EpidemIol 8 339-345
Goldstem, B D, Mella, R J W , Florey, C du V (1981) Indoor rutrogen OXIdes Bull N Y Acad Med
57 873-882
Goldstem, IF, Andrews, L R, Lieber, K , FoutrakIs, G , Kazembe, F , Huang, P , Hayes, C (1987) Acute
exposure to mtrogen diOXIde and pulmonary functiOn In SeIfert, B , Esdorn, H , Fischer, M,
Rueden, H , Wegner, J ,eds Indoor aIr '87 proceedmgs of the 4th mternatIonal conference on mdoor
air qualIty and clImate, vi, volatile orgamc compounds, combustion gases, particles and fibres,
lillcrobiOloglCal agents, August, BerlIn, Federal RepublIc of Germany BerlIn, Federal RepublIc of
Germany Institute for Water, SoIl and Air HygIene, pp 293-297
14-89
Goldstem, IF, Andrews, L R , Hartel, D (1988) Assessment of human exposure to mtrogen dIOXide, carbon
monoXide and respIrable partIculates m New York mner-clty resIdences Atmos EnvIron
22 2,127-2,139
Goren, A I, Hellmann, S (1988) Prevalence of respIratory symptoms and dIseases m schoolchIldren hvmg m a
polluted and m a low polluted area m Israel EnvIron Res 45 28-37
Graham, J A, Grant, L D, Folmsbee, L J , Gardner, DE, Schlesmger, R B, Overton, J H, Lounsbury,

S W ,McCurdy, T R, Hasselblad, V , McKee, D J, Richmond, H M, Polkowsky, B V , Marcus,
A H (1991) DIrect health effects of aIr pollutants associated WIth aCIdIC precursor emISSIOnS In Irvmg,
PM, ed ACIdIC depOSItion state of SCIence and technology, volume ill, terrestnal, matenals, health
and VISlbIhty effects Washmgton, DC The U S National ACId PrecIpItation Assessment Program (State
of SCIence and technology report 22)
Graham, N M H (1990) The epIdemIology of acute respIratory mfectIOns m chIldren and adults a global
perspective EpidemIol Rev 12 149-178
Grayson, R R (1956) SIlage gas pOlsonmg mtrogen dIOXide pneumoma, a new dIsease m agncultural workers
Ann Intem Med 45 393-408
Gregory, K L, MalmoskI, V F, Sharp, C R (1969) Cleveland clmlc fire survIvorshIp study, 1,929-1,965
Arch EnvIron Health 18 508-515
Gschwend-Elgenmann, S , D'Apuzzo, V , Schoem, M H, Kraemer, R (1989) Emfluss der

Luftschadstoffbelastlmg auf gesunde und lungenkranke Kmder 1m Suedtessm [Effects of aIr pollutIOn on
healthy chIldren and chIldren WIth respIratory dIseases m southem Ticmo] SchweiZ Med Wochenschr
119 1868-1874
Guggenblchler, J -P , Krall, M , Scmmtzberger, R, Pack, I , Schoenegger, J (1990) Zusammenhang ZWIschen

Auftreten von Pseudokrupp und Schadstoffbelastlmg der Atemluft und Wetter [Influence of aIr pollutIOn
and vanous weather condItions to mCldence of croup] Wlen Med Wochenschr 140 431-436
Hammer, D I, Hasselblad, V , Portnoy, B , Wehrle, P F (1974) Los Angeles student nurse study daily
symptom reportmg and photochemIcal OXidants Arch EnVIron Health 28 255-260
Harlos, D P, Spengler, J D, BIlhck, I (1987) Contmuous mtrogen dIOXide momtonng dunng cookmg and
commutmg personal and statIOnary exposures In SeIfert, B, Esdom, H , FIscher, M , Rueden, H,
Wegner, J ,eds Indoor aIr '87 proceedmgs of the 4th mtematIonal conference on mdoor aIr qualIty and
clImate, vi, volatile orgaIllC compounds, combustion gases, particles and fibres, mICrObIOlogICal agents,
August, Berlm, Federal Repubhc of Germany Berlm, Federal Repubhc of Germany Institute for Water,
SoIl and AIr HygIene, pp 278-282
Hamngton, W , Krupmck, A J (1985) Short-term mtrogen dIOXide exposure and acute respIratory dIsease m
chIldren J AIr Pollut Control Assoc 35 1,061-1,067
Hasabelnaby, N A, Ware, J H, Fuller, W A (1989) Indoor aIr pollution and pulmonary performance
mvestIgatmg errors m exposure assessment Stat Med 8 1,109-1,126
Hasselblad, V , Stead, A G, Creason, J P (1980) Multiple problt analySIS WIth a nonzero background
Blometncs 36 659-663
Hasselblad, V , Humble, C G, Graham, M G, Anderson, H S (1981) Indoor envIronmental deterInmants of

lung function m chIldren Am Rev Resplr DIS 123 479-485
14-90
Hasselblad, V , Eddy, D M, Kotchmar, D J (1992) SynthesIS of c~nvIronmental eVIdence mtrogen dIOXide
epIdemIOlogy studIes J AIr Waste Manage Assoc 42 662-671
Health Effects InstItute Health RevIew COmmIttee (1993) Commentary In NItrogen dIoXide and respIratory
Illness In chIldren Cambndge, MA Health Effects InstItute, pp 51-80, Research Report no 58
Hedberg, K , Hedberg, C W , Ther, C , WhIte, K E, Osterholm, M T, Jones, D B W , FlInk, J R,

MacDonald, K L (1989) An outbreak of mtrogen dioXIde-mduced respIratory Illness among Ice hockey
players JAMA JAmMed Assoc 262 3,014-3,017
Hedberg, K , MacDonald, K L, Osterholm, M , Hedberg, C , Wllllte, K (1990) NItrogen dIOXide-Induced

respIratory Illness In Ice hockey players [reply to a letter to the edItor] JAMA JAmMed Assoc
263 3,024-3,025
HelsIng, K J , Comstock, G W, Meyer, M B , Tockman, M L (1982) RespIratory effects of household

exposures to tobacco smoke and gas cookIng on nonsmokers EnVIron Int 8 365-370
Henry, R L, Bndgman, H A, Wlodarczyk, J , Abramson, R , Adler, J A, Hensley, M J (1991) Asthma In

the VICInIty of power statIons II outdoor aIr qualIty and symptoms Pedlatr Pulmonol 11 134-140
HIckey, R J , Boyce, DE, Harner, E B, Clelland, R C (1970) EcologIcal statIstIcal studIes on

enVIronmental pollutIOn and chromc dIsease In metropolItan ,lreas of the Umted States PhIladelphIa, PA
RegIonal SCIence Research InstItute (RSRI dIScussIon papel senes no 35)
HIll, A B (1965) The enVIronment and dIsease associatIon or causcltIon? Proc R Soc Med 58 295-300
Hoek, G , Brunekreef, B , MeIjer, R , Scholten, A , Bolelj, J (1984) Indoor mtrogen dIOXide pollutIon and
respIratory symptoms of schoolchIldren Int Arch Occup EnVIron Health 55 79-86
HoseIn, H R, Corey, P (1986) DomestIc aIr pollutIOn and respIratory functIon In a group of houseWIves Can
J PublIc Health 77 44-50
HouthUljs, D , RemIjn, B , Brunekreef, B , De Konmg, R (1987) Exposure to mtrogen dIoXide and tobacco
smoke and respIratory health of chIldren In SeIfert, B , Esdlorn, H , FIscher, M , RUeden, H ,
Wegner, J , eds Indoor aIr '87 proceedIngs of the 4th InternatIOnal conference on Indoor aIr qUalIty and
clImate, vI, volatIle organIC compounds, combustIon gases, partIcles and fibres, mICrObIOlogICal agents,
August, BerlIn, Federal RepublIc of Germany Berlm, Federal RepublIc of Germany InstItute for Water,
So11 and AIr HygIene, pp 463-467
Infante-Rivard, C (1993) ChIldhood asthma and Indoor envIronmental nsk factors Am J EpidemIol
137 834-844
lrwlg, L , Altman, D G, GIbson, R J W , Florey, C (1975) AIr pollutIon methods to study ItS relatIonshIp to
respIratory dIsease m BntIsh schoolchIldren In Recent advances m the assessment of the health effects
of envIronmental pollutIOn InternatIonal sympOSIUm proceedmgs, V 1, June 1974, Pans, France
Luxembourg COmmISSIOn of the European CommUnItIes, pp 289-300
Jaakkola, J J K, Paumo, M , VIrtanen, M , Hemonen, 0 P (1991) Low-level aIr pollutIOn and upper
respIratory InfectIons m chIldren Am J PublIc Health 81 1,060-1,063
Jacobsen, M , SmIth, T A, Hurley, J F, Robertson, A , Roscrow, R (1988) RespIratory InfectIons In coal

mmers exposed to mtrogen OXides Cambndge, MA Health Effects InstItute, research report no 18
14-91
Jaeschke, R ; Oxman, AD, Guyatt, G H (1990) To what extent do congestive heart fallure patients m smus
rhythm benefit from dlgO)on therapy? A systematic overview and meta-analysIs Am J Med
88 279-286
Jones, J R, Higgms, ITT, Higgms, M W , Keller, J B (1983) Effects of cookmg fuels on lung function
m nonsmokmg women Arch Environ Health 38 219-222
Kagamlmon, S , Katoh, T , Naruse, Y , Watanabe, M , Kasuya, M , Shmkal, J , Kawano, S (1986) The

changmg prevalence of respiratory symptoms m atopic children m response to air pollution Clm Allergy
16 299-308
Kagawa, J , ToyaJ.Da, T (1975) Photochemical alr pollutiOn ItS effects on respiratory function of elementary
school children Arch EnViron Health 30 117-122
Kalpazanov, Y , Stamenova, M , Kurchatova, G (1976) Alr pollution and the 1974-1975 mfluenza epidemiC m
Sofia a statistical study Environ Res 12 1-8
Keller, M D, Lanese, R R, Mitchell, R I, Cote, R W (1979a) Respiratory l1lness m households usmg gas
and electnclty for cookmg I survey of mCldence EnViron Res 19 495-503
Keller, M D, Lanese, R R, Mitchell, R I, Cote, R W (1979b) Respiratory l1lness m households usmg gas
and electnclty for cookmg n symptoms and objective findmgs EnViron Res 19 504-515
Kibler, R , HiCks, M J , Wnght, A L, TaUSSig, L M (1986) A comparative analySIS of cord blood and adult
lymphocytes mterleukm-2 and mterferon production, natural killer cell actiVity, and lymphocyte
populations Dlagn Immunol 4 201-208
Koo, L C, Ho, J H-C, Ho, C -Y , Matsukl, H , ShimiZU, H , Mon, T , Tommaga, S (1990) Personal
exposure to mtrogen diOXide and ItS assOCiation With respiratory l1lness m Hong Kong Am Rev Respir
DIS 141 1,119-1,126
Kuehr, J , Hendel-Kramer, A , Karmaus, W , Moseler, M , WeISS, K , Stephan, V , Urbanek, R (1991)

Luftschadstoffbelastung und Asthma bronchiale bel Schulklndem [Alr pollutiOn and asthma aJ.Dong school
chIldren] Soz Praeventivmed 36 67-73
Kupper, L L (1984) Effects of the use of unrelIable surrogate vanables on the valIdity of epidemiologIc
research studIes Am J Epldemiol 120 643-648
LaJ.rd, N M, Mosteller, F (1990) Some statistical methods for combmmg expenmental results Int J Technol
Assess Health Care 6 5-30
Lambert, WE, SaJ.Det, J M, Hunt, W C, Skipper, B J , Schwab, M , Spengler, J D (1993) Assessment of

exposure to mtrogen dIOXide In NItrogen dIOXide and respiratory l1lness m chIldren, part n
CaJ.Dbndge, MA Health Effects Institute, pp 33-50, Research Report no 58
Leaderer, B P, ZagranIski, R T, BerwIck, M , StOIWIJk, J A J (1986) Assessment of exposure to mdoor air

contaJ.mDants from combustion sources methodology and applIcation Am J Epldemiol 124 275-289
LebOWItz, M D (1971) Comparative urban daJ.ly mortalIty m relation to aIr pollution and weather [ph D
thesIS] Seattle, WA Umverslty of Washmgton
LebOWItz, M D, Holberg, C J , Boyer, B , Hayes, C (1985) Respiratory symptoms and peak flow aSSOCIated
WIth mdoor and outdoor alr pollutants m the southwest J Alr Pollut Control Assoc 35 1,154-1,158
14-92
Lebret, E (1987) Errors m exposure vanables and their role m obs(~urmg exposure-response relatIOns, the case
of mdoor exposure to mtrogen dIOXIde and fine particles In SeIfert, B , Esdorn, H , FIscher, M ,
Rueden, H , Wegner, J , eds Indoor aIr '87 proceedmgs of the 4th mternatIonal conference on mdoor
aIr qualIty and clImate, v 1, volatIle orgamc compounds, combustIon gases, partIcles and fibres,
mICrobIOlogIcal agents, August, Berlm, Federal RepublIc of Germany Berlm, Federal RepublIc of
Germany InstItute for Water, SoIl and Air HygIene, pp 288-292
Lmn, W S, Haclmey, J D, Pedersen, E E, Brelsacher, P , Patterson, J V , Mulry, C A, Coyle, J F

(1976) Respiratory functIon and symptoms m urban office workers m relatIOn to OXIdant aIr pollutIon
exposure Am Rev RespIr DIS 114 477-483
Llttenberg, B (1988) Ammophyllme treatment m severe, acute asthma a meta-analysIs JAMA JAmMed
Assoc 259 1678-1684
LIll, L , Wang, L H (1987) The effects of cookmg fuels on respiratory symptoms, lung functIons, and
carboxyhemoglobms ofnon-smokmg women In SeIfert, B , Esdorn, H , FIscher, M , Rueden, H ,
Wegner, J ,eds Indoor air '87 proceedmgs of the 4th mtematIonal conference on mdoor aIr qualIty and
clImate, v 3, developmg countnes, guaranteemg adequate mdoor air qualIty, control measures,
ventIlatIon effectIveness, thermal clImate and comfort, polIcy and strategIes, August, Berlm, Federal
RepublIc of Germany Berlm, Federal RepublIc of Germany InstItute for Water, SoIl and AIr HygIene,
pp 20-24
Loewenstem, J C, Wolmark, Y , Bourdel, M C, Maffiolo, G , Kratruk, F , Forette, B , Berthaux, P (1985)

Etude longltudmale sur les relatIons entre les condItIons d'envIronnement et la sante des penSIOnnaIreS
d'un hOpital de long seJour [Longltudmal study of relatIonslllps between envIromnental condItIons and
health of elderly patIents m a long-term care hOSpItal] Rev EpidemIol Sante Publ 33 262-266
Love, G J , LatI, S -P , Shy, C M, Riggan, W B (1982) Acute respiratory Illness m familIes exposed to
mtrogen dIOXIde ambIent aIr pollutIOn m Chattanooga, Tennessee Arch EnViron Health 37 75-80
Lowry, T , Schuman, L M (1956) "SIlo-filler's dlsease"-a syndrome caused by mtrogen dIOXIde JAMA
JAmMed Assoc 162 153-160
Maletzky, A J , Cooney, M K, Luce, R , Kenny, G E, Grayston, J T (1971) EpIdemiology of VIral and

mycoplasmal agents aSSOCIated WIth chIldhood lower respllatory Illness m a CIVIlIan populatIon
J PedIatr (St LoUIS) 78 407-414
Mann, C (1990) Meta-analysIs m the breech SCIence (Washmgton, DC) 249 476-480
Mantel, N , Haenszel, W (1959) StatIstIcal aspects of the analySIS of data from retrospectIve studIes of dIsease
J Nat! Cancer Inst 22 719-748
MargolIs, P A, Greenberg, R A, Keyes, L L, Lavange, L M , Chapman, R S, Denny, F W , Bauman,

K E, Boat, B W (1992) Lower respiratory Illness m mfants and low SOCIOeconOmiC status
Am J PublIc Health 82 1119-1126
McConnochIe, K M, Hall, C B, Barker, W H (1988) Lower respiratory tract Illness m the first two years of
lIfe epIdemiologIc patterns and costs m a suburban pedIatnc practIce Am J PublIc Health 78 34-39
MelIa, R J W , Florey, C du V , Altman, D G, Swan, A V (1977) ASSOCIatIon between gas cookmg and
respiratory dIsease m chIldren Br Med J 2 149-152
MelIa, R J W , Florey, C du V , Darby, S C, Palmes, ED, Goldstem, B D (1978) DIfferences m N02

levels m latchens WIth gas or electnc cookers Atmos EnVlron 12 1379-1381
14-93
Mella, R J W, Florey, C du V , Chmn, S (1979) The relation between respIratory l1lness m pnmary
schoolcluldren and the use of gas for cookmg I-results from a national survey Int J EpidemlOl
8 333-338
MelIa, R J W , Florey, C du V , Chmn, S , Goldstem, B D, Brooks, A G F, John, H H, Clark, D ,

Craighead, I B, Webster, X (1980) The relatlOn between mdoor ror pollutlOn from mtrogen dIOXIde and
respIratory Illness m pnmary schoolchlldren Clm Respir PhyslOl 16 7P-8P
MelIa, R J W , Florey, C du V , Moms, R W , Goldstem, B D, John, H H, Clark, D , CraIghead, I B,

Mackmlay, J C (1982a) Cluldhood respIratory Illness and the home enVIronment IT aSSOCIation
between respIratory Illness and mtrogen dIOXIde, temperature and relative hUmIdity Int J Epidellliol
11 164-169
MelIa, R J W , Florey, C du V , Moms, R W , Goldstem, B D, Clark, D , John, H H (1982b) Cluldhood

respIratory Illness and the home enVIronment I RelatlOns between mtrogen dIOXIde, temperature and
relative hUmIdIty Int J EpidemIol 11 155-163
MelIa, J , Florey, C , Sittampalam, Y , Watkms, C (1983) The relation between respIratory Illness m mfants
and gas cookmg m the UK a prellmmary report In AIr qualIty VIth world congress [proceedmgs of the
International Umon of Air PollutlOn Prevention ASSOCIations], May, Pans, France Pans, France SEPIC
(APPA), pp 263-269
Mella, R J W , Florey, C du V , Chmn, S , Moms, R W , Goldstem, B D, John, H H, Clark, D (1985)

Investigations mto the relations between respIratory Illness m chIldren, gas cookmg and mtrogen dIOXIde
m the U K Tokro J Exp Clm Moo 10 375-378
Mella, R. J W , Chmn, S , Rona, R J (1988) RespIratory Illness and home enVIronment of ethnIc groups
Br Moo J 296 1438-1441
Mella, R J W , Chmn, S , Rona, R J (1990) Indoor levels of N02 assocIated WIth gas cookers and kerosene
heaters m mner CIty areas of England Atmos EnVIron B Urban Atmos 24 177-180
Mendelsohn, R , Orcutt, G (1979) An empmcal analySIS of ror pollutlOn dose-response curves J EnVIron
Beon Manage 6 85-106
Meulenbelt, J , Sangster, B (1990) Acute mtrous OXIde mtoXIcatlOn clImcal symptoms, pathophyslOlogy and
treatment Neth J Moo 37 132-138
MItchell, C. A , Sclullmg, R SF, Bouhuys, A (1976) Commumty studIes of lung dIsease m Connecticut
orgamzatlOn and methods Am J EpidemIol 103 212-225
MItchell, R I, WIllIams, R , Cote, R W , Lanese, R R, Keller, M D (1975) Household survey of the

mCIdence of respIratory dIsease m relation to envIronmental pollutants In Recent advances m the
assessment of the health effects of envIronmental pollution mternatIonal sympOSIUm proceedmgs, v 2,
June 1974, Pans, France Luxembourg, BelgIUm COmImSSIOn of the European CommumtIes, publIcation
no 5360, pp 47-61
Manto, AS, NapIer, J A, Metzner, H L (1971) The Tecumseh study of respIratory l1lness I Plan of study
and observations on syndromes of acute respIratory dIsease Am J Epidellliol 94 269-279
Morgan, W J , TaUSSIg, L M (1984) The chromc bronchItis complex m chIldren PedIatr Clm N Am
31 851-864
14-94
Mostardl, R A, Ely, D L, Woebkenberg, N R, Richardson, B , Jarrett, M T (1981a) The Umverslty of
Akron study on aIr pollution and human health effects I methodology, baselme data, and aerometncs
Arch Environ Health 36 243-249
Mostardl, R A, Woebkenberg, N R, Ely, D L, Conlon, M , Atwood, G (1981b) The Umverslty of Akron

study on aIr pollution and human health effects IT effects 011 acute respiratory Illness Arch Environ
Health 36 250-255
NagIra, T , HisashIge, A , Kume, K , Ueno, M , Yamamoto, M , Aoyama, H (1981) [Health hazards among
chIldren m aIr-polluted dlstncts, report 2 Exposure to automobIle exhaust and prevalence of subjective
symptoms among schoolchIldren] NIppon Eiselgaku ZasshI ~6 596-612
National Institutes of Health (1991) GUldelmes for the dIagnosIs and management of asthma Bethesda,
MD U S Department of Health and Human ServIces, NatlClnal Heart, Lung, and Blood Institute,
NatIOnal Asthma Education Program, publIcatIOn no 91-3,042
National Research CouncIl (1971) GUIdes for short-term exposures of the publIc to aIr pollutants I GUIde for
oXides of mtrogen WashIngton, DC National Academy of SCIences AVaIlable from NTIS, Spnngfield,
VA, PB-199903
National Research CouncIl (1977) NItrogen oXides WashIngton, DC NatIOnal Academy of SCIences
NatIonal Research CouncIl (1986) Environmental tobacco smoke measunng exposures and assessmg health
effects WashIngton, DC NatIonal Academy Press, pp 9-11, 130,208,223-249,284-288
Neas, L M , Ware, J H , Dockery, D W , Spengler, J D, Ferns, B G, Jr , Spelzer, F E (1990) The

assocIation of mdoor mtrogen dIOXide levels WIth respIratory symptoms and pulmonary function m
chIldren In Indoor aIr '90 precedmgs of the 5th mternatIonal conference on mdoor aIr qualIty and
clImate, volume 1, human health, comfort and performance, July-August, Toronto, ON, Canada Ottawa,
ON, Canada International Conference on Indoor Alr QualIty and ClImate, Inc ,pp 381-386
Neas, L M , Dockery, D W, Ware, J H, Spengler, J D, SpeIZ4~r, FE, Ferns, B G, Jr (1991)

ASSOCiation of mdoor mtrogen dIOXide With respiratory symptoms and pulmonary functIon m chtldren
Am J EpidemIol 134 204-219
Neas, L M, Dockery, D W, Spengler, J D, Spelzer, FE, Ferns, B G, Jr (1992) VanatIons m the

assocIatIOn between mdoor mtrogen diOXide and chtldhood rl~SpIratory symptoms by samplmg locatIOn,
season and source Am Rev Resplr DIS 145 A93
OdajIma, H , Baba, M (1987) [RelatIonshtp between the mCldence of medlastmal and subcutaneous emphysema
complIcatmg bronchtal asthma and the concentratIOn of N02 m the atmosphere] NIppon Kyobu ShIkkan
GakkaI ZasshI 25 1,278-1,283
Ogston, SA, Florey, C du V , Walker, C H M (1985) The TaysIde mfant morbIdIty and mortality study
effect on health of usmg gas for cooking Br Med J 290 957-960
Ono, M , MurakamI, M , NItta, H , NakaI, S , Maeda, K (1990) []EpIdemIologIcal studies of aIr pollutIOn and
health effects m areas near roadways With heavy traffic m Tokyo] NIppon Koshu Eisel Zassht
37 321-332
PAARC Cooperative Group (1982a) PollutIOn atmosphenque et aff~ctlons reSpIratOlres chromques ou

a repetitIon I Methodes et sUjets [Alr pollution and chromc respiratory disease I Methods and
matenal] Clm RespIr Physiol 18 87-99
14-95
PAARe Cooperative Group (1982b) Pollution atmosphenque et affections respIratoIres chromques ou
a repetition II Resultats et discussion [AIr pollution and chromc or repeated respiratory diseases
II Results and diSCUSSIOn] Clm RespIr PhyslOl 18 101-116
Pearlman, ME, Fmklea, J F, Creason, J P, Shy, C M, Young, M M, Horton, R J M (1971) Nitrogen

diOXide and lower respIratory Illness Pedlatncs 47 391-398
Pearson, K (1904) Report on certam entenc fever mnoculation statistics Br Med J 2 1,243-1,246
Pershagen, G , Hrubec, Z , Lonch, U , ROllilqVISt, P (1984) Acute respIratory symptoms m patients With
chromc obstructive pulmonary disease and mother subjects hvmg near a coal-fired plant Arch EnVIron
Health 39 27-33
Ponka, A (1990) Absenteeism and respIratory disease among chIldren and adults m HelsInki m relation to
low-level aIr pollution and temperature EnVIron Res 52 34-46
Ponka, A (1991) Asthma and low level aIr pollution m Helsmla Arch EnVIron Health 46 262-270
Quackenboss, J J , Spengler, J D , Kanarek, M S, Letz, R , Duffy, C P (1986) Personal exposure to

mtrogen diOXide relatIOnshIp to mdoor/outdoor aIr quality and activity patterns EnVIron SCI Technol
20 775-783
Rebmallil, H ,Huenges, R , Wlchmallil, HE, Malm, EM, Huebner, H R, Roell, A , Hoerz, G , Hub, R ,
Walter, C , Doeller, G , Gerth, H -J (1991) Krupp und Luftschadstoffe Ergebmsse emer zwelJaehngen
prospektiven Laengsschmttstudle [Croup and aIr-pollutIOn results of a two-year prospective longltudmal
study] Zentralbl Hyg Umweltmed 192 104-115
RelID]n, B , Fischer, P , Brunekreef, B , Lebret, E , Bolel], J S M, NOI], D (1985) Indoor air pollution and
Its effect on pulmonary function of adult non-smokIng women I exposure estimates for mtrogen dIOXide
and passive smokIng Int J EpldelIDol 14 215-220
Richards, W , Azen, S P, WeiSS, J , StockIng, S , Church, J (1981) Los Angeles aIr pollutIOn and asthma m
chIldren Ann Allergy 47 348-354
Robertson, A , Dodgson, J , Collmgs, P , Seaton, A (1984) Exposure to OXides of mtrogen respIratory

symptoms and lung function m BntIsh coalmmers Br J Ind Med 41 214-219
Rokaw, S N, Detels, R , Coulson, A H, Sayre, J W , Tashkm, D P, Allwnght, S S, Massey, F J , Jr

(1980) The UCLA population studies of chromc obstructive respIratory disease 3 companson of
pulmonary function m three commumtIes exposed to photochelIDcal OXidantS, multiple pnmary pollutants,
or mmImal pollutants Chest 78 252-262
Rosenthal, R (1979) The 'file drawer problem' and tolerance for null results Psychol Bull 86 639-641
Ruttshauser, M , Ackermann, U , Braun, Ch, Gnehm, H P, Walliler, H U (1990a) Slgmficant aSSOCiatIOn

between outdoor N02 and respIratory symptoms m preschool chIldren In Matthys, H , ed 8th congress
of SEP European SOCIety of Pneumology, European Pedlatnc RespIratory SOCiety, September 1989,
Umverslty of Frelburg, Federal Repubhc of Gennany Lung 168(suppl) 347-352
Ruttshauser, M , Ackermann, U , Braun, Ch, Gnehm, H P, Walliler, U (1990b) Zusammenhang ZWischen

Atemwegssymptomen bel Klemkmdern und N02-KonzentratIonen m der Aussenluft [ASSOCiation between
alloway symptoms m young chIldren and N0 2 concentratIOns m the outSide aIr] Pneumologle
44 245-246
14-96
Sacks, H S, Berner, J , Reitman, D , Ancona-Berk, V A, Chalmers, T C (1987) Meta-analysIs of
randomlzed controlled tnals N Engl J Med 316 450-45';
Samet, J M (1978) A mstoncal and epldemlologlc perspective on respiratory symptoms questionnaIres

Am J Epldemlol 108 435-446
Samet, J M, Spengler, J D (1989) Nitrogen dloXlde and respIratory mfectIon pllot mvestIgatIons Cambndge,
MA Health Effects InstImte, research report no 28
Samet, J M, Utell, M J (1990) The nsk of mtrogen dlOXlde what have we learned from epldemlologlcal and
chmcal smdles? TOXlcol Ind Health 6 247-262
Samet, J M, Tager, I B, Spelzer, F E (1983) The relatIonsmp between respIratory lIlness m cmldhood and
chromc au-flow obstruction m adulthood Am Rev Resplr DIS 127 508-523
Samet, J M, Marbury, M C, Spengler, J D (1987) Health effects and sources of mdoor air pollutIOn Part I
Am Rev RespIr DIS 136 1,486-1,508
Samet, J M, Marbury, M C, Spengler, J D (1988) Health effects and sources of mdoor all' pollution
Part II Am Rev Respu DIS 137 221-242
Samet, J M, Lambert, WE, Skipper, B J , Cushmg, A H, MeLaren, L C, Schwab, M , Spengler, J D

(1992) A smdy of respIratory lIlnesses m mfants and mtrogen dloXlde exposure Arch EnVIron Health
47 57-63
Samet, J M, Lambert, WE, Skipper, B J , Cushmg, A H, Humt, W C, Young, SA, McLaren, L C,

Schwab, M , Spengler, J D (1993) Health outcomes In Nitrogen dlOXlde and respIratory lIlness m
chIldren, part I Cambndge, MA Health Effects InstImte, JPP 1-32, Research Report no 58
Schafer, D W (1987) Covanate measurement error m generalized lmear models BlOmetnka 74 385-391
Schenker, M B, Samet, J M, Spelzer, F E (1983) Risk factors for cmldhood respIratory disease the effect
of host factors and home envlfonmental exposures Am Rev RespIr DIS 128 1,038-1,043
Schwartz, J (1989) Lung functIOn and chromc exposure to all' pollutIOn a cross-sectIOnal analySIS of
NHANES II Envlfon Res 50 309-321
Schwartz, J , Zeger, S (1990) Passive smokmg, air pollutIOn, and acute respIratory symptoms m a diary smdyof
smdent nurses Am Rev Resplr DIS 141 62-67
Schwartz, J , Hasselblad, V , Pitcher, H (1988) AIr pollutIOn and morbidity a further analysIs of the
Los Angeles smdent nurses data JAPCA 38 158-162
Schwartz, J , SpIX, C, Wichmann, HE, Malm, E (1991) All' pollution and acute respiratory lIlness m five
Gennan commumtIes EnVIron Res 56 1-14
Sevenen, C, Mletens, C (1987) Untersuchungen zum Emfluss von StIckoXld- und Schwebstaubgehalt del' Luft
auf die Haeufigkelt von statlOnaer behandelten Kmdem mlt stenoslerender Laryngotracheitis
(pseudokrupp) [Smdles of the effects of atmosphenc mtnc oXldes and suspended dusts on the mCldence of
chlldren hospitalized With stenosmg laryngotracheitis (croup)] Monatsschr Kmderhellkd 135 686-691
Shy, C M (1970) The Chattanooga smdy J AII' Pollut Control Assoc 20 832-833
14-97
Shy, C M, Creason, J P, Pearlman, ME, McClam, K E, Benson, F B, Young, M M (1970a) The
Chattanooga school chtldren study effects of commumty exposure to mtrogen dIOJade 1 Methods,
descnptton of pollutant exposure, and results of venttlatory functton test10g J AIr Pollut Control Assoc
20 539-545
Shy, C M, Creason, J P, Pearlman, ME, McClam, K E, Benson, F B, Young, M M (1970b) The

Chattanooga school chtldren study effects of commumty exposure to mtrogen dIOXide II InCIdence of
acute respIratory tllness J AIr Pollut Control Assoc 20 582-588
Shy, C. M , NIemeyer, L , TruppI, L , Enghsh, T (1973) Re-evaluatton of the Chattanooga school chtldren
studIes and the health cntena for N02 exposure [reVIsed draft] Research Tnangle Park, NC US
EnVIronmental Protectton Agency, Human StudIes Laboratory
Shy, C M, Klembaum, D G, Morgenstern, H (1978) The effect of mISClaSsificatton of exposure status 10

epIdemIologIcal studIes of atr pollutIOn health effects Bull N Y Acad Med 54 1,155-1,165
Smtth, W , Anderson, T , Anderson, H A, Remmgton, P L (1992) NItrogen dIOXide and carbon monOXide
1OtoXIcatton 10 an 1Odoor Ice arena-WIscons1O, 1992 Morb Mortal Wkly Rep 41 383-385
Spelzer, FE, Fems, B G, Jr (1973a) Exposure to automobtle exhaust I prevalence of respIratory symptoms
and dIsease Arch EnVIron Health 26 313-318
Spelzer, FE, Fems, B G, Jr (1973b) Exposure to automobIle exhaust II pulmonary functIon measurements
Spelzer, FE, Fems, B , Jr , BIShop, Y M M, Spengler, J (1980) RespIratory dIsease rates and pulmonary
functton In chtldren asSOCiated WIth N0 2 exposure Am Rev Resplr DIS 121 3-10
Spengler, J D, Fems, B G, Jr , Dockery, D W, Spelzer, F E (1979) Sulfur dIOXide and mtrogen dIOXide
levels 10SIde and outsIde homes and the Imphcattons on health effects research EnVIron SCI Technol
13 1,276-1,280
Spengler, J D , Allen, G A, Foster, S , Severance, P , Fems, B ,Jr (1986) Sulfunc aCId and sulfate aerosol
events 10 two US clttes In Lee, S D, SchneIder, T , Grant, L D, Verkerk, P J ,eds Aerosols
research, nsk assessment and control strategies-proceed1Ogs of the second US-Dutch 1OternatIonal
symposlUm, May 1985, Wtlhamsburg, VA Chelsea, MI LeWIS Pubhshers, Inc ,pp 107-120
Spengler, J D, Ryan, P B, Schwab, M , Colome, S D, Wtlson, A L (1992) NItrogen dIOXide exposure

studles-volume IV Personal exposure to mtrogen dIOXide In the Los Angeles basm Chtcago, IL Gas
Research Instttute, report no GRI-92/0426
Stefanski, LA, Carroll, R J (1985) Covanate measurement error 10 10gIsttc regreSSIon Am! Stat
13 1,335-1,351
Tashkm, D P, Detels, R , Coulson, A H, Rokaw, S N , Sayre, J W (1979) The UCLA populatIon studles
of chromc obstructIve respIratory dlsease II determtnatton of rehablhty and estImatIon of senSItIVIty and
specIfiCIty EnVIron Res 20 403-424
TaUSSIg, L M, Wnght, A L, Morgan, W J , Hamson, H R, Ray, C G (1989) The Tucson chtldren's

respIratory study I desIgn and Implementatton of a prospecttve study of acute and chromc respIratory
Illness m chtldren Am J EpidemIol 129 1,219-1,231
14-98
Thlelebeule, U , Huelsse, C (1989) EpldelDlologlsche Untersuchung zur Formaldehyd- und StIckoXIdbelastung m
Innenraeumen [EpldelDlologlcal exammatIons on formaldehyde and rutrogenous OXIde mdoor aIr
pollutIon] Z Gesamte Hyg Ihre Grenzgeb 35 53-54
Tobacco Research Councll (1976) StatIstIcs of smokmg m the Uruted Kmgdom 7th ed London, Umted
Kmgdom Tobacco Research Councll
TOlDlnaga, S , Ono, M (1985) A plan of the comprehensIve study on mdoor pollutIOn and ItS health effects by
the AtChI Prefecture, Japan Tokal J Exp Clm Med 10 391-394
Tsunetosht, Y , FukutolDl, K , Yoshtda, K , DOl, M (1987) [Epidellliologlcal study of respIratory symptoms m

school chtldren wIth specIal reference to effect of aIr pollutl<ln] Tatkt Osen Gakkatsht 22 431-459
US EnvIronmental ProtectIon Agency (1971) Atr quahty cntena for rutrogen OXIdes Washtngton, DC US
EnvIronmental ProtectIon Agency, Atr PollutIOn Control Office, EPA report no AP-84 AvaIlable from
NTIS, Spnngfield, VA, PB-197333/BE
U S EnvIronmental ProtectIon Agency (1982a) Atr qualIty cntena for OXIdes of rutrogen Research Tnangle
Park, NC Office of Health and EnvIronmental Assessment, EnvIronmental Cntena and Assessment
Office, EPA report no EPA-600/8-82-Q26 AvaIlable fTom NTIS, Spnngfield, VA, PB83-131011
U S EnvIronmental ProtectIOn Agency (1982b) Atr qualIty cntena for particulate matter and sulfur OXIdes
Research Tnangle Park, NC Office of Health and EnvIronmental Assessment, EnvIronmental Cntena
and Assessment Office, EPA report no EPA-600/8-82-Q29aF-cF 3v Avatlable from NTIS, Spnngfield,
VA, PB84-156777
Vedal, S , Schenker, M B, Munoz, A , Satnet, J M, Battennan, S , Spelzer, F E (1987) Datly aIr pollutIOn
effects on chtldren's respIratory symptoms and peak expIratory flow Am J Pubhc Health 77 694-698
VlegI, G , CarroZZl, L, Paoletti, P , Vellut1D1, M , DlvIgglano, E , Baldaccl, S , Modena, P , GlUnt1D1, C ,

LeboWItz, M D (1990) Effects of home enVIronment on re~lplratory symptoms of a general populatIOn
sample m lDlddle Italy In Indoor atr '90 precedmgs of the 5th mternattonal conference on mdoor aIr
quahty and chmate, volume 1, human health, comfort and p(~rfonnance, July-August, Toronto, ON,
Canada Ottawa, ON, Canada InternatIOnal Conference on Indoor Atr QUalIty and Chmate, Inc ,
pp 399-403
VlegI, G , CarroZZl, L, PaolettI, P , Vellut1D1, M , DlvIgglano, E , Baldaccl, S , Modena, P , Pedrescht, M ,

Matnmm1, U , DI Pede, C , GlUntIru, C (1992) Effects of the home enVIronment on respIratory
symptoms of a general population sample m lDlddle Italy Atch EnVIron Health 47 64-70
Walker, AM, Blettner, M (1985) Comparmg Imperfect measures of exposure Am J EpldelDlol

121 783-790
Ware, J H , Dockery, D W , SpIrO, A , m, Spelzer, FE, Ferns, B G, Jr (1984) PaSSIve smokmg, gas
cookmg, and resptratory health of chtldren hvmg m SIX cltIe'3 Am Rev Resplr DIS 129 366-374
Warner, PO, Stevens, L (1973) Revaluation of the "Chattanooga school chtldren study" m the hght of other
contemporary governmental studIes the possIble Impact of these findmgs on the present N02 aIr quahty
standard J Atr Pollut Control Assoc 23 769-771
14-99
Warner, PO, Stevens, L (1975) Revaluation of epldelDlologlcal health effects formerly attnbutOO to measured
levels of mtrogen dlOXide m view of synergistic effects due to co-pollutants In Recent advances m the
assessment of the health effects of environmental pollution proceedmgs of an mternatIonal sympOSiUm,
v II, June 1974, Pans, France Luxembourg COmmlSSlOn of the European CommumtIes, pubhcatIon no
BUR 5360, pp 1001-1008
Watanabe, N , Yosmda, R , Yanaglmoto, T (1984) [A study on methods for analyzmg the acute effects of
environmental factors on broncmal asthma] Arerugl33 868-878
Wemmer, U (1984) Krupp-Syndrom und Schadstoffe m der Atemluft Eme statIstIsche Analyse jahreszelthcher
Schwankungen der Imnusslonswerte m RelatlOn zur Erkrankungshaeufigkelt [Croup syndrome and
aIr-polluhon a statistical analySIS of seasonal fluctuations m pollutlOn levels m relatIonsmp to the
mCldence of the disease] Fortschr Moo 102 835-837
WIDttemore, AS, Keller, J B (1988) ApprOXimations for regresslOn With covanate measurement error JASA
J Am Stat Assoc 83 1,057-1,066
WIlson, C B (1986) immunologiC baSIS for mcreasOO susceptIblhty of the neonate to mfectIon J Pedlatr
(St LoUIS) 108 1-12
World Health OrgamzatIon (1977) OXides of mtrogen Geneva, SWitzerland World Health OrgamzatlOn
(Environmental health cntena 4)
Wnght, A L, TaUSSig, L M, Ray, C G, Hamson, H R, Holberg, C J (1989) The Tucson cmldren's

respiratory study II lower respiratory tract Ilh1ess m the first year of hfe Am J EpldelDlol
129 1,232-1,246
Yockey, C C, Eden, B M, Byrd, R B (1980) The McConnelllIDsslle aCCident chmcal spectrum of mtrogen
diOXide exposure JAMA J Am Moo Assoc 244 1,221-1,223
Yosmmura, I (1990) The effect of measurement error on the dose-response curve EnViron Health Perspect
87 173-178
Yusuf, S , Peto, R , LeWIS, J , Collms, R , Sleight, P (1985) Beta blockade dunng and after myocardial
mfarctIon an overview of the randolDlzOO tnals Prog Cardlovasc DIS 27 335-371
Zeger, S L, Liang, K -Y (1986) Longltudmal data analysIs for discrete and contmuous outcomes BlOmetncs
42 121-130
14-100
APPENDIX 14A..
SUMMARY OF EPIDEMIOLOGICAL STUDIES OF

NITROGEN DIOXIDE HEALTH EFFECTS
14A-l
TABLE 14A-l. SUM:l\1ARY OF EPIDEMIOLOGICAL STUDIES OF NITROGEN DIOXIDE EFFECTS ON
RESPIRATORY ILLNESS2
Study N02 Exposure Effects Seen DISCUSSIon References
ChIldren aged 6-11 years Gas stove use RespIratory symptoms Indoor N02 not measured Meha et al (1977)
with and WIthOUt gas stoves (bronchttis, cough, wheeze) at tlme of study
In the house In 28 areas of htgher WIth gas stoves
England and Scotland present
4,827 ChIldren aged Gas stove use RespIratory symptoms Result slgmficant for boys Meha et al (1979)
5-10 years m a second hIgher In chtldren with gas but not gIrls
Bntish Cohort stoves Smolang m home,
and use of pl10t hghts
exammed
3
808 ChIldren aged 6-7 years N02 , 7-318 fJ-g/m (0004- InCIdence of respIratory Margmally sIgmficant Meha et al (1980)
m Middiesborough, 0169 ppm) m bedroom l1lness htgher In homes WIth results Subset data WIth Goldstem et al (1979)
3
England WIth gas stoves, 6-70 fJ-g/m gas stoves (p = 0 10) gas stove only and Florey et al (1979)
(0 004-0 0371 ppm) WIthout
gas stoves
ChIldren aged 5-6 years m N02 leveis ranged from Shght trend for Increase In Results not even margmally Meha et al (1982)
3
Middiesborough, England 16-530 fJ-g/m (0 009- respIratory dIsease rates slgmficant
0281 ppm) Gas stoves
only
3
SIX CIty study of 7-49 fJ-g/m Margmally slgmficant DIfferences margmally Spelzer et al (1980)
9,000 grade-school chl1dren (0 004-0 26 ppm) estnnate aSSOCiatIOn of gas stove use sIgmficant Incomplete Ware et al (1984)
m the Umted States of total personal exposure Wlth respIratory Illness rate Indoor exposure
gas stove use used as a m chIldren under 2 years
surrogate
SIX CIty study of 6,273 Measured mdoor exposure Increases m mdividual Larger Increase m Dockery et al (1989a)
chIldren aged 7-11 years In average 17 4 ppb hIgher m symptoms of 5-29%, combmed symptoms than m Neas et al (1990, 1991)
the Umted States homes WIth gas stoves and combmed symptom odds IndIVIdual symptoms
pIlot hghts ratio of 147
RespIratory l1lness study of Gas stove use Increase of 14% m Indoor N02 not measured Ogston et al (1985)
1,565 mfants m the TaysIde resprratory dIsease m homes at time of study Results
regIOn of Scotland WIth gas stove use not statistically sIgmficant
TABLE 14A-l (cont'd). SUMMARY OF EPIDEMIOLOGICAL STUDIES OF NITROGEN DIOXIDE EFFECTS ON
RESPIRATORY ILLNESS a
Study NOz Exposure Effects Seen DISCUSSIon References
RespIratory symptom study Gas stove use Increase m chest congestIOn Only hospItalIzatIOn was Ekwo et al (1983)
of 1,355 cluldren aged of 10% and mcrease of statIstIcally sIgmficant
6-12 years m the Iowa CIty hOspItahzatIon of more than End pomts dIfferent from
Schools 100% other studIes No mdoor
aIr measurements
RespIratory symptom study Weekly average NOz No eVIdence of any mcrease WIde confidence mtervals DIJkstra et al (1990)
3
of 6- to 9-year-old cluldren ranged from 22-42 p,g/m m respIratory dIsease for effects measured HouthUlJs et al (1987)
m the southeastern regIOn (0012-0022 ppm) Gas Brunekreef et al (1987)
of the Netherlands applIance
RespIratory Illness study of Annual average NOz No dIfference found m Adjustments for prevIOUS Keller et al (1979a,b)
3
chIldren under age 12 years ranged from 38-94 p,g/m chIldren's respIratory Illness may have lost any MItchell et al (1975)
m Columbus, OH (0 020-0 050 ppm) Illness effect AnalYSIS model
dIfferent from other studIes
ProspectIve cohort study of Personal exposure estnnate Careful standardIzed No sIgnIficant aSSOCIatIOns Samet et al (1993, 1992),
respIratory mfectIon durmg based on Palmes tube and ascertaInment of Illness, found between NOz Samet and Spengler (1989)
the first 18 mo of hfe m actIvIty data assessment of potentIal exposure estImates and
relatIOnslup to NOZ confoundmg factors respIratory Illness m mfants
exposure m Albuquerque,
NM
RespIratory symptom study Outdoor mean NOzlevels Increase symptom scores m End pomts dIfferent from Braun-Fahrlaender et al
3
of clnldren aged 0-5 years ranged from 25-52 p,g/m chIldren exposed to outdoor other studIes Effect of (1989)
3
m four areas of Indoor levels ranged from NO Z levels of 30 p,g/m mdoor NOz margmally
3
SWItzerland 11-34 p,g/m (00159 ppm) sIgmficant
Twelve-week study of Outdoor NOz levels ranged ChIldren under age 7 years InconSIstent results by age BerwIck et al (1984, 1987,
3
lower and upper respIratory from 9-19 p,g/m Indoor wIth exposure to more than group, pOSSIbly due to very 1989)
3
symptoms m women and NO z ranged from 30 p,g/m (0 0159 ppm) had small sample SIzes BerwIck (1987)
3
chIldren 6-91 p,g/m 2 17 tImes the lower avaIlable Leaderer et al (1986)
(0 003-0 048 ppm) respIratory Illness
TABLE 14A-l (cont'd). SUMl\tIARY OF EPIDEMIOLOGICAL STUDIES OF NITROGEN DIOXIDE EFFECTS ON
Study of 5,561 adults aged Annual means over the Decreased FEV1 and FVC Areas measured at different Detels et al (1981a,b)
25-39 years lIVIng In 5-year penod In Lancaster and Increased cough, tImes, other differences
Lancaster and Glendora, and In Glendora (Azuza phlegm, and wheeZIng Impossible to adjust for
CA statIon) averaged 3 2 and found In Glendora when
11 4 pphm, respectIvely compared to Lancaster
RespIratory disease study of Annual averages of dally Increased respIratory Illness No Indoor measurements Love et al (1982)
apprOXimately 2,800 adults NOzlevels ranged from m all age and sex groups NOz measured by Jacobs-
3
and cInldren for three 43-91 p.g/m m 1972, and found m 1972, but not Hochheslser method for
3
different 6-mo perIods In from 22-40 p.g/m In 1973 found In 1973 some penods
Chattanooga, TN
3
Study of respIratory NOz , 12-16 p.g/m No relatIonsInp of No mdoor measurements PAARC (1982a,b)
symptOlns m four French (0 006-0 008 ppm) dally respIratory symptoms with Low NOz exposure
3
cItIes means, NO, 7-140 p.g/m NOz
I-' daIly means
> I
.j:::..
Respiratory symptom and
pulmonary functIOn study of
NOz averaged 54 p.g/m
3
(0 029 ppm) m :polluted

HIgher rates of acute
respIratory dIsease m
No mdoor measurements
Small differences seen
Mostardl et al (1981a)
4th-6th graders m Akron, area, 377 p.g/m polluted area RelatIvely low NOz
OH (0019 ppm) In cleaner exposure
area
Study of asthma emergency Monthly average NOz Increased asthma No mdoor measurements RIchards et at (1981)
room VISits and levels ranged from emergency room VISItS and Pollutants could not be
hospitalIzatIons for chIldren 12-18 pphm, and NO levels hOspItalIzatIons correlated separated
at the ChIldren's HOSpItal ranged from 13-59 pphm sIgmficantly with NO and
of Los Angeles NOz , as well as coeffiCients
of haze and hydrocarbons
Study of acute Illnesses m Mean value of mtrogen Respiratory diseases No adjustment for LoewensteIn et al (1985)
elderly patIents m long-tenn OXides mdoors was correlated With NOZ covanates DetaIls of
care o 062 ppm and outdoors pollutIOn momtonng not
was 0 055 ppm given
TABLE 14A-l (cont'd). SUl\1MARY OF EPIDEl\fiOLOGICAL STUDmS OF NITROGEN DIOXIDE EFFECTS ON
Study N02 Exposure Effects Seen DIscussiOn References
3
Study of COPD rates m N0 2, 5-70 p.,g/m (0003- COPD correlated WIth N02 No mdoor measurements Pershag~n et al (1984)
COPD and normal subjects 00371 ppm) No adjustments for covanates
m Helsmkl, Fmland other than temperature
Small sample SIzes
Los Angeles Student Nurse Dal1y outdoor N02 exposure N02 exposure related to No mdoor N02 exposure Schwartz et al (1988),
Data ongmally collected dal1y averaged 0 13 ppm over a phlegm, sore throat, and eye measurements, and oilly one Schwartz and Zeger (1990)
from 1962-64, reanalyzed by 3-year penod SItes located ImtatIon outdoor statIon
Schwartz Symptoms WIthm 2 5 1111 of the subject
mcluded eye ImtatIon, cough,
phlegm, sore throat,
headache, chest dIscomfort
RespIratory dIsease study of Presence of gas stove used as No slgmficant aSSOCIatIOn No mdoor N02 exposure Schenker et al (1983)
4,071 chl1dren aged a surrogate for N0 2 between use of gas stove and No sIgmficant results
I-'
.j:::..
5-14 years m PennsylvanIa exposure any symptom or Illness
Results based on parents vanable
~
Ul questIonnaIre
The data reported by Love Dal1y N02 levels were spht No conSIstent short-tenn No mdoor measurements Harrmgton and Krupmck
et al 1982 were analyzed for mto three categones usmg effect of N0 2 on acute No blOlogIcal explanatIon for (1985)
short-tenn effects the cut-offs of 75 and respIratory dIsease was results found
3
150 p.,g/m (0 04-0 08 ppm) found
Study of mfluenza cases NO x had means of NOx related to N0 2 No mdoor measurements Kalpazanov et al (1976)
3
over a 2-mo penod m 21 and 37 p.,g/m (0 014- Two-day lag In Illnesses No measurement method for
Sofia, Bulgana o 45 ppm) for the NOx gIven
two epIde1ll1cs
Acute symptom study of Mean dal1y maXImum hourly Symptoms III asthmatIcs not Effects related to soybean Anto et al (1986)
35 asthmatIcs In Barcelona, N02 levels ranged from 271- related to N02 levels dust 111 defimtIve study Auto et al (1989)
3
SpaIn 846 p.,g/m (0 14-045 ppm) Second study relates
for two weeks In December symptoms to soybean dust
1985
TABLE 14A-l (cont'd). SUMJ\tIARY OF EPIDEMIOWGICAL STUDIES OF NITROGEN DIOXIDE EFFECTS ON
RESPIRATORY ILLNESSa
Study N02 Exposure Effects Seen DIscussIon References
Study of asthma In Quarterly mean N02 levels No relationship found No mdoor measurements Watanabe et al (1984)
20 children seen m two ranged from 3 0-5 7 pphm between frequency of Attack rates are generally
Japanese hospItals attacks and N02 levels longest when N02 IS
hIghest
EcolOgIcal study attemptmg County-wIde NO x Two mtlhon death Both posItive and negatIve Mendelsohn and Orcutt
to relate mtrates and oXIdes estImates certIficates exanuned coeffiCIents found m the (1979)
of mtrogen to mortahty multIple regressIon, whIch
were almost always not
statIstIcally sIgIuficant
EcologIcal analYSIS of N02 data from the NatIonal MortalIty rate assocIated QualIty and apphcabIhty of HIckey et al (1970)
mortalIty rates and aIr AIr Sronplmg Network with vanous dIsease end both the mortalIty and
pollutIon pOInts momtonng data preclude
consldenng the results as
~ anythIng but speculatIve
>
I
0\
Study of vanatIOns In daIly
mortahty m relatIon to dally
NonspecIfic NOx levels MultIple regreSSIOn analySIS
showed sIgIl1ficant negatIve
The results suggest that
other factors are causmg the
LebOWItz (1971)
aIr pollutIOn m several U S aSSOCIatIOn between wmter relatIOnshIp

CItIes from 1962-65 mortalIty In New York CIty
and datly NO x
concentratIon but no
aSSOCIatIon m summer In
contrast, the data In Los
AItgeles were pOSItIvely
related In the WInter but not
m the summer
A study of the prevalence Maximum NOx levels In the Vanous respIratory Effects related to both S02 Goren and Hellmatm (1988)
3
of respIratory symptoms m CItIes of 62 and 23 p.g/m , symptom rates were hIgher and NOx
school chIldren In two respectIvely In Ashdad, the more heavIly
Israeh CItIes WIth dIfferent polluted CIty Confoundmg
N02 leveis factors controlled
Study N02 Exposure Effects Seen DtscUssIOn References
Case-control study of Indoor N02 leveis Resptratory symptoms No dtfference m levels Hoek et al (1984)
231 clnldren m the detennmed by questlOnnatre between case and controls
Netherlands for resptratory and school health survey
symptoms vs N02 leveis data
wtth dtfferent N02 levels
Study of changes m N02 measurements from Stgmficant correlatIon Slllular results for S02 Kagannmon et al (1986)
resptratory symptom rates 1974-79 between dally maXlmum dunng tlns penod The fact
m relatIOn to N0 2 leveis m N02 and subacute phlegm, that S02 and N02 were
a rural dtstnct of Japan cough, and wheezmg for correlated and that no
pnck skm test (house dust covanates were mcluded m
extract)-posltIve chtldren the analysts means the study
can only be constdered
suggestIve
Study of resptratory tllness Annual outdoor N02 leveis Clnldren attendmg schools No mdoor N02 data N02 Nagtra et al (1981)
m 2,900 school clnldren vs m the lnghest polluted area levels analyzed m relatIon
levels of N02 m Oska had the lnghest rates of to dtstance between
Prefecture, Japan bronclnal astlnna and clnldren's homes and
recurrmg resptratory dtstance from htghways
mfecuons
Study of mctdence of Dally average outdoor N02 Report correlatlOn between No mdoor N02 data OdaJtma and Baba (1987)
medtastmal ~'J1d levels N02 leveis and occurrence Other factors that cause
subcutaneous emphysema m at medtastmal and medtastmal and
young bronchtal asthma subcutaneous emphysema subcutaneous emphysema
pattents m relatlOn to N02 not evaluated
levels m Japan
Study of resptratory Outdoor mean N02 value Asthma-hke symptoms was No mdoor N0 2 data, Tsunetoshl et al (1987)
symptoms mover 90,000 3 years pnor to the survey lngher m dtstnct WIth the confoundmg WIth other
school chtldren m Japan m lnghest N02 concentratIon pollutants Confoundmg
relatlOn to N02 levels due to smokmg and
soclOecononnc factors
TABLE 14A-l (cont'd). SUl\1l\1ARY OF EPIDEMIOLOGICAL STUDIES OF NITROGEN DIOXIDE EFFECTS ON
Study NO z Exposure Effects Seen DISCUSSIon References
Study of respiratory Gas stove use Higher prevalence rate for No NO Z measurements Vlegl et al (1992, 1990)
symptoms m the dlstnct of respiratory symptoms for
PlSa, Italy, usmg Itahan those usmg tank gas for
Natural Research Counctl cooktng
QuestionnaIre on 3,729
adult subjects
Study respiratory mfectlOn Annual average of NO z was The level of NOZ has httle No mdoor NO z Ponka (1990)
3
m chtldren and adults and 47 p.g/m (0 025 ppm) effect on the frequency of measurements PossIble
absenteeism In HelsmIa., disease The effect of low confoundmg WIth
Fmland temperature IS htghly temperature
SIgnIficant
Study of respiratory Mean levels of NO z Among 312 mothers, DIfference In mean levels Koo et al (1990)
tllnesses m chtldren and estimated by personal statistically slgmficant of N0:i for chtldren for
mothers m Hong Kong samplers allergIc rhlDltIs for NO z different symptoms were
levels of 22 6 vs 19 0 ppb, very small, rangmg from
whereas among the chtldren 000-1 79 p~b
there was no statistically (0-34 p.g/m)
SIgnIficant difference m
presence vs absence of the
respiratory symptoms by
NOZlevels
Study of croup mCIdence Outdoor NO z levels, daIly POSItive correlation between No mdoor NO z data No Sevenen and
and NOzlevels m Bochum, averages NOzlevels and mCIdence of dISCUSSIon of confoundmg Mietens (1987)
Germany croup as determmed by factors
hOSpItal admtssions
Study of croup mCIdence Outdoor NO z levels, allDual Monthly NO z average m No mdoor NO z data No Wemmer (1984)
and NOzlevels m and monthly average Mannhelm but not m diSCUSSIon of confoundmg
Mannhelm and Darmstadt, Darmstadt showed lmear factors
Germany correlation WIth monthly
cases of croup
RESPIRATORY U,LNESS a
Study NOz Exposure Effects Seen DIscussiOn References
Study of croup mCIdence and Outdoor NOzlevels, annual Monthly NOz average m No mdoor NOz data No WenmIer (1984)
NOzlevels m Mannhelm and monthly average MannheIm, but not It dIscussiOn of confoundmg
and Darmstadt, Germany Darmstadt, showed lmear factors
correlatIon WIth monthly
cases of croup
Study on the mfluence of NOzlevels were measured Pseudocroup has a No mdoor NOZ data GuggenblChler et al (1990)
vanous factors to mclude by a chemolunnnescence multIfactor pathogenesIs Weather condItIons cannot
NOz on the mCldence of detector at a measunng RapId changes m aIr by thIs statIstIcal evaluatIon
croup m Innsbruck, Austna statIon m the mner CIty area pollutants (especIally NO be ehmmated as an
and NOz) are followed by Important factor whether
mcreased occurrence of dIrectly or mdIrectly
croup
A pIlot study of 130 thIrd Indoor momtors for NO z Selected results of Lumted findmgs presented m Thlelebeule and Huelsse
graders of N0z levels and and other pollutants questiOnnaIres and smokmg the prehmmary study (1989)
'"""'"
~
\0
hematologICal, cl111lcal and
InmIunologIcal end pomts m
hIstory
Rostock, Germany
-
Studv of NO" exposure and
",.
respIratory dIsease functiOn

Indoor N02 measurements
unne hydroxprohne
RespIratory dIsease
questIonnaIres (Amencan
Prevalence rate of
respIratory symptoms hIgher
Ono et al (1990). Tommaga
and Ono (1985)
and symptoms m Japan measurements ThoracIc SOCIety), near roadways WIth heavy
pulmonary functIon tests m traffic and lngher pollutant
1,000 3-year-old chIldren levels
Study of acute Illness Measures of personal AsthmatIc and nonasthmatIc Prehmmary data Goldstem et al (1987)
symptoms and pulmonary exposure to NOz women and chIldren are
functIon m New York m evaluated for PFT and
relatIon to NOz exposure respIratory symptoms
Study NOz Exposure Effects Seen DIscussion References
Study of chromc respiratory Hours of SOz exposure Relative nsks of about No relationslup wIth Euler et al (1988)
dIsease symptoms m 8,572 above 4 pphm, oXIdants 1 2 for the pollutants lIsted measured NO z -
Southern CalIforma Seventh- above 10 pphm, and TSP
Day AdventISts
3
above 200 p,g/m NO z
exposure levels were not
lInked to health effects
Study of 875 cases of croup DaIly ambIent levels Statistical regreSSIOn Au pollution consIdered a Rebmann et al (1991)
m Baden-Wurttemberg m methods mmcate weak but weak factor, whereas
relation to NO z exposure m statistically SIgnificant essential condItIOns for
a 2-year prospective study mfluences of the dally NO z croup are mdividual and
mean on the occurrence of famIlIar dIspOSItion and VIruS
-
.j:>. Study of asthma attack AmbIent NO z levels
croup
Dunng the hIgh NO z (mean
mfection
Indoor NOzlevel and Ponka (1991)
-
~
0
mCIdence over a 3-year
penod m Fmland ill relation
to pollutant levels
the 3-year penod
3
averaged 38 6 fJ-g/m over
3
45 8 fJ-g/m ) levels, the
mean number of all
adrmssIOns was 29 % greater
than dunng lower levels
cooking fuel used were not
conSIdered Mmimum
temperature was aSSOCIated
WIth asthma adunssions
3
(281 fJ-g/m)
Study of upper respIratory AmbIent NO z levels A SIgnificant aSSOCIation of PasSIve smoking and SES Jaakkola et al (1991)
3
mfectIOns ill cluldren ill averaged 15 fJ-g/m upper respuatory mfectIOns evaluated Indoor NO z
Fmland m relation to NO z and aIr pollution ill the two levels and cooking fuels not
and other pollutants age groups studIed conSIdered
Study of prevalence of Indoor and outdoor NO z Stoves used as a heatmg 704 children, 7-16 years old, Kuehr et al (1991)
asthma m chIldren ill data taken mto account. deVIce had a 4 8-fold took part ill a standardIzed
relation to NO z levels m relative nsk for asthma mterview and exam
Gennany compared to other heatmg PasSIve smoking was
exmmned
Panel study of 128 cluldren MaXimum hourly levels for AmbIent NOzlevels were The subgroup analysIs had Vedel et al (1987)
whose parents completed a each 24-h yenod averaged not predIctive of any 55 subjects No Indoor
daIly dIary of respIratory 40 5 p.g/m wIth a range of symptom outcome levels or use of gas stoves
3
symptoms In Chestnut 12-79 p.g/m measures were noted
RIdge regIOn of western
PennsylvanIa In relatIOn to
NOzlevels
Study of 708 nonsmokIng Gas stove cookIng or Increased chromc cough Adjustments for SES and HelsIng et al (1982)
wlute adult reSIdents of electnc stove use and phlegm In households controlled for smokIng Comstock et a1 (1981)
Maryland evaluatIng the USIng gas stoves exposures
effect of gas cookIng on
respIratory symptoms
......
.j:::.. LongItudInal study of MaXimum daIly ambIent NOZlevels were not No Indoor exposure data Henry et a1 (1991)
~
...... exacerbatIon of asthma levels WIth avera~e levels of assocIated WIth the The model adjusted for the
...... measured by wheeZIng 75 and 169 p.g/m In the occurrence of symptoms In effect of the presence of
occurrence In relatIOn to "medIUm" and "lugh" tlus group of asthmatIcs for symptom on the prevIOUS
NO z exposure In exposure categones the exposures that occurred day
approXimately 24 asthmatIc Yearly average levels were
3
school cluldren 2 0 and 0 4 p.g/m ,
respectIvely
Study of the prevalence of Gas stove cookIng or RelatIve nsk of 1 12 (95 % ApprOXimately 41 Infants MargolIs et a1 (1992)
perSIstent respIratory electnc stove use confidence Interval of 0 63 lIved In homes WIth the
symptoms In 393 Infants In to 2 04) envIronmental nsk factor of
North CarolIna gas cookIng
TABLE 14A-2. SUMl\1ARY OF EPIDEMIOLOGICAL STUDIES OF NITROGEN DIOXIDE EFFECTS ON
PULMONARY FUNCTION
Study N~ Exposure Effects Seen DISCUSSIon References
3
SIX CIty study of 9,000 7-49 p,g/m (0 004- FEV l' and FVC decreases DIfferences margmally Speizer et al (1980)
grade school chIldren o 026 ppm) estImate of total ranged from 0 2-0 6 %, sIgmficant, mcomplete
personal exposure gas stove dependmg on exammatlon mdoor exposure
use used as a surrogate and adjustment
3
SIX CIty study analyzed for 7-49 p,g/m (0006- No effect of gas stove use DIfferences margmally Berkey et al (1986)
effects on pulmonary o 04 ppm) estimate of total on growth of pulmonary sIgmficant, mcomplete
functiOn growth personal exposure gas stove mdoor exposure
use used as a surrogate
Lung function panel study NOZ ranged from Peak flow not affected by No mdoor pollutant Vedal et al (1987)
3
of 351 chIldren at the 12-79 p,g/m (0 006- pollutant levels measurements made,
Chestnut Ridge Elementary 004 ppm) outdoor levels were low
School
..-
-I::-
>
..-
I
Lung functiOn study of
117 middle-class households
Gas stove use Peak flow was margmally
related to gas stove use
No mdoor NO z
measurements made
LebOWItz et al (1985)
tv
m Tucson, AZ (p = 0066)
3
Study of traffic policemen 75-103 p,g/m (004- No dIfferences m vanous No mdoor measurements, Speizer and Ferns
m urban Boston WIth nearby o 055 ppm) annual mean pulmonary function tests small sample SIzes (1973a,b)
suburban areas daIly concentratiOns
Study of FEVO 75 m school AmbIent annual NO z SuggestiOn of lower No mdoor measurements, Shy et al (1970a,b)
3
chIldren m Chattanooga, levels as hIgh as 286 p,g/m FEV0 75 means m hIgh much of the NO z measured
TN (0 15 ppm) (Saltzman NOzarea by Jacob-Hochheiser
method) method, no strong
dIfferences found
3
Study of nonsmokmg adults 43-96 p,g/m (0 023- No dIfference m several No mdoor exposures, Cohen et al (1972)
m Los Angeles and San 0051 ppm) annual mean ventIlatory measurements complIcated outdoor
DIego daIly concentrations 113- mcludmg spIrometry and exposures
3
118 p,g/m 90th percentile flow volume curves
TABLE 14A-2 (cont'd). SUMMARY OF EPIDEMIOLOGICAL STUDIES OF NITROGEN DIOXIDE EFFECTS ON
PUlMONARY FUNCTION
Study N02 Exposure Effects Seen DISCUSSIOn References
Lung functIOn study of Maxtmum hourly value of Mormng peak flow was Effects of other pollutants RIchards et al (1981)
12 asthmattc chtldren hvmg 22 pphm reduced, but afternoon peak could not be separated
m the SunaIr Home m flow was not Seasonal factors not
Cahforma adjusted for No mdoor
pollutant measurements
3
Office workers m Los 65-130 flg/m (0 034- No dIfference m most No mdoor measurements Lmn et al (1976)
Angeles and San FrancIsco o 07 ppm) medIan NO z, pulmonary tests Small sample SIze
110-250 90th percenttle
3
RespIratory symptom and NO Z averaged 54 flg/m Small decrease seen m ratto No mdoor measurements Mostardl et al (1981a,b)
pulmonary functIOn study of (0 029 ppm) m polluted of FEV l to FVC Small dIfferences seen
4th through 6th graders m area Relattvely low N02
Akron,OH exposure
3
Study of pulmonary NO z, 12-16 flg/m (0006- No decrease m pulmonary No mdoor measurements PAARC (1982a,b)
functton m French cIttes o 008 ppm) dally' means functIOn related to N 0z Low NO z exposure
NO, 7-140 flg/m3 daIly exposure
means
Study of 5,561 adults aged Ammal means over the Decreased FEV1 and FVC Areas measured at dIfferent Detels et al (1981a,b)
25-39 years hvmg m 5-year penod m Lancaster and mcreased cough, ttmes Other dIfferences
Lancaster and Glendora, and Glendora (Azyza phlegm, and wheezmg between areas ImpOSSIble to
CA statton) averaged 3 2 and found m Glendora when adjust for
11 4 pphm, respecttvely compared to Lancaster
3
Japanese study of school 40-360 flg/m (0 02- CorrelatIOn of peak flow CorrelatIons not adjusted Kagawa and Toyama (1975)
chIldren m Japan, aged o 19 ppm) I-h values at and 25% and 50% FVC for other pollutants
11 years ttme of testmg WIth NO z, NO, SOz, and
TSP
TABLE 14A-2 (cont'd). SUMl\1ARY OF EPIDEMIOLOGICAL STUDIES OF NITROGEN DIOXIDE EFFECTS ON
PUlMONARY FUNCTION
Study N02 Exposure Effects Seen DIScussIon References
Case control study of Cooking fuels, duration of AssocIation of low FEV and No Indoor N02 data Small Jones et al (1983)
213 nonsmokIng women In exposure to coolang fuels, gas cookIng was margInally sample SIze reduces power,
the Tecumseh Commumty and exhaust fan use sIgmficant (p= 0 07) especIally the lImIted
Health study evaluated FEV number of gas stoves In
values vs VarIOUS cooking sample
fuels
Study of 561 nonsmolang Gas stove exposure The use of gas cooking Adjustments for SES and HelsIng et al (1982)
white adult reSIdents of assocIated WIth a control for smoking
Maryland evaluatIng the sIgmficantly greater
effects of gas cooking on percentage WIth ImpaIred
pulmonary function ventilatory function as
measured both by
t-" FEV1 < 80 % predIcted and
~
t-"
by FEV 1/FVC < 70%
+:- NatIOnal Health and N02 exposures ranged from HIghly SIgnIficant regreSSIOn No mdoor N02 exposure Schwartz (1989)
NutntIOn ExammatIOn less than 0 01-0 08 ppm coefficIents showmg a measurements Outdoor
Survey II lung functIOn data IndIVIdual estimates based on decrease In FVC, FEV l' and estimates over a WIde area
coupled with EPA's average of all statIOns WIthIn PEF WIth mcreasIng N02
SAROAD aerometnc data 10 mI of census tract exposure
Lung function measurements
mcluded FVC, FEV1, and
PEF
In a sample of over Gas stove use Margmally sIgmficant No mdoor measurements Hasselblad et al (1981)
16,000 children, PFT were decrease (p= 0 052) m lung
compared to gas stove use functIOn m gIrls 9-13 years
of age PFT numbers were
adjusted for parental
smokmg habIts
TABLE 14A-2 (cont'd). SUMMARY OF EPIDEMIOLOGICAL STUDIES OF NITROGEN DIOXIDE EFFECTS ON
PUIMONARY FUNCTION
Study N02 Exposure Effects Seen DIscussIOn References
A study of PFT m women Weekly personal exposure StatIstlCally sIgmficant No assocIatIOn WIth FIscher et al (1985, 1986)
m relation to N0 2 levels m estimates ran~ed from negative assocIations longItudmal pulmonary RelUlJn et al (1985)
the Netherlands 15-300 fJ-g/m (0 008- between vanous pulmonary functIOn dechne
0159 ppm) function measures and N02
exposure ill nonsmokmg
women
A study of the effect of Gas stove use Some decreases observed m Sample SIzes too small to Rosem and Corey (1986)
domestic aIr pollutIOn on lung function m homes WIth gIve meanmgful
respIratory functIOn m a gas stoves mformatIOn
group of houseWIves m
Lebanon, CT
Study of lung functIOn and N0 2 levels of over Lung function measures m Method of analySIS and LlU and Wang (1987)
I-' 3
.j::o. respIratory functIOn m 400 fJ-g/m (0 21 ppm) m women were reduced by adjustments for covanate
>I
I-'
relatIOn to homes WIth coal kitchens elevated levels of pollutants were not gIVen
V\ or gas cooking fuels No respIratory symptoms
were related to gas
Study of cluldren's N02 levels measured by PFTs were evaluated. m Exposure measure may not BruneKreef et al ~1990)
pulmonary functIOn m Palmes tubes m homes, over 800 chIldren aged have captured short-term
relation to N02 exposure m mean concentratIOn ranged 6-12 years No relatIonslnp peak concentratIOns
3
the Netherlands from 23-72 fJ-g/m (0012- was found The power of
o 038 ppm) N02 the study to detect small
effects on lung functIOn was
consIdered adequate
Study of N02 exposure on Indoor N02 measurements, RespIratory dIsease Ongomg study expected Tommaga and Ono (1985)
pulmonary functIOn and unne hydroxyprolme questIOnnaIres, PFTs m completion m 1989-90 WIth
symptoms m Japan measurements 1,000 3-year-old clnldren analySIS at a later date
TABLE 14Aw2 (cont'd). SUMMARY OF EPIDEMIOLOGICAL STUDIES OF NITROGEN DIOXIDE EFFECTS ON
PUIMONARY FUNCTION
Study N<h Exposure Effects Seen DISCUSSIon References
Study of chIldren's N02 levels measured by BronchIal reactIon to Urban N02 levels of Gschwend-Elgenmann et al
bronchIal reactIvIty III paSSIve samplers carbachol measured III 36 2 p.g/m3 vs 26 2 p.g/m3 (1989)
relatIon to N02 exposure III 312 school chIldren III two In rural area A statIstIcal
SWItzerland expoSllfe groups dIfference seen III bronchIal
reactIVIty III healthy
chIldren but not III
asthmatIcs Effects of antI-
asthmatIc therapy III atopIC
chIldren could not be
detenmned
Study of OXides of sulfur, Outdoor daIly peak hourly Chromc exposure to the The proportIon of Detels et al (1991)
N02, hydrocarbons, and levels for N02 range from pollutant mIX results III less partICIpants retested III the
partIculate exposure on 003-011 ppm rapId growth of lung study was low (45-47%)
pulmonary functIOn III two functIon III chIldren and a due to 1lllgratIon out of the
CItIes In Southern greater rate of detenoratIon study area The Impact of
CalIfOrnIa III adulthood thIs may have been mmImal
through DIfferences
between commumtIes III age
and heIght could have
bIased the results
aAbbreViatIOns N02 = Nitrogen dIOXIde, S02 = Sulfur diOXIde, TSP = Total suspended parl1culate, FEV = Forced expiratory volume, FVC = Forced Vital capacity, NO = Nltnc OXIde,
COPD = Chromc obstrucl1ve pulmonary disease, NO x = Nitrogen OXIdes, PFT = Pulmonary funcl10n test, SES = SoclOecononuc status, PEF = Peak expiratory flow
15. CONTROLLED HUMAN E~XPOSURE STUDIES
OF NITROGEN C.XIDES
15.1 INTRODUCTION
Thts chapter dIscusses the effects of mtrogen oXldes (NOx ) on human volunteers
exposed under controlled condItIons The NO x speCIes of pnmary concern IS mtrogen
dIoXlde (N02) Nltnc oXlde (NO) and mtrates have also been evaluated m controlled human
exposures, and mtnc aCId (HN03) effects have only recently been studIed The 1982 Arr
Quahty Cntena for OXldes of NItrogen Document (U S EnVIronmental ProtectIon Agency,
1982a) presents a comprehensIve reVIew of studIes conducted up to about 1980 The present
chapter focuses maInly on summanes and cntlques of sludles conducted smce then, but also
mcludes some dIscussIOn of the earher hterature as well
Controlled human exposure studIes of N02 deal WIth relatIvely bnef, expenmental
exposures to Ingher concentratIOns compared to the annual anthmetIc mean standard
(0 053 ppm) One of the pUlposes m revlewmg these studIes IS to evaluate the data base for
short-tenn (typICally < 4 h) N02-related health effects, thus, conSIderatIOn of the tIme course
of responses and the pattern of exposure m controlled human exposure studIes IS lffipOrtant
Because of the WIdespread occurrence of N02 m both outdoor and mdoor
envIronments, there are major concerns regardmg potentIallffipacts of N02 exposure on
human health, partIcularly WIth regard to effects on the lung Doslffietry modelmg and
ammal illstological studIes mdIcate that N02 ' s lffipact should be pnmanly seen m the small
arrways and gas exchange regIOns of the lung, thus, tests that speclfically evaluate responses
m tills regIOn are of partIcular mterest m evaluatmg the effects of N02 In assessmg N02
lung effects for cntena development purposes, a number of lffiportant questIOns need to be
addressed, as posed m the followmg hst of cntIcal questIons Some of these questIons are of
a "genenc" nature, applymg to many ambIent aIr pollutrnts, and others are speclfic to N02
mhalatlon Several of the questIons may be answered only partially by controlled human
exposure studIes and are addressed further by anlmal tOXlcologlCal studIes andlor
epIdemIOlogIcal studIes dISCUSSed m Chapters 13 and 14, respectIvely
15-1
NItrogen DIoXIde Exposure and Human Health Cntical Questions
1. Does short-term N02 exposure cause acute changes m lung functIOn, mcreased
resprratory symptoms, or mcreased arrways responsIveness m normal, healthy
subjects at levels that may be expected m the ambIent (or mdoor) envIronment?
Are these effects reproducIble? If so, what IS the pOSSIbility that such acute
responses may contnbute to chromc changes m lung function, promote the
development of resprratory dIsease, cause acceleratIOn of normal age-related
declmes m lung function, or aggravate eXIstmg resprratory dIsease?
2 Are there groups Withm the population at speCIal nsk for N02 health effects
(1 e , groups compnsed of persons who exhIbIt greater responses to N02
exposure than the average healthy subject)? Groups hypotheSIZed as lIkely to be
at SpecIal nsk mclude young chIldren, adolescents, elderly subjects, and patIents
of all ages WIth asthma, chromc obstructIve lung dIsease, or other lung dIseases
If there are subject groups who are more responsIve, can they be IdentIfied
prospectively (1 e , WIthout exposmg them to N02 fIrst)?
3. Does N02 cause an mflammatory response m the lungs of healthy mdividuals or

patIents WIth lung dIsease? SpecIfically, does N02 exposure cause mcreased
capillary permeability, mcreased local blood flow, extravasatIOn of flUId or mflux
of leukocytes-especIally neutrophl1s and eosmophl1s-mto the mterstitmm and
the arrways, secretIon of pro-mflammatory medIators, mast cell degranulatIon, or
epIthehal desquamatlOn?
4. Does N02 exposure cause mcreased responses of the lung (mcludmg arrways
responsIveness, lung functIon, mflammatIon, cell damage, etc) to (a) other
pollutants such as ozone (03), sulfur dIOXIde (S02), or aCId aerosols,
(b) bronchoconstnctors such as mstamme or methacholme, (c) other agents such
as cold-dry arr or exerCIse, or (d) specIfic antigemc substances?
5 Does N02 exposure alter (a) resprratory tract host defenses, (b) arrway epIthehal
permeability or mucociliary clearance, or (c) local or systemIC Immune response
to Infection? As a consequence of N02 Impacts on host defense system
components, IS the killmg or removal of microorgamsms Imparred by N02
exposure? Also, are mflammatory responses or tissue mJury caused by
mIcroorgamsms worsened by comcident N02 exposure?
6 What IS the time course of response to acute exposures? Are there both
ImmedIate and delayed responses? Do responses mcrease or decrease WIth
mcreased exposure duratIOn? What IS the tIme course of response to repeated
exposures? Do responses mcrease or decrease WIth mcreased frequency of
exposure?
15-2
Controlled human exposure studIes serve as an Important source of mhalatIon
tOXicology data, partIcularly for the cntena pollutants such as NOx MethodologIcal and
expenmental desIgn consIderations for controlled human exposure studIes have recently been
revIewed (Folmsbee, 1988) These studIes are tYP:l.cally conducted on volunteers who have
been Informed of the pOSSIble nsks of such studIes and who have gIVen theIr "Informed
consent" to partICIpate The subject group that most often partIcIpates m such studIes are
young adult males wIth no hIstory of respIratory dIsease" allergIes, smokmg, and no
contramdIcatIOn to exerCIse In addItion to young men, partICIpants of eIther gender and of
dIfferent raCIal groups have mcluded chIldren, adolescents, elderly persons, and adults
Other subject groups that have been specIfically StudIed mclude healthy subjects wIth
allergIes, asthmatics, smokers, patients WIth chromc obstructive pulmonary dIsease (COPD),
or otherwIse healthy persons with upper respIratory InfectIOns These latter subject groups
may be conSIdered potentIally "senSItive subJects", especially asthmatics, COPD patIents,
chIldren, and the elderly For mdIviduals WIth eXIstmg lung dIsease and/or hyperresponsIVe
arrways, speCIal conSIderatIOn of the potential Impact of pollutant exposure IS requIred
These mdIviduals, mcludmg the healthy elderly populatIOn, often have lImIted pulmonary
reserves and, therefore, a gIVen msult has a greater phySIOlogICal/pathologIcal consequence
(mcreased arrways reSIstance, restnctIOn of lung volumE') ChIldren are of SpecIal concern
because theIr lungs are still growmg and developmg and, hence, the pOSSIbility of a long-
term Impact on lung health may be greater than for the mature adult lung
Controlled exposures, by de:fImtIOn, occur m a laboratory settmg The most "natural"
mode of exposure IS unencumbered breathmg WIthIn an exposure chamber Other modes of
exposure mclude facemask, hood, or mouthpIece exposures A controlled exposure Imphes
that the envIronmental vanables such as the concentratIOn of the pollutant, temperature, and
humIdIty are momtored and mamtamed at some specIfied level In addItion, the duration of
the exposure and amount of actiVIty dunng the exposure are closely regulated The actiVIty
level IS closely correlated WIth the volume of aIr breathed mto the lung In order to SImulate
an outdoor exposure where the subject IS active, many exposure studIes mclude some form of
controlled exerCIse However, exerCIse alone may have some Important confoundmg effects,
partIcularly m the case of exercise-mduced bronchoconstnctIon m asthmatics ExerCIse alone
may mduce sIgnrficant decrements m spIrometnc vanabJles or sIgnrficant mcrements m
15-3
arrway reSIstance Exercise-mduced bronchoconstnctIOn IS followed by a refractory penod
of several hours durmg which asthmatics are less susceptible to bronchoconstnctIOn
(Edmunds et al ,1978) ThIs penod of refractormess could alter the subject's responsIveness
to N0 2 or other mhaled substances The ma.Jor external determmants of the exposure "dose"
of a pollutant are the concentratIon of pollutant, the duration of the exposure, and the volume
of aIr breathed (specIfically, the route, depth, and frequency of breathmg) durmg the
exposure Further mformatIOn IS, of course, necessary to determme the actual dose dehvered
to the vanous "target" regIOns of the respiratory tract (1 e , total respiratory uptake), as IS
presented in Chapter 13 Many of these conSIderatIOns have been dISCUSSed m greater detaIl
by Folinsbee (1988)
In human exposure studies, the methods used for assessment of effects pnmanly
mvolve "noninvasive" procedures Vanous pulmonary junctlOn tests such as sprrometnc
measures of lung volumes, measures of reSIstance of lung or nasal arrways, ventilatIOn
volume (volume of arr mhaled mto the lung per mmute), breathmg pattern (frequency and
depth of breathmg), and numerous other "breathmg" tests have been utthzed (Bouhuys,
1974). These tests proVIde useful mformatIon about some of the baSIC phYSIOlogICal
functIons of the lung Certam tests proVIde mformatIOn pnmanly about large arrway
function, these mclude (a) dynamIC sprrometry tests (e g , forced expiratory tests such as
forced expiratory volume m 1 s [FEV d, maxmIal and partIal flow-volume curves [mcludmg
those usmg gases of dIfferent denSIties such as hehum], peak flow measurements, etc ), and
(b) specific airway resIstance/conductance measurements (SRaw' SGaw) The reader should
refer to the glossary for more specIfic descnptIOns of vanous tests These" standard
pulmonary functIon" tests are relatively SImple to admilllster, proVIde a good overall mdex of
lung function, and have a relatively low coeffiCIent of vanatIOn (CV), the CV IS about 3 %
for FEV! and about 10 to 20% for SRaw However, because N02 depOSItS pnmanly m
peripheral arrways, many of the above tests may not proVIde the necessary mformatIOn to
fully evaluate the effects of N02 Other tests purported to proVIde eVIdence of small arrway
function include multiple breath mtrogen washout tests, closmg volume tests, aerosol
depOSItIon/dIstnbutIOn tests, denSIty dependence of flow-volume curves (usmg gases of
dIfferent denSIties such as hehum), and frequency dependence of dynamIC comphance, but
15-4
none are used routmely and use of these procedures to assess "small arrways functIOn" IS not
wIdely accepted
Somewhat more mvaSIve procedures have also been more utIllzed m recent years to
determme human responses to arr pollutant exposures, ll1lc1udmg pharmacologIc arrway
mhalatIOn challenge tests, measurements of pulmonary dearance of mhaled aerosols,
bronchoalveolar lavage, nasal lavage, and artenal blood gas measurements
Alrway mhalatlOn challenge tests are used to evalu.lte the "responsIveness" of a
subJect's arrways to mhaled matenals Arrway responsIveness may change as a result of
alteratIOns m a dIsease state, such as mflammatIOn aSSOCJlated WIth asthma or vtral resptratory
mfectIOn, or as a result of damage to the arrway caused by dIsease or msult from mhaled
tOXlC or allergemc matenals Thus, one of the problems m evaluatlng changes m arrway
responsIveness WIth respect to mhalatIOn of arr pollutants IS that the basehne responsIveness
can be changed by other factors not assocIated WIth pollutant exposure In order to test for
the degree of arrway responsIveness, a chemIcal that causes constnctIOn of the arrways (such
as htstamme, carbachol, or methachohne) IS typICally us~xl Other challenge tests mvolve the
use of allergemc substances, exerCIse, hypertomc sahne, or cold-dry arr Responses are
usually measured by evaluatmg changes m arrway reSIstance or sprrometry after each dose of
the challenge IS admlllistered Usually, the test will proceed untll some target effect level IS
achteved (e g , doubhng of arrway reSIstance) and the auway responSIveness IS then
charactenzed by the dose requrred to achteve that level The procedures for admlllistenng
and mterpretmg mhalatIOn challenges are dISCUSSed in detaIl elsewhere (Cropp et al , 1980,
Cropp, 1979, Chat et al , 1975, FISh and Kelly, 1979, O'Byme et al , 1982)
Asthmatics as a group are sIgmficantly more responsIve than healthy normal subjects to
a vanety of arrway challenges The dIfferences in arrway responsIveness may span several
orders of magmtude (at least 100-fold) between normals and asthmatIcs (O'Connor et al ,
1987) Nevertheless, there IS conSIderable overlap betwr.en the more responsIve healthy
subjects and the less responsIve (htstamme) asthmatics (pattemore et al ,1990) Arrway
responsIveness to methachohne appears to be somewhat better than aIrway responsIveness to
htstamme at dIfferentmtmg normals and asthmatics, although responses to these two
bronchoconstnctors are well correlated (r = 070) (Chatham et al ,1982) Unfortunately,
because of the number of dIfferent provocative agents USled m the arrway challenges and the
15-5
variety of methodologIes used to admlDlster challenges, It IS dIfficult to compare responses
between laboratones m a quantitative manner Thus, It IS not useful to suggest standard
ranges of responSIveness for normals and asthmatics
Tests ofpulmonary clearance of mhaled aerosols are used to assess the effiCIency of the
mucociliary clearance mechanIsm and to estImate pulmonary epIthehal permeability
TypICally, a radIoactively labeled test aerosol, of a specIfic SIZe range that will depOSIt m the
lung region of interest, IS deposIted m the lung by mhalatIOn External detectors are then
used to assess the amount of remalDlllg test aerosol at vanous tImes after the lDltIal
deposItion of the aerosol ThIs methodology IS dISCUSsed m Clarke and Pavia (1980) and
Raabe (1982) and m Section 13 22 1 A partIcular apphcatIOn of clearance of radIOlabeled
aerosols is for the estImation of epIthehal permeability, typICally usmg technetIUm-labeled
diethylene tnamme penta-acetate or pentetate ThIs methodology IS dIscussed m Nolop et al
(1987)
In the past several years, bronchoalveolar lavage technIques have been used m chmcal
exposure studIes of several dIfferent pollutants In thIs procedure, a fiberoptIc bronchoscope
IS passed into the arrways and wedged m a subsegmental bronchus, where sterIle buffered
saline IS used to wash free cells and arrway secretIOns from the segment (Reynolds, 1987)
The resulting lavage flUId may be analyzed for vanous chemIcal medIators or reactIOn
products, numbers and types of cells, and the functIOns of some lung cell types Another
less mvaSIve procedure, known as nasal lavage, may be used to obtam nasal secretIOns and
cells (Graham et al , 1988)
There are a number of hmItatIOns of controlled human exposure or "chmcal" studIes
Many experimental anImal models are denved from genetically pure strams, thus reducmg
the expected variability m bIOlogICal response Because of theIr heterogeneIty, humans are
expected to dIsplay a WIder range of response to a vanety of phYSIOlogICal and pathologIcal
stimuh This vanability and the small sample numbers hmit the extent to whIch the data can
be generalized to the population as a whole or to certam defmed segments of the population
(e.g, asthmatics) The small sample SIZe may hmit the mterpretation of the study, especIally
when the results are negative (1 e , the null hypothesIs IS not rejected) One cannot have
great confidence in a study that fmds no effect of a treatment (m thIs case N02 exposure) If
the sample SIZe (1 e., the number of subjects) IS too small to statistically detect an effect, If
15-6
present ThIs must be kept m mmd m mtetpretmg the results of human exposure studIes
wIth a small number of subjects Investigators have reported a wIde vanatIon m
responsIveness of asthmatics to N02 , whIch may be partIally attnbuted to mtnnsic vanatIOn
m response as well as vanatIOn m exposure vanables In addition, place of resIdence, season
of the year, and mdoor home enVIronment may all be determmants of the asthmatIc's
response to N02 Controlled human exposure studies are ethIcally Inmted to acute or
subchromc fully reversIble functIonal and/or symptomatIc responses ThIs may m many
cases lImIt the magmtude of expected responses and, hence, the statistical sIgmficance of
responses m studies wIth small numbers of subjects Exposures seldom last longer than 1 to
2 weeks for up to 8 h per day These data, therefore, are pnmanly useful m evaluation of
short-term, N02 -mduced health effects
True SImUlatIOn of ambIent condItions, gIven the number of potential pollutants and the
vanety of possIble combmatIOns, IS not a realIstIc goal for controlled human exposure
studies For example, the typICal temporal pattern of ambIent concentratIOns IS seldom
duplIcated m controlled exposure studies However, sImple mIXtures of two or three
pollutants can be evaluated to determme the potentIal for eIther additive or synergIstIc
effects Further dISCUSSIon of the desIgn consIderations for human climcal studies are
presented by Bates et al (1970), Hackney et al (1975a), and Fohnsbee (1988) and were the
subject of a symposIUm proceedIngs (Frank et al , 1985). Because controlled exposure
studies of humans deal exclUSIvely WIth acute or subchromc exposures, the applIcability of
these data IS bnnted to short-term exposure effects and of lImIted usefulness m the evaluatIon
of the effects of chromc N02 exposure
More than 25 addItional studIes on the effects of N02 on healthy, normal subjects have
become avaIlable smce the 1982 AIr QualIty Cntena for OXides of NItrogen Document (D S
EnvIronmental Protection Agency, 1982a) Several new studies of the effects of N02 on
mdIviduals WIth pulmonary disease (asthma and COPD) have been publIshed, helpmg to
alleVIate a cntIcal InformatIOn defiCIt of the earlIer revu~w (U S EnvIronmental ProtectIOn
Agency, 1982a,b) Although more than 10 new reports have been publIshed, the data base
concemmg N02 effects m senSItIve subjects still reqUIres concentratIOn-response studIes m
moderately senSItIve asthmatics, mformatIOn concemmg the mflammatory response to N0 2
mhalatIon, further exammatIOn of the effects of N02 on mfectIVIty m humans, and further
15-7
evaluation of patlents Wlth COPD Only one study IS avaIlable on pulmonary epIthehal
penneability or mucocIhary clearance effects of N02 m humans
One of the more lIDpOrtant observations m studles of N02-exposed anlIDals IS that N02
exposure is associated wlth mcreased susceptiblhty to vITal and bactenal mfections due to
lIDpaInnent of host-defense mechamsms (see SectlOn 13 2 2 1) Also, epidemlOlogy studIes
clearly suggest a hnk between N02 exposure and mcreased rates of respIratory illness,
especIally m chIldren (Section 14 3 1) These studIes have proVIded a baSIS for several
recent investigations of human lIDmune host defenses after N02 exposure Studles have
utilized both in vitro exposure of cultured human cells (e g , macrophages) and ill VIVO
exposures of human subjects
ThIs chapter opens WIth dIscusslOn of effects on healthy adults of controlled human
exposures to N02 Recently pubhshed reports generally support pnor concluslOns regardmg
the effects of N02 exposure on healthy young adults Several of the newer studIes exammed
the specific effect of N02 on cardIopulmonary functlOn m normal adults (see Section 15 2)
The N02 concentrations ranged from 0 2 to 4 0 ppm In another group of studIes, the
effects of pollutant mIXtures or ambIent arr, of whIch N02 was a component, were exammed
These studIes are summanzed ill SectlOn 15 2 3
StudIes exammmg the specIfic effects of N02 m nonnal subjects support conclUSIons
earlier reached in the AIr Quahty Cntena for OXides of NItrogen Document (D S
Environmental Protection Agency, 1982a), m that they conSIstently demonstrated the absence
of effect of N02 on lung function at concentratlOns between 0 3 and 0 6 ppm (Adams et al ,
1987; Drechsler-Parks et al , 1987, Drechsler-Parks, 1987, Kagawa, 1986)
Four studIes (Avol et al , 1983, 1985a, 1987, Lmn et al , 1980a) have also been
pubhshed m whtch N02 was a component of an ambIent OXidant arr mIXture The effects of
ambient air exposures, If any, were attrIbuted to 03 There was no apparent mfluence of the
very low (0.04 to 0 07 ppm) concentratlOns of N02 present m the ambIent arr In addItlOn,
several controlled exposure studIes used pollutant mIXtures contammg N02 m concentratlOns
from 0.16 to 5 0 ppm (Kagawa, 1983a,b, Fohnsbee et al , 1981, Islam and Ulmer, 1979a,b,
Kagawa and Tsuru, 1979, Kagawa, 1986, Klemman et al , 1985, Lmn et al , 1980b, Toyama
et al., 1981, Von NiedIng et a1 , 1979, Stacy et a1 , 1983, Drechsler-Parks et a1 , 1987)
15-8
At concentratIOns less than 1 0 ppm, these studies demonstrated no ObVIOUS effects of N02 m
pollutant mIXtures, whlch contamed 0 3 , S02' and/or palltlcles m addItion to N02
After the dIScussIon of healthy subjects, N02 effects on sensItive subjects, mcludmg
asthmatics and patients wIth COPD, are presented (SectIOn 15 3) Several studIes exammmg
the effects of N02 concentratIOns m the range of 0 1 to 0 5 ppm on spIrometry m asthmatic
subjects suggest possIble small changes m lung functIOn (Bauer et al , 1986b, Roger et al ,
1985, Koemg et al , 1987a,b, Avol et al., 1986) However, these changes were absent at
hlgher N02 concentrations (Avol et al , 1986, ByIm et al , 1985, Linn et al , 1985b, 1986),
thus faIlmg to suggest a concentration-response relatIonshlp StudIes exammmg patients wIth
COPD mdicated pulmonary functIOn changes wIth bnef exposure to hlgh concentratIOns (5 to
8 ppm for 5 mm) or wIth more prolonged exposure to lower concentrations (0 3 ppm for
3 75 h).
Smce a change in airway responsIveness appears to be one of the most senSItive
mdIcators of response to N02 exposure, SectIOn 15 4 dllscusses m more detaIl the effects of
N02 exposure on aIrways responSIveness m both healthy and asthmatic subjects AIrway
responSIveness has been shown to mcrease m healthy subjects after exposure to N02
concentrations m excess of 1 0 ppm EvaluatIOn m SectIOn 15 4 of studies of N02 exposure
effects on anways responSIveness m asthmatIcs mdicates m some cases mcreased aIrway
responSIveness to a vanety of provocatIve medIators at exposure levels of 0 2 to 0 3 ppm
N02, however, the occurrence of these responses appears to be mfluenced by the exposure
protocol, particularly whether or not the exposure mcludes exerCIse
SectIOn 15 5 next reVIews the effects of N02 and lHN03 exposure on blood, unne, and
bronchoalveolar lavage flUId (BAL) bIOchemIStry ThIs IS followed by diSCUSSIOn of an
lIDpOrtant array of studies exammmg the effects of exposure to N02 or HN03 exposure on
human pulmonary host defense responses These studIes (SectIOn 15 6) examme the roles
that N02 exposure may play m potenttatmg susceptibility to respIratory InfectIOns Next,
Section 15 7 exammes the effects of mtrates on human lung functIOn Fmally, SectIOn 15 8
presents conclUSIOns and a summary of the chapter
15-9
15.2 EFFECTS OF NITROGEN OXIDES IN HEALTHY SUBJECTS
Early studIes mdlcated that the effect of N02 on arrway resIstance was noted at
concentratlOns above 1 5 ppm m healthy volunteers (Abe, 1967, Von Nled1ng et al , 1970,
1973a) Other studIes have mdIcated no slgmficant lung functlOn effects of N0 2 m healthy
normal subjects at concentratlOns below 1 0 ppm (Folmsbee et al , 1978, Hackney et al ,
1978, Bell and IDmer, 1976, Kerr et al ,1979) ThIs section presents a dIScussIon on these
and other studIes, as well as studIes on NO and N02 mlXtures
15.2.1 Lung Function Effects of Nitrogen Dioxide

ThIs sectlOn IS dIVIded accordmg to the concentratlOns of N02 used m the study The
frrst subsection deals WIth the effects of exposure to greater than 1 0 ppm, the second WIth
the effects of exposure to less than 1 0 ppm StudIes dealmg WIth N02 exposure m healthy
subjects are summanzed m Table 15-1 (The detaIls of the exposure condItlOns, number of
subjects, ventIlatlOn levels, temperature, relative humIdIty, and other expenmental
informatIon are presented m Table 15-1 OccaslOnal reference to thIs mformatlOn IS made m
the text when necessary, but the reader should refer to the table for these detaIls)
15.2.1.1 Concentrations Above 1.0 ppm

The effects of N0 2 levels greater than 1 0 ppm have been exammed m several
laboratones In two studIes, Von NIed1ng and Wagner (1977) and Von NIedmg et al (1979)
StudIed 11 males exposed to 5 0 ppm N0 2 for 2 h whIle performmg hght, mtermittent
exerCIse Arrway reSIstance mcreased from 1 51 to 2 41 cm H 20/L/s after 2 h of exposure
There was also an apparent decrease of artenal oxygen partIal pressure (Pa0:2) from 90 to
82 torr (These samples were taken from "artenahzed venous" blood drawn from the ear
lobe) The StatIStICal analySIS of thIs data IS Impacted shghtly due to an adjustment m the
Pa02 data prior to testmg for sIgmficance Von NIedmg and Wagner (1977) state
ItTo mcrease the power of the tests PaOTdIfferences ~5 mm Hg and RT-mcreases ~0 5 cm
H 20/Us were regarded as zero" ThIs transformatlOn would mcrease the hkehhood of
findmg a slgmficant effect
In a subsequent synopsIs of several studIes, Von NIedmg et al (1980) dIscussed the
results of two expenmental exposures that were prevlOusly pubhshed (m German) In the
15-10
TABLE 15-1. RESPONSES OF HEALTHY SUBJECTS TO NITROGEN DIOXIDE EXPOSUREa
Exposure ExerCIse ExercIse RelatIve Number and
N02 DuratIon DuratIon Vent Temp HUlffidIty Gender of Subject
Reference (ppm) (mm) (mm) (L1mm) (0C) (Percent) Subjects CharactenstIcs Notes on Effects
Abe (1967) 40-50 10 Bag exposure technIque
AIrway resIstance mcreased
30 rom after end of exposure
No change m spIrometry
Adams et al 06 60 60 70 21-25 45-60 20M Nonnal No effect of N02 on
(1987) 50 20F spIrometry or aIrway
resIstance
Bed and Ulmer 10 120 16 Healthy ResponsIveness to
(1976) 25 120 16 lIS acetylcholme challenge
50 120 16 5 NS mcreased after 7 5 ppm
75 120 16 (120 rom) and 5 0 ppm (14 h)
--
U\
I
Boushey et al (1988)
(part 2)
50
06
840
120/day
for 4 days
60 -30-40 210 56
8
4 Mil F
8S
Healthy, NS,
21-36 years,
ResIstance mcreased after all
but the 1 O-ppm exposure
No effects of repeated N02
exposure on respIratory
FEV1/FVC% functIon (SRaw' FVC, FEV1)
range 73-83 % or symptoms Shght mcrea<:e
"nonnal" m cIrculatmg (venous)
methacholme lymphocres 1,792 ±
responSIveness 54.<1 mm (post-N02) vs
3
1,598 ± 549/mm (baselme)
No change m BAL lympho-
cytes except an mcrease m
naturallaller cells 7 2 ± 3 1%
(post-N02) vs 4 2 ± 2 4%
(baselme) No change
observed m IL-l or TNF
TABLE 15-1 (cont'd). RESPONSES OF HEALTHY SUBJECTS TO NITROGEN DIOXIDE EXPOSURE2
Exposure ExercIse ExercIse RelatIve Number and
NOz DuratIon DuratIon Vent Temp HumIdIty Gender of Subject
Reference (ppm) (mm) (mm) (llmm) eC) (percent) Subjects CharactenstIcs Notes on Effects
Bybn et al (1985) 00 20 22 35 5M14F 20-36 years, SuggestIon of change ill SRaw ill
012 NS nonnals SRaw tended to
025 mcrease at 0 25 ppm and tended
05 to decrease at 0 50 ppm
AnalySIS of vanance mdIcates
no sIgnIficance No effects on
bronchtal reactIvIty MedIan
odor threshold 0 04 ppm
Chaney et al (1981) 02 120 0 22 40 19 M Young adult, Increase ill blood glutathtone
(15 controls) nonnal levels after NOz exposure
Devbn et al (1992) 20 240 120 50 22 40 10 Healthy NS Increased bronchtal PMNs and
--
Vl
1
N
Drechsler-Parks et al
(1987)
060 120 60 25 24 54 8 M/8 F 51-76 years
decreased macrophage
phagocytosIS
No statIstIcally SIgnIficant
changes ill lung functIon due to
NOZ exposure
Drechsler-Parks 060 120 60 25 24 55 8 M/8F 18-26 years, NS No SIgnIficant changes m
(1987) spIrometry attnbutable to NOz
Folmsbee et al 062 120 15 33 25 45 5M Healthy No SIgnIficant pulmonary
(1978) 30 33 5M functIon responses attnbuted to
NOz exposure
TABLE 15-1 (cont'd). RESPONSES OF HEALTHY SUBJECTS TO NITROGEN DIOXIDE EXPOSUREa
Exposure ExercIse ExercIse Relative Number and
NO z Duration Duration Vent Temp Hunndity Gender of Subject
Reference (ppm) (nun) (nun) (Unun) (0C) (Percent) Subjects CharactenstIcs Notes on Effects
Frampton et al 06 180 60 "",,40 22 30 7 M/2F Healthy, NS No change m spIrometry,
(1989a) (6 X 10) Raw' or carbachol reactivIty
No change m cell recovery
005 135 60 11 M/4F Nonreactive or dIfferential counts
wIth 2 0 spIkes (3 X 15) (6 X 10) (carbachol), POSSIble decrease m
no recent upper macrophage mactIvatIon of
respIratory VIrus m vItro POSSIble
mfectIOn sensItive subgroup
Frampton et al (1) 0 6 180 60 39 220 30 6 M/2F 30 3 ± 1 4 years
Total NO z uptake (1) 3 4 mg
(1989b) (2) VAR (0 05 (2) 5 6 mg, (3) - 3 3 mg
background (4) 8 1 mg BAL flUId
with 3 X 15 180 60 43 220 30 11 M/4 F 25 3 ± 1 2 years analysIs showed no
....... nun at sIgmficant effect on total
Ul
I
20 ppm) protem or albunnn There
....... (3) 06 180 60 ,.,,40 220 30 5 M/3 F 32 6 ± 1 6 years was an apparent mcrease m
w
(4) 1 5 180 60 39 220 30 12 M/3 F 23 5 ± 0 7 years alpha-2-macroglobulm 35 h
after exposure to 0 60 ppm
Healthy, NS (Group 1) but not after the
other protocols No changes
m percentage of lymphocytes
or neutrophl1s Authors
concluded that NOz at these
concentrations neIther altered
epIthehal permeabIhty nor
caused mflammatory cell
mflux
Exposure ExerCise ExerCise Relative Number and
N02 Duration Duration Vent HUmIdity Gender of Subject
Reference (ppm) (mm) (mm) (Umm) (percent) Subjects CharactenstIcs Notes on Effects
Frampton et al (1991) See There were no changes ill
Groups I, airway mechanICS (FVC,
2, and FEV!, SGaw)
4 above Responsiveness to carbachol
was SIgnIficantly mcreased
after 1 5 ppm N02
(Group 4) but not after the
other exposures (Groups 1
and 2) Degree of baselme
responsiveness to carbachol
was not related to response
after 1 5 ppm
--
VI
I
,J::o.
Frampton et al (1992)
Gomgs et al (1989)
20
10
360
120/day,
IntermIttent
222 60
12
21
Healthy, NS
Healthy, NS,
ImmedIate and 18-h post-
BAL mcrease m PMNs
Overall trend for a shght
(see Kulle and 20 3 days 22 seronegative decrement ill FEV! With
Clements, 1988) 30 22 N02 exposure (::;; 1 %)
00 23,21 Methacholme response
or 22 decreased With consecutive
tests, but not as a result of
N02 exposure or mfectIon
status Study conducted
over 3-year penod N02
did not SIgnIficantly
mcrease VIral mfectIvlty,
although a trend was
observed ThIs study had a
low power to detect small
differences m mfectIon rate
NO z DuratIOn DuratIon Vent Temp HUmIdIty Gender of Subject
Reference (ppm) (mm) (mm) (Umm) (0C) (Percent) Subjects CharactenstIcs Notes on Effects
Hackney et al (1978) 10 120 60 LIght 31 35 16 Healthy AIr-NOZ-NOz fixed
(2 con- exposure sequence
secutIve Al 5% decrease m FVC
days) after second day of NOz
Not clear that the decreased
FVC IS an NO z effect or an
order effect No other
effects
Hazucha et al (1982, 01 60 21 40 15M 23-39 years, NS No symptoms, no odor
1983) detectIon, no effect on
SRaw
Johnson et al (1990) See No change m a-I-protease
I-' Frampton mhIbItor after NO z
Ul
I et al exposure
I-'
Ul (1989b)
Groups 2
and 4
Joerres et al (1991) 10 180 Intenmttent 3 MIS F Healthy No responses
Kagawa and Tsuru 015 120 60 SOW 27-29 50-60 6M 19-24 years No symptoms, no
(1979) pulmonlLty functIon effects
Suggested mdlVldual
changes m SGaw
Kagawa (1982) 1 o ppm 120 60 SOW 28 55 8M 19-24 years Suggested change m densIty
NO dependance of expIred
flow
Exposure ExercIse ExercIse Relative Number and
NO z Duration Duration Vent Temp Hunumty Gender of Subject
Reference (ppm) (nun) (nun) (Unun) COC) (percent) Subjects CharactenstIcs Notes on Effects
Kagawa (1986) 030 120 60 SOW 28 50-60 6 19-25 years No effect on SGaw , other
NO z nuxtures studIed but
effect of NO z cannot be
ascertamed
Kerr et a1 (1979) 05 120 15 Light/ 24 45 10 Healthy, three Decreased quasIstatic
moderate ex-smokers ill complIance Nonrandom
group exposure sequence au-
NO z No change ill
spIrometry or reSIstance
Apparent complIance
change may be due to
exposure order
I--' KIm et a1 (1991) 018 30 L 10 L"" 25 22 45 9M 18-23 years, No change ill lung
VI
I
I--'
030 H 16 H""n "collegIate function
0\ athletes"
Koemg et a1 (1985) 012 60 22 75+ 4M/6F 13-18 years No effects on lung
functIOn
Koemg et a1 (1987a,b) 012 40 10 325 22 75 3 M/7F 14-19 years No effects of eIther 0 12
018 40 4M/6F 15-19 years or 0 18 ppm N02 on RT
or spIrometry
Kulle (1982) 050 120 15 24 45 10 Normal adults Decreased static lung
complIance
Lmn and Hackney 40 75 L 15 L20-29 21 50 16 M/9 F 18-45 years, NS No change ill SRaw
(1983) and LInn et a1 H 15 H 44-57 aSSOCIated WIth NO z
(1985b) Small but slgmficant
decrease ill blood
pressure, some lllild
illcrease ill symptoms
N02 DuratIon DuratlOn Vent Temp HUIDldIty Gender of Subject
Reference (ppm) (rom) (rom) (Urom) (0C) (Percent) Subjects CharactenstIcs Notes on Effects
Mohsemn (1987b) 20 60 21 50 8 M/3 F 18-36 years, NS VItamm C blocked N02-mduced

mcrease m alfway reactIvIty to
methacholme
Mohsemn (1988) 20 120 21 50 13 M/5 F Nonna!, NS, No symptoms, no lung functlOn
18-33 years changes Increased methacholme
reactIvIty
Mohsemn and Gee 30 (n =6) 180 60 38 21 Dewpomt 16 M/1 F 25 years, NS 45 % decrease m a-I-protease
(1987) 40 (n =4) 10 mhlbItor m BAL flmd
00 (n =7)
Morrow and Utell 03 225 30 "..40 21 40 lOM/lOF Healthy, young, No symptom, lung functIon or
(1989) (3 X 10) 20-48 years, aIrway reactIVIty responses for
...... FEV1/FVC the group
VI
I 76-95%
......
......:J
225 21 30-40 21 40 lOM/lOF Elderly, nonna!, No symptom, lung functlOn or
(3 X 7) 49-69 years, aIrway reactIVIty responses
FEV1/FVC
72-84%,
3 male S
4 female S
Muelenaer et al 06 240 rom 60 "..15 ",=,22 "..40 14M NS, nonatoplc, No change m unnary hydroxy-
(1987) X 3 days (4 X 15) no reSIdentIal prolme excretlOn
N02 exposure
Exposure ExerCIse ExercIse Relative Number and
N02 DuratIon DuratIon Vent Temp HUmIdIty Gender of Subject
Reference (ppm) (nun) (rom) (Urom) (0C) (percent) Subjects CharactenstIcs Notes on Effects
Rehn et at (1982) 0 Healthy, PossIble small mcrease m Raw at

027 60 22-27 25-45 youngM 027 ppm No change m nasal or
106 tracheobronchIal clearance
Sackner et al 01 240 6 Normal adults No effects of N02 m restIng adults
(1980) 03
05
10
Sandstroem et at 225 20 20 -35 8 Healthy, NS Increased levels of mast cells m BAL
(1989) 40 8 flUId at all concentratiOns Increased
55 8 numbers of lymphocytes at 4 0 and
Total 5 5 ppm BAL 24-h postexposure
n = 18
...-
VI
Sandstroem et al 40 20 romS?) 20(?) -35(?) 8 Healthy, NS Total cell counts were reduced
...-
I
00 (1990a) alternate Alveolar macrophages had enhanced

days for phagocytic actiVIty, but fewer were
12 days present Decreased numbers of mast
cells, T and B lymphocytes and natural
laller cells BAL 24-h postexposure
Stacy et at (1983) 05 240 30 55 30 60 10M 264 years No SIgnIficant effects on spIrometry or
Raw
Smeglm et a1 030 240 30 rom "",30 20 21-48 years, No change m lung functiOn or aIrway
(1985) NS reactiVIty
Suzula and o 7- 10 10 Increased reSIstance 10 rom after
IshIkawa (1965) 20 exposure
N02 DuratIon DuratIon Vent Temp HUlmmty Gender of Subject
Reference (ppm) (rom) (rom) (L/rom) CC) (Percent) Subjects CharactenstIcs Notes on Effects
Toyama et al 07 60 5 3 were No effects on aIrway conductance or

(1981) mvestIgators, responsIveness
22-19 years
Von NIedIng et al 50 15 16 Healthy Decreased Dr-CO 18 %
(l973a)
Von NIedmg et al 50 120 Inter- LIght 22 55 11M Healthy Increased reSIstance 60 % RemaIned
(1977) nnttent elevated for 60 rom PossIble decrease
mPa02
Von NIedmg et al 50 120 60 220 22 55 11M Healthy ReSIstance mcreased 60 % RemaIlled
(1979) (4 X 15) elevated 60 rom after exposure
POSSIble decrease m earlobe P02
~
VI
I aAbbrevlatlOns
~
\0 NOz = Nitrogen diOXIde BAL Bronchoalveolar lavage W Watts
M = Male IL-l Interleukm-l L Light
F = Female TNF Tumor necrosIs factor H Heavy
S = i\.cuve bmuker prvlNb Pulyrllorphonucleaf It:uk..oCyles TO
AT Total reSplral.ory reSlSLiince
NS = Nonsmoker Raw AJrway resistance DLCO = Dlffusmg capacIty for carbon monOXIde
FEV1 = Forced expIratory volume m 1 s VAR Vanable PaOZ Artenal partial pressure of oxygen
FVC = Forced VItal capacity SGaw SpeCIfic airway conductance Paz Partial pressure of oxygen
SRaw = Specific aIrway resistance
first study, 14 nonnal patients were exposed to 5 to 8 ppm N02 for up to 5 mm on
4 separate days The arrway resIstance CRaw) mcreased by an average of 058 cm H 20/LIs
(range 0.39 to 1 03 for the mdIvidual four-exposure mean) after the N02 exposures It was
noted that there were no dIfferences m response between smokers and nonsmokers
Bell and Ulmer (1976) studied the effects of 2-h exposures to 0 0, 1 0 (n = 8),
2.5 (n = 8), 5 0, and 75 ppm N02 m 16 healthy restmg subjects An addItional group of
8 healthy restIng subjects were exposed for 14 h to 5 0 ppm N02 for 2 consecutIve days
They found a small SIgnIficant mcrease m total resprratory reSIstance (RT) after exposure to
2.5 ppm N02 or greater The mam response, no more than 1 cm H20/L/s above a baselme
of 2.6 cm H20/L/s, occurred durmg the fIrSt 30 mm of exposure and the response was not
appreciably mcreased by raIsmg the N0 2 concentration to 5 0 or 7 5 ppm N02 The
mcrease in RT followmg N02 exposure was related to the baselme arrway responSiveness to
acetylcholine AIrway responSIveness to acetylcholme was mcreased after exposure to
7.5 ppm for 2 h or to 5 0 ppm for 14 h, but not after the 2-h exposures to 5 0 ppm or less
The pattern of response m the 14-h exposure mdicated an lDltIal mcrease m reSIstance durmg
the fIrSt 30 mill (=30%), a shght declme m reSIstance over the subsequent 90 mm, and then
a modest further mcrease over the next 14 h (a total mcrease of =60%) ReSIstance
returned to baselme durmg the subsequent 10 h and this response pattern was repeated on the
second exposure day The 1982 AIr Quahty Cntena for NItrogen OXides Document CIted
this study as indicatIng that responses were "clearly demonstrated to occur m healthy adults
WIth single 2-h exposures to N02 rangmg from 4,700 to 14,000 p,g/m3 (2 5 to 7 5 ppm) "
Lmn et al (1985b) exposed 25 healthy, nonsmokmg subjects (9 female, 16 male) for
75 mm to 4 0 ppm of N02 or punfied arr Subjects were exposed to each condItIOn tWIce,
for a total of four exposures The authors reported that approXImately 11 p,g/m3 of
partIculate mtrate was present durmg N02 exposures Durmg the exposures, subjects
perfonned 15 mm of hght (25 L/mm) and 15 mm of heavy (50 L/mm) exerCIse There were
no signIficant effects of N02 on Raw or symptoms Although heart rate and skm
conductance were SImIlarly unaffected, there was a shght but statistically SIgnIficant
reduction in systohc blood pressure assOCiated WIth N02 exposure Although InhalatIOn of
N02 can result in mcreased blood levels of mtnte and mtrate lOn, the mechamsm for this
small change m systohc pressure has not been estabhshed Blood pressure readmgs were
15-20
obtamed usmg an automated procedure wlule the subJecl was seated qUIetly m the body
plethysmograph
Mohsemn (1987b) studIed the effects of I-h restmg exposure to 2 0 ppm N02 on
11 normal subjects to determme the effect of ascorbIc aCId adm1ll1stratIOn pnor to N02
exposure The author hypotheslZed that the antIOXidant propertIes of ascorbIc aCId would
modIfy the effect of N02 There were a total of four exposures In the frrst set of clean arr
and N02 exposures, the subjects receIved a placebo for 3 days pnor to the exposures In the
second arr/N0 2 exposure parr, the subjects receIved vitamm C In both cases, the order of
the N0 2 and aIr exposures were randomlZed The blood ascorbIc aCId levels were mcreased
from 0 76 mg/elL after placebo to 1 90 mg/elL after vitamm C supplementatIOn NeIther
plethysmography nor spIrometry tests mdIcated a SIgnIficant effect of N02 m these subjects
>
under placebo or vitamm C condItIons There was a SIgnIficant mcrease m arrway
responsIveness to methacholme (bromIde) after N02 exposure ResponsIveness to
methacholme was quantIfied by the dose requrred to reduce SGaw by 40 % (PD40), thIs
corresponds to a 67 % mcrease m SRaw (A 50 % decrease m SGaw corresponds to a
doublmg of SRaw) After the two arr exposures, PD40 averaged about 64 mg/mL, but was
reduced to 53 mg/mL after N02 exposure and placebo treatment When the subjects were
gIven ascorbIc aCId pnor to exposure, methacholme responsIveness after N02 exposure was
unchanged AscorbIc acid pretreatment apparently blocked the aIrWay responsIveness
mcrease, WhIch had prevIously been observed WIth N02 exposure, although It had no effect
on baselme methacholme responSIveness However, ascorbIc aCId has prevIously been shown
to cause a decrease m methacholme responSIveness m both normals and asthmatIcs
(Mohsemn et al , 1983, OgI1vy et al ,1981) Thus, It IS unclear whether ascorbIc aCId
blocks the effect of N02 on arrways responsIveness or whether there was a dIrect effect of
ascorbate on methacholme responSIveness subsequent to vitamm C supplementatIOn
Mohsenm (1988) StudIed the response of 18 normal adults exposed to 2 ppm N02 for
1 h at rest There were no symptoms, no changes m lung volume, no change m flow-volume
charactenstIcs on eIther full or partIal expIratory flow-volume (PEFV) curves, and no change
m SGaw However, arrway responSIveness to methacholme was mcreased followmg exposure
m 13 of 18 subjects and decreased m only 2 of the 18 (p = 0003) subjects The dose of
15-21
methachohne needed to cause a 40% reduction ill SGaw was 101 + 44 mg/mL after arr and
81 ± 45 mg/mL after N02
Kulle and Clements (1988) studIed the effects of N02 exposure on mfectIVIty of lIve
attenuated influenza A1Korealreassortment VIrUS ill healthy nonsmokIng adults (see GOillgS
et al., 1989) Independent control and exposure groups were exposed to clean arr for 1 day
and then eIther clean arr or N02 (1, 2, or 3 ppm) for the next 3 consecutive days Included
in thIs evaluation were measurements of resprratory symptoms, lung functIOn, and arrway
reactIvity to methachohne ill the 2- and 3-ppm studIes There were no sIgmficant changes ill
resprratory or other symptoms as a result of a 3-ppm N02 exposure The only apparently
slgmficant changes ill sprrometry were observed ill the control group, who showed slIghtly
less decrease ill forced VItal capaCIty (FVC) or forced exprratory flow at 25 to 75 % of VItal
capacity (VC) (FEF25-75%) durmg the last of four consecutIve clean arr exposures AIrway
responSiVeness to methachohne was measured followillg exposure to 2 and 3 ppm The clean
air control groups showed a small sIgmficant decrease ill arrway responSIveness on the
second, third, and fourth days, but arrway responSIveness remamed unchanged ill the
N02-exposed subjects Influenza VIrUS mfection dId not alter aIrway responSIveness ill eIther
arr or N02 exposure groups ReactiVIty returned to control at 2 and 4 weeks after the
exposure senes The mfectivity portIOn of thIs study IS dISCUSsed m SectIOn 15 4
Frampton et al (1991) studied a group of 39 healthy nonsmokers exposed for 3 h to
either 0 60 ppm (n = 9), 1 5 ppm (n = 15), or a vanable concentratIOn protocol where three
15 min "peaks" of 2 0 ppm were added to a background level of 0 05 ppm (See Frampton
et al , 1989b, ill Section 15 42 for detaIls) There were no drrect effects on lung functIOn
(FVC, FEV b SGaw) after any of these exposures However, there was a small statistically
sIgmficant illcrease m FVC and FEV 1 response to carbachol challenge after the 1 5 ppm
exposure, mdicatlng an mcrease m arrway responSIveness There was no illcrease ill arrway
responsIveness after the 06 ppm or the peaks protocol However, one subject had a 20%
greater drop ill FEV1 after the peaks N02 exposure than after the arr exposure ThIs
observatIOn suggests the pOSSIbility that some subjects may be affected by N02 to a much
greater extent than others
15-22
15.2.1.2 Concentrations Below 1.0 ppm
In N02 exposure studIes conducted at concentratIOns below 1 0 ppm, the fmdmgs have
been generally negative Although some authors have mdlCated occaSIOnal fmdmgs, there
does not appear to be a conSIstent pattern of response at these low N02 concentratIOns that
would be mdicatlVe of short-term health effects
Kagawa and Tsuru (1979) studIed SIX healthy men exposed to 0 15 ppm N02 for
2 h whIle performmg hght, mtermittent exerCIse There were no symptoms reported durmg
N02 exposure Although the authors suggested that there mIght be some responses to N02
exposure, the overall pattern of response does not support the conclUSIOn that changes ill lung
function were mduced by N02 These authors reported "sIgmficance" for illdIVldual
subjects, although the precIse techmque for makmg thIs Judgment IS unclear Two mean
dIfferences were reportedly "sIgmficant" (multiple t-tesl unadjusted for multiple
compansons), a 0 5 % decrease m VC and a 16 % decrease ill the ratIO of
FEF 75%(He)/FEF 75%(arr) However, nonsIgmficant responses of greater magmtude were
observed under other exposure condItions (e g , arr control) It appears that these
"sIgmficant" observatIOns may only be chance occurrences out of nearly 100 t-tests, 6 of
which showed "sIgmficance" Furthermore, a temporary 0 5% decrease ill VC IS of httle, If
any, phYSIOlogICal sIgmficance
Subsequently, Kagawa (1983a) reported the results of exposmg an addItional seven
subjects to 0 15 ppm N02 (also to other pollutants, sep.irately and ill combmatIon) for
2 h WIth hght, mtermittent exerCIse Usmg the same plOtocol and exposure condItions as
those of Kagawa and Tsuru (1979) ill thIs new data set, no statistically SIgmficant mean
changes were found to be associated WIth N02 exposure m any of the plethysmographic or
sprrometnc tests
Toyama and colleagues (1981) exposed five healthy subjects (two were smokers, three
were illvestIgators) to 0 7 ppm N02 for 60 mm whIle at rest They observed no responses to
thIs N02 exposure that altered airway conductance or Dow-volume tests
Kulle (1982) presented a reanalySIS of the data prevIously pubhshed by Kerr et al
(1979) In thIs study, 10 normal, 13 asthmatic, and 7 chromc bronchItic subjects were
exposed to 0 5 ppm N02 for 2 h, several of the subjects were smokers (3 normals,
3 asthmatics, and 5 bronchItIcs) There were no sIgmficant effects of N02 exposure on
15-23
pulmonary functIOn, but It was unclear whether the change m quasistatlc comphance was due
to NOz exposure or was a statistICal artrfact, as the ongmal authors (Kerr et al , 1979)
suggested Rather than compare the data across the postexposure measurements obtamed
with clean air and NOz , respectively, m the reanalySIS (Kulle, 1982), a dJfference score
(post - pre) was determmed for each condInon and the chfferences were tested for
significance All subjects perceIved the odor of NOz upon entenng the exposure chamber
The author reported a sIgm:ficant mcrease m the normal subjects m the Phase IV of the smgle
breath mtrogen washout test However, the data suggest that the dIfference was probably
due to a reduced preexposure value on the NOz exposure day, an effect that could not be
attnbuted to NOz. Quasistatlc lung comphance was decreased after N02 exposure m the
normal group. The absence of a change m dynamIC comphance suggests that the ongmal
authors (Kerr et al., 1979) may have been correct m concludmg that "sIgmficance" was
probably due to chance alone No other sprrometnc or plethysmographIc measurements were
sigmficantly altered by N02 exposure WIth the excepnon of the apparently artIfactual
change m closmg volume, no new conclUSIOns can be drawn from the reanalySIS of these
data
Stacy et al (1983), as part of a large multipollutant exposure study, exposed a group of
10 men to 0 5 ppm N02 for 4 h, mcludmg two 15-mm penods of moderately heavy exerCIse
None of the plethysmographIc or sprrometnc tests showed a sIgmficant effect of N02 The
expenmental deSIgn of thIs study was complex, havmg a total of 20 treatment cells The
data were analyzed by both a multIvanate analySIS of vanance WIth an adjusted p value
(a level) of 00026 and by mdIvidual t-tests WIth a less conservatIve p value of 005
NeIther analySIS indIcated sIgmficant effects of N02
Hazucha et al (1982, 1983) studIed a group of 15 healthy adult males exposed to eIther
arr or 0.1 ppm NO z for 1 h Control measurements were performed on the day before and
the day after the exposure The subjects dId not detect the odor of N02 , nor was there an
increase of symptoms related to the N02 exposure There were no effects of N02 on
spirometry, arrway reSIstance (SRaw or RT), or methachohne responSIveness
Rehn et al (1982) reported a small (17%) mcrease in SRaw after exposure of eIght
healthy men to 027 ppm (500 p..g/m3) for 1 h However, no response was seen at 1 06 ppm
15-24
(2,000 p.,g/m3 ) ThIs was reported m a technIcal paper (m SwedIsh) and has not yet been
publIshed m a peer-revIewed Journal
Byhn et al (1985) exposed eIght normal subjects to 230, 460, and 910 p.,g/m3
(0 12, 0 24, and 0 48 ppm) for 20 mm An analysIs of vanance dId not reveal any
sIgrnficant effects of N02 on changes m SRaw' but specIfic compansons mdIcated a
sIgrnficant 11 % mcrease m SRaw at 0 24 ppm and a 9 % decrease m SRaw at 0 48 ppm
Even though statIStIcally sIgrnficant, such small changes (+ 15 %) m arrway resIstance are
well Withm the normal vanatIOn of 10 to 20% (Pelzer and Thomson, 1966, Skoogh, 1973)
Histamme bronchIal responsIveness was tested after the 0 48-ppm exposure, but there were
no changes
Koemg et al (1987a) exposed normal subjects to (1) 0 12 ppm N02 for two 30-mm
penods at rest, (2) 0 12 ppm for 30 mm at rest plus 10 mm wIth exercIse, and (3) 0 18 ppm
for 30 mm at rest and 10 mm durmg exerCIse For the at-rest 0 12-ppm N02 exposures,
there were no sIgrnficant changes m lung functIOn, symptoms, or artenal oxygen saturatIOn
Nor were there sIgrnficant N02 effects on lung functIOn wIth the mild exerCIse exposures to
o 12 and 0 18 ppm N02
Morrow and Utell (1989) StudIed both young (20 to 48) healthy subjects and elderly
(49 to 69) healthy subjects exposed to 0 3 ppm N02 for 3 75 h The young subjects
performed a total of 30 mm of moderate exerCIse dunng exposure and the older subjects
exercIsed for 21 mm There were no dIfferences between aIr exposure and N02 exposure
for symptom responses, changes m lung functIOn, or m arrway responSIveness to carbachol m
eIther young or older subjects
The effects of 0 60-ppm N02 exposures on young men and women durmg 1 h of
contmuous heavy exerCIse were studIed by Adams et a!l (1987) There were no sIgrnficant
effects of N02 exposure on arrway reSIstance, symptoms, spIrometry, or exercIse responses
KIm et al (1991) StudIed nme athletes exposed to fJ1tered arr, 0 18, and 0 30 ppm N02
for 30 mm while exercIsmg (rnnmng and walkmg) SIXteen mmutes were spent runmng at a
ventilatIOn of about 72 L/mm, 10 of the remaImllg 14 mm were spent walkmg Overall
ventilatIon IS estImated to have averaged about 50 L/mm There were no sIgrnficant changes
m respIratory symptoms, FEV l , RT , peak expIratory flow rate, or ventilatIon (V 50%vd as a
result of N02 exposure m thIs group of athletIc male subjects
15-25
In another study, young (18 to 26) and older (51 to 76) men and women were exposed
to 0.60 ppm N02 by Drechsler-Parks et al (1987) and Drechsler-Parks (1987) Subjects
perfonned hght, mternnttent exerCIse durmg the 2-h exposures There were no effects on
spIrometry or symptoms None of the mdlvldual pre-post exposure dIfferences m N02
(as compared to arr) for FVe or FEV1 were outsIde of the nonnal range (1 e , there were no
indIvidual subjects who appeared reactIve to N02)
15.2.1.3 Respiratory Symptom and Sensory Effects of Nitrogen Dioxide Exposure

Several studies reported m the preVIOUS sectIOn also exammed symptomatIc responses of
subjects exposed to N02 None of the studies of N02 exposure m nonnal subjects, mcludIng
exposure for as long as 75 mm to 4 0 ppm N~ resulted m a SIgnIficant mcrease m
respiratory symptoms Sensory effects were exammed m at least two studies (Byhn et al ,
1985, Hazucha et al ,1983) The subjects m the study of Hazucha et al (1983) were unable
to detect the odor of 0 1 ppm N02 Byhn et al (1985) reported an odor threshold of
0.04 ppm for nonnals and 0 08 ppm for asthmatIcs
15.2.1.4 Mucociliary Clearance After Nitrogen Dioxide Exposure

Rehn et al (1982) exammed the effects of N02 exposure on mucocIhary clearance m
both the nose and lung Nasal clearance was detennmed usmg the rate of saccharm
transport from nares to oropharynx TracheobronchIal clearance was detennmed by
morntoring the rate of dIsappearance of radIOlabeled Teflon aerosol After a I-h exposure to
eIther 027 or 1 06 ppm (500 or 2,000 p,g/m3 ) N02 , there were no changes m eIther nasal or
tracheobronchIal clearance rates
15.2.2 Effects of Nitric Oxide

In addItIon to N02, Kagawa (1982) exammed the effects of 1 ppm NO exposure for
2 h m eight nonnal subjects The data were analyzed by multIple t-tests uszng zndZVldual
data. All changes were referenced to the mean basehne (1 e , mean of the preexposure
measurement for the arr and the NO exposure) value rather than the correspondmg
measurement tIme from the clean arr exposure Three" SIgnIficant" zndZVldual changes m
SGaw were reported at 1 h of exposure one mcrease and two decreases After 2 h of
15-26
exposure, there were three decreases and one mcrease, .md m the postexposure penod, there
were two mcreases and two decreases, all reported to be "slgmficant". These statIstIcal
analyses may not be the most appropnate AnalysIs of the mean data usmg snmlar
procedures (I e , multIple t-test referenced to the mean baselme level) produced only one
slgmficant change an 11 % decrease m the ratIo HeV 5(larr V 50 GIVen that thiS effect
(1) occurred only at one of the three measurement pomts for the NO exposure, (2) was one
of 98 parred t-tests, and (3) was slgmficant at only the p < 005 level, It IS reasonable to
suggest that the effect may have occurred by chance
A study of the effects of a mIXture of N02 (0 3 ppm) and NO (0 6 ppm) was recently
reported by Kagawa (1990) Exposures lasted 120 mm and mcluded mild (50 W)
mtenmttent exercise There were no slgmficant changes m pulmonary functIOn (arrway
conductance [Gaw]' V 50%VC' slope of alveolar mtrogen concentratIon), symptoms, or arrway
responsiveness to acetylcholme
Von Nledmg et al (1973b) exposed healthy subjects and smokers to 15 to 39 ppm NO
for 15 mm Total respIratory resistance mcreased slgmficantly ( =10 to 12 %) after exposure
to > 20 ppm NO D1ffusmg capacity was not changed, but a small decrease (7 to 8 torr) m
Pa02 was noted
15.2.3 Effects of Nitrogen Dioxide Gas or Gas/Aerosol Mixtures on Lung

Function in Normal Subjects
Several studies of N02-contammg pollutant mIXtures were preVIOusly discussed m the
AIr QualIty Cntena for OXides of Nitrogen Document (U S EnVIronmental ProtectIon
Agency, 1982a) The general rmdmg of these studies was that N02 did not enhance the
effects caused by other OXidants, notably 0 3 (Hackney e1.. al , 1975a,b,c, Von Nledmg et al ,
1977, Horvath and Folmsbee, 1979 [prelnnmary report of Folmsbee et al , 1981], Suzuki
and IshIkawa, 1965) On the other hand, Abe (1967) studied NOT S02 mIXtures (4 to
5 ppm) and reported that theIr effects were additIve, With both gases causmg
bronchoconstnctlOn Independently, the effect of S02 was Immediate and short-Iastmg,
whereas the effect of N02 was delayed and more perslst(:mt The effect of the NOT S02
mIXture was mtennediate between the two responses Other reports suggestmg pOSSible
mteractIons of N02, pnnclpally With some type of particle, mcluded Scbhpkoeter and
15-27
Brockhaus (1963) and Nakamura (1964, CIted m U S EnvIronmental Protection Agency,
1982a.) These studIes are reVIewed extensIvely m AIr Quahty Cntena for OXIdes of
NItrogen Document (U S EnVIronmental ProtectIOn Agency, 1982a)
Table 15-2 summanzes studIes of healthy subjects exposed to N02-contammg pollutant
mixtures The pollutant mIXture of greatest mterest, m terms of research effort, has been the
combinatIon of N02 and 03 (Adams et al , 1987, Drechsler-Parks, 1987, Drechsler-Parks
et al , 1989, Folmsbee et al , 1981, Kagawa and Tsum, 1979, Kagawa, 1983a,b, Toyama
et al., 1981) Also reported were several studIes of NOT S02 combmatIon exposures
(Kagawa, 1983a,b, Klemman et al , 1985, Lmn et al ,1980a) Other pollutant mIxtures
contaming N02 were also studIed (Kagawa, 1986, Islam and Ulmer, 1979a,b, Stacy et al ,
1983; Klemman et al , 1985)
Several recent studIes evaluated the effects of 03 and N02 m combmatIon Three
studIes mvestigated the effects of 0 5 to 0 6 ppm N02 m combmatIon WIth 0 3 to 0 5 ppm
03 (Adams et al , 1987, Folmsbee et al , 1981, Drechsler-Parks, 1987) In these studIes,
N02 alone had no effect on measured health end pomts and the sigruficant effects of 0 3 on
lung function were not altered by the presence of N02 Kagawa and Tsum (1979) and
Kagawa (1983a) reported conflIctIng results In theIr fIrst study, It was suggested that the
effects of N02 and 03 were "more than addItive" However, m the second study, they
reported no sigruficant enhancement of the effect of 03 by the mIXture of other pollutants
(All pollutants-N02, 03' and S02-were at a concentratIOn of 0 15 ppm) All of the above
studIes included exerCIse dunng the 1- to 2-h exposures Toyama et al (1981) also studIed
subjects exposed to N02-03 mIXtures (05 ppm of each gas) Because the concentratIOn of
each gas was 0 7 ppm when the exposures were to a smgle pollutant, It IS ImpossIble to
determine If there was an addItive effect The above studIes taken as a whole suggest
strongly that there IS no mteractIOn between N02 and 03 that would result m enhancement of
acute 0rmduced changes m lung functIOn m normal subjects followmg short duratIOn
exposures at N02 concentratIons less than 1 ppm However, thIs conclUSIOn IS not
necessanly apphcable to other measured end pomts
Hazucha et al (1992) studIed the effects of exposure to N02 followed by exposure to
03 m a group of healthy nonsmokers Subjects were exposed to 0 60 ppm N02 and then,
3 h later, were exposed to 0 3 ppm 0 3 Mild mtermIttent exerCIse was performed dunng the
15-28
TABLE 15-2. EXPOSURE OF HEALTHY SUBJECTS TO NITROGEN DIOXIDE MIXTURESa
Exposure Exposure ExercIse ExercIse RelatIve Number and
ConcentratIon DuratIon DuratIon Vent Temp HUImdity Gender of Subject
Reference (ppm) (mm) (mm) (L/mm) CC) (Percent) Subjects CharactenstIcs Notes on Effects
Adams et al (1987) 060 NO z 60 60 70 21-25 45-60 20M Healthy young No addItIonal effect of
+ 030°3 50 20F adults NO Z over and above
effect of 03
Avo! et al (1983) 005 NO z 60 60 56 32 43 42 M/8 F Healthy young No apparent effect over
(Amb) adult cyclIsts and above that of 03
alone
Avol et al (1985a), 004 NO z 60 60 224 327 43 33 M/33 F ChIldren, No effects of ambIent
Avol et al (1987) (Amb) 8-11 years aIr exposures
Avol et al (1985b) 0055 NO z 60 60 32 32 45 46 M/13 F Adolescents, AmbIent aIr exposure
(Amb) 12-15 years effect attnbuted to 03
Drechsler-Parks 060 NOz 120 60 25 24 55 8 M/8F 18-26 years, NS No SIgnIficant changes
(1987) + 045°3 attnbutable to NO Z
060 NO z 120 60 25 24 55 8 M/8 F 51-76 years Tendency (p > 0 05)
.....
UI (+045°3) 8 M/8 F 51-76 years for NO z + 03 to be
I
tv greater than 03 alone
\0
Folmsbee et al 050 NO Z 120 30 40 25 45 10M Young adults, NS FEV l' decreased by
(1981) (+05°3) 30 85 10M Young adults, NS 8-14% No dIfferences
35 40 10M Young adults, NS between 03 + Nuz ana
40 50 10M Young adults, NS 03 alone
Hackney et al (a) 0 50 03 + 240 120 -20 31 35 4 Healthy WIth each group,
(1975b) 029 NO z (2 con- mmImal alteratIOns m
secutlve pulmonary functIOn
(b) 0 50 03 days of caused by 03 exposure
+ 029 NO z exposure Effects were not
+ 3000 CO to each mcreased by addItIon of
mIxmre) NO z or NO z and CO to
test atmospheres
\
TABLE 15-2 (cont'd). EXPOSURE OF HEALTHY SUBJECTS TO NITROGEN DIOXIDE MlXTURES a
Exposure Exposure ExercIse ExercIse RelatIve Number and
ConcentratIon DuratIon DuratIon Vent Temp HumIdity Gender of Subject
Reference (ppm) (rom) (rom) CUrom) (0e) (percent) Subjects CharactenstIcs Notes on Effects
Hackney et al (a) 0 25°3 120 60 -20 31 35 7 Healthy LIttle or no change m

(1975c) + o 29N02 (2 consecutive pulmonary functIon found
days of WIth 03 alone AddItion of
(b) 025° 3 exposure) N02 or of N02 and CO
+ 029 N02 did not noticeably mcrease
+ 3000 CO the effect Seven subjects
mcluded, some belIeved to
be unusually reactive to
respIratory Imtants
Hazucha et al 060 N02 120 60 40 22 40 15M Healthy, NS N02-03 sequence mcreased
(1992) followed by 3-h rest effect of 03 on aIrway
030°3 120 60 40 22 40 responsIveness
.....
Ul ?
I
Islatn and Ulmer 50N02 120 60 22 60 8M <30 years FVC (-5%), FEV!
w (1979a) + 0 1 03 8M 30-40 years (-11 7%), decreased WIth
0
+ 50 S02 8M >49 years exerCIse exposure to tills
mIxture m < 30 years
group
Islatn and Ulmer 016 N02 480 0 22 60 15 16-26 years No change m FVC, acetyl-
(1979b) 034 S02 cholme aIrway reactiVIty
008°3
Kagawa (1983b) 015 N02 120 60 -25 7M 19-23 years No SIgnIficant enhancement
015°3 of the effects of 03 and
0158°2 S02 by presence of N02
TABLE 15-2 (cont'd). EXPOSURE OF HEALTHY SUBJECTS TO NITROGEN DIOXIDE MIXTURES a
Exposure Exposure ExercIse ExercIse Relatlve Number and
ConcentratIOn DuratIOn Duration Vent Temp Humtdtty Gender of Subject
Reference (ppm) (mm) (mm) (L1mm) (0C) (percent) Subjects CharactenstIcs Notes on Effects
Kagawa (1986) 030 N02 120 20 -25 28-29 50-60 6 Japanese men POSSIble small decrease m
+ 030°3 (some smokers) SGaw
+ 200 p,g/m3
H 2SO4
015 N02 120 60 -25 28-29 6 Japanese men POSSIble small decrease m
+ 0 15°3 (some smokers) SGaw
+ 200 p,g/m3
H 2SO4
015 N02 120 60 -25 28 59-60 3 Japanese men POSSIble small decrease m
+ 0 15°3 (some smokers) FEV l
I-'
+ 0 15 S02.3
U\ + 200 p,g/m
wI H 2SO4
I-'
Klemman et al 050 N02 135 60 -20 20 85 11 M/9 F 20-53 years No effects on function,
(1985) + _~ 5 SO; pOSSIble symptom
+ 2U p,g/m- responses N02 effects
ZnS04 not discermble from
(NH4h S04 mIxture
+ 330 p,g/m3
NaCI
Lmn et al (1980b) 007 AmbIent 120 60 -20 33 32 14 M/20 F 29 years Small decreases m FVC,
and other FEV l' m ambIent aIr
pollutants mostly attnbutable to 03
No aSSOCIation of N02
levels WIth lung function
change
TABLE 15-2 (cont'd). EXPOSURE OF HEALTHY SUBJECTS TO NITROGEN DIOXIDE :MIXTURES 2
Exposure Exposure ExercIse Exercise Relative Number and
Concentration Duration Duration Vent Temp HumIClity Gender of Subject
Reference (ppm) (rom) (rom) (Urom) (0C) (percent) Subjects CharactenstIcs Notes on Effects
Lmnetal (1980a) 050 N02 120 60 -20 31 40 10 MI14F 26 ± 4 years, No sIgnificant effect on lung
+ 050 S02 21 NS, functIon m normals Trend
3S for a slIght decrease m PVC
after combmed exposure
Von NIedmg et al 50 120 60 -20 22 55 23-38 years, R T mcreased from 1 5 to

(1979) + 50 S02 (70W) two atopIc 24 (p < 001),
+ 01°3 questionable decrease m
Pa02 (8 torr)
01 N02 120 60 -20 22 55 23-38 years, No effects at all

+03S02 two atopIc
aAbbrevlations
N02 '" Nitrogen dioXide FVC '"Forced Vital capacity
03 '" Ozone H2S04 '"Sulfunc aCid
M '" Male SGaw '"Specific airway conductance
F '" Female ZnS04(NH,v:zS04 '"Zmc ammomum sulfate
Amb '" Ambient NaCI '"SodIUm chlonde
NS '" Nonsmoker S = Active smoker
FEV1 Forced expiratory volume m 1 s W '" Watts
CO Carbon monoXide RT = Total respIratory resistance
S02 Sulfur dioXide Pa02 '" Artenal partial pressure of oxygen
exposures NItrogen dIoXIde alone caused no sIgmficant lung functIon responses, but there
was a shghtly greater decrease m FEV1 after the N02-03 sequence than after the arr-03
sequence Methachohne arrway responsIveness was sIgruficantly mcreased WIth the N02-03
sequence compared to an arr-03 sequence, mdIcatmg that pnor N02 exposure enhanced the
arrway responsIveness mcrease tYPICally found wIth 03 exposure
Lmn et al (1980a) exposed a group of normal subjects to a mIXture of 0 5 ppm N02
and 0 5 ppm S02 for a 2-h penod, durmg whIch hght, mtermIttent exerCIse was performed
There were no lung functIOn (spIrometry, closmg volume, RT ) responses There was an
overall mcrease m symptoms due to the NOT S02 exposure, but no sIgmficant mcrease m
any specIfic symptom category Usmg the same 2-h mtermIttent, hght exerCIse exposure
protocol, Klemman et al (1985) exammed the effects of SImIlar N02-S02 levels m
combmatIOn wIth sodIUm chlonde (NaCI) aerosol (330 flg/m 3 ) and zmc ammomum sulfate
(20 p,g/m3) They found a shght mcrease m symptoms m the aerosol plus gas exposure
compared to the aerosol alone, suggestmg that the mIXture was shghtly more Imtatmg
There were no pulmonary functIOn effects (spIrometry, dosmg volume, RT) of thIs exposure
regImen Kagawa (l983a,b) reported results of S02-N02 (0 15 ppm each) exposures m
normal subjects for 2 h WIth hght, mtermIttent exerCIse Unfortunately, the analysIs of
dIfferences (usmg repeated t-tests) IS confusmg If a reasonable alpha level ( < 0 01) IS used
to determme sIgmficance (based on the large number of compansons), then there were no
StatIstICally sIgmficant changes m Gaw m response to the NOT S02 mIXture
Islam and Ulmer (1979a) exammed the effects of a mIXture of 5 ppm N02, 5 ppm S02,
and 0 1 ppm 03 on a group of 24 healthy subjects dIVIded mto three groups accordmg to
age There were two senes of 2-h exposures one at rest, the other mcludmg exerCIse
In subjects < 30 years, Raw mcreased 48 %, FVC decreased 5 %, and FEV1 decreased
11 7%, but Pa02 (determmed from ear lobe blood samples) was unchanged SImIlar effects
occurred m the older subjects, but the changes were of .1 smaller magmtude Artenal oxygen
partial pressure fell (6 8 and 8 3 torr) durmg the exposures m the older subjects, but It also
decreased (45 and 4 3 torr) durmg the control exposures The methods of data analySIS
were not presented m the paper so that the statIstIcal sIgmficance of the observed changes
cannot be evaluated Furthermore, the addItIVIty of effects due to the dIfferent pollutants
cannot be determmed
15-33
Islam and Ulmer (1979b) also studied 15 healthy subjects exposed to 0 34 ppm SOb
o 16 ppm N02 , and 0 08 ppm 03 for 8 h at rest on four succeSSive days Thts miXture did
not cause any changes m lung function, blood gases, or blood chemistry
Studies usmg several gas and/or aerosol miXtures were conducted by Stacy et al (1983)
and Kagawa (1986) Stacy et al (1983) exposed healthy, young males to miXtures of N02
(05 ppm) and aerosols of sulfunc aCid (H2S04' 100 p,g/m3), ammomum sulfate
3 3
(133 p,g/m ), ammomum bisulfate (116 p,g/m ), or ammomum mtrate (NH4N03, 80 p,g/m )
3
There were no effects of any of the pollutant miXtures on sprrometry, plethysmography, or

symptoms. Kagawa (1986) studied the effects of several N02 miXtures (A) N02
(030 ppm), 0 3 (030 ppm), and H2S04 (200 p,g/m3), (B) N02 (0 15 ppm), 03 (0 15 ppm),
and H 2S04 (200 p,g/m3), or (C) N02 (0 15 ppm), 03 (0 15 ppm), S02 (0 15 ppm), and
H 2S04 (200 p,g/m3 ) Exposure A mcluded 20 mm of exerCise (total) and exposures Band C
mcluded 60 min of exerCise over 2 h Symptoms were attnbuted to 03 exposure Small,
pOSSibly sigmficant decreases (~1O%) m Gaw were observed after exposure to miXtures A
and B. A pOSSible decrease ill FEV1 (unknown magmtude) was observed after exposure C
The differences observed with these miXtures were no different than responses observed with
03 alone, mdicatmg no enhanced response due to the presence of N02 m the miXture
Several reports of exposure to N02-contamlng ambient arr mixtures have been
pubhshed by the Rancho Los AmigOS group (Lmn et al , 1980b, Lmn and Hackney, 1983,
The mean N02 level m the
Avol et al , 1983, Avol et al , 1985a, Avol et al ,1987)
ambient arr (from the Los Angeles Air Basm) ranged from 0 04 to 0 07 ppm dunng the
approxnnately 2-h exposure penods These studies were conducted durmg the summer smog
seasons of 1978-84, but were not speclfically deSigned to test for the effects of N~ on lung
functionIn the Lmn et al (1980b) study, there was no aSSOCiation between N02 levels and
symptom or lung functiOn effects either m normal or asthmatiC subjects In the Lmn et al
(1982) study, the 03 levels were only 0 03 ppm, and there were no sigmficant effects
aSSOCIated With ambient exposure m normal or asthmatiC subjects There was a relationshIp
between 03 concentratiOn and change m FEV l m the Avol et al (1983) report There were
few differences between the responses of asthmatics and normal subjects m these studies and
no apparent mfluence of N02 level Ambient arr exposure of adolescents (Avo1 et al ,
1985a) was aSSOCiated With decreased FEV1 m male and female adolescents, With a
15-34
somewhat larger response m female subjects (-75%) than for males (-3 4%), but the
responses tended to be assocIated WIth the 03 levels A sImIlar study (Avol et al , 1987) was
conducted wIth exercIsmg chIldren, who showed a trend to larger pulmonary function
decrements wIth mcreasmg 03 levels Although these ambIent aIr exposure studIes were not
desIgned to test for the mteractIOn of N02 wIth other pollutants, even though Los Angeles
has the hIghest N02 levels m the Umted States, they do illustrate that the lung function
effects of ambIent aIr exposure (m Los Angeles) appear to be PrImarIly accounted for by the
presence of 03
There has been one study of pulmonary effects of mtnc aCId (lIN03) vapor followed by
exposure to 03 (Ans et al ,199Ib) Ten healthy men, prevIOusly determmed to be senSItive
to 03 (> 10% AFEVl after exposure to 0 20 ppm 0 3 for 3 h), were exposed on dIfferent
days for 2 h to eIther air, dIStilled water fog, or fog COltltammg 500 p,g/m3 (::=:200 ppb) of
HN03 One hour after each of these three randomly ordered exposures, the subjects were
exposed to 0 20 ppm 03 for 3 h Dunng exposure, subjects exercIsed for 50 mmlh at a
ventIlatIOn of ::=: 40 L/mm The decrease m FEV1 after the 03 exposure tended to be shghtly
larger after the au preexposure (- 26 %) than wIth eIther of the fog exposures (- 17 % and
-18 %, respectively) NeIther SRaw' methachohne responsIveness, nor symptoms were
drfferent among exposure conwtIons NItnC aCId vapOI or water fog alone wd not mduce
any symptoms or changes m puhnonary functIOn The results of thIs study do not support
the hypothesIS that HN03 exposure will mcrease responses to 03
There appears to be no ObVIOUS synergIstic or more than adwtIve mteractIOns between
N02 and other pollutant gases or partIcles that have been evaluated to date Pulmonary
functIOn responses to °3, for example, do not appear to be mcreased by the adwtIOn of low
levels « 0 6 ppm) of N02 The vanety of phySIOlogIC end pomts used to evaluate
combmatIOn exposures have, however, been hmited pnmarIly to spIrometry and
plethysmography
15.2.4 Summary
In the studIes summanzed m thIs section, several observations mwcated that, at
concentrations m excess of 20 ppm, there were functIOnal changes m the lungs of healthy
normal volunteers that could be attnbuted to N02 exposure Increases m Raw were reported
15-35
at concentratlons of 5 to 8 ppm from both short (5-mm) and longer (1- to 2-h) exposures
(Von Nieding et al , 1979, Von NIedmg and Wagner, 1977, Von NIedmg et al , 1980, Islam
and mmer, 1979a,b) At shghtly lower concentratIOns (2 to 4 ppm), no changes were seen
m resistance or spIrometry (Lmn et al , 1985b, Mohsenm, 1987b, 1988) However,
Mohsenm reported an mcrease m arrway responsIveness to methachohne (bromIde) after
exposure to 2 ppm, Frampton et al (1991) reported mcreased carbachol response after
exposure to 1.5 ppm, and Hazucha et al (1992) reported augmentatlon of ozone-mduced
airways hyperresponsiveness by pnor NOz (0 6 ppm) exposure None of the seven studIes of
exposure to less than 1 0 ppm m normal subjects demonstrated clear responses to NOz
There were several mstances of Isolated observatIOns md1catmg statIstIcal sIgmficance, but
there was no conSIstent pattern of response For example, Kagawa and Tsuru (1979)
reported small changes m VC at 0 15 ppm, but dId not venfy thIs observatIon m two
subsequent stud1es (Kagawa, 1983a,b, 1986), even at 0 30 ppm Furthermore, other stud1es
(Fohnsbee et al., 1978, Toyama et al , 1981, Stacy et al , 1983, Adams et al , 1987, and
Drechsler-Parks et al , 1987), conducted at hIgher concentratIOns (05 to 0 7 ppm), found no
eVIdence of lung functIon effects
15.3 THE EFFECTS OF NITROGEN OXIDE EXPOSURE IN

SENSITIVE SUBJECTS
Certam groups Withm the populatIon may be more responSIve to the effects of NOz
exposure, mclud1ng persons WIth respIratory dIsease, children, the elderly, and other
individuals not readily IdentIfied as members of a specIfic group The reasons for paymg
SpecIal attentIon to these groups IS that potentIal for NOz-mduced responses or exacerbatIOn
of disease may be much hIgher than m healthy young adults StudIes on other NOx gases
and NOx mIXtures are also d1scussed
The arrways of asthmatIc subjects may be hyperresponsive to a vanety of mhaled
materials, mcludmg pollens, cold-dry aIr, allergens, and aIr pollutants AsthmatICS have the
potential to be among the most susceptIble members of the populatIOn WIth regard to
respIratory responses to NOz (SectIOn 15 3 1) On the average, asthmatIcs are much more
senSItIve to mhaled bronchoconstnctors such as hIstamme, methachohne, or carbachol The
15-36
potential addItIOn of an NOz-mduced mcrease m arrway response to the already heIghtened
responsIveness to other substances raises the possibility of exacerbation of thIs pulmonary
dIsease by NOz One of the potential mechamsms by wllnch NOz could affect asthmatIcs IS
Via a change m arrways responsIveness ThIs IS discussed m SectIOn 15 4
Other potentIally susceptible groups mclude patients wIth COPD, these subjects are
discussed m SectIOn 15 3 2 A major concern wIth COPD patients IS the absence of an
adequate pulmonary reserve Any alteration m lung functIOn ill these patients can potentially
cause senous problems
15.3.1 The Effects of Nitrogen Dioxide on Asthmatics

An Important Issue m the evaluation of human clImcal exposure studIes mvolvmg
asthmatics IS the vanability in response between, and even Withm, laboratones In the
absence of sIgmficant dIfferences m the exposure protocol or exposure dose, an explanatIOn
frequently mvoked to explam the dIfferences m response IS that the charactenstIcs or seventy
of the dIsease may dIffer from one subject group to another
The Expert Panel Report from the NatIOnal Asthma Education Program (NatIOnal Heart
Lung and Blood Institute, National Institutes of Health, 1991) has recently defmed asthma m
the followmg manner
Asthma IS a lung dIsease WIth the followmg charactenstics (1) arrway

obstruction that is reversIble (but not completely so m some patIents) eIther
spontaneously or WIth treatment, (2) arrway mflammatIon, and (3) mcreased
arrway responsIveness to a vanety of stImulI
Accordmg to the National Institutes of Health (1991), about 10 millIon people, or 4% of the
populatIOn of the Umted States, have asthma The prevalence :l.S hIgher among Afncan
Amencans, older (8 to 11 years) chIldren, and urban res.Idents (Schwartz et al , 1990)
There IS a broad range of seventy of asthma ranging from mud to severe (see Table 15-3)
Common symptoms mclude cough, wheezmg, shortness of breath, chest tightness, and
sputum production A pOSItive response (skm test) to common mhalant allergens IS a tYPICal
feature of asthma Asthma IS charactenzed by an exaggerated bronchoconstnctor response to
15-37
TABLE 15-3. CLASSIFICATION OF ASTHMA BY SEVERITY OF DISEASE3
Charactenstlcs Ml1d Moderate Severe
A Pretreatment
Frequency of Exacerbations of cough and ExacerbatIOn of cough and Virtually datly wheezmg ExacerbatIOns
exacerbations wheezmg no more often than wheezmg on a more frequent baSIS frequent, often severe Tendency to have
1-2 bmes/week than 1-2 bmes/week Could have sudden severe exacerbabons Urgent VISitS to
history of severe exacerbatIOns, but hospital emergency departments or doctor's
mfrequent Urgent care treatment office > 3 bmes/year HospltahzatlOn
m hospital emergency department >2 bmes/year, perhaps With respiratory
or doctor's office < 3 times/year msufficlencyor, rarely, respiratory fal1ure and
history of mtubatlOn May have had cough
syncope or hypOXIC seizures
Frequency of Few chmcal signs or Cough and low grade wheezmg Contmuous albeit low-grade cough and
symptoms symptoms of asthma between between acute exacerbatIOns often wheezmg almost always present
exacerbatIOns present
Degree of exercise Good exerelse tolerance but ExerCise tolerance dlrntmshed Very poor exercise tolerance WIth marked
tolerance may not tolerate vigorous hrnttabon of actiVIty
exerCise, especially prolonged
runmng
Frequency of Symptoms of nocturnal Symptoms of nocturnal asthma ConSIderable, almost rughtly sleep mterruptlon
noctul11lll asthma asthma occur no more often present 2-3 bmes/week due to asthma Chest tight m early mormng
than 1-2 times/month
School or work Good school or work School or work attendance may be Poor school or work attendance
attendance attendance affected
Pulmonary function
• Peak Expiratory PEFR > 80% predicted PEFR 60-80% predIcted PEFR < 60% predicted
Flow Rate (pEFR) Vanabl1Itl <20% VanabIhty 20-30% Vanabl1lty > 30%
• Spirometry MImmal or no eVIdence of SIgns of aIrway obstruction on Substantial degree of airway obstructIOn on
airway obstruction on spirometry are eVIdent Flow spirometry Flow volume curve shows marked
spIrometry Normal volume curve shows reduced concavIty Spirometry may not be normahzed
expiratory flow volume expiratory flow at low lung even With high dose steroids May have
curve, lung volumes not volumes Lung volumes often substanbal mcrease In lung volumes and marked
mcreased Usually a > 15% Increased Usually a > 15% unevenness of ventl1atlOn Incomplete
response to acute aerosol response to acute aerosol reverslbl1lty to acute aerosol bronchodl1ator
bronchodilator adrntrustratlOn, bronchodl1ator adrntmstrabon admlmstrabon
even though basehne near
normal
• Methllchohne Methachohne ~~O Methachohne PC20 between 2 and Methachohne PC20 <2 mg/rnL
sensItivity > 20 rng/rnL 20 mg/rnL
B After optimal treatment IS estabhshed

Response to and Exacerbabons respond to Penodlc use of bronchodl1ators ReqUires contmuous, mulbple around-the-clock
duration of therapy broncodl1ators WithOut the use required dunng exacerbatIOns for drug therapy Includmg dal1y corticosterOIds,
of systerntc corticosterOIds m a week or more Systerntc sterOIds either aerosol or systerntc, often m high doses
12-24 h Regular drug usually required for exacerbatIOns
therapy not usually required as well Contmuous around-the-
except for short penods of clock drug therapy reqUired
bme Regular use of anb-Inflammatory
agents may be required for
prolonged penods of time
aCharactensbcs are general, because asthma IS highly vanable, these charactenstlcs may overlap Furthermore, an mdlvldual may SWitch
mto different categones over time
bVanabl1lty means the difference either between a mormng and evemng measure or among mornIng peak flow measurements each day for a
week
CAlthough the degree of methachohnelhlstarntne senSitIVIty generally correlates WIth seventy of symptoms and medlcabon reqUirements,
there are excepbons
Source National Institutes of Health (1991)
15-38
many phYSICal changes (e g , cold or dry arr, exercIse) and chemIcal and pharmacologIc
agents (e g , histamme or methacholme) Asthma IS typICally assocIated WIth atrway
mflammatIon and epIthehal mJury (NatIonal InstItutes of Health, 1991, Beasley et al , 1989,
Lattmen et al , 1985, Wardlaw et al , 1988)
In addItIon to baSIC anthropometnc mformatIOn such as age, heIght, weIght, gender,
and race, other mformatIon may be useful m charactenzmg asthmatIcs In order to evaluate
dtfferences between subject populatIons from one study to another, useful mformatIOn mIght
mclude baselme lung functIOn, frequency of asthma epJlsodes, nonspecIfic bronchtal
responsIveness, reversIbility of bronchoconstnctIon, types of medIcatIOn and frequency of
use, specIfic serum Immunoglobulm E (lgE) levels, skm test responses, response to exercise
challenge, duratIon of dIsease, and factors that preCIpItate or aggravate the dIsease
In many cases of chamber exposures of asthmatIcs, the exposures are accompanIed by
moderate exerCIse The potentIal for an mcrease m atrway reSIstance or dechne m lung
volumes or forced expIratory flow caused by exerCIse alone IS an Important covanate m these
studIes ExerCIse, even of moderate mtensIty, can mduce some mcrease m atrway reSIstance,
even mclean arr at normal room temperature and relatLve humIdIty (RH) (1 e , at 20°C,
50 % RH) In order to determme the true effect of an ,ellf pollutant m exercIsmg asthmatIcs,
the response to exerCIse must be conSIdered Accordmgly, m all studIes summanzed m thts
section, a control exposure to clean arr was performed, includmg exerCIse when appropnate
AsthmatIcs who partICIpate m controlled human exposure studIes typICally have mud
allergIC asthma In many cases, these mdividuals can go WIthout medIcatIOn altogether or
can discontmue medIcatIon for bnef penods of tIme If exposures are conducted outSIde theIr
normal allergy season
Controlled human exposure studIes that evaluated respIratory effects of N02 exposure
of asthmatIcs are summartzed below m two tables one that descnbes charactenstIcs of the
asthmatIc subjects tested (Table 15-4), and another one that presents the exposure condItIons
used and observed responses to N02 (Table 15-5)
SymptomatIc effects were observed m asthmatIcs exposed to 0 5 ppm for 2 h m a study
reported by Kerr et al (1979) However, only four of the subjects reported symptoms of
respIratory dIscomfort, and the authors concluded that "The symptoms reported were
mmtmal, dId not correlate WIth functIOnal changes, and are of doubtful sIgnIficance"
15-39
TABLE 15-4. CHARACTERISTICS OF ASTHMATIC SUBJECTS EXPOSED TO NITROGEN DIOXIDE2
C
Age FEVIIFVCb SRaw IgE MedIcation Au:way h
d C f
Reference Number (years) % (LecmHZOlUs) Elevated ReversibIlity Allergy Medications WitholdlDgC ReactiVIty Notes
Ahmed etal 20 Ml34 F 18-39 58-97 34-201 10/20 MET

(1983b) HIST
Em
COLD
Ahmedet al 9 20-51 53-96 43-149 Ragweed 24-48h Ragweed "HIstory of bronchial

(1983a) antigen asthma"
Avol et al (1988) 27M132 F 18-50 43-98 3 8-212 Y Y Y 140B 48hAH MET Some moderate
30m/OB 8hm,OB asthmatics
15m (Some
noncompliance)
Avol et al (1989) 24M110F 10-16 61-98 3-15 HIstory 33/34 10 IBIOB 48hAH COLD No cromolyn,
7m 24hOB MET No steroId
60B 12hm Em
10 None
I--' Bauer et al (1986a) 15 20-45 49-83 439 13m 12hm COLD Mild asymptomatic
VI
I 70B 24hOB
,J::o.
0
Byhn et al (1985) 6M12F 17-45 699 Y y 4/8 5 OccasiOnal 6h HIST Very ffilld asymptomatic
m/OB
30B-dally
Byhn et al (1988) 8 Ml12 F 17-56 376 ± 033 Some Y 12/20 2m,OB 12hOB HIST Very ffilld asymptomatic
(occasiOnal) 8hm
Hazucha et al 15M 21-46 673 HIstory None dally 48 h MET Mdd or lOactlve dIsease
(1983, 1982)
Joerres and 10Ml4 F 20-55 38-83 28-182 12/14 11114 m 10hm Hlslaffilne "Mdd asthma", all
Magnussen (1990) SOB 10 h IPB S02 subjects asymptomatic
1 ST 10hCROM except one (FEVI/FVC
61CS ratIo 38%)
2CROM 16hOB
4 IPB 10 h ICS
Kerr et a1 (1979) 9M/4F 19-50 :=:71 :=:74 3 Smokers

also Kulle (1982)
TABLE 15-4 (cont'd). CHARACTERISTICS OF ASTHMATIC SUBJECTS EXPOSED TO NITROGEN DIOXIDEa
b C
Age FEV!/FVC SRaw IgE MedicatIOn AIrway h
d e f
Reference Number (years) % (L.cmHZO/L/s) Elevated Reverslblhty Allergy MedicatIOns Wltholdml ReactlVlty Notes
Klemman et al 12M/19 F 18-55 :=74 Rt=262 16/31 8 None 4h MET WIde range of chmcal
(1983) 21 m, OB seventy
8 ST, 1 CROM
Joerres and 9M/2F 18-55 67-96 3 9-107 7/11 6 None 8h MET Mtld asymptomatic
Magnussen (1991) 50B asthmatics
Koemg et al (1985) 14 M/6 F 12-18 FEV! Rt = 457 y y y 8m 4h Em Asymptomatic extnnslc

1 95-4 10 60B MET allergiC asthmatics
Koemg et al II 4 M/6 F 11-19 23-42 Rt=507 Y Y Y 7m :=4h Em

(1987a,b) 50B MET
ill7M/3F 12-18 17-46 Rt=470 Y Y Y 6m :=4 h Em

70B MET
Koemg et al 6M/3 F 12-18 24-54 519 MET

(1989a) (FEV!) Em
.......
Ul 5M/4F
I Koemg et al 12-17 224·40 919 5m MET
~ (1989b)
....... 1 None Em
3CROM
30B
3 .<\..J.!
woo et al (1980a) 7M/12 F 33 232 345 y :=4 h PhySICian diagnosed

(mIxed NO z + 6 Ex- (FEV!) Rt = 3 45 asthma
S0Z) smok.ers
LlOO and Hackney 12 MIll F 18-34 67-100 548 ± 233 SOZ Physlctan dIagnosed
(1984) asthma
LlOO et al (1985b) 12 MIll F 18-34 67-100 548 ± 233 :=4 h SOZ

Lmn et al (1986) 15 M/6 F 20-34 3 16 421 13/21 10m :=4h COLD Mtld asthmatics
(FEV!) 5 None 19/21
>180 80B Em 10/21
1 ST 80Z 17/21
TABLE 15-4 (cont'd). CHARACTERISTICS OF ASTHlV£ATIC SUBJECTS EXPOSED TO NITROGEN DIOXIDEa
Age FEVIIFVCD SRaw IgE" MechahOn AIrway h
d f
Reference Number (years) % (LecmH20IUs) Elevated Revel"Slbility AIIergyc Medlcallons Witholdm/ ReacltVlty Notes
Mohsenm (1987b) 10 22-44 60-93 38-132 Y No steroids 24h MET Mild asthmsltCs
No caffeme
NovIllInun C
Morrow and Utell 10 M/l0 F 19-54 42-86 (SO) y 14120 4m
(1989) 395-145 SOB
x = (11 3) 10m,oB CARE
929
Orehek et al (1976) 13 MI7 F 15-44 68 ±0 6 16120 No sterOids 24h CARE Duralton asthma
(1-24 years), 6 smokers
13 nuld/7 moderate
Orehek et al (1981) 6 MIl F 31 1 54 ± 11 Grass 1 smol..er,
Pollen 3 asthmatIcs,
4 allergIC
Roger et al (1990) A 13M 19-35 55-81 26-13 5 80-2,040 Y 12/13 m,OB 48h,OB MET Mtld asthmatICs,
B 21 19-30 59-85 32-10 6 38-2,040 Y 18/21 m,OB 12h,m no cromolyn,
no sterOIds
Rubmstem et al 5M/4F 23-34 51-85 48-120 9m 8h,m MET No respIratory Illness
I-'
VI (1990) 40B 12h, DB, AH wlthm 4 weeks
I
i!3 4AH 4 h, CAF
aAbbrevIaltons
FEV1 = Forced expIratory volume m 1 s m Inhaled {3 agomst
FVC = Forced VItal capacIty AH Antthlstanune
SRaw = SpeCIfic aIrway resIstance ST Oral corltcosterold
IgE = Immunoglobulm E ICS Inhaled cortIcosteroId
M = Male CROM= Cromolyn sodIUm
F = Female IPB Ipratropnum brorntde
MET = Methachohne S~ Sulfur dIOXIde
mST = Hlstarmne Rt Forced oSCIllatIOn
Em = Exerclse-mduced bronchospasm N02 NItrogen dIOXIde
COLD = Cold aIr CARE Carbachol
DB = Oral theophyltne
b
cRatto of FEV I/FVC In percent
ElevatIon of 19B levels above those reported for the normal populatIon
~everstblhty of bronchoconstrtctIon tested WIth bronchodIlator
e
rAllergy-number of subjects WIth one or more known allergtes-by hIstory or sian testmg-Y mdlcates that subjects were claSSIfied as "allergIC asthmatIcs"
Standard medIcatIOns and number of subjects usmg them (see hst), none indIcates no regular use of medIcatIon dunng the study penod
:Penod for whIch specIfic types of medlcallon were WIthheld pnor to the study (m hours)
AIrway reactIVIty was tested uSing one or more standard methods (see Itst)
TABLE 15-5. EXPOSURE CONDITIONS AND RESPONSES IN ASTIIMATICS EXPOSED
TO NITROGEN DIOXIDEa
Exposure ExercIse ExercIse RelatIve
NO z DuratIOn DuratIon VentIlatIOn Temp HumtdIty
Reference (ppm) (mm) (mm) (L/mm) (0C) (percent) Effects
Ahmed et al (1983b) 01 60 No sIgnIficant effect on SGaw and FEV!,
vanable effect on carbachol reactIvIty No
mfonnatIOn on controlled exposure
Ahmed et al (1983a) 01 60 No effect of NO z on FEV!, SGaw ' or bronchtal
reactIvIty to ragweed antIgen, eIther ImmedIately or
24-h postexposure
Avol et al (1988) 03 120 60 40 22 46 ExercIse-related mcreases m symptoms PossIble
NOZ related decrease m FEV! and PEFR Increased
cold atr response after 0 3 ppm
06 120 60 41 More consIstent mcreases m SRaw at 0 6 ppm, but

not sIgnIficantly dIfferent from aIr and 0 3 ppm
~
VI
I
Avol et al (1989) 03 180 90 30 24 45 After 60 mm of exposure, FEV, FVC, and PEFR
~ were sIgnIficantly reduced (-3 4, -40, and -56%,
w
respectIvely) No change m atrways responSIveness
to cold atr challenge SRaw mcreased 17 % after
N02 exposure After 180 mm of exposure, the
responses had returned to baselme levels
Bauer et al (1986a) 03 30 10 30 20 9-14 Restmg 20-mm exposures produced no effects
SlIght excess decrease m FEV! and PEFR m NO Z
plus exerCIse above that caused by exerCIse alone
PEFR -16% (atr), -28% (NO z), FEV! -55%
(atr), -9 3 % (NO z) SIgnIficantly mcreased response
to cold atr after NO Z exposure
Bylm et al (1985) 012 20 22 35 No sIgnIficant change m SRaw at any NOzlevels
HIstamtne reactIVIty tended to mcrease
025 20
05 20
TABLE 15-5 (cont'd). EXPOSURE CONDITIONS AND RESPONSES IN ASTHMATICS EXPOSED
Exposure ExercIse ExerCIse Relative
NOz Duration Duration VentIlation Hunudity
Reference (ppm) (nun) (nun) (Unun) (percent) Effects
Byim et al (1988) 014 30 259 43 Overall trend for SRaw to declme durmg exposure
027 penod, not related to NO z concentration HIstanune
054 bronclual reactivIty tended to mcrease after 0 14 and
o 27 ppm NO z exposure
Hazucha et al (1982) 010 60 21 40 No sIgnIficant changes assocIated WIth NO Z
Hazucha et al (1983) exposure
Joerres and Magnussen 025 30 24 50 After resting breatlung of 0 25 ppm NO z,
(1990) responsIveness to mhaled SOZ was mcreased No
effect of NO z alone on SRaw
Klemman et al (1983) 020 120 60 ""20 22 50 No effects on spIrometry or airway reSIstance
Airway reactiVIty to methacholme results vanable-
tended to mcrease With exposure
Koemg et al (1985) 012 60 22 75 No SIgnIficant responses m pulmonary functIOn due
to NO z Increased symptoms after NO z exposures
Koemg et al I 012 60 22 75 (Same as Koemg et aI, 1985) No change m FEV!,
(1987a,b) II 012 40 10 33 22 75 RT mcreased 10 4% (NS), 3% decrease m FEV!
ill 018 40 10 39 22 75 (p < 006)
Koemg et al (1989b) 50ppb 40 10 ",,25-30 25 65 FEV! decreased 4 4 % after HN03 and 1 7 % after
HN03 HN03 air exposure R T mcreased 22 5% after
HN03 and 7 4 % after air exposure
Koemg et al (1989a) 57 ppb 45 30 25-30 22 65 FEV! decreased 3 3% after NO z exposure and 1 7%
HN03 after air exposure (difference NS) Reduction of oral
aImnoma did not mcrease response (-1 7 %)
Kulle (1982) 050 120 15 24 45 Increased respIratory symptoms m 4/13 subjects
(same as Kerr et al , Increased static lung complIance ImpossIble to
1979) deternune amount of effect due to NO Z
Joerres and Magnussen 025 30 10 30 26 20 MouthpIece exposure system No changes m
(1991) methacholme responSIveness were observed after
NO z exposure m these nuld astmnatIcs
TABLE 15-5 (cont'd). EXPOSURE CONDITIONS AND RESPONSES IN ASTHMATICS EXPOSED
Exposure ExerCIse ExerCIse Relative
NO Z Duration Duration VentdatIOn HllmldIty
Reference (ppm) (nun) (rom) (Llnun) (Percent) Effects
LlIDl et al (1980a) 05+ 120 60 ~20 31 40 No sIgnIficant effect on spIrometry or R T
03 ppm
SOz
LlIDl and Hackney 40 75 a 15 a 25 21 50 No NO z effects on SRaw' symptoms, heart rate, or
(1984) b 15 b 49 skIn conductance Small decrease m systohc blood
LlIDl et al (1985b) pressure
LlIDl et al (1986) 03 60 30 41 22 50 No effect of NO Z ExercIse-related mcrease m SRaw
under all condItions
10 60 30 41 22 50
30 60 30 41 22 50
Mohsenm (1987b) 05 60 21 50 No change m symptoms SIgnIficant group mean
mcrease m responsIveness to methacholme after NO Z
exposure No other function changes
Morrow and Utell 030 225 30 30-40 210 40 Group findmgs mdIcated no sIgnIficant responses
(1989) (3 X 10) No change m lung function, symptoms, or carbachol
reactiVIty Subjects prevIOusly StudIed (Bauer et al ,
1986a) showed possIble responses to NO z New
subject subgroup showed sIgnIficantly greater
response m aIr exposures
Orehek et al (1976) 011 60 13/20 subjects had enhanced responses to carbachol
(n = 20) after 0 11 ppm NO z
(009-0 13)
026 1/4 subjects had enhanced responses to carbachol

(n = 4) after 0 26 ppm NO z
TABLE 15-5 (cont'd). EXPOSURE CONDITIONS AND RESPONSES IN ASTBl\1ATICS EXPOSED
Exposure ExerCise Exercise Relative
NOZ Duration Duration VentdatIon HUffildity
Reference (ppm) (mm) (mm) (Umm) (percent) Effects
Orehek et al (1981) 011 60 No change m SRaw or m responsiveness to grass
(007- pollen m 3 allergiC asthmatics and 4 allergiC subjects
o 16)
Roger et al (1990) A 03 110 60 42 20 40 FEV! decreased 11 % m NO z but only 7 % m alr,
after first 10 mm of exerCise Smaller changes later
mexposure
BOIS 75 30 42 20 40 No mcrease m alrway reactivity to methacholme

030 2 h after exposure No change m FEV! or SRaw as
060 a result at NO z exposure
Rubmstem et al 030 30 20 3x 22 55 No changes m SRaw' FVC, FEV!, SBN z or
(1990) (-30) symptoms after NO z exposure NO z exposure did
not mcrease alrways responsiveness to SOZ
aAbbreViations
NOZ = Nitrogen diOXide
SGaw = Specific airway conductance
FEV1 = Forced expllatory volume 10 1 s
= Volume of Isoflow
PEFR = Peak expiratory flow
SRaw = Specific airway reSistance
FVC = Forced Vital capacity
Rr = Total respiratory resistance
NS = Not slgmficant
HN03 = Nltnc aCid
SOZ = Sulfur diOXide
SBNZ = Smgle breath mtrogen washout
Avol et al (1988) studIed a group of 59 moderate-to-severe asthmatics exposed to clean
arr, 03 ppm, and 0 6 ppm N0 2 for 2 h whIle performmg moderate (mmute ventilation
[V E] = 41 L/mm), mtermittent (6 X 10 mm) exerCIse Each subject was exposed once each
to clean arr, 030 ppm, and 0 6 ppm There were sIgmficant changes m SRaw and FEV l as
a function of exposure duration for all exposure condItions, but there was no sIgmficant
effect of N02 exposure on these measures of pulmonary functIOn Cold arr bronchIal
reactivIty (assessed by the decrease m FEV l after breathmg cold-dry arr) was measured
1 h postexposure and then agam the followmg day There was a sIgmficant mteractIon
between response and tIme of testmg (1 e , 1 h postexposure and 24 h postexposure),
suggestmg a shghtly mcreased response after exposure to 0 30 ppm, but not after 0 6 ppm
There were no resplIatory symptom responses attnbutable to N02 exposure A post hoc
analySIS of a subgroup of subjects wIth the most abnormal lung functIOn (1 e , FEVl/FVC
ratios < 0 65) revealed no statistically sIgmficant effects of N02 In addItion to the
controlled exposures, 36 subjects also were exposed to ambIent arr contammg 0 09 ppm N02
and low levels of other pollutants NeIther lung functIon, cold-arr reactIVIty, nor symptom
responses were sIgmficantly dIfferent m ambIent arr than mclean arr
Bauer et al (1986a) reported a statistically sIgmficant sprrometnc response to N02 m a
group of 15 asthmatics exposed to 0 3 ppm N02 by mouthpIece for 20 mm at rest followed
by 10 mm of exerCIse (30 L/mm) These subjects were charactenzed as havmg "mild
obstructIve lung dIsease (asthma)" All subjects had elevated response to cold arr
bronchoprovocation NItrogen dIOXide depOSItIOn studIes mdicated that 72 % (at rest) and
87% (dunng exerCIse) of the mhaled N02 was depOSIted WIthIn the respIratory tract
Accordmg to the authors, the measurements of N02 depOSItion were m general agreement
WIth the model predIctions of Miller et al (1982) (see allso SectIOn 13 2 1) After N02
exposure, 9 of 15 asthmatics had a decrease m FEV l relative to therr postexercIse FEV l m
clean arr The postexercIse FEV1 was 4 1% lower after N02 (mean = 2,788 mL) than after
arr (mean = 2,906 mL) exposure, the pre- to postexposure dIfference on the N0 2 day
(10 1%) and the pre- to post-N02 mmus the pre- to pos1-arr (1 e , delta-delta) dIfferences
(6%) were sIgmficant usmg a parred t-test These dIfferences were no longer present by
60 mm after the exposure MaXImum expIratory flow at 60 % total lung capaCIty (TLC)
(PEFV curve) was also decreased more after N0 2 exposure than after arr exposure Changes
15-47
in PVC and SGaw were not dIfferent between arr and N02 exposures AIrway
responsiveness to cold arr m tlns study was detennmed as follows At each venttlatIon rate
of cold arr breathmg, the resprratory heat exchange (RHE) was calculated From the
relationslnp of the log RHE versus the percentage decrease m FEVl , the RHE, wlnch caused
a 10% decrease m FEVl , was lmearly mtel}Jolated and IS referred to as PDlORHE
(provocative dose m RHE umts needed to decrease FEV1 by 10 %) Of the 12 subjects for
whom the PDlORHE could be detennmed, 9 showed an mcreased response to cold arr after
the N02 exposure The average PDlORHE decreased from 0 83 kcal/mm after arr exposure
to 0.54 kcal/mm after N02 exposure
One of the factors that may have led to the demonstration of mcreased response after
exposure to a low concentratIOn of N02 m thIs group of asthmatics could be the fact that a
mouthpIece exposure system contammg relatively dry arr (RH of 9 to 14% at 20°C) was
used, and that there was possIbly some mteractIOn between the N02 effect and arrway
drymg It IS well known that breathmg dry (cold) arr wIll mduce bronchoconstnctIOn m
asthmatics, and that the effect of S02 on asthmatics IS exacerbated by cold-dry arr breathed
VIa the mouth (U S EnVIronmental Protection Agency, 1986, S02 document addendum)
Concern over tlns pOSSIble confoundmg effect IS tempered by the fact that Bauer et al
(1986a) controlled for the arrway drymg effect by exposmg subjects to clean aIr at the same
temperature and RH However, If the fonnatIOn of HN03 or mtrous aCId IS potentially
involved m the observed responses, the arr chemIstry could be strongly Influenced by RH
(SequestratIOn of HN03 on surfaces IS mcreased WIth mcreased ambIent water vapor
content)
EIght asthmatics exposed to 0 0, 0 1, 025, and 0 5 ppm N02 for 20 mm were studIed
by Bylm et al (1985) Exposures were conducted m a body plethysmograph and the range
of concentrations was + 18 % to -26 % of the target concentratIOn Changes m SRaw durmg
the four exposures averaged +3%, +9%, -2%, and -14%, respectively, the CV for the
SRaw measurements was 19 % for these subjects A three-way analySIS of vanance revealed
no sIgntficant dIfferences m SRaw due to N02 exposure There was a tendency for the pre-
to postexposure dIfference for thoraCIC gas volume (TGV) to be larger for the N02 exposures
(9 to 10%) However, the absolute volume of TGV was at most 3 to 4% lower than at
comparable tImes mother N0 2 exposures and only 2 % less than the aIr exposure The
15-48
sIgmficance of thts dIfference was m the htgher preexposure values for the 0 1- and 0 5-ppm
N02 exposures, such an effect, If real, should not be attnbuted to N02 There were no
sIgmficant changes m tidal volume or resprratory rate, W htch would have been suggestIve of
an lffitant response At the htghest concentratIOn tested (05 ppm), htstamme bronchtal
responSIveness was also evaluated after exposure The authors reported a sIgmficant mcrease
m htstamme responSIveness due to N02 exposure Sigruficance was evaluated by a SIgn test
(p < 004, responSIveness mcreased m five subjects and was unchanged m three)
However, thts findmg should be mterpreted cautIOusly because the sham (arr) exposure
htstamme challenge had to be dlscontmued m two subjects, one of whom was later classIfied
as havmg mcreased responSIveness FIve of the eIght asthmatics had several months
prevIously been hyperreactive to htstamme but were not at the hme of the N02 exposures
ThIs paper suggested pOSSIble mcreased htstamme reactiVIty after 0 50 ppm N02 exposure of
asthmatICS but no drrect effect of N02 on Raw at concen1 ratIOns up to 0 5 ppm for 20 mm
3
Bylm et al (1988) also reported the effects of 260, 510, and 1,000 p,g/m (0 14, 027,
o 53 ppm, respectIvely) on a group of 20 mild asthmatICS There were no sIgmficant
changes m SRaw' although there was a general trend for SRaw to fall throughout the penod
of exposure regardless of the pollutant level There was, however, a sIgmficant mcrease
(p = 0 03) m arrway responSIveness to htstamme after 30-mm exposure to the mIddle
3
concentration (1 e., 510 p,g/m ), but not at the lowest and htghest concentratron (see note
below) The absence of a concentration-related mcrease m responSIveness, and the fact that
the sIgmficance of these fmdmgs IS based on repeated apphcatIon of a nonparametnc paIr
companson test usmg an alpha level (p value) not adjusted for multiple compansons,
suggests that these results should be mterpreted WIth caution ThIs observatIOn contrasts WIth
the earher observatIOn (Bylm et al , 1985) that suggested a pOSSIble mcreased responSIveness
after exposure to 910 p,g/m3 (Note, however, the dISCUSSIon above regardmg the statistical
approach used m the 1985 study) The raw data presented m the paper were subjected to
reanalySIS (data available on request to EPA) usmg a Fnedman nonparametnc analogue of an
F test, whtch IS probably more appropnate for these data than a senes of Wilcoxon matched
parrs SIgned rank tests The Fnedman test showed no drfference across treatment groups
(1 e , there was no StatIStiCally sIgmficant mcrease m htstamme responSIveness as a result of
N02 exposure)
15-49
In a study that was an unportant precedent to a number of studIes, Orehek et al (1976)
studIed the effects of low levels of N02 exposure on the bronchIal senSItivIty of mud
asthmatIc patients to carbachol, a bronchoconstnctmg agent Exposures took place m an
3
airtIght room Nitrogen dIOXide concentratIOn started at 246 p,g/m (0 13 ppm) and declmed
to 169 p,g/m3 (0.09 ppm) over 60 mID, the average concentratIOn was 210 p,g/m3 (0 11 ppm)
Changes m 8Raw from pre- to postexposure were measured and an arrway challenge to
carbachol was used to assess postexposure arrway responsiveness Followmg N02 exposure,
increases in 8Raw were observed ill only 3 of 20 asthmatic test subjects For all 20 of the
asthmatic subjects, dose-response curves were developed for changes m 8Raw as a result of
the subjects inhaling carbachol These response curves were compared after a I-h exposure
to either clean arr or N0 2 NItrogen dIOXide exposure was aSSOCIated WIth mcreased arrway
responsiveness to carbachol m 13 of 20 subjects The mean dose of carbachol producmg a
twofold (100%) mcrease ill 8Raw ill the 13 most sensItive subjects (1 e , responders) was
significantly decreased from 0 66 mg to 0 36 mg as a result of N02 exposure Seven of the
asthmatic subjects (nonresponders) showed neither an mcrease ill SRaw m response to the
exposure to N02 alone nor an enhanced effect of N02 on carbachol-mduced
bronchoconstnctlOn
The results of thIs study are of mterest because they are suggestive of pOSSIble
bronchoconstrictIve responses bemg produced ill some asthmatics by very low concentratIOns
of N02 The cntIcism of thIs reported change was that the compansons of SRaw were made
in subjects who were selected, not at the tune of N02 exposure, but after the fact, followmg
the carbachol exposure For example, the mean of measurements of SRaw m the
13 responders to the carbachol treatment was sIgmficantly hIgher after the N02 exposure
than It had been pnor to exposure An unportant cntIcism of thIs study (dIscuSSed by
Hazucha et al , 1983) IS that, m addItIOn to the retrospective stratIfication of subjects mto
responders and nonresponders, other statistical methods may have been more appropnate
than the selected group of parred t-tests used m thIs study
Orehek et al (1981) also StudIed seven allergIC subjects, three of whom had asthma,
who were exposed to 0 11 ppm N0 2 for 1 h The major hypotheSIS to be tested was that
N02 may alter bronchIal responSIveness to an Inhaled allergen (grass pollen) Studies were
conducted outside the typical pollen season The exposure technIque was somewhat pnmItIve
15-50
m that N02 was added to an exposure room wIth a sta:J1mg concentratIOn of 0 16 ppm, winch
was allowed to decay dunng the exposure to a concentratIOn of 0 07 ppm There was no
change m Raw or symptoms as a result of the N02 exposure There was also no dIfference
m the Raw response to allergen challenge m these subJe'cts (I e , N02 did not act
synergIstically WIth allergen challenge) Furthermore, there was no dIfference between the
responses of the three asthmatics and the other four subjects
Hazucha et al (1982, 1983) pubhshed two reports that contam complementary data
from a study m winch the Orehek protocol was repeated In contrast to the report of Orehek
et al (1976), Hazucha et al (1982, 1983) found no statistically sIgmficant change ill arrway
reactiVIty to methachohne (another bronchoconstnctmg agent) m a group of 20 methachohne-
reactive mud asthmatics followmg a 1-h restmg exposure to 0 1 ppm N02 A small (8 %)
mcrease ill SRaw (p = 0 23) was observed after N02 exposure Three of the 15 subjects had
a greater than 20 % decrease ill the dose of methachohne requIred to double SRaw (PD lOO)
However, at least three of the subjects had a change of SImuar magmtude ill the OppOSIte
dIrection, Judgmg from the graplncal presentatIOn of the methachohne dose-response curves
Respiratory system reSIstance measured by the forced oscIllatIOn method was not changed by
N02 exposure Hazucha et al (1983) suggested that the dIfference ill the conclUSIOns
regardmg statistical sIgmficance reached by Orehek et a1 (1976), despIte sImuar fmdmgs,
was because "the statistical approach used by Orehek was not appropnate" Hazucha et al
(1983) discussed the factors that led to theIr conclUSIOns that, had they analyzed theIr data ill
a sImuar manner to Orehek et al (1976), the findmgs would have been comparable
The hypotheSIS that N02 exposure may cause auway hyperresponslveness was also
exammed by Klemman et al (1983), who employed a dIfferent experImental deSIgn than
Orehek et al (1976) and Hazucha et al (1983) They StudIed 31 mlld-to-moderate
asthmatICS who were exposed to 0 2 ppm N02 for 2 h wlnle performmg hght, mtermittent
exerCIse There were no sIgmficant effects of N02 exposure on forced expIred spIrometry
Total RT (forced oscillatIOn) tended to illcrease (9 %) after N02 exposure, but the dIfference
was not sIgmficant (p = 0 11) Symptom responses tended to be shghtly Ingher after arr
exposures A number of dIfferent methods were used 10 evaluate the methachohne challenge
data The general tendency was for greater responSIveness to methachohne after N02
exposure The determmatIon of the dose that would cause a 10% decrease m FEV1 (D10)
15-51
was the most "conventIonal" approach (see O'Connor et al , 1987, for a dIScuSSIon of
techniques) to assessmg methachohne responSIveness In the 21 subjects m whIch thIs dose
could be ascertaIned, DlO was 8 6 + 162 p,g on the arr day and 3 0 + 62 p,g on the N02
days (p < 005 by t-test and Wilcoxon test) Thus, It appears that the results of thIs study
suggest a possIble mcrease m arrway responSIveness after a 2-h exposure to 0 20 ppm N02
Koenig et al (1985) have StudIed the effects of a I-h restmg exposure of asthmatIc
adolescents to 0 12 ppm N02 There were no "consIstent sIgmficant changes m pulmonary
functional parameters" after N02 exposure Although symptom data were not presented, the
authors mdicated that subjects had more symptoms after N02 exposure but that the trend was
not significant
Subsequent studIes by Koemg et al (1987a,b) of mouthpIece exposures to 0 12 ppm
N02 , which mcorporated exerCIse (30-mm rest followed by lO-mm exerCIse), mdicated
increases m RT and decreases m FEV1 after both arr and N02 exposure These changes
were apparently due to exerCIse alone (RT mcreased 8 1 % WIth arr and 10 4 % WIth N02,
postexercise FEV1 was decreased 7 4 % WIth arr and 4 1 % WIth N02) In the fmal phase of
the study, subjects were exposed to 0 18 ppm N02 usmg the same exerCIse protocol In thIS
case, no dIfferences m RT were seen and FEV1 decreases were 1 3 and 3 3 % for arr and
N02 , respectIvely ThIs dIfference (p = 006) may mdicate a pOSSIble response trend
There were no dIfferences m symptoms between exposure condItIons m eIther the 0 12- or
o 18-ppm N02 exerCIse exposure studIes
Morrow and Utell (1989) StudIed a group of 20 asthmatIcs exposed to 0 30 ppm N02
for 3.75 h The exposure mcluded three lO-mm penods of moderate exerCIse There were
no statIstIcally sIgmficant group changes m symptoms, spIrometry, plethysmography, or
airway reactIvity to carbachol as a result of the N02 exposure Some of the subjects (n = 7)
had partICIpated ill the Bauer et al (l986a) study The 13 remammg (new) subjects were
judged to have more severe asthma than the "repeaters" Although the repeaters tended to
have responses that were SImilar to those m the preVIOUS study (larger FEV1 decrements m
N02 than in arr), the new subjects had sIgmficantly greater FEVl decrements durmg the arr
exposures.
LInn et al (1985b) and LInn and Hackney (1984) exposed a group of 23 mild
asthmatics to 4 ppm N02 Subjects completed a total of four exposures (two each to N02
15-52
and clean arr) separated by 1 week Exposures lasted fbr 75 mm and mcluded two 15-mm
exerCIse penods separated by a 25-mm rest penod The :fIrst exerCIse was hght (25 L/mm)
and the second was heavy (49 L/mm) All subjects were responSIve to mhahng 0 75 ppm
SOz dunng exerCIse Mean basehne preexposure SRaw measurements vaned from 5 48 and
5 59 on the arr exposure days to 6 14 and 6 44 on the N02 exposure days, although It IS
unhkely that the shghtly hIgher basehne values on the NOz exposure days affected the
subJects' responses AIrway resIstance mcreased after exerCIse and more so after the heavy
(572%) than after the hght (176%) exerCIse (percentages represent mean values collapsed
across all exposure condItIons) There was no sIgm:fIcant dIfference m lung functIon that
could be attnbuted to NOz, if anythIng, SRaw tended to be shghtly lower WIth the NOz
exposures Other phySIOlogICal tests, such as skIn conductance and heart rate, were not
dIfferent between exposure condItIons As WIth the group of normal subjects StudIed under
sImIlar condItIons, these asthmatIcs had a shghtly, but sIgm:fIcantly, lower systohc blood
pressure towards the end of the NOz exposure The authors suggested the possIbility that
NOz deposIted m the respIratory tract may form a vaso.:lctIve substance such as an orgamc or
morgamc mtrate NItrate formatIOn after NOz mhalatmn has been observed m anImal studIes
(postlethwait and Mustafa, 1981) However, measurements of blood levels of mtrate were
not performed by Lmn et al (1985b) Both symptoms and state-traIt anxIety scores were
evaluated dunng and after exposure, there were no sIgm:fIcant VariatIons that could be
attnbuted to NOz exposure
It IS dIfficult to explam the dIfferences between thIS group of asthmatIcs exposed to
4 ppm for 75 mm (WIth exercIse) compared to the group exposed to 0 30 ppm for 30 mm
WIth exerCIse studied by Bauer et al (1986a) The subjects of Bauer et al were exposed to
N02 m dry arr through a mouthpIece, whIch could have caused some "drymg" of the upper
aIrWays ThIs would not be a factor m the Lmn et al (1985b) study, where a chamber
exposure was used Another possIble explanatIOn IS that the asthmatIcs studIed by Lmn et al
were accustomed to NOz exposure because of theIr place of reSIdence (although the ambIent
levels m Los Angeles are, of course, much lower than 4 ppm) However, the mdoor
enVIronment can be an Important avenue of NOz exposure, but IS not known for eIther
group Secondly, the asthmatIcs m the Lmn et al study, although reactIve to SOz, tended to
have mIlder dIsease, none used regular asthma medIcatIOns and all but three subjects had an
15-53
FEVI/FVC ratio m excess of 75 % All of the subjects m the Bauer et al study used some
form of bronchodIlator (oral or Inhaled) and 9 of 15 subjects had a basehne FEVl/FVC ratio
less than 75 % It IS not clear whether the effects of N02 could have been confounded by
exposure to an ambIent aeroallergen Although subjects m the Lmn et al study were
exposed m March, a tIme when outdoor pollen aeroallergens would have tended to be
minimal for the several precedmg months, wmter IS the peak season for fungal aeroallergens
(Street and Hamburger, 1976, McLean et al ,1991) Also, mcreased bronchIal reactivIty to
cold air was an important fmdmg m the Bauer et al study, but It was not measured m the
Linn et aI. study
Further studies were conducted by Lmn et al (1986) on 21 (mllliIl1al to mIld)
asthmatics exposed to 0, 030, 1 0, and 3 0 ppm N02 for 1 h The exposures mcluded
intermittent, moderate exerCIse (VE = 41 L/mm) ThIs group was charactenzed as "clmIcally
mild extrmsic (allergIc)" asthmatics who requrred Infrequent, If any, medicatiOn As m the
prevIous study WIth 4 0 ppm N02 exposures, there were no sigmficant effects of N02 on
sprrometry, SRaw' or symptoms Furthermore, there was no sigmficant effect on arrway
reactivity as measured by cold-arr challenge (see Section 15 4) In order to examme the
suggestion that the seventy of response to N02 may be related to the clmIcal seventy of
asthma, the authors selected three subjects whom they charactenzed as havmg more severe
illness. There was no mdicatIon that the responses of these subjects were related to N02
exposure, although they expenenced markedly larger changes m reSistance than other mIlder
asthmatics under all exposure conditions Heart rate or mmute ventIlatiOn did not vary
significantly With N02 exposure The preVIously observed decrease m systohc pressure,
assocIated WIth 4 0 ppm N02 exposure, was not exammed m these subjects
Mohsenm (1987a) StudIed 10 mIld asthmatics exposed to 0 5 ppm N02 for 1 h at rest m
an envIronmental chamber There were no changes m symptoms, spIrometry, or
plethysmography that could be attnbuted to N02 exposure The response to methachohne
(bromIde) was evaluated WIth partIal expIratory flow at 40% VC (PEF40%VC), rather than
changes m SRaw or FEV l , to test for "small arrway abnormahty" WIthout the mfluence of
prior deep breaths There was a sigmficant mcrease m airway responSiveness to
methachohne after the N02 exposure The dose of methachohne reqUIred to decrease
PEF40 %VC by 40 % was 9 2 + 15 after arr and 4 6 + 8 2 after N02 (p = 0 042)
15-54
Roger et al (1990) reported the results of N02 e:xposure m mild asthmatIcs The fIrst
was a pilot study of 12 mild asthmatIcs exposed to 0 30 ppm for 110 mm, mcludmg three
lO-mm penods of exerCIse Mer the :fIrst 10 mm of exerCIse m N'h, they found an 11 %
decrement m FEVv whIch was sIgmfIcantly larger than the 7% decrease seen after the clean
aIr exposure These dIfferences between aIr and N02 e~xposure persIsted for the remamder
of the exposure penod, although the overall responses were progressIvely less wIth
succeSSIve penods of exerCIse, as IS common WIth exen:ase-mduced asthma when the exerCIse
stImulus IS mtenmttent
A concentratIon-response study was subsequently conducted (Roger et al , 1990) wIth
21 mild asthmatIcs, mcludmg 6 subjects from the pilot study, who were exposed to 0 0,
o 15, 030, and 060 ppm N02 The 75-mm exposures. mcluded three lO-mm exerCIse
penods In contrast to the pilot study, there were no dIfferences m response between the arr
and N02 exposure at any exposure concentratIOn or tll11le dunng the exposure BronchIal
reactIvIty to methacholme, tested 2 h after the exposures, was SImilar for arr and N02
exposures There were no sIgmfIcant dIfferences m symptom scores across the four exposure
condItIons The authors were unable to specmcally IdentIfy factors that could have caused
the dIfference m response between the pilot study and the larger, more comprehensIve
concentratIon-response study They suggested that the pilot study asthmatIcs may have had
more reactIve arrways, based on therr poorer baselme lung functIon and greater aIrway
responSIveness to methacholme compared to the subjects m the concentratIOn-response study
Furthermore, the studIes were conducted dunng dIfferent seasons, whIch may account for
some of the vanability m response
Rasmussen et al (1990) presented a prelImmary report of a concentratIOn-response
study of healthy asthmatIc subjects exposed to 0 1, 0 2 and 0 8 ppm N02 Exposures lasted
120 mm and mcluded 10 mm of exerCIse There were no sIgmfIcant changes m lung
functIon (SR.aw' FEV1) or arrway responsIveness to hIstamme resultmg from N02 exposure at
any concentratIOn m eIther normal or asthmatIc subjects Also assessed were acoustIc
rhmometry, nasal mucociliary clearance, and alveolar epIthehal permeability, these results
were not reported
A senes of abstracts have been presented by mVe!ltIgators from Mt SmaI MedIcal
Center m MIamI (Sackner et al , 1980, Ahmed et al , 1983a,b), these reports have not
15-55
appeared m the peer-revIewed hterature but are avaIlable as technIcal reports (Ahmed et al ,
1983a,b). The latter report presents data that are quahtattvely smlliar to Orehek et al (1981)
and Hazucha et al (1983) m that some subjects (13 out of 20) showed mcreased arrways
responsiveness to carbachol after N02 exposure and some (7 out of 20) dId not Even wIth
the post hoc separatIOn of subjects mto "reactIve" and "nonreactIVe" groups, the mcrease m
arrway responsIveness m the reactIve group (n = 13) was not statIstIcally SIgnIficant There
were no SIgnificant changes m lung functIon Adequate charactenzatIOn of the exposure
condItions was not presented The former report (Ahmed et al , 1983a) dealt WIth effects of
N02 on nme ragweed-sensitIve asthmatICSThere were no group mean changes m Gaw or
FEV1 after N02 exposure There was also no change m bronchIal responsIveness to a
ragweed antIgen InhalatIon challenge eIther ImmedIately or 24 h after exposure to 0 1 ppm
N02
The effects of pnor N02 exposure on S02-mduced bronchoconstnctIon has been
exammed in two studIes (Jorres and Magnussen, 1990, Rubmstem et al ,1990) Jorres and
Magnussen (1990) exposed 14 mIld-to-moderate asthmatIc subjects to 0 25 ppm N02 for
30 min while breathmg through a mouthpIece at rest There were no changes m SRaw as a
result of the exposure Mer the exposure, arrways responSIveness to S02 was assessed by
isocapmc hyperventIlatIon of 0 75 ppm S02 usmg stepWIse mcreases m ventilatIon, the !mtIal
level was 15 L/mm with subsequent mcreases to 30, 45, 60 L/mm, and so forth Mer each
3-mm penod of hyperventIlatIon, SRaw was determmed The ventilatIOn of S02 reqUIred to
produce a 100 % mcrease m SRaw (pVlOOSRaw[S02]) was estImated usmg mterpolatIon of
ventIlation versus SRaw (dose-response) curves The PVlOoSRaw(SO~ was SIgnIficantly
reduced after N02 exposure compared to after filtered arr exposure, suggestmg that the
arrways were more responSIve to S02 as a result of the pnor N02 exposure
Rubinstem et al (1990) exposed nme asthmatICS to 0 30 ppm N02 for 30 mm
(mcludmg 20-mm hght exerCIse) There were no SIgnIficant effects of N02 exposure on lung
functIon (smgle breath nitrogen washout, SRaw' FVC, FEV1) or respIratory symptoms,
although a shght mcrease m SRaw was observed as a result of exerCIse An S02-
bronchoprovocatIon test was adm!mstered after exerCIse, but usmg a dIfferent technIque than
J6rres and Magnussen (1990) Increasmg amounts of S02 were adm!mstered by succeSSIve
doubling of the S02 concentratIon (0 25, 05, 1 0, 2 0, 40 ppm) at a constant, Isocapmc
15-56
ventilatIOn of 20 L/mm, mamtamed for 4 mm SpecIfic: arrway resIstance was measured
after each step mcrease m S02 concentratIOn The concentratIOn of S02 requITed to mcrease
SRaw by 8 umts (pD8uS02) was mterpolated from a dose-response curve of S02
concentration versus SRaw The PD8uS02 was 1 25 + 0 70 ppm after aIr exposure and
1 31 + 0 75 after N02 exposure, mdIcatmg no mean change m responsIveness to S02 Only
one subject showed a tendency toward mcreased responSIveness to S02 after N02 exposure
(see also Section 15 4)
The contrastmg fmdmgs m these two studIes IS somewhat puzzlmg because the subjects
of Rubmstem et al (1990) were exposed to a htgher N02 concentratIOn and exercIsed dunng
exposure However, Jorres and Magnussen's subjects appeared to have had shghtly more
severe asthma and were somewhat older The modest mcrease m SRaw mduced by exerCIse
m the Rubmstem et al study may have mterfered wIth the response to S02 (1 e , the subjects
may have been m a refractory state) Fmally, the dIfferent method of admImstenng the S02
bronchoprovocatlOn test (1 e , mcreased VE at constant S02 vs mcreasmg S02 at constant
VE) may produce a dIfferent response because hyperventilation alone could contnbute to the
mcrease m SRaw (Deal et al , 1979, Eschenbacher and Sheppard, 1985) Thus, although
sImilar, the two S02 challenges are not necessarily comparable
15.3.1.1 Effects of Nitric Acid Vapor on Asthmatics

Koemg and assocIates (1988, 1989a,b) have recenltly reported prehmmary results of
a study of adolescent asthmatics exposed to HN03 vapor In the fITst report (Koemg et al ,
1988), subjects were exposed to 50 and 100 ppb HN03 and to 50 ppb HN03 plus 68 p.g/m3
H 2S04 The average FEV1 decreased followmg exposure (30-mm rest followed by lO-mm
mild exercIse) under all three condItions, although there were no sIgmficant dIfferences
among the responses to these exposures
Koemg et al (1989a) reported the responses of adolescent asthmatics to a 40-mm
exposure to 50 ppb (2 p.M/m3 ) HN03 vapor exposure VIa a mouthpIece exposure system
In thts study, after 30 mm of rest and 10 mm of exerCIse while breathmg HNG.3 vapor, there
was a 4 4 % decrease m FEV1 compared to 1 8 % decrease after aIr breathmg A 22 5 %
mcrease m total respIratory resIstance was also observed after HN03 , compared to a 7 5 %
mcrease after aIr
15-57
In further studIes by Koemg et al (1989b), subjects were exposed to aIr and
57 ± 16 ppb HN03 twIce once wIthout and once wIth a prehmmary gargle of lemonade,
intended to reduce oral ammoma (NH3) levels Durmg the 45-mm exposure, subjects
exercised twIce for 15 mm at a ventIlatIon of about 25 L/mm Baselme oral NH3 of
318 ± 84 ppb was reduced to 113 + 98 ppb after lemonade gargle There were small, but
not statistIcally sIgmficant, decrements m FEV1 after all exposures, -3 3 % after HN03
alone and -1.7% after both arr and HN03 plus lemonade SImuar trends (-9 4 %, HN03 ,
-5 5%, HN03 plus lemonade, -5 1 %, arr) were observed for V50%VC The data dId not
support the hypothesIs that reductIon of oral ammoma (by usmg a lemonade gargle) would
increase the response to HN03 because HN03 , ill the absence of ammoma, would not be
converted to NH4 N03 ill the upper arrway Nevertheless, the authors made the mterestmg
suggestion that, ill mIXtures of HN03 vapor and H 2S04 aerosol, gaseous NH3 may react
more rapIdly WIth the gaseous HN03 than WIth the aerosol, thus reducmg the potentIal
neutralizatIon of H 2S04 It should be emphasIZed that thts IS speculatIon based on the
phySICOchemIcal propertIes of HN03 vapor and H 2S04 aerosol and IS not supported by
experImental observatIOns A complete report of these studIes IS not currently avatlable (1 e ,
as of October 1992)
15.3.2 Effects of Nitrogen Dioxide on Patients with Chronic Obstructive

Lung Disease
PatIents WIth COPD represent an Important potentIally senSItIve populatIOn group
Some of these patIents have arrways hyperresponsiveness to phYSICal and chemIcal stImuh
In addItIon, because of theIr already compromIsed lung functIon, they have much less reserve
than people WIth normal lung functIOn The poor dIstrIbutIOn of ventIlatIOn ill patIents WIth
COPD may lead to a greater dehvery of N02 to the segment of the lung that IS well
ventIlated, thus resultmg ill a greater regIOnal tIssue dose Tables 15-6 and 15-7 summarIZe
these studIes
In a reVIew of theIr studIes, Von NIedmg and Wagner (1979) summarIZed prevIOusly
reported fmdmgs The mam observatIOns were that Raw illcreased ill chromc bronchttIcs
exposed to 2 0 ppm N02 or greater and that, after exposure to 4 to 5 ppm N02, Pa02 was
decreased and the alveolar-artenal oxygen gradIent was WIdened
15-58
TABLE 15-6. SUBJECT CHARACTERISTICS FOR PATIENTS WITH CHRONIC OBSTRUCTIVE PULMONARY
DISEASE EXPOSED TO NITROGEN DIOXIDEa
Number
and
Gender of FEV 1/FVC SRaw or SGaw MedIcatIon AIrway
Reference Subjects Age (Percent) (Le cmH2O/Us) Dyspnea DIagnosIs MedIcatIons Wltholdmg ReactIvIty Notes
Kerr et a1 (1979) 7 24-53 75 510 CBR Dally cough
for three
consecutIve
months
Lmn et a1 (1985a) 13 M/9 F 48-69 29-67 166 19/22 6 CBR llIB 4 hIB
21 EM 120B
4 AS 2 ST
b
Morrow and Utell 13 M/7 F 47-70 43-75 030-287 Y COPD 8 mIld
(1989) 348-333 12 moderate
Von Nledmg and 116 25-74 Chromc
~
VI Wagner (1979) nonspecIfic
I
VI lung
\0
dIsease
14 R T = 593
CRR
Von Nledmg et a1 84M 30-72 35-10 COPD Chromc
(1973a) nonspecIfic
lung dIsease
Von Nledmg et al 88 CBR
(1971, 1970)
aAbbreviatIons
FEV1 = Forced expiratory volume In is EM Emphysema
FVC = Forced Vital capacity AS Asthma
SRaw = Specific airway resistance m Inhaled (3 agomst
SGaw = Specific airway conductance OB Oral bronchodilator (theophylline)
CBR = Chromc bronchitIs ST Oral corticosteroid
M = Male COPD = Chrome obstructIve pulmonary disease
F
b
= Female RT Total respiratory resistance
TABLE 15-7. EXPOSURE CONDITIONS AND RESPONSES IN COPD PATIENTS EXPOSED
Exposure ExercIse ExercIse Relative
Conc Duratlon Duration Vent1latIon Temp Hunudity
Reference (ppm) (rom) (rom) (Urom) (DC) (Percent) Responses
Kerr et al (1979) 05 120 15 25 24 45 No effects m bronclutlcs alone PossIble
decrease m quaslstatIc comphance
Lmn et al (1985a) 05 60 30 16 225 49 No change m FVC, FEV I , etc, at any N02
level SRaw tended to mcrease after first
10 exerCIse penod PossIble decrease m peak
flow at 2 ppm No symptom changes No
20 change m Sa02
Morrow and Utell (1989) 030 225 21 25 21 40 Total N0 2 mhaled dose 1 215 mg Decrease
(3 X 7) of 9 6 % m FVC after exposure 5 2 %
declme m FEV I SIgnIficant after ~ 4-h
exposure
Von NIedmg and Wagner 1-8 5-60 At 4-5 ppm for 15 rom, Pa02 decreased
(1979) (artenalized capIllary blood) Raw mcreased
WIth exposure to 1 6 ppm or greater
Von NIedmg et al (l973a) (a) 1-5 30 breaths Increase m Raw related to N0 2 concentratIOn
(15 rom) No effect on Raw below 1 5 ppm
(b) 5 60 Changes m P02 of earlobe caplllary blood
Change occurred m first 15 rom, effect dId
not mcrease WIth further exposure
Von NIedmg et al (1971, o 5-5 15 Decrease m earlobe blood P02 at 4 0 ppm
1970) and above Increased Raw at concentrations
of 1 6 ppm and above
'AbbreVllItlons
FVC = Forced Vital capacity
FEV1 = Forced expiratory volume In 1 s
NOZ = Nitrogen dioXide
SRaw = SpeCific airway resistance
SaOZ = Artenal oxygen saturation
PaOz = Artenal partial pressure of oxygen
Raw = Airway resistance
POZ = Partial pressure of oxygen
The results of two N02 exposure studIes were dISCUSSed ill Von NIedmg et al (1980)
In the fIrst study, 14 healthy and 14 bronchItic patients were exposed to 5 to 8 ppm N02 for
up to 5 mm on 4 separate days The mean mcrease ill lRaw was 1 07 cm H20/L/s Except
for three subjects wIth an mcrease ill Raw of greater th~n 2 0 cm H2 0/L/s, the responses of
the bronchItIcs were sImilar to the healthy subjects
In the second study (Von NIedmg et al , 1980), 30 healthy subjects and 40 bronchItic
subjects were exposed to 5 ppm N02 for 5 mm The subjects were dIVIded mto clusters
accordmg to theIr preexposure Raws, whIch ranged from less than 1 cm H2 0/L/s to greater
than 4 0 cm H 20/L/s There was a tendency for the response to N02 to be greater m the
subjects WIth the hIghest baselme Raw In subjects WIth baselme Raw > 4 0 cm H2 0/L/s, the
mcrease ill Raw averaged Just less than 1 5 cm H20/L/s, the mcrease was less than 0 5 cm
H2 0/L/s ill subjects WIth baselme Raw < lcm H 20/L/s Percentage changes ranged from
approXImately 25 to 50 % Unfortunately, thIs synopsIs does not provIde a more
comprehensIve reVIew of the data
More recently, Lmn and co-workers (1985a) studIed a dIverse group of 22 COPD
patIents, illcludmg men and women WIth emphysema and chromc bronchItis, exposed, while
exercIsmg mtenmttently, for 1 h to 0 5, 1 0, and 2 0 ppm N02 In agreement WIth the
preVIOUS Von NIedmg and Wagner (1979) study, no changes ill artenal oxygenation (ear
OXImetry measurements of hemoglobill saturatIOn) were observed Also, no changes ill lung
functIOn (spIrometry, plethysmography) were observed that could be attnbuted to N02 The
only exceptIOn was the tendency (not statistIcally sigruficant) for peak flow to be shghtly
lower (about 5%) dunng the 2 O-ppm exposures No Increase ill symptoms was reported
Morrow and Utell (1989) examilled the responses of 20 patients WIth COPD who were
exposed to 0 3 ppm N02 for 3 75 h, dunng whIch tIme they performed mIld exerCIse for
three 7-mill penods Forced VItal capaCIty (FVC) showed progressIve and sigruficant
decreases dunng and followillg N02 exposure, WIth the largest change (-9 6%) occurrmg
after 3 75 h of exposure Smaller decrements were seen ill FEV1 (-5 2 %) at the end of
exposure There was no effect on SGaw or dIffusmg capaCIty as a result of N02 exposure
The dIfferences between subjects WIth more severe dIsease (FEV1 < 60 % predIcted) and
those WIth milder dIsease (FEV1 > 60 % predICted) ill terms of theIr relatIve responses to
N02 were generally not sIgmficant, except for a pOSSIble shghtly greater decrease ill FEV1 ill
15-61
the milder COPD group When the COPD patients were compared wIth healthy, elderly
nonsmokers, there was an apparently sIgmficant dIfference between the two groups m theIr
response to N02, that IS, the COPD patients showed a decrement, but the healthy
nonsmokers showed an Improvement m FEV1 There were also apparent dIfferences m N02
response between healthy, elderly smokers and healthy, elderly nonsmokers These
exploratory post hoc analyses generate mterestIng hypotheses, but they do not explam
whether the COPD patIents responded to N02 because of theIr current or preVIOUS smokmg
habIt or because of some predIsposItIOn to N02 effects caused by theIr lung dIsease The
reasons for the marked dIfference m response between these subjects and those of Lmn et al
(1985a) are unclear PossIble explanations mc1ude dIfferences m ambIent concentrations due
to the place of reSIdence (Los Angeles vs Rochester, but see dIScussIon m SectIOn 15 3 1
regardmg tms factor) and, more Importantly, duratIOn of exposure (4 h vs 1 h) However,
the hIgher concentrations used ill the Lmn et al (1985a) study could be expected to produce
greater effects m equally reactive subjects DIfferences m the seventy of COPD could be
related to the dIfferences ill response, although the subjects of Lmn et al had sImuar or
worse lung function than the subjects of Morrow and Utell Note also that the mud COPD
subjects of Morrow and Utell had greater responses
15.3.3 Summary
Although fmdmgs m asthmatics have been mIXed, the pulmonary functIOn responses to
N02, Wlthm the ambIent range, are relatIvely small when compared to S02 exposure (see
Table 15-8 and FIgures 15-1 and 15-2) Several studIes (Bauer et al , 1986b, Roger et al ,
1985; Koemg et al , 1987a,b, Avol et al , 1986) suggest pOSSIble small changes m
spirometry or plethysmography at concentratIOns ill the range of 0 1 to 0 5 ppm However,
the absence of changes at mgher N02 concentrations, faI1mg to suggest a concentratIOn-
response relatlonsmp (Avol et al , 1986, Bylm et al , 1985, Lmn et al , 1985b, Lmn et al ,
1986), IS problematic PatIents WIth COPD expenence pulmonary function changes WIth
bnef exposure to mgh concentrations (5 to 8 ppm for 5 mm) or WIth more prolonged
exposure to lower concentratlons (0 3 ppm for 3 75 h) In both asthmatic and COPD
populatlons, there remam several unanswered questIOns regardmg the mteractIOn of dIsease
state and exposure vanables
15-62
TABLE 15-8. AIRWAY RESISTANCE AND FORCED EXPIRATORY VOLUME IN ONE SECOND CHANGES IN
ASTHMATICS EXPOSED TO NITROGEN DIOXIDEa
6
Percent ..::l FEV1 Percent ..::l SRaw or SGaw or Llli.T
Reference N02 Au N02 Au N02 Notes
Avol et at (1988) 03 -10 -11 +34 405 .6.SRaw IS mean for last
two measurements
06 -11 -12 +34 78 Shows the dIrectIOnal
change m response
Au (10 FEV 1 s decreased,
5 mcreased) N02 (all
FEV 1 s decreased)
Bauer et at (1986a) 03 -41 -101 NA NA Atr (10-5 +), N02 (15-)
[( -70)] [Excludes two anomalous
subJects]
Bylm et at (1985) 012 +30 +41 Data glVen for 20 mm of
exposure
..... 025 +30 -39
Ul
I
0\ 050 +30 -230
w
Bylm et at (1988) 014 -12 -75 NC
027 -12 -88
053 -12 -135
Hazucha et at (1982, o1 -19 +66 NC
1983)
Klemman et at (1983) 02 " "
-.:J.:J -261 RT = +1 +9
Koemg et at (1985) 012 0 -30 RT = -53 -44 Greater %..::lFEV 1 due to
. hIgher baselme on N02
day
Koemg et al (1987a,b) 012 -63 -61 RT = -43 +103 NC
o 18 -13 -33 RT = +51 +116

LIoo et at (1985b) 4 ppm +37 +15 Average of two exposures
(twIce) +17 +22
TABLE 15-8 (cont'd). AIRWAY RESISTANCE AND FORCED EXPIRATORY VOLUME IN ONE SECOND
CHANGES IN ASTHMATICS EXPOSED TO NITROGEN DIOXIDEa
Percent A FEV1 Percent A SRaw or SGaw or ARTb
Reference NO z Atr NO z Atr NO z Notes
Lmn et al (1986) 03 -25 -03 +63 +64 NC
10 -19 +35
30 +06 +29
Roger et al (1990) 03 -6 -12
015 -35 -39 +52 +69 Change after 3rd

030 -17 +54 exerCIse penod
060 -37 +55
aAbbrevIations
FEV1 = Forced expIratory volume In 1 s
SRaw = SpecIfic aIrway resIstance
SGaw = SpecIfic aIrway conductance
RT = Total respIratory resIstance
NA = Not avaIlable
NC = No comment
bSGaw changes were converted to SRaw for companson (SRaw = l/SGaw) posItive changes mdlcate Increased resIstance
-
c
(J)
E
4
2
L
~ M L
e LR A
C-
O ---}{------------------~------------------------------- --------------------------------------------
.5
R A
:::r -2 DATA
w A' &'tudy Symbol ppmxL %A
u.. -4 B*
Avo! at aI ,1988 A 972 -12
<3 1,944 +09
~ -6 Avol at aI , 1989
Bauer at aI ,1986
A'
B
1,080
162
-33
-41*
KOI9n1g at ai, 1987a.b K 135 -03
Lmn at ai, 1986 L 477 +03
c -8 1,590 +13
(J) 4,770 +23
E Mohsenln 1987a M 360 +15
~(J) -10 Roger at aI , 1990 R 265
530
-1 1
+04
1,060 +01
0
-12
o 1,000 2,000 3,000 4,000 5,000

ppm x L
*Statlstlcally slgmflcant
Figure 15-L Percent change (post-air vs. post-N02) in FEVl vs. N02 dose in ppm x L
in asthmatics.
20 DATA
1: A Study Symbol ppm xL
CD
E 15 Avolatal,1988 A 972 -16
e Avoletal,1989 A
1,944
1,080
+176
+ 44
~ 360 ·15
a
c::
0
10 RM Bylln at aI , 1985 B 29
59
+ 43
-37
116 + 06
'€c::S Byhn at aI , 1988 B 50 + 52
:::J 5 98 + 21
u. ~ L A' 191 -48
-
c
as
en
fii 0
B'K
B
A' R A
R
L
KoanlQ at aI , 1987a,b
Unn at ai, 1986
K
L
121
477
1,590
4,770
+ 21
+ 45
+ 07
-96
-
(J)
cr. Mohaenln 1987a M 360 +102
c:: Roger at al , 1990 R 265 + 94
CD <:I -5 BB' 530 ·21
E '#. 1,060 + 21
~
e
Co -10 L
.§
c::
0
'€c::S -15
:::J
u.
-20
0 1,000 2,000 3,000 4,000 5,000
ppm xl
Figure 15-2. Percent change ([post-N02 - post-air]/post-air) in resistance <Raw' SRaw '
or R.r) vs. N02 dose in ppm x Lin as1hmatics.
15-65
15.4 EFFECTS OF NITROGEN DIOXIDE EXPOSURE ON AIRWAY
RESPONSIVENESS
Physiological changes m the arrways mduced by a vanety of mhaled substances have
been used to assess the "responSIveness" or "reactivIty" of the arrways Comparmg results
across studies IS dIfficult because of the vanety of types of arrway challenges, the vanety of
methods used to admwster the tests, the different phYSIOlogICal end pomts used to quantify
the responses, dIfferences m waItmg penod after the exposure to determme reactIvIty, and
whether or not the exposure mvolved exerCIse A vanety of stImuh have been used to
challenge the arrways, mcludmg (1) chemIcal mediators such as hIstamme, methachohne,
carbachol, or hypertomc saIme, (2) phYSICal methods such as exerCIse or Isocapmc hyperpnea
with cold arr; (3) other pollutants such as S02, or (4) specIfic antIgemc substances such as
ragweed or grass pollen In thIs sectIOn, the effects of N02 on measures of arrway
responSIveness are dISCUSsed A more detaIled dISCUSSIon of overall aspects of most of the
studIes, mcludmg exposure condItions and measurement of other vanables, are presented m
Sections 15 2 and 15 3 and the tables associated WIth those sectIOns
DespIte the absence of bronchIal or aIrway hyperresponsiveness m some asthmatics and
ItS presence m some nonasthmatIcs (Pattemore et al , 1990), there IS a correlation between
mcreased asthma symptoms or mcreased medIcation usage and mcreased arrway
responsIveness (Bntton et al ,1988) Alterations m aIrway responSIveness may also occur as
a result of repeated challenges WIth methachohne (Beckett et al , 1992), hIstamme (Hamlelec
et al , 1988), hypertomc saIme (Belcher et al , 1987), exerCIse (Stearns et al , 1981), or, m
some cases, by interactIOn between two different challenges eIther histamme (Hamielec
et al , 1988) or hypertonic saIme challenge (Belcher et al , 1987) admwstered before an
exercise challenge can reduce the arrway response to exerCIse Pnor exerclse-mduced
bronchoconstnctIOn can reduce responsIveness to hypertomc sahne (Belcher et al , 1987), but
not, apparently, to hIstamme (Belcher et al , 1987, Hamlelec et al ,1988) Thus, although
the responses to a number of arrway challenges may be correlated (Chatham et al , 1982),
they cannot be conSIdered eqUivalent
15-66
15.4.1 Healthy Subjects
In a small number of recent studIes, the effects of N02 on arrway responsIveness m
healthy, normal subjects have been reported AIrway responsIveness has been shown to
mcrease m normal subjects after exposure to N02 concentratIOns m excess of 1 0 ppm Bell
and Ulmer (1976) found mcreased responsIveness to acetylchohne m subjects exposed to
eIther 75 ppm for 2 h or to 5 0 ppm for 14 h Mohsenm (1987b, 1988) found mcreased
responSIveness to methacholme after I-h exposures to 2 0 ppm and Frampton et al (1991)
reported mcreased carbachol responsIveness after 3-h exposures to 1 5 ppm. Mohsemn
(1987b) also reported that the mcreased arrway responslveness post-N02 exposure could be
blocked by elevatIOn of serum ascorbate levels through vItamm C pretreatment (see
SectIOn 15 2 1 1) In contrast, usmg subjects exposed to 0 1 ppm at rest, Hazucha et al
(1982) and Ahmed et al (1983b) found no sIgmficant change m arrway responsIveness to
cholmerglC agomsts (methacholme and carbachol, respectively) A 20-mm exposure to
048 ppm SImIlarly had no SIgnIficant effect on airway responsIveness to hIstamme (Bylm
et al ,1985) Kulle and Clements (1988) exammed anway responSIveness after 2-h
exposures to 2 0 and 3.0 ppm N02 on 3 consecutive days Nasal moculatIOn WIth mfluenza
VIruS occurred on the second day of N02 exposure Although there was a sIgmficant trend
for arrway responsIveness to declme m one group of sulbJects exposed to clean aIr, there was
no trend for aIrway responsIveness to mcrease after exposure to eIther N02 concentratIon
Responses were not altered after VIruS moculatIOn Thus, m three studIes, N02
concentratIOns of at least 1 5 ppm N02 Inhaled over at Least 60 mm were associated WIth
mcreased responsIveness to eIther cholmerglC or hIstammergIc agomsts The mechamsm for
thIs mcrease m responsIveness needs to be estabhshed before the chmcal ImphcatIons of thIs
fmdmg can be ascertained
15.4.2 Asthmatic Subjects

A change m arrway responsIveness appears to be one of the more senSItIve mdIcators of
response to N02 exposure m asthmatics The fmdmgs from the VariOUS studIes reported here
are summanzed m Table 15-9 See SectIOn 15 3 1 for a more detaIled descnptIOn of the
exposure and measurement methodology
15-67
TABLE 15-9. CHANGES IN AIRWAY RESPONSIVENESS ASSOCIATED
WITH NITROGEN DIOXIDE EXPOSUREa
Duration Tune
b c
NO z ofExp Challenge End Postexp Change mAR Average PD ± SD
Number (ppm) (nun) Type Pomt (nun) ExerCIse + Au NO z Notes
ASTHMATICS
Ahmed et al (1983b) 20 01 60 CARB SGaw N 13 7 604 267
Ahmed et al (1983a) 19 01 60 RAG SGaw N 10 8 8 97 ± 24 7 3 36 ± 4 63
Hazucha et al (1983) 15 01 60 METH SRaw 20 N 6 7 19 ± 04 20 ± 10
Orehek et al (1976) 20 01 60 CARB SRaw 1M N 14 3 056 036
Rasmussen et al (1990) 20 01 120 METH FEV! 1M Y (AIR-NOz = 0 00)
Orehek et al (1981) 7 011 60 GRASS SRaw 1M N 12 ± 03 13 ± 03
-
Ul
I
0\
00
(4 allergtc + 3 asthmatic)
Bylm et al (1988)
Roger et al (1990)
20
19
014
015
30
80
mST
METH
SRaw
SRaw
25
60
N
y
14
10
6
7 33 ± 07 31 ± 07
Klemman et al (1983) 31 020 120 METH FEV! 1M y 20 7 86 ± 16 30 ± 62
Rasmussen et al (1990) 20 020 120 METH FEV! 1M Y (AIR-NOz = 0 02)
Joerres and Magnussen 14 025 30 SOz SRaw 27 N 11 2 465±51 377 ± 3 5
(1990)
Joerres and Magnussen 11 025 30 METH SRaw 60 y 7 4 041 ± 16 041 ± 16
(1991)
Bylm et al (1988) 20 027 30 mST SRaw 25 N 14 6
Avol et al (1988) 37 030 120 COLD FEV! 60 Y 11 16 -84 ± 11 -107 ± 12 Delta FEV!
Avol et al (1989) 34 030 30 COLD FEV! 60 Y 12 21 -53 ± 12 -47 ± 13 Delta FEV 1
TABLE 15-9 (cont'd). CHANGES IN AIRWAY RESPONSIVENESS ASSOCIATED
Duration TIme
b c
N02 ofExp Challenge End Postexp Change mAR Average PD ± SD
Number (ppm) (mm) Type Pomt (mm) ExerCIse + AIr N02 Notes
d
Bauer et a1 (1986a) 12 030 30 COLD FEY! 60 Y 9 3 o 83 ± 0 42 0 54 ± 0 33 PDlORHE
Lmn et a1 (1986) 21 030 120 COLD FEY! 1M Y -11 4 -12 1 Delta FEY!
Morrow and Utell (1989) 20 030 225 CARB SGaw Y
Roger et a1 (1990) 19 030 80 METH SRaw 60 Y 8 9 33 ± 07 33 ± 08
Rubmstem et al (1990) 9 030 30 S02 SRaw 60 Y 4 5 13 ± 07 13 ± 08
Bylm et al (1985) 8 048 20 HIST SRaw 20 N 5
MohsellUl (1987a) 10 050 60 METH SGaw 1M N 7 2 92 ± 15 46 ± 80

~
Ul Bylm et a1 (1988) 20 053 30 HIST SRaw 25 N 12 7
I
0\
\0 Avol et al (1988) 37 060 120 COLD FEY! 60 Y 13 16 -84 ± 11 -10 4 ± 14 Delta FEY!
Roger et al (1990) 19 060 80 METH SRaw 60 Y 11 8 33 ± 07 37 ± 11
Rasmussen et a1 (1990) 20 080 120 METH FEV! 1M Y (AIR-N02 = -0 06)

Lmn et al (1986) 21 100 120 COLD FEY! 1M Y -11 4 -11 2 Delta FEY!
HEALTHY SUBJECTS
Ahmed et al (1983b) 20 o1 60 CARB SGaw N 10 10 207 196
Hazucha et al (1983) 15 01 60 METH SRaw 20 N 6 7 162 ± 27 183 ± 30
Bylm et a1 (1985) 8 048 20 HIST SRaw 20 N 1 2
Frampton et al (1991) 15 15 180 CARB FEV! 30 Y 11 4 -48±1 -75 ± 1 Delta FEV!

TABLE 15-9 (cont'd). CHANGES IN AIRWAY RESPONSIVENESS ASSOCIATED
Duration Time
b
NOz ofExp Challenge End Postexp Change mAR Average PD ± SDc
Number (ppm) (rom) Type Pomt (rom) ExercIse + AIr NO z Notes
e
Kulle and Clements (1988) 21 20 120 METH FEV I 1M N -10 7 -127 Delta FEY!
Kulle and Clements (1988) 21 30 120 MElli FEY I 1M N -70 -9 9 Delta FEY I
Mohsenm (1988) 18 20 60 MElli SGaw 1M N 12 2 101 ± 44 81 ± 45

Bell and Ulmer (1976) 16 25 120 ACH Rr 1M N 08 06
-
VI
0
I
......:J
aAbbreVIations
N0 2 = Nitrogen dioxide
CARB = Carbachol
N = Rest
FEVl
Y
GRASS
HIST
= Forced explratOly volume In 1 s
= Included exercise
= Grass pollen
= Histamine
RAG = Ragweed S02 = Sulfur diOXide
METH = MethacholIne COLO = Cold-dry air
SRaw = Specific airway resistance ACH = AcetylcholIne
1M = Immediately after exposure RT = Total respiratory resistance
b
Change In AR + = Increased airway responsiveness (AR) after N02 compared to air, - = decreased AR after N02 compared to air
cpO ± SO = Mean ± Standard deViation (SO) of provocative dose (PO) (±SEM = standard error of mean) See individual papers for calculation of PO
<!POIORHE = RespIratory heat exchange (loss) for 10% drop In FEV1
eSeparate control and exposure groups First day of three consecutive daIly exposures
There have been several studIes of NOTexposed asthmatIcs m whIch the arrway
responsIveness was evaluated usmg cholmergic agomsts (carbachol, acetylcholme,
methacholme) Subjects were exposed to 0 1 to 0 2 ppm N02 m five such studIes
Of these, both Hazucha et al (1983) and Roger et al (1990) found no sIgnIficant change m
group mean response to methacholme challenge Ahmed et al (1983b) reported a trend for
arrway responsIveness to carbachol to mcrease after a 1-h exposure to 0 1 ppm N02 , but the
trend was not sIgnIficant (p = 007) Nevertheless, some subjects appeared to be more
responSIve than others Orehek et al (1976) reported that 13 of 20 subjects exposed to
o 1 ppm N02 expenenced an mcreased arrway responslveness to carbachol In these
13 subjects, the mean PD lOO decreased from 0 66 to 0 36 mg However, m the seven
"nonresponders", the PD lOO of 036 mg remamed unchanged A number of questIons have
been raIsed about the analytIcal approach used m thIs s1udy, and these are dIscussed m more
detaIl m SectIon 15 3 1 Klemman et al (1983) also evaluated arrway responSIveness to
methacholme after a 2-h exposure to 0 2 ppm N02 The dose of methacholIne requITed to
cause a 10% drop m FEV l decreased from 8 6 to 3 0 ~tg As a group, these studIes appear
to suggest that some mdIvIduals, If not a subgroup of asthmatIcs, may expenence mcreased
arrway responSIveness after N02 exposure
It ffilght be antICIpated, when there IS a trend for a. response at a low concentratIOn, that
exposure to mcreased concentratIOns would tend to confrrm the trend by producmg a less
eqUIVOCal response Mohsenm (1987a) found a sIgnIficant decrease m the dose of
methacholme requIred to produce a 40 % decrease m flow at 40 % of VC on a partIal flow
volume curve, the PD40 decreased from 9 2 after arr to 4 6 after exposure to 0 5 N02 for
1 h On the other hand, at both 0 3 and 06 ppm for 110 mm, Roger et al (1990) found no
dIfference m arrway responSIveness to methachohne ~tIorrow and Utell (1989) also found
no change m arrway responSIveness to carbachol after a 3 75-h exposure to 0 3 ppm These
dIfferences cannot be explamed eIther on the basIs of N02 concentratIon or total N02 dose
because the total dose m the Mohsenm (1987a) study was lower than eIther of the other two
StudIes
HIstanIme arrway challenges have been used m three studIes following N02 exposure
Two studIes by Bylm et al (1985, 1988), at N02 concentratIons rangmg from 0 14 to
053 ppm, suggest pOSSIble mcreased responSIveness to hIstanIme after a 20- to 30-mm
15-71
restIng NOz exposure In the frrst study, 5 of 8 subjects showed an mcrease m response
after a 0.48-ppm exposure, and m the second study, 14 of 20 subjects showed an mcrease m
response after a 0 27-ppm exposure However, the second, larger study (n = 20) dId not
confmn the observanons (at 0 53 ppm) of the frrst study and a somewhat more conservatIve
statistical approach (Fnedman nonparametnc test) failed to confrrm the sigruficance of these
fmdings In a prehmmary report, Rasmussen et al (1990) exammed the effects of 3-h
exposures to 0 1, 0 2, and 0 8 ppm NOz on arrway responsIveness to illstamme They found
no significant group mean change m arrway responsIveness Agam, these results are
suggestive that some asthmancs may expenence mcreased arrway responsIveness after NOz
exposure, but the mconsistent nature of the fmdmgs from study to study and the absence of a
dose-response relatIOnsillp IS problemanc
Bauer et al (1986a), Lmn et al (1986), and Avol et al (1988, 1989) have exammed
the effects of NOz exposure on arrway responsIveness to cold arr mhalatIOn Bauer et al
(1986a) found an mcrease in cold arr arrway responsIveness after a 30-mm exposure to
0.30 ppm NOz The arrway responsIveness was expressed as the quantity of resprratory heat
loss requrred to produce a 10% drop m FEV l , tills averaged 0 83 kcal/mm after arr exposure
and 0 54 kcallmm (p < 0 05) after N02 exposure, mdicatmg an mcrease m arrway
responsiveness Lmn et al (1986) found no change m arrway responsIveness to cold arr after
1-h exposures to 0.3, 1 0, or 3 0 ppm NOz m a group of 21 asthmancs Avol et al (1988)
found a trend for a group mean mcrease m arrway responsIveness to cold arr after 0 3 ppm,
but not after 0 60 ppm, NOz exposure, tills mcreased response was observed m only 11 of
the 29 subjects at 0 30 ppm In a study of young asthmatics, also exposed to 0 30 ppm N02
for 1 h, Avol et al (1989) found no mean change m cold arr arrway responSIveness Indeed,
only 12 of 33 subjects demonstrated a change m cold arr arrway responsIveness m the
drrectIOn md1cauve of mcreased responsIveness Agam, these cannot be explamed on the
basis of NOz concentratIOn or total NOz exposure dose because both were lower m the Bauer
et al (1986a) study, where a sigruficant change m the arrway responSIveness was observed
Companson of the studIes m Table 15-9 and 15-4 mdicates that the Bauer et al (1986a)
study was shorter, mc1uded less exerCIse, and utIhzed a mouthpIece exposure system
AddItional dISCUSSIOn IS presented m Section 15 3 1
15-72
AIrway responsiveness to S02 has been evaluated after 30 mm of exposure to 0 25 to
030 ppm N02 m two studies Jorres and Magnussen (1990) found an mcreased arrway
responsiveness to S02 after a restmg exposure to 0 25 ppm N02, but Rubmstem et al (1990)
found no change m arrway responsiveness to S02 after a 0 30-ppm N02 exposure of slIDJ.1ar
duratiOn that mcluded 20 mm of exerCise The S02 challenges were admilllstered by
different techniques, Jorres and Magnussen used a senes of mcreasmg levels of ventJ.1atiOn at
a constant S02 concentratiOn, whereas Rubmstem et al (1990) used mcreasmg concentratiOns
of S02 at a constant ventJ.1atiOn
The effects of N02 on arrway responsiveness to a specIfic antigen have been exammed
m only two studies Ahmed et al (1983a) reported no mcrease m arrway responsiveness to
ragweed antigen m a group of allergiC asthmatics followmg 60 mm of exposure to 0 1 ppm
N02 Orehek et al (1981) found no change m arrway responsiveness to grass pollen m a
group of allergIc subjects (mcludmg three asthmatics) after a 60-mm exposure to 0 11 ppm
N02 0
From the studies for willch mdividual data were readJ.1y avaJ.1able, the number of
subjects whose arrway responsiveness mcreased and whose arrway responsiveness decreased
is hsted m Table 15-9 TabulatiOn of data from tills table provided mformatiOn regardmg the
dIrectiOn of the change (i e , mcrease or decrease) m airway responSIveness followmg N02
exposure One of the problems m tills kInd of analySIS is that it is often dIfficult to
distmgUlsh between a negative and a no-change SItuatIon (i e , it is less lIkely that arrway
responsIveness would decrease from ItS baselme level than mcrease)
Of the 105 subjects exposed to < 0 20 ppm, the overall data mdicated 67 subjects WIth
mcreased arrway responsiveness and 38 WIth decreased arrway responSiveness SlIDJ.1ar ratios
were observed for exerCise and rest exposures For the studIes of exposure to 0 20 to
030 ppm, usmg all types of challenges, arrway responsiveness mcreased m 96 subjects and
decreased m 73 For studies mvolvmg exerCise dunng the exposure, arrway responsiveness
mcreased m 71 and decreased m 65 However, both studIes mvolvmg restmg exposure
showed SIgnIficant mcreases m arrway responsIveness, whereas only two of nme studIes
usmg exerCise exposures were signtficant In the restmg studies, arrway responsiveness
mcreased m 25 subjects and decreased m 8 subjects These studIes also were of shorter
duratiOn (= 30 mm) than many of the exerCise studIes AIrway responsIveness mcreased m
15-73
29 and decreased m 13 subjects m studIes of 30-mm duration, whereas there were 41
increases and 53 decreases m exposures lastIng 60 mm or longer At concentratIOns greater
than 0.30 ppm, the overall total mdIcated 48 mcreases and 33 decreases m arrway
responsiveness For restIng studies, 24 subjects had mcreased arrway responSiveness and
only 9 showed decreased arrway responSiveness (5 did not change), whereas 23 mcreased and
24 decreased m the exerCise studies These data are summanzed m Table 15-10
The studies m which the change m arrway responSiveness was assessed after N02
exposure are presented m three concentration ranges m Table 15-10 and are diVided
according to whether or not exerCise was mvolved m the exposure The data are presented
as the fraction of the total number of subjects With mcreased arrway responSiveness The
increase m arrway responSiveness does not appear to be aSSOCiated With any particular type of
airway challenge The overall percentage of mcreased arrway responSiveness m
N02-exposed subjects was 59 % This is accounted for almost entrrely by the restmg studies,
With an overall percentage of 69% (p < 001) (106 mcreased and 48 decreased), because, m
the exercismg studIes, responses were about equally balanced between mcreased and
decreased responSiveness (104 mcreased and 96 decreased) There was a trend (p < 0 05)
for a shghtly larger percentage (=75%) of subjects to have mcreased arrway responSiveness
after N02 exposure when the exposure is performed both under restmg conditions and at
concentratIOns above 0 20 ppm In fact, of the SiX studies reportmg a sigmficant response
(Klemman et a1 , 1983, Bauer et a1 , 1986a, Byhn et a1 , 1988, Jorres and Magnussen, 1990,
Mohsenm, 1987a, Byhn et al , 1985), four were restmg exposures and, m four, the exposure
duration was 30 mm or less
The imphcation of this trend is unclear because the bnef duratIOn and low ventilation
dunng exposure mdIcate that the N02 exposure dose m these studIes is relatively low If this
trend is real, some mterestIng hypotheses could be generated Is it pOSSible that exerCise
during exposure somehow mterferes With the mechamsm causmg mcreased arrway
responSiveness? It is known, for example, that repeated exerCise mduces a refractory state
such that the subject is less senSitive to exercise-mduced bronchoconstnctIon (Edmunds
et al , 1978, Ben-Dov et a1 ,1982) In many cases of N02 exposures mvolvmg exerCise,
repeated bouts of exerCise were performed dunng exposure, which could pOSSibly have made
the subjects refractory to the effects of N02 Dunng exerCise, the responSiveness to
15-74
TABLE 15-10. FRACTION OF NITROGEN DIOXIDE-EXPOSED SUBJECTS WITH
INCREASED AIRWAY RESPONSIVENESS 3
NItrogen DIOXIde Exposures Exposure

ConcentratIOn ([N02l) (ppm) All Exposures wIth ExercIse at Rest
ASTHMATICS
o 05 < [N02l < 0 20 064 (105)b 059 (17) 065 (88)b
020 ::;; [N02l ::;; 030 057 (169) 052 (136) 076 (33)b
030 < [N02l 059 (81) 049 (48) 073 (33)c
All [N02l 059 (355)b 052 (201) 069 (154)b
HEALTHY
[N02l < 10 047 (36) 047 (36)
I--'
Ul [N02l > 10 079 (29)b 073 (15) o 86 (14)c
~
aData are fractlOn of subjects mdlCatmg an mcrease m aIrways responslveness above the value for clean aIr Numbers m parenthesls mdlcate actual number
h
of subjects m each category Total number = 354
v p < 001 two-tal1ed Slgn test
c
p < 0 05 two-taIled Slgn test
methachohne IS reduced substantially (Inman et al , 1990) and exerCIse causes a more rapId
reversal of methachohne-mduced bronchoconstnctIon than occurs at rest (Freedman et al ,
1988) On the other hand, IS there a biphasic response of N02 causmg mcreased arrway
responsiveness at low exposure doses (for example, causmg mast cell degranulatIOn, VIS a VIS
Sandstroem et al [1990a]), With a reversal of thIs response occurnng at hIgher exposure
doses, pOSSibly through a drrect relaxmg effect on arrway smooth muscle? For example,
nitrites formed in the lungs of N02-exposed anImals (Postlethwait and Mustafa, 1981) may
have a drrect relaxing effect on smooth muscle, mcludmg bronchIal smooth muscle
In healthy subjects, an mcrease m arrway responsiveness clearly occurs at hIgher N02
exposure concentrations (Beil and Ulmer, 1976, Frampton et al , 1991, Mohsenm, 1988)
In the nomlal subjects at all concentratIOns, there were 37 arrway responsiveness mcreases
and 23 arrway responsiveness decreases At greater than 1 0 ppm, there were 23 mcreases
and 6 decreases, that IS, a ratIO of 079 (p < 001)
15.5 EFFECTS OF NITROGEN DIOXIDE OR NITRIC ACID

EXPOSURE ON BLOOD, URINE, AND BRONCHOALVEOLAR
LAVAGE FLUID BIOCHEMISTRY
The effects of N02 on the constituents of bronchoalveolar lavage (BAL) flUId, blood,
and urine have been exammed, both m VIVO and m VItro The general purpose of these
studies has been to examme mechamsms of pulmonary effects or to determme N02-mduced
alterations m body flUIds that could potentially result m systemIC effects InvestigatIOns have
been aImed at determmmg the effects of N02 on levels of serum enzymes and antIOXidants,
as well as drrect effects on red blood cells and hemoglobm StudIes of the effects of N~ on
airway linmg fluids have focused on changes m alpharantltrypsm levels Potential effects of
N02 on collagen metabohsm have been mvestIgated by exammmg unnary excretIOn of
collagen metabohtes
15.5.1 Biochemical Effects in Blood

Chaney et al (1981) exammed the effects of 020 ppm N02 on vanous blood
parameters m 19 healthy subjects exposed for 2 h while exerclsmg mtermittently A control
15-76
group of 15 subjects was exposed to clean arr They observed a sIgmficant mcrease m
glutatluone (GSH) levels after exposure None of the other blood parameters (red blood cell
GSH reductase, 2,3-dIphosphoglycerate, methemoglobm, vItamm E, lIDmunoglobulm, and
complement C3) were changed sIgmficantly The sIgmficance of the response reported m
tlus study appears to be the result of a dIfference between the control group and the exposure
group m general (dIfferent subjects were used m each group) The changes m GSH were
small and were WIthm the normal range, wIth the average baselme level of GSH bemg
approXImately 38 5 mg/dL The postexposure average of the arr group was
364 mg/dL ± 1 35 (standard error of the mean [SEMD and of the N02 groups was
403 + 1 19 (SEM) mg/dL The authors suggested that the mcreased level of GSH may be
m response to oXIdatIon of hemoglobm to methemoglobm by N02 However, GoM et al
(1988) have recently demonstrated substantIal decreases m GSH levels durmg prolonged
submaXImal exerCIse, wluch was followed by elevated GSH levels m the postexercIse penod,
GSH levels vaned from 0 15 mM durmg exerCIse to 0 6 mM 3 days postexercIse, varymg
about a baselme level of approXImately 0 4 mM It IS not clear to what extent the
observatIons of Chaney et al (1981) may have been confounded by tlus exerCIse effect
It should be noted that Posm et al (1978) found l1l0 aSSOCIatIon between N02 exposure
(l ppm for 2 5 h) and GSH levels, although there were apparent changes m blood
bIochemIstry mcludmg mcreased levels of GSH reductase However, It IS not clear from the
Posm et al (1978) study that any of the observed "effects" can be attnbuted to N02
exposure, there was no concentratIOn-response relatIonslup, effects were not reproducIble
from concentratIOn to concentratIOn, and sImIlar effects were seen wIth clean aIr exposures
In VItro exposure of human blood to lugh levels of N~ (6 and 45 ppm) resulted m
methemoglobm formatIOn (ChIOd! et al ,1983) However, Borland et al (1985) were unable
to demonstrate mcreased methemoglobm levels m smokers exposed to lugh NO levels from
CIgarette smoke Methemoglobm IS also formed durmg m VItro exposure to NO (1,000 ppm)
(Cluod! and Mohler, 1985) These observatIons appeal to have no relevance to the potentIal
effects of ambient N02
15-77
15.5.2 Bronchoalveolar Lavage Fluid Biochemistry
Mohsenm and Gee (1987) have reported that subjects exposed to 3 to 4 ppm N02 for
3 h had a 45% decrease m the actiVIty of alpha-I-protease mhIbitor (aIPI) the major lung
protease inhibItor of the enzyme elastase These levels were measured m BAL flUid obtamed
3 5 to 4 h after exposure Alpha-I-protease mhIbitor IS "Important m protectmg the lung
from proteolytic damage, partIcularly from the elastase of neutrophIls" The mean elastase
inhIbitory capacIty decreased from 95 ± 12 % m the aIr group to 55 % m the N02-exposed
group. (Due to analytical ImpuntIes m the standard, the 95 % InhIbItIon measured m the
air-exposed group was presumed eqUIvalent to 100 %, thus the 45 % dIfference) The authors
noted that even a 50% reductIon m alPI actIvIty IS not assocIated wIth an mcreased nsk of
emphysema (Kabrraj et al ,1982) However, reduction m protease mhIbitIon could result m
connectIve tIssue damage and could conceIvably be Important m mdividuals wIth an
a-l-antitrypsm deficIency
Johnson et al (1990) also exammed the response of alPI to m VIVO N02 exposure m a
group of 24 healthy nonsmokers The subjects were exposed to eIther 1 5 ppm N02 for
3 h or to a vanable concentratIon consIstmg of a baselme level of 0 05 ppm N02 wIth three
15-mm "peaks" of 20 ppm DetaIls of the exposure protocol and subject charactenstIcs are
provided m Frampton et al (1989b) (dISCUSSed m Table 15-1, SectIOn 15 2)
Bronchoalveolar lavage was performed 3 5 h after exposure and the flUid was frozen for
subsequent analySIS. The functIOnal actIvIty of alPI was taken to be the elastase mhIbitOry
actIvity corrected for the concentratIOn of alPI determmed by Immunoassay NeIther the
levels of aIPI, as determmed by ImmunoreactIvIty, nor ItS functional actiVIty were
SIgnificantly changed by N0 2 exposure
The dIfferent fmdmgs by Johnson et al (1990) and Mohsenm and Gee (1987) wIth
regard to alPI actIVIty may be accounted for by the consIderably larger (about two- to
threefold) exposure levels m the latter study Furthermore, dIfferent methods were used to
handle the BAL flUid and to quantIfy alPI concentratIons m the two studIes As dIscussed
by Mohsenm and Gee (1987), there appears to be a large range of alPI actIvIty that IS
compatIble wIth lung health, and there IS broad range of actiVIty of alPI m relatIOn to ItS
concentration The Importance of smaIl changes m alPI IS not clearly estabhshed, and
15-78
therefore, the usefulness of changes m al PI activIty as a marker of N02 exposure will
reqUITe addItional research
15.5.3 Urine Biochemistry

Muelenaer et al (1987) studIed normal males exposed to 0 6 ppm N02 for 4 h/day on
three consecutive days to examme the possIbility that N02 exposure caused dIffuse
pulmonary mJury They used hydroxyprolme excretIOn as a marker of mcreased collagen
catabohsm or connective tIssue mJury Subjects had no resIdentIal N0 2 exposure, no
allergIes or mfectIOns that mIght have produced mflammatory responses, and were mffilffially
exposed to envrronmental tobacco smoke DespIte controlling for these potentially
confoundmg vanables, the authors observed no sIgmficant changes m hydroxyprolme
excretIOn as a result of N02 exposure, eIther ImmedIately or for up to 9 days after exposure
15.6 EFFECTS OF NITROGEN DIOXIDE OR NITRIC ACID VAPOR

EXPOSURE ON HUMAN PULMONARY HOST DEFENSE
RESPONSES
From the epIdemIOlogIcal (Chapter 14) and anImal tOXIcology (SectIon 13 22 1)
hterature, It IS clear that there 1S conSIderable concern regardmg the role N02 exposure may
play m potentiatIng susceptibility to both bactenal and vITal mfectIons Important host
defenses that may be affected by N02 exposure mclude the mucociliary clearance system,
alveolar macrophages (e g , altered vrral mactIvatIOn), and humoral and cell-medIated
Immune responses (e g , changes m antIbodIes and changes m cell populatIOns and therr
actIVIties m the lung) The effects of N02 exposure on vrral mfectIVIty have been studIed m
human volunteers The effects of N02 on macrophage functIOns have been exammed usmg
macrophages from NOTexposed subjects or macrophages exposed to N02 m VItro The
effects of N02 on mucociliary clearance m humans are dISCUSSed m SectIOn 15 2 1 4
Kulle and Clements (1988) and Gomgs et al (1989) (two reports of the same study)
exammed the effect of N02 exposure on the mfectIVIty rate of hve attenuated Influenza
NKorealreassortment VIrUS m healthy, nonsmokmg adults exposed to N0 2 Seven separate
groups were exposed to eIther clean arr (n = 23, 21, 21) or to N0 2 at 1 0 (n = 22),
15-79
2.0 (n = 21, 22), or 3 0 ppm (n = 22) The exposures consIsted of 1 prehmmary day of
clean air exposure and then 3 consecutIve days of the treatment (1 e , eIther NO z or clean
air). The virus was admffilstered mtranasally after the second exposure day (1 e , the thrrd of
the four days) InfectivIty was defmed as eVIdence of vrrus recovery or a nse m eIther nasal
wash or serum antIbody titers after vrrus moculatIOn InfectivIty rates m the three clean aIr
groups were 65, 71, and 71 %, respectively, and were 77, 57, 91, and 91 % m the 3 0, 20,
2 0, and 1 0 ppm NO z exposure groups, respectively Although the rates of InfectIOn were
elevated after NO z exposure m three of four NOz-exposed groups, these changes were not
sIgmficant The mvestIgators and an expert reVIew commIttee (Kulle and Clements, 1988)
concluded that the results of the study were mconclusive rather than negative, tills Imphes
that the hypothesIs that NO z exposure may alter the frequency or seventy of vrralInfectIOns
was neIther confIrmed nor demed by the results of tills study
Gomgs et al (1989) have further elaborated on the results of the above study They
made the pomt that the expenmental desIgn had a low power to detect a 20 % dIfference m
infection rate of mfluenza A/Korea (1 e , 71 % vs 91 %) and, thus, the lack of statistical
SIgnificance IS not unexpected At least 70 subjects would be requITed to detect such a
dIfference usmg tills vrrus, willch has a relatively illgh rate of InfectiVIty Fmally, the
mfluenza A/Korealreassortment vrrus IS not bkely to Infect the lower resprratory tract where
most of the NOz deposItion occurs There IS also the possIbility that the results may have
been confounded by an mfluenza epIdemIc, willch occurred concurrently wIth tills study,
although caused by a different but related vrrus The epIdemIc occurred between Year 1 and
Year 2
Frampton et al (1989a) StudIed two groups of normal subjects exposed to NOz under
two different protocols that had the same concentration X tIme (C x 1) product One group
was exposed contInuously for 3 h to 0 60 ppm and the other was exposed to a background
level of 005 ppm with three "spikes" of 20 ppm for 15 mm each The C x T product for
each of these two protocols was the same The major aImS of tills study were to test the
hypotheSIS that the ability of alveolar macrophages to mactIvate mfluenza vrrus was reduced
by NO z exposure, and to examme the pOSSIbility that a senes of peak exposures would cause
more imparrment than a constant concentratIOn (see also Section 13 22 1) Healthy, normal
nonsmokers WIth no illstory of arrway hyperresponsiveness or of recent upper resprratory
15-80
Infectlon were exposed to both arr and N02 m random &equence Exposures mc1uded SIX
10-mm exerCIse penods, comcIdmg WIth the "spIkes" m the second protocol There were no
sIgmficant effects of these exposures on sprrometry or plethysmography under eIther
protocol Alveolar macrophages obtamed by BAL were tested m VItro for therr ability to
mactIvate mfluenza (A/AAIMarton/43 H1N1) VlfUS and for the m VItro productIOn of
Interleukm-1 (IL-1) by vlfUs-exposed macrophages Interleukm-1 IS an Important
promflammatory protem produced by macrophages that performs a number of functIOns,
mc1udmg mductlon of fibroblast prolIferatIon and actlvatlon of lymphocytes, and IS
chemotactlc for monocytes dunng the Immune response to InfectIOn There were no
dIfferences m total cell recovery, VIabIhty, or dIfferentla1 cell counts between arr- and
NOTexposed samples for either protocol There was a trend (p < 0 07) for less effectIve
mactIvatIOn of VlfUS by macrophages obtamed from subjects exposed contmuously to
o 60 ppm N02 ThIs trend was due to the responses of only four of the nme subjects The
macrophages harvested from these four subjects also showed an mcrease m IL-l productIOn
not seen m macrophages from the other subjects No effects of VlfUS mactlvatIOn were seen
m the subjects exposed to the 2 O-ppm spIkes Although the results of thIs study were not
statIstIcally sIgmficant, the study had relatIvely low power to detect an effect The fmdmgs
are provocatIve and suggest that further work IS necessary to test the hypotheSIS that N02
may mfluence host defense mechamsms m humans
Frampton et al (1989b) also analyzed the protem content of BAL flUId obtamed from
N02-exposed subjects at eIther 3 5 or 18 h postexposure Three dIfferent exposure protocols
were used 3-h exposure to 0 60 ppm or 1 5 ppm N02 or a 3-h vanable concentratIOn
exposure where three 15-mm "peaks" of 20 ppm were supenmposed on a background of
005 ppm N02 Exposures mc1uded 10 mm of exerCIse dunng each half-hour of exposure
There were no sIgmficant changes m pulmonary functlon or resprratory symptoms observed
after N02 exposure AIrway reactlvIty, assessed by carbachol mhalatIOn, was mcreased after
the 1 5 ppm N02 exposure (Frampton et al ,1991) Two groups of subjects were exposed
to 0 60 ppm so that BAL could be obtamed eIther at 3 '; or 18 h postexposure AnalYSIS of
BAL flUId obtamed 3 5 h after a 0 60-ppm exposure mdicated an mcrease m alpha-2-
macroglobuhn (aTM), a regulatory protem that has antJiprotease actlvity and
Immunoregulatory effects The observed mcrease m a T M appears to be tranSIent (no change
15-81
was seen at 18 h postexposure) and was not observed at a hIgher N02 concentratIOn
(1 5 ppm) Further mformatIOn appears to be necessary to estabhsh the nnphcatIOns of thIs
fmding
The effects of N02 on macrophage functIon m N02-exposed annnals IS dISCUSsed m
SectIOn 13 2 2 1 NItrogen dIoXIde-mduced changes have been noted m macrophages
harvested from annnals exposed to N0 2 concentratIOns less than 1 °ppm These studIes are
dIscussed in detaJ.1 m the annnal tOXIcology chapter (Chapter 13)
The effect of ill VItro exposure to N02 on alveolar macrophages harvested by BAL was
examined by Pmkston et al (1988) FIfteen healthy adults underwent BAL to proVIde
macrophages for culture After an 18-h mcubatIOn, the cells were exposed to 5, 10, or
15 ppm N02 or 5 % carbon dIOXIde as a control for an addIoonal 3 h Followmg the
exposure, some of the cells were mcubated for an addloonal24 h, and cell-free supernatants
were then obtamed for analySIS of neutrophIl chemotactIc factor (NCF) Other macrophage
cultures were mcubated for 24 h wIth mfluenza vrrus and the supernatant was then obtamed
for analySIS of IL-1 There were no changes m macrophage VIability, determmed by trypan
blue exclUSIOn, m cells exposed to any of the three N02 concentraoons There were no
changes m release of NCF m any of the NOTexposed cell cultures Furthermore, N0 2
exposure dId not nnparr the ability of cells to release NCF after stnnulatIOn wIth acovated
zymosan Nitrogen dIOXIde exposure dId not stnnulate release of IL-l from exposed
macrophages Influenza vrrus stnnulated the release of IL-l, but there were no sIgnIficant
differences between N02-exposed and arr-exposed macrophage cultures Therefore, N02
exposure trIggered neIther the release of NCF, whIch would attract neutrophIls to the
arrways, nor the release of IL-l, whIch actIvates lymphocytes (among other functIOns)
Equally nnportant, N02 exposure dId not nnpaIr the ability of macrophages to produce eIther
IL-1 or NCF m response to conventIonal stnnuh
Sandstroem et al (1989) exposed a group of 18 healthy nonsmokers to 2 25, 40,
and/or 5 5 ppm (n = 8 m each concentratIOn group) for 20 mm of moderate exerCIse
CV E ~ 35 L/mm) m an exposure chamber Bronchoalveolar lavage was performed at least
3 weeks before and 24 h after each exposure Increased levels of mast cells m BAL flUId
were observed after all N02 exposures Increased levels of lymphocytes were observed only
at the two hIgher concentraoons
15-82
In order to detennme the tIme course of tlns response, Sandstroem et al (1990a)
exposed 32 subjects to 4 ppm N02 for 20 mm, mcludlllg 15 mm of mud exerCIse, and then
perfonned BAL at 4, 8, 24, or 72 h postexposure (m four dIfferent groups of eIght subjects)
Increased levels of mast cells and lymphocytes were observed at 4, 8, and 24 h, but not at
72 h postexposure There was no change m macrophage numbers nor m albumm
concentratIOn m BAL flmd Eosmophtls, neutrophtls, and epIthehal cell counts were not
altered as a result of N02 exposure Unpleasant odor and mud nasopharyngealrrntatIOn
were typICal symptoms There were no changes m spIrometry The observatIOn of mcreased
numbers of mast cells appears to be umque to tlns study, although other mvestIgators
(Frampton et al , 1989a,b) may not have looked for changes m mast cell numbers The
authors consIdered the mcreased numbers of mast cells and lymphocytes to represent a
nonspeCIfic mflammatory response
Rasmussen et al (1992) StudIed 14 healthy nonsmokmg adult subjects exposed to
2 3 ppm N02 and to clean aIr for 5 h wIth a I-week mterval between exposure IndIcatIons
of a decrease m alveolar penneability were observed aJter the N02 exposure The results
support the assumption that a delayed response IS a fea1ure of the human response to N02
and stresses the Importance of an extended penod of observatIOn m future N02 exposure
studIes
Three recent studIes exammed the effects of multllhour exposures to 1 to 2 ppm N02 on
lavaged cells and medIators Devhn et al (1992) StudIed healthy subjects exposed to
2 0 ppm N02 for 4 h WIth alternatmg 15 mm penods of rest and moderate exerCIse One of
the mam :fmdmgs after N02 exposure was a threefold mcrease m polymorphonuclear
leukocytes (PMNs) m the first lavage sample representmg predommantly bronclnal cells and
flUId In addItIon, macrophages recovered from the predommantly alveolar fraction showed
a 42 % decrease m ability to phagocytose Candlda albzcans and a 72 % decrease m release of
superoXlde amon Frampton et al (1992) exposed eXeJrCIsmg subjects to 2 0 ppm N02 for
6 h Bronchoalveolar lavage was performed eIther tmmedmtely or 18 h postexposure There
was a modest mcrease m lavage flUId PMN levels «twofold mcrease) but no change m
lymphocytes Alveolar macrophage productIon of superoXlde amon was not altered m these
subjects These two studIes suggest that N02 exposure may mduce a mud bronclnal
mflammatIOn and may also lead to tmparred macrophage functIon Jorres et al (1992)
15-83
exammed both healthy and asthmatic subjects exposed to 1 ppm N02 for 3 h, but observed
no changes m cells or medIators m BAL flUId or m the appearance of bronchIal mucosal
biopsies after thIs exposure NeIther macrophage function nor a specIfic bronchIal washmg
were exammed m thIs study
Boushey et al (1988) studied five healthy volunteers exposed to 0 60 ppm N02 on
4 days over a 6-day penod Exposures lasted 2 h each and mc1uded alternatmg 15-mm
penods of rest and exerCIse (V E = 30 to 40 L/mm) On the fmal (fourth) day of N02
exposure, venous blood samples were obtamed and a BAL was performed Baselme BAL
and pulmonary function data were obtamed on a separate occaSIOn There were no effects of
repeated N02 exposure on pulmonary function (SRaw' FVC, FEV1) or respIratory symptoms
Following the fourth day of N02 exposure, a shght mcrease ill cuculatmg (venous blood)
lymphocytes was observed (1792 ± 544/mm post-N02 vs 1598 ± 549/mm3 baselme)
3
The only change observed ill BAL cells was an apparent mcrease (p < 0 04) m natural1a11er
(NK) cells from 42 + 24% (baselme) to 7 2 + 3 1 % (post-N02) The authors expressed
reservations that the apparent mcrease ill NK cells may have been an artIfact of the cell
separation process Interleukm-l and tumor necroSIS factor levels ill BAL flUId were not
detectable Tumor necroSIS factor IS another promflammatory protem that, among other
actiVIties, promotes adherence of PMNs to endothehal cells and enhances theu phagocytic
actiVity
Sandstroem et al (1990b) studIed a group of eIght healthy nonsmokers exposed to
4.0 ppm N02 for 20 mmlday (moderate exerCIse, V E ~ 35 L/mm) on alternate days over a
12-day penod (seven exposures total) Bronchoalveolar lavage was performed 2 weeks
before the first exposure and 24 h after the last exposure The fust 20 mL of BAL flUId was
treated separately and presumed to represent pnmanly bronchIal cells and secretIOns After
N02 exposure, there was a reductIon ill numbers of macrophages m the bronchoalveolar
portion, although on a per cell baSIS, alveolar macrophage phagocytIc actIVIty was mcreased
There were decreased numbers of mast cells ill the bronchIal portIOn of the lavage flUId
In addition, there were reduced numbers of T-suppressor, B lymphocyte, and NK cells ill the
alveolar portIOn of the BAL flUId compared to the baselme lavage These observatIOns
contrast WIth those seen by Sandstrom et al (1989) after smgle N02 exposures, suggestmg
some alteratIon m bronchIal and alveolar cell populatIons after repeated N0 2 exposure The
15-84
most ObVIOUS dIfference between Sandstrom et al (1990b) and Boushey et al (1988) IS the
higher N02 concentratIon and the longer duratIOn of the former study Further work IS
necessary to confIrm these observatIons, to determme the tIme course of response to repeated
exposure, and to determme the N02 exposure dose necessary to mvoke modIfIcatIon of
bronchoalveolar cell populatIons
The effects of HN03 vapor exposure (m VIVO) have been exammed m two recent
studIes Becker et al (1992) exposed nme healthy subJ(~cts to 200 p.,g/m3 (80 ppb) of HN03
vapor for 120 mm, mcludmg 100 mm of moderate exerCIse (V E = 42 L/mm)
Bronchoalveolar lavage performed 18 h postexposure mdicated an mcreased phagocytIc
actIVIty of macrophages harvested from the HNOTexposed lung Alveolar macrophages also
showed mcreased resIstance to InfectIOn WIth respIratory syncytIal virus Compared to arr
exposure, there were no mcreases m mflammatory medlators (such as prostaglandm~,
leukotnene B4 , C3a, or neutrophIls) or m cell damage mdicators such as lactate

dehydrogenase (LDH) or lavage flUId protem The abs€mce of markers of tIssue damage
(LDH) or permeability (lavage flUId protem), suggest that, under these exposure condItIOns,
HN03 dId not cause frank tIssue damage
Ans et al (1991a) exposed 10 healthy subjects to 500 jl-g/m3 HN03 vapor for 4 h,
mcludmg moderate exerCIse lLavage flUId was obtamed from both bronchIal as well as
bronchoalveolar washmgs, and bronchIal bIOpSy speciImms were obtamed No change m
LDH levels or lavage protem were observed as a result of HN03 exposure These
mvestIgators found no dIfferences m dIfferentIal cell counts m the lavage flUId of both
bronchIal and bronchoalveolar washmgs They also exposed a dIfferent group of subjects to
3
500 p.,g/m HN03 plus 0 20 ppm 03 and found no potentIatIOn of the 0Tmduced
mflammatory response by the addItIOn of HN03 vapor 10 the exposure TheIr data suggest
that, at these concentratIons, HN03 does not cause tIssue mJury, nor does HN03 alter the
mflammatory response typICal of 03 exposure
15.7 EFFECTS OF NITRATES ON HUMAN LUNG FUNCTION

FIVe studIes have been conducted on human exposure to mtrate aerosols smce 1979
(see Table 15-11) These studIes have been dISCUSSed m the Acid Aerosol Issues Paper (U S
15-85
TABLE 15-11. EXPOSURE CONDITIONS AND RESPONSES IN SUBJECTS EXPOSED TO NITRATES2
Nitrate Species Exposure Exercise ExercIse RelatIve
and Conc DuratIon DuratIon Ventl1atIon Temp HUIDldity Number of Subject Aerosol
3 (OC)
Reference (p.g/m ) (nun) (nun) (Umm) (percent) Subjects Char MMAD Effects
Klemman et al NH4N03 120 60 "",20 31 40 20 Normal 11 No slgmficant changes m
(1980) 200 normals or asthmatIcs
except possible decrease m
19 Asthma Rr No symptom effects
Sackner et al NaN°3 10 5 Normal 02 No changes
(1979) 10,100,100 5 Asthma
1,000 6 Normal
6 Asthma
1,000
6 Normal
6 Asthma
Stacy et al (1983) 80 (N'!4N03) 240 30 55 30 60 12 Normal 055 No effects
I-' 80 (N'J4N~) 12 Normal
UI
I +0 5 ppm
00
0\ N02
Utell et al (1979) NaN°3 16 (X2) 25 10 Normal 046 No effects
7,000 (32 Total) 11 MIld
AsthmatIcs
Utell et al (1980) NaN°3 16 (X2) 25 11 Influenza 049 No symptoms SGaw
7,000 (32 Total) PatIents decreased 17 % and max
40% TLC decreased 12%
after mtrate, WIthIn 2 days
of onset of Illness
SImllar effects 1 week
later, but not 3 weeks
later
aAbbreVIations
MMAD = Mass medIan aerodynamIC dIameter NaN03 = SOdIum mtrate max4O%TLC = MaXimum eXpIratory flow at 40% ofTLC on
NH4NOJ = Ammomum mtrate SGaw = SpecIfic aIrway conductance a PEFV curve
R T = Total respIratory reSIstance
Environmental ProtectIon Agency, 1989) The only ObVIOUS effect was a decrease m Gaw
3
and m PEFV curves m normal subjects wIth mfluenza exposed to 7,000 p,g/m of sodIUm
mtrate (NaN03) aerosol ThIs IS probably three orders of magmtude (1 e , approXlIllately
1,000 tImes) above the mtrate concentratIon that could eXist m the ambIent aIr These
studIes mdicate that, at least as far as lung functIOn IS concerned, there IS no present concern
for adverse effects from current ambIent levels of mtrate aerosols
Sackner et al (1979) studIed a dIverse group of normal and asthmatIc subjects exposed
to concentratIOns reachIng 1,000 p,g/m3 of NaN03 for 10 mm at rest There were no
sIgmficant effects on an extensIve battery of pulmonary functIOn tests
Utell et al (1979) studIed both normal and asthmatIc volunteers exposed to
7,000 p,g/m3 of 046 p,m NaN03 aerosol for 16 mm Via mouthpIece The major health effect
end pomts measured m their study mc1uded ~w, both full and PEFV curves, arrway
reactIvIty to carbachol, and aerosol deposItIon Aerosol deposItIon as a percentage of mhaled
aerosol averaged about 50% for normals and about 56% for asthmatIcs, the group dIfferences
were not SIgnIficant The exposure to NaN03 aerosol was mdIstmgmshable from the control
NaCI exposure m normals Slffiuarly, there were no effects of NaN03 exposure on
asthmatIcs
Utell et al (1980) subsequently studied 11 subjects WIth mfluenza exposed to the same
NaN03 reglffien as above The subjects were ImtIally exposed at the tlffie of illness and then
were reexposed 1, 3, and 6 weeks later Aerosol deposItIOn ranged from 45 to 50 % over the
four exposure seSSIOns All subjects had cough and fever, and 10 of 11 subjeCts had Viral or
lffimunoiogic eVIdence of acute mfluenza Baselme measurements of FVC and FEV1 were
Withm normal1lIDits and dId not change throughout tht~ 6-week penod There were small but
sIgmficant decreases ill Gaw followmg NaN03 mhalatlOn, but not after NaCI exposure ThIs
dIfference was present durmg acute illness and 1 week later, but was not seen at 3 and
6 weeks after illness The decrease m SGaw seen on the ImtIa1 exposure was accompamed
by a decrease m partIal expIratory flow at 40%TLC, tIns was also observed at the I-week
follow-up exposure ThIs study suggests that the presence of an acute vrral respiratory tract
mfectIon may render humans more sus~eptIble to the acute effects of mtrate aerosols
Nevertheless, the concentratIOn of mtrates used m thIs exposure study exceed maXlIllum
ambIent levels by more than 100-fold
15-87
In adchtIon to NaN03 aerosols, ammomum mtrate (NH4 N03) exposure has been studIed
by Klemman and assocIates (1980) Twenty normal and 19 asthmatIc subjects were exposed
to a nommal 200 fl-g/m3 of 1 1 fl-m NH4 N03 aerosol The 2-h exposures mcluded mild,
intermIttent exerCIse and were conducted under warm conchtIons (31°C, 40% RH) There
were no SIgm:ficant phySIOlogICally meanmgful effects of the NH4 N03 exposure m eIther
subject group
Stacy et al (1983) also StudIed the effects of 80 fl-g/m3 of NH4N03 m a group of
healthy male adults As m the Klemman et al (1980) study, there were no changes m lung
functIon or symptoms
15.8 CONCLUSIONS AND DISCUSSION

At the beginmng of thIs chapter, a senes of questIOns were posed concernmg the
potential biologIcal responses to N02 exposure m humans Some of these questIOns can be
answered in part usmg the data presented m thIs sectIOn, others will clearly requIre addItIonal
research.
Symptoms aSSOCIated WIth N02 exposure m healthy subjects have been lImIted to
detectIOn of the odor of N02 , m some cases at surpnsmgly low concentratIOns, less than
0.1 ppm (Byhn et al ,1985) Few of the stuches exammed m thIs reVIew noted a sIgmficant
mcrease m respiratory symptoms Sandstrom et al (1990a) noted mild nasopharyngeal
irritation after exposure to 4 ppm for 20 mm
NItrogen choXIde exposure at suffiCIently hIgh concentratIOns produces changes m lung
function in healthy subjects A number of mvestIgators have reported mcreased arrway
resistance after exposure to N02 concentratIOns exceedmg 2 5 ppm (Beil and Ulmer, 1976,
Von NIedmg et al., 1979, Von NIedmg and Wagner, 1977, Von NIedmg et al , 1980)
However, at concentratIOns of N02 between 2 and 4 ppm, some mvestIgators have not
observed any N0 2-mduced changes m arrway reSIstance or spIrometry (Lmn et al , 1985b,
Mohsenin, 1987b, Mohsemn, 1988, Sandstroem et al ,1990a) At N02 exposure
concentratIOns below 1 0 ppm, there IS httle If any convmcmg eVIdence of change m lung
volumes, flow-volume charactenstlcs of the lung, or arrways reSIstance m healthy subjects
NItrogen diOXIde IS beheved to have ItS pnmary effect on small arrways However, routme
15-88
spIrometry and anway resIstance measurements are not sensItIve mdlCators of small anways
functIOn Thus, the absence of change m these phYSIOlogICal mdlCators of large anways
functIOn at low N02 concentratIOns should not be viewloo as eVIdence that N02 has no effects
on lung functIon Further developments will be necessary to permIt sensItIve, reproducIble,
nonmvaSlVe evaluatIOn of small anways, the pnmary sIte of N02 deposItIon m the lung
NItrogen dIoXide exposure does result m mcreased anway responsIveness m normal
subjects exposed to concentratIOns m excess of 1 0 ppm Mohsenm (1987b) and Frampton
et al (1991) reported an mcrease m anway responsIveness after exposure to 2 0 and
1 5 ppm, respectIvely Repeated bouts of aIrway mflammatIOn could promote deleterious
long-term changes m the lung, such as loss of elastIcIty and acceleratIOn of age-related
changes m lung functIOn However, the development of such responses IS only speculatIve,
gIven the present level of sCIentlfic eVIdence
Potentially sensItive subjects m the population mclude cluldren, older adults, patients
wIth asthma or capo, or mdIviduals who may be unusually sensItive to N02 for other
reasons There are msufficient data on chIldren, adolescents, or older adults, eIther healthy
or wIth asthma, to determme theIr N02 responsIveness relatIve to healthy young adults
At the concentrations that may fall withm the amlnent range (e g , < 1 0 ppm), the
effects of N02 on lung function (1 e , spIrometry, arrway resIstance) m asthmatIcs have
tended to be small For example, Bauer et al (1986a) observed a 4 to 6 % declme m FEV1
m asthmatIcs exposed to 0 3 ppm N02 for 30 mm Koemg et al (1988) reported a 4%
decrease m FVC, but no sIgmficant change mother sprrometry vanables, after exposure of
adolescent asthmatIcs to 0 30 ppm N02 On the other hand, several other mvestigators
(Avol et al , 1988, Bylm et al , 1985, Hazucha et al , 1982, 1983, Klemman et al , 1983,
Koemg et al , 1985, Lmn et al , 1985b, 1986, Mohsenm, 1987a, Roger et al , 1990) have
not found any sIgmficant changes m spIrometry or aIrway resIstance of asthmatics exposed to
concentrations < 1 0 ppm Agam, spIrometry and aIrway reSIstance are not senSItIve
measures of small anways functIOn, where N02 IS known to be pnmanly deposIted
A second important category of senSItive subjects mcludes patients WIth capo, who
have shown mcreased anway reSIstance after bnef exposures to greater than 1 6 ppm N02
(Von NIedmg et al , 1970, 1971, 1973a) (see Table 15-6) In addItIOn, dunng a longer (4-h)
exposure, Morrow and Utell (1989) reported decreased (approx 5%) FVC m capo patIents
15-89
exposed to 0 30 ppm Other mvestIgators (Lmn et al , 1985a, Kerr et al , 1979) did not fmd
responses m COPD patients even with exposures to levels as rugh as 2 0 ppm It appears
that brief acute exposure to relatIvely rugh concentratIOns of N02 (> 2 ppm) will cause
bronchoconstnctIon m some COPD patients and that these responses may also be observed
WIth longer exposures to lower concentratIOns
An unresolved Issue WIth the current data base IS the eXistence of N02-mduced
pulmonary responses m asthmatics that have been reported at low but not at rugh
N02 exposures Although small functional responses have been observed m studies from
various laboratones, effects are not conSIstently present and demonstratIng reproducIbIhty of
responses has been chfficult, even Wlthm the same laboratory Furthermore, all responses to
N02 that have been observed m asthmatics have occurred at concentrations between 0 2 and
0.5 ppm. Changes in lung function or arrway reactivity have not been seen even at much
higher concentrations (1 e , up to 4 ppm) There IS, at present, no plaUSible explanatIOn for
this apparent lack of a concentratIOn-response relatIOnsrup There IS a possibility that a
portion of the vanability m response to N02 may be attnbuted to dIfferences m the seventy
of asthma ThIs IS a complex Issue and has not been studied adequately at trus time
In patIents With chromc obstructive lung disease, Bauer et al (1987) and Morrow and Utell
(1989) have observed decreased lung functIOn (FVC, FEVl ) after exposure to 0 30 ppm for
4 h, but Linn et al (1985a) and Von Nledmg and Wagner (1979) found no effects m COPD
patients from short duratIOn exposures below 2 0 ppm It appears that further work will be
necessary to proVIde enough mformatIOn to estImate the concentratIOn-response relatIOnsrups
for NO z exposure of asthmatIcs and COPD patients, who appear to be the sensItive
subpopulatIons
In several studIes of asthmatics exposed to N02 , alfway responsiveness to a vanety of
agents has been demonstrated However, m many other studies usmg sImuar expenmental
exposures, there was no slgrnficant change m arrway responsiveness In order to evaluate
this apparent duemma, a meta-analysIs was utilized as descnbed m Section 15 4 Without
regard to the type of arrway challenge, N02 concentratIOn, exposure duratIOn, or other
vanables, the overall trend was for arrway responsiveness to mcrease (59 % of 354 subjects
increased). ThIs trend was somewhat more convmcmg for exposures conducted under
nonexercismg conditions (69% of 154 subjects mcreased), mdeed, the excess posItive
15-90
responses were almost entIrely accounted for by exposures conducted under restIng
condItIons The nnphcatIOns of tlns overall trend are unclear and will reqUIre further
mvestIgatIons to verIfy If there IS an mteractIOn WIth exerCIse-mduced changes m lung
functIon that may pOSSIbly obscure changes m arrway responsIveness due to N02 exposure
Increased aIrWay responsIveness could potentIally lead to temporary exacerbatIOn of asthma,
pOSSIbly leadmg to mcreased medIcatIOn usage or even mcreased hOSpItal admISSIOns The
lowest observed effect level for tlns response appears to be m the 0 2- to 0 3-ppm range
Several recent studIes have exammed the pOSSIbility that N02 could mduce a pulmonary
mflammatory response and/or alter nnmune system host defenses These studIes tYPICally
mclude collectIon of cells and arrways flUIds from the lung usmg BAL In contrast to
03 exposure, N0 2 does not, at the concentratIons studierl, mduce an mcrease m BAL levels
of neutroplnls, or eosmoplnls, the typIcal markers of mflammatIOn followmg 03 exposure
However, Devhn et al (1992) have reported mcreased PMNs m bronclnal washmgs
Sandstroem et al (1990a) have observed an mcrease ill mast cells and lymphocytes m BAL
flUId, wlnch they attnbute to a nonspecIfic mflammatory response Boushey et al (1988)
have reported an mcrease m natural killer lymphocytes ill BAL flUId Macrophage numbers
have not been mcreased by N02 exposure, nor did then ability to kill VIrUS appear to have
been altered by exposure, although Frampton et al (1989a) suggested that, m some subjects,
macrophage responses may have been nnparred Rasmussen et al (1992) observed
mdicatIons of a decrease m alveolar permeability after exposure to 2 3 ppm N02 for 5 h
Mucociliary clearance was not altered after N02 exposure m the one study m wlnch It was
measured (Rehn et al ,1982) NItrogen dIOXide was found to cause a reductIOn m alpha-1-
antIprotease actIVIty m one study (Mohsenm and Gee, 1987), but not m another (Johnson
et al ,1990) Followmg N02 exposure, Frampton et al (1989b) found an mcrease m alpha-
2-macroglobuhn, a molecule that has nnmunoregulatory as well as antIprotease actIVIty
ImmunologIcal responses to N02 exposure are Just begmnmg to be elUCIdated and addItIonal
research will be requIred to determme whether these responses have any imphcatIons for
epIdemIologIcally determmed aSSOCIatIOns between N02 exposure and mcreased respIratory
tract mfectIons
The effects of repeated N02 exposure have been exammed m two studIes (Sandstroem
et al , 1990b, Boushey et al ,1988) Boushey et at (1988) reported only a shght mcrease
15-91
(12 %) m cIrculating lymphocytes and a possIble mcrease m natural killer lymphocytes after
four 2-h exposures to 0 60 ppm There were no detectable changes m mflammatory
mediators Sandstroem et al (1990b), on the other hand, found decreased numbers of mast
cells, macrophages, and lymphocytes m the BAL flUId DespIte the decreased numbers, the
phagocytIc actIvIty of alveolar macrophages was enhanced These observatIOns suggest that
host defense responses are dIfferent after repeated exposure than after a smgle acute
exposure More research appears to be necessary to confIrm and expand these observatIOns
because of the Important potential connectIOn between altered host defense responses and
increased resprratory InfectIvity
In healthy adults, a vanety of mIXtures of other pollutants WIth N02 have been
exammed, pfImanly usmg spIrometry and arrway reSIstance measurements as end pomts
In general, N02 does not cause SIgnIficant exacerbatIOn of responses to other pollutants, such
as 03' S02, or particulate matter In other words, there IS no more than an additIve
response when N02 IS mcluded m the pollutant mIXture However, further mvestIgatIOn of
N02 mixtures appears warranted usmg other bIOlogICal markers, mcludmg measures of
epIthelial permeability, clearance, arrway responSIveness, arrway mflammatIon, and measures
that are senSItive to changes m small arrways functIOn In asthmatIcs, there IS a tendency for
mcreased responSIveness to cold arr, methachohne, carbachol, and hIstamme after N02
exposure (see preVIOUS diSCUSSIOn) In one study, asthmatIcs were also more responSIve to
S02 after a preVIOUS exposure to N02 (Jorres and Magnussen, 1990) In additIon to
interactions with other pollutants, N02 exposure could potentially enhance (or mhIbIt)
responses to other substances, partIcularly arrborne antigens In two studies (Ahmed et al ,
1983a, Orehek et al , 1981), the response to grass pollen InhalatIOn was exammed m
sensitive subjects after exposure to 0 1 ppm N02, but no SIgnIficant difference m the
response after arr and N02 exposures was observed GIVen the mcrease m responSIveness to
nonantIgemc substances such as methachohne, hIstamme, S02, or cold arr dISCUSSed
prevIOusly, It may be worthwhIle to reexamme thIs hypotheSIS usmg hIgher N02
concentratlons or more prolonged exposures
Responses to other NOx specIes have also been studIed NItnc OXide does not appear
to cause any lung function effects at low concentratIOns « 1 0 ppm) eIther alone (Kagawa,
1982) or combmed WIth N02 (Kagawa, 1990) Von NIedmg et al (1973b) reported
15-92
mcreased arrways resIstance m subjects exposed to excessIvely hIgh concentratIOns of NO
(> 20 ppm) Responses to HN03 vapor have been studied m adolescent asthmatIcs (Koemg
et al , 1989a,b) and m healthy adults (Ans et al , 1991b, Becker et al ,1992) Further
mvestlgatIOn IS needed to examme the responses to HN03 vapor NItrates (e g , sodIUm
mtrate) have not been found to cause any deletenous effects (Utell et al , 1979, 1980,
Klemman et al , 1980, Stacy et al , 1983) at levels that mIght be expected ill the atlnosphere
The followmg conclusIOns may be drawn from the studIes discussed here
1 NItrogen diOXide causes decrements m lung fullctlon, partIcularly mcreased arrway

°
reSIstance m healthy subjects at concentratIOns exceedmg 2 ppm for 2 h
2 NItrogen dIOXide exposure results m mcreased arrway responSIveness m healthy,

°
nonsmokmg subjects exposed to concentratIOns exceedmg 1 ppm for exposure
duratIOns of 1 h or longer
3 NItrogen dIOXide exposure at levels above 1 5 ppm may alter numbers and types of
mflammatory cells m the dIStal arrways or alveoh, but these responses depend upon
exposure concentratlon, duratIOn, and frequency NItrogen dIOXide may alter
functIOn of cells Withm the lung and productlon of medIators that may be Important
m lung host defenses
4 NItrogen diOXide exposure of asthmatlcs causes, m some subjects, mcreased arrway

responSIveness to a vanety of provocatlve mediators, mcludmg chohnergic and
hIstammergic chemIcals, S02, and cold arr HoweveI, the presence of these
responses appears to be mfluenced by the exposure protocol, partIcularly whether or
not the exposure mcludes exerCIse
5 Modest decrements m sprrometnc measures of lung functIon (3 to 8 %) may occur m

some asthmatlcs and COPD patlents under certam N02 exposure conditlons
6 NItnC aCId levels m the range of 50 to 200 ppb may cause some pulmonary functIOn
responses m adolescent asthmatlcs, but not m healthy adults Other commonly
occurnng NOx speCIes do not appear to cause any pulmonary functIOn responses at
concentratIOns expected m the ambIent envIronment, even at hIgher levels than m
worst-case scenanos However, not all mtrogen OXides aCId specIes have been
studIed suffiCIently
7 No aSSOCiatIOn between lung functIOn responses and respIratory symptom responses

were observed Furthermore, there IS httle eVIdence of a concentratIOn-response
relatIOnshIp for changes m lung functlon, arrway responSIveness, or symptoms at the
N02 levels that are reVIewed here
15-93
REFERENCES
Abe, M (1967) Effects of InlXed N02 -S02 gas on human pulmonary functions effects of aIr pollutiOn on the
human body Bull Tokyo Med Dent Umv 14 415-433
Adams, W C, Brookes, K A, Schelegle, E S (1987) Effects of N02 alone and m combmahon wIth 03 on
young men and women J Appl PhySIol 62 1698-1704
Ahmed, T , Dougherty, R , Sackner, M A (1983a) Effect of N02 exposure on specIfic bronchtal reactivIty m
subjects WIth allergIc bronchtal asthma [final report] Warren, MI General Motors Research
Laboratones, contract report no CR-83/07/BI
Ahtned, T, Dougherty, R , Sackner, M A (1983b) Effect of 0 1 ppm N02 on pulmonary functions and
non-specIfic bronchtal reactivIty of nonnals and asthmatics [fmal report] Warren, MI General Motors
Research Laboratones, contract report no CR-83/111BI
Ans, R , Chnstian, D , Balmes, J R (1991a) The effects of mtnc aCId vapor alone, and m combmation WIth
ozone, m exerclsmg, healthy subjects as assessed by bronchoalveolar and prOXImal aIrway lavage
Am Rev Resplr DIS 143(suppl) A97
Ans, R , Chnstian, D , Sheppard, D , Balmes, J R (1991b) The effects of sequential exposure to aCIdIC fog and
ozone on pulmonary function ill exerclsmg subjects Am Rev RespIr DIS 143 85-91
Avol, E L, Lmn, W S, Venet, T G (1983) A companson of atnblent OXIdant effects to ozone dose-response
relationshtps Downey, CA Rancho Los Amtgos HospItal, EnVIronmental Health ServIce, research and
development senes 83-RD-29
Avol, E L, Lmn, W S, Shatnoo, D A, ValenCIa, L M , Anzar, U T, Venet, T G, Hackney, J D

(198Sa) Respiratory effects of photochemtcal OXIdant aIr pollutiOn m exerclsmg adolescents Am Rev
Avol, E L, Lmn, W S, Venet, T G, Hackney, J D (1985b) Short-term health effects of ambIent aIr
pollution ill adolescents year 2 - health effects assessment ill chtldren [final report] Downey, CA
Rancho Los Amtgos MedIcal Center, EnVIronmental Health Service, research and development senes
85-RD-43
Avol, E L, Lmn, W S, Venet, T G, Hackney, J D (1986) Short-tenn health-related effects of aIr pollution
relatable to power plants a combmed laboratory and field study [final report year 1] Downey, CA
Rancho Los Amtgos MedIcal Center, EnVIronmental Health ServIce, R&D senes 86-RD-75
Avol, E L, Lmn, W S, Shatnoo, D A, SpIer, C E, ValenCIa, L M , Venet, T G, Tnm, S C, Hackney,

J D (1987) Short-tenn respIratory effects of photochenucal OXIdant exposure ill exerclsmg chtldren
JAPCA 37 158-162
Avol, E L, Lmn, W S, Peng, R C, ValenCIa, G , LIttle, D , Hackney, J D (1988) Laboratory study of

asthmatic volunteers exposed to mtrogen dIOXIde and to atnblent aIr pollution Am fud Hyg
Assoc J 49 143-149
Avol, E L, Lmn, W S, Peng, R -C , Whynot, J D, Shamoo, D A, Little, DE, Smtth, M N ,Hackney,

J D (1989) Expenmental exposures of young asthmatic volunteers to 0 3 ppm mtrogen diOXIde and to
atnblent aIr pollution TOXIcol fud Health 5 1025-1034
Bates, D V, Bell, G , Burnhatn, C , Hazucha, M , Mantha, J , Pengelly, L D , Stlvennan, F (1970)

Problems ill studIes of human exposure to aIr pollutants Can Med Assoc J 103 833-837
15-94
Bauer, M A, Utell, M J , Morrow, P E, Speers, D M, GIbb, F R (1986a) Inhalation of 0 30 ppm
mtrogen dIOXide potentiates exercIse-Induced bronchospasm m asthmatics Am Rev Respir DIS
134 1203-1208
Bauer, M A, Utell, M J , SmeglIn, AM, Speers, D M, GIbb, F R, Morrow, P E (l986b) Effects of

low-level mtrogen dIOXide on lung function m eXerCISIng subjects WIth chromc obstructive pulmonary
dIsease (COPD) Am Rev RespIr DIS 133(suppl) A215
Bauer, M A, Utell, M J , Speers, D M, GIbb, F R, Morrow, P E (1987) Effects of 030 ppm mtrogen
dIOXide on lung function and breathIng patterns In subjects WIth chromc obstructive lung dIsease (COPD)
Am Rev Respir DIS 135(suppl) A58
Beasley, R , Roche, W R, Roberts, J A, Holgate, S T (1989) Cellular events In the bronchI In llliid asthtna
and after bronchIal provocation Am Rev RespIr DIS 139 806-817
Becker, S , Roger, L J , DevlIn, R B, Koren, H S (1992) Increased phagocytosIS and antiVIral actiVIty of
alveolar macrophages from humans exposed to mtnc aCId Am Rev Respir DIS 145 A429
Beckett, W S, Marenberg, ME, Pace, P E (1992) Repeated methacholIne challenge produces tolerance m
norntal but not In asthmatic subjects Chest 102 775-779
Bell, M , Ulmer, W T (1976) Wirkung von N02 1m MAK-Bereich auf Atemmechantk und bronchIale
Acetylchoimempfindhchkeit bel Normalpersonen [Effect of N02 m workroom concentratIOns on
respIratory mechamcs and bronchial susceptIbIhty to acetylcholIne In normal persons] Int Arch Occup
Belcher, N G , Rees, P J , Clark, T J H, Lee, T H (1987) A companson of the refractory penods mduced
by hypertomc airway challenge and exerCIse m bronchial asthma Am Rev RespIr DIS 135 822-825
Ben-Dov, I , Bar-YIshay, E, Godfrey, S (1982) Refractory penod after exercise-mduced asthtna unexplatned by
respIratory heat loss Am Rev Respir DIS 125 530-534
Borland, C , Harmes, K, Cracknell, N , Mack, D , Higenbottam, T (1985) MethemoglobIn levels In smokers

and non-smokers Arch EnVIron Health 40 330-333
Bouhuys, A (1974) BreathIng phYSIology, enVIronment and lung dIsease New York, NY Grune & Stratton,
Inc
Boushey, H A, Jr , RubInsteIn, I , BIgby, B G, StItes, D P, Locksley, R M (1988) StudIes on air

pollutIOn effects of mtrogen dIOXide on airway calIber and reactiVIty In asthtnatIc subjects, effects of
mtrogen dIOXide on lung lymphocytes and macrophage prodU<,ts m healthy subjects, nasal and bronchial
effects of sulfur dIOXide m asthmatIc subjects Sacratnento, CA CalIfOrnIa Atr Resources Board, report
no ARBIR-89/384 AVailable from NTIS, Spnngfield, VA, PB89-183057
Bntton, J R, Burney, P G J , Chtnn, S , Papacosta, A 0, Tatter'Sfield, A E (1988) The relation between

change m airway reactiVIty and change In respIratory symptoms and medIcation In a commumty study
Am Rev Respir DIS 138 530-534
ByIIn, G , LIndvall, T , Rehn, T , SundIn, B (1985) Effects of short-term exposure to atnblent mtrogen dIOXide
concentratIons on human bronchIal reactiVIty and lung function Eur J RespIr DIS 66 205-217
Bylm, G , HedenstIerna, G , Lmdvall, T , SundIn, B (1988) AmbIent mtrogen dIOXide concentratIons mcrease
bronchial responsIveness m subjects WIth llliid asthma Eur Resplr J 1 606-612
15-95
ChlU, H , Farr, R S, Froehuch, LA, MathIson, D A, McLean, J A, Rosenthal, R R, Sheffer, A L, IT,
Spector, S L, Townley, R G (1975) Standardization of bronchIal mhalation challenge procedures
J Allergy Clm Immunol 56 323-327
Chaney, S , BlomqUist, W , DeWitt, P , Muller, K (1981) BlOchemiCal changes m humans upon exposure to
mtrogen diOXide wlule at rest Arch Environ Health 36 53-58
Chatham, M , Bleecker, E R, SIDlth, P L, Rosenthal, R R, Mason, P , Norman, P S (1982) A companson

of lustamme, methacholme, and exercise lUrway reactivity m nonna! and asthInatic subjects Am Rev
Respir DIs 126 235-240
ChIodl, H , Mohler, J G (1985) Effects of exposure of blood hemoglobm to mtnc OXide Environ Res
37 355-363
ChlOdl, H , Collier, C R, Mohler, J G (1983) In vitro methemoglobm formation m human blood exposed to
NOZ EnVIron Res 30 9-15
Clarke, S W , PaVia, D (1980) Lung mucus productlOn and mucoclhary clearance methods of assessment
Br J Clm Pharmacol 9 537-546
Cropp, G J A (1979) The exercise bronchoprovocation test standardization of procedures and evaluation of
response J Allergy Clm Immunol 64 627-633
Cropp, G J A, Bemstem, I L, Boushey, H A, Jr , Hyde, R W , Rosenthal, R R, Spector, S L,

Townley, R G (1980) GUldelmes for bronchIal mhalation challenges With pharmacologiC and antigemc
agents ATS News (Spnng) 11-19
Deal, E C, Jr , McFadden, E R, Jr , Ingram, R H, Jr , Jaeger, J J (1979) Hyperpnea and heat flux lIDtial
reaction sequence m exerclse-mduced asthma J Appl PhyslOl Respir EnViron ExerCise PhyslOl
46 476-483
Devlm, R , Horstman, D , Becker, S , Gemty, T, Madden, M , Koren, H (1992) InflaIDlDatory response m

humans exposed to 2 0 ppm NO z Am Rev Respir DIS 145 A456
Drechsler-Parks, D M (1987) Effect of mtrogen dlOXide, ozone, and peroxyacetyl mtrate on metabolIc and
pulmonary function Cambndge, MA Health Effects Institute, research report no 6
Drechsler-Parks, D M, Bedl, J F, Horvath, S M (1987) Pulmonary function responses of older men and
women to NO z EnVIron Res 44 206-212
Drechsler-Parks, D M, Bedl, J F, Horvath, S M (1989) Pulmonary function responses of young and older
adults to IDlxtures of 03' NOz and PAN TOXicol Ind Health 5 505-517
Edmunds, AT, Tooley, M , Godfrey, S (1978) The refractory penod after exerclse-mduced asthIna Its
duration and relation to the seventy of exercise Am Rev Resplr DIS 117 247-254
Eschenbacher, W L, Sheppard, D (1985) Respiratory heat loss IS not the sole stimulus for bronchoconstnction
mduced by Isocapmc hyperpnea With dry lUr Am Rev Resplr DIS 131 894-901
FiSh, J E, Kelly, J F (1979) Measurements of responsiveness m bronchoprovocation testmg J Allergy Clm

Immunol 64 592-596
15-96
Folmsbee, L J (1988) Human chmcal mhalabon exposures expenmental desIgn, methodology, and
phYSIOlogiCal responses In Gardner, DE, Crapo, J D, Massaro, E J ,eds TOXlcology of the lung
New York, NY Raven Press, pp 175-199 (Target organ tOXlcology senes)
Folmsbee, L J (1992) Does mtrogen dloXlde exposure mcrease allways responsIveness? TOXlcol Ind Health
8 1-11
Folmsbee, L J , Horvath, S M, Bedl, J F, Delehunt, J C (19780) Effect of 0 62 ppm N02 on

cardiopulmonary funcbon m young male nonsmokers EnVllon Res 15 199-205
Folmsbee, L J , Bedi, J F, Horvath, S M (1981) Combmed effects of ozone and mtrogen diOXlde on
respiratory funcbon m man Am Ind Hyg Assoc J 42 534-541
Frampton, M W , Smeglm, AM, Roberts, N J , Jr , Fmkelstem, J N , Morrow, P E, Utell, M J (1989a)

NItrogen diOXlde exposure m VIVO and human alveolar macrophage macbvabon of mfluenza VIruS m
Vitro Envlfon Res 48 179-192
Frampton, M W , Fmkelstem, J N , Roberts, N J , Jr , Smeglm, AM, Morrow, P E, Utell, M J (1989b)

Effects of mtrogen dloXlde exposure on bronchoalveolar lavage protems m humans Am J Resplf Cell
Mol BIOI 1 499-505
Frampton, M W , Morrow, P E, Cox, C, Glbb, F R, Speers, D M, Utell, M J (1991) Effects of

mtrogen dloXlde exposure on pulmonary funcbon and airway reacbVity m nonna! humans Am Rev
Frampton, M W , Voter, K Z, Morrow, P E, Roberts, N J , Jr , Gavras, J B, Utell, M J (1992) Effects

of N02 exposure on human host defense Am Rev Resplr DIS 145 A455
Frank, R , O'Nell, J J , Utell, M J , Hackney, J D, Van Ryzm, r , Brubaker, P E, eds (1985) Inhalabon
tOXlcology of alf pollubon chmcal research conSideratiOns Philadelpma, PA Amencan Society for
Testmg and Matenals (ASTM SpecIal techmcal pubhcatiOn no 872)
Freedman, S , Lane, R , GIllett, M K, Guz, A (1988) Abohbon of methacholme mduced bronchoconstnctlon

by the hyperventllatiOn of exerCIse or vohtiOn Thorax 43 6 ~ 1-636
GomI, K , VlgUle, C , Stanley, W C, Brooks, G A, Packer, L (1988) Blood glutatmone oXldabon dunng
human exerCIse J Appl PhysiOl 64 115-119
Gomgs, S A J , Kulle, T J , Bascom, R , Sauder, L R , Green, D J , Hebel, J R, Clements, M L (1989)

Effect of mtrogen diOXlde exposure on suscepbblhty to mfluenza A VIruS mfecbon m healthy adults
Graham, D , Henderson, F , House, D (1988) Neutropml mflux measured ill nasal lavages of humans exposed
to ozone Arch EnVlfon Health 43 228-233
Hackney, J D, Lum, W S, Buckley, R D, Pedersen, E E, Kaluza, S K, Law, DC, Fischer, D A

(1975a) Expenmental studIes on human health effects of ror !pollutants I deSIgn conSIderatiOns Arch
EnVlfon Health 30 373-378
Hackney, J D, Lum, W S , Mohler, J G, Pedersen, E E, Brelsacher, P , Russo, A (1975b) Expenmental

studIes on human health effects of ror pollutants II four-hour exposure to ozone alone and m
combmabon WIth other pollutant gases Arch EnVlfon Health 30 379-384
15-97
Hackney, J D, LInn, W S, Law, DC, Karuza, S K, Greenberg, H , Buckley, R D, Pedersen, E E
(1975c) Expenmental studIes on human health effects of aIr pollutants ill two-hour exposure to ozone
alone and m combmation WIth other pollutant gases Arch EnVIron Health 30 385-390
Hackney, J D, ThIede, F C, Lmn, W S, Pedersen, E E, SpIer, C E, Law, DC, FIscher, D A (1978)

Expenmental studIes on human health effects of aIr pollutants IV Short-tenn phySIologIcal and chmcal
effects of mtrogen dlOXIde exposure Arch EnVIron Health 33 176-181
Hamtelec, C M, Mannmg, P J , O'Byrne, P M (1988) ExercIse refractonness after htstamme Inhalation m

asthmatic subjects Am Rev RespIr DIS 138 794-798
Hazucha, M J , Gmsberg, J F, McDonnell, W F, Haak, ED, Jr , Ptmmel, R L, House, DE,

Bromberg, P A (1982) Changes m bronchtal reactivIty of asthmatics and nonnals followmg exposures to
o 1 ppm N02 In SchneIder, T, Grant, L, eds AIr pollution by mtrogen OXIdes proceedmgs of the
US-Dutch mternational sympOSIUm, May, Maastncht, The Netherlands Amsterdam, The Netherlands
ElsevIer SCIentific Pubhshmg Company, pp 387-400 (StudIes m envIronmental SCIence 21)
Hazucha, M J , Gmsberg, J F, McDonnell, W F, Haak:, ED, Jr , Plmmel, R L, Salaam, SA, House,

DE, Bromberg, P A (1983) Effects of 0 1 ppm mtrogen dIOXIde on aIrways of nonnal and asthmatic
subjects J Appl PhySIOI Resplr EnVIron ExerCIse PhySIOI 54 730-739
Hazucha, M J , Seal, E , Folmsbee, L J , Bromberg, P A (1992) Lung function response of healthy subjects
followmg sequential exposures to N0 2 and 03 Am Rev Resplr DIS 145 A456
Horvath, S M, Folmsbee, L J (1979) Effects of pollutants on cardIopulmonary function Research Tnangle

Park, NC US EnVIronmental Protection Agency, Health Effects Research Laboratory, final report on
EPA contract no 68-02-1723
Inman, M D, Watson, R M, Ktlhan, K J , O'Byrne, P M (1990) Methacholme aIrway responsiveness

decreases durmg exerCIse m asthmatic subjects Am Rev Resplr DIS 141 1414-1417
Islam, M S, Ulmer, W T (1979a) Beemflussung der Lungenfunktion durch em Schadstoffgemtsch aus Ozon
(03), SchwefeldlOxyd (S0z) und Stickstoffdloxyd (NOv 1m MAK-Berelch (Kurzzeltversuch) [The
mfluence of acute exposure agaInst a combmation of 50 ppm S02' 50 ppm N02 and 0 1 ppm 03 on the
lung functIon m the MAK (lower tOXIC hmtt) area (short-time test)] WISS Umwelt 3 131-137
Islam, M S, Ulmer, W T (1979b) DIe Wlrkung emer Langzeltexposition (8h/Tag ueber 4 Tage) gegen em
Gasgemtsch von S02 + N0 2 + 03 lID drelfachen MIK-Berelch auf dIe Lungenfunktion und
Bronchtalreaglblhtaet bel gesunden Versuchspersonen [The effects of long-time exposures (8 h per day on
4 succesSIve days) to a gas mIXture of S02 + N02 + 03 m the threefold MIC range (maXImum emtSslOn
concentration) on lung functions and reactiVIty of the bronchtal system of healthy persons] WISS Umwelt
4 186-190
Jorres, R , Magnussen, H (1990) AIrways response of asthmatics after a 30 mm exposure, at restmg ventilation,
to 0 25 ppm N02 or 0 5 ppm S02 Eur Resplr J 3 132-137
Jorres, R , Magnussen, H (1991) Effect of 0 25 ppm mtrogen dIOXIde on the aIrway response to methacholme m
asymptomattc asthmatic patients Lung 169 77-85
Jorres, R., Nowak, D , Gnmmmger, F , Seeger, W , Fasske, E , OldIgS, M , Magnussen, H (1992) The effect
of 1 ppm mtrogen dIOXIde on bronchoalveolar lavage cells and bronchIal bIOpSy specImens m normal and
asthmatic subjects Am Rev Resplr DIS 145 A456
15-98
Johnson, D A, Frampton, M W , Wmters, R S, Morrow, P E, Utell, M J (1990) Inhalation of mtrogen
dIoXIde faIls to reduce the actIvIty of human lung alpha-1-protemase mhIbitor Am Rev Respir DIS
142 758-762
KabIraJ, M U , Simonsson, B G, Groth, S , Bjorklund, A , Bulow, K , Lmdell, S -E (1982) BronchIal

reactivIty, smokIng, and alphal-antItrypsm a population-based study of mIddle-aged men Am Rev
Kagawa, J (1982) RespIratory effects of 2-hr exposure to 1 0 ppm mtnc OXIde m normal subjects EnVIron Res
27 485-490
Kagawa, J (1983a) RespIratory effects of two-hour exposure WIth mtermIttent exerCIse to ozone, sulfur dIOXIde
and mtrogen dIOXIde alone and m combmatIon m normal subjects Am Ind Hyg Assoc J 44 14-20
Kagawa, J (1983b) Effects of ozone and other pollutants on pulmonary function ill man In Lee, S D,
Mustafa, M G, Mehlman, M A, eds InternatIonal sympOSIUm on the bIOmedIcal effects of ozone and
related photochemIcal OXIdantS, March 1982, Pmehurst, NC Pnnceton, NJ Pnnceton SCIentific
PublIshers, Inc ,pp 411-422 (Advances m modem envIromnental tOXIcology v 5)
Kagawa, J (1986) Expenmental studIes on human health effects of aerosol and gaseous pollutants In Lee,
S D, SchneIder, T, Grant, L D, Verkerk, P J ,eds Aerosols research, nsk assessment and control
strategIes - proceedmgs of the second US-Dutch mternatIonal sympOSIUm, May 1985, WIllIamsburg,
VA Chelsea, MI LeWIS PublIshers, Inc ,pp 683-697
Kagawa, J (1990) Health effects of exposure to mIxtures of mtnc OXIde and mtrogen dIOXIde m healthy young
women In Indoor air '90 precedmgs of the 5th mternatIOl1ial conference on mdoor air qualIty and
clImate, volume 1, human health, comfort and perfonnance, July-August, Toronto, ON, Canada Ottawa,
ON, Canada InternatIonal Conference on Indoor Air QualIty and ClImate, Inc ,pp 307-312
Kagawa, J , Tsuru, K (1979) [RespIratory effects of 2-hour exposure to ozone and mtrogen dIOXIde alone and ill
combmatIon ill normal subjects perfOrmIng mtermIttent exerCIse] Nmon Kyobu ShIkkan GakkaI ZasshI
17 765-774
Kerr, H D, Kulle, T J , McIlliany, M L, SWIdersky, P (1979) Effects of mtrogen dIOXIde on pulmonary

functIon ill human subjects an envIronmental chamber study EnVIron Res 19 392-404
Kim, S U , Koemg, J Q, PIerson, WE, Hanley, Q S (1991) Acute pulmonary effects of mtrogen dIOXIde
exposure dunng exerCIse m competitIve athletes Chest 99 815-819
KleInman, M T, Lmn, W S, Bailey, R M, Jones, M P, Hackney, J D (1980) Effect of aInmomum mtrate

aerosol on human respIratory functIon and symptoms EnVIron Res 21 317-326
Klemman, M T, Bailey, R M, Lmn, W S, Anderson, K R, VVhynot, J D, Shamoo, D A, Hackney,

J D (1983) Effects of 0 2 ppm mtrogen dIOXIde on pulmonary function and response to
bronchoprovocatIOn ill astmnatics J TOXIcol EnVIron Health 12 815-826
KleInman, M T, Bailey, R M, Whynot, J D, Anderson, K R, Lmn, W S, Hackney, J D (1985)

Controlled exposure to a mIxture of S02' N02, and particulate air pollutants effects on human
pulmonary function and respIratory symptoms Arch EnVIron Health 40 197-201
Koemg, J Q, Covert, D S, Morgan, M S, Honke, M , Honke. N , Marshall, S G, PIerson, W E (1985)

Acute effects of 0 12 ppm ozone or 0 12 ppm mtrogen dIOXIde on pulmonary function m healthy and
astmnatIc adolescents Am Rev RespIr DIS 132 648-651
15-99
Koenig, J Q, PIerson, WE, Marshall, S G, Covert, D S, Morgan, M S, Van Belle, G (1987a) The
effects of ozone and mtrogen dIoXide on lung functIOn m healthy and asthmatic adolescents Cambndge,
MA Health Effects Institute, research report no 14
Koerng, J. Q, Covert, D S, Marshall, S G, Van Belle, G , PIerson, W E (1987b) The effects of ozone and
mtrogen dIoXide on pulmonary function m healthy and m asthmatic adolescents Am Rev Resplr DIS
136 1152-1157
Koemg, J Q, Covert, D S, PIerson, WE, McManus, M S (1988) The effects of mhaled mtnc aCId on
pulmonary functlOn m adolescent asthmatics Am Rev Resplr DIS 137(suppl) 169
Koemg, J Q, Covert, D S, PIerson, W E (1989a) Effects of mhalatIon of aCIdIC compounds on pulmonary

function m allergIC adolescent subjects In SymposIUm on the health effects of aCId aerosols, October
1987, Research Tnangle Park, NC EnVIron Health Perspect 79 173-178
Koerng, J Q, Hanley, Q S, Anderson, T L, Rebolledo, V , PIerson, W E (1989b) An assessment of

pulmonary function changes and oral ammoma levels after exposure of adolescent asthmatic subjects to
sulfunc or mtnc aCId Presented at 82nd ammal meetmg and exhIbItion of the AIr and Waste
Management ASSOCIation, June, AnaheIm, CA PIttsburgh, PA Atr and Waste Management ASSOCIation,
paper no 89-92 4
Kulle, T J (1982) Effects of mtrogen dIOXide on pulmonary functIon m nonnal healthy humans and subjects
with asthma and chromc bronchitis In SchneIder, T , Grant, L, eds Atr pollution by mtrogen OXides
proceedmgs of the US-Dutch mternatIonal sympOSIUm, May, Maastncht, The Netherlands Amsterdam,
The Netherlands ElseVIer SCIentific PublIshmg Company, pp 477-486 (StudIes m envIronmental
SCIence 21)
Kulle, T J , Clements, M L (1988) SusceptibIlIty to VIrus mfectIon WIth exposure to mtrogen dIOXide
Cambndge, MA Health Effects Institute, research report no 15 Avaxlable from NTIS, Spnngfield,
VA, PB88-234463
Laxtmen, LA, Hemo, M , Laxtmen, A , Kava, T , Haahtela, T (1985) Daxnage of the axrway epIthelIum and
bronchial reactiVIty m patients WIth asthma Am Rev Respir DIS 131 599-606
Lmn, W S, Hackney, J D (1983) Short-tenn human respIratory effects of mtrogen dIOXide detennmatIon of
quantitative dose-response profiles, phase I exposure of healthy volunteers to 4 ppm NO z Atlanta, GA
Coordmatmg Research CouncIl, Inc , report no CRC-APRAC-CAPM-48-83 AvaIlable from NTIS,
Spnngfield, VA, PB84-132299
Lmn, W S, Hackney, J D (1984) Short-tenn human respIratory effects of mtrogen dIOXide detennmatIon of
quantitative dose-response profiles, phase II exposure of asthmatic volunteers to 4 ppm NOZ Atlanta,
GA Coordmatmg Research CouncIl, Inc, report no CRC-CAPM-48-83-Q2 AvaIlable from NTIS,
Spnngfield, VA, PB85-104388/XAB
Lmn, W S, Jones, M P, Baxley, R M, Klemman, M T, SpIer, C E, FIscher, D A, Hackney, J D

(1980a) RespIratory effects of mIxed mtrogen dIOXide and sulfur dIOXide m human volunteers under
SImulated ambIent exposure condItions EnVIron Res 22 431-438
Lmn, W S, Jones, M P, Bachmayer, E A, SpIer, C E, Mazur, SF, Avol, E L, Hackney, J D

(1980b) Short-tenn respIratory effects of polluted ambIent aIr a laboratory study of volunteers m a
hIgh-OXidant commumty Am Rev RespIr DIS 121 243-252
15-100
Lmn, W S, B3.1ley, R M, Shamoo, D A, Venet, T G , WIghtman, L H, Hackney, J D (1982)
RespIratory responses of young adult asthmatics to sulfur dIOXide exposure under sImulated ambIent
condItions EnvIron Res 29 220-232
Lmn, W S, Sh3.1noo, D A, SpIer, C E, ValencIa, L M, Anzac, U T, Venet, T G, Avol, E L,

Hackney,]" D (1985a) Controlled exposure of volunteers wIth chrOnIC obstructive pulmonary dIsease to
nItrogen dIoXide Arch EnVIron Health 40 313-317
Lmn, W S, Solomon, J C, Tnm, S C, SpIer, C E, Shamoo, D A, Venet, T G, Avol, E L, Hackney,

J D (1985b) Effects of exposure to 4 ppm nItrogen dIOXide m healthy and asthmatic volunteers Arch
Lmn, W S, Shamoo, D A, Avol, E L, Whynot, J D, Anderson, K R, Venet, T G, Hackney, J D

(1986) Dose-response study of asthmatic volunteers exposed to nItrogen dIoXide dunng mtenmttent
exerCIse Arch EnVIron Health 41 292-296
McLean, A C, Parker, L, Von Rels, J , Von Rels, J (1991) Airborne pollen and fungal spore samplmg on the
central CalIfOrnIa coast the San LUIS ObISPO pollen project AIm Allergy 67 441-447
MIller, F J , Overton, J H, Myers, E T, Graham, J A (1982) Pulmonary dOSImetry of nItrogen dIOXide m

anImals and man In SchneIder, T , Grant, L, eds Air pollution by nItrogen OXides proceedmgs of the
US-Dutch mternatIonal symposIUm, May, Maastncht, The l\etherlands Atnsterdam, The Netherlands
ElseVIer SCIentific PublIshmg Company, pp 377-386 (StudIes m envIronmental SCIence 21)
Mohsenm, V (1986) Effect of N02 exposure on bronchIal reactivIty of nonna! and asthmatic subjects
In AImual meetmg of the Amencan Lung ASSOCiation and the Amencan ThoraCIC SocIety, May, Kansas
CIty, MO Am Rev Resplr DIS 133(suppl) A215
Mohsenm, V (1987a) AIrway responses to nItrogen dIOXide m asthmatic subjects J TOXIcol EnVIron Health
22 371-380
Mohsenm, V (1987b) Effect OfVltamm C on N02-mduced 3.1rway hyperresponslveness m nonnal subjects

a randOID1zed double-blmd expenment Am Rev Resplr DIS 136 1408-1411
Mohsenm, V (1988) Airway responses to 2 0 ppm nItrogen dIOXide m normal subjects Arch EnVIron Health
43 242-246
Mohsenm, V , Gee, J B L (1987) Acute effect of nItrogen diOXId~, exposure on the functional actiVIty of
alpha-I-protease mhIbitor m bronchoalveolar lavage flUid of nonna! subjects Am Rev Resplr DIS
136 646-650
Mohsenm, V , DuBOIS, A B, Douglas, J S (1983) Effect of ascOl biC aCId on response to methacholme
challenge m asthmatic subjects Am Rev RespIr DIS 127 143-147
Morrow, P E, Utell, M J (1989) Responses of susceptible subpopulatIons to nItrogen dIOXide Cambndge,

Muelenaer, P, ReId, H , Morns, R , Saltzman, L, Horstman, D , CollIer, A , Henderson, F (1987) Urmary

hydroxyprolme excretion m young males exposed expenmentally to nItrogen dIOXide In SeIfert, B ,
Esdorn, H , FIscher, M , Rueden, H , Wegner, J ,eds Indoor aIr '87 proceedmgs of the
4th mternatIonal conference on mdoor aIr qUalIty and climate, V 2, envIronmental tobacco smoke,
multIcomponent studIes, radon, SIck buddmgs, odours and UTItants, hyperreactIvitIes and allergIes,
August, Berlm, Federal Republic of Germany Berlm, Fedelal Republic of Germany Institute for Water,
Sod and Air HygIene, pp 97-103
15-101
Nakamura, K (1964) [Response of pulmonary aIrway resistance by mteractIon of aerosols and gases m different
phySical and chemical nature] Nippon Eiseigaku Zasshi 19 322-333
National Institutes of Health (1991) GUidelmes for the diagnosis and management of asthma Bethesda, MD
U S Department of Health and Human ServiCes, National Heart, Lung, and Blood Institute, National
Asthma Education Program, pubhcatlOn no 91-3042
Nolop, K B, Maxwell, D L, Flemmg, J S, Braude, S , Hughes, J M B, Royston, D (1987)

99m,.., 113m
A companson of lc-DTPA and In-DTPA aerosol clearances m humans effects of smokmg,
hypennflatIon, and m Vitro OJadatIon Am Rev RespIr Dis 136 1112-1116
O'Byrne, PM, Ryan, G , Moms, M , McConnack, D , Jones, N L, Morse, J L C, Hargreave, F E

(1982) Asthma mduced by cold aIr and itS relation to nonspecific bronchial responsiveness to
methacholme Am Rev Respir Dis 125 281-285
O'Connor, G , Sparrow, D , Taylor, D , Segal, M , WeiSS, S (1987) AnalySiS of dose-response curves to

methacholme an approach SUitable for population studies Am Rev RespIr Dis 136 1412-1417
Ogdvy, C. S, DuBOiS, A B, Douglas, J S (1981) Effects of ascorbic aCid and mdomethacm on the aIrways of
healthy male subjects With and Without mduced bronchoconstnctIon J Allergy Clm Immunol
67 363-369
Orehek, J , MassarI, J P, Gayrard, P , Gnmaud, C , Charpm, J (1976) Effect of short-tenn, low-level

mtrogen diOXide exposure on bronchial sensitivity of asthmatic patients J Clm Invest 57 301-307
Orehek, J , Gnmaldi, F , Muls, E , Durand, J P, Viala, A , Charpm, J (1981) Reponse bronchique aux
allergenes apres exposition controlee au dlOxyde d'azote [Bronchial response to allergens after controlled
N02 exposure] Bull Eur PhyslOpathol Respir 17 911-915
Pattemore, P K, Asher, M I, Hamson, A C, MItchell, E A, Rea, H H, Stewart, A W (1990) The

mterrelatIonship among bronchial hyperresponsiveness, the diagnosis of asthma, and asthma symptOlns
Am Rev Respir Dis 142 549-554
Pelzer, A -M , Thomson, M L (1966) Effect of age, sex, stature, and smokmg habits on human airway
conductance J Appl PhyslOl 21 469-476
Pmkston, P , Smeglm, A , Roberts, N J , Jr , Gibb, F R, Morrow, P E, Utell, M J (1988) Effects of m

vitro exposure to mtrogen dlOXide on human alveolar macrophage release of neutrophil chemotactic factor
and mterleukm-1 Environ Res 47 48-58
Posm, C , Clark, K , Jones, M P, Patterson, J V , Buckley, R D, Hackney, J D (1978) NItrogen dlOXide

mhalatIon and human blood biochemistry Arch Environ Health 33 318-324
PostlethwaIt, EM, Mustafa, M G (1981) Fate of mhaled mtrogen dlOXide m Isolated perfused rat lung
J TOXicol Environ Health 7 861-872
Raabe, 0 G (1982) DepOSItion and clearance of mhaled aerosols In Witschi, H ,ed Mechamsms m
reSpiratory tOXicology Boca Raton, FL CRC Press, pp 27-76
Rasmussen, T R, Kjaergaard, S K, Pedersen, 0 F (1990) Effects among asthmatic and healthy subjects of
short-tenn exposure to mtrogen dlOXide m concentrations comparable to mdoor peak concentrations
In Indoor aIr '90 precedmgs of the 5th mternatIonal conference on mdoor aIr quahty and chmate,
volume 1, human health, comfort and perfonnance, July-August, Toronto, ON, Canada Ottawa, ON,
Canada International Conference on Indoor Air QUality and Chmate, Inc ,pp 301-306
15-102
Rasmussen, T R, Kjaergaard, S K, Tarp, U , Pedersen, °F (1992) Delayed effects of N0 2 exposure on
alveolar permeabl1Ity and glutathIone peroXIdase m healthy humans Am Rev Respir DIS
146 654-659
Rehn, T , Svartengren, M , PhIhpson, K , Camner, P (1982) MukocIhaer transport Ilunga och naesa samt
luftvaegsmotstand efter exponermg foer kvaeyedioXId [MUCOCIhary transport m the lung and nose after
exposure to mtrogen dIOXIde] Vallmgby, Sweden SwedIsh State Power Board, project KHM technIcal
report no 40
Reynolds, H Y (1987) Bronchoalveolar lavage Am Rev Respir DIS 135 250-263
Roger, L J , Horstman, D H, McDonnell, W F, Kehrl, H , Seal, E , Chapman, R S, Massaro, E J

(1985) Pulmonary effects m asthmatIcs exposed to 0 3 ppm N02 dUlmg repeated exerCIse TOXIcologIst
5 70
Roger, L J , Horstman, D H, McDonnell, W , Kehrl, H , Ives, P J , Seal, E , Chapman, R , Massaro, E

(1990) Pulmonary functIon, aIrway responSIveness, and respIratory symptoms m asthmatIcs followmg
exerCIse m N0 2 TOXIcol Ind Health 6 155-171
Rubmstem, I , BIgby, B G, ReIss, T F, Boushey, H A, Jr (1990) Short-term exposure to 03 ppm mtrogen

dIOXIde does not potentIate aIrway responSIveness to sulfur dIOXIde m asthmatIc subjects Am Rev
Respir DIS 141 381-385
Sackner, M A, Dougherty, R D, Chapman, G A, ZarzeckI, S , ZarzemskI, L, Schreck, R (1979) Effects

of sodIUm mtrate aerosol on cardIopulmonary functIon of dogs, sheep, and man EnVIron Res
18 421-436
Sackner, M A, Broudy, M , Fnden, A , Cohn, M A (1980) Effe.cts of bleathmg low levels of mtrogen
dIOXIde for four hours on pulmonary functIon of nonna! adults Am Rev Respir DIS 121 254S
Sandstroem, T , Kolmodm-Hedman, B , Stjemberg, N , Andersson, M C (1989) Inflannnatory cell response m

bronchoalveolar flUId after mtrogen dIOXIde exposure of healthy subjects Am Rev RespIr DIS
139(suppl) A124
Sandstroem, T, Andersson, M C, Kolmodm-Hedman, B , Stjemberg, N , Angstrom, T (1990a)

Bronchoalveolar mastocytosIS and lymphocytosIs after mtrogen dIOXIde exposure m man a tIme-kInetIc
study Eur RespIr J 3 138-143
Sandstroem, T , Bjermer, L, Kolmodm-Hedman, B , Stjemberg, N (199Ob) NItrogen dIOXIde (N02) mduced

mflaxnmatIon m the lung, attenuated response after repeated exposures Am Rev RespIr DIS
141(suppl) A73
Schhpkoeter, H W , Brockhaus, A (1963) Versuche ueber den Emfluss gasfoermtger Luftverunrelll1gungen auf
dIe DepOSItIon und EhmmatIon Inhaherter Staeube [Expenments about the mfluence of gaseous aIr
pollutIOn on the depOSItIon and ehmmatIon of Inhaled dust] Zentralbl Baktenol Parasitenkd
Infekttonskr Hyg Abt lOng 191 339-344
Schwartz, J , Gold, D , Dockery, D W, WeISS, S T, Speizer, F E (1990) PredIctors of asthma and

perSIstent wheeze m a natIonal sample of chIldren m the Urnted States aSSOCIatIon WIth SOCIal class,
pennata! events, and race Am Rev RespIr DIS 142 555-562
Skoogh, B -E (1973) Nonnal aIrways conductance at dIfferent lung volumes Scand J Clm Lab Invest
31 429-441
15-103
Smeglm, AM, Utell, M J , Bauer, M A, Speers, D M, GIbb, F R, Morrow, P E (1985) Low-level
nitrogen dioXide exposure does not alter lung function m exerclsmg healthy subjects In Annual meetmg
abstracts of the Amencan ThoraCIC SOCIety, May, AnaheIm, CA Am Rev RespIr DIS 131(suppl)
A171
Stacy, R W , Seal, E , Jr , House, DE, Green, J , Roger, L J , RaggIO, L (1983) A survey of effects of
gaseous and aerosol pollutants on pulmonary function of normal males Arch EnVIron Health
38 104-115
Stearns, DR, McFadden, E R, Jr , Breslm, F J , Ingram, R H, Jr (1981) ReanalySIS of the refractory

period m exertlonal asthma J Appl PhyslOl RespIr EnViron ExerCise PhyslOl 50 503-508
Street, D H, Hamburger, R N (1976) Atmosphenc pollen and spore samplmg m San DIego, Callfonna
I MeteorolglCal correlations and potential clmlCal relevance Ann Allergy 37 33-40
SuzukI, T , Islnkawa, K (1965) [Research on the effects of smog on the human body report of the speclahzed
study on prevention of aIr pollutIOn, no 2] Tokyo, Japan Research Coordmatlon Bureau of the SCIence
and Technology Agency, JG, pp 199-221
Toyama, T, Tsunoda, T , Nakaza, M , HIgashi, T , Nakadate, T (1981) [Airway response to short-tenn

mhalatlon of NO z , 03 and theIr lDlxture m healthy men] Sangyo Igaku 23 285-293
U S. EnVIronmental Protection Agency (1982a) Air qualIty cntena for OXides of mtrogen Research Tnangle
Park, NC Office of Health and EnVIronmental Assessment, EnVIronmental Cntena and Assessment
Office, EPA report no EPA-600/8-82-Q26 AVailable from NTIS, Spnngfield, VA, PB83-131011
US EnVIronmental Protection Agency (1982b) ReView of the national ambIent air quahty standards for mtrogen
OXides assessment of SCientific and techmcal mformatlOn, OAQPS staff paper Research Tnangle Park,
NC Office of AIr Quallty Plannmg and Standards, EPA report no EPA-450/5-82-Q02 Aval1able from
NTIS, Spnngfield, VA, PB83-132829
U S. EnVironmental ProtectIOn Agency (1986) Second addendum to air qualIty cntena for particulate matter and
sulfur OXides (1982) assessment of newly aVailable health effects mformatlon Research Tnangle Park,
NC Office of Health and EnvIronmental Assessment, EnVIronmental Cntena and Assessment Office,
EPA report no EPA-600/8-86-Q20F AVailable from NTIS, Spnngfield, VA, PB87-176574
U S EnVIronmental ProtectIOn Agency (1989) An aCid aerosols Issue paper health effects and aerometncs
Research Tnangle Park, NC Office of Health and EnVIronmental Assessment, EnVIronmental Cntena
and Assessment Office, EPA report no EPA-600/8-88-Q05F Aval1able from NTIS, Spnngfield, VA,
PB91-125864
Utell, M J , Swmbume, A J , Hyde, R W , Speers, D M, Glbb, F R, Morrow, P E (1979) AIrway

reactivity to mtrates m normal and lDlld asthmatic subjects J Appl PhyslOl Resplr EnVIron ExerCIse
PhyslOl 46 189-196
Utell, M J , Aqudma, AT, Hall, W J , Speers, D M, Douglas, R G, Jr , Glbb, F R, Morrow, P E,

Hyde, R W (1980) Development of aIrway reactlVlty to mtrates m subjects With mfluenza Am Rev
Von Nlcdmg, G , Wagner, H M (1977) Expenmental studIes on the short-tenn effect of air pollutants on
pulmonary function m man two-hour exposure to NO z , 03 and SOz alone and m combmatlOn
In Kasuga, S , SuzukI, N , Ymnada, T, Kimura, G , Inagakl, K , Onoe, K ,cds Proceedmgs of the
fourth mtematlonal clean air congress, May, Tokyo, Japan Tokyo, Japan Japanese Umon of Air
Pollution Prevention ASSOCiations, pp 5-8
15-104
Von NIedmg, G , Wagner, H M (1979) Effects of N02 on chrom(, bronchItIcs EnvIron Health Perspect
29 137-142
Von Nledmg, G , Wagner, H M, Krekeler, H , Snndt, U , Muysers, K (1970) AbsorptIon of N02 m low
concentratIons m the respIratory tract and ItS acute effects Olll lung functIon and CIrculatIon Presented at
the second mternatIonal clean aIr congress, December, Washmgton, DC, paper no MB-15G
Von Nledmg, G , Wagner, M , Krekeler, H , Snndt, U , Muysers, K (1971) GrenzwertbestInnnung der akuten
N02-WIrkung auf den resplratonschen Gasaustausch und dll~ Atemwegswlderstaende des chromsch
lungenkranken Menschen [Mlllimum concentratlOns of N02 causmg acute effects on the respIratory gas
exchange and aIrway reSIstance m patients WIth chromc brollchltIs] Int Arch Arbeltsmed 27 338-348
Von Nledmg, G , Krekeler, H , Fuchs, R , Wagner, M , Koppenhagen, K (1973a) StudIes of the acute effects
of N02 on lung functlOn mfluence on dlffuslOn, perfuslOn and ventIlation m the lungs Int Arch
Arbeltsmed 31 61-72
Von NIedmg, G , Wagner, H M, Krekeler, H (1973b) InvestigatIon of the acute effects of mtrogen monoXIde
on lung function m man In Proceedmgs of the thlrd mtematlOnal clean mr congress, October,
Duesseldorf, Federal Repubhc of Gennany Duesseldorf, Fl',deral Repubhc of Gennany Verem
Deutscher Ingemeure, pp A14-A16
Von Nledmg, G , Wagner, M , Loellgen, H , Krekeler, H (1977) Zur akuten WIrkung von Ozon auf dIe
LungenfunktIon des Menschen [The acute effect of ozone on the pulmonary functIon of man] VDr Ber
(270) 123-129
Von NIedmg, G , Wagner, H M, Krekeler, H, Loellgen, H , Fnes, W , Beuthan, A (1979) Controlled studIes
of human exposure to smgle and combmed action of N02, 03' and S02 Int Arch Occup EnVIron
Health 43 195-210
Von NIedmg, G , Wagner, H M, Casper, H , Beuthan, A, Snndt, U (1980) Effect of expenmental and
occupatIonal exposure to N02 m senSItive and nonnal subjects In Lee, S D, ed NItrogen OXIdes and
theIr effects on health Ann Arbor, MI Ann Arbor SCience Pubhshers, Inc, pp 315-331
Wardlaw, A J , Dunnette, S , GleiCh, G J , Collms, J V , Kay, A B (1988) Eosmophlls and mast cells m
bronchoalveolar lavage m subjects WIth nnld asthma relatIonshlp to bronchlal hyperreactIvity Am Rev
15-105
16. HEALTH EFFECTS ,t\SSOCIATED
WITH EXPOSURE TO NITR~OGEN DIOXIDE
16.1 INTRODUCTION
Tms chapter concIsely summanzes and mtegrates key mformation and conclUSIOns from
precedmg chapters mto a coherent framework or perspectIve upon wmch to base
mterpretations concernmg human health nsks posed by ambIent or near-ambIent levels of
mtrogen dIoXIde (N02) m the Umted States Toward thIS end, the chapter IS orgamzed mto
several sectIOns, each of wmch dIscusses one or more major components of an overall health
nsk evaluatIOn (1) quahtative and quantItatIve charactenzation of key health effects of N02
and theIr bIOlogICal bases, (2) IdentIficatIon of populatIOn groups potentIally at enhanced nsk
for health effects associated WIth N02 exposure, (3) amlJ1ent and mdoor N02 levels and
related exposure aspects, and (4) a summary of N02 concentratIon-health effect reiationsmps
16.2 KEY HEALTH EFFECTS OF NITROGEN DIOXIDE

Tills sectIon conCIsely dIscusses two key types of health effects that are of most concern
at ambIent or near-ambIent concentratIons of N02 (1) mcreases m arrway responSIveness of
asthmatIc mdividuals after short-term exposures, and (2) mcreased occurrence of resprratory
illness among cluldren associated WIth longer term exposures to N02 A thrrd category of
N02 effects, emphysema, IS also dIscussed but appears to be only of major concern WIth
exposures to much mgher than ambIent levels of N02
16.2.1 Airway Responsiveness in Asthmatics and Short-Term

(One- to Three-Hour) Exposure to Nitrogen Dioxide
AsthmatIcs have arrway hyperresponsiveness to a vanety of chemIcal and phYSICal
stImulI and are conSIdered to be one of the most NOTresponsive groups m the populatIon
The phySIOlogICal end pomt that, to date, appears to be the most senSItIve indicator of
response to N02 m asthmatICS is a change m arrway responSIveness Arrway InhalatIOn
challenge tests are used to evaluate the "responSIveness" of a subject's airways to Inhaled
16-1
matenals To test for the degree of arrway responSIveness, a pharmacologIcally active
chenucal (such as mstamme, methacholme, or carbachol) that causes constnctIOn of the
arrways IS used Responses are usually measured by evaluatmg changes m arrway reSIstance
or spirometry after each dose of the challenge IS admllllstered AIrway hyperresponsiveness
IS an abnonual degree of arrway narrowmg, caused pnmanly by arrway smooth muscle
shortening m response to nonspecIfic stImuh An extenSIve dISCUSSIon of such responses IS
presented m Chapter 15
The Expert Panel Report from the U S NatIonal Asthma EducatIon Program
(NatIonal InstItutes of Health, 1991) has recently defmed asthma
Asthma IS a lung dIsease WIth the followmg charactenstIcs (1) arrway

obstructIon that IS reverSIble (but not completely so m some patIents) eIther
spontaneously or WIth treatment, (2) arrway mflammatIon, and (3) mcreased
arrway responSIveness to a vanety of stlffiuh
About 10 mIlhon people m the Umted States, or 4% of the populatIOn, have asthma
(National InstItutes of Health, 1991) The prevalence IS mgher among Afncan Amencans,
older (8 to 11 years) cMdren, and urban reSIdents (Schwartz et al ,1990) There IS a broad
range of seventy of asthma, rangmg from mild to severe Common symptoms mclude
cough, wheezmg, shortness of breath, chest tIghtness, and sputum productIon A pOSItIve
response (slan test) to common Inhalant allergens IS a typICal feature of asthma Asthma IS
also aSSOCIated WIth arrway mflammatIon and epIthehalIlljury (NatIonal InstItutes of Health,
1991, Beasley et al , 1989, Lattmen et al , 1985, Wardlaw et al ,1988) Asthma IS further
charactenzed by an exaggerated bronchoconstnctor response to many phYSICal changes
(e.g., cold or dry aIr, exerCIse) and to chemIcal/pharmacologIC agents (e g , mstamme or
methacholine). The dIfferences III arrway responSIveness may span several orders of
magmtude (at least lOa-fold) between normal and asthmatIc mdividuals (O'Connor et al ,
1987). Despite the absence of arrway hyperresponsiveness m some asthmatICS and the
presence of arrway hyperresponsiveness m some nonasthmatIcs (Pattemore et al , 1990),
there is a correlatIon between mcreased asthma symptoms or mcreased medIcatIOn usage and
increased arrway responSIveness (Bntton et al , 1988)
16-2
At concentratiOns below 1 0 ppm N02 , there IS h1tle (If any) convillcillg eVIdence of
lung functiOn decrements or changes ill arrway responslVeness ill healthy illdlVlduals There
IS, however, some evidence that acute exposure to N02 may cause an illcrease ill arrway
responsIveness ill asthmatIcs ThIs response has been observed only at relatively low N02
concentratiOns, mostly wIthin the range of 0 20 to 0 30 ppm N02 , wmch IS of concern Wlthm
the ambIent envrronment AnalYSIS of data on asthmatu;s expenmentally exposed to N02 ill
studIes usmg vanous challenges produced arrway responsIveness illcreases ill 96 subjects and
decreases ill 73 subjects (Fohnsbee, 1992) In the concentratiOn range between 0 20 and
o 30 ppm, the excess illcrease ill arrway responsIveness was attnbutable to subjects exposed
to N0 2 at rest Because N02 does not appear to cause arrway mflammatIon at these levels
(although modest responses occur at higher [> 1 5-ppm] concentratiOns) and the illcrease m
arrway responsIveness appears to be fully reversIble, the lmphcatiOns of the observed
mcrease ill responsIveness are unclear Although It IS conceIvable that illcreased nonspecIfic
arrway responsIveness caused by N02 could lead to mcreased responses to a specIfic antigen,
there IS presently no plausIble eVIdence to support this hypothesIs On the other hand, It IS
possIble that persIstence of arrway hyperresponsiveness may be associated wIth an accelerated
rate of dechne m pulmonary functiOn wIth age (O'Connor et al , 1987)
An unresolved Issue WIth the current data base IS the eXlstence of N02-mduced
pulmonary functiOn changes ill asthmatIcs that have been reported at low, but not at high,
N0 2 concentratiOns Although small changes ill sprrometry or arrway resIstance have been
observed ill stuwes from vanous laboratones, effects are not consIstently present and
demonstratlng reproducIbility of responses has been dtfficult, even Wlthm the same
laboratory Furthermore, most responses to N02 that have been observed ill asthmatIcs have
occurred at concentrations between 0 2 and 0 5 ppm Changes ill lung function or arrway
responSIveness have not been observed even at much mgher concentratiOns (1 e , up to
4 ppm) There IS, at present, no plausIble explanatiOn for tills apparent lack of a
concentration-response relatiOnsillp for both arrway responSIveness and pulmonary functiOn
changes
In summary, controlled human exposure studIes al e hmited to acute, fully reversIble
functional and/or symptomatIc responses Although It IS clear that some asthmatIcs are more
susceptible than nonasthmatlcs to N02 , the observed effects do not follow a
16-3
concentration-response relatIonshIp Therefore, the fmdmgs do not provIde clear quantItatIve
conclusions about the health effects of short-tenn exposure to N02
16.2.2 Respiratory Morbidity in Children Associated with Exposure to

Nitrogen Dioxide
The effects of N02 on resprratory illness and the factors detennmmg occurrence and
severity are important pubhc health concerns because of the potentIal for exposure to NOz
and because chIldhood respiratory illness IS very common (Samet et al , 1983, Samet and
Utell, 1990) ThIs takes on added Importance because recurrent chIldhood resprratory illness
may be a risk factor for later susceptIbility to lung damage (Glezen, 1989, Samet et al ,
1983, Gold et al , 1989)
The diSCUSSIon of epidemIologIcal fmdmgs m Chapter 14 mdicates that the combmed
eVIdence IS supportive of an effect of estImated exposure to NOz on respIratory symptoms
and disease in chIldren aged 5 to 12 years as mdIcated by the EPA meta-analySIS of rune
selected mdoor studies presented m Chapter 14 However, m the mdividual studies of
mfants 2 years of age and younger, no conSIstent relatIonshIp was found between estImates of
N02 exposure and the prevalence of resprratory symptoms and dIsease Based on a meta-
analyses of these mfant studies, the overall combmed estImate IS pOSItIve, however, It clearly
contains the no-effect value of 1 0, (1 e , IS not statIstIcally sIgmficant), and so we cannot
conclude that the eVIdence suggests an effect m mfants
Several uncertamtIes need to be conSIdered m mterpretmg the subject mdoor arr studIes
and results of the U S EnVIronmental ProtectIOn Agency (EPA) meta-analySIS
Measurement error m exposure IS potentIally one of the most Important methodologIcal
problems in epIdemIOlogIcal studies of N02 (as dISCUSSed m more detaIl m Chapter 14)
Thus measured N02 concentratIOns are not exposure values per se, rather, estImatmg actual
exposure requIres knowledge of both pollutant levels and related human actIVIty patterns
The effects StudIed may be related to peak exposures, average exposures, or a combmatIOn of
the two To the extent that health effects depend on peak exposures rather than average
exposures, the exposure estlmates used m the above studIes and meta-analyses mtroduce
exposure measurement error These studIes cannot dIstmgUlsh between the relatIve
contributIons of peak and average exposures and theIr relatIOnshIp WIth the observed health
16-4
effects Addltl0nally, a by-product of N02, mtrous aCId (HONG), may be a factor m
observed effects, however, only very lmuted health and aerometnc data are avaliable that
examme such pOSSIbilitIes Also, although the level of sumlanty and common elements
between the outcome measures m the N02 studIes provIde some confidence m theIr use m
the quantItatIve analySIS, the symptoms and illnesses combmed are to some extent dIfferent
and could mdeed reflect dIfferent underlymg processes Thus, cautIOn IS necessary m
mterpretmg the meta-analysIs results
Although there IS eVIdence that suggests that mcreased estimated N02 exposure IS
associated WIth mcreased resprratory symptoms m chIldren aged 5 to 12 years, the exposure
estImates may be madequate to determme a quantItatIve :relatIOnship between estImated
exposure and symptoms The studies that measured NO l exposure dId so only for penods of
1 to 2 weeks and reported the values as averages None of the studIes attempted to relate the
effects seen to the pattern of exposure, such as short-tenn peaks Furthermore, the
extrapolatIon to pOSSIble patterns of ambIent exposure IS dIfficult
As for pOSSIble mechamsms underlymg N0 2-mductIOn of resprratory morbIdIty effects
of the types observed to be mcreased m the above epIdemIOlogIcal studIes, anImal studies
dISCUSSed m Chapter 13 show that N02 exposure can (1) Impau components of the
resprratory host defense system and (2) mcrease susceptI1bility to resprratory mfectIon
Increases m resprratory symptoms and disease among children observed m epIdemIologIc
studIes of N0 2 exposure may, therefore, reflect mcreased susceptIbility to respIratory
mfectIOn due to N02 Impacts on resprratory defenses The anImal tOXicology data, as
dISCUSSed below, proVIde a bIOlogICally plaUSIble baSIS for hypotheslZmg such a relatIOnship,
but the hypothesIs requires further testmg (see Section 162 3)
16.2.3 Biological Bases Relating Nitrogen Dioxide Exposure to Respiratory

Morbidity: Effects of Nitrogen Dioxide on the Respiratory Host
Defense System
The lung IS one of the common SItes of attack of llllcroorgamsms Although many
types of mlcroorgamsms are Imphcated m resprratory mfectIon, VIruses represent a major
cause, partIcularly for mfants and chIldren In a vIral resprratory mfectIon, vIral rephcatIOll
and altered Immune responses to vIral mfectlons produce SIgns and symptoms of respIratory
illness (Douglas, 1986) The resprratory system has several defense mechamsms agamst
16-5
inhaled InfectIous and chemIcal agents Host defense mechamsms compnse a complex,
cooperatIve response system of several cell types, cell products, tissues, and organs Two
major approaches (dISCUSSed below) have been used to demonstrate the effects of N02 on
host defenses' (1) evaluation of effects on selected mechamsms of host defenses, and (2) use
of infectIVIty models, whIch reflect the overall functlOmng of all host defense mechamsms
against the Infectious agent used
Ammal studIes proVIde Important eVIdence IndIcatIng that several defense system
components are targets for tnhaled N02, Includtng key elements of host defenses such as
alveolar macrophages (AMs) and the humoral and cell-medIated Immune system Ammal
tOXIcological studIes (Chapter 13) further show that N02 exposure can Imparr the respIratory
host defense system suffiCIently so as to result m the host beIng more susceptible to
respIratory Infection Human chmcal studIes (Chapter 15) of host defenses are rare and therr
results are equivocal, but suggestive of the potential for N02 effects
Although the ciliated eplthehal cells Involved m mucociliary transport In the conductmg
arrways exhIbit morphologIcal changes at N02 concentrations as low as 0 5 ppm for 7 mo of
exposure (Yamamoto and TakahashI, 1984), mucociliary clearance IS not affected by N02
exposures at <5.0 ppm (9,400 p,g/m3) (Schlesmger et al ,1987) As a foreIgn agent
depOSItS below the mucociliary regIOn m the gaseous exchange regIOn of the lung, host
defenses are provided pflffiarily by the AM, whIch acts to remove or kill viable partIcles, to
remove nonVIable partIcles, and to process and present antigens to lymphocytes for antibody
production Exposure to N02 has produced a vanety of effects on AMs m several anImal
SpecIes. For example, Schlesmger et al (1987) and Schlesmger (1987a,b) observed a
decrease m the phagocytIC ability of rabbIt AMs after a 13-day (2 h/day) exposure to
3
0.3 ppm (560 p,g/m ) and an mcrease m phagocytOSIS after 2 days of exposure to 1 0 ppm
3
(1,880 p,g/m ) AddItIOnal effects observed at hIgher concentrations (e g , between 0 5 and
5 ppm) include decreased pulmonary bactencldal actiVIty, altered metabohsm, mcreases m
numbers of macrophages, and morphologIcal changes (Rombout et al , 1986, Aranyl et al ,
1976; Goldstein et al , 1974, SuzukI et al , 1986, Chang et al , 1986, MochItate et al , 1986,
Robison et al , 1990) Decreases m the ability of AMs to engulf foreIgn particles
(phagocytOSIS) and bactencldal actiVIty are hkely hIghly related to mcreased susceptibility to
pulmonary infections Controlled human exposure studIes (0 6 ppm for 3 h) have also
16-6
exammed AM functIOn and show that these cells, when exposed to N02 , tended (p = 0 07)
to mactIvate mfluenza VtnlS m VItro less effectIvely than cells collected after aIr exposure
(Frampton et al ,1989a) Also Devlm et al (1992) reported that macrophages recovered
from the predommantly alveolar fractIOn of bronchoalveolar lavage flUId showed a 42 %
decrease m ability to phagocytose Candlda alblcans
Together, the humoral and cell-mediated Immune systems are essentIal for antIbody
productIOn and the secretIOn of cellular products that (l) regulate normal defense responses
and/or (2) are lethal to certam illvadmg orgamsms Although the pulmonary Immune system
would better reflect defenses agamst respIratory InfectIon, It has not been adequately StudIed
after N02 exposure However, there IS some mdIcatIOn that exposure to N02 suppresses
some of the systemIC Immune responses and that the effe:cts are both concentratIOn- and tIme-
dependent For example, a slgmficant suppressIOn of antIbody productIOn by spleen cells has
been reported m experImental anImals exposed for 1 mo to N02 concentratIons as low as
04 ppm (FU]ImakI et al ,1982) Subchromc exposure (7 weeks) to N02 also resulted m
decreased numbers of cIrculatmg T lymphocytes, T-helper/mducer lymphocytes, and
T-cytotoxic/suppressor lymphocytes ill mIce at N02 levels as low as 025 ppm (470 p,g/m3 )
(RIchters and Dam]I, 1988) The cause of thIs suppreSSIOn IS not clear
Ammal InfectIVIty studIes present key data relatmg N02 exposure to effects on the
overall functIOnmg of host defense mechamsms In thesi~ studIes, anImals were exposed to
varymg concentratIons and duratIons of N02 , followed by exposure to an aerosol contammg
an InfectIOUS agent MICrobIally mduced mortalIty was used as the health end pomt
Exposure to N02 mcreased both bactena- and mfluenza-mduced mortalIty after subchromc
exposures to levels as low as 0 5 to 1 0 ppm N02 (Ehrhch and Henry, 1968, Ito, 1971,
Ehrhch et al ,1977) After acute (2-h) exposure, 2 0 ppm N02 has been the lowest effectIve
concentratIOn measured usmg the bactenal InfectIVIty model (Ehrhch et al ,1977) NItrogen
dIOXide mcreases mIcrobIally mduced mortalIty by Impamng the host's ability to defend the
respIratory tract from InfectIOUS agents, thereby mcreasmg susceptIbility to vIral,
mycoplasma, and bactenal InfectIOns (Ehrhch and Henry, 1968, Ito, 1971, Ehrhch et a1 ,
1977, Parker et al , 1989, Gardner et al , 1977a,b, 1979, 1980, 1982, Graham et al , 1987,
Jakab, 1987a,b, Motomiya et al , 1973, Miller et al ,1987) Usmg an anImal model
deSigned to evaluate the effects of N02 on nonfatal respiratory InfectIOn, N02 decreased the
16-7
intrapulmonary bactencidal actIvIty m mIce m a concentratIon-related manner, wIthout a
change in mucociliary clearance (Goldstem et al ,1973) Exposure to N0 2 was found to
mcrease the seventy of mycoplasma-mduced lesIons Withm the lung, but dId not mcrease the
susceptIbility of the mIce to the mfectIon (Parker et al ,1989) Annnal studIes have also
shown that mfluenza mfectIon IS exacerbated WIth N02 exposure (Ito, 1971) In studIes WIth
cytomegalovirus and paramyxovrrus (Jakab, 1987a,b, Rose et al , 1988), the pathogenesIs of
these mfectIons was enhanced
The animal toxicology hterature also proVIdes eVIdence that the host's response to
mhaled N02 can be SIgmficantly mfluenced by the exposure duratIOn, concentratIon, and
temporal pattern of exposure The relatIonslup of concentratIOn (C) tImes duratIon (T, tIme)
to susceptIbility to respIratory mfectIons mdicates that, when the product of C x T IS held
constant and the mdIvidual C's and T's are vaned, a dIfference m response occurs The
mcidence of mortalIty was sIgmficantly more mfluenced by the concentratIon of N02 than by
the duration of the exposure (Gardner et al ,1977a,b) The exposure pattern of N02 IS also
important when comparmg and determmmg the effects of contmuous versus mtermittent
exposure. When such data were adjusted for dIfferences m C x T, the mCIdence of
respiratory mfectIon was essentIally the same for both groups (Gardner et al ,1979) When
animal studIes were deSIgned to mImIC a typICal urban outdoor exposure enVIronment havmg
penodIc spIkes of N02 supenmposed on a lower contInuous background level of N02 , the
evidence mdIcates that the anImals exposed to the basehne plus short-term spIkes were
sIgmficantly more susceptIble to a laboratory-mduced mfectIOn than eIther the control or the
background-N02-exposed mIce (Miller et al , 1987, Gardner et al , 1982, Graham et al ,
1987). It should be noted that the exposure patterns tested m anImals are hkely to be
dIfferent from mdoor N02 exposure patterns ThIs body of work for host defenses m mICe
shows that an average exposure value (C x T) IS not an exact mdex or predIctor of effects,
rather, actual patterns of exposure more accurately represent the causatIve exposure
It IS also of interest that morphologIcal studIes, too, mdicate that N02 concentratIOns
playa more Important role m mducmg lung leSIons than do exposure duratIOns when the
product of C X T IS constant (Rombout et al ,1986) The mfluence of concentratIOn was
greater WIth intermIttent N02 exposure than WIth contmuous exposure
16-8
Recent controlled human exposure studIes examInmg the effects of N02 on pulmonary
host defense systems have reported a trend (not statistically sIgmficant) toward an elevated
rate of mfectIon by a laboratory-mduced, hve attenuated mfluenza (A/Korea/reassortment)
VIrUS (Gomgs et al ,1989) Frampton et al (1989a) also reported a trend (p < 0 07) for
less effective mactIvatIon of VIrUS by AMs obtamed from human subjects exposed
contInuously to 0 60 ppm N02 , but no effects of VIrUS 1l'lactIva1.l0n were seen m subjects
exposed contmuously to 0 05 ppm wIth 2 O-ppm spIkes Exposure to N02 may transIently
Increase levels of antIprotease alpha-2-macroglobuhn (a2M) mlung lavage flUId Although
servIng as an IndIcator of changes In the protease-antIprotease balance, alteratIOns In a2M In
alveoh may have sIgmficance for local Immunoregulation and may alter AM defenses agamst
mfectIon (Frampton et al ,1989b) These rIndIngs suggest, but do not prove, that N02 may
play a role In IncreasIng the susceptIbility of adults to respIratory VIrUS mfectIOns
There IS a hypotheSIS that the epIdemIOlogIcal associations between N02 exposure and
respIratory symptoms/dIsease represent Increased risk for resprratory mfectIOn The weIght
of the eVIdence from several anImal tOXicologICal and human chmcal studIes, as summarIZed
above, shows that N02 decreases host defense mechamsms agaInst bacterial and vIral
mfections Some of these host defense studies are on mechamsms active In humans (e g ,
AM functions) Other studies are on net defense functlOnmg USIng outcome measures not
valId for 'humans (1 e , mortalIty In the mfectIvity model), but nonetheless InvolvIng
mechamsms shared wIth humans Thus, these anImal and human chmcal studIes proVIde a
bIOlogICally plaUSIble basIs for the hypothesIs However, to test the hypothesIs, It would be
necessary to perform addItIOnal anImal tOXicologICal studIes, to conduct more dIagnostic tests
for mfectIOn In future epIdemIolOgical studies, and to apply addItional approaches In
controlled human exposure studIes
16.2.4 Emphysema and Exposure to Nitrogen Dioxide

StudIes on several ammal specIes have shown that chromc exposure to hIgh N02 levels
(relatIve to ambIent) can cause emphysema Because emphysema IS an IrreverSIble dIsease,
representIng an Important pubhc health concern, whether N02 creates a nsk for thIs dIsease
In humans IS a major question Although thIs question cannot be deflmtely answered yet, the
potential for nsk warrants dISCUSSIOn here The deflmtIOn of emphysema as used In the
16-9
Umted States IS an anatomIC one best charactenzed by NatIOnal InstItutes of Health (NllI)
(1985) critena "An anImal model of emphysema IS defmed as an abnonnal state of the
lungs in which there IS enlargement of the arrspace dIStal to the tennmal bronchIole
Airspace enlargement should be detennmed qualItatIvely m appropnate specImens and
quantItatIvely by stereoiogic methods" An addItIonal essentIal cntenon for human
emphysema IS the destructIOn of alveolar walls
Several studIes (Haydon et al , 1967, Freeman et al , 1972, Port et al , 1977) relate
long-tenn (1- to more than 30-mo) exposure of rats and rabbIts to hIgh concentratIons of
N02 (> 8 ppm, much greater than ambIent levels) WIth morphologIC lung leSIons that meet
the 1985 NllI workshop cntena for a human model of emphysema (1 e , alveolar wall
destruction occurred m addItIon to other charactenstic changes) One study (Hyde et al ,
1978) reported on dogs exposed to a mIXture of 0 64 ppm N02 and 0 25 ppm mtnc OXIde
(NO) for 68 mo Upon exammatIOn 32 to 36 mo after exposure ceased, the dogs had
morphologIC lesions that meet the 1985 NllI workshop cntena for human emphysema
In the same dogs, pulmonary functIon was also measured Pulmonary functIOn decrements
observed at the end of exposure progressed postexposure ThIs suggests that the
morphological effects may also have been progreSSIve Another group of dogs m the same
study was exposed to a mixture of "low" N02 (0 14 ppm) and "hIgh" NO (l 1 ppm), but
emphysema was not observed Because the study dId not mclude an NOTonly group, It IS
not pOSSIble to dIscern the effects of N02 m the mIXture However, the presence of
emphysema in the "hIgh" NOT"low" NO group and ItS absence m the "low" N02-"hIgh"
NO group Imphes that N02 was a sIgmficant etIologIC factor
Emphysema was reportedly observed m numerous other N02 studIes WIth several
specIes of anImals, but eIther the reports lacked suffiCIent detaIl for mdependent conclUSIOns
to be drawn or only the cntena for anImal (not human) emphysema were met Several other
studies dISCUSSed m Chapter 13 were negative for emphysema V mous factors such as the
exposure protocol and morpholOgiC methods may also playa role m the outcome of studIes
Potential differences may relate to the anImal specIes used, age of the anImals dunng
exposure, concentratIon and duratIon of exposure, and the duratIOn after exposure ceases
before the animals are evaluated for emphysematous pathology
16-10
In spIte of the fact that there IS a farrly extensive tOXicologIC data base concernmg
morphologIc effects of N02 , It IS still not possible to est.abhsh a reasonably accurate
"no-observed-effect" level for emphysema ThIs IS lIkely due to a combmatIOn of factors.
the compleXity of changes occurrmg with N02 exposure, the lack of pubhshed papers
utIhzmg highly sensitive morphometnc technIques, mterspecies differences m response, and
inadequate descnptIOn of methods and findmgs m some pubhshed reports Quahtatively,
then, It IS clear that N02 can cause emphysema m antm.l1s. However, although the lowest
effective N02 concentrations/exposure durations that mdluce emphysematous lung leSions can
not yet be determmed from available studies, the N02 exposures that have been found to
cause emphysema (accordmg to the NIH cntena) are faJ higher than those currently reported
m ambIent arr
16.3 CONCENTRATION-RESPONSE RELATIONSmpS: HEALTH

EFFECTS OF EXPOSURE TO NITROGEN DIOXIDE
16.3.1 Clinical Studies
Table 16-1 summanzes key health effects observedl m controlled human exposure
(chmcal) studies WIth N02 exposure durations of 0 5 to 3 h The phYSIOlogICal end point
that, to date, appears to be the most senSitive mdicator of response IS a change m arrway
responSIveness to bronchoconstnctors m asthmatics ThIS mcrease m airway responsIveness
has been observed m some, but not all studIes, and only at relatIvely low N02 concentratIOns
withm the range 0 2 to 0 3 ppm Additionally, small dt::creases m functIOnal exprratory
volume m 1 s (FEV1) or forced VItal capaCIty (FVC) m adult or adolescent asthmatics have
been observed m response to the same levels of N02 However, N02 concentratIOn-response
relatIOnships are not eVIdent for eIther arrway responsIveness or pulmonary function changes
A second category of senSItive subjects are patients WIth chromc obstructive pulmonary
disease (COPD) Although small decreases have been observed m FVC and FEV1 m COPD
patients exposed to 0 3 ppm m one study, no effects were seen m other studIes at higher
exposure levels At higher exposure levels (more than 1 5 ppm), N02 exposure results m
mcreased arrway responSIveness and mcreased arrway rt::Sistance m healthy adults However,
16-11
TABLE 16-1. KEY HUMAN HEALTH EFFECTS OF EXPOSURE TO
NITROGEN DIOXIDE-CLINICAL STUDIES3
NO Z (ppm)
(Exposure Duration) Observed Effects References
o 2-0 3 (0 5-2 0 h) Trend toward mcreased aIrway Klemman et al (1983)

responsIveness to challenges m asthmatIcs Bauer et al (1986a,b)
(Folmsbee, 1992) However, no Koemg et al (1988)
Significant effects observed by SaIne or Bylm et al (1985, 1988)
other mvestigators at NO z levels up to Mohsemn (1987a)
4 ppm Small (4-6 %) decreases m FEV 1 Jorres and Magnussen (1990)
or FVC m adult or adolescent asthmatics,
m response to NO z alone
03 (3 75 h) Small decreases (5-9%) m FVC and Morrow and Utell (1989)

FEV 1 m COPD patients WIth mlld
exerCIse No effects seen by other
mvestigators for COPD patients at
o 5-2 0 ppm NO z
1 5-2 0 (2-3 h) Increased aIrway responSIVene&S to Mohsemn (1987b)

bronchoconstnctors m healthy adults Frampton et al (1991)
However, effects not detected by other
mvestigators at 2-4 ppm
2200 (1-3 h) Lung function changes (e g , mcreased Bell and Ulmer (1976)
aIrway reSistance) m healthy subjects Von NIedmg et al (1979)
Effects not found by others at 2-4 ppm Von Niedmg and Wagner (1977)
Von NIedmg et al (1980)
RNOZ = NItrogen diOXide

FEV1 = Functional expIratory volume ill 1 s
FVC = Forced VItal capaCIty
COPD = Chrome obstructive pulmonary disease
some researchers have not observed any NOz-mduced changes m aIrway reSIstance at NO z
levels between 2 and 4 ppm
16.3.2 Epidemiological Studies

The collective, combmed eVIdence from epIdemIOlogy studIes exammmg relatIOnshIps
between estimates of exposure to NOz and lower respIratory symptoms and dIsease m
children aged 5 to 12 years (as evaluated by an EPA meta-analysIs yIeldmg quantitatIve
16-12
estnnates of effects) tends to demonstrate that illcreased nsk for resplIatory illness among
clnldren IS assocIated WIth exposure to N02 , as summarIZed ill Table 16-2 In illdIVIdual
illdoor studIes of Infants 2 years of age and younger, no conSIstent relatIOnshIp was found
between estImates of N02 exposure and the prevalence of respIratory symptoms and dIsease
Based on a meta-analyses of these Infant studIes, the combilled odds ratIO for the illcrease ill
respIratory dIsease per illcrease of 0015 ppm N02 was 1 09 WIth a 95% confidence illterval
of 095 to 1 26 Thus, although the overall combilled estImate IS pOSItIve, It clearly contaIns
the no-effect value of 1 0, (1 e , IS not statIstIcally SIgnIficant), and so we cannot conclude
that the eVIdence suggests an effect ill Infants comparable to that seen ill older clnldren (see
Table 16-2) HIgher levels (>03 ppm dunng a shIft at work) ill an occupatIonal settmg
were related to an elevated prevalence of acute resplIatory symptoms ill adults Also,
epIsodIC exposures occurnng over a penod of I-h or longer at levels pOSSIbly as hIgh as
1 5 ppm or hIgher have resulted ill the occurrence of acute resplIatory symptoms Lastly,
exceptIonally hIgh acute occupatIOnal exposures of 25 to 100 ppm N02 result ill bronchIal
pneumoma, bronchItIs, or bronchIohtIs, and very extreme occupatIonal N02 exposures
(> 200 ppm) have been assocIated WIth effects that range from hypoxemIa and tranSIent
obstructIon of the arrways to death
16.3.3 Animal Toxicological Studies

Numerous concentratIOn-response studIes have been conducted WIth anImals usmg a
WIde range of exposure duratIons and end pomts, all of whIch mfluence the outcome The
major classes of effects observed at concentratIOns less than 1 a ppm illclude decrements ill
host defenses, alteratIOns ill lung metabohsm (e g , illcn,ased hpId peroXldatIOn and
antIOXIdant metabohsm), epIthehal remodehng of the lower respIratory tract, thIckenmg of
the centnacmar illterstItmm, and a vanety of extrapulmonary changes Such findillgs can be
qualItatIvely extrapolated to humans, but major uncertamtIes ill respIratory tract dOSImetry
and speCIes senSItIVIty currently preclude a quantItatIve extrapolatIOn SubstantIally hIgher
N02 concentratIOns (> 12 ppm) have caused emphysema. as defmed by NIH cntena
In InfectIVIty studIes exammmg exT and pattern of exposure, concentratIon had more
mfluence than tIme of exposure ill illcreasmg susceptIbIhty to respIratory bactenal InfectIon
ill mIce Furthermore, the exact pattern of exposure played a major role ill expenmental
16-13
TABLE 16-2. KEY HUMAN HEALTH EFFECTS OF EXPOSURE TO
NITROGEN DIOXIDE-EPIDEMIOLOGICAL STUDIES
NO Z (ppm)
(Exposure Durahon) Observed Effects References
o 0lS-ppm Increase, where mean A meta-analYSIS shows mcreased nsk of lower Meha et al (1977,
weekly concentratIons m respIratory symptoms/disease m cwldren 5 to 1979, 1980, 1982)
bedrooms In studies reportIng 12 years old asSOCIated WIth exposure estImates Ware et al (1984)
levels were predommately of NO z levels The 95 % confidence mterval of Neas et al (1991)
between 0 008 and 0 065 ppm the odds ratIo estInIated by Hasselblad et al Ekwo et al (1983)
N02 (in 1- and 2-week mtegrated (1992) was lito 1 3 Predommant source of DIJkstra et al (1990)
average NOz concentratiOn exposure contrast IS homes WIth gas stoves vs Keller et al (1979)
estimatmg an unspecified long- homes WIth electnc stoves
term average)
o 0lS-ppm mcrease m annual In mdividual mdoor studIes of mfants 2 years of SalUet et al (1993)
average of 2-week NO z levels, age and younger, no conSIstent relahonswp was Margohs et al (1992)
where mean weekly found between estImates of NO Z exposure and Dockery et al (1989)
concentrahons m bedrooms were the prevalence of respIratory symptoms and Ogston et al (1985)
predommately between 0 005 and disease Based on a meta-analyses of these Ware et al (1984)
o OSO ppm NOz mfant studies, the combmed odds raho for the Ekwo et al (1983)
mcrease m respIratory disease per mcrease of Mella et al (1983)
0015 ppm NO z was 1 09 WIth a 95% confidence
mterval of 0 9S to 1 26 Thus, although the
overall combmed estImate IS pOSItIve, It clearly
contaIns the no-effect value of 1 0, (1 e , IS not
statIshcally SIgnIficant), and so we cannot
conclude that the eVIdence suggests an effect m
mfants comparable to that seen molder cwldren
(see Chapter 14)
>0.3 ppm (average exposure Elevated prevalence of acute respIratory Gamble et al (1987)
durmg work swft) symptoms
EpisodiC exposure durmg hockey Occurrence of acute respIratory symptoms Smith et al (1992)
game to N02 levels of 1 5 ppm (cough, chest pam, dyspnea) Hedberg et al (1989)
or wgher
2S to 100 ppm (episodiC Broncwal pneumoma, broncwtIs, and Grayson (1956)

occupatIonal exposure) broncwohtIs mduced by exceptionally wgh NO z
exposure
> 200 ppm (extreme epIsodiC Extreme exposure health outcomes range from Douglas et al (1989)
exposures) hypoxemia/transIent airway obstructiOn to death
16-14
outcomes Even so, duratIOn IS still Important For example, as exposure proceeds from
weeks to months at a gIven concentratIOn, structural changes m the lung become more
severe Also, at longer exposure duratIOns, lower N02 concentratIOns cause effects Due to
the large number of anImal tOXIcolOgical studIes and the vanety of exposure regImes, It IS not
pOSSIble to succmctly dIsplay the full range of concentratIOn-responses Therefore
Table 16-3 hsts a few key studIes showmg the lowest concentratIOns that caused several types
of effects.
16.4 SUBPOPULATIONS POTENTIALLY AT RISK FOR NITROGEN

DIOXl[DE HEALTH EFFECTS
Certam groups Withm the populatIOn may be more suscepllble to the effects of N02
exposure, mc1udmg persons wIth preeXIstmg respIratory dIsease, chIldren, and the elderly
The reasons for paymg SpecIal attentIon to these groups IS that (1) they may be affected by
lower levels of N02 than other subpopulatIOns and (2) the Impact of an effect of gIven
magmtude may be greater Some causes of heIghtened susceptIbility are better understood
than others Subpopulations that already have reduced ventilatory reserves (e g , the elderly
and persons wIth asthma, emphysema, and chrome bronchItIs) will be more Impacted than
other groups by decrements m pulmonary functIOn For example, a healthy young person
may not even notice a small percentage change m pulmonary functIOn, but a person whose
actiVIties are already hmited by reduced lung function may not have the reserve to
compensate for the same percentage change
The National Institutes of Health (1991) estImates that approXImately 10 millIon persons
m the Umted States have asthma In the general populatIOn, asthma prevalence rates
mcreased by 29 % from 1980 to 1987 For those under W years old, asthma rates mcreased
from approXImately 35 to 50 per 1,000 persons, a 45% lllcrease The arrways of asthmatICS
may be hyperresponsive to a vanety of mhaled matenals, mc1udmg pollens, cold-dry alI,
allergens, and alI pollutants Asthmatics have the potent Ial to be among the most susceptible
members of the population WIth regard to respIratory responses to N02 (SectIOn 15 3 1)
On the average, asthmatics are much more senSItive to mhaled bronchoconstnctors such as
hIstamme, methachohne, or carbachol The potential addItIOn of an NOTmduced mcrease in
16-15
TABLE 16-3. KEY ANIMAL TOXICOLOGICAL EFFECTS OF EXPOSURE TO
NITROGEN DIOXIDE3
N02 (ppm)
(Exposure Duration) SpecIes Observed Effects References
0.04 ppm Rat Increased lIpId peroXIdatIon (ethane Sagal et al (1984)
(contmuous, 9 mo) m exhaled breath)
02 ppm (contmuous Mouse Increased susceptibility to respIratory MIller et al (1987)
base for 1 year) plus mfectIOn and decreased VItal capacIty
o 8 ppm (l-h peak, and respIratory system complIance,
2 X/day, compared to control or baselme only
5 days/week)
o 25 ppm Mouse SystemIc effect on cell-medIated Rtchters and Damj1 (1988, 1990)
(7 h/day, ImmunIty
5 days/week,
7 weeks)
0.3 ppm RabbIt Decreased phagocytosIS of alveolar Schlesmger (1987a,b)
(2 h/day, 2 days) macrophages
o 4 ppm (contmuous, Mouse Decreased systemIc humoral Immumty FU]ImakI et al , (1982)
4 weeks)
0.4 ppm (contmuous, Rat Increased antIOXIdants and antIoXIdant Saga! et al (1984)
9mo) metabollsm
04 ppm (contmuous, Rat SlIght mcrease m thIckness of aIr-blood Kubota et al (1987)
up to 27 mo) bamer at 18 mo, becommg sIgmficant
by 27 mo, also alterations m bronchIolar
and alveolar epIthelIum by 27 mo
0.5 ppm (contmuous, Mouse Increased susceptibIlIty to respIratory EhrlIch and Henry (1968)
3 mo) mfectIon
o 5-28 ppm (6 rom Mouse LInear mcrease m susceptibIlIty to Gardner et al (1977a,b)
to 1 year) respIratory mfectIOn WIth time, Coffm et al (1977)
mcreased slope of curve WIth mcreased
concentration, C more Important than T
05 ppm (contmuous Rat Alterations m Type 2 cells and mcreased Crapo et al (1984)
base, 6 weeks) plus mterstltIal matnx of prOXImal alveolar Chang et al (1986, 1988)
15 ppm (l-h peak, regIon, no changes m tennmal
2 X/day, bronchIolar regIon of adults
5 days/week)
a
N02 = NItrogen dIOXIde
C = Concentration of exposure
T = Duration (hme) of exposure
arrway response to the already heIghtened responSIveness to other substances raises the
possibility of exacerbatIOn of tills pulmonary dIsease by N02 , as discussed In Section 15 4
Other potentially susceptible groups mclude patIents WIth COPD, such as emphysema
and chronic broncilltIs Some of these patients have arrway hyperresponslVeness to phySIcal
and cheffilcal stlmuh A major concern With COPD patIents IS the absence of an adequate
16-16
ventilatory reserve, a susceptIbility factor descnbed abo\'e In addItIon, the poor dIstnbutIon
of resprratory tract venttlatIOn ill COPD may lead to a greater dehvery of N02 to the
segment of the lung that IS well ventilated, thus resultmg m a greater regIOnal tIssue dose
Also, N02 exposure may alter already Imparred defense mechamsms, makIng thIs population
potentIally susceptIble to respIratory mfectIon It IS estImated (U S Department of Health
and Human ServIces, 1990, Collms, 1988) that 14 mtlhon persons (:::=6%) suffer from
COPD ill the Umted States
Because more than 2 millIon Amencans have emphysema, It would be Important to
know whether N02 has the potentIal to exacerbate the dIsease Lafuma et al (1987) exposed
both normal hamsters and hamsters WIth laboratory-mduced (WIth elastase) emphysema to
2 °
ppm N02 for 8 h/day, 5 days/week for 8 weeks NJltrogen dIOXide exposure appeared to
aggravate the elastase-mduced emphysematous leSIOn The illvestIgators suggested that the
results may Imply a role for N02 ill enhancmg preeXIstmg emphysema In contrast,
Mauderly et al (1989, 1990) found that when elastase-mduced emphysematous rats were
chromcally (7 h/day, 5 days/week, 2 years) exposed to 9 5 ppm N02 , they were not more
susceptIble to N02 m terms of exacerbatIon of the elastase-mduced leSIOns Therefore, It IS
not clear what the potentIal would be for exacerbation of emphysema ill humans at ambIent
concentratIOns
Based upon epIdemIOlogy studIes, cluldren aged 5 to 12 years constItute a subpopulation
potentIally susceptIble to an illcrease ill resprratory morbldIty associated WIth N02 exposure
(Chapter 14) Data on the reSIdent populatIon of the Umted States proVIde mformatIOn on
the number of cluldren ill vanous age ranges (Table 16-4) ApproXImately 18 mtlhon
cluldren are ill the age group 5 to 9 years, whereas around 17 mtlhon cluldren are ill the age
group 10 to 14 years However, the fraction of the numbers of potentlally-at-nsk cluldren ill
vanous age groups that are actually exposed to N02 concentratIOns/patterns suffiCIent to
illduce resprratory morbIdIty has not been determilled
Another potentIal susceptIble subpopulatIOn group IS ImmunocompromIsed illdIviduals,
who would have an mcreased susceptIbility for mfectIOUS pulmonary dIsease as well as other
health effects Such people would hypothetIcally be more susceptible to agents, such as
N02 , that further compromIse host defenses ImmunocompromIsed groups could illclude
those people WIth abnormalItIes ill polymorphonuclear leukocyte (pMN) number or function
16-17
TABLE 16-4. ESTIl.\.fATES OF THE RESIDENT POPULATION OF
CHILDREN AND YOUNG ADULTS OF THE UNITED STATES,
BY AGE AND SEX, JULY 1, 1989
PopulatIOn
Age Total Male Female
All Ages 248,239,000 120,982,000 127,258,000
<1 3,945,000 2,020,000 1,925,000
1 to 4 14,808,000 7,578,000 7,229,000
5 to 9 18,212,000 9,321,000 8,891,000
10 to 14 16,950,000 8,689,000 8,260,000
15 to 19 17,812,000 9,091,000 8,721,000
Source Centers for DIsease Control (1990)
and those with humoral and/or cell-medIated unmumty dysfunctIOns Hopewell (1989)
discusses potentIally unmunocompronused groups m general, WIthout regard to pollutant
exposures ReductIon m the number of crrculatmg PMNs IS partIcularly common m patIents
undergoing chemotherapy for malIgnanCIes, m patIents WIth acute leukenua, and m patIents
who have had bone marrow transplantatIOn Also, the use of cortIcosterOIds, antmeoplastIc
drugs, irradIatIOn, and alcohol can decrease the effectIveness of PMNs by decreasmg
chemotaxis or adherence In addItIon, alteratIOns m PMN chemotaxIs have been descnbed m
cirrhosIs, renal faIlure, and Hodgkm's dIsease
AntIbody productIon IS pnmanly a functIon of B lymphocytes, thus decreased antIbody
productIon occurs when numbers of B cells are cntically reduced or when the abIhty to
respond to specIfic antIgens IS unparred CondItIons aSSOCIated WIth defectIve antIbody
productIon mc1ude patIents (1) Infected WIth the human unmunodeficiency VIrUS (lllV),
(2) WIth multiple myeloma, (3) WIth chromc lymphocytIC leukemIa, and (4) m the
splenectOlnIzed state
Cell-mediated Immumty IS mamly responSIble for fendmg off mtracellular pathogens
and neoplastic disease Killmg of nucrobes withm the lung IS accomphshed pnmanly by
AMs and secondanly by vanous T lymphocytes AbnormalItIes of cell-medIated unmumty
are produced by vanous diseases and mc1ude acquIred unmune defiCIency syndrome (AIDS)
and untreated Hodgkm's dIsease Also, therapeutIc mterventIOns that cause defects of cell-
16-18
medIated nnmumty are radiatIOn treatment, comcosterolds, azathIopnne, and
CytotoXIc/nnmunosuppressive drugs
The number of people wIth reduced nnmune function related to kIdney transplants,
AIDS, and chemotherapy can be estnnated The US Bureau of the Census (1991) mdicates
that, based on reports of procurement programs and transplant centers m the Umted States,
approXImately 8,890 kIdney transplant procedures were done m 1989 Also, Karon et al
(1990) reported that the Centers for Disease Control (CDC) estimated m 1990 that
(1) approXImately 1 mllhon persons m the Umted States were then currently mfected with
mv and (2) an estimated 52,000 to 57,000 cases of AIDS were expected to be diagnosed
dunng 1990 As of October 1991, state and local health departments had reported to the
CDC 196,034 AIDS cases among persons of all ages m the Umted States (Centers for
Disease Control, 1992) As for potentially at-nsk chemotherapy patients, m 1990,
approXImately 1 mllhon new cases of cancer occurred m the Umted States (U S. Bureau of
the Census, 1991) Steele et al (1991) estnnate that about 25% of the total number of
patients diagnosed with cancer m 1 year are prescnbed chemotherapy as a frrst course of
treatment In addluon, many cancer patients are treated. by radiation
Although the above nnmunocompromised groups represent potentially at-nsk
susceptible populatIOns for N02 effects, no human research has exammed N0 2 exposure m
these groups Thus, there only now eXIsts a hypothesued aSSOCiation WIth mcreased
susceptibility to N02 Although it IS clear that N02 can affect AMs, humorallffiffiumty, and
cell med1ated nnmumty m otherwIse normal anImals (Chapter 13), the ammal-to-human
extrapolatIOn cannot yet be made quantitatively Nevertheless, it may be prudent to conSider
mcludmg such reduced nnmune functIOn groups as suseeptIble subpopulatIOns at potentIally
mcreased nsk for N02-mduced health effects
16.5 NITROGEN DIOXIDE LEVELS, EXF'OSURES, AND ESTIMATES

16.5.1 Ambient and Indoor Nitrogen Dioxide Levels
In urban areas, hourly N02 patterns at fiXed-SIte, ambIent arr momtors often show a
bnnodal pattern of mommg and evenmg peaks, related to motor vehIcular traffic patterns,
supenmposed on a lower baselme level SItes affected by large stationary sources of N02
16-19
(or NO that rapIdly converts to N02) are often charactenzed by short epIsodes at relatIvely
hIgh concentrations Electnc generatmg statIons provIde a source of N02 m such rural and
urban areas Occurrences of hourly average N02 concentratIOns > 0 10 ppm are very
infrequent In fact, only about 5 % of hourly average N02 concentratIOns exceed
;::: 0 05 ppm (Aerometnc InformatIon Retneval System, 1992, U S EnVIronmental ProtectIOn
Agency, 1991a,b)
The hIghest hourly and annual ambIent N02 levels reported are from momtormg
stations in Cahforma The seasonal patterns at CalIforma statIOns are usually qUIte marked
and reach theIr hIghest levels through the fall and wmter months, whereas statIons elsewhere
in the United States usually have less promment seasonal patterns and may peak m the
wmter, ill the summer, or contam httle dIscernable vanatIon One-hour N02 values can
exceed 0.2 ppm, but, m 1988, only 16 statIons (12 m CalIforma) reported an apparently
credIble second hIgh I-h value greater than 0 2 ppm Because at least 98 % of 1-h values at
most stations are below 0 1 ppm, such values above 0 2 ppm are qUIte rare excurSIons
Thus, ambIent 1-h values of 0 1 ppm are more typICal 1-h maxillmms (Aerometnc
Information Retneval System, 1992, US EnVIronmental ProtectIon Agency, 1991a,b)
Since 1980, the U S natIOnWIde mean annual-average level among reportmg N02
statIons has been consIstently below 0 03 ppm For the penod 1980 to 1990, there were
indicatIOns of a downward trend for the compOSIte annual-average N02 concentratIOn
(U.S. EnVIronmental ProtectIon Agency, 1991b) The 1990 compOSIte N02 average was 8%
less than the 1981 level, a statIStIcally sIgmficant dIfference For 103 Metropohtan StatIstIcal
Areas reporting a vahd year's data for at least one statIon m 1988, 1989, and 1990, annual
averages ranged from 0 007 to 0 061 ppm The collectIve mode for the peak annual average
in the 1988 and 1989 penod was apprmamately 0 02 ppm The only recently measured
exceedances of the current 0 053 ppm N02 annual NatIOnal AmbIent AIr Quahty Standard
occurred at statIOns ill Southern CalIforma (Aerometnc InformatIon Retneval System, 1992,
U.S. EnVIronmental Protection Agency, 1991a,b)
Most people, however, spend a sIgmficant portIOn of theIr tIme mdoors ThIs can
result m illcreased N02 exposure, dependmg on the presence and use of mdoor sources
(e.g., gas stoves, kerosene heaters, and unvented gas space heaters) or reduced exposure,
depending on the absence of such sources and on the tIghtness of home constructIOn and the
16-20
use of arr conditIomng and other bUlldmg features that affect the degree of penetration of
outdoor N02 mto buildmgs Rados et al (1987a) rep01t maxunum kItchen N02 values for
I-h of 0419 ppm durmg gas stove use, and a mean maxnllum of 0 182 ppm averaged over
the 4-h samplmg penod
Several studIes have exammed the Issue of human exposure to N02 and the relatIOnshIp
of mdoor/outdoor arr qualIty for occupants of homes WI1 h and wIthout sIgmficant mdoor
sources of N02 (Quackenboss et al , 1986, Sexton et al , 1983, Colome et al , 1987,
Leaderer et al ,1987) Quackenboss et al (1986) found that m the wmter m Portage, WI,
mdoor weekly average N02 concentratIOns were 3 2 tnnes hIgher than outdoor N02 levels m
gas stove homes, whIle mdoor levels were 0 6 times outdoor N02 leveis m electnc stove
homes durmg the same penod The fact that indoor N02 levels m electnc stove homes were
below measured outdoor levels may be due to chemIcal reactIons of N02 wIth mdoor
surfaces GIven the large amount of tune spent at home by most subjects, Quackenboss
et al (1986) found relatIvely hIgh correlatIOns between weekly measurements of mdoor N02
concentratIOns and total personal exposure m gas stove homes (r = 0 85 for summer and
o 87 for wmter) and to a lesser extent m electnc stove homes (r = 0 68 for summer and
o 61 for wmter) Correlation between outdoor N02 levels and total personal exposure IS less
m the summer (r = 055 for gas stove homes and r = 068 for electnc stove homes) and
much lower m the wmter (r = 020 and 0 28, respectIvely) Another factor that would
affect total exposure IS respIratory ventIlation rate, whIe h may dIffer mdoors and outdoors
dependmg on levels and patterns of human actIvIties
Colome et al (1987), m a study of over 600 randomly sampled reSIdences m Southern
CalIforma, report that outdoor concentratIOns of N02 Me found to be the smgle most
nnportant determmant of average mdoor levels of N02 m Southern CalIfOrnIa Outdoor N02
levels accounted for between 15 to 40 % of the vanatIoll m mdoor concentratIOns m thIs
study Based on the regreSSIOn analySIS of data from multIple homes, mdoor/outdoor ratIOS
vaned from 0 46 to 1 00, dependmg on the season of the year
It IS remarkable that the contnbutIOn of gas cookmg to mdoor N02 levels IS as hIghly
conSIstent as It IS among studies for locatIOns (kItchens, bedrooms, actiVIty rooms) Withm the
reSIdences and by season, gIVen the great vanabIhty of the factors that govern the emISSIons
(source type, source conditIOn, source use, and source ventmg) and dilutIon and removal of
16-21
NO z mdoors (house volume, lllfIltratIon, etc) TIns consIstency IS not observed until the
Impact of outdoor concentratIOns IS corrected for because background levels can vary
conSIderably over tIme and geographtc area The nnpact of gas cookmg and pOSSIbly other
unvented or Improperly vented combustIon sources on mdoor N02 levels IS supenmposed
upon the indoor background level resultmg from outdoor levels In areas where outdoor
levels are low, concentratIOns mdoors from gas apphances will be htgher than, and m many
cases, much htgher than outdoor levels (e g , Marbury et al , 1988, Quackenboss et al ,
1987, 1988, Spengler et al , 1983, Leaderer et a1 , 1986, Ryan et al ,1988a,b) If outdoor
concentrations are htgh, then mdoor levels m homes wIth gas apphances can be closer to or
even lower than the outdoor levels (Wilson et al , 1986)
A by-product of N02, HONO, may be a factor contnbutmg to observed health effects,
however, no health data and hmlted exposure data are available to enable further evaluatIon
of thts pOSSIbility (see Chapter 7) Brauer et al (1991) suggested that HONO IS potentIally
less hkely to be neutrahzed by ammoma than other aCIds AddItIonally, HONO may be
absorbed at a htgher rate ill the pulmonary tract than IS N02 due to ItS greater solubility
The contrast in both mean and hourly peak values between N02 and HONO (e g , respective
peak and mean levels of 0 280 ppm and 0 069 ppm for N02 versus 0 029 ppm and
0.019 ppm for HONO), as indIcated by data from Brauer et al (1990), suggests that for
HONO to be a SIgmficant nsk factor, It would have to be more tOXIcologICally potent than
NO z (Neas et al , 1991).
16.5.2 Patterns of Potential Exposure to Nitrogen Dioxide and Related

Health Effects
Relationshtps between estImates of N02 exposure and mcreased respIratory symptoms
and dIseases have been observed m epIdemIOlogIcal studIes of children aged 5 to 12 years
(see Chapter 14) Actual exposure would optnnally be measured WIth personal exposure
momtors WIth rather bnef averagmg tImes, but thts IS not yet techmcally feaSIble Even so,
dehvered dose is responSIble for effects Although dose has an ObVIOUS broad relatIOnshIp to
exposure, It is very sIgmficantly mfluenced by ventilatIOn rates/patterns and respIratory tract
anatomy For example, even m the same mIcroenVIronment, a sedentary child would receIve
a dIfferent dose than a sedentary adult, and exerCIse would result m still dIfferent doses
16-22
LackIng such precIse estImates of dose, It IS necessary 10 use avaIlable exposure estImates
Here exposure IS defmed as the combmation of an mdIvidual's average N02 exposure
concentratIOn over tIme for all settmgs or envrronments Average mdoor resIdential
concentratIOns (e g , whole-house average or bedroom level) tend to be the best predIctors of
personal N02 exposure (see Chapter 8) Exposure was estImated m the N02 epIdemIOlogIcal
studIes by eIther drrect measure of pollutant levels or by use of the surrogate measure
proVIded by dIfferences m N02 levels observed m homes WIth gas cookers and homes WIth
electnc stoves The concentratIOn measures for both at e tYPICally denved from 1- to 2-week
averages as determmed by Palmes tubes
Measunng N02 levels averaged over 1 to 2 weeks presents two concepts that requrre
dIScussIon Frrst, how does such a measure proVIde data on discernmg the hypotheSIZed
dIfference between two patterns of exposure and therr potentially dIfferent relatIOnshIps to
observed health effects, and, second, how adequately does such a measure estImate long-term
exposures
16.5.2.1 Patterns of Exposure

Exposure to N02 can be characterIZed by dIfferent patterns For example, one
exposure pattern, best typIfied by a home WIthout an N02 emISSIon source, IS a cumulatIve
average level that estImates exposure resultmg from a mildly fluctuanng background level
WIthout tranSIent hIgher levels bemg expenenced A st'"cond exposure pattern IS usually
associated WIth the use of a gas cookIng stove m the home It conSIsts both of a cumulative
average fluctuatmg background level and short-tenn (1 to 2-h) peak concentratIOns
Although hour-by-hour characterIZatIOn of exposure would be most helpful m exammmg
exposure-response data, m both cases, cumulatIve averages are the avaIlable human exposure
data, typIcally 2-week averages
It IS Important to conSIder eVIdence useful m evaluatmg the relationshIp between N02
exposure patterns and health effects to dIscern the potential effects of ambIent au patterns
The epIdemIOlogy studIes reVIewed m Chapter 14 predommantly contrast exposures between
electnc stove homes and gas stove homes, except for those studIes exammmg ambIent
exposures Spengler et al (1979) and several key studIes reVIewed m Chapters 7, 8, and 14
show that a stnkmg dIfference m N02 levels eXIsts between homes usmg gas versus electnc
16-23
cooking Short-term NOz levels m homes wIth emISSIon sources have been charactenzed for
1-h tIme penods (see Chapter 7) Harlos et al (1987a) report maxnnum 1-h kItchen NOz
levels of 0419 ppm dunng gas stove use, and mean maxnnums of 0 182 ppm averaged over
the 4-h samphng penod As dISCUSSed m Chapter 7, both short-term peak concentrations and
longer term mean concentratIons are lower m activIty rooms and bedrooms than m kItchens
Bemg out of the kItchen or house dunng gas stove use would thusly lImIt exposure to hIgh
short-term levels House and bedroom averages correlate better than kItchen averages wIth
personal exposure data (see Chapter 7) ThIs mamly reflects the small amount of time spent
m the kItchen (wIth hIgh peaks) as opposed to other mdoor locations and the smaller
contnbutIon that peaks make to the total exposure
Agam, as discussed above, ambIent levels are typICally charactenzed by 1-h and annual
averages. Annual averages m 1988 and 1989 m Umted States Metropohtan Statistical Areas
ranged from 0 007 to 0 061 ppm, wIth a collective mode representmg a U S annual average
3
of approXImately 0 02 ppm TypICal1-h values range from zero to 0 1 ppm (188 p,g/m ),
with a mode of 005 ppm (see FIgure 7-8) Thus, outdoor 1-h values more typICally peak
near 01 ppm
Available data do not adequately examme the relative contnbutIons of peak and average
exposures and theIr relationshIp wIth observed health effects Advances m momtonng and m
the determmation of health outcome measures are needed to better examme the potential
relationshIp between peak exposures and health outcomes as contrasted to longer term
pollutant measures These needs represent Important areas for future research
16.5.2.2 Long-Term Exposure Estimates

Several of the epIdemIology studies m the quantitative analySIS m Chapter 14 used a
smgle 2-week NOz average or used two 2-week NOz averages to charactenze long-term
exposure The representativeness of such estImates of long-term exposure (e g , 1 year) IS a
conSideration in generahzmg the results of these studIes to the long-term ambIent SItuatIon
To roughly estImate the pOSSIble dIvergence from an actual annual ambIent mean resultmg
from selectmg one or two 2-week averages, data from the U S EnVIronmental ProtectIOn
Agency's Aerometnc InformatIon and Retneval System data bank (AIRS, 1991) for
16-24
10 statIons, selected from among those havmg faI1'ly complete records for 1988 or 1989
(see Chapter 7), have been analyzed for the vanabthty m theIr 2-week averages
(Table 16-5) These statiOns represent vanous regiOns of the Umted States but emphasIZe
Cabforma, where htgh levels most frequently occur For each statIon, 2-week averages were
calculated week by week, these were then ranked and the 10th and 90th percentiles were
detennmed These two percentiles were then dIVIded by the statiOn's annual mean to provIde
a common frame of reference For example, the 10th and 90th percentile fractiOns for a
smgle 2-week average for Los Angeles m 1988 were 0 77 and 1 27 tImes the annual mean,
respectIvely Thts would mdIcate that 80 % of the 2-week averages were between 77 and
127% of the annual average of 0061 ppm (0047 to 0 078 ppm, respectively) In a SImilar
manner, percentiles were calculated from two 2-week averages, usmg the means of 2-week
averages that were 26 weeks apart, thus provIdmg data for two OpposIte seasons such as
wmter and summer The 26 possIble averages were raIJIked as before Because these
averages represent more weeks of data taken at two dIfferent tImes, It IS expected that they
would come doser to the true annual average, thts IS generally the case
The results suggest that most (80 %) of the smgle 2-week averages are Withm 80 and
125 % of the mean, except possIbly for CItIes (such as Dallas) wIth very low means The two
2-week averages produce a better estImate, WIth most lymg between 85 and 120 % of the
mean The reader IS cautiOned that these numbers and ,analyses may not be representatIve of
actual exposure SItuatiOns Also, the use of a smgle outdoor momtor may not produce a
representatIve exposure estImate These selected data and analyses are offered only to
descnbe potentIal relatiOnshtps between ambIent N02 atmual averages and 2-week data
penods
Further, forty SItes were chosen (for theIr aval1abthty of data) to try to roughly estImate
the uncertamty of these estImates The SItes were spht mto three categones dependmg on the
value of the annual average, that IS, (1) 0 001 to 0 020 ppm, (2) 0020 to 0 040 ppm, or
(3) > 0 040 ppm N02 For each SIte, up to 52 2-week averages (startmg at the begmnmg of
each week) were calculated, along WIth the overall annual average Each 2-week average
can be thought of as an estImate of the annual average, and the standard error of thts
estImate was calculated across all SItes Withm a partIcular exposure range The standard
error was estImated from the absolute deViatiOns mstead of the deViatiOns squared to aVOid
16-25
TABLE 16-5. U.S. ENVIRONMENTAL PROTECTION AGENCY
ANALYSIS OF VARIABILITY IN TWO-WEEK AMBIENT AVERAGES OF
ONE-HOUR NITROGEN DIOXIDE DATA AT 10 SELECTED LOCATIONS
FractIOn of Annual Average
Annual 2-Week Average Two 2-Week Average

Average 10th 90th 10th 90th
CIty Year (ppm) Percentile Percentile
Los Angeles, CA 1988 0061 077 127 087 120
Azusa, CA 1989 0051 081 127 083 1 17
Upland, CA 1988 0047 079 138 087 122
Anaheim, CA 1988 0046 071 123 086 110
New York, NY 1988 0041 084 119 091 1 16
ChIcago, IL 1989 0034 086 118 093 110
Cmcmnatl, OH 1989 0030 084 123 088 111
Worcester, MA 1988 0029 081 1 19 083 123
Miami, FL 1989 0018 077 126 090 1 18
Dallas, 'IX 1989 0011 045 146 075 131
Source Aerometric Information Retneval System (1991)
possible problems from nonnonnally dIstnbuted data In a slffil1ar manner, standard errors
were estlffiated from two 2-week averages, usmg the average of 2-week averages that were
26 weeks apart The number of Sites, ranges of annual means, and average standard errors
of the one 2-week and two 2-week estlffiates are given m Table 16-6
Table 16-6 shows that the standard error of the estlffiate goes up WIth the annual
average itself In general, one 2-week estlffiate has a standard error of about 25 % of the
mean, whereas the two 2-week estlmate has a standard error of about 15 % of the mean
A slffil1ar analySIS was made for mdoor Sites usmg data from homes m the Albuquerque
area supphed by Lambert (1991) One hundred SItes were selected (by Lambert), mc1udmg
25 electnc stove homes and 75 gas stove homes The extenSIve data set conSIsted of
26 2-week averages for each home Standard errors were calculated for three dIfferent
estimates. (1) one 2-week average, (2) two 2-week averages, and (3) a fIxed value estlffiate
depending on whether the home used a gas stove versus an electnc stove When all the
electric stove homes were combmed, the overall average N02 for the electnc stove homes
was 6.51 p.g/m3 (0 003 ppm) The gas stove homes averaged 32 67 p,g/m3 (0 017 ppm)
16-26
TABLE 16-6. AVERAGE ANNUAL NITROGEN DIOXIDE MEANS (ppm) AND
STANDARD ERRORS OF ESTIMATES ]i'OR 40 SITES IN THE
UNITED STATES BY ANNUAL AVERAG]& AS DERIVED BY THE
U.S. ENVIRONMENTAL PROTECTION AGENCY FROM
THE AEROMETRIC INFORMATION RETRIEVAL SYSTEM (1991)
Average Standard Error of EstImate
Ranges of One 2-Week Two 2-Week
Annual Averages Number of SItes Average Mean Average Average
0001-0020 7 00159 00046 00028
0020-0040 16 00313 00080 00041
>0040 17 00495 00111 00056
These two overall averages were used as the ftxed estIm.ate of each home's annual N02
level The estnnated standard errors were calculated m the same manner as was done for the
outdoor data The results are presented m Table 16-7.
TABLE 16-7. AVERAGE ANNUAL NITROGEN DIOXIDE MEANS (ppm)

AND STANDARD ERRORS OF ESTIMATES FOR 100 HOMES
BASED ON DATA OF LAMBERT (1991) AS DERIVED BY THE
U.S. ENVIRONMENTAL PROTECTION AGENCY
Average Standard Error of the EstImate
Source of Number of Overall
Average One2-Week Two 2-Week FIXed
Exposure Homes
Electnc Stove 25 0003 0001 00008 00014
Gas Stove 75 0017 0010 0005 0012
The standard errors from the estnnates of mdoor exposure are somewhat hIgher than
the standard errors of the outdoor estnnates The standard error of the one 2-week average
IS about 50 % of the mean, and the standard error of the two 2-week average IS about 25 % of
the mean The fixed estnnate (usmg an overall average for electric homes and a separate
overall average for gas stove homes) had a shghtly larg(~r standard error than dId the one
2-week average ThIs suggests that measured 2-week averages are better for charactenzmg
exposure than a fixed average based only on the presence or absence of a gas stove
16-27
However, a single 2-week average IS only shghtly better Although the standard errors are
quite large (compared WIth the mean), the estImates are adequate to dIstmgUlsh a hIgh
exposure (usually WIth a gas stove present) from a low exposure (usually WIth an electnc
stove present) household
16.5.3 Nitrogen Dioxide Exposure Estimates

The followmg exposure analySIS estImates the potentIal Impact of outdoor N02
concentratIons on exposure m chIldren and adults ThIs analySIS IS based on a SImple
approach that does not adequately take mto account the mteractIOn of actIVIty or locatIOn and
the N02 level in that locatIOn durmg the tIme penod m that mIcroenVIronment Instead,
averages are used Further efforts are beyond the scope of thIs document, but would be
necessary to produce a more appropnate analySIS ThIs hmIted exposure estImate proVIdes a
perspective for this document Two factors are needed for thIs analySIS The fIrst factor IS
the fractIon of tIme the chIldren spent outdoors ThIs, of course, will vary by age, season,
and locality The second factor IS the mcrease m mdoor concentratIOns of N02 (e g , m the
bedroom) as a functIon of the outdoor concentratIOn, whIch also vanes by season and
locality.
The fraction of time spent outdoors IS estImated by several studIes (see Table 16-8),
and the estImates are hIghly dependent on age In general, the fractIons ranged from about
0.3 to 20 % of the tIme bemg spent outdoors Rather than assume that a smgle value apphes,
several dIfferent percents (0 3, 1, 3, 5, 10, 15, and 20) are evaluated m the analySIS
The contnbutIon of outdoor N02 concentratIOns to mdoor levels must be estImated
To start, average outdoor values for the whole season are used The analySIS assumes no
indoor sources The model used IS based on a phYSICal mass balance equatIOn (Butler et al ,
1990; Drye et al., 1989) The model (see Chapter 8) states that the mdoor concentratIOn
(Cm ) will be a hnear functIon of the outdoor concentratIOn (Cout), WIth a constant tenn (A)
For purposes of estImatIng the mcrease m mdoor N02 from outdoor N02 , only the
regresSIOn coeffiCIent for the mdoor/outdoor (I/O) ratIO Itself IS needed An mdoor/outdoor
ratio of 0 59 may be an appropnate value (see Chapter 7) Combmmg the estImates denved
by Drye et ale (1989) and Butler et al (1990) for N02 concentratIOn m a bedroom (Cbed)
for summer and winter usmg a SImple average mto a smgle equatIOn yIelds
16-28
TABLE 16-8. NITROGEN DIOXIDE EXPOSURE ESTIlVIATES IN PARTS PER
:MILLION (ppm) DERIVED BY THE U.S. ENVIRONMENTAL
PROTECTION AGENCY AS FUNCTION OF OUTDOOR NITROGEN DIOXIDE
CONCENTRATION AND PERCENT TIME OUTDOORS, WHERE
INDOOR/OUTDOOR RATIO EQUALS 0.59 AND ASSUMING A
BASELINE CONCENTRATION OF 0.005 ppm
OutdoorN02 Percent of TIme Outdoors
ppm o 3a Ib 3
c
5
d lOe 15
f 20g,h
0005 0005 0005 0005 0005 0005 0005 0005

0010 0008 0008 0008 0008 0008 0008 0008
0015 0011 0011 0011 0011 0011 0012 0012
0020 0014 0014 0014 0014 0014 0015 0015
0025 0017 0017 0017 0017 0018 0018 0018
0030 0020 0020 0020 0020 0021 0021 0022
0035 0023 0023 0023 0023 0024 0025 0025
0040 0026 0026 0026 0026 0027 0028 0029
0045 0029 0029 0029 0029 0030 0031 0032
0050 0032 0032 0032 o OJ2 0033 0034 0035
aHarlos et al (1987b) Clnldren < 1 year old

b
Dorre et al (1990) ChIldren 2 to 3 years old, nnmmum tune
cDorre et al (1990) ChIldren 2 to 3 years old, mean tune
d
Noy et aJ. (1986) HouseWives
eClausmg et al (1986) High school students
f
Quackenboss et al (1982) Family members
gSchwab et al (1990) Fourth through sixth graders
hAdaIr and Spengler (1989) ChIldren can spend as much as 50% of theIr hme outdoors m the summer
(16-1)
From EquatIOn 16-1, the total N02 exposure (CtotaZ) can then be estnnated for a clnld who
spends Pout fraction of Ins tnne outdoors, assummg a basehne mdoor concentratIOn of Cm
(16-2)
16-29
The increase ill N02 exposure (Cmcr) IS estnnated by
(16-3)
Table 16-8 presents values for tlns exposure estnnate as a functIon of outdoor N02
concentratIon and percent of tnne outdoors for the I/O ratIo 0 59 As long as the regressIOn
coefficient is lngh (0 59 ill this case), the fractIon of tnne outdoors will have httle nnpact on
the exposure For smaller values of the coefficIent (e g , near 0 3), the actIVIty pattern
would have a much larger nnpact
Table 16-9 shows changes ill the exposure estnnate ill a nest of subtables where the
percent tnne outdoors and the outdoor N02 level vary for specIfic I/O ratIos of 0 1 to 0 8
Indoor/outdoor ratIos depend on several factors, such as season, use of arr conmtIonmg, tIght
versus loose homes, and locatIon ill the Umted States (see Chapter 7)
16-30
TABLE 16-9. NITROGEN DIOXIDE EXPOSURE ESTIMATES IN PARTS PER
MILLION (ppm) DERIVED BY THE U.S. ENVIRONMENTAL
PROTECTION AGENCY AT SELECTED OUTDOOR NITROGEN DIOXIDE
CONCENTRATIONS, INDOOR/OUTDOOR CONCENTRATION RATIOS,
AND PERCENTAGES OF TIME SPENT OUTDOORS, COMPARED
WITH A NITROGEN DIOXIDE EXPOSURE OF 0.005 ppm3
Outdoor Percentage of Time Outdoors Outdoor Percentage of Time Outdoors
N02 (ppm) N02 (ppm)
03 3 5 10 15 20 03 3 5 10 15 20
I/O R of 0 1 I/O RofO 5

0020 0007 0007 0007 0007 0008 0009 0009 0020 0013 0013 o 013 0 013 0 013 0014 0014
0025 0007 0007 0008 0008 0009 0010 0011 002', 0015 0015 0015 0015 0016 0016 0017
0030 0008 0008 0008 0009 0010 0011 0012 0030 0018 0018 o 018 0 018 0 019 0019 0020
0035 0008 0008 0009 0009 0011 0012 0013 003') 0020 0020 o 020 0 021 0 021 0022 0023
0040 0009 0009 0009 0010 0012 0013 0015 0040 0023 0023 o 023 0 023 0 024 0025 0026
0045 0009 0009 0010 0011 0013 0014 0016 004') 0025 0025 o 026 0 026 0 027 0028 0029
0050 0010 0010 0011 0012 0014 0016 0018 0050 0028 0028 o 028 0 029 0 030 0031 0032
0055 0010 0010 0011 0012 0014 0017 0019 005', 0030 0030 0031 0031 0032 0034 0035
0060 0011 0011 0012 0013 0015 0018 0020 0060 0033 0033 o 033 0 034 0 035 0037 0038
I/O RofO 2 I/O RofO 6
0020 0008 0008 0008 0009 0009 0010 0010 0020 0014 0014 0014 0 014 0 015 0015 0015
0025 0009 0009 0009 0010 0011 0011 0012 0025 0017 0017 o 017 0 017 0 018 0018 0019
0030 0010 0010 0011 0011 0012 0013 0014 0030 0020 0020 o 020 0 020 0 021 0021 0022
0035 0011 0011 0012 0012 0013 0015 0016 003, 0023 0023 o 023 0 024 0 024 0025 0025
0040 0012 0012 0013 0013 0015 0016 0018 0040 0026 0026 o 026 0 027 0 027 0028 0029
0045 0013 0013 0014 0015 0016 0018 0019 004') 0029 0029 0029 0030 0031 0031 0032
0050 0014 0014 0015 0016 0018 0019 0021 0050 0032 0032 o 033 0 033 0 034 0035 0036
0055 0015 0015 0016 0017 0019 0021 0023 005', 0035 0035 o 036 0 036 0 037 0038 0039
0060 0016 0016 0017 0018 0020 0023 0025 0060 0038 0038 o 039 0 039 0 040 0041 0042
I/O RofO 3 I/ORofO 7
0020 0010 0010 0010 0010 0011 0011 0012 00201 0016 0016 0016 0016 0016 0016 0016
0025 0011 0011 0011 0012 0012 0013 0014 0025 0019 0019 o 019 0 019 0 020 0020 0020
0030 0013 0013 0013 0013 0014 0015 0016 0030 0023 0023 o 023 0 023 0 023 0024 0024
0035 0014 0014 0015 0015 0016 0017 0018 0035 0026 0026 o 026 0 026 0 027 0027 0028
0040 0016 0016 0016 0017 0018 0019 0020 o 04(JI 0030 0030 0030 0 030 0031 0031 0032
0045 0017 0017 0018 0018 0020 0021 0023 0045 0033 0033 o 033 0 034 0 034 0035 0035
0050 0019 0019 0019 0020 0022 0023 0025 00501 0037 0037 o 037 0 037 0 038 0039 0039
0055 0020 0020 0021 0022 0023 0025 0027 0055 0040 0040 0040 0041 0041 0042 0043
0060 0022 0022 0023 0023 0025 0027 0029 00601 0044 0044 o 044 0 044 0 045 0046 0047
I/ORofO 4 I/O R of 0 8
0020 0011 0011 0011 0011 0012 0012 o 013 0020 0017 0017 0017 0017 0017 0017 0018
0025 0013 0013 0013 0014 0014 0015 0015 0025- 0021 0021 o 021 0 021 0 021 0022 0022
0030 0015 0015 0015 0016 0016 0017 0018 00301 0025 0025 o 025 0 025 0 025 0026 0026
0035 0017 0017 0018 0018 0019 0020 0021 0035- 0029 0029 o 029 0 029 0 030 0030 0030
0040 0019 0019 0020 0020 0021 0022 0023 0040 0033 0033 o 033 0 033 0 034 0034 0034
0045 0021 0021 0022 0022 0023 0025 0026 0045- 0037 0037 o 037 0 037 0 038 0038 0039
0050 0023 0023 0024 0024 0026 0027 0028 0050 0041 0041 0041 0041 0042 0042 0043
0055 0025 0025 0026 0026 0028 0029 0031 00551 0045 0045 o 045 0 045 0 046 0046 0047
0060 0027 0027 0028 0029 0030 0032 0034 0060 0049 0049 o 049 0 050 0 050 0051 0051
a N02 = NItrogen diOXIde

I/O R = Indoor/outdoor ratiO
16-31
REFERENCES
Adatr, J H, Spengler, J D (1989) Tune activIty and exposure assessment the SIX CIty mdoor atr qualIty
expenence Presented at 82nd atillual meetmg of the AIr and Waste Management AssoCIatIOn, June,
Anaheun, CA PIttsburgh, PA Alr and Waste Management AssocIatIOn, paper no 89-100 5
AIRS, Aerometnc Information Retneval System [database] (1991) [Data on NOx] Research Tnangle Park, NC
U S EnvIronmental Protection Agency, Office of Alr QualIty Plannmg and Standards DISC, IBM 3090
AIRS, Aerometnc Information Retneval System [database] (1992) [Data on NOx] Research Tnangle Park, NC
U S EnvIronmental Protection Agency, Office of AIr QualIty Plannmg and Standards
AranyI, C, Fenters, J , ErhlIch, R , Gardner, D (1976) Scannmg electron illlcroscopy of alveolar macrophages
after exposure to oxygen, mtrogen dIOXide, and ozone EnVIron Health Perspect 16 180
Bauer, M A, Utell, M J , Morrow, P E, Speers, D M, Glbb, F R (1986a) InhalatIOn of 030 ppm

mtrogen dIOXide potentiates exerclse-mduced bronchospasm m asthmatics Am Rev Respir DIS
134 1203-1208
Bauer, M A, Utell, M J, Smeghn, AM, Speers, D M, Glbb, F R, Morrow, P E (1986b) Effects of

low-level mtrogen dIOXide on lung function m exerclsmg subjects WIth chromc obstructIve pulmonary
dIsease (COPD) Am Rev RespIr DIS 133(suppl) A215
Beasley, R ; Roche, W R, Roberts, J A, Holgate, S T (1989) Cellular events m the bronchI m IDlld asthma
and after bronchIal provocation Am Rev RespIr DIS 139 806-817
Bell, M , Ulmer, W T (1976) WIrkung von N02 1m MAK-BerelCh auf AtemmechanIk und bronchIale
AcetylchohnempfindlIchkeit bel Normalpersonen [Effect of N02 m workroom concentrations on
respIratory mechamcs and bronchIal susceptibIlIty to acetylcholme m normal persons] Int Arch Occup
EnvIron Health 38 31-44
Brauer, M , Ryan, P B, Sub, H H, KoutrakIs, P , Spengler, J D, LeslIe, N P, BIllIck, I H (1990)

Measurements of mtrous aCId mSIde two research houses EnVIron SCI Technol 24 1521-1527
Brauer, M , KoutrakIs, P , Keeler, G J , Spengler, J D (1991) Indoor and outdoor concentrations of morgamc
aCIdiC aerosols and gases J Alr Waste Manage Assoc 41 171-181
Britton, J R, Burney, P G J , ChInn, S , Papacosta, A 0, Tattersfield, A E (1988) The relatIOn between

change m aIrWay reactiVIty and change m respIratory symptoms and medIcation m a commumty study
Am Rev Respir DIS 138 530-534
Butler, D A, Ozkaynak, H , BIllick, I H, Spengler, J D (1990) PredIctmg mdoor NCh concentratIOns as a

function of home charactenstics and ambIent N02 levels In Indoor atr'9O precedmgs of the 5th
mternational conference on mdoor atr qualIty and clImate, volume 2, charactenstics of mdoor aIr,
July-August, Toronto, ON, Canada Ottawa, ON, Canada InternatIOnal Conference on Indoor Alr
Quahty and ClImate, Inc ,pp 519-524
Bylm, G , LIndvall, T , Rehn, T , Sundm, B (1985) Effects of short-term exposure to ambIent mtrogen dIOXide
concentrations on human bronchIal reactIVIty and lung function Eur J Resplr DIS 66 205-217
Bylm, G , Hedenstierna, G , LIndvall, T , Sundm, B (1988) AmbIent mtrogen dIOXide concentratIOns mcrease
bronchial responSIveness m subjects WIth illlld asthma Eur Resplr J 1 606-612
16-32
Centers for DIsease Control (1990) Estunates of the resIdent populatlOn of the Umted States, by age, sex, and
race, July 1, 1989 Morb Mortal Wkly Rep 38 11
Centers for DIsease Control (1992) Statistics from the Centers for DIsease Control AIDS 6 139-141
Chang, L -Y , Graham, J A, MIller, F J , OSpltal, J J , Crapo, J D (1986) Effects of subchromc mhalation

of low concentrations of mtrogen dIOXIde I The proX1111al alveolar regIOn of]uvemle and adult rats
Chang, L -Y , Mercer, R R, Stockstill, B L, MIller, F J , Graham, J A, OSpltal, J J , Crapo, J D (1988)

Effects of low levels of N02 on termmal bronc!uolar cells and Its relatIve tOXICIty compared to 0 3
Clausmg, P , Mak, J K, Spengler, J D, Letz, R (1986) Personal N02 exposures of !ugh school students
EnVIron Int 12 413-417
Coffin, D L, Gardner, DE, Sldorenko, G I, Plillgm, M A (1977) Role of tune as a factor m the tOXICIty
of cheImcal compounds m mtenmttent and contmuous exposures Part n Effects of mtenmttent
exposure J TOXIcol EnVIron Health 3 821-828
Collms, J G (1988) Prevalence of selected chromc condItIOns, Umte.d States, 1983-85 HyattsvIlle, MD U S
Department of Health and Human ServIces, NatIonal Center lor Health StatistIcs, DHHS pubhcatIOn no
(PHS) 88-1250 (Advance data from VItal and health statistics no 155)
Colome, S D, WIlson, A L, Becker, E W , Cunmngham, S J , Baker, P E (1987) AnalYSIS of factors

asSOCIated WIth mdoor resIdential mtrogen dIOXIde multlvanate regresSIOn results In SeIfert, B ,
Esdorn, H , FIscher, M , Rueden, H , Wegner, J ,eds Indoor alr '87 proceedmgs of the 4th
mternatIOnal conference on mdoor alr qualIty and chmate, V 1, volatIle orgamc compounds, combustion
gases, partIcles and fibres, ImCrObIOloglcal agents, August, Berlm, Federal Repubhc of Germany Berlm,
Federal RepublIc of Germany Institute for Water, SoIl and .A~r HYgiene, pp 405-409
Crapo, J D , Barry, BE, Chang, L -Y , Mercer, R R (1984) AlteratIOns m lung structure caused by
mhalatIOn of OXIdants J TOXIcol EnVIron Health 13 301-3 H
Devlm, R , Horstman, D , Becker, S , Gernty, T , Madden, M , Koren, H (1992) Inflammatory response m

humans exposed to 2 0 ppm N02 Am Rev RespIr DIS 14'; A456
DI]kstra, L , Houthul]S, D , Brunekreef, B , Akkerman, I , Bolel], J S M (1990) RespIratory health effects of

the mdoor enVIronment m a populatIOn of Dutch chIldren Am Rev RespIr DIS 142 1172-1178
Dockery, D W, Spengler, J D , Neas, L M, Spelzer, FE, Ferns, B G, Jr , Ware, J H, Brunekreef, B

(1989) An epldeImologlc study of respIratory health status and. mdlcators of mdoor alr pollutIOn from
combustion sources In Harper, J P, ed CombustIOn processes and the quahty of the mdoor
enVIronment transactIOns of an mternatIOnal SpecIalty conferfmce, September 1988, NIagara Falls, NY
PIttsburgh, PA AIr & Waste Management ASSOCIatIon, pp 262-271 (A&WMA transactions senes
TR-15)
Dorre, W H, Hom, K , FIedler, K (1990) TIme budget of young chIldren as a baSIS for apphcation to
exposure assessment In Indoor alr'9O precedmgs of the 5th mternatIonal conference on mdoor alr
qUalIty and clilllate, volume 2, charactenstics of mdoor aIr, July-August, Toronto, ON, Canada Ottawa,
ON, Canada InternatIonal Conference on Indoor Au Quahty and Chmate, Inc ,pp 525-530
16-33
Douglas, R G., Jr (1986) Pathogenetic mechamsms m VIral respIratory tract mfections In Sande, M A,
Hudson, L D, Root, R K, eds RespIratory mfections New York, NY ChurchIll LIvmgstone, Inc,
pp.25-46
Douglas, W W , Hepper, N G G, Colby, T V (1989) SIlo-filler's dIsease Mayo Clm Proc 64 291-304
Drye, E E, Ozkaynak, H , Burbank, B , BIllIck, I H, Baker, P E, Spengler, J D, Ryan, P B, Colome,

S. D (1989) Development of models for predIctmg the dIstnbutIOn of mdoor mtrogen dIOXIde
concentrations JAPCA 39 1169-1177
EhrlIch, R , Henry, M C (1968) Chromc tOXICIty of mtrogen dIOXIde I effect on reSIstance to bactenal
pneumoma Arch EnvIron Health 17 860-865
EhrlIch, R , Fmdlay, J C, Fenters, J D, Gardner, D E (1977) Health effects of short-term mhaiatIOn of

nitrogen dIOXIde and ozone mIxtures EnVIron Res 14 223-231
Ekwo, E E, Wemberger, M M, Lachenbruch, P A, Huntley, W H (1983) RelatIOnshIp of parental smoking

and gas cooking to respIratory dIsease m chIldren Chest 84 662-668
Folinsbee, L J (1992) Does mtrogen dIOXIde exposure mcrease airways responSIveness? TOXIcol Ind Health
8 1-11
Frampton, M W , Smeghn, AM, Roberts, N J , Jr , Fmkelstem, J N , Morrow, P E, Utell, M J (1989a)

Nitrogen dlOXlde exposure m VIVO and human alveolar macrophage mactivation of mfluenza VIrUS
m VItro EnVIron Res 48 179-192
Frampton, M W , Fmkelstem, J N , Roberts, N J , Jr , Smeglm, AM, Morrow, P E, Utell, M J (1989b)

Effects of mtrogen dIOXIde exposure on bronchoalveolar lavage protems m humans Am J Resplr Cell
Mol BIOI 1 499-505
Frampton, M W , Morrow, P E, Cox, C , Glbb, F R, Speers, D M, Utell, M J (1991) Effects of

mtrogen dIoXlde exposure on pulmonary functIOn and aIrway reactIVIty m nonna! humans Am Rev
Resprr DIS 143 522-527
Freeman, G , Crane, S C, Funosl, N J , Stephens, R J , Evans, M J , Moore, W D (1972) Covert

reduction m ventIlatory surface m rats dunng prolonged exposure to subacute mtrogen dIOXIde Am Rev
FUJimakJ., H , ShImIZU, F , Kubota, K (1982) Effect of subacute exposure to N0 2 on lymphocytes requIred for
antibody responses EnVIron Res 29 280-286
Gamble, J , Jones, W , Mmshall, S (1987) EpIdemIologIcal-enVIronmental study of dIesel bus garage workers
acute effects of N~ and respIrable partIculate on the respIratory system EnVIron Res 42 201-214
Gardner, DE, Coffin, D L, PlIDgm, M A, Sldorenko, G I (1977a) Role of time as a factor m the tOXICity
of chemIcal compounds m mtenmttent and contmuous exposures Part I Effects of contmuous exposure
J TOXlcol EnvIron Health 3 811-820
Gardner, DE, MIller, F J , Blommer, E J , Coffin, D L (1977b) RelationshIps between mtrogen dIOXide
concentration, time, and level of effect usmg an ammal mfectivlty model In DimItnades, B , ed
International conference on photochemIcal OXidant pollution and ItS control proceedmgs, V I, September
1976, Raleigh, NC Research Tnangle Park, NC U S EnVIronmental Protection Agency, EnVIronmental
SCIences Research Laboratory, pp 513-525, EPA report no EPA-600/3-77-Q01a AvaIlable from NTIS,
Spnngfield, VA, PB-264232 (EcolOgical research senes)
16-34
Gardner, DE, MIller, F J , Blommer, E J , Coffin, D L (1979) Influence of exposure mode on the tOXICIty
of N02 EnvIron Health Perspect 30 23-29
Gardner, DE, Graham, J A, lllmg, J W , Blommer, E J , MIller, F J (1980) Impact of exposure patterns
on the tOXicologICal response to N02 and modificatIOns by .ldded stressors In Proceedmgs of the
US-USSR thIrd Jomt symposIUm on problems of envIronmental health, October 1979, Suzelal, USSR
Research Tnangle Park, NC NatIonal InstItute of EnvIronmental Health SCIences, pp 17-40
Gardner, DE, MIller, F J , lllmg, J W , Graham, J A (1982) Non-respIratory functIOn of the lungs host
defenses agamst mfectIon In SchneIder, T , Grant, L ,ed', AIr pollutIOn by mtrogen OXides
proceedmgs of the US-Dutch mternatIonal symposIUm, May, Maastncht, The Netherlands AInsterdam,
The Netherlands ElsevIer SCIentIfic PublIshmg Company, pp 401-415 (StudIes m envIronmental SCIence
21)
Glezen, W P (1989) A1Itecedents of chromc and recurrent lung dI'3eaSe childhood respIratory trouble
Gomgs, S A J , Kulle, T J , Bascom, R , Sauder, L R, Green, D J , Hebel, J R, Clements, M L (1989)

Effect of mtrogen dIOXide exposure on susceptIbIlIty to mfluenza A VIrus mfectIon m healthy adults
Gold, DR, Tager, I B, WeISS, S T, Tosteson, T D, Speizer, F E (1989) Acute lower respIratory Illness
m childhood as a predIctor of lung functIOn and chromc respIratory symptoms Am Rev Respir DIS
140 877-884
Goldstem, E , Eagle, M C, Hoepnch, P D (1973) Effect of mtrogen dIOXide on pulmonary bactenal defense
mechamsms Arch EnVIron Health 26 202-204
Goldstem, E , Warshauer, D , Lippert, W , Tarkmgton, B (1974) Ozone and mtrogen dIOXide exposure munne
pulmonary defense mechamsms Arch EnVIron Health 28 85-90
Graham, J A, Gardner, DE, Blommer, E J , House, DE, Menache, M G, MIller, F J (1987) Influence
of exposure patterns of mtrogen dIOXide and modIficatIons lby ozone on susceptIbIlIty to bactenal
mfectIous dIsease m lllice J TOXIcol EnVIron Health 21 113-125
Grayson, R R (1956) SIlage gas pOlsonmg mtrogen dIOXide pneumoma, a new dIsease m agncultural workers
Ann Intern Med 45 393-408
Harlos, D P, Spengler, J D , BIllick, I (1987a) Contmuous mtwgen dIOXide momtonng dunng cookmg and
commutmg personal and statIonary exposures In SeIfert, B , Esdorn, H , FIscher, M , Rueden, H ,
Wegner, J ,eds Indoor aIr '87 proceedmgs of the 4th mternatIOnal conference on mdoor aIr qualIty and
clImate, V 1, volatIle orgamc compounds, combustIon gasf's, partIcles and fibres, lllicrobioiogical agents,
August, Berlm, Federal RepublIc of Gennany Berlm, Federal RepublIc of Gennany InstItute for Water,
SoIl and AIr HygIene, pp 278-282
Harlos, D P, Marbury, M , Samet, J , Spengler, J D (1987b) Relatmg mdoor N02 leveis to Infant personal
exposures Atmos EnVIron 21 369-376
Hasselblad, V , Eddy, D M, Kotchmar, D J (1992) SyntheSIS of envIronmental eVIdence mtrogen dIOXide

epidellliology studIes J AIr Waste Manage Assoc 42 662-671
Haydon, G B, DaVIdson, J T, Ltllmgton, G A, Wassennan, I< (1967) Nttrogen dtoXIde-mduced emphysema

m rabbIts Am Rev RespIr Dts 95 797-805
16-35
Hedberg, K , Hedberg, C W , Ther, C , WhIte, K E, Osterholm, M T, Jones, D B W, Flmk, J R,
MacDonald, K L (1989) An outbreak of mtrogen dlOXIde-mduced respIratory tllness among Ice hockey
players JAMA JAmMed Assoc 262 3014-3017
Hopewell, P C (1989) EvaluatIon of pulmonary dIsease m the ImmUllOCOmpromIsed host In Kelley, W N ,

ed Textbook of mtemal medlcme volume 2 Phtladelpma, PA J B Lippmcott Company,
pp 2082-2087
Hyde, D ; Orthoefer, J., Dungworth, D , Tyler, W , Carter, R , Lum, H (1978) Morphometnc and
morphologIC evaluatIon of pulmonary lesIOns m beagle dogs chromcally exposed to mgh ambIent levels of
air pollutants Lab Invest 38 455-469
Ito, K (1971) [Effect of mtrogen dIOXide mhalatIon on mfluenza VIruS mfectIon m mIce] NIppon Eiselgaku
Zassm26 304-314
Jakab, G J (1987a) ModulatIon of pulmonary defense mechamsms by acute exposures to mtrogen dIOXide
EnvIron Res 42 215-228
Jakab, G J (1987b) ModulatIon of pulmonary defense mechamsms by acute exposures to mtrogen dIOXide
E>.. p enentla Suppl 51 235-242
Jorres, R , Magnussen, H (1990) Auways response of asthmatIcs after a 30 rom exposure, at restmg venttlatlOn,
to 0 25 ppm N02 or 0 5 ppm S02 Eur Respir J 3 132-137
Karon, J. M , Dondero, T J , Jr , Workshop Group (1990) mv prevalence estImates and AIDS case
proJectlOns for the Umted States report based upon a workshop Morb Mortal Wkly Rep 39
(November 20) 12
Keller, M D , Lattese, R R, Mitchell, R I, Cote, R W (1979) RespIratory tllness m households usmg gas
and electncity for cookmg II symptoms and objectIve findmgs EnVIron Res 19 504-515
Klemman, M T, Batley, R M, Lmn, W S, Anderson, K R, Whynot, J D, Shamoo, D A, Hackney,

J D (1983) Effects of 0 2 ppm mtrogen dIOXide on pulmonary functlOn and response to
bronchoprovocatIon m asthmatIcs J TOXIcol EnVIron Health 12 815-826
Koemg, J Q, Covert, D S, PIerson, WE, McManus, M S (1988) The effects of mhaled mtnc aCId on
pulmonary functIon m adolescent asthmatIcs Am Rev Respir DIS 137(suppl) 169
Kubota, K , MurakamI, M , Takenaka, S , KaWai, K , Kyono, H (1987) Effects of long-term mtrogen dIOXide
exposure on rat lung morphologIcal observatIons EnVIron Health Perspect 73 157-169
Lafuma, C , Harf, A , Lattge, F , BOZZI, L, Poncy, J L, Blgnon, J (1987) Effect oflow-Ievel N02 chromc
exposure on elastase-mduced emphysema EnVIron Res 43 75-84
Lattmen, LA; Hemo, M , Laitmen, A , Kava, T , Haahtela, T (1985) Datnage of the aIrway epIthelIum and
broncmal reactIVIty m patIents WIth asthma Am Rev Respir DIS 131 599-606
Lambert, W E (1991) [Letter to Dr Denms KotcIDnar concemmg mtrogen dIOXide measurements for a sample
of 100 homes participatmg m the UNM study of mfant respIratory tllness] Albuquerque, NM The
Umversity of New MeXICO, New MeXICO Tumor RegIstry MedIcal Center, July 10
Leaderer, B P, Zagramskt, R T, BerwIck, M , StolwIJk, J A J (1986) Assessment of exposure to mdoor aIr

contamInants from combustIon sources methodology and applIcatIon Am J EpidemIol 124 275-289
16-36
Leaderer, B P, Zagramsla, R T, BerwIck, M , StOlWIJk, J A J (1987) PredIctIng N02 levels m resIdences
based upon sources and source use a multivanate model Atmos EnvIron 21 361-368
Marbury, M C, Harlos, D P, Samet, J M, Spengler, J D (1988) Indoor reSIdentIal N02 concentratIons m

Albuquerque, New MeXIco JAPCA 38 392-398
MargolIs, P A, Greenberg, R A, Keyes, L L, Lavange, L M, Chapman, R S, Denny, F W , Bauman,

K E, Boat, B W (1992) Lower respIratory Illness m mfants and low socIOeconomIC status
Am J PublIc Health 82 1119-1126
Mauderly, J L, BIce, DE, Cheng, Y S, Gillett, N A, Henderson, R F , Pickrell, J A, Wolff, R K

(1989) Influence of expenmental pulmonary emphysema on tOXicologICal effects from Inhaled mtrogen
dIOXide and dIesel exhaust Cambndge, MA Health Effects InstItute, report no HEI-RR-89/30
AVailable from NTIS, Spnngfield, VA, PB90-247347
Mauderly, J L, Cheng, Y S, GIllett, N A, Gnffith, W C, Henderson, R F, PIckrell, J A, Wolff, R K

(1990) Influence of preeXistIng pulmonary emphysema on su,sceptIbilIty of rats to chromc InhalatIOn
exposure to mtrogen dIOXide InhalatIon TOXIcol 2 129-150
Mella, R J W , Florey, C du V , Altman, D G, Swan, A V (1'977) ASSOCIatIOn between gas cookIng and
respIratory dIsease m chIldren Br Med J 2 149-152
Mella, R J W , Florey, C du V , ChInn, S (1979) The relatIOn between respIratory Illness m pnmary
schoolchIldren and the use of gas for cookIng I-results from a natIOnal survey Int J EpidemIOI
8 333-338
Mella, R J W , Florey, C du V , ChInn, S , Goldstem, B D, Brooks, A G F, John, H H, Clark, D ,

Craighead, I B, Webster, X (1980) The relatIon between mdoor air pollutIon from mtrogen dIOXide and
respIratory Illness m pnmary schoolchIldren Clm RespIr Physiol 16 7P-8P
Mella, R J W , Florey, C du V , Moms, R W , Goldstem, B D, John, H H, Clark, D , Craighead, I B,

Maclanlay, J C (1982) ChIldhood respIratory Illness and the home enVIronment II aSSOCIatIOn between
respIratory Illness and mtrogen dIOXide, temperature and re12ltIve hUmIdIty Int J EpidemIol
11 164-169
Mella, J , Florey, C , Sittampalam, Y , WatkIns, C (1983) The relatIon between respIratory Illness m Infants
and gas cookIng m the UK a prellmmary report In AIr qUalIty VIth world congress [proceedmgs of the
InternatIOnal Dmon of AIr PollutIon PreventIOn ASSOCIatIons], May, Pans, France Pans, France SEPIC
(APPA), pp 263-269
MIller, F J , Graham, J A, Raub, J A, lllmg, J W , Menache, M G, House, DE, Gardner, D E (1987)

Evaluatmg the tOXICIty of urban patterns of OXidant gases II Effects m mIce from chromc exposure to
mtrogen dIOXide J TOXIcol EnVIron Health 21 99-112
MochItate, K , TakahashI, Y , OhsumI, T , MIUra, T (1986) ActIv.ttIon and mcrement of alveolar macrophages
mduced by mtrogen dIOXide J TOXIcol EnVIron Health 17 229-239
Mohsenm, V (1987a) AIrway responses to mtrogen dIOXide m astmnatIc subjects J TOXIcol EnVIron Health
22 371-380
Mohsenm, V (1987b) Effect of VItamIn Con N02-mduced airway hyperresponsiveness m normal subjects
a randOmIzed double-blmd expenment Am Rev RespIr DIS 136 1408-1411
16-37
Morrow, P E, Utell, M J (1989) Responses of susceptible subpopulatlOns to mtrogen dlOXlde Cambndge,
MotoIl11ya, K , Ito, K , Yoslnda, A , Idewara, S , Otsu, Y , Naka]una, Y (1973) [The effects of exposure to
N02 gas on the mfectIon of mfluenza Vl11lS of mouse-long term expenment m low concentration]
Kankyo Kagaku Kenkyu Hokoku (Clnba Dalgaku) 1 27-33
National Instd;utes of Health (1985) The defimtIon of emphysema report of a National Heart, Lung, and Blood
Institute, DIVISIon of Lung DIseases workshop Am Rev RespIr DIS 132 182-185
National Institutes of Health (1991) GUldelmes for the dIagnOSIS and management of astlnna Bethesda, MD
U S Department of Health and Human ServIces, National Heart, Lung, and Blood Institute, NatlOnal
Asthma Education Program, pubhcatIon no 91-3042
Neas, L. M , Dockery, D W, Ware, J H , Spengler, J D, Spelzer, FE, Ferns, B G, Jr (1991)

ASSOCIation of mdoor mtrogen dloXlde WIth respIratory symptoms and pulmonary functlOn m clnldren
Am J EpldeIl1101 134 204-219
Noy, D ; Lebret, E , WIllers, H , Wmkes, A , Bolel], J S M, Brunekreef, B (1986) EstImatmg human

exposure to mtrogen dloXlde results from a personal momtonng study among houseWIves EnVIron Int
12 407-411
O'Connor, G ; Sparrow, D , Taylor, D , Segal, M , WeISS, S (1987) AnalYSIS of dose-response curves to

methacholme an approach SUItable for population studIes Am Rev RespIr DIS 136 1412-1417
Ogston, SA, Florey, C du V , Walker, C H M (1985) The TaySIde mfant morbIdIty and mortahty study
effect on health of usmg gas for cooking Br Med J 290 957-960
Parker, R F., DaVIS, J K, Cassell, G H, Wlnte, H , DZIedZIC, D , Blalock, D K, Thorp, R B, Slmecka,

J W (1989) Short-term. exposure to mtrogen dlOXlde enhances susceptIblhty to munne respIratory
mycoplasmosls and decreases mtrapuhnonary klllmg of Mycoplasma pulmonzs Am Rev Resplr DIS
140 502-512
Pattemore, P K, Asher, M I, Hamson, A C, Mitchell, E A, Rea, H H, Stewart, A W (1990) The

mterrelatIonslnp among bronclnal hyperresponslveness, the dIagnOSIS of asthma, and astlnna symptoms
Am Rev. RespIr DIS 142 549-554
Port, CD, Ketels, K V , Coffin, D L, Kane, P (1977) A comparative study of expenmental and
spontaneous emphysema J TOXlcol EnVIron Health 2 589-604
Quackenboss, J J , Kanarek, M S, Spengler, J D , Letz, R (1982) Personal momtonng for mtrogen dlOXlde
exposure methodologIcal consideratlOns for a commumty study EnVIron Int 8 249-258
Quackenboss, J J , Spengler, J D, Kanarek, M S, Letz, R , Duffy, C P (1986) Personal exposure to

mtrogen dloXlde relatIonslnp to mdoor/outdoor aIr qualIty and actiVIty patterns EnViron SCI Technol
20 775-783
Quackenboss, J J , LebOWItz, M D , Crutchfield, CD, Burtclnn, D (1987) Indoor-outdoor relatlOnslnps for

partIculate matter and venficatIon of exposure claSSIfications In SeIfert, B , Esdorn, H , FIscher, M ,
Rueden, H , Wegner, J , eds Indoor aIr '87 proceedmgs of the 4th mternatIonal conference on mdoor
aIr qUalIty and chmate, V 1, volatlle orgamc compounds, combustion gases, particles and fibres,
mICrObIologIcal agents, August, Berlm, Federal Repubhc of Germany Berlm, Federal Repubhc of
Germany Institute for Water, Soll and Air HygIene, pp 534-538
16-38
RIchters, A , DamJI, K S (1988) Changes m T-Iymphocyte subpopulatIons and natural kIller cells followmg
exposure to ambIent levels of mtrogen dIoXide J TOXIcol Environ Health 25 247-256
RIchters, A , DamJI, K S (1990) The relatIonsmp between Inhalation of mtrogen dIOXide, the Immune system,
and progressIOn of a spontaneously occurnng lymphoma m AKR lllice J EnViron Pathol TOXIcol
Oncol 10 225-230
RobIson, T W , Duncan, D P, Forman, H J (1990) Chemoattractant and leukotnene B4 production from rat
alveolar macrophages exposed to mtrogen dIOXide Am J RespIr Cell Mol BIOI 3 21-26
Rombout, P J A, Dormans, JAM A, Marra, M , Van Esch, G J (1986) Influence of exposure regImen
on mtrogen dioXIde-mduced morphologIcal changes m the rat lung EnViron Res 41 466-480
Rose, R M, Fuglestad, J M, Skormk, W A, Hammer, S M, Wolfthal, SF, Beck, B D, Bram, J D

(1988) The pathophysIology of enhanced susceptIbIhty to munne cytomegalovIrus respiratory mfectIon
dunng short-tenn exposure to 5 ppm mtrogen dIOXide Am Rev RespIr DIS 137 912-917
Ryan, P B, Soczek, M L, Spengler, J D , BIllick, I H (1988a) The Boston reSIdential N02 charactenzatIOn
study I prehmmary evaluatIOn of the survey methodology JAPCA 38 22-27
Ryan, P B, Soczek, M L, Treltman, R D , Spengler, J D, BIlliCk, I H (1988b) The Boston reSIdential

N02 charactenzatIon study-ll survey methodology and population concentration estImates Atmos
EnViron 22 2115-2125
SagaI, M , Ichmose, T , Kubota, K (1984) StudIes on the bIOchellli(~al effects of mtrogen dIOXide IV RelatIOn
between the change of hPId peroXIdatIOn and the antImudatIve protective system m rat lungs upon hfe
span exposure to low levels of N02 TOXIcol Appl Pharmacol 73 444-456
Samet, J M, Utell, M J (1990) The nsk of mtrogen dIOXide what have we learned from epidellliologlCal and
chmcal studIes? TOXIcol fud Health 6 247-262
Samet, J M, Tager, I B, Speizer, F E (1983) The relatIonsllip between IeSpIratory Illness m chIldhood and
chromc mr-flow obstruction m adulthood Am Rev RespIr DIS 127 508-523
Samet, J M, Lambert, WE, SkIpper, B J , Cushmg, A H, Hunt, W C, Young, SA, McLaren, L C,

Schwab, M , Spengler, J D (1993) Health outcomes In NItrogen dIOXide and respiratory Illness m
cmldren, part I Cambndge, MA Health Effects Institute, Iesearch report no 58
SclI1esmger, R B (1987a) Effects of mterImttent inhalation exposurl;,s to llliXed atmospheres of N02 and H 2S04
on rabbIt alveolar macrophages J TOXIcol EnViron Health 22 301-312
SclI1esmger, R B (1987b) InterImttent inhalatIOn of mtrogen d1oXIdl~ effects on rabbIt alveolar macrophages
J TOXIcol EnViron Health 21 127-139
SclI1esmger, R B, Dnscoll, K E, Vollmuth, T A (1987) Effect of repeated exposures to mtrogen dIOXide and
sulfunc aCId llliSt alone or m combmatIOn on mucocIhary clearance from the lungs of rabbIts Environ
Res 44 294-301
Schwab, M , Spengler, J D , Ozkaynak, H (1990) Usmg longitudmal data to understand cmldren's actiVIty
patterns m an exposure context data from the Kanawha County Health Study In Indoor mr '90
precedmgs of the 5th mternatIOnal conference on mdoor mr qualIty and chmate, volume 2, charactenstIcs
of mdoor mr, July-August, Toronto, ON, Canada Ottawa, ON, Canada International Conference on
Indoor Alr Quahty and Chmate, Inc ,pp 471-476
16-39
Schwartz, J , Gold, D., Dockery, D W, WeIss, S T, Spelzer, F E (1990) PredIctors of asthma and
persIstent wheeze m a natIonal sample of chxldren m the Umted States assocIatIOn wIth socIal class,
pennatal events, and race Am Rev Resplr DIS 142 555-562
Sexton, K , I..etz, R., Spengler, J D (1983) Estunatmg human exposure to mtrogen dIoXide an mdoor/outdoor
modelmg approach EnVIron Res 32 151-166
Sxmth, W , Anderson, T , Anderson, H A, Remmgton, P L (1992) NItrogen dIoXide and carbon monoXide
mtoXIcatIonin an mdoor Ice arena-Wlsconsm, 1992 Morb Mortal Wkly Rep 41 383-385
Spengler, J D , Ferns, B G, Jr , Dockery, D W, Spelzer, F E (1979) Sulfur dIOXide and mtrogen dIOXide
levels mSIde and outsIde homes and the ImplIcatIons on health effects research EnVIron SCI Technol
13 1276-1280
Spengler, J D , Duffy, C P, I..etz, R , TIbbIttS, T W , Ferns, B G, Jr (1983) NItrogen dIOXide mSIde and
outsIde 137 homes and ImplIcatIons for ambIent au quahty standards and health effects research EnVIron
SCI Technol 17 164-168
Steele, G D, Wmchester, D P, Menck, H R (1991) Patterns of care Umted States (provIsIonal, 1985,
1988) COmmISSIOn on Cancer-Amencan College of Surgeons and the Amencan Cancer SocIety,
NatIonal Cancer Data Base
Suzuki, T , Ikeda, S , Kanoh, T , Mxzoguchx, I (1986) Decreased phagocytosIS and superoXIde anIon productIon
m alveolar macrophages of rats exposed to mtrogen dIOXide Arch EnVIron Contam TOXIcol
15 733-739
US Bureau of the Census (1991) StatistIcal abstract of the Umted States 1991 ll1th ed Washmgton, DC
US Bureau of the Census, pp 111 and 123
U S Department of Health and Human ServIces (1990) VItal and health statIstics current estImates from the
NatIonal Health IntervIew Survey, 1989 HyattSVIlle, MD PublIc Health ServIce, NatIonal Center for
Health StatIstics, DHHS publIcatIon no (PHS) 90-1504 (Senes 10 data from the NatIOnal Health Survey
no 176)
U S EnVIronmental ProtectIon Agency (1991a) NatIonal air qualIty and exmssIOns trends report, 1989 Research
Tnangle Park, NC Office of AIr QualIty Plannmg and Standards, EPA report no EPA/450/4-91/003
AVailable from NTIS, Spnngfield, VA, PB91-172247/XAB
US Environmental ProtectIon Agency (1991b) NatIonal air qualIty and exmsslons trends report, 1990 Research
Tnangle Park, NC Office of AIr QualIty Plannmg and Standards, EPA report no EPA-450/4-91-Q23
Avaxlable from NTIS, Spnngfield, VA, PB92-141555/XAB
Von Nledmg, G , Wagner, H M (1977) Expenmental studIes on the short-tenn effect of air pollutants on
pulmonary functIon m man two-hour exposure to NO z , 03 and SOz alone and m combmatIon
In Kasuga, S , Suzula, N , Yamada, T , KImura, G , InagakI, K , Onoe, K , eds Proceedmgs of the
fourth mternatIonal clean au congress, May, Tokyo, Japan Tokyo, Japan Japanese Umon of AIr
PollutIon PreventIon AssocIatIons, pp 5-8
Von Nleding, G , Wagner, H M, Krekeler, H , Loellgen, H , Fnes, W , Beuthan, A (1979) Controlled studies
of human exposure to smgle and combmed actIon of NO z , 03' and SOz Int Arch Occup EnVIron
Health 43: 195-210.
16-40
Von NIedmg, G , Wagner, H M, Casper, H , Beuthan, A, SlDldt, U (1980) Effect of expenmental and
occupational exposure to N02 ill sensItive and nonnal subjects In Lee, S D, ed NItrogen OXides and
their effects on health Ann Arbor, MI Ann Arbor SCIence JPubhshers, Inc, pp 315-331
Wardlaw, A J , Dunnette, S , GleIch, G J , Collms, J V , Kay, A B (1988) Eosillophds and mast cells ill
bronchoalveolar lavage ill subjects WIth lDlld asthma relatlOllsmp to broncmal hyperreactIvlty Am Rev
Ware, J H , Dockery, D W, SpirO, A , III, Speizer, FE, Ferns, B G, Jr (1984) PassIve smokmg, gas
cookmg, and respiratory health of cmldren hvmg ill SIX cItIe'S Am Rev RespIr DIS 129 366-374
Wdson, A L, Colome, S D, Baker, P E, Becker, E W (1986) ResIdentIal illdoor air qualIty

charactenzatIon study of mtrogen dIoXide Phase I Volumes 1, 2 and 3 Southern Cahfonna Gas
Company, October
Yamamoto, I , Takahasm, M (1984) Ultrastructural observatlOns of rat lung exposed to mtrogen dlOXIde for
7 months KItasato Arch Exp Med 57 57-65
16-41
APPENDIX A~.
GLOSSARY OF TERMS AND SYMBOLS
ABBREVIATIONS, ACRONYMS, AND SYMBOLS
A Angstrom (10- 10 meter)

"A" straIll A partIcular type of mfluenza vrrus
9-AA 9-Ammo-acndme
AaD°2 DIfference between alveolar and artenalIzed partial pressure of oxygen
AAS AtomIc absorption spectroscopy
AATCC Amencan ASSOCiatIOn of TextIle ChemIsts and Colonsts
ACH AIr changes per hour
Ad A partIcular straIll of laboratory mouse
AD Annular denuder
AICHE Amencan Institute of ChemIcal Engmeers
AIDS AcqUIred Immune deficIency syndrome
AIRS Aerometnc Information Retneval System
Al Alummum
Al3 + Alummum Ion
Al2( S04)3 Alummum sulfate
AM Alveolar macrophage
(¥TM Alpha-2-macroglobuhn
AMP Adenosme monophosphate, adenosme 5' phosphate
AMT AnthmetIc mean thickness
ANC ACId-neutrahzmg capaCIty
ANOVA AnalYSIS of vanance
ANSA 8-ammo-1-naphthalene-sulfomc aCId
ANSI Amencan National Standards Institute
APCD AIr Pollution Control Dlstnct
A-I
APHA American Pubhc Health ASSOCiatIOn
alPI Alpha-I-protease mlnbltor
A1PRl8 A partlcular stram of mfluenza vrrus
A1PRl8/34 A partlcular stram of mfluenza vrrus
AQCR AIr QualIty Control RegIOn
AQIRP AIr QualIty Improvement Research Program
AQSM AIr QualIty SImUlatIOn Model
AS'IM Amencan SOCIety for Testmg and Matenals
atm One atmosphere, a umt of pressure
ATP Adenosme tnphosphate
avg Average
BAKI PotaSSIUm IodIde solutIOn aCldrfied WIth bonc aCId
BAL Bronchoalveolar lavage
BaS 04 Banum sulfate
BHA Butylated hydroxyamsole
BHPN N-bIS(2-hydroxypropyl)mtrosamme
BHR BronchIal or airways hyperresponslveness
BHT Butylated hydroxytoluene
BMRC Bntlsh MedIcal Research CouncIl
BP Blood pressure
Br Bromine
BrN03 Bromme mtrate
BrO Bromme monOXide
b
scat Extinctlon coeffiCIent due to scatter by aerosols
°C Degrees CelsIUS (Centlgrade)
l3
C Carbon-13
l4
C Carbon-14, a radIoactlve form of carbon
Ca CalCIUm
Ca2 + CalCIUm Ion
CAA Clean AIr Act
cAMP Cychc adenosme monophosphate, adenosme 5'-phosphate
A-2
CAMP Commumty AIr Momtonng Program
CASAC Clean AIr ScientIfic AdvISOry Commlttee
C57BL A partIcular stram of laboratory mouse
C57BL/6 A partIcular stram of laboratory mouse
CD-l A partIcular stram of laboratory mouse
CDC Centers for DIsease Control
cGMP Cychc guanosme monophosphate, gulIDosme 5'-phosphate
CH4 Methane
C3H A partIcular stram of laboratory mouse
C3H 6 Propylene
CbB Chohnesterase
CI Confidence mterval
CI Chlonne
cr Chlonde IOn
Cl2 Chlonne molecule
CL Lung comphance
C Ldyn DynamIc lung comphance
CLM Chemllummescence
CLM-PC Chemllummescence WIth photolytIc converter
ClN03 Chlonne mtrate
CIO Chlonne monmade
StatIC lung comphance
cm CentImeter
CNG Compressed natural gas
CNS Central nervous system, the bram and spmal cord
CO Carbon monmade
CO2 Carbon dIOXIde
13
C02 Carbon-13 labeled carbon dIOXIde
CoA Coenzyme A
COH CoeffiCIent of haze
COPD Chromc obstructIve pulmonary dIsease
A-3
CPK Creatme phosphokInase
CR-l A partIcular stram of laboratory mouse
CRD Chromc respIratory disease
CRD Completely randomlZed design
CSTR Contmuously strrred tank reactor
CXT Exposure concentratlOn m ppm mulbphed by bme of exposure m hours or
other bme measurement
Cu-Cd Copper-cadmmm
CV Closing volume
CV CoeffiCient of vanance
CVM Contmgent valuatlOn method
DIO Dose that would cause a 10% decrease m functlOnal expIratory volume
m 1 second
D = CT Dose equals concentratlOn mulbphed by bme
DD Denuder drfference
DEN Diethylmtrosamme (also DENA)
DIAL Duferenbal absorpbon hdar
DIFKIN DlffuslOn Kmebcs Model
DIN Total morgamc mtrogen
DLco DlffuslOn capaCity of the lung for carbon monoXlde
DMA DlIDethylamme
DMN DlIDethylmtrosamme
DNA Deoxynbonuc1eic aCid
DOAS Drfferenbal opbcal absorpbon spectroscopy
DON Dissolved orgamc mtrogen
DPPD N,N-dlphenylphenylened1amme
BC PreflX of Intemabonal CommiSSion on Enzymes' identIficatlOn numbers
BDF Environmental Defense Fund
BGR Exhaust-gas recrrculatlOn
BKG ElectrocardlOgram
EPA U S Envrronmental ProtectlOn Agency
EPRI Electnc Power Research Insbtute
A-4
EV Electnc velucle
Degrees FahrenheIt
FAV Fmal acute value
FCV Fmal chromc value
Fe Iron
FEF Forced exprratory flow
FeS04 Iron sulfate
FET FIrst-edge tnne
FEV Forced exprratory volume
FEV075 o 75-Second forced exprratory volume
FEV 10 One-second forced expIratory volume
FEV25 _75 % Forced exprratory volume at 25 to 7'5 % of VItal capacIty
FP Filter pack
FRM Federal Reference Method for aIr quahty measurement
ft Foot
FT Founer transform spectroscopy (also FS)
FTIR Founer transform mfrared spectroscopy
FVC Forced VItal capaCIty
FW Fresh weIght of plant matenal
g Gram
Gaw AIrway conductance
GC Gas chromatography
GC Guanylate cyclase
GC-ECD Gas chromatography WIth electron capture detectIOn
GC-FID Gas chromatography WIth flame IOmzatIOn detectIon
GC-MS Gas chromatograph m combmatIon WIth mass spectrometry
GDH Glutamase dehydrogenase
GM General Motors COIpOratIOn
GMP Guanosme 5'-phosphate, guanosme monophosphate
GOGAT Glutamme oxoglutarate ammotransferase (or glutamate synthase)
G-6-P Glucose-6-phosphate
A-5
GP-CLM Gas-phase chemtlummescence
GPT Gas-phase tItration
GS Glutamme synthetase
GSH A tnpeptide, glutatlu.one (reduced form)
GSSG The dIsulfide (oXldlZed) form of GSH
GlE/CIlE Global Troposphenc Expenment/Chemlcal InstrumentatIOn Test and
EvaluatIOn
h Hour
H· Hydrogen (free radIcal)
H+ Hydrogen Ion
3
H TntIum, a radIOactIve form of hydrogen
ha Hectare
HBEF Hubbard Brook Expenmental Forest
Hb02 Oxyhemoglobm
HC Hydrocarbon
HCI HydrocWonc aCId
HCN Hydrogen cyamde
HOV Heavy-duty velu.c1e
HF Hydrogen fluonde
5-IllAA 5-Hydroxymdoleacetlc aCId
HIV Human lIDmunodeficlency VIruS
hv Planck's constant (h) tlIDes the frequency of radIated energy (v) = Quanta
of energy (E)
HN02 NItrouS aCId (hqUld form)
HN03 Nltnc aCId (also HONO~
HO· Hydroxyl free radIcal (also OH)

H02 • Hydroperoxyl free radIcal
H 20 Water
H 20 2 Hydrogen peroXIde
HONO NItroUS aCId (gaseous form)
H02N02 Peroxymtnc aCId
A-6
HPIC HIgh perfonnance Ion chromatograph
HPLC HIgh perfonnace hqUld chromatograph
HR Heart rate
H 2S Hydrogen suHide
H 2S04 Sulfunc aCId
5-HT Serotonm
3H -thymldme Tntiated thymldme
IARC InternatIOnal Agency for Research on Cancer
IC Ion chomatography
IF IrngatIon and fertlhzatIOn
IFS Integrated Forest Study
Ig Immunoglobuhns
IgA Immunoglobuhn A fractIOn
IgG Immunoglobuhn G fraction
IgG l Immunoglobuhn G 1 fractIOn
IgG2 Immunoglobuhn G2 fraction
IgM Immunoglobuhn M fraction
IL-l Interleukm-l
m Inch
IR Infrared
IRGA Infrared gas analysIs
k Rate constant or diSSOCiatIOn constants
K Potassmm
K+ Potassmm Ion
kg KIlogram
Ian KIlometer
L LIter (also £)
LAR Leaf area ratio
LC50 Lethal concentratIOn 50 %, that concentratIOn which IS lethal to 50 % of test
subjects
LD50 Lethal dose 50 %, dose which IS lethal to 50 % of the subjects
A-7
LDH Lachc aCId (lactate) dehydrogenase
LDV LIght-duty vehIcle
UP Laser-mduced fluorescence
LM LIght mIcroscope
LNG Liquefied natural gas
10gEF Base 20 loganthm of the emISSIon factor
LPG LIquefied petroleum gas
LPS Bactenal hpopolysacchande
LT50 The time requrred for 50 % of the test ammals to dIe when gIven a lethal
dose
Leukotnene B4
m Meter
M Molar
M Thrrd body (m a reachon)
M85 Fuel blended from 85 % methanol and 15 % gasohne
MlOO Methanol
MAl{ Maxnnum permIsSIble concentrahon (m Germany)
max Maxnnum
MDL Mmlmum detectIOn hmlt
MERL Manne Ecosystem Research Laboratory
MFR Maxnnal flow rate
Mg MagneSIUm
Mg2 + MagneSIUm Ion
p.g MIcrogram
p.g/m3 Micrograms per CUbIC meter
3
mg/m MIlhgrams per CUbIC meter
MgO MagneSIUm OXide
MgS04 MagneSIUm sulfate
mm Minute
MIT Massachusetts Institute of Technology
mL MIlhhter
p.L Mlcrohter
A-8
/-tm MIcrometer
mM Millnnolar
MMD Mass medIan diameter
MMEF Maxunal midexprratory flow
MMFR Mid-maxunal flow rate
mo Month
MPC Maxunum permIssIble concentration (m the U S S R )
i
MSA
MSCET
.
Metropohtan Statistical Area
Month and State current emISSIon trends
1
MT Metnc ton
N AtomIc mtrogen
N Normal
N2 Molecular mtrogen
13
N Nitrogen-13, a radioactIVe form of mtrogen
15
N Nitrogen-l 5
Na+ Sodium IOn
NA Not apphcable
NAAQS Natronal AmbIent Air Quahty Standard
NaCI Sodium chlonde, common table salt
Na2C03 Sodium carbonate
NAD+ Nicotmamide-adenme dmucleotIde (-I- mdicates OXIdJzed form)
NADB National AIr Data Bank
NADH Nicotmamide-adenme dmucleotIde (reduced form)
NADP NatIOnal ACId DepOSItIOn Program
NADP+ Nicotmamide adenme dmucleotIde phosphate
NADPH Nicotmamide-adenme dmucleotIde phosphate (reduced form)
NaF SodIUm fluonde
NAMS National AIr Momtonng StatIOn
NaN°2 SodIUm mtnte
NaN°3 SodIUm mtrate
NaOH SodIUm hydrOXide
A-9
NAPAP NatiOnal ACId PreCIpItatIon Assessment Program
NaR NItrate reductase
NAR Net assnmlatlon ratIo
NAS NatIonal Academy of SCIences
NASA NatiOnal AeronautIcs and Space AdmlDlstration
NASN NatiOnal AIr Surveillance Network
NCF Neutroplnl chemotactIc factor
NDIR Nondlsperslve Infrared
NDMA NitrosodImethylamme
NEDA N-(1-Naphthyl)-ethylenedmmme dIhydrochlonde
NEDS NatIonal EmISSIons Data System
NEIC NatIonal Enforcement InvestIgatiOns Center
ng Nanogram
NGV Natural gas vehIcle
NH3 Ammoma
NH4 + Ammomum Ion
15 + Nltrogen-15 labeled ammomum Ion
NH4
NHLBI NatiOnal Heart, Lung, and Blood InstItute
NH4N03 Ammomum mtrate
(NI4hS04 Ammomum sulfate
NIH NatIonal InstItutes of Health
NIR NItrIte reductase
NIST NatiOnal InstItute of Standards and Technology
NK Natural killer cell
nm Nanometer
NMHC Nonmethane hydrocarbon
N-6-MI N-mtrosoheptamethyleneImme
NMOR N-mtrosomorpholme
NO NItrIC OXide
N02 NItrogen dIOXide
15
NOz NItrogen-IS labeled mtrogen dIOXide
A-IO
N02- Nltnte Ion
N03 NItrate radIcal or mtrogen tnmade
N03 - NItrate Ion
lSN0 - Nltrogen-15 labeled mtrate Ion
3
N 20 NItroUS made
N 20 3 D1ll1trogen tnmade
N 20 4 D1ll1trogen tetroXide
N 20 S D1ll1trogen pentmade
NOHb Nltrosylhemoglobm
NOx NItrogen oXides
NOy Sum of oXides of mtrogen and other OXIdJ.zed mtrogen compounds,
excludIng mtrous OXide
NPN n-Propyl mtrate
4-NQO 4-Nltroqumohne-l-oXIde
NRA NItrate reductase actiVIty
NSA Nltrosatmg agent
NSF National SCIence FoundatIOn
NSS NatIOnal Stream Survey
NSWS NatIOnal Surface Water Survey
AtomIC oxygen
°
°2 Molecular oxygen
°3 Ozone
OAQPS Office of AIr QualIty Planmng and Standards
O(lD) EXCIted atomIC oxygen
ODS Oxygen depletIOn sensor
OH Hydroxyl group
OH- HydroXide Ion
ON+ Nltrosomum Ion
[lSO]-N02 Oxygen-15 labeled mtrogen dloX1de
Oep) Ground state atomIC oxygen
OR Odds ratIO
P Phosphorus
A-ll
32p
Phosphorus-32, a radIOactive form of phosphorus
PaC02 Artenal partIal pressure of carbon dIOXIde
PAC02 Alveolar partIal pressure of carbon dIOXIde
PAR p-AmmIohIppunc aCId
PAN Peroxyacetyl mtrate
Pa02 Artenal partIal pressure of oxygen
PA02 Alveolar partIal pressure of oxygen
PARS PrecuslOn Accuracy Reporting System
PBzN Peroxybenzoyl mtrate
PD40 Dose requIred to reduce specIfic arrway conductance by 40 %
PD lOO Dose of methacholme requIred to double specIfic arrway resIstance
PDlORHE ProvocatIve dose m respIratory heat exchange umts needed to decrease
functIOnal expIratory volume m 1 second by 10 %
ConcentratIon of sulfur dIOXIde requIred to mcrease specIfic arrway
resIstance by 8 umts
PEF Peak expIratory flow
PEFR Peak expIratory flow rate
PBFV PartIal expIratory flow volume
PEF40%VC PartIal expIratory flow at 40 % of VItal capacIty
PF Photofragmentation
PFC Plaque-formmg cell
6-P-G 6-Phosphogluconate
pH Log of the recIprocal of the hydrogen IOn concentration
PHA Phytohemagglutmm
PI Inorgamc phosphate
PM PartIculate Matter
PM Photomultipher
PMN PolymOlphonuc1ear leukocyte
PN PartIculate mtrate
P02 PartIal oxygen pressure
ppb Parts per billIon
pphm Parts per hundred millIon
A-12
ppm Parts per mIlhon
PPN PeroxypropIOnyl mtrate
ppt Parts per trIlhon
PSC Polar stratosphenc cloud
PSD PaSSIve samplmg devIce
P value Probability
PVlOOSRaw(S02) VentilatIOn of sulfur dIOXide requIred to produce a 100 % mcrease m
specIfic arrway resIstance
Q CardiaC output
QRS A complex of three dIstmct electrocardIOgram waves whIch represent the
begmmng of ventncular contractIOn
RAMS RegIOnal AIr Momtonng System
RAPS RegIOnal AIr PollutIOn Study
Raw AIrway resIstance

RBC Red blood cell, erythrocyte
RCBD RandomIZed complete block dIagram
RC(0)02N02 Peroxyacylmtrate
RD Relative duration
RGR Relative growth rate
RH RelatIve humIdIty
RHE RespIratory heat exchange
RIBD RandomIZed mcomplete block dIagram
RM Reference method for arr qualIty measurement
RNA RibonucleIc aCId
R02• Orgamc peroxy radIcal (where R IS an orgamc mOIety)
RR RelatIve nsk
RSD RelatIve standard deViatIOn
RSV RespIratory syncytIal VlfUS
RT Total respIratory reSIstance
RUBIS CO RIbulose-l,5-biphosphate carboxylase-oxygenase
RV ReSIdual volume
S Sulfur
A-13
SAl SCIence ApphcatlOns, Inc
SD Standard devIatlOn
SEM Scannmg electron mIcroscope
SEM Standard error of the mean
SES SocIoeconomIc status
SF6 Sulfur hexafluonde
SGaw Specific arrway conductance
SGOT Serum glutamlc-oxaloacetIc transammase
SGPT Serum glutamIC-pyruVIC transammase
SH- Sulfbydryl group
SMSA Standard Metropohtan StatIstICal Area
SN Suspended mtrates
S02 Sulfur dIOXide
sol- Sulfate Ion (also S04 =)
SOD SuperoXIde dlsmutase
SOx Sulfur OXides
SP Single photon
SPF SpecIfic pathogen free
SRaw SpecIfic arrway resIstance
SRBC Sheep red blood cell
SRM Standard reference matenal
SS Suspended sulfates
STP Standard temperature and pressure
TA Tungstlc aCId
TBA ThIobarbitunc aCId
IDLAS Tunable-dIode laser spectroscopy
TEA Tnethanolamme
TEM TransmIsSIon electron mIcroscope
TFR TranSItIon flow reactor
Tg Terragram, 106 metnc tons or 10 12 grams
TGS-ANSA A 24-hour method for the detectIon of analySIS of N~ m ambIent aIr
A-14
TGV ThoracIc gas volume
TLC Total lung capacIty
T-NH3 Total ammoma
TNT Tnmtrotoluene
TP Total phosphate
TP Two photon
TPTT 20 % transport time
TSP Total suspended partIculate
TTFMS Two-tone frequency modulated spectroscopy
UV UltravIolet
UVGSH Unvented gas space heater
VC VItal capacIty
VB Ventilatory volume
VE Mmute ventdatIon
VEE Venezuelan equme encephalomyehtIs (VIrUS)
V/FFV Vanable- or fleXlble-fuel vehIcle
Vmax MaXImum expiratory flow rate
VOC Volatde orgamc compound
VT Total volume
V/V Volume per volume
VSO%VC Ventilation at 50 % VItal capacIty
WBC White blood cell
WTP Wllhngness to pay
Xe Xenon
ZEV Zero EmISSIOn Vehicle
Zn Zmc
> Greater than
< Less than
= ApproXImately
A-I5
GLOSSARY
AaD02 Alveolar-artenal chfference or gradIent of the partIal pressure of oxygen An overall

measure of the effiCIency of the lung as a gas exchanger In healthy subjects, the
gradIent is 5 to 15 nulhmeters of mercury (torr)
A1PRfS virus- A type of vrrus capable of causmg mfluenza m laboratory anImals, also,
A1PRfS/34
AbSCISSIon The process whereby leaves, leaflets, fruItS, or other plant parts become detached
from the plant
Absorption coeffiCIent A quantIty whIch charactenzes the attenuatIOn WIth dIstance of a beam
of electromagnetic radIatIon (1Jke hght) ill a substance
Absorption spectrum The spectrum that results after any radIatIon has passed through an
absorbmg substance
AbstractIOn Removal of some constItuent of a substance or molecule
Acetaldehyde- CH3 CHO, an illtermed1ate ill yeast fermentatIOn of carbohydrate and ill alcohol
metabohsm, also called acetic aldehyde, ethaldehyde, ethanal
Acetate rayon A staple or filament fiber made by extruSIon of cellulose acetate It IS

sapomfied by dilute aIkah, whereas VIscose rayon remams unchanged
Acetylchohne A naturally occurrmg substance m the body that can cause constnctIon of the
bronchI ill the lungs
Acid: A substance that can donate hydrogen Ions
Acid dyes- A large group of synthetIc coal-tar-denved dyes that produce bnght shades m a
wide color range Low cost and ease of apphcatIOn are features that make them the
most WIdely used dyes for wool Also used on nylon The term aCId dye IS denved
from therr precIpItatIon ill an aCId bath
Acid mucopolysacchande A class of compounds composed of protem and polysacchande

Mucopolysacchandes compnse much of the substance of connectIve tIssue
ACid phosphatase An enzyme (BC 3 1 3 2) that catalyzes the dISaSSOCiatIon of phosphate

(P04) from a WIde range of monoesters of orthophosphonc aCId ACId phosphatase IS
active m an aCIdIc pH range
ACId rain- Rain havmg a pH less than 5 6, the mffilffium expected from atmosphenc carbon
diOXide
A-16
Acrolem CH2 = CHCHO, a volatIle, flammable, oily hqUId givmg off rrntant vapor Strong
rrntant of sIan and mucuous membranes Also caIled acryhc aldehyde or 2-propenal
Acryhcs (plastIcs) PlastIcs that are made from acryhc aCid and are hght m weight, have
great breakage resistance, and lack odor and taste Not resistant to scratchmg, bums,
hot water, alcohol, or cleanmg flUIds Examples mclude Lucite and PleXiglas Acryhcs
are thennoplastIcs and are softened by heat and hardened mto defimte shapes by
coohng
Acryhc fiber The genenc name of manufactured fibers denved from acryhc resms
(milllffium of 85 % acrylomtnte umts)
ACtllllC A tenn apphed to wavelengths of hght too small to affect one's sense of sight, such
as ultraViolet
Actmomycetes Members of the genus Actmomyces, nonmotile, nonsporefonnmg, anaerobic

bactena, mcludmg both soil-dweIlmg saprophytes and disease-producmg parasites
ActivatIon energy The energy requrred to bnng about a chemical reactIon
Acute respiratory disease Respiratory mfectiOn, usuaIly with rapid onset and of short
duratiOn
Acute tOXiCity Any pOisonous effect produced by a smgJle short-tenn exposure that results m
severe biological harm or death
Acyl Any orgamc ramcal or group that remams mtact when an orgamc aCid fonns an ester
Adenoma An ordmanly bemgn neoplasm (tumor) of epithehal tissue, usuaIly weIl

crrcumscnbed, tendmg to compress adjacent tIssue rather than mfiltratmg or mvadmg
Adenosme monophosphate (AMP) A nucleotide found among the hydrolysis products of all
nucleiC aCids, also caIled adenyhc aCid
Adenosme tnphosphatase (ATPase) An enzyme (EC 3 6 I 3) m muscle and elsewhere that

catalyzes the release of the mgh-energy, tennmal phosphate group of adenosme
tnphosphate
Adrenalectomy Removal of an adrenal gland This gland is located near or upon the kidney
and is the Site of ongm of a number of honnones
Adsorption AdheSiOn of a thm layer of molecules to a hqUId or sohd surface
AdvectiOn Honzontal flow of arr at the surface or aloft, one of the means by wmch heat is
transferred from one regiOn of the earth to another
A-I?
Aerodynanuc diameter The dIameter of a urnt densIty sphere havmg the same settlmg speed
(under gravIty) as the partIcle m questIon of whatever shape and densIty
Aerosol' Solid particles or hqUld droplets that are dIspersed or suspended m a gas
AgglutinatIon The process by whIch suspended bactena, cells, or smular partIcles adhere
and form mto clamps.
Airborne pathogen A disease-causmg microorgamsm that travels m the aIr or on partIcles m

the aIr.
Air pollutant A substance present m the ambIent atmosphere, resultIng from human actIVIty
or from natural processes, whIch may cause damage to human health or welfare, the
natural envIronment, or matenals or objects
Air spaces: All alveolar ducts, alveolar sacs, and alveoh To be contrasted WIth arrways
Airway conductance (Gaw)' RecIproCal of arrway reSIstance Gaw = (lIRaw)
AIrway resistance <Raw) The (fnctIOnal) reSIstance to aIrflow afforded by the arrways
between the airway openmg at the mouth and the alveoh
Airways. All passageways of the respIratory tract from mouth or nares down to and mcludmg
respiratory bronchIoles To be contrasted WIth aIr spaces
Alanme aminotransferase An enzyme (BC 2 6 1 2) transfemng ammo groups from L-alanme

to 2-ketoglutarate Also known as alanme transammase
Albumm' A type of SImple, water-soluble protem WIdely dIstnbuted throughout anImal tIssues
and fluids, partIcularly serum
o
Aldehyde: An orgamc compound charactenzed by the group -GH
Aldolase An enzyme (BC 4 1 2 7) mvolved m metabohsm of fructose that catalyzes the

formatIon of two three-carbon mtermedIates m the major pathway of carbohydrate
metabolism
Algal bloom: Sudden spurt m growth of algae that can adversely affect water quahty
AlkalI: A salt of sodIUm or potaSSIUm capable of neutrahzmg aCIds
Alkalme phosphatase A phosphatase (BC 3 1 3 1) WIth an optImum pH of 8 6, present

ubiqUItously
Allergen: A material that, as a result of commg mto contact WIth appropnate tIssues of an
animal body, mduces a state of senSItIvIty resultmg m vanous reactIOns, generally
aSSOCIated WIth IdIOsyncratIc hypersensItIvItIes
A-18
Alpha-hydroxybutyrate dehydrogenase An enzyme (Ee 1 1 1 30), present mamly in
mltochondna, that catalyzes the converSIOn of hydroxybutyrate to acetoacetate
mtermedJ.ate bIochemIcal pathways
Alpha rhythm A rhythmIc pulsatIOn obtamed m bram waves exhIbited m the sleepmg state of
an mdIvldual
Alveolar capillary membrane Fmest portIOn of alveolar capillanes, where gas transfer to and
from blood takes place
Alveolar macrophage (AM) A large, mononuclear, phagocytIC cell found on the alveolar
surface, responSIble for partIcle clearance from the deep lung and for vIral and bactenal
killmg
Alveolar oxygen partial pressure (PA02) Partial pressure of oxygen m the arr contamed ill
the arr sacs of the lungs
Alveolar septa The tissue between two adjacent pulmonary alveoh, consIstIng of a
close-meshed capillary network covered on both surfaces by thm alveolar eplthehal
cells
Alveolus An arr cell, a termmal, sac-hke dIlation m the, lung Gas exchange (oxygen/carbon
dIOXide) occurs here
AmbIent The atmosphere to whIch the general populatIOn may be exposed Construed here
not to mclude atmosphenc condItIOns mdoors, or m the workplace
Amme A substance that may be denved from ammoma (NH3) by the replacement of one,
two or three of the hydrogen (II) atoms by hydrocarbons or other radIcals (pnmary,
secondary, or tertIary ammes, respectively)
Ammo aCIds Molecules conslstmg of a carboxyl group, a baSIC ammo group, and a reSIdue
group attached to a central carbon atom Serve as the bUlldmg blocks of protems
p-AmmohIppunc aCId (PAH) A compound used to detennme renal plasma flow
Ammotnazole A systemIC herbICIde (C 2H 4N4 ) used m 3lIeas other than croplands, that also
possesses some antithyrOId actiVIty, also called amltrole
AmmomficatIOn Decomposloon WIth productIOn of ammoma or ammomum compounds,

especIally by the actIOn of bactena on mtrogenous orgamc matter
Ammomum Amon (NH4 +) or radIcal (NH4) denved from ammoma by combmatIOn WIth
hydrogen Present m ramwater, sons and many commerCIal fertilizers
Amnestic Pertams to ImmUnologIC memory upon recellVmg a second dose of antIgen, the
host "remembers" the :fITst dose and responds faster to the challenge
A-19
Anaerobic' Llvmg, actlVe or occurrmg m the absence of free oxygen
Anaerobic bacteria A type of microscoPic orgamsm that can hve m an envrronment not
containmg free oxygen
Anaphylactic dyspneiC attack Drfficulty m breathmg associated With a systemic allergic

response
AnaphylaxJ.s· A term commonly used to denote the lffiffied1ate, transient kind of

lffimunological (allergiC) reaction charactenzed by contraction of smooth muscle and
d1lation of capillanes due to release of pharmacologIcally active substances
Angiosperm' A plant havmg seeds enclosed m an ovary, a flowenng plant
Angina pectons' Severe constrlcung pam m the chest that may be caused by depletion of
oxygen delivery to the heart muscle, usually caused by coronary dIsease
8
Angstrom (A): A urnt (10- cenumeter) used m the measurement of the wavelength of hght
Anhydnde' A compound resulung from removal of water from two molecules of a carboxyhc
(-COOH) aCId Also, may refer to those substances (anhydrous) that do not contam
water in chemIcal combmation
Anion. A negatively charged atom, radIcal, or Ion
Anorexia. DlffiImshed appetite, averSIOn to food
AnOXiC' WIthout or depnved of oxygen
Antagornsm' When the effects of a miXture are less than the sum of the effects of each
mdIvldual chemIcal
Anthraqumone. A yellow crystallme ketone (C 14H 80z) denved from anthracene and used m
the manufacture of dyes
Anthropogernc Of, relaung to, or mfluenced by humans An anthropogernc source of

pollution IS one caused by human actIOns
Antibody' Any body or substance evoked by the sumulus of an antigen and that reacts
speclfically WIth an antigen m some demonstrable way
Antigen' A matenal such as a foreIgn protem that, as a result of commg m contact WIth
appropnate tissues of an ammal, after a latent penod, mduces a state of senSItiVity
and/or the production of an antibody
Antistatic agent A chemIcal compound apphed to fabncs to reduce or ehmmate accumulation

of static electncity
A-20
AracIndomc aCJld Long-cham fatty-acId that serves as a precursor of prostaglandms
Area source In aIr pollutIOn, any small mdIvidual fuel combustIOn or other pollutant source,
also, all such sources grouped over a specIfic area
Aromatic Belongmg to that senes of carbon-hydrogen c:ompounds m wInch the carbon atoms
form closed rmgs contammg unsaturated bonds (as m benzene)
Artenal partial pressure of oxygen (Pa02) PortIon of total pressure of dIssolved gases m
artenal blood as measured dIrectly from artenal blood
Artenahzed partIal pressure of oxygen The portIOn of total pressure of dIssolved gases m
artenal blood attnbuted to oxygen, as measured flOm nonartenal (e.g, ear-pnck)
blood
Artenosclerosls Commonly called hardenmg of the artenes A condItion that eXists when
the walls of the blood vessels tIncken and become m:fIltrated wIth exceSSIve amounts of
mmerals and fatty matenals
ArtIfact A spunous measurement produced by the samphng 01 analysIs process
AscorbIc aCId Vltamm C, a strong reducmg agent wIth antIoXJldant propertIes
Aspartate transammase Also known as aspartate amm01 ransferase (BC 2 6 1 1) An enzyme

catalyzmg the transfer of an amme group from glutamIC acid to oxaloacetIc aCId,
forming aspartIc aCId m the process Serum level of the enzyme IS mcreased m
myocardIal mfarctIon and m dIseases involvmg destructIon of hver cells
AsphyXia ImpaIred exchange of oxygen and carbon dIOXide, excess of carbon dIOXide,
and/or lack of oxygen, usually caused by ventilatory problems
Asthma A dIsease charactenzed by an mcreased responSIveness of the arrways to VarIOUS

stImuh and mamfested by slowmg of forced eXpIratIOn that changes m seventy eIther
spontaneously or as a result of therapy The term asthma may be modIfied by words or
phrases mdIcatmg ItS etiology, factors provokmg attacks, or duratIOn
AsymptomatIc PresentIng no subjective eVIdence of dIslease
Atmosphere The body of arr surroundmg the earth Also, a measure of pressure (atm) equal
to the pressure of arr at sea level, 14 7 pounds per square mch
Atmosphenc depOSItion Removal of pollutants from the: atmosphere onto land, vegetation,
water bodIes, or other objects by absorption, sechmentatlOn, Browman dIffuSIOn,
Impaction, or precIpItation m ram
A-21
Atomic absozption spectrometry A measurement method based on the absozptiOn of radIant
energy by gaseous ground-state atoms The amount of absozptIon depends on the
population of the ground state, whIch IS related to the concentratiOn of the sample bemg
analyzed
Atopic Chmcal hyperreactIvity of the arrways assocIated WIth asthma and allergIes
Atropme: A pOIsonous, whIte crystalline alkalOId (C 17H 23 N03) denved from belladonna and
related plants, used to reheve spasms of smooth muscles It IS an antIchohnergic agent
that blocks the parasympathetic actiOns of acetylchohne and other chohnerglc agents
Autocorrelation Statistical mterdependence of vanables bemg analyzed, produces problems,

for example, when observations may be related to preVIOUS measurements or other
conditions
AutOImmune dIsease A condItion m whIch antibodIes are produced agamst the subject's own
tissues.
Autologous. A term referrmg to cellular elements, such as red blood cells and alveolar
macrophages, from the same orgamsm, also, somethmg natually and normally
occurring m some part of the body
AutotrophIc A term applied to those mlcroorgamsms that are able to mamtam hie WIthout an
exogenous orgamc supply of energy, or whIch only need carbon dIOXide or carbonates
and SImple morgamc mtrogen
AutotrophIc bactena A class of mlcroorgamsms that reqUIre only carbon dIOXide or

carbonates and a SImple morgamc mtrogen compound for carrymg on hie processes
Auxin· An orgamc substance that causes lengthenmg of the stem when apphed m low
concentratiOns to shoots of growmg plants
Awn: One of the slender bnstles that termmate the glumes of the spIkelet m some cereals and
other grasses
Azo dye: Dyes m whIch the azo group IS the chromophore and Joms benzene or naphthalene
rings
Background measurement A measurement of pollutants m ambIent arr due to natural sources,

usually taken m remote areas
Bactencldal actiVIty The process of killmg bactena
Barre. Bars or stnpes m a fabnc, caused by uneven weavmg, Irregular yarn, or uneven dye
dIstribution
Basal cell· One of the Innermost cells of the deeper epIdermIS of the skm
A-22
Base catIon Ca2 +, Ml+, K+, or Na+
Base saturatIon The degree to whIch soil catIon exchange capacIty IS OCCUpIed by base
catIOns ThIs IS expressed as a percent, usmg charge-eqUIvalents
BenzenethIol A compound of benzene and a hydrosulfide group
Beta ({1)-hpoprotem A bIOChemIcal complex or compound contammg both hpid and protem
and charactenzed by havmg a large molecular weIght, nch m cholesterol Found m
certam fractIOns of human plasma
Bilateral renal sclerosIs A hardenmg of both kIdneys of ehromc mflammatory ongm
BIOmass That part of a gIven habItat consIstmg of hvmg matter
BIosphere The part of the earth's crust, waters, and atmosphere where hving orgamsms can
SUbSISt
BiphaslC Havmg two dIstmct succeSSIve stages
Bleb A collectIOn of flUId beneath the skIn, usually smaller than bullae or bhsters
Blood urea The chIef end product of mtrogen metabohsm ill mammals, excreted m human
unne m the amount of about 32 grams (1 ounce) a day
Bloom A greemsh-gray appearance lffiparted to sIlk and pile fabncs either by nature of the
weave or by the ilmsh, also, the creamy whIte color observed on some good cottons
Blue-green algae A group of slffiple plants that are the only mtlOgen-:f1xmg organisms that
photosynthesIZe as do hIgher plants
Bnghtener A compound, such as a dye, that adheres to fabncs m order to proVIde better
bnghtness or whIteness by convertmg ultravIOlet radIatIOn to VISIble hght Sometlffies
called optIcal bleach or whItenmg agent The dyes used are of the florescent type
Broad bean The large flat edIble seed of an Old World upnght vetch (Vlcwfaba), or the
plant Itself, WIdely grown for ItS seeds and for fodder
BronchI. The ilrst subdIVISIOns of the trachea, whIch conduct aur to and from the bronchIoles
of the lungs
BronchIole One of the :fmer subdIVISIons of the bronchIal (trachea) tubes, less than
1 milllmeter m dIameter, and havmg no cartilage 1Il ItS wall
Bronchtohtis InflammatIon of the bronchtoles, whtch may be acute or chromc If the

etIology IS known, It should be stated If permanent OcclusIon of the lumens IS present,
the term bronchtohtIs obhterans may be used
A-23
BronchIohtIs fibrosa obhterans syndrome ObstructIon of the bronchIoles by fibrous
granulatIon ansmg from an ulcerated mucosa, the condItIon may follow InhalatIOn of
irritant gases
BronchitIs A nonneoplastIc dIsorder of structure or functIon of the bronchI resultmg from

infectIous or nonmfectIous lITltatIOn The term bronchItIs should be modIfied by
appropnate words or phrases to mdicate Its etIology, Its chromcIty, the presence of
aSSOCIated arrways dysfunctIon, or the type of anatomIC change The term chromc
bronchitIs, when unqualIfied, refers to a condItIOn aSSOCIated WIth prolonged exposure
to nonspecIfic bronchIallITltants and accompamed by mucus hypersecretIon and certam
structural alteratIons m the bronchI AnatomIC changes may mclude hypertrophy of the
mucous-secretIng apparatus and epIthehal metaplaSIa, as well as more claSSIC eVIdences
of mflammahon In epIdemIologIc studIes, the presence of cough or sputum productIOn
on most days for at least three months of the year for at least two consecutIve years has
sometnnes been accepted as a cntenon for the dIagnOSIS
Bronchoconstrictor An agent that causes a reductIon m the cahber (dIameter) of a bronchIal

tube
Bronchodilator An agent that causes an mcrease m the cahber (dIameter) of a bronchus or

bronchIal tube
Bronchopneumoma Acute mflammatIon of the walls of the smaller bronchIal tubes, WIth
irregular area of consohdatIOn due to spread of the mflammatIOn mto penbronchIolar
alveoh and the alveolar ducts
Bronchospasm Temporary narrowmg of the bronchI due to a VIolent, mvoluntary contractIOn

of the smooth muscle of the bronchI
Bronchus. One of the subdIVISIons of the trachea servmg to convey arr to and from the lungs
The trachea dIVIdes mto nght and left mam bronchI, whIch m tum form lobar,
segmental, and subsegmental bronchI
Browman dIffusion DIffuSIOn by random movement of partIcles suspended m hqUId or gas,

resulting from the nnpact of molecules of the flUId surroundmg the partIcles
BTPS condItIons (BTPS) Body temperature, barometnc pressure, and saturated WIth water
vapor These are the condItIons eXlstmg m the gas phase of the lungs For humans,
the normal temperature IS 37 °e, the pressure IS based on the barometnc pressure, and
the partial pressure of water vapor IS 47 torr
Buffer A substance m solutIon capable of neutrahzmg both aCIds and bases and thereby
mamtammg the ongmal pH of the solutIon
Buffermg In reference to soIl aCIdIficatIon, thIs IS reSIstance to change resultmg from

reserves of aCId or base catIOns on the sOIl catIon-exchange SItes
A-24
Buffenng capacity Ability of a body of water and Its watershed to neutrahze mtroduced aCid
Butanol A four-carbon, straIght-cham alcohol, C4H9 0H, also known as butyl alcohol
Butylated hydroxytoluene (BHT) A crystallme phenohc antIoXidant
Butylated hydroxyamsol (BHA) An antIOXIdant
14C labehng Use of a radIoactIVe fonn of carbon as a fracer, often m metabohc studies
14C-prohne An ammo aCid that has been labeled With radioactIve carbon
Calcareous Resembhng or conslstmg of calCIUm carbonate (hme), or growmg on hmestone

or hme-contammg sons
Calone Amount of heat requIred to raIse temperature of 1 gram of water at 15°C by 1 °C
Cannula A tube that IS mserted mto a body cavity, or other tube or vessel, usually to remove
flUid
Capillary The smallest type of vessel, resembles a harr Usually m reference to a blood or
lymphatic capillary vessel
Carbachol A chohnerglc parasympathetic stImulant, carbamoylchohne chlonde

(C6HlSCIN202), that produces constnctIOn of the bronchial smooth muscles sImuar to
acetylchohne
Carbon monoXIde An odorless, colorless, tOXIC gas WIth a strong affImty for hemoglobm and
cytochrome, It reduces oxygen absorptIon capacity, transport, and utJhzatIon
Carboxyhemoglobm A farrly stable umon of carbon monoXIde With hemoglobm that

mterferes With the nonnal transfer of carbon dIOXide and oxygen dunng cIrCUlatIOn of
blood Increasmg levels of carboxyhemoglobm result m vanous degrees of
asphyXiatIon, mcludIng death
Carcmogen Any agent producmg or playmg a stImulatory role m the fonnatIOn of a

mahgnancy
Carcmoma Mahgnant new growth made up of eplthehal cells tendIng to mfutrate the
surroundIng tissues and glvmg nse to metastases
Cardiac output The volume of blood passmg through the heart per umt time
CardIovascular Relatmg to the heart and the blood vessels or the cIrCUlatIOn
Carotene LIPId-soluble yellow-to-orange-red pigments IUmversally present the photosynthetic

tIssues of higher plants, algae, and the photosynthetIc bactena
A-25
Cascade unpactor A device for measunng the SIZe dlstnbutIOn of partIculates and/or
aerosols, consistmg of a senes of plates wIth onfices of graduated SIZe that separate the
sample into a number of fractIOns of decreasmg aerodynamIc dIameter
Catabolism' Destructive metabohsm mvolvmg the release of energy and resultmg m

breakdown of complex matenals m the orgamsm
Catalase An enzyme (BC 1 11 1 6) catalyzmg the decomposItion of hydrogen peroXide to

water and oxygen
Catalysis' A modIficatIOn of the rate of a chemIcal reaction by some matenal, which IS

unchanged at the end of the reaction
CatalytIC converter An arr pollution abatement deVIce that removes orgamc contammants by
oXidIZing them mto carbon dIOXide and water
Catecholamme A pyrocatechol WIth an alkalamme SIde cham, functIOnmg as a hormone or

neurotransmItter, such as epmephnne, norepmephnne, or dopamme
Cathepsms: Enzymes that have the ability to hydrolyze certam protems and peptIdes, occur m
cellular structures known as lysosomes
Cation A posItively charged Ion
Cation exchange capaCIty. The ability of a soI1 to absorb posItively charged Ions by
electostatIc forces ThIs absorptIOn occurs on negatIvely charged SItes on clays and
organic matter m soI1s
Cellular permeability Ability of gases to enter and leave cells, a senSItive illdlcator of illJUry
to deep-lung cells
Cellulose: The baSIC substance that IS contamed m all vegetable fibers It IS a carbohydrate
and constitutes the major substance ill plant hie Used to make cellulose acetate and
rayon
Cellulose acetate Commonly refers to fibers or fabncs ill which the cellulose IS only partIally
acetylated WIth acetate groups An ester made by reactmg cellulose WIth acetic
anhydnde WIth sulfate as a catalyst
Cellulose rayon A regenerated cellulose that IS chemIcally the same as cellulose except for
phYSICal dIfferences ill molecular weIght and crystalhmty
Cellulose tnacetate A cellulose fiber that IS completely acetylated Fabncs of tnacetate have
higher heat reSIstance than acetate and may be safely Ironed at higher temperature
Such fabncs have unproved ease-of-care charactenstIcs because after heat treatment
during manufacture, a change m the crystallme structure of the fiber occurs
A-26
CellulosIcs Cotton, VIscose rayon, and other fibers made of natural-fiber raw matenals
CelsIUs scale The thermometnc scale m whIch the freezmg pomt of water IS 0 and the
boJ.1mg pomt IS 100
Central hepatic necrosIs The pathologIC death of one or more cells, or of a portlOn of the
hver, mvolvmg the cells adjacent to the central vems
Central nervous system (CNS) The bram and the spmal cord
Centroacmar area The center portlOn of a gland shaped .as a bunch of grapes
Cerebellum The large postenor bram-mass lymg above the pons and medulla and beneath the
postenor portlOn of the cerebrum
Cerebral cortex The layer of gray matter covenng the entIre surface of the cerebral
hemIsphere of mammals
Cham reaction A reaction that stimulates ItS own repebtJlon
Challenge Exposure of a test orgamsm to a VITUS, bactena, or other stress-causmg agent,

used m conjunction wIth exposure to a pollutant of mterest, to explore possIble
susceptibility brought on by the pollutant
Chamber study Research conducted usmg a closed vessel m whIch pollutants are reacted or
substances are exposed to pollutants
Chemtlummescence A measurement techmque m whIch ramatlOn IS produced as a result of

chemIcal reactlOn
ChemotactIc' Relatmg to attractlOn or repulslOn of hvmg protoplasm by chemIcal stImuh
Chlorophyll A group of closely related green photosynthetic pIgments occurrmg m leaves,

bactena, and orgamsms
Chloroplast A plant cell mclUSlOn body contammg chlorophyll
ChlOroSIS DlscoloratlOn of normally green plant parts that can !be caused by dIsease, lack of
nutnents, or vanous arr pollutants, resultmg m the failure of chlorophyll to develop
Cholesterol A sterOId alcohol (C2H 4S0H), the most abundant sterOId m anImal cells and
body flmds
Chohnesterase (CHE) One (EC 3 1 1 8) of a family of enzymes capable of catalyzmg the

hydrolySIS of acylchohnes
A-27
Chondrosarcoma' A mahgnant neoplasm denved from cartilage cells, occumng most
frequently near the ends of long bones
Chromatid Each of the two strands formed by longitudmal duplIcatIOn of a chromosome that
becomes VISIble dunng an early stage of cell dIVISIOn
Chromophore A chemIcal group that produces color In a molecule by absorbmg near

ultravIOlet or viSIble radIatIOn when bonded to a nonabsorbmg, saturated resIdue that
possesses no unshared, nonbondmg valence electrons
Chromosome, One of the bodIes (46 m humans) m the cell nucleus that IS the bearer and
carner of genetIc mformatIon
Chronic obstructIve pulmonary disease (COPD) ThIs term refers to diseases of uncertam
etIology charactenzed by persIstent slowmg of arrflow dunng forced expIratIon It IS
recommended that a more specIfic term, such as chromc obstructIve bronchitIs or
chromc obstructIve emphysema, be used whenever possIble Synonymous WIth chromc
obstructIve lung disease (COLD)
Cilia: MotIle, often harrhke extensIons of a cell surface
Ciliary action' Movements of cilia In the upper respIratory tract, which move mucus and
foreIgn matenal upward
CIhogeneSIS. The formatIOn of cilia
CItriC acid (Krebs) cycle A major bIochemIcal pathway In cells, InvolVIng termmal OXidatIon
of fatty aCIds and carbohydrates. It yIelds a major portIOn of energy needed for
essentIal body functIOns and IS the major source of carbon dIOXide It couples the
glycolytIc breakdown of sugar In the cytoplasm WIth those reactIOns producmg
adenosine tnphosphate In the mitochondna It also serves to regulate the syntheSIS of a
number of compounds requrred by a cell
Clara cell A nonciliated cell m the epIthelIum of the respIratory tract
Closmg capaCIty (CC) Closmg volume plus reSIdual volume, often expressed as a ratIO of
total lung capacity (TLC) (1 e , CC/TLC %)
Closmg volume (CV) The volume exhaled after the exprred gas concentratIOn IS mflected
from an alveolar plateau dunng a controlled breathmg maneuver (Most commonly
obtamed dunng a smgle-breath mtrogen washout test) Because the value obtamed IS
dependent on the specIfic test techmque, the method used must be deSIgnated In the
text, and when necessary, specIfied by a qua1lfymg symbol Closmg volume IS often
expressed as a ratIo of the VItal capaCIty (VC) (1 e , CV/VC%)
Codon A sequence of three nucleotIdes that encodes mformatIon requrred to drrect the
syntheSIS of one or more ammo aCIds
A-28
CoefficIent of haze (COR) A measurement of VISIbility mterference m the atmosphere
Cohort A group of mdividuals or VItal statIstIcs about them havmg a statIstIcal factor m
common m a demographIc study (e g , year of buth, sex, level of exposure to a
pollutant, etc )
Collagen The major protem of the whIte fibers of connectIve tIssue, cartilage, and bond
Compnses over half the protem of the mammal.
CollisIOnal deactIvatIon ReductIOn m energy of excIted molecules caused by collisIOn wIth

other molecules or other objects such as the walls of a contamer
Colonmetnc A chemIcal analysIs method relymg on measurement of the degree of color

produced m a solutIon by reactIon wIth the polluumt of mterest
Commumty exposure A SItuatIOn m whIch people m a $IZeable area are subjected to ambIent
pollutant concentratIOns
Comphance (CvCsJ A measure of mstensIbIhty Pulmonary comphance IS gIven by the

slope of a statIC volume-pressure curve at a pomt, or the hnear approxnnatIOn of a
nearly straIght portIOn of such a curve, expressed as the change m volume per umt
change m mstendmg pressure (hters per centImeter of water or mllhhters per centImeter
of water) Because the statIc volume-pressure chatractenstIcs of lungs are nonhnear
(statIc comphance decreases as lung volume mcrea.ses) and vary accordmg to the
preVIOUS volume hIstory (statIc comphance at a gIVen volume mcreases unmedmtelY
after full mflatIOn and decreases followmg deflatIOn), careful specIficatIon of the
condItIOns of measurement are necessary Absolute values also depend on organ SIZe
See also dynamIC comphance
Complement Thermolabile substance present m serum that IS destructIve to certam bactena

and other cells that have been senSItIZed by SpecUlC complement-flXillg antIbody
Compound A substance WIth ItS own dIStInct propertIes, formed by the chemIcal combmatIon
of two or more elements m fIXed proportIOn
Concanavalm-A One of two crystalhne globuhns occurnng m the Jack bean, a potent
hemagglutmm
Conductance (G) The recIprocal of reSIstance See aIrway conductance
ConIfer A plant, generally evergreen, needle-leafed, bearmg naked seeds smgly or m cones
Converter See catalytIC converter
CoordmatIOn number The number of bonds formed by the central atom m a complex
A-29
Copolymer The product of the process of polymenzatIon m whIch two or more monomenc
substances are mIXed pnor to polymenzatIon Nylon IS a copolymer
CopropOIphynn One of two porphynn compounds found normally m feces as a

decomposition product of bIhrubm (a bue pIgment) Porphynn IS a WIdely dIstnbuted
pigment consIstmg of four pyrrole nucleI jomed m a nng
Cordage. A general term whIch mcludes bandmg, cable, cord, rope, strmg, and twme made
from fibers Synthetic fibers used m makIng cordage mclude nylon and dacron
CorrosIOn. Destruction or detenoratIon of a matenal because of reaction wIth ItS

enVIronment
Corticosterone: A steroId obtamed from the adrenal cortex It mduces some depOSItion of
glycogen m the hver, sodIum conservation, and potassIUm excretion
Cosmopohtan· In the bIOlogICal SCIences, a term denotIng worldWIde dIstnbutIOn
Coulometnc: Chemical analySIS performed by determmmg the amount of a substance released

m electrolySIS by measurmg the number of coulombs used
Coumarm A tOXIC whIte crystalline lactone (C9H 60:z) found m plants
Coupler. A chemIcal used to combme two others m a reactIOn (e g , to produce the azo dye
ill the Gness-Saltzman method for mtrogen dIoXIde)
CreVIce corrOSIon LocalIzed corrOSIon occurrmg WIthIn creVIces on metal surfaces exposed
to corrosives
Critical Load A quantitative estImate of an exposure to one or more pollutants below whIch
sigmficant harmful effects on specIfied senSItive elements of the ecosystem do not occur
accordmg to present knowledge
Crosslink To connect, by an atom or molecule, parallel chams m a complex chemIcal

molecule, such as a polymer
Cryogemc trap. A pollutant samphng method m whIch a gaseous pollutant IS condensed out
of sampled arr by coohng (e g , traps m one method for mtrosammes are mamtamed
below -79°C, usmg solvents mamtamed at theIr freezmg pomts)
Cuboidal Resembhng a cube m shape
Culuvar An orgamsm produced by parents belongmg to dIfferent speCIes or to dIfferent

strams of the same specIes, ongmatmg and persIstmg under cultivatIon
Cuticle. A thIn outer layer, such as the thIn contmuous fatty :fUm on the surface of many
hIgher plants
A-30
CyanosIs A dark blUIsh or purphsh coloratIOn of the S~Jll and mucous membrane due to
deficient oxygenatIOn of the blood
Cychc GMP Guanosine 5' -phosphonc aCId
Cytochrome A class of hemoprotem whose pnncIpal bllOlogICal functIOn IS electron and/or

hydrogen transport
Cytology The anatomy, phYSIOlogy, pathology, and chemIstry of the cell
Cytoplasm The substance of a cell exclusIve of the nucleus
Dacron The trade name for polyester fibers made by E I du Pont de Nemours and Co ,
Inc , made from dimethyl terephthalate and ethylene glycol
Dark adaptatIon The process by whIch the eye adjusts lunder reduced illummatIOn and the
sensItIvIty of the eye to hght IS greatly mcreased
Dark respiratIOn Metabohc actIvIty of plants at mght, ('onsummg oxygen to use stored sugars
and releasmg carbon dIOXIde
DeCIduous plants Plants that drop theIr leaves at the end of the growmg season
DegradatIOn (textiles) The decomposItIOn of fabnc or ItS components or charactenstIcs

(color, strength, elastIcIty) by means of hght, heat, or arr pollutIon
DemtnficatIOn A bactenal process occurnng ill soils, or water, m whIch mtrate IS used as
the termmal electron acceptor and IS reduced prunartly to molecular mtrogen It IS
essentIally an anaerobIc process, It can occur m the presence of low levels of oxygen
only If the microorgamsms are metabohzmg m an anoXIC microzone
De novo. Over agam.
Deoxynb'pnuclelc aCId (DNA) A nucleIc aCId consIdenxl to be the carner of genetIc

mformatIon coded m the sequence of punne and pyrumdme bases (orgamc bases)
It has the form of a double-stranded hehx of a lmear polymer
Depauperate Fallmg short of natural development or SIze
DeposItIon
ACIdIC Removal of aCIdIC pollutants from the atmosphere by dry and wet deposItIon
Dry Removal of pollutants from the atmosphere through mteractIOns WIth vanous
surfaces of plants, land, and water
A-31
Resprratory tract The depOSItIng of mhaled pollutants Withm the resprratory tract,
whlch depends on breathmg patterns, arrway geometry, and the phYSICal and chemIcal
propemes of the mhaled pollutants
Wet Removal of pollutants from the atmosphere by preCIpItatIOn (e g , ram or snow)
Derivative spectrophotometer An mstrument wIth an mcreased capability for detectmg

overlappmg spectrallmes and bands and also for suppressmg mstrumentally scattered
hght
Desorb: To release a substance that has been taken mto another substance or held on ItS
surface, the OpposIte of absorptIOn or adsorption
Desquamation The sheadmg of the outer layer of any surface
Detection Imnt A level below whlch an element or chemIcal compound cannot be rehably
detected by the method or measurement bemg used for analySIS
Detntus' Loose matenal that results drrectly from dIsmtegratIOn
DeVarda alloy An alloy of 50% copper, 45% alummum, and 5% zmc
DIastohc blood pressure The blood pressure as measured durmg the penod of fillmg the
caVIties of the heart wIth blood
Diazonium salt A chemIcal compound (usually colored) of the general structure ArN2+ cr,
where Ar refers to an aromatic group
Diazonzer A chemICal that, when reacted wIth ammes (RNH2 for example), produces a
d1azomum salt (usually a colored compound)
Dichotomous sampler A devIce used to collect separately fme and coarse particles from an
aerosol and to measure gravlIDetncally the concentratIOn of such duferent-slZed
particles m the ambIent arr
DIfferentiation The process by whlch a cell, such as a fertilized egg, dIVIdes mto specIalIZed
cells, such as the embryomc types that eventually develop mto an entrre orgamsm
Dufusion: The process by whlch molecules or other partIcles mtermmgle as a result of therr
random thermal motIOn
Diffusmg capaCIty of the lung (DL , DL 02' ~CO2, DL CO) Amount of gas (oxygen, carbon
monoxide, carbon d1oXlde) commonly expressed as milliliters of gas (standard
temperature and pressure, dry) dllfusmg between alveolar gas and pulmonary capillary
blood per torr mean gas pressure dllference per mmute (such as mL 02/mm-torr)
Synonymous WIth transfer factor and dIffuSIon factor
A-32
Dnner A compound formed by the umon of two hke radIcals or molecules
Dnnenze FormatIOn of dnners
1,6-diphosphofroctose aldolase An enzyme (Be 4 1 1 13) cleavmg fructose 1,6-biSphosphate

to dIhydroxyacetone phosphate and glyceraldehyde-3-phosphate
D-2,3-diphosphoglycerate A salt or ester of 2,3-diphosphoglycenc aCId, a major component

of certam mammalIan erythrocytes mvolved m the Jelease of oxygen from
oxyhemoglobm Also a postulated mtermedIate m 1he bIOchemIcal pathway mvolvmg
the converSIOn of 3- to 2-phosphoglycenc aCId
Dzplococcus pneumomae A specIes of sphencal-shaped bactena belongmg to the genus

Streptococcus May be a causal agent m pneumoma
Drrect dye A dye WIth an affImty for most fIbers; used mamly when color reSIstance to
washmg IS not nnportant
DIsperse dyes Also known as acetate dyes, these dyes wlere developed for use on acetate
fabncs, and are now also used on synthetIc fIbers
DIStal Far from some reference pomt such as medIan lme of the body, pomt of attachment,
or ongm
DIUrnal Havmg a repeatIng pattern or cycle 24 hours long
DLCO The dIffusmg capaCIty of the lungs for carbon monoxide The ability of the lungs to
transfer carbon monOXIde from the alveolar arr mto the pulmonary capIllary blood
Dorsal kyphOSIS Abnormal curvatIve of the spme, hunchback
Dose The quantIty of a substance to betaken all at one tune or m fractIOnal amounts Withm a
given period, also the total amount of a pollutant de~hvered or concentratIOn per umt
tnne tnnes tIme
Dose-response curve A curve on a graph based on respoltlses occurnng m a system as a

result of a senes of stImuh mtensitIes or doses
Dry depOSItIon The processes by wllich matter IS transfeJTed to ground from the atmosphere,
other than precIpItatIOn, mcludes surface absOIptIon of gases and sednnentatIon,
Browman diffuSIOn, and ImpactIOn of partIcles
Dyemg A process of colonng fIbers, yarns, or fabncs Wllth eIther natural or synthetIc dyes
DynamIC calIbratIOn Testmg of a momtonng system usmg a contInuous sample stream of

known concentratIon
A-33
Dynamic compliance (Cdyn) the ratlO of the tIdal volume to the change m mtrapleural
pressure between the pomts of zero flow at the extremes of tidal volume (L/cm H20 or
mL/cm H 20) Because at the pomts of zero arrflow at the extremes of tidal volume,
volume acceleration IS usually other than zero, and because, particularly m abnormal
states, flow may still be takIng place Withm lungs between reglOns that are exchangmg
volume, dynamlc comphance may differ from static comphance, the latter pertammg to
conditlon of zero volume acceleratlOn and zero gas flow throughout the lungs
In normal lungs at ordmary volumes and respiratory frequencIes, static and dynamIC
compliance are the same
Dyne!. A trademark for a modacryhc staple fiber spun from a copolymer of acrylomtnle and
vmyl chloride It has mgh strength, qUlck-drymg propertIes, and reSIstance to a1ka11es
and aCIds
DyspepsIa. Ind1gestlon, upset stomach
Dyspnea' Shortness of breath, dIfficulty or dIstress m breathmg, rapId breathmg
Ecosystem The mteractmg system of a blOlogIcal commumty and ItS envIronment
Eddy: A current of water or arr runmng contrary to the mam current
Edema Pressure of excess flUld m cells, mtercellular tissue, or caVIties of the body
Elastance (B) The recIprocal of comphance (expressed m centImeters of water per hter or
centlmeters of water per millIhter)
Elastomer. A synthetIc rubber product that has the phYSICal propertIes of natural rubber
Electrocard1ogram The grapmc record of the electncal currents that ImtIate the heart's
contraction
Electrode One of the two extremIties of an electnc CIrCUlt
Electrolyte' A nonmetallic electnc conductor m wmch current IS carned by the movement of

lOns; also a substance that dIsplays these quahtIes when dissolved m water or another
solvent
Electronegatlvity Measure of affImty for negative charges or electrons
Electron microscopy A techmque that utilizes a focused beam of electrons to produce a

high-resolUtlon Image of mmute objects such as partIculate matter, bactena, VIruses,
and DNA
Electromc excitatlon energy Energy aSSOCIated m the transitlon of electrons from theIr
normal low-energy orbItals to orbItals of mgher energy
A-34
Electropluhc Havmg an affImty for electrons
ElectrophoresIS A techmque by which compounds can be separated from a complex mIXture

by theIr attractIOn to the pOSltlve or negatlve pole of an apphed electnc potentlal
Eluant A hqmd used m the process of elutlon
Elute To perform an elutIOn
ElutIOn SeparatIOn of one matenal from another by washmg or by dlssolvmg one m a

solvent ill which the other IS not soluble
Elutnate To separate a coarse, msoluble powder from III fmer one by suspending them
m water and pounng off the fmer powder from the upper part of the flUid
EmISSIon spectrometry A rapId analytIcal techmque based on measurement of the

charactenstlc radmtlon emItted by thennally or electncally excIted atoms or Ions
Emphysema A condItIOn of the lung charactenzed by albnonnal, pennanent enlargement

of arrspaces dIstal to the tennmal bronchiole, accompamed by the destructIOn of
their walls, and wIthout ObVIOUS fIbrOSIS
Emphysematous lesIOns A wound or mJury to the lung as a result of emphysema
Empmcal modehng Charactenzatlon and descnptIOn of a phenomena based on expenence or

observatIOn
Encephahtls Inflammatlon of the bram
EndoplasmIc reticulum An elaborate membrane structm e extending from the nuclear

membrane or eucaryotlc cells to the cytoplasmIc membrane
Endothehum A layer of flat cells hmng espeCIally blood and lymphatlc vessels
Entropy A measure of dIsorder or randomness m a sysl em Low entropy IS aSsociated WIth

highly ordered systems
Enzyme- Any of numerous protems produced by hvmg cells that catalyze bIOlogICal
reactlons
Enzyme CommIssIon (Ee) The InternatIOnal CommISSIOn on Enzymes, estabhshed ill 1956,
developed a scheme of classIfIcatIOn and nomenclature under which each enzyme IS
assIgned an EC number that IdentIfIes It by function
EoSillOphIls Leukocytes (white blood cells) that stain readily wIth the dye eosm
A-35
Epidemiology. A study of the dlstnbution and detennmants of dIsease m human populatIOn
groups.
Epldennis. The outennost hvmg layer of cells of any orgamsm
Epididymal fat pads The fatty tIssue located near the epIdIdymIs The epIdIdymIs IS the fIrst
convoluted portIOn of the excretory duct of the testIs
Epiphyte' A plant growmg on another plant but obtammg food from the atmosphere
Epithelial: Relating to eplthehum, the membranous cellular layer that covers free surfaces or
hnes tubes or caVIties of an anImal body, whIch encloses, protects, secretes, excretes
and/or aSSImilates
Erosion corrOSIon AcceleratIon or mcrease m rate of detenoratIOn or attack on a metal

because of relatIve movement between a corroSIve flUId and the metal surface
Characterized by grooves, gullies, or waves m the metal surface
Erythrocyte: A mature red blood cell
Eschenchza colz A short, gram-negatIve, rod-shaped bactena common to the human

intestInal tract A frequent cause of mfectIons m the urogemtal tract
Esophageal Relating to the portIOn of the dIgestIve tract between the pharynx and the
stomach
Estrus. That portIon or phase of the sexual cycle of female anImals charactenzed by
wIlhngness to pennit COItuS
Estrus cycle The senes of phYSIOlogIC utenne, ovanan, and other changes that occur m
hIgher anImals
EtiolatIon Paleness and/or altered development resultmg from the absence of hght
Etiology The causes of a dIsease or condItIon, also, the study of causes
Eucaryotic: Pertainmg to those cells havmg a well-defmed nucleus surrounded by a

double-layered membrane
EutrophIcatIon' Elevation of the level of nutnents m a body of water, whIch can contnbute to
accelerated plant growth and fIlhng
Excited state: A state of hIgher electromc energy than the ground state, usually a less stable
one
EXpIratory (maxunum) flow rate The maxImum rate at whIch arr can be expelled from the
lungs
A-36
Exposure level ConcentratIOn of a contammant to winch an mdivIdual or a populatIOn IS
exposed
ExtmctIon coefficIent A measure of the space rate of dnnmutlOn, or extmctlOn, of any

transmItted hght, thus, It IS the attenuatIOn coeffiCIent apphed to VIsIble radIatIon
Extramedullary hematopOIesIs The process of formatIon and development of the VarIOUS

types of blood cells and other formed elements not mcludmg that occurrmg m bone
marrow
Extravasate To exclude from or pass out of a vessel mto the tIssues, apphes to unne, lymph,
blood, and SImIlar fluids
Far ultravIOlet RadIatIOn m the range of wavelengths from 100 to 190 nanometers
Federal Reference Method (FRM) For mtrogen dIOXIde, the EPA-approved analyzers based
on the gas-phase chemIlummescent measurement pnncIple and assocIated cahbration
procedures, regulatory spectficatlOns prescnbed m TItle 40, Code of Federal
RegulatIOns, Part 50, AppendIX F
Fenestrae AnatomIcal aperatures often closed by a membrane
FEVt/FVC A ratIO of tImed (t = 05, 1, 2, 3 seconds) forced expIratory volume (FEVJ to

forced VItal capacity (FVC) The ratIo IS often e~pressed m percent
(100 x FEVt/FVC) It IS an mdex of arrway obstructIon
FIber A tme, threadlIke pIece, as of cotton, Jute, or aslbestos
FIber-reactIve dye A water-soluble dyestuff that reacts chemIcally WIth the cellulose m fibers
under alkalme condItIons; the dye contams two chlonne atoms that combme WIth the
hydroxyl groups of the cellulose
FIbnn A wlnte msoluble elastIc ttlamentous protem del1.ved from fibnnogen by the action of
thrombm, especially m the clottmg of blood
FIbroadenoma A bemgn neoplasm denved from glandular epIlhehum, mvolvmg prohferatmg

fibroblasts, cells found m connectIve tIssue
FIbroblast An elongated cell WIth cytoplasmIc processes present m connectIve tIssue, capable
of formmg collagen fibers
FIbroSIS The formatIOn of fibrous tIssue, usually as a n~paratIve or reactIve process and not
as a nonnal constItuent of an organ or tIssue
Fme partIcles AIrborne partIcles smaller than 2 to 3 mllcrometers m aerodynamIc dIameter
A-37
Flocculation Separation of matenal from a solution or suspenSIOn by reaction WIth a
flocculant to create fluffy masses contammg the matenal to be removed
Flow volume curve Graph of mstantaneous forced expIratory flow recorded at the mouth,
against correspondmg lung volume When recorded over the full VItal capacIty, the
curve mcludes maximum expIratory flow rates at all lung volumes m the vItal capacIty
range and IS called a maxImum expIratory flow-volume curve (MEFV) A partIal
expIratory flow-volume curve (PEFV) IS one which descnbes maxImum expIratory flow
rate over a portIon of the VItal capacIty only
Fly ash: Fme, solId partIcles of noncombustible ash carned out of a bed of solId fuel by a
draft.
Fogs: SuspensIon of lIqUId droplets formed by condensation of vapor or atomIZation, the

concentration of partIcles IS sufficIently high to obscure VISIbility
Folded-path optical system A long (e g , 8 to 22 meters) chamber WIth multiple mIrrors at

the ends which can be used to reflect an mfrared beam through an ambIent aIr sample
many times, a spectrometer can be used WIth such a system to detect trace pollutants at
very low levels
Forced expiratory flow (FEP) Related to some portIOn of the forced VItal capacIty (FVC)
curve ModIfiers refer to the amount of the FVC already exhaled when the
measurement IS made For example
FEF75 % = Instantaneous forced exhaled flow after 75 % of the forced VItal capacIty has
been exhaled
FEF200-1,200 = Mean forced expIratory flow between 200 millIhters and

1,200 millIhters of the forced VItal capacIty (formerly called the maxImum expIratory
flow rate [MEFR])
FEF25-75 % = Mean forced expIratory flow dunng the mIddle half of the forced VItal
capacIty (formerly called the maxImum midexpIratory flow rate [M:MFR])
FEFmax = The maxImal forced expIratory flow achieved dunng an forced VItal
capacity
Forced expIratory volume (FEV) Denotes the volume of gas that IS exhaled m a gIVen tIme
mterval from the begmnmg of the executIOn of a forced VItal capaCIty ConventIOnally,
the times used are 0 5, 075, or 1 second, symbolIZed FEVo 5, FEVo 75' and FEV l 0'
respectively These values are often expressed as a percent of the forced VItal capaCIty,
for example, (FEV1 oIFVC) x 100
Forced mspIratory VItal capaCIty (FIVC) The maxImal volume of arr msprred WIth a
maxImally forced effort from a pOSItIOn of maXImal expIratIon
A-38
Forced VItal capaCIty (FVC) The maxunum volume of au that can be forcIbly expelled from
the lungs after the deepest mspIratIon
FractIOnal threshold concentratIon The portIOn of the COlllcentratIon at whIch an event or a

response begms to occur, expressed as a fractIon
Free radIcal Any of a vanety of hIghly reactIve atoms or molecules charactenzed by havmg
an unpaIred electron
Fritted bubbler A porous glass devIce used m aIr pollutant samplmg systems to mtroduce
small bubbles mto solutIOn
FunctIonal resIdual capaCIty (PRC) The volume of gas n~mammg m the lungs at the end of a
normal eXpIratIOn It IS the sum of expIratory reserve volume and reSIdual volume (see
pulmonary measurements)
Gas chromatography (GC) A method of separatmg and ~Ulalyzmg mIXtures of cheInlcal

substances A flow of gas causes the components of a mIXture to mIgrate dIfferentIally
from a narrow startmg zone m a SpecIal porous, m:mluble sorptIve medIUm The
pattern formed by zones of separated pIgments and of colorless substances m thIs
process IS called a chromatogram, and can be analyzed to obtam the concentratIOn of
IdentIfied pollutants
Gas exchange Movement of oxygen from the alveoh mto the pulmonary capillary blood as
carbon dIOXIde enters the alveoh from the blood ]n broader terms, the exchange of
gases between alveoh and lung capillanes
Gas-hqUId chromatography A method of separatIng and analyzmg volatile orgamc

compounds m whIch a sample IS vaponzed and sw~:pt through a column filled WIth sohd
support matenal covered WIth a nonvolatile hqUId Components of the sample can be
IdentIfied and theIr concentratIOns can be determmerl by malysIs of the charactenstIcs
of theIr retentIOn m the column because compoundll have varymg degrees of solubility
m the hqUId medIUm
Gas trappmg Trappmg of gas behmd small arrways that were opened durmg mspIratIon but
closed dunng forceful expIratIon It IS a volume dlfference between forced VItal
capaCIty and VItal capaCIty
Gastnc JUIce A thm watery dIgestIve flUId secreted by glands m the mucous membrane of
the stomach
GastroententIs InflammatIOn of the mucous membrane of stomach and mtestme
Genotype The type of genes possessed by an organIsm
Geometnc mean An estImate of the average of a dIstnbutIon SpecIfically, the nth root of
the product of n observatIons
A-39
Geometnc standard devIatIon A measure of vanabIhty of a dIstnbutIon It IS the
antlloganthm of the standard devIation of the loganthms of the observatIOns
Globulins (a, b, q). A fanuly of protems precIpItated from plasma (or serum) by
half-saturatIon wIth ammomum sulfate, or separable by electrophoresIs The mam
groups are the a, b, and q fractIOns, drffenng wIth respect to aSSOCIated hpids and
carbohydrates and m theIr content of antibodIes (lffimunoglobuhns)
Glomerular nephrotic syndrome Dysfunction of the kidneys charactenzed by exceSSIve

protem loss m the unne, accumulatIOn of body flUIds, and alteratIOn m
albumm/globuhn ratio
Glucose. A sugar that IS a pnncipal source of energy for humans and other orgamsms
Glucose-6-phosphate dehydrogenase An enzyme (EC 1 1 1 49) catalyzmg the

dehydrogenatIOn of glucose-6-phosphate to 6-phosphogluconolactone
Glutamlc-oxaloacetIc transammase (SGOT) An enzyme (BC 2 6 1 1) whose serum level

increases m myocardIal Infarction and m dIseases mvo1vmg destruction of hver cells
Also known as aspartate amInotransferase
GlutamIc-pyruvic transammase (SGPT) Now known as alanme ammotransferase

(BC 2 6 1 2), the serum levels of thIs enzyme are used m hver function tests
GlutathIone (GSH) A tnpeptIde composed of glycme, cystine, and glutamIC aCid
GlutathIone peroXidase An enzyme (BC 1 11 1) that catalyzes the destructIOn of

hydropermades formed from fatty aCIds and other substances Protects tissues from
OXidative damage It IS a selemum-contammg protem
Glutathione reductase. The enzyme (BC 1 6 4 2) that reduces the OXIdIZed form of
glutathIone
Glycolytic pathway The bIochemIcal pathway by whIch glucose IS converted to lactic aCId m
vanous tissues, yIeldmg energy as a result
Glycoside A type of cheffilcal compound formed from the condensation of a sugar WIth
another chemIcal radIcal VIa a hemIacetal hnkage
Goblet cells. EpIthehal cells that have been dIstended WIth mucm and when thIs IS dIscharged
as mucus, a goblet-shaped shell remams
GOlgl apparatus: A membrane system mvolved WIth secretory functions and transport m a
cell Also known as a dictyosome
Grana The lamellar stacks of chlorophyll-contammg matenal m plant chloroplasts
A-40
Gnege carpet A carpet m Its unIilllshed state (1 e , bejore It has been scoured and dyed)
The tenn also IS used for woven fabncs m the unbleached and unIilllshed state
Ground state The state of mmnnum electromc energy of a molecule or atom
Guanylate cyclase (GC) An enzyme (BC 4 6 2 1) cataLyzmg the transformanon of guanosme

tnphosphate to guanosme 3' 5'-cychc phosphate
3H-Th~mIdme Thymine deoxynbonucleoside One of the four major nucleosides m DNA

H-thymidme has been umformly labeled wIth tntlUm, a radioacnve form of hydrogen
Haze Fme dust, smoke, or fme vapor reducmg transparency of arr
HemagglunnatIOn The agglutmatIOn of red blood cells Can be used as a measurement of

annbody concentratIOn
Hematocnt The percentage of the volume of a blood sample occupIed by cells
Hematology The medIcal specIalty that pertams to the blood and blood-formmg nssues
HemochromatosIs A dIsease charactenzed by pIgmentatIOn of the sIan possIbly due to

mhented exceSSIve absorptIOn of Iron
Hemoglobm (Hb) The red, respIratory protem of the led blood cells, hemoglobm transports
oxygen from the lungs to the nssues as oxyhemoglobm (Hb02) and returns carbon
diOXide to the lungs as hemoglobm carbamate, completmg the respIratory cycle
HemolysIs AlteratIOn or destructIOn of red blood cells, causmg hemoglobm to be released

mto the medlUm m whIch the cells are suspended
Hepatectomy Complete removal of the hver m an expenmental annual
Hepanc Relatmg to the hver
Hepatocyte A hver cell
Heterogeneous process A chemIcal reactIon mvolvmg reactants of more than one phase or
state, such as one m whIch gases are absorbed mto aerosol droplets, where the reactIOn
takes place
Heterologous A term refernng to donor and recIpIent cellular elements from dIfferent
orgamsms, such as red blood cells from sheep al1ld alveolar macrophage from rabbIts
Heterotrophs Fung! and bactena that rely on organIC matter for theIr energy source
A-41
Hexose monophosphate shunt Also called the phosphogluconate oXIdative pathway of glucose
metabohsm, whIch affords a total combustIOn of glucose mdependent of the CItnC aCId
cycle. It is the Important generator of mcotmamIde-adenme dmucleotIde phosphate
(reduced form) necessary for synthesIs of fatty aCIds and the operatIOn of vanous
enzymes It serves as a source of nbose and 4- and 7-carbon sugars
HIgh volume (hI-vol) sampler A hIgh flow-rate deVIce used to collect particles from the
atmosphere and to gravImetncally measure the concentratIOn of partIcles across a broad
range of sizes in ambIent arr
Histamine A depressor amme denved from the ammo aCId hIstIdme and found m all body
tissues, WIth the hIghest concentratIOn m the lung, a powerful stImulant of gastnc
secretIOn, a constnctor of bronchIal smooth muscle, and a vasodilator that causes a fall
m blood pressure
Homogenate Commonly refers to tIssue ground mto a creamy conSIstency m whIch the cell
structure IS dtsmtegrated
Host defense mechamsm Inherent means by whIch a bIOlogIC orgamsm protects Itself agamst
mfectIon, such as antIbody formatIon, macrophage actIon, ciliary actIon, etc
Host resistance The reSIstance exhIbIted by an orgamsm, such as a human, to an mfectmg

agent, such as a VlTIlS or bactena
Humoral: RelatIng to the extracellular fJ.ll1ds of the body, blood and lymph
Hybrid: An orgamsm descended from parents belongmg to dIfferent vanetIes or specIes
Hydrocarbons' A vast family of compounds contammg carbon and hydrogen m vanous

combinaoons, found especIally m fossil fuels Some contnbute to photochemIcal smog
HydrolySIS' Decomposloon mvolvmg sphttmg of a bond and addItIon of the H and OH parts
of water to the two SIdes of the spht bond
Hydrometeor A product of the condensatIOn of atmosphenc water vapor (e g , fog, ram,

haIl, snow)
Hydroxyprohne An ammo aCId found among the hydrolySIS products of collagen
HygroSCOpIC' Pertammg to a marked ability to accelerate the condensatIon of water vapor
HygrOSCOpIC growth Growth mduced by mOIsture, often apphed m reference to the growth m
SIZe of mhaled partIcles WIthm the respIratory tract m combmatIon WIth reSIdent
moisture
Hyperplasia Increase m the number of cells m a tIssue or organ excludmg tumor formatIOn
A-42
Hyperplastic Relatmg to hyperplasia, an mcrease m the number of cells
Hypertrophy Increase m the SIZe of a tissue element, excludmg tumor formatiOn
HypertenSiOn Abnormally elevated blood pressure
Hypohmma PortIons of a lake below the thermochne m wInch water IS stagnant and unIform
m temperature.
HypOXIa A lower than normal amount of oxygen ill the arr, blood, or tissues
Immunoglobulm (lg) A class of structurally related protems consIstmg of two parrs of

polypeptide chams AntibodIes are lIDmunoglobms and alllIDmunoglobulms probably
functiOn as antibodIes
Immunoglobulm A (lgA) A type of antibody that comprIses approXImately 10 to 15 % of the

total amount of antIbodIes present in normal serum
Immunoglobulm G (lgG) A type of antibody that comprIses approXImately 80 % of the total

amount of antibodIes present m normal serum Su bfractiOns of IgG are fractiOns
G 1 and G2
Immunoglobulin M (lgM) A type of antibody that compnses approXImately 5 to 10% of the

total amount of antIbodIes present III normal serum
ImpactiOn An lIDpmgmg or stnkIng of one object agam:st another, also, the force transmItted
by tIns act
Impactor An mstrument wInch collects samples of suspended partIculates by drrectIng a

stream of the suspenSiOn agamst a surface, or mto a hqUld or a VOId
Index of prohferatiOn RatIo of promonocytes to polymorpInc monocytes m the blood
InfarctiOn Sudden msufficIency of artenal or venous blood supply due to emboh, thrombI, or
pressure
InfectiVIty model A testmg system m wInch the susceptlbIhty of anImals to arrborne

InfectIOUS agents WIth and WIthout exposure to aIr pollutants IS mvestIgated to produce
InformatIon related to the pOSSIble effects of the pollutant on humans
Inflorescence The arrangement and development of flowers on an aXIS, also, a flower cluster
or a smgle flower
Influenza A 2/TaIwan Vrrus An InfectIous-vrral dIsease, beheved to have ongmated m

TaIwan, charactenzed by sudden onset, clnlls, fevers, headache, and cough
A-43
Infrared LIght inVISIble to the human eye, between the wavelengths of 7 x 10-7 and
3
10- meter (7,000 and 10,000,000 Angstroms)
Infrared laser A deVIce that utIhzes the natural oscillatIOns of atoms or molecules to generate
coherent electromagnetIc radIatIon m the Infrared regIOn of the spectrum
Infrared spectrometer An mstrument for measurmg the relatIve amounts of radIant energy m
the Infrared regIOn of the spectrum as a functIon of wavelength
Ingestion To take m for dIgestIon
In situ· In the natural or ongmal pOSItIon
Instrumental averagmg tIme The tIme over whIch a smgle example or measurement IS taken,
resultmg m a measurement that IS an average of the actual concentratIOns over that
period
Insult An injury or trauma
Intercostal Between the nbs, especIally of a leaf
Interferant A substance that a measurement method cannot dIstInguISh completely from the
one being measured, whIch therefore can cause some degree of false response or error
Interferon· A macromolecular substance produced m response to mfectIOn WIth actIve or

mactIvated VIruS, capable of mducmg a state of reSIstance
Intergranular corrOSIon A type of corrOSIOn that takes place at and adjacent to gram
boundanes, WIth relatIvely lIttle corrOSIon of the grams
InterstItIal edema An accumulatIOn of an exceSSIve amount of flUIds m a space WIthm

tissues
InterstitIal pneumoma A chromc mflammatIon of the mterstItIal tIssue of the lung, resultmg
in compreSSIOn of arr cells
IntralumInal mucus Mucus that collects WIthm any tubule
Intraperitoneal InjectIon An mjectIon of matenal mto the serous sac that hnes the abdomInal
caVIty
In utero WIthIn the womb, not yet born
In VItro· Refers to expenments conducted outSIde the lIvmg orgamsm
In vivo. Refers to expenments conducted withm the hvmg orgamsm
A-44
IrradtatIOn Exposure to any fonn of radIatIOn
IschemIa Local anemIa due to mechanIcal obstructIOn (mamly artenal narrowmg) of the
blood supply
Isoenzymes Also called Isozymes One of a group of elllzymes that are very sImIlar m
catalytIc propertIes, but may be dIfferentIated by VarIatIons m phYSICal propertIes, such
as Isoelectnc pomt or electrophoretIc mobility LactIc aCJld dehydrogenase IS an
example of an enzyme havmg many Isomenc fonns
Isopleth A lme on a map or chart connectmg pomts of (~ual value
Jacobs-HochheIser method The ongmal Federal Reference Method for mtrogen dIoxide,
currently unacceptable for arr pollutIOn work
Klebslella pneumomae A specIes of rod-shaped bactena found m soIl, water, and m the
mtestmal tract of humans and other anImals Cemun types may be causatIve agents m
pneumoma
KyphOSIS An abnonnal curvature of the spme, WIth conveXIty backward
Lactate A salt or ester of lactIc aCId
LactIc aCId (lactate) dehydrogenase (LDH) An enzyme IEC 1 1 1 27) WIth many Isomenc
fonns that catalyzes the OXIdatIOn of lactate to pymvate Vlla transfer of hydrogen to
mcotmamIde-adenme dmucleotIde Isomenc fonns: of lactIc aCId dehydrogenase m the
blood are mdIcators of heart damage
Lamellar bodIes Arranged m plates or scales One of the characteristIcs of Type II alveolar
cells
Lavage flUId Any flUId used to wash out hollow organs, such as the lung
LeachIng The removal of elements from soIl, htter, or plant fohage by water
LeCIthIn Any of several waxy hygroSCOPIC phosphatIdes that are WIdely dIstnbuted m
anImals and plants, they fonn COllOIdal solutIons lfl water and have emulsIfymg,
wettmg, and hygroscopIC propertIes
Legume A plant WIth root nodules contammg mtrogen-fixmg bactena
LeSIon A wound, mJury, or other more or less Clfcumsc nbed pathologIc change m the
tIssues
Leukocyte. Any of the whIte blood cells
A-45
Lewis base A base, defmed m the LeWIS aCId-base concept, IS a substance that can donate an
electron parr
Lichens Perenrnal plants whIch are a cOmbInatIOn of two plants, an alga and a fungus,
grOWIng together m an aSSOCiatIOn so mtImate that they appear as one
Ligand: Those molecules or amons attached to the central atom m a complex
LIght-fastness The ability of a dye to mamtam ItS ongInal color under natural or mdoor
light
Linolernc acid An unsaturated fatty aCId essentIal m nutntIOn
Lipase. An enzyme that accelerates the hydrolYSIS or syntheSIS of fats or the breakdown of
hpoprotems
LipIds: A heterogeneous group of substances that occur WIdely m bIOlogICal matenals They
are charactenzed as a group by theIr extractability m nonpolar orgarnc solvents
LIpofuscin Brown pIgment granules representIng hpid-contammg resIdues of lysosomal

dIgestIon Proposed to be an end product of hpid OXidatIOn that accumulates m tIssue
LIpoprotein Complex or protem contammg hpid and protem
Loading rate The amount of a nutnent avaIlable to a urnt area of body of water over a gIven
penod of tIme
Locomotor activity Movement of an orgamsm from one place to another of ItS own vohtIon
Long path length Infrared absorptIon A measurement techmque m whIch a system of mrrrors
in a chamber IS used to dIrect an mfrared beam through a sample of arr for a long
dIstance (up to 2 kIlometers), the amount of mfrared hght absorbed IS measured to
obtam the concentratIOns of pollutants present
Lung comphance (CI) The volume change produced by an mcrease m a urnt change m
pressure across the lung (1 e , between the pleural surface and the mouth)
Lycra' A spandex textile fiber created by E I du Pont de Nemours & Co , Inc, WIth
excellent tensile strength, a long flex hie and hIgh reSIstance to abraSIon and heat
degradatIon Used in braSSIeres, foundatIon garments, surgIcal hOSIery, SWIm SUItS, and
mihtary and mdustnal apphcatIOns
Lymphocytes WhIte blood cells formed m lymphOId tIssue throughout the body, they
compnse about 22 to 28 % of the total number of leukocytes m the cIrculatmg blood
and functIon m lffimurnty
A-46
Lymphocytogram The ratIo, m the blood, of lymphocytes wIth narrow cytoplasm to those
wIth broad cytoplasm
Lysosomes Organelles found m cells of hIgher orgamsms that contaIn hIgh concentratIOns of
degradatIve enzymes and are known to destroy foreIgn substances that cells engulf by
pmocytosiS and phagocytosIS Beheved to be a major sIte where protems are broken
down
Lysozymes LytIC enzymes destructIve to cell walls of certam bactena Present m some body
flUIds, mcludmg tears and serum
Macaca specLOsa A specIes of monkeys used m research
Macrophage Any large, amebOId, phagocytIc cell hav11lg a nucleus wIthout many lobes,
regardless of ongm
MalaIse A feehng of general dIscomfort or uneasmess, often the fIrst mdIcatIOn of an

InfectIon or dIsease
Malate dehydrogenase An enzyme (Ee I I 1 37) WIth at least SIX Isomenc forms that
catalyze the dehydrogenation of malate to oxaloacetate or ItS decarboxylatIOn (removal
of a carbon dIOXIde group) to pyruvate Malate, oxaloacetate, and pyruvate are
mtermedtate components of bIOchemIcal pathways:
Manmtol An alcohol denved from reductIon of the sugar fructose Used m renal functIOn
testIng to measure glomerular (capillary) :fI1tratIolll
Manometer An mstrument for the measurement of pressure of gases or vapors
Mass median dIameter (MMD) Geometnc medIan SIZe of a dlstnbutIon of partIcles based on
weIght
Mass spectrometry (MS) A procedure for IdentIfymg the VarIOUS kmds of partIcles present m
a gIven substance by IOnIZmg the partIcles and subJectmg a beam of the IOnIZed
partIcles to an electnc or magnetIc field such that the field deflects the partIcles m
angles dIrectly proportIonal to the masses of the partIcles
MaxImal expIratory flow (V max x) Forced expIratory flow, related to the total lung capaCIty
or the actual volume of the lung at whIch the measurement IS made ModIfiers refer to
the amount of lung volume remammg when the measurement IS made For example
V max75 % = Instantaneous forced expIratory flow when the lung IS at 75 % of ItS total
lung capaCIty
V max3 0 = Instantaneous forced expIratory flow when the lung volume IS 3 0 hters
A-47
MaxImal expiratory flow rate (MEFR) Obsolete termmology See FEF200 - 1,200 under
forced expiratory flow
Maximal midexprratory flow rate (M:MFR or:MMEF) See FEF25 _75 % under forced
exprratory flow
Maximal ventilatIon (max V E) The volume of arr breathed m 1 mmute dunng repetItIve
maxImal resprratory effort Synonymous wIth maxImum ventuatory mmute volume
Maximal voluntary ventilatIon (MVV) The volume (lIters per mmute at body temperature
and pressure, saturated) of arr breathed by a subject dunng voluntary maxImum
hyperventilatIon (rapId deep breathmg) lastmg a specIfic penod of tIme Replaces
maxImal breathmg capacIty
Mean (anthmetIc) The sum of observatIOns dIVIded by sample sIZe
Mechanical clearance See mucocthary actIOn
Median A value m a collectIon of data values that IS exceeded m magmtude by one-half the
entnes m the collectIon
MBFR' See FEF200-1,200 under forced exprratory flow
Mesoscale Of or relating to meteorologIcal phenomena from 1 to 100 kJlometers m

horizontal extent
Messenger RNA A type of RNA that conveys genetIc mformatIOn encoded m the DNA to
drrect protem syntheSIS
MetaplaSIa The abnormal transformatIon of an adult, fully dIfferentIated tIssue of one land
mto a dIfferentiated tIssue of another land
Metaproterenol A bronchodtlator used for the treatment of bronchIal asthma
Metastases The shiftmg of a dIsease from one part of the body to another, the appearance of
neoplasms m parts of the body remote from the seat of the pnmary tumor
Meteorology The SCIence that deals WIth the atmosphere and ItS phenomena
Methacholme A parasympathomtmetIc bronchoconstnctor drug WIth stmuantIes to carbachol

and acetylcholme
2
Methemoglobm: A form of hemoglobm m whIch the normal reduced state of !fon (fe +) has
been oxidIZed to femc !fon (Fe3 +) It contams oxygen m frrm umon WIth Fe3 + and IS
not capable of exchangmg oxygen m normal resprratory processes
Methimazole' An antIthyrOId drug stmuar m actIOn to propylthIouracu
A-48
Methyltransferase Any enzyme transfemng methyl groups from one compound to another
Microcoulometnc Capable of measunng mIlhonths of coulombs used m electrolysIs of a

substance, to determme the amount of a substance m a sample
Microflora A small or stnctly localIzed plant
MIcron One-mIlhonth of a meter
MIcrophage A small phagocyte, a polymorphonuclear l,eukocyte that IS phagocytIc
MIlhmoiar One-thousandth of a molar solutIOn A solutIOn of one-thousandth of a mole

(m grams) per hter
Mmeral aCId amon An amon assocIated wIth strong, or mmeral aCIds such as sulfunc, mtnc,
or hydrocWonc aCId These amons mclude mtrate (N03), sulfate (SOl), and cWonde
(CO
Mmute ventilatIOn (V E) See pulmonary measurements
Mmute volume The mmute volume of breathmg, a product of ndal volume tImes the
respIratory frequency m one mmute, synonymous wIth mmute ventilatIOn
Mitochondna Organelles of the cell cytoplasm that con1.am enzymes acnve m the
conservanon of energy obtamed m the aerobIc part of the breakdown of carbohydrates
and fats, m a process called reSpIratIOn
MMFR Maxnnal midexpIratory flow See FEF25_75 % under forced expIratory flow
Mobile sources. Automobiles, trucks, and other pollunon sources that are not fIxed m one
locatIOn
Modacryhc fIber A manufactured fIber m whIch the fIber-fonnmg substance IS any long
cham synthenc polymer composed of less than 85 % but at least 35 % by weIght of
acrylomtnte umts
MOIety One of two or more parts mto whIch somethmg IS dIVIded
Mole The mass, m grams, numencally equal to the molecular weIght of a substance
Molecular correlanon spectrometry A spectrophotometrIc techmque that IS used to IdentIfy

unknown absorbmg matenals and measure theIr concentranons by usmg preset
wavelengths
Molecular weIght The weIght of one molecule of a substance obtamed by addmg the
gram-atomIC weIghts of each of the mdividual atoms m the substance
A-49
Monocyte A relatIvely large mononuclear leukocyte, normally constItutmg 3 to 7 % of the
leukocytes of the cIrculatIng blood
Morbichty. The quantIty or state of bemg chseased, also, used m reference to the ratIo of the
number of sIck mchviduals to the total populatIOn of a commumty (1 e , morbIdIty rate)
Mordant A substance that acts to bmd dyes to a textIle fiber of fabnc
Morphological. Relatmg to the form and structure of an orgamsm or any of ItS parts
Morphology Structure and form of an orgamsm at any stage of ItS hfe hIstory
Morphometry The quantItatIve measurement of structure (morphology)
Mortahty rate For a given penod of tIme, the ratIO of the number of deaths occurnng per
1,000 populatIon Also known as death rate
Moving average: A procedure mvolvmg takmg averages over a speclfic penod pnor to and
includmg a year in questIOn, so that succeSSIve averagmg penods overlap (e g , a
three-year movmg average would mclude data from 1967 through 1969 for the 1969
average and from 1968 through 1970 for 1970)
Mucociliary action Ciliary actIOn of the mucous membranes lmmg respIratory tract arrways
that aids m removmg partIcles from the lungs
Mucociliary clearance Removal of matenals from the upper respIratory tract VIa ciliary
actIon
Mucociliary transport The process by whIch mucus IS transported, by ciliary actIOn, from the
lungs
Mucosa' The mucous membrane It conSIsts of epIthehum, lamma propna, and, m the
chgestive tract, a layer of smooth muscle
Mucous membrane A mucus-secretmg membrane that hnes passages and caVItIes

commumcatIng WIth the extenor of the body
Mucus The clear, VISCId secretIon of mucous membranes, consIstmg of mucm, epIthehal
cells, leukocytes, and vanous morgamc salts suspended m water
Murine Relatmg to mIce
Mutagen' A substance capable of causmg, WIthm an orgamsm, bIOlogICal changes that affect
potentIal offsprmg through genetIc mutatIOn
A-50
Mutagemc Havmg the power to cause mutatlons A mutatIOn IS a change m the character of
a gene (a sequence of base parrs m DNA) that IS perpetuated m subsequent dIVISIons of
the cell in which It occurs
MyocardIal mfarctlon Infarctlon of any area of the heart muscle usually as a result of
occlusIOn of a coronary artery
Mycorrlnzae FungI that lIve m aSSOCiatIOn WIth plant roots and aSSIst m the uptake of water
and nutnents m exchange for carbohydrates
Nares The nostnls
Nasopharyngeal Relatlng to the nasal caVIty and the phrurynx (throat)
NatIOnal AIr Surveillance Network (NASN) Network of momtonng statlons for samplIng arr
to determme extent of arr pollutIOn, establIshed jomtly by federal and state
governments
Near ultraVIOlet RadIatlon of the wavelengths 2,000 to 4,000 Angstroms
NecrOSIS Death of cells that can dIscolor areas of a planlt or kill the entIre plant
Necrotlc Pertammg to the pathologIC death of one or more cells, or of a portIOn of tIssue or
organ, resultmg from IrreversIble damage
Neonate A newborn
Neoplasm An abnormal tlssue that grows more rapIdly than nonnal, synonymous WIth
tumor
NeoplaSia The pathologIC process that results m the fomlatIOn and growth of a tumor
NeutrophIl A mature white blood cell formed m bone marrow and released mto the
crrculatlng blood NeutrophJ.1s normally account for 54 to 65 % of the total number of
leukocytes
Nmhydnn An orgamc reagent used to IdentIfy ammo aCJlds
Nitramme A compound consIstmg of a mtrogen attachedl to the mtrogen of amme
NItrate A salt or ester of mtnc aCId (N03- IS used to symbohze the IOmc form, N03 IS used
for the radIcal)
NItnficatIOn The pnncIpal natural source of mtrate m winch ammomum IOns (NH4 +) are
OXIdIZed to mtntes by specIalIZed mIcroorgamsms Other orgamsms OXIdIZe mtntes to
mtrates
A-51
Nitnfiers' Sou mlcroorgamsms that convert ammomum Ions (NH4+) or orgamc mtrogen to
nitrate Ions (N03), a process referred to as mtnficatIOn Orgamsms that convert
Nl4+ to N03- are referred to as autotrophIc mtnfiers, and orgamsms that convert
organic mtrogen to N03- are referred to as heterotrophIc mtnfiers
NItrite A salt or ester of mtrous aCId (N02)
Nitrocellulose Any of several esters of mtnc aCId formed by Its action on cellulose, used m
explosives, plastics, varmshes, and rayon, also called cellulose mtrate
NItrogen cycle: Refers to the complex pathways by whIch mtrogen-contammg compounds are
moved from the atmosphere mto orgamc lIfe, mto the soIl, and back to the atmosphere
Nitrogen fIXation. The metabohc aSSImIlatIOn of atmosphenc mtrogen by sou

mlcroorgamsms, whIch becomes avaIlable for plant use when the mICroorgamsms dIe,
also, industnal converSIOn of free mtrogen mto combmed forms used m productIOn of
fertJ1I.zers and other products
NItrogen OXide' A compound composed of only mtrogen and oxygen Components of

photochemIcal smog
Nitrogen saturation A condItion m WhICh ecosystems are unable to accumulate any more
nitrogen
Nitrogen washout The multiple breath curve obtamed by plottIng the fractional concentration
of mtrogen in exprred alveolar gas versus tIme for a subject SWItched from breathIng
ambient au to an msprred mIXture of pure oxygen A progreSSIve decrease of mtrogen
concentratIOn ensues, whIch may be analyzed mto two or more exponential
components
Nitrosamme: A compound conSIstIng of a mtrosyl group connected to the mtrogen of an

amine
Nitrosation. AddItion of a mtrosyl group
N-NItrOSO compounds Compounds carrymg the functional mtrosyl group
Nitrosyl: A group composed of one oxygen and one mtrogen atom (-N=O)
Nitrosylhemogiobin (NOHb) The red, respIratory protem of erythrocytes to whIch a mtrosyl

group IS attached
NIP Ratio. Ratio of mtrogen to phosphorous dIssolved m lake water, Important due to ItS
effect on plant growth
Nucleolus A small sphencal mass of matenal WIthIn the substance of the nucleus of a cell
A-52
Nucleopluhc Havmg an aff1ll1ty for atomIC nucleI, electron-donatmg
NucleosIde A compound that consIsts of a purme or pynmidme base combmed wIth

deoxynbose or nbose and found m RNA and DNA
5'-Nucleotidase An enzyme (BC 3 1 3 5) that hydrolyzes nucleosIde 5'-phosphates mto

phosphonc aCId (H3P04) and nucleosides
NucleotIde A compound conslstmg of a sugar (nbose or deoxynbose), a base (a purme or a

pynmIdme), and a phosphate, a basIc structural urnt of RNA and DNA
Nylon A genenc name chosen by E I du Pont de Nemours & Co ,Inc for a group of
protem-hke chemIcal products classed as synthetic' lmear polymers, two mam types are
Nylon 6 and Nylon 66
OcclusIOn A pomt at whIch an openmg IS closed or obstructed
Olefm An open-cham hydrocarbon having at least one double bond
Olfactory Relatmg to the sense of smell
Olfactory epIthehum' The mner ltmng of the nose and mouth that contams neural tIssue
senSItive to smell
OhgotrophIc A body of water defiCIent m plant nutnelllts, also generally havmg abundant
dIssolved oxygen and no marked stratIficatIOn
OrbItals Areas of hIgh electron denSIty m an atom or molecule
Orion An acryhc fiber produced by E I du Pont de Nemours and Co , Inc , based on a

polymer of acrylomtnte, used extensIvely for outdoor uses, it IS reSIstant to chemIcals
and WIthstands hIgh temperatures.
Oronasal breathIng Breathmg through the nose and mouth smmltaneously, typICal human
breathmg pattern at moderate to hIgh levels of exerCIse versus normally predommant
nasal breathmg whIle at rest
Osteogemc osteosarcoma The most common and mahgnant of bone sarcomas (tumors)
It anses from bone-formmg cells and affects chIeHy the ends of long bones
Ovanan pnmord1al follicle A spherOIdal cell aggregatIOn m the ovary m whIch the
pnmordial oocyte (Immature female sex cell) IS surrounded by a smgle layer of
flattened follicular cells
A-53
OXIdant- A chemIcal compound that has the ability to remove electrons from another
chemIcal specIes, thereby oXIdlZmg It, also, a substance contammg oxygen that reacts m
arr to produce a new substance, or one formed by the actIOn of sunlIght on OXIdes of
mtrogen and hydrocarbons
OXIdatIon- An Ion or molecule undergoes OXIdatIon by donatmg electrons
Oxidative deammatIOn Removal of the amme (NH2) group from an ammo compound by
reactIon WIth oxygen
OXIdatIve phosphorylatIon The mItochondrIal process by whIch "hIgh-energy" phosphate

bonds form from the energy released as a result of the OXIdatIOn of vanous substrates
PrinCIpally occurs m the tncarboxyhc aCId pathway
Oxyhemoglobm_ Hemoglobm m combmatIOn WIth oxygen It IS the form of hemoglobm

present m artenal blood
Ozone layer A layer of the stratosphere from 20 to 50 kIlometers above the earth's surface
characterIZed by hIgh ozone content produced by ultraVIolet radIatIon
Ozone scavengmg Removal of ozone from ambIent arr or plumes by reactIOn WIth mtnc
oxide, producmg mtrogen dIOXIde and molecular oxygen
Parred electrons Electrons havmg OppOSIte mtnnslC spms about theIr own axes
Parenchyma: The essentIal and dIstInctIve tIssue of an organ or an abnormal growth, as

distInguished from ItS SupportIve framework
Parenchymal Refernng to the dlstmgulshmg or specIfic cells of a gland or organ
Partial pressure The pressure exerted by a smgle component m a mIXture of gases
PartIcle Any object, sohd or hqmd, havmg defImte phYSICal boundanes m all drrectIOns,
mcludes, for example, rme sohd partIcles, such as dust, smoke, fumes, or smog, found
in the arr or in emISSIons
PartIculate matter (PMx) Matter m the form of small arrborne hqmd or sohd partIcles
In the abbreVIatIon, the subscnpt "x" mdIcates the partIculate mean aerodynamIC
dIameter
PartIculates Fme hqmd or sohd partIcles, such as dust, smoke, mIst, fumes, or smog, found
in the arr or m emISSIOnS
Pascal_ A umt of pressure m the InternatIOnal System of Umts One pascal IS equal to
7.4 X 10-3 torr The pascal IS eqUIvalent to 1 N per square meter
Pathogen- Any VIrUS, mlcroorgamsm, or other substance causmg dIsease
A-54
PathophysiOlogical Derangement of functiOn seen m disease, alteratiOn m functiOn as
distmgUlshed from structural defects
Peak expiratory flow (PEF) The highest forced expiratory flow measured with a peak flow
meter
Peptide bond The bond formed when two ammo aCids react with each other
Percentiles The percentage of all observatiOns exceedmg or preceding some pomt, thus,
90th percentile is a level below which 90 % of the observatiOns will fall
Perenmal Trees and other plants that hve more than one year are called perenmals
Perfusate A hqUid, solutiOn or collOidal suspenSiOn that has been passed over a special
surface or through an appropnate structure
PerfuSiOn ArtIfiCial passage of flUid through blood vessels
Permanent-press fabncs Fabncs m which apphed reSInS contnbute to the easy care and
appearance of the fabnc and to the crease and seam flatness by reacting with the
cellulose on pressmg after garment manufacture
PermeatiOn tube A tube that is selectively porous to specIfic gases
PeroXidatiOn Refers to the process by which certam orgamc compounds are converted to
peroXides
Peroxyacetyl mtrate (PAN) Pollutant created by actiOn of sunhght on hydrocarbons and

mtrogen OXides m the arr, an mgredient of photochemical smog
pH A measure of the effective aCidity or alkahmty of ,1 solutiOn It is expressed as the

negative loganthm of the.!tldrogen ion concentraltlon Pure water has a hydrogen ion
concentratiOn equal to 10 M per hter at standaJrd conditiOns (25°C) The negative
loganthm of this quantity is 7 Thus, pure water has a pH value of 7 (neutral) The
pH scale is usually considered as extendmg from 0 to 14 A pH less than 7 denotes
aCidity, and a pH more than 7 denotes alkahmty
Phagocytosis A mechamsm by which alveolar macrophages and polymorphonuclear

leukocytes engulf particles, one of several lung dl~fense mechamsms by which foreign
agents (biOlogiCal and nonbiOlogical) are removed from the respiratory tract
Phenotype. The observable charactenstics of an orgamsm, resultmg from the mteraction

between an mdividual genetiC structure and the enVIronment m which development
takes place
Phenylthiourea A crystallme compound (C 7H gN2S) that is bItter or tasteless dependmg on a

smgle dommant gene m the taster
A-55
Phlegm: VISCId mucus secreted ill abnormal quantIty ill the resprratory passages
Phosphatase Any of a group of enzymes that hberate illorgamc phosphate from phosphonc
esters (BC sub-subclass 3 1 3)
Phosphocreatine kInase An enzyme (BC 2 7 3 2) catalyzmg the formatIon of creatille and

adenosine trIphosphate, Its breakdown IS a source of energy ill the contractIon of
muscle; also called creatille phosphate
Phospholipid A molecule conslstillg of hpid and phosphonc aCId group(s) An example IS

lecithm Serves as an lll1portant structural factor ill bIOlogICal membranes
Photochemical OXidants Pnmary ozone, mtrogen dIOXide, and peroxyacetyl mtrate, WIth
lesser amounts of other compounds, formed as products of atmosphenc reactIons
involvillg organic pollutants, mtrogen OXides, oxygen, and sunhght
Photochemical smog AIr pollutIOn caused by chemical reactIon of vanous arrborne chemIcals
ill sunhght
PhotodissociatIon The process by whIch a chemIcal compound breaks down illtO slll1pler
components under the mfluence of sunhght or other ramant energy
Photolysis' DecompOSItIon upon rrradIatlOn by sunhght
PhotomultIplier tube An electron multIpher ill whIch electrons released by photoelectnc

emission are multIphed ill succeSSIve stages by dynodes that produce secondary
emiSSIOns
Photon A quantum of electromagnetIc energy
PhotostatIonary A substance or reactIon that reaches and mamtaills a steady state ill the
presence of light
PhotosyntheSIS The process ill whIch green parts of plants, when exposed to hght under
suitable condItIons of temperature and water supply, produce carbohydrates usmg
atmosphenc carbon mOXIde and release oxygen
Phyllosphere Usually refers to the leaf surface of plants
Phytotoxic' POIsonous to plants
Phytoplankton. MInute aquatIc plant hie
Pi (II) bonds Bonds ill whIch electron denSIty IS not symmetncal about a lme Jommg the
bonded atoms
A-56
PmocytotIc Refers to the cellular process (pmocytosIS) m whIch the cytoplasmIc membrane
forms mvagmatIons m the form of narrow channels leadmg mto the cell LIqUIds can
flow into these channels and the membrane pmches off pockets that are mcorporated
mto the cytoplasm and dIgested
PIttmg A form of extremely localIzed corrOSIOn that re'suIts m holes m the metal One of the
most destructive forms of corrOSIon
PItuItary A stalk-lIke gland near the base of the bram fhat IS attached to the hypothalmus
The antenor portIOn IS a major reposItory for hormones that control growth, stimulate
other glands, and regulate the reproductIve cycle
Placenta The organ m the uterus that provIdes metabolIc mterchange between the fetus and
mother
PlasmId ReplIcatmg umt, other than a nucleus gene, that contams nucleoprotem and IS
mvolved m vanous aspects of metabolIsm m orgamsms, also called paragenes
PlasmolysIs The dISsolutIOn of cellular components, or the shnnkmg of plant cells by

osmotic loss of cytoplasmIc water
Plastic A plastic IS one of a large group of orgamc compoundls synthesIZed from cellulose,
hydrocarbons, protems, or resms and capable of bemg cast, extruded, or molded mto
various shapes
PlastIcizer A chemIcal added to plastIcs to soften, mcrease malleability, or make them more
readIly deformable
Platelet (blood) An megularly-shaped dISk WIth no definIte nucleus, about one-thrrd to one-
half the SIZe of an erythrocyte and contammg no Jb.emoglobm Platelets are more
numerous than leukocytes, numbermg from 200,000 to 300,000 per CUbIC millImeter of
blood
Plethysmograph A deVIce for measurmg and recordmg changes m volume of a part, organ,
or the whole body, a body plethysmograph IS a chamber apparatus surroundmg the
entrre body
Pleura The serous membrane envelopmg the lungs and lIning the walls of the chest caVIty
Plume EmissIOn from a flue or chImney, usually m a s:tream-hke dIstnbutIon downwmd of

the source, which can be dIstmguished from the surroundmg arr by appearance or
chemIcal charactenstIcs
Pneumoma (mterstItlal) A chromc mflammatIOn of the mterstItIal tissue of the lung, resultmg
m compressIOn of the arr cells An acute, mfectIOuS dIsease
A-57
Pneumonocytes A nonspecIfic tenn sometnnes used m refemng to types of cells
characteristic of the resprratory part of the lung
Podzol: Any of a group of zonal soils that develop m a mOIst chmate, espeCIally under
conIferous or mIXed forests
Pomt source A smgle statIonary locatIOn of pollutant dIscharge
Polarography' A method of quantItatIve or qualItatIve analySIS based on current-voltage

curves obtamed by electrolySIS of a solutIon WIth steadIly mcreasmg voltage
Pollution gradient· A senes of exposure SItuatIOns m whIch pollutant concentratIOns range

from hIgh to low
PolyacrylonitrIle. A polymer made by reactmg ethylene OXIde and hydrocyanIC aCId Dynel
and Orlon are examples
Polyamides PolymenzatIOn products of chemIcal compounds whIch contam ammo (-NH2)

and carboxyl (-COOH) groups CondensatIOn reactIOns between the groups fonn
amides (-CONHV Nylon IS an example of a polyamIde
Polycarbonate Any of vanous tough transparent thennoplastIcs charactenzed by hIgh Impact

strength and high softenmg temperature
Polycythemia An increase above the nonnal m the number of red cells m the blood
Polyester fiber A manufactured fiber m whIch the fiber-fonnmg substance IS any long-cham
synthetIc polymer composed of at least 85 % by weIght of an ester of a dIhydnc alcohol
and terephthalIc aCId Dacron IS an example
Polymer. A large molecule produced by lmkmg together many hke molecules
PolymerizatIOn In fiber manufacture, convertmg a chemIcal monomer (SImple molecule) mto

a fiber-fonnmg matenal by Jommg many hke molecules mto a stable, long-cham
structure
Polymorphic monocyte Type of leukocyte WIth a muitilobed nucleus
Polymorphonuclear leukocytes Cells that represent a secondary nonspecIfic cellular defense

mechanism They are transported to the lungs from the bloodstream when the burden
handled by the alveolar macrophages IS too large
Polysacchandes Polymers made up of sugars An example IS glycogen, whIch conSIsts of

repeatmg UnIts of glucose
Polystyrene' A thennoplastIc plastIc that may be transparent, opaque, or translucent It IS

lIght m weIght, tasteless, and odorless, It also IS resIstant to ordmary chemIcals
A-58
Polyurethane Any of vanous polymers that contam NHCOO lmkages and are used especIally
m fleXIble and ngld foams, elastomers, and resml)
Pores of Kohn Also known as mteralveolar pores, pores between arr cells Assumed to be
pathways for collateral ventilatIon
PreCIpItatIOn Any of the vanous forms of water partIcles that fall from the atmosphere to the
ground, ram, snow, etc
Precursor A substance from whIch another substance liS formed, specIfically, one of the
anthropogemc or natural emISSIOns or atmosphenc constItuents that reacts under
sunlIght to form secondary pollutants compnsmg photochemIcal smog
Probe In arr pollutIOn samplmg, the tube or other condlUIt extendmg mto the atmosphere to
be sampled, through whIch the sample passes to treatment, storage, and/or analytIcal
eqUIpment
Prolme An ammo aCId (CSH 9N02) that can be synthesIZed from glutamate by anImals
Promonocyte An munature monocyte not normally seen m the crrculatmg blood
Protemuna The presence of more than 0 3 gram of urmary protem m a 24-hour unne
collectIOn
Pulmonary Relatmg to the lungs
Pulmonary edema An accumulatIon of exceSSIve amounts of flUId m the lungs
Pulmonary lumen The spaces m the mtenor of the tubular elements of the lung (bronchIoles
and alveolar ducts)
Pulmonary measurements Measurements of the volume of arr moved dunng a normal or

forced mSpIratIOn or expIration SpecIfic lung volume measurements are defmed
mdependently
Lung volume measurements = TIdal volume, mspIratory reserve volume, expIratory

reserve volume, reSIdual volume (four baSIC mdependent volumes)
CapacItIes = CombmatIOns of baSIC volumes
Tota1lung capacIty (TLC) = TIdal volume + mspIratory reserve volume + expIratory

reserve volume + reSIdual volume, the volume of gas ill the lungs at the time of
maXImal msprratIon or the sum of all volume compartments The method of
measurement should be mdIcated, as WIth reSIdual volume
A-59
VItal capacIty (VC) = TIdal volume + msprratory reserve volume + exprratory
reserve volume, the greatest volume of gas that can be expelled by voluntary effort
after maxunal msprratIOn Also forced VItal capaCIty and forced msprratory VItal
capaCIty
FunctIonal resIdual capaCIty (PRC) = ResIdual volume + exprratory reserve volume,

the volume of gas remammg m the lungs at the restmg, end-tIdal exprratory posItIon
EqUIvalent to the sum of reSIdual volume and exprratory reserve volume The method
of measurement should be mdIcated as wIth reSIdual volume
Insprratory capaCIty (IC) = TIdal volume + msprratory reserve volume

Insprratory vital capaCIty (IVC) = The maxunal volume that can be msprred from the
resting end-expiratory posItIon, also forced msprratory VItal capaCIty
Expiratory reserve volume (ERV) = The maxunal volume that can be exhaled from the
restIng end-tIdal exprratory posItIOn See also FunctIOnal reSIdual capaCIty
Residual volume (RV) = That volume of arr remammg m the lungs after maxunal
exhalation The method of measurement should be mdicated m the text or, when
necessary, by appropnate qualIfymg symbols
ResIdual volume to total lung capaCIty ratIo (RV/TLC) = A ratIo that expresses the
percentage of the total lung capaCIty OCCUpIed by reSIdual volume, vanes somewhat
wIth age, but ordmanly should be no more than 20 to 30 %
TIdal volume = That volume of arr Inhaled or exhaled wIth each breath durmg qUIet
breathmg, used only to mdIcate a subdIVISIon of lung volume When tIdal volume IS
used m gas exchange formulatIons, the symbol VT should be used
Mmute ventllatIon (MV) = The volume of gas exchanged per mmute at rest or durmg
any stated actIvIty, It IS the tIdal volume tImes the number of resprratIons per mmute
See ventllatIon
Pulmonary resistance Sum of arrway reSIstance and VISCOUS tIssue reSIstance
Purine bases Orgamc bases that are constItuents of DNA and RNA, mc1udmg adenme and
guanme
Purulent. Contammg or formmg pus
Pynmidine bases Orgamc bases found m DNA and RNA Cytosme and thymme occur m
DNA and cytosme and uracn are found m RNA
QRS: GraphIcal representatIOn on the electrocardIogram of a complex of three dIstmct waves

that represent the begmnmg of ventncular contractIOn
A-60
QuasistatIc comphance TIme dependent component of elastIcIty, comphance IS the recIprocal
of elaStICIty
Ram out Removal of partIcles and/or gases from the atmosphere by theIr mvolvement m
cloud fonnation (partIcles act as condensatIOn nudeI, gases are absorbed by cloud
droplets), WIth subsequent precIpItatIOn
RayleIgh scattenng Coherent scattenng m which the m1ensity of the hght of wavelength A
scattered m any dIrectIOn, makIng an angle WIth the mCIdent dIrectIOn, IS drrectly
proportIOnal to 1 + coi and mversely proportIOncu to A4
ReactIve dyes Dyes that react chemIcally WIth cellulose m fibers under alkalme condttIons
Also called fiber reactIve or chemIcally reactive dyes
ReductIOn Acceptance of electrons by an Ion or molecule
Reference method (RM) For mtrogen dtoXIde, an EPA-approved gas-phase chemI1ummescent

analyzer and assocIated cahbratIOn technIques, regulatory specIficatIOns are descnbed m
TItle 40, Code of Federal RegulatIOns, Part 50, Appendtx F Fonnerly, Federal
Reference Method
ReSIdual capaCIty The volume of arr remammg m the lungs after a maXImum expIratory
effort, same as reSIdual volume
ReSIdual volume (RV)' The volume of arr remammg m the lungs after a maXImal expIratIon
The reSIdual volume IS equal to the total lung capaCIty mmus the VItal capaCIty
Resm Any of vanous sohd or semlsohd amorphous natlllral orgamc substances, usually
denved from plant secretIOns, which are soluble m orgamc solvents but not m water,
also any of many synthetIc substances WIth SImJ.1aI propertIes used m I1ll1Shmg fabncs,
for pennanent press shrInkage control or water repellency
ReSIstance flow (R) The ratIO of the flow-resIstIve comlponents of pressure to SImultaneous
flow (m centImeters of water per hter per second) Flow-resIstIve components of
pressure are obtamed by subtracting any elastIc or mertlal components, proportIOnal
respectIvely to volume and volume acceleratIon l\.1ost flow reSIstances m the
respIratory system are nonhnear, varymg WIth the magmtude and drrectlon of flow,
WIth lung volume and lung volume history, and pOSSIbly WIth volume acceleratIOn
Accordmgly, careful specIficatIon of the condttIOns of measurement IS necessary, see
arrway reSIstance and total pulmonary reSIstance
Ribosomal RNA The most abundant RNA m a cell and an mtegral constItuent of nbosomes
Ribosomes DIscrete umts of RNA and protem that are llllstrumental m the syntheSIS of
proteins m a cell Aggregates are called polysomes
A-61
Runoff: Water from precIpItation, lITIgation, or other sources that flows over the ground
surface to streams
Sclerosis Pathological hardemng of tissue, especIally from overgrowth of fibrous tissue or

increase In interstitial tissue
Secondary partIcles (or secondary aerosols) DIspersIOn aerosols that form In the atmosphere
as a result of chemIcal reactions, often mvolvmg gases
Selective leachIng The removal of one element from a sohd alloy by corrOSIOn processes
Septa. A thIn wall dIVIdIng two cavItIes or masses of softer tissue
SeromucOld' Pertammg to a mIXture of watery and mucmous matenal such as that of certaIn
glands
Serum antIprotease A substance, present In serum, that InhIbItS the actiVIty of protemases
(enzymes that destroy protems)
Sigma (s) bonds. Bonds In whIch electron denSIty IS symmetncal about a hne Jommg the
bonded atoms
Silo-filler's dIsease Pulmonary lesIOn produced by OXides of mtrogen produced by fresh

silage
Single breath mtrogen ehmInatIOn rate Percentage nse In mtrogen fractIOn per umt of
volume expired
Single breath nitrogen technIque A procedure In whIch a VItal capaCIty mspIratIon of

100% oxygen IS followed by exammatIon of mtrogen m the VItal capaCIty expIred
Singlet state: The hIghly reactIve energy state of an atom In whIch certam electrons have
unparred spms
Sink: A reactant With or absorber of a substance
SodIum arsemte (Na3As03) A compound used WIth sodIUm hydroXide m the absorbmg
solution of a 24-hour mtegrated manual method for mtrogen dIOXide
Sodium dithIOmte' A strong reducmg agent (a suppher of electrons)
Sodium metabisulfite (Na2S20S) A compound used m absorbmg solutions of mtrogen dIOXide

analySIS methods
Sorb. To take up and hold by absorptIOn or adsorptIOn
Sorbent A substance that takes up and holds another by absorptIon or adsorptIon
A-62
SorbItol dehydrogenase An enzyme that mterconverts the sugars sorbItol and fructose
Sorption The process of bemg sorbed
Spandex A manufactured fiber m whIch the fiber-formmg substance IS a long cham synthetic
elastomer composed of at least 85 % of a segmented polyurethane
SpecIfic arrway conductance (SGaw) AIrway conductance dIVIded by the lung volume at
whIch It was measured, that IS, normalIzed arrway conductance AIrway conductance
(Gaw)/thoracic gas volume (TGV)
SpecIfic arrway resIstance (SRaw) AIrway resIstance muJltIphed by the volume at whIch It
was measured SRaw = arrway resIstance (Raw) )< thoraCIC gas volume (TGV), hter
(L) x centimeter of water per hter per second (cm H20/L/s)
Spectrometer An mstrument used to measure ramatIOn spectra or to determme wavelengths

of the VarIOUS radiations
Spectrophotometry A technIque m whIch VISIble, ultraVIOlet, 01 Infrared radiatIOn IS passed

through a substance or solutIOn and the mtensity oj hght transmItted at VarIOUS
wavelengths IS measured to determme the spectrum of hght absorbed
Spectroscopy Use of the spectrometer to determme cone entratIons of an arr pollutant
Spermatocytes A cell destmed to gIve nse to spermatozoa (spenn)
Sphmgomyehns A group of phosphohpids found m braIltl, spmal cord, kIdney, and egg yolk
Sphygmomanometer An apparatus, consIstmg of a cuff and a pressure gauge, that IS used to

measure blood pressure
SpIrometer A mechanIcal deVIce, mcludmg bellows or other sealed, movmg parts, that
collects and stores gases and proVIdes a graphIcal record of lung volume changes over
time See breathmg pattern and respiratory cycle
SpIrometry The measurement, by a form of gas meter (spIrometer), of volumes of arr that
can be moved m and out of the lungs
Spleen A large vascular organ located on the upper left SIde of the abdommal caVIty It IS a
blood-formmg organ m early lIfe It IS a storage organ for red corpuscles and because
of the large number of macrophages, acts as a blood fIlter
Sputum Expectorated matter, espeCIally mucus or mucopurulent matter expectorated as a

result of dIseases of the arr passages
Squamous Scale-lIke, scaly
A-63
Standard deviation Measure of the dIsperSion of values about a mean value It is calculated
as the positive square root of the average of the squares of the mdividual deViations
from the mean
Standard temperature and pressure 0 °C, 760 ml1hmeters of mercury
Standard temperature and pressure, dry (STPD) conditions These are the conditiOns of a
volume of gas at 0 °C and 760 torr, Without water vapor An STPD volume of a given
gas contams a known number of moles of that gas
Staphylococcus aureus A sphencally shaped, Infectious species of bactena found especially

on nasal mucous membrane and skin
Static lung comphance (CLstaU Measure of lung's elastiC recoil (volume change resultmg
from change ill pressure) With no or mSigmficant arrflow
Steady state exposure Exposure to arr pollutants whose concentration remams constant for a
penod of time
Steroids. A large famJ.1y of chemical substances compnsmg many hormones and vitamms and
having large rmg structures
Stilbene' An aromatic hydrocarbon (C 14H 12) used as a phosphor and m makmg dyes
StOIchiometric factor Used to express the converSion effiCiency of a nonquantItatIve reaction,

such as the reaction of mtrogen diOXide With azo dyes m arr momtormg methods
Stoma A minute opening or pore (plural is stomata)
Stratosphere That region of the atmosphere extendmg from 11 lalometers above the surface
of the earth to 50 lalometers At 50 lalometers above the earth, temperature nses to a
maximum of 0 °C
Streptococcus pyogenes A species of bactena found ill the human mouth throat, and
respiratory tract and ill mflammatory exudates, blood stream, and leSiOns m human
diseases It causes formation of pus or even fatal septlcemIas
Stress corrOSiOn cracking Cracking caused by slIDultaneous presence of tensile stress and a
speclfic corrOSive mediUm The metal or alloy is vrrtually unattached over most of itS
surface, while fme cracks progress through it
Strong interactions Forces or bond energies holdmg molecules together Thermal energy
will not disrupt the formed bonds
Sublobular hepatic necrOSiS The pathologiC death of one or more cells, or of a portion of the
hver, beneath one or more lobes
A-64
SucceSSIOn The progressIve natural development of vegetatIOn towards a clImax, dunng
wInch one commumty IS gradually replaced by others
Succmate A salt of SUCClIDC aCId mvolved m energy productIOn m the cItnc aCId cycle
Sulfamazme One of a group of sulfa drugs HIghly effectIve agamst pneumococcal,

staphylococcal, and streptococcal InfectIOns
y=-= Sulfamethazme An antIbactenal agent of the sulfonamIde group, actIve agamst homolytIC
streptococCI, staphylococCI, pneumococcI, and menmgococci
,
J Sulflpllhmide A crystalline sulfonamIde (C6H gN20 2S), the amIde of sulfanilic aCId and
lr parent compound of most sulfa drugs
_~!ffiidryl gro~p _A chemIcal radIcal consIstmg of sulfur and hydrogen (-SH) that confers
~I
llII---'
,r -
reducillg potentIal to the chemIcal compound to wInch It IS attached
, ~_~~ _~-~ifur dIOXide (S02) Colorless gas wIth pungent odor leleased-pnmanly from burmng of
fossI1 fuels, such as coal, contammg sulfur
Sulfur dyes Used only on vegetable fibers, such as cottons They are msoluble m water and
must be converted chemIcally ill order to be soluhle They are resIstant (fast) to
alkahes and washmg and farrly fast to sunhght
Supernatant The clear or partIally clear hqmd layer that separates from the homogenate upon
centnfugatIOn or standIng
Surfactant A substance capable of altenng the phySIOchemIcal nature of surfaces, such as one
used to reduce surface tenSIOn of a hqmd '
SymbIOtIC A close aSSOCiatIOn between two orgamsms of different specIes ill wInch at least
one of the two benefits
SynergIstIc A relatIOnsInp m wInch the combmed actIOn or effect of two or more

components IS greater than that of the components actmg separately.
Systohc Relaimg to the rhythmIcal contractIon of the heart
Tachypnea Very rapId breathmg
Teragram (Tg) One mI1hon metnc tons, 1012 grams
TeratogenesIs The msturbed growth processes resultmg ill a defonned fetus
Teratogemc Causmg or relatmg to abnonnal development of the fetus
Threshold The level at wInch a phYSIOlogICal or psychologIcaJl effect begms to be produced
A-65
ThylakOId' A membranous lamella of protem and hpid m plant chloroplasts where the
photochemical reactIOns of photosynthesIs take place
Thymidme: A nucleosIde (C1oH14N20S) that IS composed of thymme and deoxynbose, occurs

as a structural part of DNA
Tidal volume (VT)' The volume of arr that IS msprred or exprred m a smgle breath durmg
regular breathIng.
Titer: The standard of strength of a volumetnc test solutIon For example, the tItratIOn of a
volume of antIbody-contammg serum wIth another volume contammg VIruS
Tocopherol a-d-Tocopherolis one form of Vitamm E prepared synthetIcally The a form

exhibIts the most bIOlogIcal actIvIty It IS an antIOXidant and retards rancIdIty of fats
Torr A unit of pressure sufficIent to support a l-mIlhmeter column of mercury, 760 torr =
1 atmosphere
Total lung capacIty (TLC) The sum of all the compartments of the lung, or the volume of arr
in the lungs at maXImum msprratIon
Total pulmonary resIstance (Rr) ResIstance measured by relatmg flow-dependent

transpulmonary pressure to arrflow at the mouth Represents the total (fnctIOnal)
resistance of the lung tIssue <Rtl) and the arrways (Raw), RL = Raw + ~l
Total suspended particulates (TSP) Sohd and hqUld partIcles present m the atmosphere
Trachea' Commonly known as the wmdplpe, a cartilagmous arr tube extendmg from the
larnyx (vOIce box) mto the thorax (chest), where It dIVIdes, servmg as the entrance to
each of the lungs
TracheobronchIal region The area encompassed by the trachea to the gas exchange region of
the lung; the conductmg arrways
Transaminase Ammotransferase, an enzyme transferrmg an ammo group from an a-ammo

acid to the carbonyl carbon atom of an a-keto aCId
TranSmIssivIty (UV) The percent of ultravIolet radIatIOn passmg through a medIUm
Transmittance The fractIon of the radIant energy entenng an absorbmg layer that reaches the
layer's further boundary
TransprratIon The process of the loss of water vapor from plants
Triethanolamine An amme ([HOCH2CHibN) used m the absorbmg solutIOn of one

analytical method for mtrogen dIoXide
A-66
Troposphere That portIOn of the atmosphere m whtch temperature decreases rapidly with
altitude, clouds form, and mlXlUg of alf masses by convectIOn takes place Generally
extends to about 7 to 10 miles above the earth's su rface
Type 1 cells ThIn, alveolar surface, epithehal cells acro,ss whtch gas exchange occurs
Type 2 cells Thtcker, alveolar surface, epithehal cells that produce surfactant and serve as
progemtor cells for Type 1 cell replacement
Ultraviolet L~ht mVisible to the human eye of wavelengths between 4 x 10-7 and
5 x 10- meter (4,000 to 50 Angstroms)
Urea-formaldehyde resm A compound composed of urea. and formaldehyde m an

arrangement that conveys thermosettmg properties
Urobl1mogen' One of the products of destructIOn of blood cells, found m the hver, mtestmes,
and urme
Uterus The womb, the hollow muscular organ m which the lffipregnated ovum (egg)
develops mto the fetus
Vacuole A mmute space m any tissue
Vagal Refers to the vagus nerve Thts miXed nerve arlses near the medulla oblongata and
passes down from the cramal caVity to supply the llarynx, lungs, heart, esophagus,
stomach, and most of the abdommal Viscera
Valence The number of electrons capable of bemg bondled or donated by an atom durmg
bondmg
Van Slyke reactions ReactIOn of pflffiary ammes, mcludmg ammo aCids, With mtrous aCid,
yieldmg molecular mtrogen.
Vanance A measure of disperSion or vanatIOn of a sample from itS expected value, it is

usually calculated as the square root of a sum of squared deViations about a mean
diVided by the sample sIZe
Vat dyes Dyes that have a htgh degree of reSistance to fadmg by hght, mtrogen OXides, and
washIng Widely used on cotton and Viscose rayon Colors are bnlliant and of almost
any shade The name was ongmally denved from thelf apphcation m a vat
Venezuelan equme encephalomyehtis A form of equme encephalomyehtis found m parts of

South Amenca, Panama, Tnmdad, and the Umted States, and caused by a VlfUS
Fever, d1arrhea, and depreSSion are common In humans, there is fever and severe
headache after an mcubation penod of 2 to 5 days
A-67
VentIlauon PhysIological process by whIch gas IS exchanged between the outsIde arr and the
lungs The word ventIlatIon sometlmes deSIgnates ventIlatory flow rate (or ventilatory
mmute volume), winch IS the product of the tidal volume multIphed by the ventilatory
frequency CondItions are usually mdIcated as modIfiers, for example
VE = Exprred volume per mmute (hters per mmute, body temperature and pressure,
saturated [BTPS]),
VI = Insprred volume per mmute (hters per mmute, BTPS)

VentIlation IS often referred to as "total ventilation" to dIstmgUlsh It from "alveolar
ventilation" (see ventIlation, alveolar)
VentilatIOn, alveolar (V A) The portion of the total ventIlatIOn that IS mvolved m gas
exchange WIth the blood, alveolar ventilation IS less than total ventilatIOn because when
a tidal volume of gas leaves the alveolar spaces, the last part does not get expelled from
the body but occupIes the dead space, to be remsprred WIth the next mspIratIon Thus,
the volume of alveolar gas actually expelled completely IS equal to the tidal volume
mmus the volume of the dead space ThIs truly complete exprratIOn volume times the
ventilatory frequency constitutes the alveolar ventilatIOn
Ventilation, dead-space (V D) VentilatIOn per mmute of the phYSIOlogIC dead space (volume
of gas not mvolved m gas exchange WIth the blood), at body temperature and pressure,
saturated condItions, defmed by the followmg equatIOn
Ventilanon/perfusion ratio (V A/Q) Ratio of the alveolar ventilatIOn to the blood perfuSIOn
volume flow through the pulmonary parenchyma, such as pulmonary blood flow or
nght heart cardIa output, thIs ratio IS a fundamental determmant of the oxygen and
carbon dioXlde pressure of the alveolar gas and of the end-capillary blood Throughout
the lungs, the local ventilatIOn/perfusIon ratIOS vary, and, consequently, the local
alveolar gas and end-capillary blood compOSItions also vary
Villus. A prOjectIOn from the surface, especially of a mucous membrane
Vmyl chloride A gaseous chemIcal suspected of causmg at least one type of cancer It IS
used pnmanly in the manufacture of polyvmyl chlonde, a plastic
VIscose rayon Filaments of regenerated cellulose coagulated from a solutIOn of cellulose

xanthate Raw matenals can be cotton hnters or chIps of spruce, pme, or hemlock
VIsible regIOn LIght between the wavelengths of 4,000 and 8,000 Angstroms
VISUal range The dIstance at whIch an object can be dIstmguished from background
A-68
VItal capacIty (VC) The greatest volume of arr that can be exhaled from the lungs after a
maxnnum msprratlOn (see Pulmonary measurements)
Vitamm E Any of several fat-soluble vitamms (tocopherols) essential m nutntlOn of vanous

vertebrates
Washout The capture of gases and partIcles by fallmg ramdrops
Weak mteractIons Forces, electrostatic m nature, that bmd atoms and/or molecules to each
other Thermal energy will dISrupt the mteractIon Also called Van der Waal's forces
Weathenng In thIs context, weathenng refers to the releases of base catIOns from SOll
mmerals to catIomc forms, whIch can be taken up by plant.s, leached, or absorbed to
cation-exchange SItes
Wet depOSItion The process by whIch abnosphenc substances ale returned to earth m the
form of ram or other precIpItation
Wheat germ hpase An enzyme, obtamed from wheat germ, that IS capable of cleavmg a fatty
aCId from a neutral fat, a hpolytIc enzyme
X-ray fluorescence spectrometry A nondestructive technIque that utIhzes the pnnciple that
every element emIts charactenstic x-ray emISSIons when eXCIted by hIgh-energy
radiation
Zeohtes Hydrous silicates analogous to feldspars, occurrmg m lavas and vanous sOlls
Zooplankton Mmute anunal hfe floatmg or sWlIDmmg weakly m a body of water
A-69
1< U S GOVERNMENT PRINTING OPFICE 1993-550-001 I 80325

30001ni2 Nox

Hochgeladen von

Dokumentinformationen

Originalbeschreibung:

Originaltitel

Copyright

Verfügbare Formate

Dieses Dokument teilen

Dokument teilen oder einbetten

Freigabeoptionen

Stufen Sie dieses Dokument als nützlich ein?

Sind diese Inhalte unangemessen?

Copyright:

Verfügbare Formate

30001ni2 Nox

Hochgeladen von

Copyright:

Verfügbare Formate

EPA600/8-91/049cF

Air Quality Criteria for

Volume III of III

Environmental Cntena and Assessment Office

@ Prmted on Recycled Paper

The U S EnvIronmental ProtectiOn Agency (EPA) promulgates the NatiOnal Ambient

1 EXECUTIVE SUMMARY OF AIR QUALITY CRITERIA FOR

3 GENERAL CHEMICAL AND PHYSICAL PROPERTIES OF

4 AMJ3IENT AND INDOOR SOURCES AND EMISSIONS OF

5 TRANSPORT AND TRANSFORMATION OF NITROGEN

6 SAMPUNG AND ANALYSIS FOR NITROGEN OXIDES

7 AMBIENT AND INDOOR CONCENTRATIONS OF NITROGEN

8 ASSESSING TOTAL HUMAN EXPOSURE TO NITROGEN

9 EFFECTS OF NITROGEN OXIDES ON VEGETATION 9-1

10 THE EFFECTS OF NITROGEN OXIDES ON NATURAL

11 EFFECTS OF NITROGEN OXIDES ON VISffiILITY 11-1

12 EFFECTS OF NITROGEN OXIDES ON MATERIALS 12-1

Air Quality Criteria for Oxides of Nitrogen

TABLE OF CONTENTS (cont'd)

13 STUDIES OF THE EFFECTS OF NITROGEN COMPOUNDS

14. EPIDEMIOLOGY STUDIES OF OXIDES OF NITROGEN 14-1

15. CONTROLLED HUMAN EXPOSURE STUDIES OF NITROGEN

16 REALTII EFFECTS ASSOCIATED WITH EXPOSURE TO

APPENDIX A' GLOSSARY OF TERMS AND SYMBOLS A-I

UST OF TABLES ill-xn

13 STUDIES OF THE EFFECTS OF NITROGEN COMPOUNDS

13 6 2 Blochemtcal and Cellular MechanIsms 13-197

14. EPIDEMIOLOGY STUDIES OF OXIDES OF NITROGEN 14-1

14 3 2 8 Chattanooga Studies 14-47

15 CONTROLLED HUMAN EXPOSURE STUDIES OF

15 4 1 Healthy Subjects 15-67

16. HEALTH EFFECTS ASSOCIATED WITH EXPOSURE

1653 NItrogen DIOXIde Exposure Estunates 16-28

APPENDIX A GLOSSARY OF TERMS AND SYJ\1J30LS A-I

13-1 Effects of NItrogen DIOXIde on MucocIhary ACtIVIty 13-18

13-2 Effects of Nitrogen DIOXIde on Alveolar Macrophages 13-24

13-3 Effects of NItrogen DIOXIde on the Immune System 13-35

13-4 InteractIon of NItrogen DIOXIde WIth InfectIous Agents 13-39

13-5 Effects of NItrogen DIOXIde on LIpId Metabohsm 13-56

13-6 Effects of NItrogen DIOXIde on Lung Ammo ACIds, Protems,

13-7 Effects of NItrogen DIOXIde on AntIOXidant Metabohsm and

13-8 Effects of NItrogen DIOXIde on Pulmonary FunctIOn 13-79

13-9 Effects of Acute Exposure to NItrogen DIOXIde on

13-10 Effects of Subehromc Exposure to NItrogen DIOXIde on

13-11 Effects of Chrome Exposure to NItrogen DIOXIde on

13-12 Effects of NItrogen DIOXIde on the Development of Emphysema 13-121

13-13 Extrapulmonary Effects of NItrogen DIOXIde Body WeIght 13-126

13-14 Effects of NItrogen DIOXIde on Red Blood Cells and

13-15 Effects of NItrogen DIOXIde on Leukocytes and Platelets 13-132

13-16 Effects of NItrogen DIOXIde on Red Blood Cell Membranes 13-135

13-17 Effects of NItrogen DIOXIde on Serum Protems and

13-18 Effects of NItrogen DIOXIde on the LIver 13-139

13-19 Effects of NItrogen DIOXIde on the KIdney and

13-20 Effects of NItrogen DIOXIde on the Central Nervous

13-21 Effects of NItrogen DIOXIde on ReproductIOIl, Development,

13-22 Effects of NItrogen DIOXIde on Carcillogenesis or

13-23 TOXIcolOgiC InteractIons to SImple MIXtures Contammg

13-24 Effect of NItnC OXide on RespIratory Tract J\1orpho10gy 13-187

14-1 RespIratory Symptom Rates of Umted KIngdom ChIldren by

14-2 Hasselblad et al (1992) Mulnple LogIsnc AnalySIS of Data

14-3 Unadjusted Rates of One or More RespIratory Symptoms Among

14-4 Hasselblad et al (1992) Mulnple LogIStIC AnalYSIS of Data