Thunderstorm asthma: an overview of mechanisms and management strategies

ABSTRACT

Introduction

Epidemic thunderstorm asthma (ETSA) is due to a complex interaction of environmental and individual susceptibility factors, with outbreaks reported globally over the last four decades. Australia has been particularly susceptible with nearly half of episodes reported internationally, culminating in the catastrophic Melbourne 2016 event.

Areas covered

Reported ETSA episodes are reviewed for common environmental and meteorological risk factors. Allergen aerobiology interaction with thunderstorm activity and rapid weather condition changes is examined. Assessment of the clinical and immunological data highlights risk factors for ETSA presentation, hospital admission, and intensive care admission. Risk factors associated with ETSA deaths are evaluated. Public health strategies, as well as pharmacological and immunological management approaches to reduce individual susceptibility and prevent ETSA are discussed.

Expert opinion

Improved understanding of the specific meteorological factors predisposing to the greatest risk of ETSA to improve forecasting is required. Better monitoring of aeroallergen levels in areas of greatest geographic risk, with further research into allergen aerobiology underpinning mechanisms of allergen exposure is needed. The role of climate change in increasing the risk of ETSA outbreaks requires further research. Public awareness and education are required to reduce exposure, and to improve uptake of pharmacological and immunological risk reduction and preventive strategies.

KEYWORDS:

• Aeroallergens
• allergic asthma
• allergic rhinitis
• asthma mortality
• immunotherapy

Article highlights

• Outbreaks of epidemic thunderstorm asthma (ETSA) can overwhelm health services and be associated with asthma fatalities.

• Environmental factors predisposing to ETSA include the presence of high levels of allergen-containing bioaerosols, combined with meteorological factors of thunderstorm and lightning activity associated with rapid weather condition changes.

• Individual susceptibility factors for ETSA include allergen sensitization, the presence of allergic rhinitis, pre-existent asthma with lack of inhaled steroid usage, and outdoor exposure.

• Public health and environmental strategies to reduce ETSA risk incorporates aeroallergen measurement and meteorological forecasting with an early warning to reduce exposure.

• Pharmacotherapy of allergic rhinitis and asthma, and allergen immunotherapy to reduce individual susceptibility are important primary and secondary prevention strategies.

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This paper was not funded.