Effectiveness of Air Filters and Air Cleaners in Allergic Respiratory Diseases
Air filtration is frequently recommended as a component of environmental control measures for patients with allergic respiratory disease. Residential air filtration can be provided by whole house filtration via the home’s heating, ventilation, or air conditioning system, by portable room air cleaners, or a combination of the two. Appliances to filter the sleep breathing zone also have been developed. High-efficiency whole house filtration, high-efficiency particulate air sleep zone air filtration, and high-efficiency particulate air room air cleaners all appear to provide various degrees of benefit. Recent studies of various types of filtration, used alone or as part of more comprehensive environmental control measures, are reviewed.
Keywords: Air cleaner, Air filter, Air filtration, Breathing zone, CADR, Clean air delivery rate, Environmental control, Furnace filter, HEPA, HVAC, Indoor air, Indoor allergens, Intervention measures, Ozone, Particulate matter, PM, Room air cleaner, Sleep breathing zone, Ventilation, Whole house filtration
Environmental control practices (ECPs) are a group of measures recommended to reduce exposure to indoor allergens (eg, dust mites, household pets, cockroaches, mold, mice) or nonallergic triggers (eg, environmental tobacco smoke [ETS], wood smoke, volatile organic compounds, particulate matter [PM]) . Historically, many of the common suggestions have been empiric and not based on scientific data or evidence-based clinical trials. As a better understanding of the impact of the characteristics of housing stock [2, 3] and occupants  on the indoor living environment has evolved, more effective measures have been identified. These may include modification of the occupant’s habits, remediation, and/or modification of the dwelling and its furnishings, structure, or ventilation, including the use of air filtration. One major drawback in many ECP studies has been the focus on a single allergen (eg, dust mites ) or intervention (eg, room air filtration for cat or dog allergy [6–8]). In fact, most allergic individuals have polysensitivity to multiple allergens. ECPs are therefore much more likely to be beneficial if targeted against triggers or allergens known to be problematic for the individual.
In the case of filtration, little attention has been paid to variations among the various appliances themselves, and no clinical comparisons have been done between the benefits of whole house filtration (WHF) versus those of portable room air cleaners (PRACs). According to the most recent American Housing Survey, 75% of US housing units have ducted forced air heat, while 63% have ducted central air conditioning . When used in combination, these ducted heating systems are termed heating, ventilation, air conditioning (HVAC) systems. HVAC systems offer the opportunity for WHF, but poorly maintained or contaminated systems may actually increase the risk of asthma and other allergic respiratory symptoms . Simple forgetfulness by the occupants in replacing the filter at suggested maintenance intervals may be the most common issue. HVAC service technicians frequently find round air filter that have not been changed for years when providing repair or maintenance services . Dirty filters themselves can become a source for air contamination by allergens, particularly fungal spores , and can then be trapped, colonized, and released downstream as the overloaded filter fails . Other issues, including air bypass from poor filter fit and duct leakage, may further confound the effectiveness of filtration in HVAC systems.
A barrier to proof of effectiveness for ECPs is the complexity of the gene–host–environment interactions. Expectations have been tainted by the fact that short-term drug studies of only a few weeks’ or months’ duration can show statistical effectiveness for improvement of symptoms. However, despite major advances in the drugs available for the treatment of allergy and asthma, none have been shown to arrest disease progression permanently. Improved understanding on how to avoid or reduce triggers would be expected to have this benefit. This may not occur in the short term. Observational epidemiology has already led to the recognition of a wide range of triggers found in the indoor environment, ranging from dust mite to diesel exhaust particulates. Applied epidemiologic studies are helpful in understanding targeted avoidance and prevention of disease progression.
Morgan et al. , as part of the Inner-City Asthma Study Group, conducted a randomized controlled trial of comprehensive ECPs in 937 children with atopic asthma. All were sensitized, as demonstrated by positive skin test, to at least one indoor allergen. A baseline home evaluation included both direct visual inspections and dust collection from the child’s bedroom. Targeted ECPs were then implemented based on skin testing results and the home evaluation. Interventions included the use of a high-efficiency particulate air (HEPA) room air cleaner in the child’s bedroom if the child was exposed to ETS, sensitized and exposed to cat or dog allergens, or sensitized to mold. The intervention group reported significantly fewer symptoms of asthma during the intervention year and the follow-up year. The maximal number of days with symptoms was lower in the intervention group by 0.82 day per 2-week period in the first year (P < 0.001) and 0.60 day per 2-week period in the second year (P < 0.001). This effect is similar to that described in placebo-controlled studies of inhaled corticosteroids. The authors concluded that an “individualized, home-based, comprehensive environmental intervention decreases exposure to indoor allergens, and results in reduced asthma-associated morbidity.” This study and its outcomes represent the current thought that multiple ECPs, but not single interventions, are effective in modulating symptoms of allergic disease.