Respiratory Impacts of Tailpipe and Non-tailpipe Particulates on Adults With Asthma: A Feasibility Study
Conditions: Asthma
Sponsor: Queen Mary University of London

 
 
 
IONA Protocol V4.0 12.04.2023 
 
IONA V4.0 12.04.2023 
PI: Dr James Scales 
 
Page 1 of 37 
 
 
 
Joint Research Management Office (JRMO) Research Protocol 
for Research Studies 
 
 
 
 
Full Title  
Respiratory impacts of tailpipe and non-tailpipe 
particulates on adults with asthma: A feasibility 
study  
 
Short Title 
(IONA) Assessing the impact of non-tailpipe 
emissions from traffic on the asthmatic airway  
 
 
Sponsor 
Queen Mary University of London (Queen Mary) 
 
Contact person: 
 
Dr Mays Jawad 
Research & Development Governance 
Operations Manager 
Joint Research Management Office 
Empire House 
67-75 New Road  
                                                           Whitechapel, E1 1HH Phone: 
020 
7882 
7275/6574 
 
Email: research.governance@qmul.ac.uk  
 
IRAS Number 
320784 
Integrated Research Application System 
 
Sponsor (EDGE) Number 
156019 
 
REC Reference 
QMERC22.170. 
Research Ethics Committee 
 
CPMS number:  
55343  
 
Chief Investigator (CI) 
 
Dr James Scales 
Research Fellow (AUKCAR) 
Wolfson Institute of Population Health 
Barts and the London School of Medicine and 
Dentistry 
Queen Mary University of London 

 
 
 
IONA Protocol V4.0 12.04.2023 
 
IONA V4.0 12.04.2023 
PI: Dr James Scales 
 
Page 2 of 37 
 
Yvonne Carter Building, 58 Turner St,E1 2AB 
020 7882 7172 
j.scales@qmul.ac.uk  
 
Funder 
Asthma and Lung UK Centre for Applied 
Research [AUK-AC-2012-01 and AUK-AC-
2018-01] 
Investigator list 
Dr James Scales 
 
 
Centre for Primary Care 
Wolfson Institute of Population Health 
Barts and the London School of Medicine and 
Dentistry 
Queen Mary University of London 
Prof Chris Griffiths (Supervisor)         Centre for Primary Care 
Wolfson Institute of Population Health 
Barts and the London School of Medicine and 
Dentistry 
Queen Mary University of London 
 
Dr Ian Mudway (Co-I)  
 
Environmental Research Group 
Imperial College London 
 
Dr David Green (Co-I) 
 
Environmental Research Group 
Imperial College London 
 
Dr Hajar Hajmohammadi (Co-I) 
Centre for Primary Care 
Wolfson Institute of Population Health 
Barts and the London School of Medicine and 
Dentistry 
Queen Mary University of London 
 
Dr Victoria Tzortziou Brown (Co-I) 
Centre for Primary Care 
Wolfson Institute of Population Health 
Barts and the London School of Medicine and 
Dentistry 
Queen Mary University of London 
 
 
Protocol version control 
Version 
number 
Author 
Effective 
date 
Reason for change 
0.1 
JS 
12.04.2022 
Original copy 

 
 
 
IONA Protocol V4.0 12.04.2023 
 
IONA V4.0 12.04.2023 
PI: Dr James Scales 
 
Page 3 of 37 
 
0.2 
JS 
23.06.2022 
Corrections requested by QMUL REC 
1.0 
JS 
11.07.2022 
Approved by QMUL REC 
1.1 
JS 
09.08.2022 
Inclusion of pilot study  
2.0 
JS  
23.08.2022 
Approved by QMUL REC 
2.1 
JS 
25.08.2022 
Study title change 
3.0 
JS 
01.09.2022 
Approved by QMUL REC 
3.1 
JS 
19.01.2023 
Include Oscillometry , QC changes requested by 
HEI 
3.2 
JS 
19.01.2023 
Alter exclusion criteria to exclude pregnant or 
breast feeding mothers. Changes requested by 
HEI 
3.3 
JS 
28.02.2023 
Include changes from ISC  
3.4 
JS 
13.03.2023 
Include changes from NHS REC 
4.0 
JS 
12.04.2023 
Include changes from NHS REC 
 
 
 
 
 
1. Contents 
 
1. 
Contents ............................................................................................................ 3 
2. 
Glossary ............................................................................................................ 7 
3. 
Signature page .................................................................................................. 8 
4. 
Summary and synopsis ..................................................................................... 8 
5. 
Introduction ...................................................................................................... 10 
5.1. 
Background ............................................................................................... 10 
5.2. 
Rationale ................................................................................................... 10 
6. 
Study objectives .............................................................................................. 11 
6.1. 
Primary objective....................................................................................... 11 

 
 
 
IONA Protocol V4.0 12.04.2023 
 
IONA V4.0 12.04.2023 
PI: Dr James Scales 
 
Page 4 of 37 
 
6.2. 
Secondary objective .................................................................................. 11 
6.3. 
Primary endpoint ....................................................................................... 11 
Secondary endpoint ............................................................................................ 12 
7. 
Study population .............................................................................................. 12 
7.1. 
Recruitment ............................................................................................... 13 
7.2. 
Inclusion criteria ........................................................................................ 14 
7.3. 
Exclusion criteria ....................................................................................... 14 
8. 
Study design .................................................................................................... 15 
9. 
Study procedures ............................................................................................ 15 
9.1. 
Pilot Study ................................................................................................. 15 
9.2. 
Overview ................................................................................................... 16 
9.3. 
Participant pathway summary ................................................................... 16 
9.4. 
Exposure site selection: ............................................................................ 17 
9.5. 
Air Pollution Measurements and Characterization of Non-Tailpipe 
Emissions: ........................................................................................................... 18 
9.6. 
Pre-assessment screening ........................................................................ 21 
9.7. 
Randomization .......................................................................................... 22 
9.8. 
Health effects assessment on exposure visit days: ................................... 22 
9.9. 
Abstaining from medication. ...................................................................... 24 
9.10. 
Exercise and exposure protocol: ............................................................ 24 
9.11. 
Participant withdrawal ............................................................................ 24 
9.12. 
End of study definition ........................................................................... 25 
9.13. 
Study Timeline ....................................................................................... 25 
10. 
Statistical considerations ............................................................................. 25 
10.1. 
Sample size ........................................................................................... 25 
10.2. 
Method of analysis .................................... Error! Bookmark not defined. 
11. 
Ethics........................................................................................................... 26 

 
 
 
IONA Protocol V4.0 12.04.2023 
 
IONA V4.0 12.04.2023 
PI: Dr James Scales 
 
Page 5 of 37 
 
11.1. 
Risks to participants: Asthma attack or unwell ....................................... 27 
11.2. 
Risk mitigation: Asthma attack or unwell ................................................ 27 
11.3. 
Response to Asthma attack or unwell participants: ................................ 28 
11.4. 
Risks to participants: Accidental personal data release ......................... 28 
11.5. 
Risk Mitigation: Accidental personal data release .................................. 28 
11.6. 
Annual Safety Reporting ........................................................................ 29 
12. 
Public involvement ....................................................................................... 29 
13. 
Data handling and record keeping ............................................................... 29 
13.1. 
Data management ................................................................................. 29 
13.2. 
Confidentiality ........................................................................................ 30 
13.3. 
Record retention and archiving .............................................................. 30 
14. 
Laboratories................................................................................................. 30 
14.1. 
Central and local laboratories ................................................................ 30 
14.2. 
Sample preparation and collection ......................................................... 31 
14.3. 
Laboratory procedures ........................................................................... 31 
14.4. 
Sample storage and transfer .................................................................. 32 
15. 
Safety reporting ........................................................................................... 32 
15.1. 
Urgent Safety Measures ........................................................................ 32 
16. 
Monitoring and auditing ............................................................................... 32 
17. 
Study committees ........................................................................................ 34 
17.1. 
Project Management Group (PMG) ....................................................... 34 
17.2. 
Independent Scientific Group (ISC) ....................................................... 34 
18. 
Finance and funding .................................................................................... 34 
19. 
Insurance and indemnity .............................................................................. 34 
20. 
Dissemination of research findings .............................................................. 34 
21. 
References .................................................................................................. 35 

 
 
 
IONA Protocol V4.0 12.04.2023 
 
IONA V4.0 12.04.2023 
PI: Dr James Scales 
 
Page 6 of 37 
 
 
 

 
 
 
IONA Protocol V4.0 12.04.2023 
 
IONA V4.0 12.04.2023 
PI: Dr James Scales 
 
Page 7 of 37 
 
2. Glossary 
AUKCAR - Asthma and Lung UK Centre for Applied Research 
BMI – Body Mass Index 
CO-I - Co-Investigator  
FEF – Forced Expiratory Flow 
FeNO - Fractional Exhaled Nitric Oxide 
FEV1 – Forced Expiration in One Second 
FVC – Forced Vital Capacity 
GCP – Good Clinical Practice  
HGV – Heavy Goods Vehicles 
ICL – Imperial College London 
IONA – Assessing the impact of non-tailpipe emission from traffic on the asthmatic 
airway 
IgE - Immunoglobulin E 
ISC – Independent Scientific Committee  
Kph – Kilometres Per Hour 
LAQN – London Air Quality Network 
LGV Light Goods Vehicles 
Mph – Miles Per Hour 
NTE – Non-tailpipe emissions 
NO2 – Nitrogen Dioxide 
O3 - ozone 
PI – Principal Investigator  
PM – Particulate Matter 
PMG – Project Management Group 
PPI – Public and patient Involvement 
QMUL – Queen Mary, University of London 
SOP – Standard Operating Procedures. 
TLC – Tidal Lung Capacity 
UK – United Kingdom 

 
 
 
IONA Protocol V4.0 12.04.2023 
 
IONA V4.0 12.04.2023 
PI: Dr James Scales 
 
Page 8 of 37 
 
3. Signature page 
 
 
 
CI Agreement 
 
The study, as detailed within this Research Protocol, will be conducted in accordance 
with the principles of Good Clinical Practice (GCP), the UK Policy Framework for 
Health and Social Care Research, and the Declaration of Helsinki and any other 
applicable regulations. I agree to take responsibility for the statistical analysis and 
oversight of this study. 
 
 
CI Name: 
Dr James Scales 
 
Signature: 
 
 
Date: 
23/06/2022 
 
 
 
4. Summary and synopsis 
 
Short title 
(IONA) Assessing the impact of non-tailpipe emissions 
from traffic on the asthmatic airway  
 
Methodology 
Randomised experimental three condition crossover 
panel study 
 
Objectives / aims 
Objective 1: Assess and compare the acute health 
effects: changes in lung function and airway 
inflammation, in mild/moderate asthmatics exposed at 
three selected microenvironments with contrasting traffic 
profiles to increase contrast in particulates from brake 
wear, tyre wear, and road abrasion.   
Objective 2: Provision of an air pollutant database 
(PM2.5 and PM10 mass and chemical composition, PNC 
and NO2) and a time series of source apportioned PM2.5 
and PM10 covering all exposure days at the three 

 
 
 
IONA Protocol V4.0 12.04.2023 
 
IONA V4.0 12.04.2023 
PI: Dr James Scales 
 
Page 9 of 37 
 
selected sites. 
Objective 3: Examine the relationship between 
variations in daily non-tailpipe source fractions derived 
from tire, brake and road wear, with the deposited dose 
determined in the nasal airways and the physiologic and 
immunologic responses observed.  
Objective 4: Provision of a biobank of plasma samples 
for future work examining molecular signature of 
exposure and response. 
 
Number of 
participants 
48 
Inclusion and 
exclusion criteria 
Inclusion criteria: 
• 
Doctor diagnosed asthma starting on or before 
age 16 years 
• 
Prescribed regular inhaled corticosteroid 
medication 
• 
Able to use a static exercise bicycle for the study 
duration 
 
Exclusion criteria: 
• 
Tobacco smoking, or living with smoker 
• 
Body mass index (BMI) > 30 
• 
Asthma hospitalisation within 12 months 
• 
Three or more asthma episodes requiring oral 
corticosteroid medication within 12 months 
• 
Other major lung disease 
• 
Chest surgery within 6 months 
• 
Unable to give informed consent 
• 
Occupational exposure to particulate matter (PM) 
or high levels of air pollution 
 
Statistical 
methodology and 
analysis (if 
applicable) 
Mixed effects models, taking into account repeated 
measurements within participants. 
Study duration 
01/08/2022- 1/12/2024 
 

 
 
 
IONA Protocol V4.0 12.04.2023 
 
IONA V4.0 12.04.2023 
PI: Dr James Scales 
 
Page 10 of 37 
 
5. Introduction 
 
5.1. Background 
The global burden of disease survey estimated air pollution contributed to one in 
eight deaths in 20191. Urban areas such as London are a heterogeneous patchwork 
of different air pollutants, which all have different impacts on human health. Air 
pollution disproportionally impacts people living with asthma, increasing hospital 
admissions2 and the likelihood of death3. Reports suggest that 65% of asthma deaths 
could be avoided by suitable primary care support4. Understanding how different air 
quality environments affects people living with asthma will improve asthma 
management in primary care by increasing the specificity guidance provided to 
people with asthma. 
In an effort to reduce air pollution a number of government and industrial policies 
have been developed to increase sales of electric and hybrid cars. Electric and 
hybrid vehicles produce less air pollution from exhausts but due to their increased 
weight, they increase air pollution from tyre and road wear with an uncertain 
contribution from brake wear. Particles arising from tire and brake wear, as well as 
the resuspension of road dust represent a greater proportion of roadside PM by mass 
than direct tailpipe emissions. As tailpipe emissions will decrease as nations strive to 
meet their NetZero commitments, greater attention on non-tailpipe sources is 
urgently required to evaluate their relative hazard compared with other pollutant 
sources. Our previous in vitro studies on dendritic cells and airway macrophages 
have indicated enhanced immune responses with the coarse particulate fraction 
(PM2.5-10) from non-tailpipe constituents5. To date no research has explored the 
health impacts of non-tailpipe air pollution on human health in a real-world setting.  
 
5.2. Rationale 
 
In an effort to reduce air pollution a number of government and industrial policies 
have been developed to increase sales of electric and hybrid cars. Electric and 
hybrid vehicles produce less air pollution from exhausts but due to their increased 
weight, they increase air pollution from tyre and road wear with an uncertain 
contribution from brake wear. Air pollution particles arising from tire and brake wear, 
as well as resuspension of road dust, now represent a greater proportion of roadside 
PM by mass than direct tailpipe emissions. These Non-Tailpipe Emissions (NTE) 
remain unregulated, and their health impacts under explored, particularly in 
vulnerable groups. 
 
Previous work by our team 6-12 demonstrated the feasibility of a quasi-experimental 
human real-world exposures using a crossover design for disentangling relative 
contributions of pollutant metrics on acute cardiopulmonary endpoints in healthy 
adults. Whilst this work showed the key role played by primary gaseous and 
particulate emissions, the study focused on responses in healthy adults and did not 

 
 
 
IONA Protocol V4.0 12.04.2023 
 
IONA V4.0 12.04.2023 
PI: Dr James Scales 
 
Page 11 of 37 
 
examine biological pathways likely to lead to symptom exacerbation in vulnerable 
asthmatic populations. The study did examine a range of metals such as Fe, Cu, Ni 
and V, reflecting their capacity to cause oxidative stress, but did not explicitly relate 
these to NTEs, nor employ them for detailed source appointment.  
Our previous work has consistently shown that coarse mode PM is more effective at 
driving dendritic cell maturation and T-cell activation, than PM2.5 samples from urban 
background and roadside sites, or freshly collected diesel tailpipe PM. Given that 
such changes were observed in vitro this provides suitable rationale that health 
changes may be observed in asthmatic participants as people living with asthma are 
uniquely sensitive to the impacts of air pollution. 
 
To date, no research has explored whether real-world NTE are causally related to 
worsening of asthma. Therefore, we aim to explore the hypothesis that clinically 
important adverse acute asthmatic responses are driven by non-tailpipe components 
within coarse mode PM. 
 
6. Study objectives 
 
6.1. Primary objective 
 
Objective 1: Assess and compare the acute health effects: changes in lung function 
and airway inflammation, in mild/moderate asthmatics exposed at three selected 
microenvironments with contrasting traffic profiles to increase contrast in particulates 
from brake wear, tyre wear, and road abrasion.  
6.2. Secondary objective 
Objective 2: Provision of an air pollutant database (PM2.5 and PM10 mass and 
chemical composition, PNC and NO2) and a time series of source apportioned PM2.5 
and PM10 covering all exposure days at the three selected sites.  
Objective 3: Examine the relationship between variations in daily non-tailpipe source 
fractions derived from tire, brake and road wear, with the deposited dose determined 
in the nasal airways and the physiologic and immunologic responses observed.  
Objective 4: Provision of a biobank of plasma and nasal mucus samples for future 
work examining molecular signature of exposure and response. 
6.3. Primary endpoint 
• 
Lung function as measured by Forced Expiratory Volume in one second 
(FEV1) 

 
 
 
IONA Protocol V4.0 12.04.2023 
 
IONA V4.0 12.04.2023 
PI: Dr James Scales 
 
Page 12 of 37 
 
Secondary endpoint 
• 
Spirometry (FVC, FVC/FEV1 ratio, z Scores) 
• 
Fractional Expired Nitric Oxide (FeNO) 
• 
Peak expiratory flow 
• 
Oscillometry 
• 
Asthma symptoms  
• 
Asthma control Test 
• 
Quality of Life: AQLQ 
• 
Immune responses: damage-associated molecular patterns (DAMPs) and 
alarmins, such as high mobility group box 1 (HMGB1) S100 proteins, 
myeloperoxidase-DNA complexes (MPO-DNA), IL-33, Th2 and Th17 
cytokines and metal deposition in the nasal airways  
 
Control variables 
• Estimated VO2max 
• Heart rate 
• Air quality measured as: PM10 and PM2.5, particle number concentration 
(PNC) and gaseous pollutants ozone (O3), nitrogen dioxide (NO2), black 
carbon.  
• Pollen count 
• Temperature and humidity 
• Physical activity (accelerometry) 
• Personal air quality (Plume labs) 
 
Biobanking 
• 
Venous blood 
• 
Nasal Mucus 
• 
Urine 
Banking 
• 
PM filters 
 
7. Study population 
Asthma is a complex disease now recognized to include multiple phenotypes. 
Therefore, to ensure maximum generalisability of our findings, we will recruit 
participants with the most common phenotype: allergic asthma that started in 
childhood/adolescence. We will exclude those with a BMI >30 to exclude obese, 
steroid-resistant phenotypes. Participants (male and female) recruited to the study 
will be over 18 years old with mild to moderate stable asthma. We will exclude those 

 
 
 
IONA Protocol V4.0 12.04.2023 
 
IONA V4.0 12.04.2023 
PI: Dr James Scales 
 
Page 13 of 37 
 
hospitalized with an asthma attack in the last 12 months, and those with more than 
three episodes requiring oral corticosteroids in the last 12 months. To reduce the 
impact of confounders participants must neither smoke, nor live with current 
smokers, must live within greater London, and have no occupational exposure to PM 
or oxidant gases. 
With input and guidance from our active patient and public involvement group at the 
Asthma UK Centre for Applied Research (AUKCAR), participants will be recruited 
from primary care. 
7.1.  Recruitment 
 
Primary Care settings 
Guided by experts within the Primary Care CRN teams and by NOCLOR, we will use 
a PIC site approach. In the first instance participants will be recruited via general 
practice. We will approach general practices in East London with the help of Dr 
Victoria Tzortziou-Brown, research lead for North East London Integrated Care 
Board, inviting them to act as PIC sites and other areas of central London with the 
help of NOCLOR.  
With guidance from the study team, a member of the practice administrative team, 
GP or practice nurse will run searches of their patient electronic health records using 
READ / SNOMED codes to identify eligible patients according to the study inclusion / 
exclusion criteria. 
Eligible participants identified by searches will be approached via secure electronic 
mail out using AccuRx, with an invitation to join the study. The invitation will provide a 
very brief summary of the study with a link to the Patient Information Sheet and 
further information on the IONA study website, through which they can express an 
interest in participation, and provide contact details. A draft text can be found at SMS 
text exampleV0.2 28.02.23 
Once potential participants have expressed an interest in the study, Dr James Scales 
will contact them by phone or a Teams/Zoom call to discuss the study, clarifying any 
points and answering questions. Potential participants will have at least 24hours to 
consider participation. To confirm their consent, they will have the option of emailing 
copies of signed consent forms to Dr Scales, or signing consent forms at the first 
study visit. 
As an NIHR portfolio study, we will seek Service Support Costs and CRN support for 
recruitment. 
Non primary care settings 

 
 
 
IONA Protocol V4.0 12.04.2023 
 
IONA V4.0 12.04.2023 
PI: Dr James Scales 
 
Page 14 of 37 
 
If recruitment in primary care proves ineffective, our secondary recruitment approach 
will target people with asthma who study and work in Queen Mary, University of 
London and Imperial College London. With input and guidance from our active 
patient and public involvement group at the Asthma UK Centre for Applied Research 
(AUKCAR), participants will be recruited from research lists, lecture visits, posters 
and social media mail outs across the university campuses and general population. 
Participants may be university students and staff. However if participants are 
members of staff or students they will not be recruited by members of staff in direct 
supervisory roles. 
Example recruitment documents:  
Lecture slide (LINK) 
Poster (LINK) 
SMS template (LINK) 
Email template (LINK) 
Website Copytext. (LINK) 
7.2. Inclusion criteria 
 
Inclusion criteria: 
• 
Doctor diagnosed asthma starting on or before age 16 years 
• 
Prescribed regular inhaled corticosteroid medication 
• 
Able to use a static exercise bicycle for the study duration 
 
7.3. Exclusion criteria 
 
• 
Tobacco smoking, or living with smoker 
• 
BMI > 30 
• 
Asthma hospitalisation within 12 months 
• 
Three or more asthma episodes requiring oral corticosteroid medication within 
12 months 
• 
Other major lung disease 
• 
Chest surgery within 6 months 
• 
Unable to give informed consent 
• 
Occupational exposure to PM or high levels of air pollution 
• 
Under the age of 18 
• 
Women at any stage of pregnancy  
• 
Any breast feeding women 
 

 
 
 
IONA Protocol V4.0 12.04.2023 
 
IONA V4.0 12.04.2023 
PI: Dr James Scales 
 
Page 15 of 37 
 
Occupational exposure is defined as people who work as Taxi drivers, couriers, 
waste removal drivers and utility services drivers. If other occupations with high 
exposure to pollution need to be considered the study team will discuss potential 
eligibility with the PMG group, comprising of experts in air pollution and asthma 
management. 
 
 
8. Study design 
 
Randomized cross-over semi-experimental panel study 
9. Study procedures 
9.1. Pilot Study  
 
A pilot study will be completed to future explore the efficacy of the study design. The 
pilot will be completed following the same protocol outlined in this document in 
sections 9.2 to 19.1 with the following alterations: 
Recruitment:  
20 participants will be recruited in a convenience sample using the following inclusion 
and exclusion criteria: 
Inclusion: 
• 
Healthy participants with no known respiratory health issues.  
• 
Able to exercise intermittently for two hours 
• 
No surgery within 12months 
Exclusion: 
• 
Unable to give informed consent 
• 
Occupational exposure to PM or high levels of air pollution 
• 
Under the age of 18 
• 
Women at any stage of pregnancy  
• 
Any breast feeding women 
 
Screening: 
As the exclusion criteria prohibits participants with respiratory health issues pilot 
participants will not provide a screening blood sample (4 x 10ml in single draw) for 
eosinophil levels, and specific common aero-allergens immunoglobulin E (IgE) levels. 
 
Expenses: 

 
 
 
IONA Protocol V4.0 12.04.2023 
 
IONA V4.0 12.04.2023 
PI: Dr James Scales 
 
Page 16 of 37 
 
 Only expenses pertaining to travel will be paid to participants of the pilot study.  
 
Biobank: 
Due to the novelty of the research we will biobank samples from the pilot study in 
accordance to the procedures outlined in section 14. 
 
Dissemination: 
• 
Findings will be disseminated to the study team and PPI group to inform any 
decision making prior to the commencement of data collection for IONA. 
• 
There is no intention at this time to compare health to asthmatic data, due to 
likely differences in air quality. However findings will still be highly novel and 
we will still seek to publish in peer reviewed journals.  
 
9.2. Overview 
48 participants with mild and moderate asthma will be recruited from QMUL and 
Imperial College London universities and research lists into a single experimental 
group. Participants will visit the field-testing sites located in three different air quality 
environments in a randomised cross over design. Sites targeted will be: 
(1) A busy road junction characterized by stop-go traffic to enhance emissions 
from brake wear 
(2) High speed continuous traffic, to enhance tire wear emissions 
(3) An urban background site away from clear traffic sources 
 
During the exposure protocol participants will ride on a static bike for two hours at a 
standardised intermittent intensity. Participants will perform identical respiratory 
health assessment following the exercise task. In parallel to exposures at sites we 
will perform real-time measurements of PM10 and PM2.5, particle number 
concentration (PNC) and gaseous pollutants ozone (O3), nitrogen dioxide (NO2), 
black carbon.  
9.3.  Participant pathway summary 
Participants will be invited to take part by either Dr James Scales or by a primary 
care practitioner in their General Practice clinics. Participants will provide informed 
consent after they have read the study information sheets and have time consider 
their involvement (minimum 24 hours) and ask any questions. 
Upon providing informed consent the participants will visit QMUL laboratories for a 
screening assessment. During this one hour visit they will complete a submaximal 
exercise test on a static bike (to provide estimates of maximal exercise capacity to 
standardise exercise exposure protocol) and perform pre and post bronchodilator 

 
 
 
IONA Protocol V4.0 12.04.2023 
 
IONA V4.0 12.04.2023 
PI: Dr James Scales 
 
Page 17 of 37 
 
spirometry and exhaled nitric oxide testing and oscillometry. At this point participants 
will be sent an online link to the symptom surveys. Surveys will be explained to the 
participants and they will be asked to complete the surveys they days before the 
testing visits. Participants will be provided with personal air quality monitor, heart rate 
monitor and physical activity monitor to wear three days before the exposure visit. 
Participants will be invited to visit one of three field based study sites in a random 
order. Study sites will be located in walled gazebos next to air quality monitoring sites 
(managed by our collaborators at ICL) positioned near roads to provide the required 
air quality exposure. The protocol for the three visits will be identical and each visit 
will be separated by at least two weeks (washout). Participants will initially provide a 
urine sample at home and will bring the sample with them to the testing site.  To 
control for participant exposures before testing, a taxi will be provided for the 
participant. Participants will travel with car windows closed, and air recirculation 
turned on. Participants will arrive that the study site at 10:00am, and will be joined by 
up to three other participants. In the first hour the participants will perform the 
respiratory health assessments and will provide a blood and a nasal mucus sample. 
After performing all the pre exercise tests participants will wear a heart rate monitor 
and will commence the exercise protocol (six exercise bouts of 15 minutes separated 
by fifteen-minute rest periods on a static exercise bike). Half-way through the 
protocol participants will perform spirometry, impulse oscillometry and FeNO testing. 
Upon completing the two-hour exercise protocol participants will complete the same 
battery of health assessments and will provide nasal mucus samples. Participants 
will leave the assessment area at about 14:00pm. Air pollution measurements will be 
taken for the duration of the time that the participant visits the exercise location.  
24 hours after the exercise protocol participants will visit the QMUL laboratories to 
perform the health assessment tests again and to provide a mucus sample via nasal 
lavage, blood sample via venepuncture and provide a urine sample. After repeating 
this process three times (one visit to each field site) they will receive an expenses 
payment of £200 and leave the study. Participants will be paid £60 per exposure visit 
and £20 pre-screening visit. Participants will be paid for each visit they attend and will 
be paid when they complete participation or withdraw from the study.  
9.4. Exposure site selection: 
The two air quality supersites in London, located in a suburban park in South London 
(Honor Oak Park) and close to a major trunk road in Central London (Marylebone 
Road), will be used as a basis for this study. These are owned and managed by ICL 
and provide the required facilities and the highly time resolved chemical composition 
measurements required to quantify the non- tailpipe component of PM. An additional 
measurement location will be established at ICL’s White City campus for the duration 
of the study using ICL’s mobile measurement facility,13 equipped with the same 
highly time resolved chemical composition measurement capability as the supersites. 
This location provides the contrast in non-tailpipe contributions being next to the high 

 
 
 
IONA Protocol V4.0 12.04.2023 
 
IONA V4.0 12.04.2023 
PI: Dr James Scales 
 
Page 18 of 37 
 
speed A40 flyover and the required facilities to support the trial which are not 
available at other LAQN measurement locations. 
 
 
Figure 1: Air quality supersites: Marylebone Road (left), Honor Oak Park (centre), 
mobile measurement station (right) 
The Marylebone Road station is located 2m from kerbside, this major trunk road 
carries 51,000 vehicles per day - 4% Heavy goods vehicles (HGV), 3% Buses, 16% 
light goods vehicles (LGV);14 average speed is 34 kph (21 mph). The stop-go traffic 
on this congested road increases brake wear relative to tire wear and resuspension. 
This is confirmed by the LAEI, which estimates 51% of NTE as brake wear compared 
to 39% as resuspension and 10% as tyre wear. There is a large area of sidewalk 
next to the cabin that will be segregated from the public for the exercise compound 
and public toilets are less than 100m away, equipment will be stored in the station 
between exposures. 
The proposed location on ICL’s White City campus is 5 m from the kerbside of the 
busy A40 flyover, carrying 93,000 vehicles per day - 6% HGVs, 17% LGVs;14 
average speed was 33-59 kph (21-37mph). This road is a major route into and out of 
Central London, the high number of HGV and associated vehicle weight will lead to 
increased resuspension and tire wear.15,16 Due to the higher speeds and more free 
flowing traffic, the LAEI estimates this location to have only 85% of the brake wear 
emissions of the Marylebone Road measurement location thereby increasing the 
contrast between the two traffic locations. There is ample room on the campus to 
segregate as an exercise compound and the adjacent Michael Uren Engineering Hub 
will provide equipment storage and toilet facilities.  
9.5. Air Pollution Measurements and Characterization of Non-Tailpipe 
Emissions: 
The air quality monitoring stations will provide, measurement data according to the 
data quality assurance procedures described below, they will also enable a robust 
determination of the sources of tailpipe, non-tailpipe and other urban and regional 
sources of PM10 and PM2.5. 
Table 1: Air quantity station measurement configuration 

 
 
 
IONA Protocol V4.0 12.04.2023 
 
IONA V4.0 12.04.2023 
PI: Dr James Scales 
 
Page 19 of 37 
 
Measurement 
Stop-go traffic 
High speed 
continuous 
traffic  
Urban background  
Marylebone Road White City 
Honor Oak Park 
PM10 and PM2.5 
Optical Particle Counter, Fidas 200E, Palas, DE 
NO2 
T200 Chemiluminescence NO/ NOx, 
Teledyne, USA 
T500U Cavity 
Attenuated Phase 
Shift (CAPS), 
Teledyne, USA 
NO, NOX or NOY 
T200U 
Chemiluminescence 
NO/ NOY, Teledyne, 
USA 
O3 
T400, UV Absorption O3 Analyzer, Teledyne, USA 
37 elements (Al, 
Si, P, S, Cl, K, Ca, 
Sc, Ti, V, Cr, Mn, 
Fe, Co, Ni, Cu, Zn, 
Ga, Ge, As, Se, 
Br, Rb, Sr, Y, Zr, 
Nb, Cd, In, Sn, Sb, 
I, Ba, Hg, Tl, Pb, 
Bi) 
Xact Multi-Metals Monitoring System, Cooper Environmental 
Services, USA 
Organic Mass, 
NO3, SO4, NH4  
Aerosol Chemical Speciation Monitor (ACSM), Aerodyne 
Research Inc, USA 
Black Carbon 
Aethalometer AE33, Magee Scientific, USA 
 
 
 
The measurement stations are all part of the London Air Quality Network 
(www.londonair.org) and or the UK government’s Automatic Urban and Rural 
Network (https://uk-air.defra.gov.uk/networks/network-info?view=aurn)  
• 
PM10 and PM2.5 is measured using the Fidas 200E which is certified for use 
on UK air quality networks and have demonstrated equivalence to the reference 

 
 
 
IONA Protocol V4.0 12.04.2023 
 
IONA V4.0 12.04.2023 
PI: Dr James Scales 
 
Page 20 of 37 
 
method through extensive laboratory and field tests in the UK and EU (https://uk-
air.defra.gov.uk/networks/monitoring-methods?view=mcerts-scheme).  
• 
Oxides of nitrogen (NO, NOX, NO2) is measured using ozone 
chemiluminescent; this is the standard approach for monitoring networks in the UK 
and internationally. 
• 
The urban background station is more focused on atmospheric research and 
is therefore equipped with more highly specified measurement equipment; it 
measures NO2 using Cavity Attenuated Phase Shift (CAPS) and NOY rather than 
NOX to minimize sample loss in this lower concentration environment.   
• 
O3 is measured at all stations using UV Adsorption. 
 
The air quality supersites stations at Honor Oak Park and Marylebone Road are 
equipped with high time resolution chemical composition measurement techniques 
and particle counters as part of the UK’s Government’s Particle Numbers and 
Concentrations Network or through funding from UK Research and Innovation 
funding and are managed and operated by Imperial College London 
The Xact Multi-Metals Monitoring System (Cooper Environmental, USA) measures 
37 elements between Al and Bi at an hourly time resolution using ED-XRF (Tremper 
et al., 2018). To maximise size and chemical composition information, PM2.5 and 
PM10 are collected onto the Teflon filter tape on alternate hours using a switching 
valve and intermediate hours are interpolated as described by (Manousakas et al., 
2022).  
The ACSM (Aerodyne Research Inc, USA) is a widely research instrument (Ng et al., 
2011) and is extensively being used in advanced measurement networks around the 
world to measure the non-refractory composition of aerosols.(Bressi et al., 2021) All 
ACSMs used in this study utilize a quadrupole mass spectrometer, the Honor Oak 
Park instrument uses a PM2.5 lens(Joo et al., 2021) while the roadside instruments 
use a PM1 lens to minimize lens transmission losses of freshly emitted aerosols 
close to vehicles(Xu et al., 2017). 
 The AE33 Aethalometer measures the attenuation of light transmitted through the 
sample collected on a filter, which is then converted to a black carbon measurement.   
The road surface conditions will be collected from surface sensors at Marylebone 
Road (DRS511, Vaisala, Finland) and using a camera at White City Flyover 
(DSC111, Vaisala, Finland), this will be used to differentiate wet and dry road surface 
conditions a per Hicks et al 2021(Hicks et al., 2021).  
 9.5.2 Source Apportionment 

 
 
 
IONA Protocol V4.0 12.04.2023 
 
IONA V4.0 12.04.2023 
PI: Dr James Scales 
 
Page 21 of 37 
 
 
The equipment discussed will identify sources of NTE by quantifying and source 
apportioning the high time resolution chemical composition measurements described 
above to produce time series and factor profiles of source emissions in organic 
aerosols and elemental compositions.   
Using high time resolution data in this way addresses many of the challenges faced 
when quantifying the different sources in the urban environment as the higher time 
resolution yields a greater variability from changing emission characteristics, 
boundary layer dynamics, and reflects short lived events which are obscured by the 
long sampling time of filter-based approaches(Wang et al., 2018). This variability is 
fundamental to improving the performance of multivariate statistical approaches 
which are used to estimate the source contributions and fingerprints to solve a mass 
balance. Positive Matrix Factorization (PMF) (Paatero and Tapper, 1994) is the most 
commonly used of these and the solutions describe the complex, time-dependent 
aerosol composition as a linear combination of factor profiles and their contributions. 
It has been used extensively for the identification of heavy metals, water soluble and 
carbonaceous sources (Hopke et al., 2020) and for high-time resolution elemental 
data from the Xact (Font et al., 2022b, Hasheminassab et al., 2020, Liu et al., 2019, 
Rai et al., 2020, Rai et al., 2021, Wang et al., 2018, Yu et al., 2019, Manousakas et 
al., 2022).  
PMF will be applied to the PM10 and PM2.5 Xact data and ACSM data from all 3 
stations using the Source Finder software (SoFi Pro, https://datalystica.com/), which 
has been used by the ICL team in numerous studies (Font et al., 2022b, Fröhlich et 
al., 2015, Manousakas et al., 2022, Reyes-Villegas et al., 2016, Visser et al., 2015b) 
to provide hourly source factor time series and factor profiles for the duration of the 
exposures. For the ACSM data, the Sofi software has been used in many recent 
advances to reduce the uncertainty associated with rotational ambiguity by 
introducing a priori information about the source profiles (Canonaco et al., 2013, 
Canonaco et al., 2021) and is now widely used in that community.(Crippa et al., 
2014) Recent work on data from Zurich (Manousakas et al., 2022) has shown that 
source apportionment of the XACT PM10 and PM2.5 data can be used to quantify 
the emissions from a range of sources in urban background locations.  
Separating the tire and road wear sources is not straight forward as they are 
internally mixed and generated by the same frictional forces. To help understand 
some of these processes in greater depth, additional size fractionated measurements 
of polymers are planned at Honor Oak Park and Marylebone Road during 2022/23 
under a separate project (NERC, ‘Understanding UK airborne microplastic pollution: 
sources, pathways and fate’). 
9.6. Pre-assessment screening 

 
 
 
IONA Protocol V4.0 12.04.2023 
 
IONA V4.0 12.04.2023 
PI: Dr James Scales 
 
Page 22 of 37 
 
Following provision of written informed consent, study volunteers will undergo pre-
assessment screening at QMUL. They will complete baseline FeNO and spirometry, 
pre- and post-bronchodilator, to confirm asthma status (based on FEV1 reversibility 
and patient interview). A blood sample (10ml in single draw) will be collected to 
assess a full blood count including eosinophil levels, and specific immunoglobulin E 
(IgE) levels across a panel of common aero-allergens (to be included as a study 
confounding variable). Participants will then perform a submaximal cycle ergometer 
exercise test (Latin Protocol) to establish the exercise watt levels to be used at the 
site visits. If they wish participants can warm up by walking on a treadmill prior to the 
exercise test. Participants will be given a personal air quality monitor to wear for 
three days before the exposure visit.  
9.7. Randomization 
 
The study will use a 6X3 Williams crossover inequality test of paired differences.17 as 
such the participants will be randomised to a sequence for their exposures to the 
three sites. Six sequences will be used (ABC/ BCA/ CBA/ ACB/ BAC/ CAB). 
9.8. Health effects assessment on exposure visit days: 
Participant flow through an exposure session is summarised in figure 2, while 
participant flow through the study is summarised in figure 3. On the morning of the 
site visits participants will first provide a urine sample while at home (9:00 am) 
Participants will be provided with a taxi to the study site. The participants will be 
transported taxi with closed windows and air circulation enabled, to the exposure 
sites. 
Once at the exposure sites (10:00am-11:00am) baseline spirometry and 
determination of FeNO and sample collection (4x10 ml blood collection and baseline 
nasal lavage) will be performed at the field laboratory. At this time a brief health 
questionnaire will be administered to assess recent asthma control and ensure the 
volunteer is free of respiratory infection and has not experienced a recent 
exacerbation of their asthma.  
During the two and a half hour exposure and exercise protocol (11:00am-13:30 pm), 
participants’ heart rate will be monitored throughout the exposure period; at the half 
way point, after sufficient recovery (12:15am) participants will perform spirometry 
FeNO and Oscillometry. Immediately post-exposure the participants will perform 
spirometry, oscillometry FeNO and mucus sample collection at the field lab. The 
following day, volunteers will return for 28-hour post measurements; biosamples, 
spirometry and FeNO.  

 
 
 
IONA Protocol V4.0 12.04.2023 
 
IONA V4.0 12.04.2023 
PI: Dr James Scales 
 
Page 23 of 37 
 
Pre-Study Screening
3 day pre
Pre
Exposure 
Post
24 
hour 
post
3 days post
Phys lab
Self assess
Field 
lab
Field lab
Field 
lab
Phys 
lab
Self assess
Consent
x
Exercise test
x
FeNO
x
x
x
x
x
Oscillometry
x
x
x
x
x
Spirometry
x
x
x
x
x
Asthma control test
x
QOL: AQLQ
x
Baseline questionare
x
Daily Symptom Q
x
x
x
x
x
x
PEF Test
x
x
Personal air quality
x
Physical activity
x
Venepuncture
x
x
Nasal lavage
x
x
x
Urine sample
x
x
Heart rate
x
IONA: Schedule of assessment and exposure
 
Figure 2. Flow of participants through IONA study days 
Our primary endpoint, lung function (FEV1) will be assessed using a portable desktop 
computerized spirometer (Vitalograph). All procedures will be performed in 
accordance with American Thoracic Society guidelines. Predicted volumes will be 
calculated according to the global lung index guidelines to adjust for ethnicity.20 As 
Forced Expiratory Flow (FEF)25-75 is a volume dependent measurement, decreases in 
forced vital capacity (FVC) following exposure to air pollutants affect this parameter. 
It has been demonstrated however that isovolume adjustments to this parameter 
provide a useful means of accessing intrinsic narrowing of the peripheral airways.21 
We therefore propose to correct the measured flows to the participants predicted 
total lung capacity, using the forced expiratory flow at 50 and 60% of predicted total 
lung capacity (TLC): FEF50%TLC and FEF60%TLC respectively.22 The area under the 
forced expiratory flow curve will also be determined, as this has been suggested to 
be a sensitive indicator of bronchoconstriction. Fractional Expired Nitric Oxide and 
impulse oscillometry and asthma symptoms will also be collected before, during and 
after the exposure tasks in accordance with European Respiratory Society 
guidelines.  

 
 
 
IONA Protocol V4.0 12.04.2023 
 
IONA V4.0 12.04.2023 
PI: Dr James Scales 
 
Page 24 of 37 
 
 Figure 3. Flow of participants through IONA. 
9.9. Abstaining from medication.  
Participants will continue to use all their routine asthma medication during the study. 
In agreement with ERS spirometry guidance participants will be asked to abstain 
from using reliever medication for six hours prior to performing spirometry. If 
participants need to use their medication in the six hours prior to the first spirometry 
testing of an assessment visit they will be offered an opportunity to reschedule the 
assessment visit. If participants need to use their inhaler during the testing protocol 
the testing will end immediately. If a participant wishes to continue with the study, 
they will be offered another testing date, after a brief discussion with Griffiths (GP 
specialising in Asthma). If testing is stopped after discussion with Griffiths 
participants will still receive all expenses, and this will be made clear to the 
participants at the start of the study. 
9.10. 
Exercise and exposure protocol: 
To control for variations in air quality, exposure will occur for two-and-a-half hours 
between 11:00am and 13:30pm on weekdays. Between pre- and post- health 
assessments, participants will be asked to cycle on a static exercise bike at a watt 
equivalent to 60% of estimated heart rate maximum for six exercise bouts of 15 
minutes separated by fifteen minute rest periods. This exercise intensity was chosen 
to maximise inhaled doses of PM and gaseous pollutants over the exposure period 
while remaining below the first ventilation threshold to reduce variation in ventilatory 
drift, and minimising discomfort for the participants. Physiological drift will be 
monitored by Ratings of Perceived Exertion questionnaire and real-time monitoring of 
the participants heart rate and estimated breathing rate.  
9.11. 
Participant withdrawal 
 
Participants will be informed and reminded that they can withdraw from the study at 
any time. Participants will be able to choose to start cease their involvement with the 
study or to cease their involvement and have their data removed from the study. 

 
 
 
IONA Protocol V4.0 12.04.2023 
 
IONA V4.0 12.04.2023 
PI: Dr James Scales 
 
Page 25 of 37 
 
Consent forms and information sheets will tell participants their last time opportunity 
to have their data removed from the study. 
9.12. 
End of study definition 
The end of this study is defined as the date on which the last data is collected.  
9.13. 
Study Timeline 
Responsibility
Sep-22
Oct-22
Nov-22
Dec-22
Jan-23
Feb-23
Mar-23
Apr-23
May-23
Jun-23
Jul-23
Aug-23
Sep-23
Oct-23
Nov-23
Dec-23
Jan-24
Feb-24
Mar-24
Apr-24
May-24
Jun-24
Jul-24
Aug-24
Sep-24
Oct-24
Nov-24
Dec-24
Pilot Study
Student set up
Data collection
Data analysis
Set up study meeting/ teams
JS
Confirm protocol
JS
Study Sponsorship
JS
Research ethics
JS
Study documents
JS
Statement of work
JS
QA/QC plan
JS/HH
Confirm budget
CG
Develop risk assessment
JS
ID field testing requirements
JS
Recruit study team
JS
PPI group meeting
CG
Set up ISC
IM
Ten month progress report
CG
Final report
CG
QA Manager 0.05 24 months
CG
QM PDRA (8 months 100%)
JS
Max Priestman (6 months 100%)
DG
Amber Vaughan (0.8 11 months)
IM
Pilot program
JS
Recruitment
JS
Participant exposure period
JS
Health data processing
JS
Data linkage
JS/HH
Analysis
KK/HH
Write up
CG
Site preparation
DG
Data collection
DG
Data preparation
DG
Data linkage
JS/HH
Consumable purchases
IM
Sample processing
IM
Data linkage
JS/HH
GANTT CHART
IONA Project Management
PDRA support
Exposure study
Air quality monitoing
Sample processing
Pilot Project
 
 
10. Statistical considerations 
 
10.1. 
Sample size  
Since we will randomize the participants to assign a sequence for their exposures to 
the three sites we will have six sequences (ABC/ BCA/ CBA/ ACB/ BAC/ CAB), a 
6X3 Williams crossover inequality test of paired differences.17 For a significance level 
of 0.05, a Δ (Difference between the reduction in FEV1 between 2 sites) of 4.69 with 
a standard deviation of 6.4 23 and a total of 30 participants (5 per sequence) we have 
a power of 91.54%. However, assuming a dropout rate of 20 to 30% and taking into 
account that specific exposures to contrast are not available yet and will be assessed 
when the exposure methods are developed, we intend to recruit 48 participants in 
total. We will define 12 groups of 4 individuals and then assign a group to each 
participants. Each two groups will have a same sequence.   
10.2. 
Descriptive analysis 

 
 
 
IONA Protocol V4.0 12.04.2023 
 
IONA V4.0 12.04.2023 
PI: Dr James Scales 
 
Page 26 of 37 
 
After data quality check, we prepare data description tables including number of 
observations, mean and standard deviation of variables. We will use graphical 
methods (e.g. scatterplots) to get insight in the correlation between different 
exposure variables and the associations between specific exposures and health 
endpoints as well.  
10.3. 
 Statistical modelling   
We will use mixed effect regression model to estimate the effects of different 
pollutant sources ( tailpipe or non-tailpipe) on the change in health point, which will 
be defined by difference of various factors such as FEV1 and FVC between pre-
exposure and post-exposure (0, 2, or 18 hours). For each endpoint, one key time 
post-exposure has been selected, based on the time of maximal effect in previous 
controlled exposure studies, for example for FEV1 this is 2 hours post exposure.23 In 
this model, when measurements and pollutant characterization become available, the 
exposure covariates will be the integrated average concentration of the various 
pollutants and /or sources during the exposure period. We will take the results of the 
source apportionment and feed them into the model. The method will provide 
estimates of exposure due to tailpipe emissions (Black Carbon and Organic Aerosol) 
and non-tailpipe, specifically break wear and tyre & road wear, emissions. We will 
include these exposure types in the model. We will start with a single-exposure 
covariate models (for every source type), then we can decide how to develop a 
model with all of the significant source types. Levels (eg. Integrated average 
concentration) of each source (tailpipe/non-tailpipe) will be included in the model. 
The effects of different pollutants will be compared based upon statistical significance 
and the effect size for selected exposure contrasts, such as a pre-defined change of 
the concentration of the pollutant or interquartile range. Two pollutant models will be 
specified as well to evaluate which pollutant has the strongest association with a 
certain health endpoint.  
In our models we will account for potential confounders which may be present as the 
exposure contrast cannot be entirely predicted by the design: we will include 
meteorological variables such as temperature, relative humidity and wind direction 
during the exposure time; as well as individual characteristics such as age, gender, 
severity of asthma and allergies. 
We will use R (version 4.1.3 or newer; R Development Core team) for the application 
of mixed models using functions from the lme4 and nlme packages.  
11. 
Ethics 
The study will be sponsored and managed by QMUL and supported by Imperial 
College London, according to MRC guidance: 
https://www.mrc.ac.uk/publications/browse/good-research-practice-principles-and-
guidelines/ 

 
 
 
IONA Protocol V4.0 12.04.2023 
 
IONA V4.0 12.04.2023 
PI: Dr James Scales 
 
Page 27 of 37 
 
This study has received University Research Ethics Committee approval 
(QMERC22.170.). The study will be carried out according to the principles of the 
Helsinki Agreement.  
 
11.1. 
Risks to participants: Asthma attack or unwell 
 
There are risks associated with exposing people living with asthma to high air 
pollution via exercise protocols. Such activities may increase the likelihood of 
accidental events, with asthma attacks being the most likely.  
11.2. 
Risk mitigation: Asthma attack or unwell 
In order to mitigate potential accident events during the study we will take the 
following precautions: 
• 
The study will only proceed after University Ethics Committee approval and 
sponsor indemnity 
• 
Our protocol has been devised with people living with asthma and asthma 
specialist clinicians and researchers from Asthma and Lung UK public and 
patient involvement (PPI) group. 
• 
Participants will only be recruited if they have mild - moderate stable asthma, 
as defined by British Thoracic Society Guidelines 
• 
Participants will be screened by a physiologist (Dr James Scales) and a 
second opinion may be sought from Griffiths, a clinician with specialist 
knowledge in asthma, if required. 
• 
Usual medication will be continued 
• 
The exercise intensity and locations have been selected to be highly 
representative of day to day exposures, as such participants will not be 
exposed to unusually high air pollution.  
• 
Participants will be further screened for unstable asthma on the day of 
exercise exposures 
• 
Basic rescue asthma medication (albutarol and large volume spacer) will 
always be available at assessment sites, with researchers trained in its use 
and administration 
• 
Participants will be closely monitored during the exercise protocol and will be 
repeatedly encouraged to provide feedback about their physical state during 
the exercise. 
• 
Prof Chris Griffiths or a nominated respiratory clinician will be available during 
all exposure testing 
• 
A risk register and an adverse events register will be maintained for the 
duration of the study 

 
 
 
IONA Protocol V4.0 12.04.2023 
 
IONA V4.0 12.04.2023 
PI: Dr James Scales 
 
Page 28 of 37 
 
• 
Accidents will be discussed with the Chief Investigator and reported promptly 
to the Sponsor as per Good Clinical Practice regulations, and reviewed at 
study Project Management Group   
11.3. 
Response to Asthma attack or unwell participants: 
 
This section should be read alongside SOP 16 and the field testing risk assessment. 
If a participant has an asthma attack during the protocol they will be encouraged to 
use their rescue medication as advised by their physician. Salbutamol inhalers and 
spacers will be available at the testing site if needed. A researcher on site will be 
trained in appropriate first aid. Each site has facilities available to make participants 
comfortable, including toilets, blankets, isolated room, water and food. 
 
In the event of a participant feeling unwell the research team will:  
 
• 
Calmly reassure the participant and encourage the participant make 
themselves suitably comfortable.  
• 
The participant will be observed for any signs of distress or breathing 
difficulty.  
• 
Place a pulse oximeter on the participant and assess oxygen saturation and 
pulse.  
• 
If required, first aid will be administered by trained researchers.  
• 
If first aid fails to address the situation the team will seek emergency advice. 
• 
All three sites, have been chosen to have unblocked access for emergency 
vehicles. 
• 
A report will be completed within 48 hours to be discussed with the project 
management team.   
11.4. 
Risks to participants: Accidental personal data release 
As with all human participant research there is a risk of inadvertent release or loss of 
personal data through incorrect storage of electronic or hardcopy data or through 
incorrectly transferring or handling data. 
11.5. 
Risk Mitigation: Accidental personal data release 
To mitigate this we shall follow best practice guidelines provided in Standard 
operation procedures (SOP) by our Clinical Trials Unit. Paper records will be stored 
securely in locked filling cabinets in password locked rooms in the pass-protected 
Centre for Primary Care and Public Health. Electronic records will be stored in a 
password-protected study database on a secure server, in the Centre for Primary 
Care and Public Health.  In the study database, personal details (name, address, 

 
 
 
IONA Protocol V4.0 12.04.2023 
 
IONA V4.0 12.04.2023 
PI: Dr James Scales 
 
Page 29 of 37 
 
date of birth) will be kept separate from research data, which will be identified by a 
unique study reference number. In tables of data, participants will only be identified 
by number not by initials or name. Data management procedures will be completed 
in compliance with the GDPR and trial regulations. Survey reported data will be 
stored in the QMUL data safehaven, where data will be held in a UK server and 
access will be facilitated by two factor authentication. Survey software with integrated 
data validation checks and audit trails will be used to record study data. Any data 
transfers between QMUL and Imperial College London will be completed via 
encrypted Secure File Transfer Protocol. All data will be backed-up weekly to ensure 
data is safeguarded from accidental loss. 
11.6. 
Annual Safety Reporting  
 
The CI will send an Annual Progress Report to the REC and the sponsor using the 
Health Research Authority (HRA) template on the anniversary of the REC 
“favourable opinion”. 
 
12. 
Public involvement 
 
This proposal was designed with input from the Asthma and Lung UK Centre for 
Applied Research PPI group. Examples of impact the PPI group has already had 
include: 
• 
Highlighting the need for breaks during the two hour walking task. 
• 
Highlighting the need to make sure roads are matched for traffic flow to 
mitigate possible confounders of noise and anxiety. 
• 
Discussed acceptability of respiratory tests. PPI group highlighted the peak 
expiratory flow, FeNO and spirometry will be familiar tests to most potential 
participants 
 
As the study progresses the PPI group will be invited to project management group 
(PMG) meetings. The group will collaborate as advisors and partners in the study 
and are invited to provide unsolicited advice. To ensure the PPI group can provide 
meaningful advice and guidance the CI will regularly keep them informed of study 
developments via email. The meetings will follow the EUPATI (European Patients 
Academy on Therapeutic Innovation) roadmap (https://bit.ly/3bugCMk) discussing 
themes of: Research design and planning, research conduct and operations and 
dissemination and communication. 
13. 
Data handling and record keeping 
 
13.1. 
Data management 
 

 
 
 
IONA Protocol V4.0 12.04.2023 
 
IONA V4.0 12.04.2023 
PI: Dr James Scales 
 
Page 30 of 37 
 
Survey Lab will be used to store electronic case report forms all data will be held on 
GDPR compliant databases with integrated data validation checks and audit trails. All 
collected data will be held on backed up encrypted servers. Any data transfers 
between ICL and QMUL will be performed via Secure File Transfer Protocols. Paper 
records, CRFs and consent forms and recruitment logs will be held locally in double 
locked locations in Yvonne Carter Building 58 Turner St E12AB (QMUL). 
Data Sharing: we will comply with HEI policy on data sharing. A copy of study data 
will be held on the HDRUK BREATHE secure data hub  
https://www.breathedatahub.com. BREATHE’s mission is ‘Better respiratory health 
through better connected data’. 
 
13.2. 
Confidentiality 
We shall follow best practice guidelines provided in SOPs by our Clinical Trials Unit. 
Paper records will be stored securely in locked filling cabinets in password locked 
rooms in the pass-protected Centre for Primary Care and Public Health. Electronic 
records will be stored in a password-protected study database on a secure server, in 
the Centre for Primary Care and Public Health. In the study database, personal 
details (name, address, date of birth) will be kept separate from research data, which 
will be identified by a unique study reference number. In tables of data, participants 
will only be identified by number not by initials or name. Data management 
procedures will be completed in compliance with the GDPR and trial regulations. 
Survey reported data will be stored in the QMUL data safe haven, where data will be 
held in a UK server and access will be facilitated by two factor authentication. Survey 
software with integrated data validation checks and audit trails will be used to record 
study data. Any data transfers between QMUL and Imperial College London will be 
completed via encrypted Secure File Transfer Protocol. All data will be backed-up 
weekly to ensure data is safeguarded from accidental loss. 
13.3. 
Record retention and archiving 
 
In accordance with the UK Policy Framework for Health and Social Care Research, 
research records will be kept for 20 years after the study has completed while 
personal records will be stored for one year after the study has been completed. At 
the completion of the study data will be moved to a trusted archive centre. At the end 
of the retention period data will be destroyed in accordance best practice guidelines 
at the time of destruction. 
 
14. 
Laboratories  
 
14.1. 
Central and local laboratories  
The air quality supersites are major field observatories owned and managed by 
David Green’s team at ICL. They are funded by Natural Environment Research 

 
 
 
IONA Protocol V4.0 12.04.2023 
 
IONA V4.0 12.04.2023 
PI: Dr James Scales 
 
Page 31 of 37 
 
Council and UK government and provide >100m2 of indoor and outdoor laboratory 
space in contrasting traffic and urban background locations and are ideally suited to 
understanding the sources of pollution affecting the urban environment. They are 
equipped with high time resolution instrumentation that operates continuously 
reporting data to national and international air quality networks. 
The mobile measurement trailer is a mobile laboratory owned and managed by DR 
David Green’s team at ICL. It carries an identical instrument setup to the two 
supersites and can be used independently or part of a measurement triplicate as in 
this experiment. It has been used in a number of field campaigns (e.g. 24,25 and has 
recently be deployed to Manchester (UK) and Birmingham (UK) and Barcelona (ES) 
to quantify NTE.   
The laboratories at ICL have a dedicated room for the storage of human tissues 
under the provisions of the UK’s Human Tissue act. 
14.2. 
Sample preparation and collection 
Nasal mucus samples will be collected via nasal lavage. Nasal lavages will be 
performed at three time points, pre and 2-hour post at the field testing sites while the 
18 hours-post exposure measure will be collected in QMUL physiology laboratories. 
Samples will be biobanked in 5 mL aliquots at -80oC at ICL under Human Tissue Act 
licence 12521 (local Human Tissue Act lead, Dr Ian Mudway).  
In addition to the nasal lavage sample 4x10mL of whole blood from a single draw via 
venepuncture from a vein in the lower arm will also be collected pre-, 2- and 18-hours 
post exposure. Blood plasma from these samples will be biobanked in 1 mL aliquots 
at -80oC at ICL under Human Tissue Act licence 12521 (local Human Tissue Act 
lead, Dr Ian Mudway). 
Samples will be collected in disinfected facilities at the field-testing site. Screens will 
be used to ensure participant privacy.   
14.3. 
Laboratory procedures 
 
Samples across the interval pre- to 1-hour post exposure will be used to examine 
metal deposition in the nasal airways and the acute release of endogenous 
constitutively expressed native damage-associated molecular patterns (DAMPs) and 
alarmins, such as high mobility group box 1 (HMGB1) S100 proteins, 
myeloperoxidase-DNA complexes (MPO-DNA), reflecting both cellular injury and 
NETosis induction, plus IL-33 released from damaged epithelial cells and Thymic 
stromal lymphopoietin (TSLP). Here we hypothesise that metal deposition in the 
nasal airways, reflecting brake (Cu, Ba and Sb), tire (Zn) and road wear (Fe, Al), 
causes oxidative stress, triggering cell injury, DAMP/alarmin release resulting in an 
allergic skewing of the airway. This will be examined across the interval pre- to 18-

 
 
 
IONA Protocol V4.0 12.04.2023 
 
IONA V4.0 12.04.2023 
PI: Dr James Scales 
 
Page 32 of 37 
 
hours post exposure, through examination of the concentration of panels of Th2 and 
Th17 cytokines using Cytometric bead array (CBA) technology. This will allow us to 
examine the immune and physiologic responses observed in the exposed volunteers 
in relation to: (a) the site classification, (b) the daily variation of ambient 
metals/metalloid across the sites; and (c) daily variation in the nasal deposited dose 
of source-specific metals, including tailpipe tracers (V. Ni and Cr). Nasal lavage 
samples will also be retained as a downstream resource for the quantification of tire 
wear tracers, which is outside available budget, but aligns with ongoing work within 
the MRC Centre for Environment and Health at ICL. Urine samples will be retained 
as a downstream source for the quantification on analgesic use and tire wear tracers, 
which is outside of available budget but also aligns with the MRC Centre for 
Environment and Health at ICL 
 
14.4. 
Sample storage and transfer 
 
Samples will be transferred from the collection sites in London and Luton to ICL in 
cooler boxes (4oC) using authorized courier services. Upon arrival samples will be 
stored with HTA approved facilities at -80oC. All transport, storage and disposal 
protocols will adhere to the College’s SOPs, which can be found on the ICL 
Governance site. 
15. 
Safety reporting 
 
Accident events occurring between visits/questionnaires/sample collections will not 
be recorded or reported as they are not the aim or focus of this study. 
 
15.1. 
Urgent Safety Measures 
The CI may take urgent safety measures to ensure the safety and protection of the 
study subjects from any immediate hazard to their health and safety. The measures 
should be taken immediately. In this instance, the approval of the REC prior to 
implementing these safety measures is not required. However, it is the responsibility 
of the CI to inform the sponsor and Main Research Ethics Committee (via telephone) 
of this event immediately.  
The CI has an obligation to inform both the Main REC in writing within 3 days, in the 
form of a substantial amendment. The sponsor (Joint Research Management Office 
[JRMO]) must be sent a copy of the correspondence with regards to this matter.  
16. Monitoring and auditing 
 
For further explanation of monitoring and auditing this section should be read along 
with the documents: 

 
 
 
IONA Protocol V4.0 12.04.2023 
 
IONA V4.0 12.04.2023 
PI: Dr James Scales 
 
Page 33 of 37 
 
1) Hei-form-forQAQC plan (IONA) V5SOP  
2) SOP 01 Spirometry V1.0. 23.08.2022 
3) SOP 02 Height Weight V1.0. 23.08.2022 
4) SOP 03 FeNO V1.0. 23.08.2022 
5) SOP 04 Nasal Lavage V1.0. 23.08.2022 
6) SOP 05 Venepuncture V1.0. 23.08.2022 
7) SOP 06 Exercise Testing V1.0. 23.08.2022 
8) SOP 07 Data Management and QC V1.0. 23.08.2022 
9) SOP 08 Automatic Urban and Rural Network (AURN) LSO Manual 
01.10.2021 
10) SOP 09 Air Quality Data Validation and Ratification Process 
11) SOP 10 ERG Data Ratification Instruction Manual V1.14 01.02.2012 
CONFIDENTIAL 
12) SOP 11 UK Airborne Particulate Concentration and Numbers LSO Manual 
Aerosol Chemical Speciation Monitor (ACSM) V1.14 CONFIDENTIAL 
13) SOP 12 UK Airborne Particulate Concentration and Numbers LSO Manual 
Xact 625i Ambient Metals Monitor, Cooper Environmental CONFIDENTIAL 
14) SOP 13 UK Airborne Particulate Concentration and Numbers LSO Manual 
AE33 Aethalometer CONFIDENTIAL 
15) SOP 14 Particle Concentrations & Numbers & the Black Carbon Networks in 
the UK - QA/QC Procedures CONFIDENTIAL 
16) SOP 15 Oscillometry 28.02.2023 
17) SOP 16 Asthma response 28.02.2023 
 
The Sponsor or delegate retains the right to audit any study, study site or central 
facility. In addition, any part of the study may be audited by the funders where 
applicable. 
Dr James Scales will be responsible for the data management, storage, record 
keeping, coding, data linkage, and metadata generation. All researchers have up to 
date GCP and Data Governance training. All data will be managed according to 
European Union General Data Protection (GDPR) guidelines. 
QMUL studies adhere to the NHS Research Governance, Framework for Health and 
Social Care, the Data Protection Act and the Human Tissue Act. We follow QA and 
QC protocols are developed by the PCTU. 
We shall hold a trial Master file recording all key study documents and study 
discussions, ethical review board reports and staff training logs. Detailed meta-data 
will be kept. Methodologies and analyses will be summarised in readme files, 
including information on variables names, missing data labels, definition of acronyms, 
etc. For example, sample tracking records, SOPs and information on QA/QC 
procedures, stored as pdfs on secure servers with metadata tables linking relevant 
documentation to datasets. For new data acquisitions/ collations data 

 
 
 
IONA Protocol V4.0 12.04.2023 
 
IONA V4.0 12.04.2023 
PI: Dr James Scales 
 
Page 34 of 37 
 
dictionary/metadata describing data content will be created embedded in the data or 
stored separately. Methods and analysis techniques will be documented and stored 
in relevant study folders. 
17. 
Study committees 
17.1. 
Project Management Group (PMG)  
Monthly project management meetings will be chaired by Dr James Scales and will 
consist of the co-investigators. An open invite will be available to AUKCAR PPI group 
representative. Queen Mary University London will lead the health assessment and 
analysis with Dr James Scales having day-to-day involvement project managing the 
programme. Imperial College London will lead the exposure data collection and 
processing and supervise the statistical protocols and analysis, with ongoing 
statistical support of the QMUL (junior statistician).  
17.2. 
Independent Scientific Group (ISC) 
We will convene an ISC to meet three times during the two year study. Its role is to 
monitor and advise on study conduct and progress on behalf of the Sponsor and HEI. 
Meetings may be by teleconference at the discretion of the Chair. The ISC 
composition is designed to provide expertise in all relevant facets of the study design 
and conduct. ISC meetings will include at least one member of the AUKCAR PPI 
group. 
18. 
Finance and funding 
 
This work is funded by Asthma + Lung UK as part of the Asthma UK Centre for 
Applied Research [AUK-AC-2012-01 and AUK-AC-2018-01] and The Health Effects 
Institute(USA) 
 
19. 
Insurance and indemnity 
The insurance that Queen Mary has in place provides cover for the design and 
management of the study as well as "No Fault Compensation" for participants, which 
provides an indemnity to participants for negligent and non-negligent harm. 
 
20. 
Dissemination of research findings 
 
Dissemination is a standing item on the PMG agenda, ensuring interim study findings 
are rapidly and effectively communicated. Our PPI group will co-write or review all 

 
 
 
IONA Protocol V4.0 12.04.2023 
 
IONA V4.0 12.04.2023 
PI: Dr James Scales 
 
Page 35 of 37 
 
study outputs for dissemination via traditional and social media throughout the study.  
This project is designed as a feasibility study to inform applications to further funding. 
As such data will be presented in applications to NIHR, MRC and Wellcome trust. 
Specific dissemination tools will include: 
1) Webinars on websites of our institutions, to provide more detailed summaries of 
results, with downloads of key documents.  
2) Presentations, especially to London partner organisations including the GLA, 
councils and Health and Wellbeing Boards. 
4) Presentations at national and international conferences, including the European 
Respiratory Society and the American Thoracic Society.  
3) Peer reviewed publications targeted at the world's leading medical journals. 
21. 
References 
 
1. 
Murray CJ, Abbafati C, Abbas KM, et al. Five insights from the global 
burden of disease study 2019. The Lancet. 2020;396(10258):1135-
1159. 
2. 
Delamater PL, Finley AO, Banerjee S. An analysis of asthma 
hospitalizations, air pollution, and weather conditions in Los Angeles 
County, California. Science of the Total Environment. 2012;425:110-
118. 
3. 
Liu Y, Pan J, Zhang H, et al. Short-term exposure to ambient air 
pollution and asthma mortality. American journal of respiratory and 
critical care medicine. 2019;200(1):24-32. 
4. 
Levy ML. National review of asthma deaths (NRAD). The British Journal 
of General Practice. 2014;64(628):564. 
5. 
Selley L, Schuster L, Marbach H, et al. Brake dust exposure 
exacerbates inflammation and transiently compromises phagocytosis in 
macrophages. Metallomics. 2020;12(3):371-386. 
6. 
Steenhof M, Janssen NA, Strak M, et al. Air pollution exposure affects 
circulating white blood cell counts in healthy subjects: The role of 
particle composition, oxidative potential and gaseous pollutants - the 
RAPTES project. Inhalation Toxicology. 2014;26(3):141-165. 
7. 
Strak M, Hoek G, Godri KJ, et al. Composition of PM affects acute 
vascular inflammatory and coagulative markers - The RAPTES project. 
PLoS ONE. 2013;8(3):e58944. 

 
 
 
IONA Protocol V4.0 12.04.2023 
 
IONA V4.0 12.04.2023 
PI: Dr James Scales 
 
Page 36 of 37 
 
8. 
Steenhof M, Mudway IS, Gosens I, et al. Acute nasal pro-inflammatory 
response to air pollution depends on characteristics other than particle 
mass concentration or oxidative potential: The RAPTES project. 
Occupational and Environmental Medicine. 2013;70(5):341-348. 
9. 
Strak M, Hoek G, Steenhof M, et al. Components of ambient air 
pollution affect thrombin generation in healthy humans: the RAPTES 
project. Occup Environ Med. 2013;70(5):332-340. 
10. 
Strak M, Janssen NA, Godri KJ, et al. Respiratory health effects of 
airborne particulate matter: the role of particle size, composition, and 
oxidative potential-the RAPTES project. Environ Health Perspect. 
2012;120(8):1183-1189. 
11. 
Steenhof M, Gosens I, Strak M, et al. In vitro toxicity of particulate 
matter (PM) collected at different sites in the Netherlands is associated 
with PM composition, size fraction and oxidative potential--the RAPTES 
project. Part Fibre Toxicol. 2011;8:26. 
12. 
Strak M, Steenhof M, Godri KJ, et al. Variation in characteristics of 
ambient particulate matter at eight locations in the Netherlands – The 
RAPTES project. Atmospheric Environment. 2011;45(26):4442-4453. 
13. 
Font A, Tremper AH, Priestman M, et al. Source attribution and 
quantification of atmospheric nickel concentrations in an industrial area 
in the United Kingdom (UK). Environ Pollut. 2022;293:118432. 
14. 
DfT. Department for Transport Road traffic statistics. 
https://roadtraffic.dft.gov.uk/#6/55.254/-6.053/basemap-regions-
countpoints. Published 2022. Accessed 11/05/2022. 
15. 
Fussell JC, Franklin M, Green DC, et al. A review of road traffic-derived 
non-exhaust particles: emissions, physicochemical characteristics, 
health risks and mitigation measures. Environmental Science & 
Technology. 2022. 
16. 
USEPA. AP42 Emission factor Documentation for AP-42. In: Agency 
USEP, ed. Vol Section 13.2.1 Paved Roads. Washington DC, USA2011. 
17. 
Wang B-S, Wang X-J, Gong L-K. The Construction of a Williams Design 
and Randomization in Cross-Over Clinical Trials Using SAS. Journal of 
Statistical Software, Code Snippets. 2009;29(1):1 - 10. 
18. 
Nathan RA, Sorkness CA, Kosinski M, et al. Development of the asthma 
control test: a survey for assessing asthma control. J Allergy Clin 
Immunol. 2004;113(1):59-65. 
19. 
Martineau AR, Hanifa Y, Witt KD, et al. Double-blind randomised 
controlled trial of vitamin D3 supplementation for the prevention of 

 
 
 
IONA Protocol V4.0 12.04.2023 
 
IONA V4.0 12.04.2023 
PI: Dr James Scales 
 
Page 37 of 37 
 
acute respiratory infection in older adults and their carers (ViDiFlu). 
Thorax. 2015;70(10):953-960. 
20. 
Graham BL, Steenbruggen I, Miller MR, et al. Standardization of 
Spirometry 2019 Update. An Official American Thoracic Society and 
European Respiratory Society Technical Statement. American Journal 
of Respiratory and Critical Care Medicine. 2019;200(8):e70-e88. 
21. 
Weinmann GG, Bowes SM, Gerbase MW, Kimball AW, Frank R. 
Response to acute ozone exposure in healthy men. Results of a 
screening procedure. Am J Respir Crit Care Med. 1995;151(1):33-40. 
22. 
Blomberg A, Mudway IS, Nordenhäll C, et al. Ozone-induced lung 
function decrements do not correlate with early airway inflammatory or 
antioxidant responses. Eur Respir J. 1999;13(6):1418-1428. 
23. 
McCreanor J, Cullinan P, Nieuwenhuijsen MJ, et al. Respiratory effects 
of exposure to diesel traffic in persons with asthma. N Engl J Med. 
2007;357(23):2348-2358. 
24. 
Font A, Tremper AH, Lin C, et al. Air quality in enclosed railway 
stations: Quantifying the impact of diesel trains through deployment of 
multi-site measurement and random forest modelling. Environmental 
Pollution. 2020;262:114284. 
25. 
Font A, Tremper AH, Priestman M, et al. Source attribution and 
quantification of atmospheric nickel concentrations in an industrial area 
in the United Kingdom (UK). Environmental Pollution. 
2022;293:118432.