The clinical manifestations of ozone poisoning are most apparent in the respiratory system, which is the main organ to be affected. Other organs and systems are also affected, such as the eyes and the central nervous system (CNS). The detrimental effects of ozone are due to ozone molecules, as well as its byproducts, including reactive oxygen species (ROS) [1] [2]. Ozone is present in varying concentrations in both indoor and outdoor air, and exposure to significant concentrations takes place in high altitude flights.

The respiratory symptoms associated with ozone toxicity include coughing, wheezing, chest pain, shortness of breath, chest discomfort and nasal mucosal and pharyngeal irritation. The severity of symptoms and the levels of ozone at which symptoms are elicited vary between individuals. Moreover, the effects of ozone are more marked during exercise. It has been suggested that adults in their second and third decades of life are more prone to the effects of ozone, as well as overweight individuals.

Ozone decreases lung function, both on acute and chronic exposure and it has been shown that repeated exposure precipitates symptoms and worsens already existing complaints. A positive correlation between higher ozone levels and respiratory-related hospital admissions and morbidity has been observed [3]. In the general population, ozone increases the extent to which airways respond to stimuli such as histamine, induces inflammation of the airways and increases the permeability of pulmonary blood vessels resulting in leakage of plasma proteins in the lungs [4]. Individuals with asthma may suffer from more frequent acute exacerbations, as well as an increase in the severity of such events [5] [6]. Furthermore, they have a lowered tolerance towards triggers that are known to cause asthmatic attacks.

Ozone may cause eye irritation and dryness, and worsen allergic conjunctivitis. Fatigue has been noted as well, along with other neurological symptoms that include headaches and decreased concentration [7].

• Fatigue

  Adrenal Fatigue Initially thinking that adrenal fatigue was some wishy-washy pseudo-illness of professional hypochondriacs, I came across the following description : “ Morning fatigue – not feeling awake until about 10 am Afternoon fatigue – sleepiness [thepowerofozone.com]

  Fatigue has been noted as well, along with other neurological symptoms that include headaches and decreased concentration. A physical exam will confirm the respiratory symptoms reported. [symptoma.com]

  Fatigue, headache, heaviness of the head and/or change in respiratory functioning results at 1-2 ppm. An ozone level at 5-10 ppm triggers breathing difficulty, malaise and/or increased breathing rate. [ekasuga.co.jp]

  Chest X-rays were normal in 2 to 3 weeks, but 9 months later they still complained of fatigue and exertional dyspnea (labored respiration). 25.00 ppm and up Ozone concentrations that are immediately hazardous to human life are unknown but on the basis [ozoneservices.com]

  Additional symptoms include headache, blurred vision, nausea, fatigue, and vomiting. The smell of ozone is noticeable even at low levels. [disabled-world.com]

• Collapse

  The presence of the lipid molecules is crucial for the exchange of oxygen and carbon dioxide, as they prevent the wet surfaces of the lung from collapsing. [phys.org]

  We first explored the relationship between the outcome and ozone exposure within four genetic risk score groups collapsed because of sample size: 1 or 2 risk alleles; 3; 4; and 5 or 6. [respiratory-research.biomedcentral.com]

• Chest Discomfort

  The respiratory symptoms associated with ozone toxicity include coughing, wheezing, chest pain, shortness of breath, chest discomfort and nasal mucosal and pharyngeal irritation. [symptoma.com]

  (Provided to CBC) Health Canada lists the symptoms of ozone exposure as "coughing, chest discomfort, reduced lung function, shortness of breath and irritation of the eye, nose and throat." Its website includes a strong warning: "No ozone generators! [cbc.ca]

• Outdoor Worker

  Children, people with lung disease, older adults, and people who are active outdoors, including outdoor workers, may be particularly sensitive to ozone. " Jogging, playing and anything that increases the rate of breathing are particularly dangerous to [membrane.com]

  Reduced lung function can be a particular problem for outdoor workers, competitive athletes, and others who exercise outdoors. Ozone can make asthma symptoms worse. [ourair.org]

• Cough

  The respiratory symptoms associated with ozone toxicity include coughing, wheezing, chest pain, shortness of breath, chest discomfort and nasal mucosal and pharyngeal irritation. [symptoma.com]

  Breathing pain, coughing, wheezing, difficulty when exercising. Permanent lung damage. [lorrainefrantzedwards.blogspot.com]

  Ozone at 0.4-0.5 ppm causes irritation of the upper air passage, and 0.6-0.8 ppm results in chest pain, coughing and/or decreased lung function and lung diffusing capacity. [ekasuga.co.jp]

  Acute symptoms Common signs and symptoms are as follows: Cough Light-headedness Dyspnea Chest tightness Choking Diaphoresis Loss of consciousness (at very high concentrations or in very susceptible individuals) Coughing is the most common manifestation [emedicine.medscape.com]

  Symptoms of ozone exposure in healthy people include coughing, wheezing, and pain when taking a deep breath. Studies show that children don't usually report symptoms even when they have measurable decreases in lung function. [airnow.zendesk.com]

• Joint Stiffness

  stiffness – overwhelming fatigue – have phases in my life full of plans and motivation followed by phases where I would fall into total procrastination and halt everything – extremely dry skin – tinnitus – cold hands and feet – tingling sensations in [thepowerofozone.com]

• Compulsive Disorder

  Disorder, constant obsessive circular thoughts – all sorts of other cognitive and emotional disturbances resulting in a very “jumpy” personality – suicidal thoughts – emotional impulsivity – depression – moodiness – not being able to understand written [thepowerofozone.com]

• Depersonalization

  I think that the joint pain, feelings of having a veil between myself and reality (derealization or depersonalization) might have been part of lyme; or maybe it was candida. [thepowerofozone.com]

• Impulsivity

  […] socially, near complete eradication of empathy – OCD, Obsessive Compulsive Disorder, constant obsessive circular thoughts – all sorts of other cognitive and emotional disturbances resulting in a very “jumpy” personality – suicidal thoughts – emotional impulsivity [thepowerofozone.com]

• Hunger

  I also tend to ascribe episodes of air hunger or the sensation of not being able to breath to lyme disease or some other infection, since breathing vaporized diluted hydrogen peroxide (1% to 3%) completely reversed it. [thepowerofozone.com]

• Headache

  Fatigue has been noted as well, along with other neurological symptoms that include headaches and decreased concentration. A physical exam will confirm the respiratory symptoms reported. [symptoma.com]

  Fatigue, headache, heaviness of the head and/or change in respiratory functioning results at 1-2 ppm. An ozone level at 5-10 ppm triggers breathing difficulty, malaise and/or increased breathing rate. [ekasuga.co.jp]

  Can cause nausea and headaches in some individuals. Extended exposure could cause lung edema (an abnormal accumulation of serous fluid in connective tissue or serous cavity). [ozoneservices.com]

  Different studies on the effects of ozone show that short term exposure to ozone will cause respiratory problems, burning sensation in the eyes, coughing headaches increased sensitivity to allergens, among other symptoms. [cambridgemask.com]

  (Graph 19) The workers cite 22 medical problems they have suffered from ozone, including chest pain, bronchospasm, laryngitis, conjunctivitis, headaches, hoarseness, loss of senses of smell and taste, nausea and vomiting. [courthousenews.com]

A physical exam will confirm the respiratory symptoms reported. There are several modalities that can be used to observe and measure the effects of ozone on the respiratory system, these are:

• Bronchoscopy: This shows inflamed airways [8].
• Bronchoalveolar lavage (BAL): This is used to acquire samples of epithelial lining fluid for biochemical analysis. It reveals the presence of neutrophils as well as several inflammatory mediators, namely cytokines, leukotrienes and other eicosanoid derivatives. There is also an increase in lactose dehydrogenase, which is an indicator of cell damage. Plasma proteins may also be present.
• Pulmonary function tests (spirometry): These show decreased lung function in several parameters, examples of these being forced expiratory volume (FEV) and forced vital capacity (FVC) [9].

Serum levels of inflammatory molecules and white blood cells may also be elevated.

• Candida

  I think that the joint pain, feelings of having a veil between myself and reality (derealization or depersonalization) might have been part of lyme; or maybe it was candida. [thepowerofozone.com]

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3. Johnston RA, Schwartzman IN, Flynt L, Shore SA. Role of interleukin-6 in murine airway responses to ozone. Am J Physiol Lung Cell Mol Physiol. 2005;288(2):L390–397.
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5. Aleman MM, Kesic MJ, Mills KH, Peden DB, Hernandez ML. The IL-1 axis is associated with airway inflammation after O3 exposure in allergic asthmatic patients. J Allergy Clin Immunol. 2015;136(4):1099–1101 e1092.
6. Hernandez ML, Lay JC, Harris B, et al. Atopic asthmatic subjects but not atopic subjects without asthma have enhanced inflammatory response to ozone. J Allergy Clin Immunol. 2010;126(3):537–544 e531.
7. Apte MG, Buchanan ISH, Mendell MJ. Outdoor ozone and building-related symptoms in the BASE study. Indoor Air. 2008;18(2):156–170.
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9. Cho HY, Zhang LY, Kleeberger SR. Ozone-induced lung inflammation and hyperreactivity are mediated via tumor necrosis factor-alpha receptors. Am J Physiol Lung Cell Mol Physiol. 2001;280(3):L537–546.