I meet Ash Brennan in the break room of Seattle Children's Hospital on a September afternoon when the Air Quality Index outside reads 167. "Unhealthy," according to the color-coded charts, though Ash just calls it "a regular Wednesday." She's twelve years into her career as a respiratory therapist, which means she started in 2013, back when Seattle summers meant sun and outdoor concerts, not checking your phone's AQI app before deciding whether your kids can play outside.
"People don't realize respiratory therapy even exists until they need us," she says, stirring a coffee that went cold an hour ago. "We're the ones managing ventilators, teaching asthma kids how to use inhalers properly, doing breathing treatments at 2 AM. August through October now? We're basically running a field hospital for smoke inhalation, except the field is the entire Pacific Northwest and the hospital never closes."
She's 38, with two kids of her own—eight and five—which adds a particular edge to watching children struggle to breathe because the air outside contains the particulate matter equivalent of smoking half a pack of cigarettes.
When did you first notice the change?
2015. The summer we had those big Eastern Washington fires and the smoke just settled over Seattle for weeks. I remember thinking, "Okay, this is weird. This doesn't happen here." We got slammed with kids coming in with asthma exacerbations—that's when your regular asthma suddenly gets way worse—and our ED was packed. But it still felt like an event. Something unusual.
By 2018, we were preparing for it. By 2020, we just accepted it as part of the calendar. Flu season, wildfire season, back to school. The hospital started stocking extra albuterol in July. We have protocols now for smoke season that didn't exist when I started.
Which is either progress or just really organized surrender, I haven't decided which.
What does smoke season look like from inside a children's hospital?
You watch the wave build. Check the forecasts—not weather forecasts, fire forecasts. You see Canada burning or Eastern Oregon burning, and you know: three days, maybe four, before the smoke reaches us. Then the calls start. Parents asking if they should keep kids inside. Pediatricians sending patients to us because their regular inhalers aren't cutting it anymore.
The kids who come in... it's not just asthma kids anymore, though they get hit worst. We're seeing previously healthy six-year-olds with reactive airway disease. Babies with bronchiolitis because their lungs are tiny, they're breathing this shit at twice the rate adults do, and their airways are the diameter of a drinking straw.1
We had a kid last August, four years old, came in with an O2 sat in the low eighties. That's bad—you want to see mid-nineties minimum. Her mom kept apologizing, saying she'd kept her inside, but their apartment doesn't have AC and it was 95 degrees, so she'd opened the windows.
What's she supposed to do? Cook her kid or poison her? Those are the choices now.
You mentioned protocols. What does preparation look like?
We start in July now. Inventory checks on nebulizers, albuterol, steroids. Make sure the ED has extra capacity. Staff up—bring in per diem RTs, extend shifts. The hospital puts out these parent education materials: "How to Create a Clean Air Room," "When to Seek Emergency Care." All very official and helpful.
Here's what they don't put in the pamphlets: all that preparation is for the kids whose parents can prepare. You need money for air purifiers—good ones run $300, $400. You need housing with decent seals around windows. You need the ability to miss work to take your kid to the doctor.
The kids we see in the worst shape? They're from families who can't do any of that. So we're not just treating smoke exposure. We're treating inequality made visible by smoke.2
How has this changed how you think about your job?
I used to think my job was helping kids recover from respiratory crises. Now I think my job is managing a permanent crisis that will get worse.
That's a different thing entirely.
I have colleagues who've left. Burned out, moved to other specialties, moved to other states. Can't blame them. It's hard to watch kids suffer from something completely preventable while politicians argue about whether climate change is real. Like, I'm standing here with a seven-year-old on a BiPAP machine because there's too much particulate matter in her lungs, and someone's on TV saying we need more studies.
But also—someone has to be here. These kids need care regardless of how we got here. So you develop this weird pragmatism. Gallows humor. We have a running joke about renaming the department "Seasonal Smoke Inhalation Unit." We track which air purifier brands actually work—Coway and Blueair, if you're wondering, the cheap ones are garbage. We swap tips on explaining to parents that no, moving to Portland won't help, it's worse there.
One of the nurses has a coffee mug that says "I survived smoke season 2024" like it's a marathon. Which, honestly, it kind of is.
Do you talk to your own kids about this?
Long pause.
Yeah. I have to. My eight-year-old asks why she can't play outside when it's sunny. How do you explain that to a kid? "The sun is out but the air is poison because forests are burning 200 miles away because the planet is too hot now."
I tell her the truth, age-appropriate version. The air has smoke in it that makes it hard to breathe, so we stay inside on bad days. We have air purifiers in every room at home—I'm basically a walking advertisement for air purifiers at this point. I check the AQI every morning like people used to check the weather. When it's under 50, I practically shove them outside. Go, run, breathe clean air while you can.
My five-year-old doesn't remember summers without smoke. This is just normal to him. Which is maybe easier? I genuinely don't know. I remember August meaning hiking and swimming and sleeping with the windows open. He'll remember August meaning indoor recess and purple air quality maps and his mom checking her phone every two hours.
What's the trajectory from here?
Laughs without humor.
Worse. The data's pretty clear—more fires, longer fire seasons, more smoke.3 We're already seeing it. 2023 was brutal because of the Canadian fires. This year, 2025, we got smoke in June. June used to be our clearest month. Now it's just early smoke season.
The hospital's planning for it. We're talking about permanent infrastructure changes—better air filtration systems, dedicated respiratory wings. Which is good, I guess? But it's also like we're adapting to a crisis instead of preventing it. We're building hospitals for a smoking planet.
The thing that keeps me up at night isn't the kids I see—I can help them, that's what I'm trained for. It's the math. Every year, more kids affected. Every year, longer smoke season. Every year, worse air quality. At some point, do we just have an entire generation with compromised lung function? What does that mean for their health at 30, 40, 50?
We don't know. We're running the experiment in real time, and the kids are the test subjects.
How do you cope with that knowledge?
Therapy. Good health insurance, thank God. Dark humor in the break room. I focus on what I can control—the kid in front of me, right now, who needs a breathing treatment. I can do that. I'm good at that.
And look, there's meaning in it. When a kid comes in barely breathing and leaves a few hours later with clear lungs, that matters. When I teach a parent how to use a spacer correctly and their kid's asthma gets under control, that's real. It's not solving climate change, but it's solving something.
Plus, I'm stubborn. I grew up here. I love the Pacific Northwest—the real one, the one I remember, not whatever this is becoming. But I'm not leaving. So if staying means becoming an expert in smoke-related pediatric respiratory distress, fine. Someone needs to be the expert.
I just wish we were experts in something else.