The COVID-19 pandemic has significantly strained healthcare systems worldwide, particularly in emergency departments (EDs) [1,2]. Among the severe manifestations of the disease are patients resulting in acute respiratory failure (ARF). Understanding the multifaceted factors influencing these patients is crucial for effective management and intervention strategies. In this context, environmental factors such as air pollution and meteorological conditions have emerged as potential contributors to the severity of COVID-19 [[3], [4], [5], [6], [7], [8], [9]]. However, the exact role of these factors remains a subject of debate, with conflicting evidence about their impact on disease progression and outcomes.

Weather conditions have been shown to influence respiratory health outcomes. Meteorological variables such as temperature, humidity, and wind speed can influence viral transmission dynamics and the body's immune response to infections, making them critical factors in the spread and severity of COVID-19 [[8], [9], [10]]. For instance, colder temperatures can exacerbate respiratory illnesses due to increased viral transmission and the physiological effects of cold on lung function. In ED settings, fluctuating temperatures and seasonal changes may correlate with spikes in COVID-19 admissions. Research suggests that extreme weather events, such as heat waves or storms, may also impact patient vulnerability [11]. High temperatures can worsen respiratory distress in patients with pre-existing conditions, while storms can lead to increased mold and pollen levels, complicating respiratory issues. Additionally, weather-related disruptions to healthcare access can delay treatment, further worsening outcomes for those with ARF [11].

Air quality plays a critical role in respiratory health, particularly in the context of COVID-19. Studies have shown that elevated levels of the air pollutants such as particulate matter 2.5 (PM2.5), particulate matter 10 (PM10), nitrogen dioxide (NO₂), sulfur dioxide (SO2), and ozone (O₃) can impair lung function, exacerbate inflammation, and weaken immune responses, potentially leading to more severe respiratory conditions and increased risk of ARF in COVID-19 patients [[3], [4], [5], [6], [7]]. In urban areas with high pollution levels, patients may experience worsened outcomes, as pollutants can increase viral load and further complicate respiratory management in the ED [12]. Pre-existing air quality issues can further predispose populations to severe cases, complicating healthcare strategies during the COVID-19 pandemic.

Despite these potential links, the relationship between weather patterns, air pollution, and the severity of COVID-19 cases, particularly those with ARF, remains understudied. Additionally, the emergence of new SARS-CoV-2 variants has added further complexity to this equation, as different variants may interact with environmental factors in unique ways, potentially altering the course of the disease [[13], [14], [15], [16]]. To address these uncertainties, this study aims to assess the combined effects of weather conditions, air pollution, and SARS-CoV-2 variants on the risk of COVID-19-related ARF in ED settings, and explore the implications of these factors for respiratory management strategies in the ED during the pandemic. By integrating environmental and virological data, this research seeks to clarify how dynamic external factors influence healthcare demands and patient outcomes.