"This is an emergency she has difficulty breathing" said the tearful woman forcing open the door to the office of Bardhyl Vaqari who has worked in the specialist Tirana clinic for more than 20 years.

"An acute asthma attack" said the doctor on seeing the child.

"The number of people with respiratory allergies and cardiovascular problems has greatly increased" he told AFP adding that the number of patients on the clinic's books has more than doubled to 8000 in the last four years.

On the noisy and congested streets outside clapped-out bangers and Hummer trucks cross paths with Mercedes BMWs and overloaded buses that leave a trail of black smoke and heavy odour.

Having been cut off from the world under a strict communist regime until 1991 the Western Balkan city had just a few hundred cars on its roads in the 1990s.

But today through a mixture of pride luxury-seeking and necessity given the lack of public transport there are more than 190000 cars circulating in a city of about one million people.

"Albanians take the car even when going to buy bread in a nearby store. That's why the traffic is overloaded all day and this increases pollution levels" said Altin Duka a despairing 65-year-old shopkeeper.

The average age of vehicles on Tirana's roads is around 16 years twice the European average according to Gani Cupi deputy manager of Albania's Road Transport Services.

Many of the vehicles do not meet the standards of the European Union which Albania hopes to join.

"The traffic load the age of vehicles their technical condition but also the poor quality of fuel are all factors contributing to the capital's pollution" said Cupi.

- Taxing dilemmas -

In a bid to clean up the air Albanian authorities considered doubling taxes on ageing vehicles but then dropped such plans. Analysts suggested the cost would weigh too heavily on citizens in one of the poorest countries in Europe.

New cars are already exempt from paying annual tax for the first three years but authorities in 2012 lifted a levy on the import of old vehicles as the EU considered it a "fiscal discrimination".

Tirana's Mayor Erion Veliaj has pledged to battle against the fumes by increasing the number of green spaces introducing hybrid buses and improving infrastructure in the city which is crammed with mostly illegal constructions.

"The number of vehicles does not stop growing" he told AFP pointing out that about 500 people die in the city each year "because of respiratory or cardiovascular problems related to pollution".

A report this year from the European Environment Agency noted a 20 to 30 percent decrease in Tirana's concentration levels of PM10 and PM2.5 -- damaging particulate matter -- according to data assessment from 2011 to 2013.

But Laureta Dibra head of the air and climate change department at Albania's Environment Ministry told AFP that PM10 levels had actually been rising in areas of heavy traffic in recent years.

Tirana remains "among the most polluted cities in Europe" added the director of the National Environment Agency Julian Beqiri.

"The level of the population's exposure to pollutants is still a problem" he said.

- On your bikes -

In an effort to improve air quality in the capital and educate residents Tirana organised two car-free days in 2015 when the air was said to be at least four times less polluted than usual.

Worried activists are campaigning to promote the bicycle as a means of transport and a way of life.

Ecovolis a bike sharing system rents out at least 200 bicycles from different stations around Tirana at 60 leke (44 euro cents $0.47) per bike per hour -- but many people still prefer getting behind the wheel.

Although Albania's energy minister claims that 95 percent of fuel meets the required standards even Prime Minister Edi Rama attacked its quality in May last year.

"It is so bad that even a strong car like a Mercedes ends up being bad for Albanians' lungs" he said calling for urgent measures to improve fuel controls.

The government says restrictions have since been tightened but those at the frontline of the fumes remain unhappy.

"I come home in the evening with a completely dry throat and a bitter taste my mouth" said Bequir Veseli 37 a traffic policeman who spends eight hours a day at the centre of a chaotic roundabout.

"I have trouble breathing but what can I do? The next day I have to go back to my post".