Congressional Testimony Fuels Debate on Deployment-Related Respiratory Disease

by U.S. Medicine

August 1, 2011

WASHINGTON — A pulmonary physician recently testified at a Senate subcommittee hearing about the number of troops returning from Iraq and Afghanistan with moderate to severe respiratory diseases, underscoring the growing debate about whether deployment to those theaters of operations increases the risk of developing lung problems.

Sgt. Robert B. Brown supervises at a burn pit at Camp Fallujah in the Al Anbar Province of Iraq as smoke and flames rise into the night sky behind him, May 2007. (Photo courtesy of USMC, photographer Cpl. Samuel D. Corum)

“There have been several studies reporting a startling number of respiratory disorders in personnel returning from Iraq and Afghanistan,” said Matthew King, MD, who has treated veterans and troops at Vanderbilt University Medical Center and the VA Medical Center in Nashville.

King testified on behalf of the American Thoracic Society and was among representatives from 22 non-DoD organizations and advocacy groups who spoke to the Senate Defense Appropriations Subcommittee about a range of issues that they believed should be addressed in DoD’s FY 2012 budget.

Respiratory Problems In Troops

King, whose descriptive case series on the issue was published last month in the New England Journal of Medicine,  said that pulmonologists are “deeply concerned” about the respiratory issues that some military personnel are suffering, such as constrictive bronchiolitis (CB). Patients with this condition, he said, often have normal pulmonary function tests, yet suffer severe respiratory symptoms.

King said troops in Iraq and Afghanistan are faced with a barrage of respiratory insults, “ranging from dust storms to inhaled smoke from burn pits to aerosolized metal and chemicals from exploding IEDS, blast overpressure or shock waves to the lung, outdoor aero-allergens such as date pollen and indoor aero-allergens such as mold aspergillus.”

One issue complicating research is that deployed troops do not receive pre- and post- deployment pulmonary function tests that could help doctors know the extent of lung damage, he said. ATS is recommending that DoD begin giving those function tests to all deployed military personnel. King also said ATS is recommending that VA and DoD jointly create and fund a program to study respiratory exposures of troops deployed to Iraq and Afghanistan, and that a center of excellence be developed by DoD to facilitate improved research and clinical treatment of troops experiencing severe deployment-related respiratory illnesses.

Charles Connor, president and CEO of the American Lung Association (ALA), also told the subcommittee his organization was “extremely concerned” about respiratory diseases affecting soldiers and marines coming back from theater are experiencing. Connor also suggested that military personnel needed to be tested for respiratory and lung function pre-deployment so that doctors can make useful comparison with post-deployment results, instead of comparing soldiers to the population average.

Their concerns were similar to those voiced by Vanderbilt University pulmonologist Robert Miller, MD, at a Senate hearing in October 2009. Miller said then that Vanderbilt began, in early 2004, to receive referrals from providers at Fort Campbell who were asking for assistance in evaluating soldiers who complained of shortness of breath on exertion and could no longer pass physical fitness testing. Routine tests could not explain the cause for the soldiers’ limitations. Their CB diagnosis was eventually established at Vanderbilt by surgical lung biopsy, he said.

“The typical soldier previously had been able to complete a two-mile run within regulation time, but now had to walk much of the course,” Miller said in written testimony at the time. “In almost all cases, standard respiratory evaluations obtained at Fort Campbell had been normal, including chest X-rays, chest CT scans and pulmonary-function testing.”

Congressional Testimony Fuels Debate on Deployment-Related Respiratory Disease Cont.

Military Examines Lung Issues

Military officials were not present at the recent congressional hearing. Col. Lisa L. Zacher, M.D., pulmonary consultant to the U.S. Army Surgeon General, and Dr. Coleen Baird, M.D., MPH, program manager for Environmental Medicine at the U.S. Army Public Health Command, told U.S Medicine in a written statement said the Army and DoD is taking “a serious but standardized and comprehensive approach” to identifying, defining and determining pulmonary disorders that could be related to deployment.

However, they said the military does not believe that respiratory issues will be a problem for most troops serving in Iraq and Afghanistan.

“Indications are that the vast majority of OIF/OEF veterans will not have significant lung problems, but we intend to identify and characterize those with definitively diagnosed pulmonary disease,” they said. “Those who ultimately develop disease will be dependent not only on type and extent of exposure but on co-morbidities (e.g., pre-existent asthma), concomitant exposures (e.g., tobacco use) and genetic pre-disposition.”

Zacher and Baird cited preliminary results of clinical and animal studies that were proposed by a working group convened by DoD. Those results do  not suggest that deployment or exposure to Southwest Asian environmental dusts is generally associated with severe chronic lung disease, although dust exposure may well aggravate pre-existing asthma, they said.

They also questioned the CB research outlined by King and Miller.

“…A small number of servicemembers and veterans (currently around 50) have been diagnosed with constrictive bronchiolitis,” they wrote. “This severe lung disease has been proposed to result from inhalational exposures while these servicemembers were deployed; however, there is not a clear link between a type of exposure known to cause the disease and the history of some of these patients. The DoD is working with academic researchers to improve diagnosis of the disease and to identify possible causes of disease.”

Cecile Rose, MD, MPH at National Jewish Medical Center in Denver is leading a blinded pathological review of tissue from the Vanderbilt and other potential deployment-related Interstitial Lung Disease cases, Zacher and Baird said.

Zacher and Baird said a working group also has recommended pre- and post-deployment pulmonary function testing of troops. DoD believes, however, that pre- and post-deployment spirometry of asymptomatic individuals is “probably not warranted” and that physical fitness testing of troops serves as an indirect measure of pulmonary function and should identify individuals who have respiratory complaints. 

“We believe that pre- and post-deployment spirometry of asymptomatic individuals in a relatively healthy population is probably not warranted,” they wrote. “However, we agree that a baseline pulmonary function test of servicemembers would be useful to assess a servicemember longitudinally in the event of new symptoms or concerns. We also are very aware of the logistical challenges that would need to be overcome.”

Zacher and Baird also said DoD  is considering identifying several military treatment facilities as referral centers for difficult or complex respiratory cases after standard evaluations. 

“We believe that Centers of Excellence within DoD or outside of DoD would serve to consolidate such cases and increase our understanding of the nature and magnitude of respiratory conditions in our forces,” they said.

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