A Burning Question

Military deployment-related respiratory problems: an update

PURPOSE OF REVIEW

Military personnel deployed to Southwest Asia and Afghanistan were potentially exposed to high levels of fine particulate matter and other pollutants from multiple sources, including dust storms, burn pit emissions from open-air waste burning, local ambient air pollution, and a range of military service-related activities that can generate airborne exposures. These exposures, individually or in combination, can have adverse respiratory health effects. We review exposures and potential health impacts, providing a framework for evaluation.

RECENT FINDINGS

Particulate matter exposures during deployment exceeded U.S. National Ambient Air Quality Standards. Epidemiologic studies and case series suggest that in postdeployment Veterans with respiratory symptoms, asthma is the most commonly diagnosed illness. Small airway abnormalities, most notably particularly constrictive bronchiolitis, have been reported in a small number of deployers, but many are left without an established diagnosis for their respiratory symptoms. The Promise to Address Comprehensive Toxics Act was enacted to provide care for conditions presumed to be related to deployment exposures. Rigorous study of long-term postdeployment health has been limited.

SUMMARY

Veterans postdeployment to Southwest Asia and Afghanistan with respiratory symptoms should undergo an exposure assessment and comprehensive medical evaluation. If required, more advanced diagnostic considerations should be utilized in a setting that can provide multidisciplinary expertise and long-term follow-up.

Consensus Statements on Deployment-Related Respiratory Disease, Inclusive of Constrictive Bronchiolitis: A Modified Delphi Study

BACKGROUND

The diagnosis of constrictive bronchiolitis (CB) in previously deployed individuals, and evaluation of respiratory symptoms more broadly, presents considerable challenges, including using consistent histopathologic criteria and clinical assessments.

RESEARCH QUESTION

What are the recommended diagnostic workup and associated terminology of respiratory symptoms in previously deployed individuals?

STUDY DESIGN AND METHODS

Nineteen experts participated in a three-round modified Delphi study, ranking their level of agreement for each statement with an a priori definition of consensus. Additionally, rank-order voting on the recommended diagnostic approach and terminology was performed.

RESULTS

Twenty-five of 28 statements reached consensus, including the definition of CB as a histologic pattern of lung injury that occurs in some previously deployed individuals while recognizing the importance of considering alternative diagnoses. Consensus statements also identified a diagnostic approach for the previously deployed individual with respiratory symptoms, distinguishing assessments best performed at a local or specialty referral center. Also, deployment-related respiratory disease (DRRD) was proposed as a broad term to subsume a wide range of potential syndromes and conditions identified through noninvasive evaluation or when surgical lung biopsy reveals evidence of multicompartmental lung injury that may include CB.

INTERPRETATION

Using a modified Delphi technique, consensus statements provide a clinical approach to possible CB in previously deployed individuals. Use of DRRD provides a broad descriptor encompassing a range of postdeployment respiratory findings. Additional follow-up of individuals with DRRD is needed to assess disease progression and to define other features of its natural history, which could inform physicians better and lead to evolution in this nosology.