Lung Disease Following Deployment in Iraq and Afghanistan

by Kalie VonFeldt, MS, PA-C;

Maura Robinson, BS; and

Cecile Rose, MD, MPH

United States military personnel and civilian contractors deployed to Iraq and Afghanistan may be at risk for respiratory symptoms and chronic lung disease, including asthma and constrictive bronchiolitis. Respiratory therapists can play an important role in ensuring that patients who have respiratory symptoms following deployment are provided with appropriate referral and high-quality lung function testing as part of their diagnostic evaluation.

Since 2001, approximately 2 million US military men and women have deployed to Iraq or Afghanistan in support of OIF (Operation Iraqi Freedom) or OEF (Operation Enduring Freedom), respectively. Over the past decade, evidence has emerged that military personnel and civilian workers sent to southwest Asia may be at risk for developing potentially disabling chronic lung diseases, including asthma and constrictive bronchiolitis (CB).1,2 Specific environmental inhalation exposures of concern include ambient desert dusts, emissions from burn pits where waste products are incinerated, industrial pollutants, secondhand smoke, and airborne contaminants associated with degraded soils.

Reports of increased acute respiratory illnesses in deployed troops began surfacing in 2004.3 Subsequent epidemiologic studies showed that deployers have higher rates of newly reported respiratory symptoms than nondeployers (14% versus 10%), although rates of physician-diagnosed asthma and chronic Lung Disease Following Deployment in Iraq and Afghanistan

bronchitis were not increased.4 More recent studies suggest that obstructive airways diseases, including asthma and constrictive bronchiolitis, are occurring in excess in returning troops.1,5 The magnitude and spectrum of respiratory illnesses from deployment are difficult to judge. Lack of predeployment spirometry and challenges with diagnosis limit accurate estimates of disease incidence and prevalence.

Inhalational Exposures of Concern

Burn pits

According to Department of Defense (DoD) estimates, in a typical military operation, each American soldier generates nine to 12 pounds of waste a day. That waste must be burned in pits or incinerators, or trucked to landfills, which are often not readily available. The open burning of solid and chemical wastes has been practiced in areas of southwest Asia where military personnel are stationed.6 Open air burn pits and simple incinerators with limited pollution controls generate smoke plumes with poorly characterized and highly variable constituents. Increasing concern about burn pit combustion product exposures is being expressed by returning troops.

Desert Dust

Exposure to crustal dust and sand storms, sometimes lasting for days and often intense enough to obscure visibility, is an ongoing problem facing deployed troops .
Adding to this problem is the severe degradation of soils in areas of southwest Asia due to overuse by heavy vehicles, along with often poor environmental controls for local industries. Air sampling has shown high levels of PM 2.5 (the particulate size that is respirable and able to penetrate the small airways) on many of the bases where US troops live and work.7 These dusts may contain high levels of metals (including lead) and may impair lung defense mechanisms.

Industrial fires

Exposure to smoke from burning oil wells was a concern during Operations Desert Shield/Desert Storm8 in the early 1990s. Although oil well fires have not been as much of a concern in the more recent southwest Asia theaters of operation, exposure to smoke from other types of industrial fires has been a problem in certain areas. A fire at the Mishraq State Sulfur Mine plant in Mosul, Iraq, in June 2003 burned for 3 weeks and released a sustained plume of smoke over a geographic area extending 25 km to the south and 50 km north to the Mosul Airfield. The plume contained variable but frequently high quantities of particulate matter, hydrogen sulfide (H2S), and sulfur dioxide (SO2).9 These oxides of sulfur are known causes of bronchiolitis.10 The US Army Public Health Command estimates that more than 6,000 returning troops (based on unit location) may have been exposed to the sulfur fire plume.

Cigarette smoking and secondhand smoke.Tobacco addiction is a significant health problem for our armed forces, and the potential effects of cigarette smoke on the lung function of US military personnel are substantial. In 2005, the rate of smoking in the military was reported at 32.2%, compared to 21% of the civilian population.   By 2008, there was no significant change, with a smoking rate of 31%, despite declining smoking rates in the general public.12 Studies by the DoD have found a significant rise in smoking initiation and recidivism with troop deployment, especially in soldiers with prolonged or repeated deployments and in those with combat exposure.   Besides the well-known long-term health risks of smoking, new onset smoking has been associated with risk for acute eosinophilic pneumonia in deployed military personnel.

Airways Diseases Associated with DeploymentNome