Small Study Looked at Those Serving in Iraq, Afghanistan

Soldiers from the U.S. Army’s 101st Airborne Division and Iraqi Army searched for a weapons cache on a farm outside of Hawijah, Iraq, in 2006. Epidemiological studies indicate that exposure to sand, dust storms, burn pits, air pollution, and even blasts contributed to an increased risk of servicemembers and veterans developing respiratory illnesses after deployment to Iraq and Afghanistan. Army photo by Spc. Timothy Kingston

EAST ORANGE, NJ—For more than 20 years, many veterans have reported respiratory issues following deployment to southwest Asia. Epidemiological studies indicate that exposure to sand, dust storms, burn pits, air pollution and even blasts contribute to an increased risk of servicemembers and veterans developing respiratory illnesses. As everyone deployed to the region experienced many of those exposures, could the associated respiratory problems be larger than reported?

The Airborne Hazards and Burn Pits Center of Excellence (AHBPCE) at the New Jersey War Related Illness and Injury Study Center (NJ WRIISC) studies respiratory concerns and unexplained shortness of breath or dyspnea and other health issues among veterans exposed to these risk factors through the Burn Pit Registry and other studies.

Standard tests of lung function such as spirometry and lung volume have found normal results in many veterans with respiratory systems, but researchers at AHBPCE thought those evaluations might be missing something.

“We at AHBPCE are hearing the concerns veterans have and are trying to understand the mechanisms involved and address their concerns,” said pulmonologist Anays Sotolongo, MD, director of the Center of Excellence.

Sotolongo and colleagues at AHBPCE looked at a condition commonly reported after deployment to Iraq or Afghanistan, exercise-induced bronchoconstriction (EIB). Symptoms include shortness of breath, wheezing or cough during or after exercise in individuals with otherwise normal pulmonary function testing results. EIB frequently leads to reduction in exercise, feelings of isolation, depression and impaired quality of life.

Because of the wide-ranging reports of pulmonary symptoms and the known association of EIB among athletes, particularly those who exercise in environments with high levels of particulate matter such as cities with significant air pollution or gaseous irritants like the chlorine in pools, the researchers decided to focus specifically on veterans who had not sought care for respiratory concerns.

“We understand veteran concerns over deployment and are looking to learn about the people who are not coming to us and are not seeking treatment,” said Michael Falvo, scientific director of the AHBPCE. “There’s broad concern and uncertainty among veterans who may or may not have symptoms but certainly experienced exposure during deployment” to environmental factors associated with respiratory issues.

An Elevated Rate?

The study, published in Military Medicine, enrolled 24 veterans from across all branches.¹ The participants included three females and 21 males who had served in either Afghanistan or Iraq for at least 30 days and did not have a diagnosis of asthma or other lung disease, cardiovascular disease, neurological impairment or disorder, uncontrolled hypertension, pregnancy or moderate or severe traumatic brain injury within the last three years.

Participants had an average age of 35 and had served in southwest Asia for a median of 13 months. More than four years had passed since deployment, on average.

While none of the participants had a diagnosis of a pulmonary disorder or had sought care for one, 58.3% reported persistent cough, 37.5% had wheezing, and 37.5% said they experienced shortness of breath.

The high rates of respiratory symptoms “caught us off guard,” said study co-author Falvo. “It was significantly higher than expected for individuals not seeking treatment.”

Using a conservative approach to assessing EIB, the team found that 16.7% of the veterans experienced an exercise-induced fall in forced expiatory volume of 10% or more in one second. That roughly mirrored rates seen in the general population.

A secondary method, outlined in previous literature, showed far higher rates of EIB, however. That method also considered a drop in peak flow of 10% or more or a mid-expiratory flow reduced by 15% or more. Using that standard, 41.7% of the participants had probable EIB, with four cases considered mild, five moderate and one severe.

“This finding is particularly concerning in that our sample was non-treatment seeking yet reported frequent lower respiratory symptoms,” the authors noted. Further, the participants had low levels of self-reported physical activity, with just 37.5% meeting the minimum of 150 minutes of exercise per week.

The 42% rate is also higher than seen in previous studies of military personnel, in which just 6% demonstrated significant airflow obstruction following a 1.5-mile run, they added.

“Given these studies were performed in military recruits, the higher observed rate of EIB and probable EIB in deployed veterans in the present study may suggest a role for unique environmental factors experienced during deployment rather than deployment in general,” they said. Another possibility is that more exercise training in an environment with high levels of particulate, as seen in athletes, could contribute to the increased rates of EIB detected in this group.

Notably, unlike athletes, the veterans still showed signs of bronchoconstriction years after leaving that environment. Falvo suggested that the veterans could have been affected via a different mechanism than athletes or that direct damage to the lining of the lung or nervous system responses to the damage could have led to differences in outcomes.

Follow-Up

Study co-author Sotolongo suggested that veterans who are not sure whether they have seasonal allergies or other respiratory issues following deployment start by enrolling in the Burn Pit Registry or contacting their primary care provider. Simply tell them, “I was in Iraq; I’m concerned. Do I need more testing?” she urged.

Any person who reports shortness of breath on exercise or in activities of daily living warrants follow-up, said Falvo. Many factors could be responsible, including exercise-induced asthma, chronic obstructive lung disease, cardiovascular disease and others.

Veterans who experience discomfort or shortness of breath during or after exercise can also take some preventive steps themselves which may enable them to continue to exercise. Runners who find exercise more difficult in the cold can wear a scarf that covers the nose to warm incoming air, noted Sotolongo. Veterans who find the chlorine associated with indoor pools irritating could try swimming outside where the chemicals are much more diffuse.

1. Klein-Adams JC, Sotolongo AM, Serrador JM, Ndirangu DS, Falvo MJ. Exercise-Induced Bronchoconstriction in Iraq and Afghanistan Veterans With Deployment-Related Exposures. Mil Med. 2019 Dec 31. pii: usz410. Doi: 10.1093/milmed/usz410. [Epub ahead of print]