Considerations Unique to the Military
Active-duty personnel present unique challenges in the diagnosis and management of asthma. Service members should be questioned thoroughly on deployment and exposure history. A significant portion of the current military population has deployed to SWA in the past decade, many for multiple deployments. Research addressing respiratory complaints in the deployed military population is ongoing. To date, military research has demonstrated
that while many service members with deploymentrelated respiratory exposures have a paucity of objective findings after pulmonary medicine evaluation, some demonstrate functional limitations consistent with asthma or airway hyperresponsivenesss. 28 Further retrospective studies did not find a relationship between deployment and diagnosis rates or severity in asthma patients in the Army. 29 A comprehensive evaluation is recommended for service members with dyspnea to include investigating for potential asthma- or exercise-induced bronchospasm, in addition to diagnoses such as vocal cord dysfunction, GERD, and OSA. 28-30
A recent study in service members with respiratory complaints related to deployment included surgical lung biopsy; however, the clinical applicability of these results is unclear, given the lack of a firm association between the histologic diagnoses and clinical condition of the subjects. 31 In general, it is not recommended to perform surgical lung biopsy for patients with deployment history to SWA in the absence of objective findings on chest imaging or significant changes in pulmonary function testing. Screening spirometry has been postulated as a way to improve monitoring for military members proximate to deployment and longitudinally. However, an unpublished cost analysis estimates that for the over 500,000 activeduty service members, screening spirometry would cost in the tens of millions of dollars. 32 This analysis did not include the costs of follow-up specialty care or further
tests. Although screening spirometry does not appear to be feasible presently, research evaluating screening spirometry is in progress in the military. 33
If diagnosed with asthma, service members should be able to perform all required duties, wear protective gear, and have stable disease requiring infrequent, if any, oral corticosteroid treatment. According to U.S. Army retention regulations, soldiers diagnosed with asthma may be placed on temporary profile (duty restrictions) for up to 12 months when medically advised. If at the end of that trial the soldier is unable to wear a protective mask or pass the timed physical fitness run outdoors (on medications), then the soldier should be placed on a more restrictive physical profile and referred for a medical evaluation board. If able to pass the physical fitness run (or an alternate aerobic fitness event) within standards and perform all military training and duties on ICSs and bronchodilators, the soldier may be placed on a less restrictive temporary profile. If the soldier does not require medications or activity limitations, then no profile qualifications are required. Chronic asthma should also require a physical profile if it results in repetitive hospitalizations, emergency department visits, excessive time lost from duty, or repetitive use of oral corticosteroids. 3
Conclusion
The evaluation and management of asthma in the military requires appropriate diagnosis, treatment, and longitudinal follow-up. The diagnosis should always be confirmed with pulmonary function and bronchoprovocation testing. Conditions mimicking asthma should be excluded, particularly when asthma does not respond to appropriate therapy. It is imperative that patients with asthma who do not demonstrate an expected course of improvement with therapy seek evaluation by a pulmonary disease specialist. This serves to re-evaluate whether the initial diagnosis was correct, assess for potential disease mimics and aggravating comorbidities, and ensure that asthma therapy is in accordance with published guidelines. Service members with asthma can remain on active duty when management with inhaled therapies allows them to meet standards and perform required duties.