"I talk to people every week just to validate what we’ve done and there have been biopsies done all over the country that are finding the same thing in Nevada, Kansas, Colorado, Seattle, Chicago," he says. "So everybody is finding this, if they’re looking for it."
Still, the biopsies are beginning to look a bit different. They still contain the same features of small airway narrowing, associated arteriopathy and pigment deposits, but are more likely to have changes of inflammation and hypersensitivity than scarring, Dr. Miller says. One explanation is that part of his population may have been skewed up front because a lot of the soldiers seen early on were exposed to the Mishraq sulfur mine fires in 2003 – an argument raised by military officials who argued that this type of exposure is unique to the study cohort.
Interestingly, a recent case report by Dr. Anthony Szema, with The State University of New York at Stony Brook, identified titanium, iron, and copper in the lung biopsy of a soldier with nonspecific interstitial pneumonitis and bronchiolitis (J. Occup. Environ. Med. 2012;54:1-2).
Lessons Learned From 9/11
Two other key recommendations from the working group are to institute predeployment respiratory testing, including spirometry, and to follow the troops longitudinally. Annual pulmonary function test data from World Trade Center firefighters has proven invaluable in assessing the impact of exposure, revealing a very acute and substantial decline in forced expiratory volume in 1 second (FEV1) averaging 600 cc within the first 6 months after 911, typically followed by a return to the normal age-related decline in FEV1, Dr. Rose says.
"We’re really just starting to follow our patients now, so whether this is an acute decline that then stabilizes or whether this is a persistent accelerated decline in lung function, we just don’t know," she admits.
So far, pulmonary function testing has been relatively stable, although patients will typically say they are more short of breath, Dr. Miller says. When they’ve been able to check it, their exercise tests are getting worse, a change he suggests is probably better explained by deconditioning and weight gain than by progression and disease.
Dr. Miller says the best way to assess predeployment lung function is for each soldier to serve as his or her own control, but that it may not be practical to test everyone who’s deployed. Still, if enough cardiopulmonary testing is performed, it may help determine how a soldier at a particular age, height, and weight with a specific 2-mile run time would correlate with a cardiopulmonary test. At the very least, the 2-mile run times should be put in the medical record, and that is not the case now, he says.
For their part, military officials have said they do not believe long-term respiratory problems will be an issue for the majority of troops deployed to Iraq and Afghanistan, and that predeployment spirometry is not warranted.
Although troops typically express relief at a diagnosis, the prognosis for constrictive bronchiolitis is grim. None of the patients have responded well to oral corticosteroids or in a few cases, to second-line immunosuppressive drugs, Dr. Rose says.
Recent news reports are being used by veterans to push for better care, with one group, DisabledVeterans.org, recently launching a breathing survey to document soldiers’ health and experience with the Department of Veterans Affairs.
The exact scope of the problem is unknown, but the financial ramifications for the government are potentially staggering given the roughly two million troops deployed since 2001. The prospective DOD Millennium Cohort study reported respiratory problems in 14% of troops deployed to Iraq/Afghanistan and 10% of troops not deployed (Am. J. Epidemiol. 2009;170:1433-42), while a retrospective study by Dr. Szema reported respiratory symptoms requiring spirometry in 14.5% of Iraq/Afghanistan troops vs. just 2% of troops deployed elsewhere (J. Occup. Environ. Med. 2011;53:961-5).
For Dr. Miller, it has become a matter of advocacy.
"What these guys sacrifice is incredible, even when they’re not injured, and they deserve better than what they’re getting when they’re injured, whether it’s loss of limb, PTSD or a lung injury," he argues. "I hope we can prevail in what we’re doing."