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Military personnel and veterans who have deployed to Afghanistan, Iraq, and parts of Southwest Asia (SWA) since 1990 are at risk of developing a host of respiratory symptoms and deployment-related respiratory diseases (DRRDs). This review aims to summarize our current understanding of DRRD and inform pulmonary practitioners of recent updates to DRRD screening, diagnosis, evaluation, and management. The most common respiratory diseases in these patients include asthma, chronic sinonasal disease, laryngeal disease/dysfunction, and distal lung disease. Pulmonary function testing and chest imaging are the most commonly used diagnostic tools, but techniques such as lung clearance index testing via multiple breath washout, forced oscillation testing/impulse oscillometry, and quantitative chest computed tomography (CT) assessment appear promising as noninvasive modalities to aid in lung disease detection in this population. We also summarize guidance on conducting an occupational and deployment exposure history as well as recommendations for testing. Finally, we discuss the Sergeant First Class Heath Robinson Honoring our Promise to Address Comprehensive Toxics Act of 2022 (PACT Act) that includes a list of health conditions that are “presumptively” considered to be related to SWA military deployment toxic exposures, and provide resources for clinicians who evaluate and treat patients with DRRD.

PURPOSE We noted incidental findings on chest computed tomography (CT) imaging of expiratory central airway collapse (ECAC) in dyspneic patients after military deployment to southwest Asia (mainly Iraq and Afghanistan). We developed a standardized chest CT protocol with dynamic expiration to enhance diagnostic reliability and investigated demographic, clinical, and deployment characteristics possibly associated with ECAC. MATERIALS AND METHODS We calculated ECAC in 62 consecutive post-9/11 deployers with dyspnea who underwent multi-detector chest CT acquisition. ECAC was defined as ≥70% reduction in the cross-sectional tracheal area at dynamic expiration. We compared demographics (age, smoking, body mass index), comorbid conditions (gastroesophageal reflux, obstructive sleep apnea [OSA]), and clinical findings (air trapping, forced expiratory volume in 1 second percent predicted) in deployers with and without ECAC. We examined associations between ECAC and forced expiratory volume in 1 second percent predicted, air trapping, OSA, deployment duration, and blast exposure. RESULTS Among 62 consecutive deployers with persistent dyspnea, 37% had ECAC. Three had severe (>85%) collapse. Those with ECAC were older (mean age 46 vs. 40 y, P=0.02), but no other demographic or clinical characteristics were statistically different among the groups. Although not statistically significant, ECAC odds were 1.5 times higher (95% confidence interval: 0.9, 2.5) for each additional year of southwest Asia deployment. Deployers with ECAC had 1.6 times greater odds (95% confidence interval: 0.5, 4.8) of OSA. CONCLUSIONS Findings suggest that ECAC is common in symptomatic southwest Asia deployers. Chest high-resolution CT with dynamic expiration may provide an insight into the causes of dyspnea in this population, although risk factors for ECAC remain to be determined. A standardized semiquantitative approach to CT-based assessment of ECAC should improve reliable diagnosis in dyspneic patients.

Case Presentation A 28-year-old man presented with shortness of breath, chest pain, and scant hemoptysis. Three weeks previously, he was admitted for coronavirus disease 2019 pneumonia that had been diagnosed by nasal swab polymerase chain reaction. Chest CT imaging demonstrated bilateral ground-glass opacities without evidence of VTE. He was treated with hydroxychloroquine, up to 7 L/min oxygen, and self-proning. After 8 days of hospitalization, he was discharged on 4 L/min oxygen. After discharge, his symptoms and hypoxia resolved.

Electronic Nicotine Delivery Systems (ENDS), commonly referred to as “e-cigs,” were first introduced in the United States in 2007. Since then, their use has grown substantially, with the largest market among adolescents and young adults. ENDS are often perceived by the public as safe alternatives to traditional cigarettes and as aids in smoking cessation. Little is known about inhalational hazards of e-cigs. We describe the case of a 45-year-old man who developed acute respiratory symptoms associated with onset of severe fixed airways obstruction 9 months after he quit traditional cigarettes and began high-dose vaping. Lung biopsy showed respiratory bronchiolitis. Analysis of his heated e-cigarette solution identified a mixture containing vanillin, aldehydes, alcohols and other chemicals, the inhalation effects of which have not been well-studied. This case report adds to the growing literature describing potentially severe lung health effects of vaping and provides a framework for taking a clinical vaping history so that the health consequences of e-cigarettes may be better understood.

This article includes pulmonary function data collected via multiple breath nitrogen washout for 103 healthy U.S. adults recruited at National Jewish Health in Denver, Colorado. Testing was performed by certified technicians and reviewed by expert pulmonologists for quality and consistency. Data were collected from a diverse population that included 52 males and 51 females with an average age of 39 years (range 20-77 years). Participants were of non-Hispanic White (85%), African-American/Black (6%), Hispanic (4%), more than one race (4%) or American Indian/Alaskan Native (1%) race/ethnicity. The majority were never smokers (85%), but 12% were former smokers and 3% were current smokers. Height, weight, and body mass index (BMI) were collected in addition to multiple breath washout (MBW) test parameters such as the lung clearance index (LCI) score.

This overview provides an update on silicosis epidemiology with review of exposures and emerging trends in acute and accelerated silicosis in the twenty-first century. The silicosis epidemics in mining, denim sandblasting, and engineering stone industries are highlighted. Clinical presentations of silicosis and silica-related conditions such as autoimmune, kidney, and mycobacterial disease, as well as lung cancer, are discussed. Important aspects of the new OSHA 2017 Silica Standard are presented. This review also includes practical guidance for clinicians to address questions that may arise when evaluating silica-exposed patients and to the public health responses needed following a diagnosis of silica-related disease.

OBJECTIVE The aim of this study was to determine utility and sensitivity of lung clearance index (LCI) testing as a marker of lung injury in symptomatic military deployers compared with healthy controls. METHODS We tested 24 healthy controls and 28 deployers with respiratory symptoms (17 of 28 with definite and 11 of 28 with probable deployment-related lung disease). We compared mean LCI scores between deployers and controls using t tests; adjusted tests were derived from multiple regression models. RESULTS Mean LCI scores were significantly higher (P = 0.001) in deployers [7.76, 95% confidence interval (95% CI) 7.34 to 8.17] than controls (6.95, 95% CI 6.73 to 7.17). Adjusting for body mass index (BMI), smoking, and age, there were no significant differences (P = 0.10) between mean LCI scores in deployers (7.42, 95% CI 7.13 to 7.71) and controls (7.06, 95% CI 6.74 to 7.39). CONCLUSIONS The trend toward higher LCI scores in symptomatic deployers may be linked to underlying lung disease and/or BMI but requires further investigation in a larger population.

Objective Persistent respiratory symptoms following post-9/11 military deployment to Iraq and Afghanistan are well-recognized, but the spectrum of respiratory diseases remains poorly characterized. This study describes deployment-related respiratory diseases and the diagnostic utility of resting and exercise pulmonary function testing. Methods Between 2009 and 2017, 127 consecutive military workers ("deployers") with new-onset respiratory symptoms underwent clinical evaluation. Deployment-related respiratory diseases were classified as proximal and/or distal. Using descriptive statistics and logistic regression, we analyzed lung function parameters associated with deployment-related distal lung disease (DDLD). Results Common deployment-related respiratory diseases included asthma (31.5%), intermittent laryngeal obstruction (14.2%), rhinosinusitis (15%), and DDLD (68.5%). Decreased diffusion capacity (odds ratio [OR] = 4.6, 95% confidence interval [CI]: 1.4 to 15.1, P = 0.01) was significantly associated with DDLD. Conclusions A comprehensive diagnostic approach may identify a spectrum of proximal and distal respiratory diseases that can occur in symptomatic post-9/11 deployers, requiring a personalized approach to care.

OBJECTIVE The aim of this study was to examine military occupational specialty (MOS) codes to identify those at risk from inhalation exposures during Southwest Asia deployment. METHODS Exposure intensity to diesel exhaust, sandstorms, burn pit smoke, combat dust, and occupational vapors/dusts/gases/fumes (VDGF) were scored for all Army/Marine MOS codes by an expert panel. Based on MOS code, panel-rated exposure scores were compared with questionnaire data from military personnel with postdeployment respiratory illnesses. RESULTS All exposures except VDGF were rated higher (range P

Coal mine workers are at risk for a range of chronic respiratory diseases including coal workers' pneumoconiosis, diffuse dust-related fibrosis, and chronic obstructive pulmonary disease. The purpose of this review is to describe coal mining processes and associated exposures to inform the diagnostic evaluation of miners with respiratory symptoms.Although rates of coal workers' pneumoconiosis declined after regulations were enacted in the 1970s, more recent data shows a reversal in this downward trend. Rapidly progressive pneumoconiosis with progressive massive fibrosis (complicated coal workers' pneumoconiosis) is being observed with increased frequency in United States coal miners, with histologic findings of silicosis and mixed-dust pneumoconiosis. There is increasing evidence of decline in lung function in individuals with pneumoconiosis. Multiple recent cohort studies suggest increased risk of lung cancer in coal miners.A detailed understanding of coal mining methods and processes allows clinicians to better evaluate and confirm chronic lung diseases caused by inhalational hazards in the mine atmosphere.

Rationale Military deployments to austere environments since November 9, 2001 may put “deployers” at risk for respiratory disease. Sensitive, noninvasive tools for detecting large and small airways injury are needed to identify early disease and help inform management for this at-risk population. Objectives We examined multiple breath washout (MBW) as a tool for identifying deployment-related airways disease and assessed host and exposure risk factors compared to healthy controls. Methods Between March 2015 and March 2020, 103 healthy controls and 71 symptomatic deployers with asthma and/or distal lung disease completed a questionnaire, spirometry and MBW testing. SAS v. 9.4 was used to compare MBW parameters between deployers and controls via univariate analyses and adjusted for demographic factors using multiple linear regression. Measurements and main results Deployers were significantly more likely than controls to have an abnormal lung clearance index (LCI) score indicating global ventilation inhomogeneity. Adjusting for sex, smoking status, smoking pack-years and body mass index, LCI scores were significantly more abnormal among those with deployment-related asthma and distal lung disease compared to controls. The unadjusted variable Sacin (a marker of ventilation inhomogeneity in the acinar airways) was higher and thus more abnormal in those with both proximal and distal airways disease. Deployers who reported more frequent exposure to explosive blasts had significantly higher LCI scores. Conclusions This study demonstrates the utility of MBW in evaluating exposure-related airways disease in symptomatic military personnel following deployment to austere environments, and is the first to link exposure to explosive blasts to measurable small airways injury.

PURPOSE OF REVIEW Military personnel and civilian contractors who have deployed to Iraq, Afghanistan, and other south-west Asia locations since 2001 may be at risk for a spectrum of disorders collectively known as deployment-related respiratory diseases. Diagnosis is often challenging as typical symptoms of cough, dyspnea, and decreased exercise tolerance may be accompanied by subtle abnormalities on noninvasive diagnostic testing despite significant histopathologic abnormalities identified on lung biopsy. This review describes the emerging spectrum of deployment-related respiratory diseases, addresses diagnostic challenges, and updates recommendations for evaluation and management. RECENT FINDINGS Investigators from Vanderbilt University, Nashville, TN, found constrictive bronchiolitis on 38 surgical lung biopsies in a case series of army deployers with unexplained chest symptoms. More recently, in a group of 50 consecutive deployed patients evaluated at San Antonio Military Medical Center, 36% were found to have airway hyperreactivity, whereas 42% were undiagnosed. SUMMARY We propose a diagnostic and management algorithm for evaluation of the patient with postdeployment respiratory symptoms who are at risk of deployment-related lung disease.

Rationale: An unknown number of post–9/11 military deployers to Iraq and Afghanistan have returned with respiratory symptoms and may be at risk for deployment-related distal lung disease, detected ...

Deployment in southwest Asia is associated with a wide range of respiratory disorders related to tobacco use and to workplace and environmental exposures. Physicians should carefully consider deployment history when assessing and treating veterans with lung disorders.