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Clinical Management of Airborne Hazards
What Providers Need to Know
Omowunmi Osinubi, MDAnays Sotolongo, MD
1 in 3report “definite or probable exposure to environmental hazards”
1 in 4report “persistent major health concerns due to deployment exposures”
IOM Report 2011
“…service in Iraq or Afghanistan –– might be
associated with long-term health effects, in highly exposed ..or susceptible
populations...”
Airborne Hazards & Open Burn Pit
RegistryPublic Law 112-260
Monitor and ascertain health effects from
exposures
Monitor the health care of Veterans with concerns
Provide high quality health services
Addressing Veterans’ Health Concernsat the Initial In-person Registry Evaluation
• Veteran may discuss:– Upper/lower respiratory symptoms– Physical activity limitations or decreased
ability to exercise – Other health conditions or concerns related to:
• Gastrointestinal, neurocognitive, neuroendocrine, rheumatologic, musculoskeletal, reproductive health and cancer OR
– Have no current health problems, but concerned about possible future health effects of exposures
Clinical History• “Breathing problems” & “Hoarseness”
• Started in 2005 in Iraq
• Worsening over time
• Limiting work activities
• Diagnostic work-up to date (normal)• Spirometry, Chest x-ray, cardiac stress
test/echo • Chest CT – “small hiatal hernia”
• Trial of inhalers – “Not helpful”
• Psychiatry - “Severe PTSD”
“I was at Balad,…. I was next to the
burn pit…..I breathed in the
smoke, now I can’t breathe!
“VA Burn-pit Registry”
In-Person Evaluation Process • Providers can review the SAQ using a web portal.
– https://staff.mobilehealth.va.gov/AHBurnPitRegistry/ • Take 5-10 minutes to review the completed Registry SAQ
• Summarize deployment history and exposures• Review symptoms and health history
– Current symptoms- severity and duration– Health conditions- timing and certainty of diagnosis– Tobacco, ETOH, other substance use/abuse– Functional limitations– Concerns about cause of symptoms or health conditions
• Physical examination• Review diagnostic work-up to date• Form an assessment• Create a care plan (including appropriate testing) with patient• Engage in health risk communication
Registry Initial NoteChoose the following on check list: Runny nose/post –nasal drip Chronic sinus congestion Sore throat, hoarseness, change in voice Cough for more than 3 weeks Shortness of breath; breathlessness Gastrointestinal problem
Exposure History • Military Exposures
– Military occupation specialty – Deployment-related
exposures
• Non Military Exposures– Civilian occupational
exposures– Civilian non-occupational
exposures
Military Exposure History
Army Corps of Engineers (10 years) Motor pool construction trucks
o Diesel exhaust fumeso Construction dusts
Military Exposure History
Deployment-related exposures (1/04-6/05) Kuwait: “monster sand and dust storms” Iraq: “Balad burn pit- burned 24/7” Sick often – “Iraqi crud”
Civilian Exposures
Works in waste management Grain dusts Temperature extremes (-40 to 100+ degree F) Heavy physical job demand (> 50 Ibs frequently)
Non-vocational exposures/social history Non-significant
Summary of Exposures
Burn pit smoke
Sand & dust storms
Construction dusts Diesel exhaust
Grain dusts Temperature extremes
Heavy physical work
Psychological trauma
Deployment History and ExposuresViewing instructions is optional and not included in final note
Choose the following exposure concerns: Off base air pollution On base air pollution Hobbies and non military jobs Military jobs while not deployed
Contributory ExposuresBurn Pits
Diesel Exhaust
Construction& Grain Dust
Sand & Dust Storms
Temperature Extremes
AirborneExposures
RADS
Irritant-induced Asthma
Vocal Cord Dysfunction
Dia
gnos
tic W
ork-
Up Work up:
• Cardiac Stress Test• Echocardiography
• Spirometry• Imaging Studies
• Inhaler Ineffectiveness
Diseases:
o Cardiovascular dz
oObstructive Lung dzoInterstitial Lung dz
o ? Vocal Cord Dysfunction
Review Vet’s Diagnostic Work-up to Date
CPRS auto-populates with tests done in past 2 years : Spirometry Chest x-ray Stress Echocardiogram
Diagnostic Evaluation
Spirometry (Pre/Post BD)
Body BoxDLCO
CPET w/ ABGs and 12-
lead ECG
FOT(Pre/Post BD)
FeNO
Diagnostic Test Results• PFT & DLCO
– FEV1 85.4%; FVC 96.9% FEV1/FVC 75%.– FEF 25-75% (55%), +20% bronchodilator– RV 134% predicted– DLCO 114% predicted
• CPET– VO2 max: 88% predicted– VE/MVV: 61% at peak– Appropriate ↓dead space– Throat tightness/discomfort at peak exercise
Diagnostic Test Results
• Forced oscillometry (FOT)↓airways resistance & ↓reactance post bronchodilator
• Expired nitric oxide (FeNO) ↑121 ppb (normal <50 ppb)
(-) airway disease
normal FEV1/FVC
Cardiopulmonary exercise
(+) airway disease
(+) Response in small airways
Resistance FOT
FeNO
ENT Evaluation
• Flexible laryngoscopyBilateral vocal cord nodules Vocal cords normal
movementPharynx is hyperemic Posterior pharyngeal wall
cobble stoningEvidence of acid reflux
What about her poor sleep?
• Polysomnographyobstructive sleep
apnea-hypopnea syndrome & frequent upper airway resistance
Aero Digestive Inflammation
GERD
Chronic Cough
Rhinitis
Sleep Apnea
Summary/Takeaways Case #1
IrIA /RADS:
• Exposure assessment• Symptom onset
• Radiographic Imaging
• Reversible airflow obstruction• PFT, FOT, CPET
VCD:
• Stridor vs. wheezing• Awareness of VCD
• Identify potential cause(s)/trigger(s)
• Flexible laryngoscopy
• Functional impairment
Chief Concerns
• Severe shortness of breath since Iraq
• Decreased exercise capacity
• Multiple episodes of acute respiratory distress
Post Deployment History
Progressive SOB & DOE, OrthopneaCurrent smoker 15 pack-year Frequent hospitalizations for respiratory exacerbations
Comorbid conditionsIDDMHTNGERDPTSDSleep apnea
Unable to work due to respiratory impairment
Airborne Hazard Concerns - Clinical Assessment • Physical exam & oxygen sat
• Chest X-ray (PA and lateral)
• Pulmonary function tests
• Allergy consult
• Cardiac evaluation - EKG, Echo,
• Pulmonary consult
Diagnostic Work-up (Contd.)Allergy ConsultImmune deficiency excluded
PFT:Diffusion:
DLCO= 29.5 (101%)
Spirometry: FV loops-curvilinear FEV1/FVC= 0.70 FEV1= 3.85L (77%) No BD response MVV ↓60 l/min
Lung Volumes: TLC= 7.90L (96%) VA= 5.13 L (67%) RV/TLC= 35%
Diagnostic Work-up (Contd.)EKG: Sinus tachycardia Left atria enlargement No change from study 8
months prior
Echocardiogram: Trace mitral regurgitation Mild tricuspid regurgitation LV systolic function normal
– estimated EF = 55% Pulmonary artery systolic
pressure not assessed Technically suboptimal
study
What types of additional work-up would be appropriate for this Veteran?
“It was when I was under the care of a pulmonologist ...
that my condition … received a more thorough workup”
High Resolution Chest CT Imaging ILD Evaluation by HRCT:• Axial Scans:
– Supine & Prone• Full inspiration• 1-1.5 mm collimation
at 1 to 2 cm intervals• Dynamic, during forces
expiration views:– Aortic Arch– Carina– Above diaphragm
Patient’s HRCT Findings:• CT 4/2013 & 7/2013:
– Mild emphysema– Mosaic perfusion– Mild bronchitis– RUL minor ground
glass– No ILD/effusion/LAD
• Findings unchanged(CT 4/2013 vs. 7/2013)
Six-minute Walk Test
BMI: 26.8 (overweight)WHR: 0.96
Baseline SpO2: 94%
6MWD: 350m (51% pred)Peak HR: 134/min
HR @2min post: 108/minPost exertion SpO2: -11% (84%)
Other: Requires 2 LPM oxygen to stay above 90%
What about lung biopsy?
• When is lung biopsy indicated?• What type of biopsy is indicated?
– Bronchoscopy with biopsy– Surgical lung biopsy (VATs)
• What are the limitations of each type?• What are the possible complications?
Hospitalized in 2013
Presented with acute respiratory distressBronchoscopy:
• Early granulomatous reaction • Consistent with silicosis• Larger tissues sample was recommended
Constrictive Bronchiolitis in OEF/OIF
NEJM: CB in soldiers exertional dyspnea38 of 49 (78%) diagnosed with CB
• PFTs, CPET within normal limits• Moderate reduction in DLCO
ATS Research abstract: National Jewish Hospital
US Army Public Health Command (USAPHC): Epidemiologic evidence to date is inadequate to
support or refute an association between deployment and chronic respiratory conditions
Pulmonary Findings in Iraq/Afghanistan Deployers
Centrilobular Nodularity
Mosaic air trapping
Emphysema
Right Upper & Lower Lobe Open Biopsies
Preliminary Pathology report:Mild anthracosilicotic depositsHemosiderin-laden intra-alveolar
macrophagesDx: Smoking-related interstitial lung disease
Addendum to pathology report (SEM/EDXA)Particles contain Si, Al, & O; K & Na
(environmental silicates)Rare particles Ti, Fe & Cr (possibly steel)
Summary/Takeaways Case #2
High Resolution CT• Assess lung parenchyma
for fibrosis
Constrictive Bronchiolitis• Rare disease• Irreversible (steroids may
help)• ? Clinical course in
diagnosed soldiers
Lung Biopsy• Gold standard for
interstitial lung disease• ? Benefit/Risk ratio
B-ILD and DIP• Related to smoking• Rx: STOP SMOKING
Airborne Hazard Concerns Iraq & Afghanistan War Veterans
• Many combat Veterans have airborne hazard exposure concerns.
– Have high index of suspicion for upper & lower respiratory problems & a low bar for further evaluation.
– Identify physical /behavioral health co-morbidities early and treat.
• Case management services to support change in lifestyle interventions.
Questions?
New Jersey War-related Illness and Injury Study Center
http://www.warrelatedillness.va.gov/