Burn Pit Exposure

Podcast Transcript

Raed Dweik, MD:

Hello and welcome to the Respiratory Exchange Podcast. I'm your host Raed Dweik, chairman of the Respiratory Institute at Cleveland Clinic. This podcast is intended for health care providers and covers topics related to respiratory health and disease. My colleagues and I will be interviewing experts about timeless and timely topics in the areas of pulmonary, critical care, allergy, sleep, and infectious disease. I hope you enjoy today's episode.

Raed Dweik, MD:

Hello, and welcome everyone to this episode of the Respiratory Exchange Podcast. I'm your host Raed Dweik, MD, chairman of the Respiratory Institute at Cleveland Clinic, and my guests today are Dr. Maeve MacMurdo, who directs our occupational lung disease program, and Dr. Neha Solanki, who's a pulmonologist with an interest in the environment's effect on the lungs.

Our topic today is deployment-related lung diseases. And let's start really with the basics with Dr. MacMurdo. What are deployment-related lung diseases, Maeve?

Maeve MacMurdo, MBChB:

Good question, and the answer is really any lung disease related to deployment. And what we're realizing is that people who are deployed, who are still actively deployed, can develop a range of lung diseases from things like asthma and vocal cord dysfunction, which we'll talk about, to the kind of more rare things like interstitial lung disease. And so, this term really captures the full spectrum of potential risk a deployer might face from having been deploy.

Raed Dweik, MD:

In the military.

Maeve MacMurdo, MBChB:

In the military.

Raed Dweik, MD:

Military deployment. One particular related lung disease or diseases that have been garnering a lot of attention lately, is those related to burn pits. Neha, maybe you can tell us a little bit about burn pits, what they are and how they came about?

Neha Solanki, MD:

Sure. So a lot of our troops who were stationed in Iraq, Afghanistan, Gulf War, were exposed to burn pits. The natural question is what is a burn pit? This has been in the news a lot recently. But it's essentially large sites where all this waste is being dumped, waste that the troops are using. And this can include chemical waste, weapons, ammunitions, metal, aluminum, cans, medical and human waste, plastics, rubber, food, all these things are dumped into one area and then burned, and this is what we call burn pits.

Raed Dweik, MD:

And I suppose they're usually close in proximity to where the military camps are, you know, going to be part of the problem, right?

Neha Solanki, MD:

Yes. In fact, these burn pits, whenever they have more than 100 troops in one area and they're there for over 90 days, that's when they install these burn pits. Not so much anymore, it was more the case years ago. There are still a couple active burn pits, but much less these days.

Maeve MacMurdo, MBChB:

Also, they were banned in 2010. So Congress actually passed legislation banning the use of burn pits for the most part. But there are still some exceptions. And definitely while the US armed forces may not be using burn pits, contractors still can. So exposure is a whole lot less with modern deployment, but it's not zero. There are still some burn pits in active use.

Raed Dweik, MD:

And obviously, they were banned for a reason. So can you tell us why were they banned? Maybe we can start with you, Maeve.

Maeve MacMurdo, MBChB:

Yeah. So I think the challenge is as Dr. Solanki pointed out, burn pits really are burning everything, literally anything that can be burned. Even things that can't be burned are being placed in these burn pits, and often doused with jet fuel. So burning everything, using jet fuel, potentially releases a lot of harmful exposures, harmful particulate matter, volatile organic compounds, which are potentially toxic gases. And things we just don't know about. Again, there's no control over what's being burned. It's very hard to know what's actually being exposed.

Deployers were often directly responsible for actually operating these burn pits. So they actually go in and scrape the burn pit, turn it over to help things burn more quickly. But even deployers who weren't doing that still potentially faced exposure. Because if you think about these big pits burning everything, the fumes, the smoke from there is going to rise and spread. So the entire base potentially is impacted by this exposure. And while at the time that was hard to know whether burn pits caused lung disease, there is increasingly a concern that among deployers and veterans who have returned back from deployment, we are seeing a rise in the rates of, again, unusual cancers, unusual lung diseases, unusual exposure-related diseases we don't typically see. So, the concern became could these burn pits be responsible?

Raed Dweik, MD:

So do we even know what's in the gas that comes out from these pits? Has anybody ever measured it? I don't remember seeing anything.

Neha Solanki, MD:

Yeah. So that's, I think this is what makes burn pits so controversial, especially with the VA, for so long. We don't know exactly what goes in there, they keep no record of what they're throwing away. Then the people who are exposed to it they haven't been following them long term to see what health issues they develop. So it's very difficult to track and prove that somebody's symptoms are caused by the burn pits. So we don't know exactly what fumes are released. I think it's probably similar to what we see in wildfire air pollution in that anything and everything is burned. So I think that we have to think of it in a similar way.

I think the thing we're most concerned about, or that I'm concerned about, is the particulate matter which Maeve brought up. Particulate matter is basically, very, very small particles, usually less than 10 micrometers. And also, there are some that are less than 2.5 micrometers. And this is very, very small, less than the diameter of a strand of hair. Way less than a diameter of a strand of hair. And what happens is these particles, you breathe them in, and they go down into the airways, into the lungs, and they start inflaming the lung through this cytokine response, basically, and that causes inflammation and can result in respiratory diseases. So that's one thing.

And then volatile compounds also act with a similar mechanism. But we don't know exactly which compounds are in these because we don't know exactly what's being burned every time.

Maeve MacMurdo, MBChB:

And every burn is different, right?

Neha Solanki, MD:

Mm-hmm.

Maeve MacMurdo, MBChB:

I mean, again, day to day, week to week, what deployers are burning changes, which makes it really hard to study potentially. But we know from big populations is that particulate matter, particularly PM 2.5, that really small particulate matter is bad for human health.

Neha Solanki, MD:

Very bad.

Maeve MacMurdo, MBChB:

It's been linked to mortality. It's been linked to lung disease and it's been linked to heart disease. So having these high-level exposures potentially can cause a lot of harm. I think the other thing that we talk about a lot is that deployers aren't just exposed to burn pits. Again, burn pits get a lot of attention.

But there are a whole lot of other exposures, also really hard to measure. Again, thinking about where people were most recently deployed, there's a whole lot of sandstorms, which means potentially respirable crystalline silica, so silica dust from the sandstorms and just air pollution in general. They've actually looked at the bases where deployers were based or operated, and they found that for the most part, the amount of PM 2.5, that small particulate matter, the really, really tiny stuff, was much higher than the air quality standards, even outside of burn pits. So it's not just the burn pits. It's the whole range of deployment-related exposures.

Raed Dweik, MD:

I think in my mind what makes the burn pits a bit different is that they are not a natural phenomenon. We made them. Like a sandstorm? Okay, that's the natural thing. Even wildfires are a natural thing. But these things are really manmade that we made.

Neha Solanki, MD:

Something that we're doing. Mm-hmm.

Raed Dweik, MD:

And we should know what we put in them or should come out, but we don't, you know?

Neha Solanki, MD:

Well, it's like it reminds me of Agent Orange a little bit too. We did that and our veterans are affected by Agent Orange even until this day. We're doing the burn pits and our veterans are affected by the burn pits. So it's definitely something we should be mindful of and take care of our veterans.

Maeve MacMurdo, MBChB:

I think the VA is trying to. I'm not sure if we're going to talk about that. But they are starting to monitor and kind of track burn pit exposure.

Raed Dweik, MD:

Yeah. We can back to that later on. I just want to try to understand, like you mentioned, the general health effects from, or the impacts of, burn pits. Are there other specific diseases that had been linked to these burn pits that you know of? Any specific diseases?

Maeve MacMurdo, MBChB:

Like we were talking about, the challenges of linking a specific exposure to these diseases, but among deployers who have returned who have been exposed to burn pits, we're seeing much, much higher rates of asthma, of allergic rhinitis, or sinusitis and nasal congestion. And then there's been a number of case reports and studies looking at more real lung diseases.

One that came up frequently, it's called constrictive bronchiolitis or bronchial obliterans, which is basically a chronic, progressive, destructive interstitial lung disease where the lungs themselves are actually obliterated, they're destroyed.

There's been other things, too. So we're seeing something called eosinophilic pneumonia, which we can see with exposure to high levels of dust, and again, things like smoking use. So there's really been a whole wide range, but the challenge is linking that disease to that exposure, because deployers are deployed for a potentially a four-year term.

They're people who are fit and they're healthy so they're not going to complain till things get really, really bad.

Neha Solanki, MD:

Right.

Maeve MacMurdo, MBChB:

So timing it and teasing it out. It's really tough sometimes.

Neha Solanki, MD:

And I was going to say, the obliterative bronchiolitis is very tricky for clinicians as well because a veteran will come in and he or she is short of breath. You order lung function testing, which is a test we use to see how people breathe out. And oftentimes that test can appear normal.

In early stages of obliterative bronchiolitis, it's actually when someone gets a biopsy that we see that their lungs are very affected by the burn pit exposure. So you have to have a very high index of suspicion. And it's good to have a clinician that is aware of burn pit exposures.

Raed Dweik, MD:

I know this issue has been in the media a lot recently, as well as there is legislation in Congress, maybe can you each talk about one of these? Maybe Maeve can talk to us about the media attention lately and maybe what Congress is doing about it. I think recently, they passed an act related to this?

Dr. Maeve MacMurdo, MBChB:

Yes, and it's been a huge step forward. So recently, Congress passed that PACT Act, which basically expands what the VA consider to be presumptive. So to kind of explain that more, because it's a little bit complicated. Like we talked about, it's really, really hard to link deployment to one exposure. And this act kind of recognizes that and says, you know what, we know that if you were deployed in these regions, you were potentially exposed to burn pits. We can't know for sure, but likely you were. If you develop diseases which are related to burn pit exposure or might be, we will recognize those being related to your service and will provide care for those conditions. And the PACT Act really expanded what those conditions are. Historically, pre- the PACT Act, there were really only three that were recognized, which was asthma, chronic sinusitis and allergic rhinitis. Now, it's really a really important wide range of things, including some rare cancers, lung cancer.

Scarring in the lungs, pulmonary fibrosis, interstitial lung disease, constrictor bronchiolitis, COPD, it's a huge list. The VA website is actually a really good resource. But it's really important because the challenge of a lot of these diseases is they're really, really rare. And so to take the time to prove that these diseases were caused by burn pit exposure would have taken decades, meaning that veterans would have been basically suffering until then without being able to get reimbursement or coverage for their health care. Taking this step really, really changes things.

Raed Dweik, MD:

So now what do you have this, how changed the landscape is now instead of starting with this is not exposure related until you prove it, now we assume its exposure related unless we prove otherwise. So it's kind of flipped the narrative here. Is that fair to say?

Maeve MacMurdo, MBChB:

Exactly, it takes the burden off the veterans and puts it on us, the providers and the doctors and says, you know, if it's not exposure related, you can prove that.

Raed Dweik, MD:

Yeah.

Maeve MacMurdo, MBChB:

But if you're a veteran who's got this new health problem, who's served your country, you know, having to fight to get medical care. The assumption is that if you were exposed, what you've got is likely related.

Again, not everything. There are still things which aren't covered. But a really broad range of conditions now are covered. And that makes a really big difference. Because like Dr. Solanki was talking about Agent Orange. For a long time we fought and were worried that it caused health problems, but there was really no way of proving it, because the health problems it causes take a long time to develop. And to get these studies and to show that relationship takes so long. So this is really important. Again, it's going to help, hopefully, decades of veterans not having to go through what the Agent Orange vets did. Just was just saying, you know, I think it's related. I think it's related and finally being proved right. But decades too late.

Neha Solanki, MD:

Yes, this is a huge, huge, wonderful thing for veterans that this act was even passed. The PACT Act stands for a promise to address comprehensive toxics act of 2022. And Congress just passed it. And this is, this is just wonderful, because you're right. Before veterans, they would come in short of breath, and they can pinpoint it to it being from the time that they were in Iraq because they had no issues breathing before, but it wasn't a covered benefit. And now because of the Act it is a covered benefit. So that, this is a great thing.

Raed Dweik, MD:

You know, as I mentioned earlier, there is a lot of media attention about this. What do you think the level of awareness about this now is? Is it high? Low? You know, what do you think? Are people aware of this? Are veterans fully aware or do they need to be spread the news or what are your thoughts on that?

Maeve MacMurdo, MBChB:

I think spread the news. I think veterans who have health problems are increasingly aware. I know the day the Act got passed, I called several my patients who had what I thought was deployment rare lung disease and went, hey, guess what? I need you to file right away.

Raed Dweik, MD:

Yeah.

Maeve MacMurdo, MBChB:

And so but they were already on it again, I think these guys are proactive, but for the general public? I think burn pits really weren't talked about. And exposure and deployment really wasn't talked about. It seems very separate from kind of what goes on back in the United States. And I think for physicians, it can be hard to recognize that actually this thing that happened five, 10 years ago is actually still causing health problems.

Raed Dweik, MD:

Yeah. So that's the other point I'd like to ask you, Neha, is probably the deployed you know, military personnel would know they have the symptoms, they are looking around for an explanation. But what about physicians? You mentioned earlier that if you really don't have that, as top of mind high on your list, we do a lung test, you do an x-ray, and they're normal. You know, you tell them kind of it's in your head kind of thing.

So what is your advice to the providers, to people who see these in military deployed personnel with lung symptoms?

Neha Solanki, MD:

Yeah, that is a great, great question. And it goes back to the fundamentals of our medical education, and that is taking a very good history when talking to the patient. I think most of the times, what probably happens is someone comes in short of breath, you know, they get the basic workup, everything is normal. They say, oh, this is nothing, you're fine. And then it gets sent away. But what should be done is the patient should be asked about all of their history. And I know Dr. MacMurdo is our expert here and can talk about that a little bit more, but one of the things that is important to ask always is whether they served. And if they served, where they served, how long they served there, did they have any kind of exposure to burn pits while they were there? So your index of suspicion as the provider is much higher for considering burn pit exposure in your differential diagnosis.

Raed Dweik, MD:

Yeah, that's very helpful. I think for our providers who are listening to this to kind of be aware of that. Don't dismiss these symptoms, you know, before really taking a thorough history and hopefully start the evaluation, at least. Which brings me to the next step which is how do we evaluate? And then how do we treat these patients? So starting with evaluation. You know, my understanding is that veterans usually think if this is covered by the government, do they have to go to the VA? First of all, is that the only place for the veterans to go to take care of this? Is the VA the only resource?

Maeve MacMurdo, MBChB:

So the VA is a great resource, but it's not the only resource. And we often work with providers at the VA, for sure, for more challenging cases. Again, sometimes it's obvious. Sometimes it's very clear cut, and this is asthma related to deployment. But for things like constrictive bronchiolitis, like sarcoidosis, like pulmonary fibrosis or scarring in the lungs, that can be really challenging, can cause a whole host of things that can cause these problems. And on simple testing, like an x-ray, exposure causes, again, deployers and veterans are often very healthy and breathing tests may be normal, it can be really easy to miss. So we are always happy to be sort of a second opinion, a second resource. And people can sit here at the Cleveland Clinic for this. This is something we provide pretty frequently.

Raed Dweik, MD:

So what evaluation, I'm trying to think about here a provider either a primary care physician or a pulmonologist in the community has a patient present with these symptoms. Should they do their basic evaluation? Should they refer them right away? What is your advice on how to approach these? You know, a veteran comes in short of breath to a primary care doc or a pulmonologist in the community, what should they do? Should they just send them to the VA? Should they start some testing? Should they?

Neha Solanki, MD:

Yeah, that's a wonderful question. So a general provider in the community, if they are, whether they're a pulmonologist, or whether they're a general internist or a family medicine provider, you know, they should do a general workup. Start with a chest x-ray. They're a pulmonologist, the lung function testing. But at Cleveland Clinic, we do offer testing that I think a lot of places in the area don't or are not able to offer, such as cardiopulmonary exercise testing. And that's very important in getting to the bottom of the dyspnea or the shortness of breath that the patient has. So I think the basic workup should be done by the community provider. And, if the provider still believes that the shortness of breath is unexplained, even after the chest x-ray and the lung function testing, at that point, they should refer the veteran to a place who has specialized expertise.

Maeve MacMurdo, MBChB:

Fully agree

Raed Dweik, MD:

So basically what you are saying is - don't give up. If you do a basic evaluation, and you encourage everyone to do that basic evaluation, whatever you can, if it's an x-ray, if it's a breathing test, just do it and see if you find something there that you can treat and deal with, fine. If you don't find anything, just don't dismiss this, send it to the next level, to an expert center that can look more into it. Is that fair Maeve?

Maeve MacMurdo, MBChB:

Exactly. I think again, this can be really hard to diagnose, especially some of these conditions, which are not straightforward. And so if you've done your testing, and it's normal, but your patient is still suffering, don't write it off. Because there is more testing we can do. And the cardiopulmonary exercise test, or the CPET we call it, is a really helpful test to really tease out what's driving shortness of breath. Basically, people get on a bike and in real time, we measure how your heart functions, how your lungs function, we look at how your muscles are functioning. And we can do that all and piece it together to try and tease out what's driving you feeling short of breath. Or if it's more than one thing, what things are contributing. That's kind of basic.

But the other thing we do here, which is really cool, and I think is not done a lot of places, is something called invasive CPET. So that's a CPET, where we actually, as well as doing those measurements, look at what the heart is doing in real time. Dr. Tonelli is one of our specialists that performs this procedure and it's being really helpful in digging out more complicated causes of dyspnea.

Raed Dweik, MD:

Yeah, and I'm trying to ask what are the same advice maybe for the patients or veterans and their families because, you know, if they are told you are okay, don't worry about it kind of thing is they should not give up. That there are places that can help them and do more evaluation like us, and other of course, places as well.

Maeve MacMurdo, MBChB:

Absolutely. And Jeff Stein is our coordinator. He is an ex-deployer. He was in the Marines for a long time. He's fantastic.

And he helps to get, for me at least, veterans kind of into the system and get the testing they need coordinated. So we can arrange it over a couple of days. So people can come, get the testing they need, see the doctors they need to see and then go home again.

Neha Solanki, MD:

Mm-hmm. I always tell my patients that you have to be your own best advocate when it comes to your own health. And I think in this case, that's very true. I think that if you're unsatisfied with what has been given as an explanation for your shortness of breath, you have to advocate for yourself and find somebody who is able to give you an answer.

Raed Dweik, MD:

Yeah. So this has been really very helpful and enlightening to me. I hope it will do the same to our listeners. Are there any other points any of you would like to make before I close and give some takeaway points from this? Any thoughts?

Maeve MacMurdo, MBChB:

I think the one thing I'd say is that, you know again, this is still a little bit, not black box, but there's a lot we don't know. And there is some really great research being done to try and figure out more of what's going on. I mentioned earlier, but the VA has formed this registry of cohort that deployers and veterans can voluntarily enter into to track their health outcomes related to their exposure. And those studies are really important because even though the PACT Act has passed, and even though those conditions are recognized as being presumptive, they still really need to dig in more and find out more information about exactly what exposures cause problems.

Because this could happen again. Again, burn pits are banned now, but deployers still remain at risk. There are always gonna be new exposures. And so having the best information possible about what exposure causes disease really helps us try and prevent future outbreaks.

Raed Dweik, MD:

And Neha anything else to add?

Neha Solanki, MD:

The only thing I would like to say is that if you are a veteran that has been affected by burn pits, volunteer that information to your provider if you have not already. And if you are a provider, please ask your patients about potential exposures to things such as burn pits if they were veterans that were deployed to a war. That's pretty much it from my perspective.

Raed Dweik, MD:

Wonderful. So, thank you both. Let me try to summarize to our audience some take home points. The first one is that deployment-related lung disease is really a whole slew of diseases that are also the result of different exposures, whether they're sandstorms, burn pits and other things. The major development in this has been recently the PACT Act passed by Congress, which really recognizes these exposures as health hazards and then makes them more likely to be recognized and treated. One particular form of exposure that has garnered a lot of attention are burn pits and these, it turns out, have all kinds of things that go into them and we know very little about what kind of smoke that comes out of them that contains, but we know definitely that it has particulate matter and it has a significant impact on health, particularly lung health and disease.

There are resources for veterans now to be taken care of, they can connect with the VA, but also many health centers around the country, including ours, are ready and to evaluate these patients and support them, so don't give up if you see your primary care doc or your local physician and you don't get answers. There are places that can give you answers for this.

With that, I'd like to thank you both really for joining me today. Again, this is your host, Dr. Dweik and my guests today were Dr. Neha Solanki, MD, a pulmonologist with a specific interest in the environmental effect on the lung, and Dr. Maeve MacMurdo whose expertise is in occupational l lung diseases. So thank you both for joining me.

Maeve MacMurdo, MBChB:

Thank you.

Neha Solanki, MD:

Thank you for having us.

Raed Dweik, MD:

And thank you everyone, have a great day.

Thank you for listening to this episode of the Respiratory Exchange. For more stories and information from Cleveland Clinic Respiratory Institute, you can follow us on Twitter at CleClinicLungs, or follow me at raeddweikMD. Thank you.