Deployment-Related Lung Disease: Burn Pits and More

Podcast Transcript

Raed Dweik, MD:

Hello, and welcome to the Respiratory Inspirations Podcast. I am your host, Raed Dweik, Chairman of the Respiratory Institute at Cleveland Clinic. This podcast of short digestible episodes is intended for patients and their families 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 lung disease, severe critical illness, allergy, sleep and infectious disease. Our goal is to help you stay informed in order to take better care of yourself and your loved ones. I hope you enjoy this episode.

Hello, and welcome everyone to this episode of the Respiratory Exchange podcast. I am your host Dr. Raed Dweik, 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 is a pulmonologist with interest in the environment's effect on the lungs.

Our topic today is deployment-related lung diseases. Let's start 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 still actively deployed can develop a range of lung diseases from things like asthma and vocal cord dysfunction, to 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 deployed.

Raed Dweik, MD:

In the military?

Maeve MacMurdo, MBChB:

In the military.

Raed Dweik, MD:

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

Neha Solanki, MD:

Sure. A lot of our troops who were stationed in Iraq and Afghanistan in the Gulf War were exposed to burn pits. So, the natural question is what is burn pit? And 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. This can include chemical waste, weapons, munitions, 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 the military camps, and that's going to be part of the problem, right?

Neha Solanki, MD:

Yes. In fact, these burn pits are created whenever they have more than 100 troops in one area and they are there for over 90 days. That is 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:

Technically, 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 while the U.S. armed forces may not be using burn pits, contractors still can. So, exposure is a whole lot less with modern deployment, but it is 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:

Yes. 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 and volatile organic compounds, which are potentially toxic gases. And things about which we just do not know. Again, there is no control of what's being burned. It is very hard to know what's actually being exposed.

Deployers were often directly responsible for 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 it was hard to know whether burned pits caused lung disease, there is increasingly a concern that among deployers and veterans who have returned from deployment, we are seeing a rise again in the rates of unusual cancers, unusual lung diseases, and unusual exposure-related diseases we do not typically see. So, the concern became, could these burn pits be responsible?

Raed Dweik, MD:

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

Neha Solanki, MD:

I think this is what makes burn pits so controversial, especially with the VA for so long. We do not know exactly what goes in there. They keep no record of what they are throwing away. Then, the people who are exposed to it haven't been followed 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. We do not 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.

The thing we're most concerned about, or that I'm concerned about, is the particulate matter, which Maeve brought up. And those are basically 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 you breathe in these particles and they go down into the airways, into the lungs, and they start inflaming the lungs through this cytokine response that causes inflammation and can result in respiratory diseases. That is 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:

Yes.

Maeve MacMurdo, MBChB:

Again, day to day, week to week, what deployers are burning changes, which makes it really hard to study. But we know from big populations 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 has 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, which get a lot of attention, but there are a whole lot of other exposures that are also really hard to measure. Again, thinking about where people were most recently deployed, there are 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, 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 is not just the burn pits. It is the whole range of deployment-related exposures.

Raed Dweik, MD:

Yeah, I think in my mind what makes the burn pits a bit different is that they are not a natural phenomenon. We made them. A sandstorm? Okay, that is the natural thing, like wildfires are a natural thing. But these things are manmade.

Neha Solanki, MD:

Something that we are doing. Yes.

Raed Dweik, MD:

And we should know what we put in them, but we don't.

Neha Solanki, MD:

Well, it reminds me of Agent Orange a little bit too. We did that and our veterans are affected by Agent Orange, even to 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 track burn pit exposure.

Raed Dweik, MD:

We'll come back to that later. I 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?

Maeve MacMurdo, MBChB:

The challenge is linking a specific exposure to these diseases. But among deployers who have returned, who have been exposed to burn pits, we're seeing much higher rates of asthma, of allergic rhinitis, or sinusitis, and nasal congestion. And then there've been a number of case reports and studies looking at more real lung diseases. One that came up frequently is called constrictive bronchiolitis, or bronchial obliterans, which is basically a chronic, progressive, destructive interstitial lung disease where the lungs themselves are actually obliterated. They are destroyed.

There have been other things too. We're seeing something called eosinophilic pneumonia, which we see with exposure to high levels of dust, and again, things like smoking use. So, there's really been a wide range of issues, but the challenge is linking that disease to that exposure, because deployers are deployed for, potentially, a four-year term. They are people who are fit and healthy, so they are not going to complain until 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 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 is 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. It is 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. And there is legislation in Congress. Maeve can you talk to us about the media attention and what Congress is doing about it. I think recently, they passed an act related to this.

Maeve MacMurdo, MBChB:

Yes. It is a huge step forward. Recently, Congress passed the PACT Act, which basically expands what the VA considers to be presumptive. So, let’s explain that more because it's a little bit complicated. Like we talked about, it is really hard to link deployment to one exposure. And this act recognizes that and says, 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 expanded what those conditions are. Historically, pre the PACT Act, there were only three that were recognized, which were asthma, chronic sinusitis and allergic rhinitis. Now, it's a wide range of things, including some rare cancers, lung cancer, scarring in the lungs, pulmonary fibrosis, interstitial lung disease, constrictor bronchiolitis, and COPD. It is a huge list.

The VA website is a 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 suffering until then without being able to get reimbursement or coverage for their health care. Taking this step really changes things.

Raed Dweik, MD:

So, instead of starting with this is not exposure-related disease until you prove it, now we assume it is exposure-related unless we prove otherwise. So, it has 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, if it is nextexposure-related, you can prove that.

Raed Dweik, MD:

Yes.

Maeve MacMurdo, MBChB:

But if you're a veteran who's got this new health problem, who's served your country, the assumption is that if you were exposed. What you have is likely related.

Neha Solanki, MD:

Yes.

Maeve MacMurdo, MBChB:

Again, not everything. There are still things which are not covered. But a really broad range of conditions now are covered. And that makes a really big difference. 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 caused take a long time to develop. And to do these studies and to show that relationship takes so long. So, this is important. Again, it's going to help, hopefully, decades of veterans so they don't have to go through what the Agent Orange vets did. I think it's related and finally being proved right, but decades too late.

Neha Solanki, MD:

Yes, this is a huge and wonderful thing for veterans that this act was even passed. The PACT Act stands for Promise to Address Comprehensive Toxics Act of 2022. And Congress just passed it. And this is wonderful, because you are right, before, veterans would come in short of breath and they could pinpoint it to being from the time that they were in Iraq because they had no issues breathing before. But it was not a covered benefit. And now, because of the Act, it is a covered benefit. So, 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 is now? Is it high? Low? What do you think? Are veterans fully aware, or do they need us to spread the news?

Maeve MacMurdo, MBChB:

I think spread the news. I think veterans who have health problems are increasingly aware. The day the act got passed, I called several of my patients who had what I thought was deployment rare lung disease, and said Hey, guess what? I need you to file right away. But they were already on it. Again, these guys are proactive, but for the general public? I think burn pits really weren't talked about. And exposure and deployment really were not talked about. It seems very separate from what goes on back in the United States. And I think for physicians, it can be hard to recognize that this thing that happened five or 10 years ago is still causing health problems.

Raed Dweik, MD:

Yes. So that's the other point I'd like to ask you, Neha. Probably the deployed military personnel would know they have the symptoms and they are looking around for an explanation. But what about physicians? You mentioned earlier that if you don't have that as top of mind, we doctors do a lung test and an X-ray and they are normal. You know, you tell them, the patient, it's in your head.

Maeve MacMurdo, MBChB:

Yes.

Raed Dweik, MD:

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

Neha Solanki, MD:

Yes, that is a great question. 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 time what probably happens is that someone comes in short of breath and they get the basic workup. Everything is normal. They say, this is nothing, you're fine, and they are 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 in the military. And if they served, where they served and 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:

That is very helpful. I think for our providers who are listening, remember to be aware of that. Don't dismiss these symptoms before taking a thorough history and, hopefully, starting the evaluation. Which brings me to the next step. How do we evaluate? And then, how do we treat these patients? So, starting with evaluation. Veterans usually think, if this is covered by the government, do they have to go to the VA? Is that the only place for veterans to go to take care of this? Is the VA the only resource?

Maeve MacMurdo, MBChB:

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

Raed Dweik, MD:

So, I am trying to think about a provider, either a primary care physician or a pulmonologist in the community who 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, the doctor, do? Should they send them to the VA? Should they start some testing?

Neha Solanki, MD:

That is a wonderful question. So general provider in the community, whether they are a pulmonologist or a general internist or family medicine provider, they should do a general workup. Start with a chest X-ray. If they are a pulmonologist, do the lung function testing. But at Cleveland Clinic, we offer testing that I think a lot of places in the area are not able to offer, such as cardiopulmonary exercise testing. And that is very important at 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 after the chest X-ray and the lung function testing, they should refer the veteran to a place that has specialized expertise.

Maeve MacMurdo, MBChB:

I fully agree.

Raed Dweik, MD:

Basically, what you are saying is do not give up. If you do a basic evaluation, whatever you can, whether it is an X-ray or a breathing test, just do it, and see if you find something there that you can treat and deal with. If you don't find anything, don't just dismiss this. Send it to the next level, an expert center that can look into it. Is that fair, Maeve?

Maeve MacMurdo, MBChB:

Exactly. I think again, this can be hard to diagnose, especially some of these conditions, which are not straightforward. 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 tease out what is driving shortness of breath. Basically, people get on a bike and in real time, we measure how your heart functions, how your lungs function, and we look at how your muscles are functioning. We can do all that and piece it together to try and tease out what's driving the shortness of breath. Or, if it's more than one thing, what things are contributing. That is 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. That is a CPET where, as well as doing those measurements, we look at what the heart is doing in real time. And Dr. Adriano Tonelli is one of our specialists that performs this procedure, and it has been really helpful in digging out more complicated causes of dyspnea.

Raed Dweik, MD:

Yes. And what is your advice for the patients or veterans and their families? Because if they are told, ‘you are okay, don't worry about it,’ they should not give up, there are places that can help them and do more evaluation, like us.

Maeve MacMurdo, MBChB:

Absolutely. And Jeff Stein is our coordinator at Cleveland Clinic. He is an ex-deployer. He was in the Marines for a long time. He is fantastic. He helps to get veterans into the system and get the testing they need coordinated. We can arrange it over a couple of days. So, people can come and get the testing they need, see the doctors they need to see, and then go home again.

Raed Dweik, MD:

Yes.

Neha Solanki, MD:

I always tell my patients that you must be your own best advocate when it comes to your health. And I think in this case, that is 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:

This has been very helpful and enlightening to me. I hope it will do the same for our listeners. Are there any other points to make before I give some takeaway points from this? Any thoughts?

Maeve MacMurdo, MBChB:

The one thing I would say is that there is a lot we still do not 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 cohorts that deployers and veterans can voluntarily enter 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 need to dig in and find out more information about exactly what exposures cause problems.

Neha Solanki, MD:

Right.

Maeve MacMurdo, MBChB:

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

Raed Dweik, MD:

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 is, it from my perspective.

Raed Dweik, MD:

Wonderful. 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 are sandstorms, burn pits and other things. The major development in this has been the recent PACT Act passed by Congress, which recognizes these exposures as health hazards and then makes them more likely to be treated. One particular form of exposure that has garnered a lot of attention are burned pits, and these it turns out, have all kinds of things that go into them, and we know very little about what the smoke that comes out of them contains. But we know for sure 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 to evaluate these patients and support them. So, don't give up if you see your primary care doctor or 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 for joining me today. Again, this is your host, Dr. Dweik and my guest today were Dr. Neha Solanki, a pulmonologist with a special interest in environmental effects on the lungs, and Dr. Maeve MacMurdo, whose expertise is in occupational lung diseases. 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.