Military Service is a Vulnerable Occupation: Lung Disease as a - - PDF document

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Military Service is a Vulnerable Occupation: Lung Disease as a Paradigm Michael J. Falvo, PhD Research Physiologist, VA War Related Illness & Injury Study Center Airborne Hazards and Burn Pits Center of Excellence Assistant Professor,

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Military Service is a Vulnerable Occupation: Lung Disease as a Paradigm

Michael J. Falvo, PhD

Research Physiologist, VA War Related Illness & Injury Study Center – Airborne Hazards and Burn Pits Center of Excellence Assistant Professor, Rutgers New Jersey Medical School

Disclosure

  • I have nothing to disclose
  • Contents of this presentation do not represent

the views of the U.S. Department of Veterans Affairs or the United States Government

Deployment‐Related Exposures

Agent Orange Nerve Agent Solvents Anti‐ Malarial Dust & Sand Fuels Pesticides Radiation Depleted Uranium Vaccines Oil Well Fires Burn Pits

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Mean PM2.5 Concentration (06‐07)

Redrawn from: Engelbrecht et al. 2008

15μg/m3 35μg/m3

Non‐Inhalational Exposure

Figure from Cernak and Noble‐Haeusslein 2010, J Cereb Blood Flow Metab

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Uniquely Vulnerable, Susceptible?

Falvo et al., 2015, Epidemiologic Rev

Epidemiologic Findings

  • 15 epidemiologic studies (2005 – present)
  • Relationship to deployment?

– Respiratory Symptoms: 9 studies, favorable – Asthma: 10 studies, mixed results – COPD: 7 studies, largely null – Other Outcomes: 6 studies, inconclusive

  • Limitations

↑ Chronic Lung Disease

5000 10000 15000 20000 25000 0.00% 0.50% 1.00% 1.50% 2.00% 2.50% 3.00% 3.50% 2003 2004 2005 2006 2007 2008 2009 2010 2011

  • No. of Veterans

Prevalence (%)

Redrawn from: Pugh et al. 2016 Mil Med

Asthma Asthma COPD COPD ILD ILD

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Clinical Findings

  • 18 clinical studies (2004 – present)

– 4 Case reports/series – 5 Retrospective chart reviews – 2 Pre‐deployment evaluations – 6 Post‐deployment evaluations – 1 Pre‐ and post‐deployment evaluation

  • Main findings

– Dyspnea….still complicated

Morris et al. (n=50), 84% Butzko et al. (n=178), 72% Krefft et al. (n=28), 82% Falvo et al. (n=143), 75% Holley et al. (n=267), 64%

50% 55% 60% 65% 70% 75% 80% 85% 90% 95% 100%

% Preserved Spirometry

National VA Post‐Deployment Health Resource (Public Law 105‐368)

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WRIISC  AHBPCE

2007

  • Increased reports of airborne hazards exposure

and concerns (Helmer et al. 2007) 2010

  • Working Group at National Jewish publishes

recommendations (Rose et al. 2010) 2011 • Full PFTs on all referrals 2013

  • Expanded cardiopulmonary evaluations for

Veterans with primary respiratory complaints 2018

  • Airborne Hazards and Burn Pits Center of

Excellence

NJ WRIISC Referral Cohort

40.00 50.00 60.00 70.00 80.00 90.00 100.00 110.00

FEV1/FVC

n = 485

Post‐9/11 Pre‐9/11

74.9 16.5 6.8 0.8 Normal Obstructed Restricted Mixed

N = 485

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Preserved Spirometry

Age

46.0 (37.0, 50.0) yrs

Sex

86.3% male

Post‐Deploy Length

12.8 (7.3, 23.4) yrs

Tobacco Pack Years

0.0 (0.0, 10.0)

n = 364

20 40 60 80 100 120 Burn Pits Air Pollution Sand/Dust Petrochem Blast

Deployment‐Related Exposures

Exposed Concerned 10 20 30 40 50 60

2+ Symp Short of Breath Wheeze Cough

Lower Respiratory Symptoms (≥ 2d∙wk⁻¹)

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BD Reversibility

‐15.00 ‐10.00 ‐5.00 0.00 5.00 10.00 15.00 20.00 25.00

FEV1 BD %change

n = 357 +12%

30 50 70 90 110 130 150

DLCO (%predicted)

Isolated ↓ DLCO

HgB corrected; Miller et al. 1983 predicted

n = 349

*

Falvo et al. 2018 Clin Resp J

  • N = 123

– Preserved spirometry – Current smokers excluded

  • Low DLCO

– DLCO ≤ LLN – Miller ’83 – HgB corrected

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Forced Oscillation Technique (FOT)

20 Hz 5 Hz

Figure from: Brashier & Salvi 2015

Resistance (Rrs) Reactance (Xrs)

R5 R20

Figures from: Brashier & Salvi 2015

5 20 5 20 5 100

%

  • 75% (93/124) demonstrate distal airway

dysfunction

Butzko et al. 2019 Respir Physiol Neurobiol

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Butzko et al. 2019 Respir Physiol Neurobiol

‐80.00 ‐60.00 ‐40.00 ‐20.00 0.00 20.00 40.00 60.00 80.00 R4 Δ (% Change)

BD Reversibility for R4

‐100.00 ‐80.00 ‐60.00 ‐40.00 ‐20.00 0.00 20.00 40.00 AX4 Δ (% Change)

BD Reversibility for AX4

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10 20 30 40 50 Not troubled When hurrying 15 min 100 yards Severe

MMRC Dyspnea

0.00% 0.00% 0.00% 2.00% 8.10% 27.30% 20.20% 15.20% 13.10% 8.10% 5.10% 1.00% Nothing at all Very Slight Moderate Severe Very Severe Maximal

Borg Breathlessness at Peak

n = 99

CPET Patterns for Exertional Dyspnea

< 0.80 ≥ 0.80 Rest < 36 < 3 ↑ ex Rest 36‐42 3‐8 ↑ ex < 50% 50 ‐ 75%

VE/VCO2 Slope Peak VO2 (%) etCO2 (mmHg) VE/MVV

75 ‐ 99% ≥ 100% 30.0 ‐ 35.9 < 30 36.0 ‐ 44.9 ≥ 45.0

Post‐Exercise Spirometry

No Δ FEV1 or PEF post‐CPET ≥ 15% reduction in FEV1 or PEF post‐CPET

Hemodynamics ECG Pulse Oximetry

↑ SBP (10 mmHg/3.5 mL O2·kg·min VO2)

No sustained arrhythmias, ectopic foci, and/or ST segment changes during CPET or recovery

No Δ in SpO2 from baseline ↔ or ↓ SBP during CPET, or excessive ↑ SBP (≥ 20 mmHg/3.5 mL O2·kg·min VO2)

Altered rhythm, foci, and/or ST ‐ but did not lead to test termination

>5% ↓in SpO2 from baseline

Altered rhythm, foci, and/or ST ‐ led to test termination Adapted from: EACPR/AHA Statemen; Guazzi et al. 2012 Circ

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CPET Pattern Results

Hemodynamics ECG Pulse Oximetry

↑ SBP (10 mmHg/3.5 mL O2·kg·min VO2)

No sustained arrhythmias, ectopic foci, and/or ST segment changes during CPET or recovery

No Δ in SpO2 from baseline ↔ or ↓ SBP during CPET, or excessive ↑ SBP (≥ 20 mmHg/3.5 mL O2·kg·min VO2) (1‐2%)

Altered rhythm, foci, and/or ST ‐ but did not lead to test termination

>5% ↓in SpO2 from baseline (9.1%)

Altered rhythm, foci, and/or ST ‐ led to test termination (1‐2%)

VE/VCO2 Slope Peak VO2 (%) etCO2 (mmHg) VE/MVV

< 30

50.5%

≥ 100%

18.2%

Rest 36‐42 3‐8 ↑ ex

58.1%

< 0.80

53.2%

30.0 ‐ 35.9

35.3%

75 ‐ 99%

50.5%

36.0 ‐ 44.9

12.1%

50 ‐ 75%

27.2%

Rest < 36 < 3 ↑ ex

41.9%

≥ 0.80

46.8%

≥ 45.0

2.0%

< 50%

4.0%

Post‐Exercise Spirometry

No Δ FEV1, PEF post‐CPET (84.9%) ≥ 15% ↓ in FEV1, PEF post‐CPET (15.1%) 83.8 (71.0, 95.5) 29.7 (27.4, 32.8) 32.2 (30.2, 34.4) 0.77 (0.63, 0.96)

Conclusions

  • Beyond spirometry
  • DLCO, FOT, CPET…

Acknowledgements

  • Drew Helmer, MD
  • Anays Sotolongo, MD
  • WRIISC/AHBPCE Clinical, Research, Edu Teams
  • VA Post‐Deployment Health Service
  • Funding

– VA (1I01CX001329, 1I01CX001515) – DoD (W81XWH‐16‐1‐0663, W81XWH‐17‐1‐0575)

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Questions

  • Q1. Which of the following deployment‐

related exposures are NOT relevant for the Veteran with dyspnea on exertion?

a) Smoke from open burn pits b)Blast overpressure waves from IEDs c) Aircraft/military truck engine exhaust d)Multiple anthrax vaccinations

  • Q2. Which of the following conditions is

NOT increasing in prevalence among post‐ 9/11 Veterans receiving care at VA Medical Centers?

a) Constrictive bronchiolitis b)Asthma c) COPD d)Interstitial lung disease

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  • Q3. Which pulmonary function assessment

is most sensitive for assessing the small airways?

a) Fractional exhaled nitric oxide b)Forced oscillation technique c) Diffusing capacity of the lung for carbon monoxide d)Exercise flow‐volume loop