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Journal of Occupational & Environmental Medicine:
doi: 10.1097/JOM.0b013e31824fe102

Clarifications From Representatives of the Department of Defense Regarding the Article “Recommendations for Medical Screening and Diagnostic Evaluation for Postdeployment Lung Disease in Returning US Warfighters”

Zacher, Lisa L. MD, Col, USA; Browning, Robert MD, CDR, USN; Bisnett, Teresa MD, Lt Col, USAF; Bennion, James R. MD, MPH, Col, USAF, FS; Postlewaite, R. Craig DVM, MPH; Baird, Coleen P. MD, MPH

Section Editor(s): Teichman, Ron MD, MPH; Guest Editor

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From the Office of the Surgeon General (Dr Zacher), US Army, Brooke Army Medical Center, Ft. Sam Houston, TX; Navy Pulmonary and Critical Care (Dr Browning), US Navy, Walter Reed National Military Medical Center, Washington, DC; Consultant to the Surgeon General for Pulmonary and Sleep Medicine (Dr Bisnett), US Air Force, Washington, DC; Occupational Medicine (Dr Bennion), Air Force Medical Support Agency, Washington, DC; Force Readiness and Health Assurance (Dr Postlewaite), Office of the Assistant Secretary of Defense (Health Affairs), Falls Church, Va; and US Army Public Health Command (Dr Baird), Aberdeen, MD.

Address correspondence to: Coleen P. Baird, MD, MPH, United States Army Public Health Command, 5158 Blackhawk Rd, Aberdeen Proving Ground, MD 21010 mail to:

This work was supported by the US Department of Defense.

Disclosure: The authors declare no conflict of interest.

This issue of the Journal of Occupational and Environmental Medicine includes a white paper titled “Recommendations for Medical Screening and Diagnostic Evaluation for Postdeployment Lung Disease in Returning US Warfighters.” This article is a report of the proceedings of a 1-day meeting held at the National Jewish Health in February 2010 by a group of Department of Defense (DoD), Veterans Affairs, and civilian physicians and environmental scientists. The discussion addressed concerns that US military service members deployed to Iraq and Afghanistan may be at risk for respiratory symptoms and chronic lung disease due to exposures to airborne contaminants (eg, from open-air burn pits, desert dust, industrial fires and emissions, and vehicular exhaust) and explored recommendations to address these concerns. The discussion centered on several environmental studies conducted in the theater of operations and on limited unpublished clinical data available at that time compiled by civilian researchers. Although DoD participants welcomed the opportunity to participate, we provide some additional information and clarification regarding the recommendations and their implications for policy. We believe that the implementation of spirometry on a population basis deserves further study but is not warranted at this time. We do not believe that changes in physical training score are a specific indicator of change in pulmonary function. We concur with the proposed indications for consideration of biopsy and at this time do not advise biopsy for individuals without abnormal test results.

1. The use of screening spirometry in an asymptomatic population is not recommended by any respiratory health society. Recent guidelines by the US Preventive Task Force for chronic obstructive pulmonary disease recommend against routine use of spirometry in asymptomatic smokers1 even though tobacco smoking is the primary cause of chronic lung disease and the most common environmental exposure. In addition, a recent evidence-based medicine review did not recommend spirometry for case-finding in adults with persistent respiratory symptoms or in those who have pulmonary risk factors due to poor specificity.2 Although asthma is reported to affect 10% of the US population, there are no recommendations for routine screening in asymptomatic individuals. Although certain military occupations may face increased risk of adverse respiratory outcomes due to specific tasks performed or exposure scenarios, medical surveillance for occupational lung disease is typically recommended only for specific, at-risk groups based on high-risk exposures to toxic materials. When indicated, it is best performed longitudinally to evaluate individual and group changes in respiratory health over time.3 The routine use of spirometry can be fraught with overdiagnosis, misinterpretation, technically inadequate studies, and, in this case, adverse career implications for military personnel.4,5 Before the initiation of widespread screening or surveillance with spirometry, feasibility studies should be performed to assess the predictive value, prevalence of disease, and health care resource utilization of such a program. There are currently two studies ongoing at Fort Hood, Texas, in a predeployment population and at Fort Sam, Houston, Texas, in a new recruit population. We intend to share the results with members of the Defense Health Board, a group of esteemed civilian medical and scientific experts who provide medical advice to the Secretary of Defense, to determine the best course of action before any broad policy is recommended.

2. At present, we consider changes in the aerobic portions of the annual physical fitness test score to be a useful consideration in the assessment of pulmonary health. Nevertheless, there are many factors that contribute to aerobic conditioning, including body mass index, unrelated medical conditions such as musculoskeletal injuries, and most commonly the ability to exercise regularly (time, access, prioritization). A study evaluating Army Physical Fitness Testing scores before and after deployment showed that, in general, scores went down after deployment and took about 6 months to return to baseline, with a high degree of individual variability.6 Although the results of the physical fitness tests could be made available to providers, in the absence of pulmonary symptoms it is unlikely they would identify the need for further evaluation. We are interested in exploring whether change in fitness score correlates with change in pulmonary function or otherwise serves as a predictor of respiratory health.

3. At the time of the meeting, preliminary data were presented suggesting that one potential cause of exertional dyspnea in military personnel who have deployed was constrictive bronchiolitis, a rare pathological entity most commonly associated with lung and bone marrow transplantation. This case series was published in the New England Journal of Medicine last year, however, the DoD clinicians do not recommend any diagnostic algorithm that includes surgical lung biopsy without the clinical presentation, abnormal pulmonary function testing, and/or findings on high-resolution (inspiratory/expiratory) computed tomographic scans suggestive of this disease or any parenchymal lung disease.7 The algorithm as presented requires one or both of these findings before a biopsy is advisable, but biopsy should not be considered in the absence of a comprehensive evaluation to exclude other causes of exertional dyspnea.

The DoD remains committed to the health of our service members and will continue to evaluate the incidence, prevalence, and nature of respiratory disease potentially associated with airborne hazards in deployment settings, and the DoD will use this information to inform policy.

Lisa L. Zacher, MD, Col, USA

Robert Browning, MD, CDR, USN

Teresa Bisnett, MD, Lt Col USAF

James R. Bennion, MD, MPH, Col USAF, FS

R. Craig Postlewaite, DVM, MPH

and Coleen P. Baird, MD, MPH

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1. US Preventive Services Task Force. Screening for chronic obstructive pulmonary disease using spirometry: US Preventive Services Task Force Recommendation Statement. Ann Intern Med. 2008;148:529–534.

2. Evidence Report/Technology Assessment No. 121. Use of Spirometry for Case Finding, Diagnosis, and Management of Chronic Pulmonary Disease. Publication No. 05-EO17–2. Rockville, MD: Agency for Healthcare Research and Quality; 2005.

3. Medical Screening and Surveillance. The Occupational Safety and Health Administration, United States Department of Labor. (downloaded 12/16/2011)

4. Morris MJ, Schwartz D, Nohrenberg JA, Dooley SN. Asymptomatic airway hyperreactivity in military personnel. Mil Med. 2007;172:1194–1197.

5. Enright P. The use and abuse of office spirometry. Prim Care Respir J. 2008;17:238–242.

6. Knapik J, Darakjy S, Jones S, Marin R, Hoedebecke E, Michener T, et al. Injuries and Physical Fitness Before and After Deployment by the 10th Mountain Division to Afghanistan Operation Enduring Freedom, Technical Report, December 10, 2007, 12-MA-05SD-07. Aberdeen Proving Ground, MD: US Army Center for Health Promotion and Preventive Medicine; 2007.

7. King M, Eisenberg R, Newman JH, et al. Constrictive bronchiolitis in soldiers returning from Iraq. N Eng J Med. 2011;365:222–230.

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