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Deployment Related Respiratory Disease Toolkit for Providers

Deployment Related Respiratory Disease Toolkit for Providers
Last updated May 2023
This is an interactive clinical guide for providers seeing Veterans with airborne hazards and respiratory concerns. This guide uses a stepwise strategy to walk through how to evaluate a Veteran for Deployment-Related Respiratory Disease. Click each section title below to expand the section. If viewing the toolkit on a mobile device, view in landscape orientation for best results. To see a snapshot of the content below, click here.
This toolkit is not intended to replace the use of best clinical judgment or guidelines for clinical care.

STEP 1
Conduct a History and Physical
As part of the evaluation, a detailed deployment and exposure history should be conducted. In discussing exposure and health-related concerns, it is important for providers to be attuned to the need for effective communication which includes listening and acknowledging concerns regarding exposures and long-term health outcomes. The brief exposure and history questionnaire should include:

  • Military Questionnaire
    • Military Service
      • In which branch of service did the Veteran serve:
        • Army
        • Air Force
        • Navy
        • Marine Corps
        • Coast Guard
        • Reserves
        • National Guard or Contractor/Other
    • Service Dates: month/year beginning of service - month/year end of service
    • Military Occupational Specialty Code(s): (e.g., Army MOS, Marine Corps MOS, Airforce AFSC, Navy Rate or NEC)
    • What was the date of your first physical fitness test (also known as physical fitness readiness test) of your military career?
    • What was your run-time for this physical fitness test?
      • (2-mile run for Army, 1.5-mile run for Airforce and Navy, 3-mile run for Marine Corps)
    • Pre-Deployment Physical Fitness Test
      • Did you complete a physical fitness test prior to Southwest Asia deployment?
      • Did you pass this pre-deployment physical fitness test?
      • What was the run-time of your pre-deployment physical fitness test?
        • (2-mile run for Army, 1.5-mile run for Airforce and Navy, 3-mile run for Marine Corps)
    • Post-Deployment Physical Fitness Test
      • Did you complete a physical fitness test after your Southwest Asia deployment?
      • What was the date of your post-deployment physical fitness test? (Approximate month/year)
      • Did you pass your post-deployment physical fitness test?
      • What was the run-time of your pre-deployment physical fitness test?
        • (2-mile run for Army, 1.5-mile run for Airforce and Navy, 3-mile run for Marine Corps)
        • If no physical fitness test completed, ask why - was it not required or was veteran on profile or undergoing medical evaluation board for another medical condition?
    • Deployment History Southwest Asia (e.g., Kuwait, Iraq, Saudi Arabia, Oman, Bahrain, Qatar, Syria, U.A.E., Jordan) Afghanistan and Djibouti Deployments
      • Did you deploy to any of these locations between 1990 through today?
      • How many times have you deployed to Southwest Asia since 1990 up until today?
      • Locations and dates of Southwest Asia Deployments:
        • Location (provide country)
        • Dates: month/year of beginning of deployment - month/year of end of deployment
      • OPTIONAL for non-Southwest Asia Deployments:
        • Location (provide country)
        • Dates: month/year of beginning of deployment - month/year of end of deployment
    • Airborne Hazard Exposures
      • Did you have exposures to any of the following (Yes/No/Unsure)?
      • If yes, how frequently (Daily/Occasionally/Once)?
        • Smoke from Burn Pits?
        • Trash-burning (e.g., burn barrels for human waste/feces)?
        • Sandstorms?
        • Oil well fires?
        • Diesel (vehicular or jet fuel)?
        • Mixing or burning of chemical agent-resistant coating (CARC) paint?
          • (CARC has isocyanates, which are respiratory sensitizers that are therefore asthmagenic)
        • Fires (e.g., military vehicle fire, industrial fire)?
        • Explosions/Blasts (e.g., improvised explosive devices)?
          • If yes, did you experience loss of consciousness with any explosion?
        • Other job-related vapors, gases, dust, or fumes? (Please list)
    • Symptoms During and/or Post-Deployment
      • What respiratory symptoms, if any, did you experience during deployment?
        • Nasal congestion/postnasal drip?
        • Cough?
        • Shortness of breath?
        • Chest tightness/wheezing?
        • Respiratory infection?
        • Other?
      • Did you see a medic or seek any medical treatment during or after this deployment?
        • Did you use inhalers, prednisone, antibiotics for respiratory infection or other medications for respiratory issues?
      • Have you ever seen a specialist for your symptoms?
        • If so, were you diagnosed with a respiratory condition?
        • Did your symptoms improve or resolve?
        • Do you still have symptoms and/or did your symptoms worsen?”
  • Is the patient a previously deployed Veteran or a currently deployed military individual? If yes, has the patient deployed to the following:
    • Southwest Asia theater of operations or Egypt any time after August 2, 1990 or Afghanistan, Djibouti, Syria or Uzbekistan on or after September 11,2001.
    • Regions and countries include: Iraq, Afghanistan, Kuwait, Saudi Arabia, Bahrain, Djibouti, Gulf of Aden, Gulf of Oman, Oman, Qatar, United Arab Emirates, waters of the Persian Gulf, Arabian Sea, Red Sea, Syria, Uzbekistan and Egypt.
    • Operations and campaigns include: Desert Shield and Desert Storm (ODS/S), Iraqi Freedom (OIF), Enduring Freedom (OEF) and New Dawn (OND).
  • Does the Veteran endorse exposure to burn pits and/or other sources of vapors, gases, dust and fumes?
  • Does the Veteran present with persistent respiratory symptoms e.g., unexplained shortness of breath, decreased exercise tolerance, and/or chronic cough?
    • Decreased exercise tolerance is the inability to exercise and engage in physical activity that would be typical for the individual’s age. It is different from someone being “out of shape” due to not exercising regularly. Individuals with decreased exercise tolerance cannot build the necessary stamina with exercise. Exercising can cause more discomfort to people with this condition.
  • Has the Veteran ever been evaluated for breathing problems? If so, does the Veteran currently have respiratory diagnosis? And is this condition being managed?

STEP 2
Diagnostic Evaluations
Research indicates that the most commonly reported consequence of exposure to airborne hazards are asthma, rhinitis and sinusitis. To evaluate these or other possible conditions, first consider performing the following:

  • Complete pulmonary function testing with pre/post bronchodilator response.
  • Chest CT imaging
  • Sinus imaging
  • Refer to initial specialty clinics (Pulmonary, ENT)
  • Respiratory questionnaire
If your patient presents Asthma, Sinusitis, or Rhinitis, use evidence-based treatment to improve symptoms. If symptoms do not improve:

STEP 3
If Symptoms Persist, Consider Other Co-morbidities
Differential Diagnosis
  • Consider pulmonary consult or evaluate for other contributing factors and/or comorbid conditions including but not limited to: OSA, GERD, cardiac factors, laryngeal disorders, anemia.
  • Other diagnostic testing may include:
    • Transthoracic echo
    • Endoscopy
    • Laryngoscopy
    • Sleep Study
    • Bloodwork to consider:
      • Complete Blood Count (CBC) w/ DIFF
      • Comprehensive Metabolic Panel (CHEM)
      • Erythrocyte Sedimentation Rate (ESR)
      • C-Reactive Protein
      • Rheumatoid Factor
      • Anti-Nuclear Antibody (ANA)
      • Thyroid Function Test (TSH
      • Vitamin B-12 and Folate
      • Liver Function Test
        • AST (Aspartate transaminase)
        • ALT (Alanine Transaminase)
        • ALP (Alkaline Phosphatase)
        • BiIli (Bilirubin)
      • Urinalysis
      • IGE (Immunoglobulin E)
      • Hemoglobin A1C
Use evidence-based treatment to manage symptoms. If symptoms do not improve:

STEP 4
Consider Advanced Assessments and/or
Referral to Specialty Referral Center
If symptoms and/or co-morbidities do not improve with evidence-based treatment, then consider referral to a specialist for the following:

  • Paired Inspiratory-expiratory High Resolution CT scan;
  • Cardiopulmonary exercise test (CPET)
  • Methacholine challenge test

If results of testing remain non-diagnostic for persistent symptoms, despite treatment:

STEP 5
Optimize Symptom Management or Consider Lung Biopsy
Manage Symptoms
  • Managing symptoms without a lung biopsy may be a reasonable alternative. Discuss with the Veteran the risk benefit of undergoing a lung biopsy.
  • Managing symptoms may be achievable with the optimization of treatment of various organ dysfunctions and improvement of overall health with nutrition, exercise, pulmonary rehabilitation and mental health.
  • Management of individual symptoms along with monitoring symptoms may best support overall Veteran health and well-being, even in the absence of a confirmed diagnosis.
Differential Diagnosis for Lung Biopsy

We recommend that pathology specimen be sent to the Joint Pathology Center, in addition to the local pathologist.
  • Constrictive Bronchiolitis* or other small airways inflammation
  • Granulomatous pneumonitis
  • Hyperinflation or emphysema
  • Chronic pleuritis and Pleural fibrosis
  • Vasculopathy
  • Interstitial lung disease
  • Autoimmune disease
Depending on diagnoses, refer to the appropriate subspecialist for additional treatment, such as:
  • Steroids
  • Methotrexate
  • Immunosuppressive agents
  • Continue to manage symptoms and optimize health

Continue to manage symptoms and optimize health of the Veteran.

Please remember to always discuss the ability to file a claim for VA benefits with the Veteran. For more information on presumptive conditions and compensation eligibility, visit
www.va.gov/disability/eligibility/hazardous-materials-exposure/specific-environmental-hazards/#am-i-eligible-for-va-disabilit
*Constrictive Bronchiolitis (CB): A histological pattern of lung injury characterized by subepithelial fibrosis of the small airways that narrows and sometimes obliterates bronchiolar lumens. Note that this abnormality is one of a spectrum of distal lung histopathology that has been seen in deployed Veterans with airborne hazards exposure.
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