What Providers Need to Know Omowunmi Osinubi MD Anays Sotolongo MD 1 in 3 r eport definite or probable exposure to environmental hazards 1 in 4 r eport persistent major health concerns due to deployment exposures ID: 162181
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Slide1
Clinical Management of Airborne Hazards
What Providers Need to Know
Omowunmi Osinubi, MD
Anays Sotolongo, MDSlide2
1 in 3
r
eport “definite or probable exposure to environmental hazards”
1 in 4
report “persistent major health concerns due to deployment exposures”Slide3
Airborne Hazards & Post Deployment Health
Burn Pit Smoke
Sand and Dust
Oil Well Fires
Slide4
IOM Report 2011
“…service in Iraq or Afghanistan –– might be associated with long-term health effects,
in highly exposed ..or susceptible populations...”Slide5
Airborne Hazards
& Open Burn Pit
Registry
Public Law 112-260
Monitor and ascertain health effects from exposures
Monitor the health care of Veterans with concerns
Provide high quality health servicesSlide6
1
On-line self-assessment questionnaire (SAQ
)
2
Optional in-person clinical evaluationSlide7
Addressing Veterans’ Health Concernsat the Initial In-person Registry Evaluation
Veteran may discuss:
Upper/lower respiratory symptomsPhysical activity limitations or decreased
ability to exercise Other health conditions or concerns related to:Gastrointestinal, neurocognitive, neuroendocrine, rheumatologic, musculoskeletal, reproductive health and cancer OR
Have no current health problems, but concerned about possible future health effects of exposuresSlide8
Airborne Hazards ReferralCase Study #1
48 Year Old OIF
Veteran
Non-SmokerSlide9
Clinical History
“Breathing problems” & “Hoarseness”
Started in 2005 in Iraq
Worsening over timeLimiting work activitiesDiagnostic work-up to date (normal)
Spirometry, Chest x-ray, cardiac stress test/echo Chest
CT – “small hiatal hernia”
Trial
of inhalers – “Not helpful”
Psychiatry - “Severe
PTSD
”Slide10
“I was at
Balad
,…. I was next to the burn pit…..I breathed in the smoke, now I can’t breathe!
“VA Burn-pit Registry”Slide11
In-Person Evaluation Process
Providers can review the SAQ using a web portal.https://staff.mobilehealth.va.gov/AHBurnPitRegistry/
Take 5-10 minutes to review the completed Registry SAQ
Summarize deployment history and exposuresReview symptoms and health historyCurrent symptoms- severity and duration
Health conditions- timing and certainty of diagnosisTobacco, ETOH, other substance use/abuseFunctional limitations
Concerns about cause of symptoms or health conditions
Physical examination
Review diagnostic work-up to date
Form an assessment
Create a care plan (including appropriate testing) with patient
Engage in health risk communicationSlide12
Registry Initial Note
Choose the following on check list:
Runny nose/post –nasal drip
Chronic sinus congestion
Sore throat, hoarseness, change in voice
Cough for more than 3 weeks
Shortness of breath;
breathlessness
Gastrointestinal problemSlide13
Exposure History
Military Exposures
Military occupation specialty
Deployment-related exposures
Non Military Exposures
Civilian occupational exposures
Civilian non-occupational exposuresSlide14
Military
Exposure History
Army Corps of Engineers (10 years)
Motor pool construction trucks
Diesel exhaust fumes Construction dustsSlide15
Military Exposure History
Deployment-related exposures (1/04-6/05)
Kuwait:
“monster sand and dust storms”
Iraq: “
Balad
burn pit- burned 24/7”
Sick often – “Iraqi crud”Slide16
Civilian Exposures
Works in waste management
Grain dusts
Temperature extremes (-40 to 100+ degree F)
Heavy physical job demand (> 50 Ibs frequently)
Non-
vocational
exposures/social
history
Non-
significantSlide17
Summary of Exposures
Burn
pit
smoke
Sand
& dust
storms
Construction dusts
Diesel exhaust
Grain
dusts
Temperature extremes
Heavy
physical
work
Psychological traumaSlide18
Deployment History and Exposures
Viewing instructions is optional and not included in final note
Choose the following exposure concerns:
Off base air pollution
On base air
pollution
Hobbies and non military jobs
Military jobs while not deployedSlide19
Contributory ExposuresBurn Pits
Diesel Exhaust
Construction& Grain Dust
Sand & Dust Storms
Temperature Extremes
Airborne
Exposures
RADS
Irritant-induced Asthma
Vocal Cord DysfunctionSlide20
Diagnostic Work-Up
Work up:
Cardiac Stress Test
Echocardiography
SpirometryImaging Studies
Inhaler Ineffectiveness
Diseases:
Cardiovascular
dz
Obstructive Lung
dz
Interstitial Lung
dz
? Vocal Cord DysfunctionSlide21
Review Vet’s Diagnostic Work-up to Date
CPRS auto-populates with tests done in past 2 years :
Spirometry
Chest x-ray
Stress EchocardiogramSlide22
Diagnostic Evaluation
Spirometry (Pre/Post BD)
Body Box
DLCO
CPET w/ ABGs and 12-lead ECG
FOT
(Pre/Post BD)
FeNOSlide23
Diagnostic Test Results
PFT & DLCO
FEV1 85.4%; FVC 96.9% FEV1/FVC 75%.
FEF 25-75% (55%), +20% bronchodilator
RV 134% predictedDLCO 114% predicted
CPET
VO2 max: 88% predicted
VE/MVV: 61% at peak
Appropriate ↓
dead space
Throat tightness/discomfort at peak
exerciseSlide24
Diagnostic Test Results
Forced oscillometry (FOT)
↓airways resistance & ↓reactance post bronchodilator
Expired nitric oxide (
FeNO)
↑
121
ppb
(
normal <50 ppb
)Slide25
(-)
airway disease
normal FEV1/FVC
Cardiopulmonary
exercise
(+)
airway disease
(+)
Response in small airways
Resistance
FOT
FeNOSlide26
ENT Evaluation
Flexible laryngoscopy
Bilateral
vocal cord
nodules Vocal
cords
normal movement
P
harynx
is
hyperemic
P
osterior
pharyngeal wall
cobble stoning
Evidence of acid refluxSlide27
What about her poor sleep?
Polysomnography
obstructive sleep apnea-hypopnea syndrome & frequent upper airway
resistance
Aero Digestive Inflammation
GERD
Chronic Cough
Rhinitis
Sleep ApneaSlide28
Summary/Takeaways Case #1
IrIA /RADS
:
Exposure assessmentSymptom onset
Radiographic Imaging
Reversible airflow obstruction
PFT,
FOT,
CPET
VCD:
Stridor vs.
wheezing
Awareness of VCD
Identify potential cause(s)/trigger(s)
Flexible laryngoscopy
Functional
impairmentSlide29
Airborne Hazards ReferralCase Study
#2
31 year old OIF Marine Corps VeteranSlide30
Chief Concerns
Severe shortness of breath since IraqDecreased
exercise capacity Multiple episodes of acute respiratory
distressSlide31
Military Exposure History
Combat truck convoys
Sand and dust stormsSlide32
Military Exposure History Contd.Slide33
Post Deployment History
Progressive SOB & DOE, OrthopneaCurrent smoker 15 pack-year
Frequent hospitalizations for respiratory exacerbations
Comorbid conditionsIDDMHTN
GERDPTSD
Sleep apnea
Unable
to work due to respiratory
impairmentSlide34
Airborne Hazard Concerns - Clinical Assessment
Physical exam & oxygen satC
hest X-ray (PA and lateral)
Pulmonary function testsAllergy consult
Cardiac evaluation - EKG, Echo, Pulmonary consultSlide35
Diagnostic Work-up
Chest
x-ray:
R costophrenic angle blunting
Mild hyperaerationSlide36
Diagnostic Work-up (Contd.)
Allergy
ConsultImmune deficiency
excludedPFT:Diffusion:
DLCO= 29.5 (101%)
Spirometry
:
FV loops-curvilinear
FEV
1
/FVC= 0.70
FEV
1
= 3.85L (77%)
No BD response
MVV
↓60 l/min
Lung Volumes:
TLC= 7.90L (96%)
VA= 5.13 L (67%)
RV/TLC= 35
%Slide37
Diagnostic Work-up (Contd.)
EKG
:Sinus tachycardia
Left atria enlargementNo change from study 8 months prior
Echocardiogram
:
Trace mitral regurgitation
Mild tricuspid
regurgitation
LV systolic function normal – estimated EF = 55%
Pulmonary artery systolic pressure not assessed
Technically suboptimal
studySlide38
What types of additional work-up would be appropriate for this Veteran?
“
It was when I was under the care of a pulmonologist ... that my condition … received a more thorough workup”Slide39
High Resolution Chest CT Imaging
ILD Evaluation by HRCT:
Axial Scans:Supine & Prone
Full inspiration1-1.5 mm collimation at 1 to 2 cm intervals
Dynamic, during forces expiration views:Aortic ArchCarina
Above diaphragm
Patient’s
HRCT Findings
:
CT 4/2013 & 7/2013:
Mild emphysema
Mosaic perfusion
Mild bronchitis
RUL minor ground glass
No ILD/effusion/LAD
Findings unchanged
(CT 4/2013 vs. 7/2013)Slide40
Six-minute Walk Test
BMI:
26.8 (overweight
)
WHR:
0.96
Baseline SpO
2
:
94%
6MWD:
350m (51%
pred
)
Peak
HR
:
134/min
HR
@2min post
:
108/min
Post exertion SpO
2
:
-11% (84%)
Other:
Requires 2 LPM oxygen to stay above 90%Slide41
What about lung biopsy?When is lung biopsy indicated?
What type of biopsy is indicated?Bronchoscopy with biopsySurgical lung biopsy (VATs)
What are the limitations of each type?What are the possible complications?Slide42
Hospitalized in 2013
Presented with acute respiratory distress
Bronchoscopy:
Early
granulomatous reaction Consistent with silicosis
L
arger
tissues sample was
recommendedSlide43
Constrictive Bronchiolitis in OEF/OIF
NEJM: CB in soldiers
exertional dyspnea
38 of 49 (78%) diagnosed with CB PFTs, CPET within normal limitsModerate reduction in DLCO
ATS Research abstract: National Jewish Hospital
US Army Public Health Command (USAPHC):
Epidemiologic evidence to date is inadequate to support or refute an association between deployment and chronic respiratory conditionsSlide44
Pulmonary Findings in Iraq/Afghanistan Deployers
Centrilobular
Nodularity
Mosaic air trapping
EmphysemaSlide45
Right Upper & Lower Lobe Open Biopsies
Preliminary Pathology report:Mild
anthracosilicotic depositsHemosiderin-laden intra-alveolar macrophages
Dx: Smoking-related interstitial lung diseaseAddendum to pathology report (SEM/EDXA)Particles contain Si, Al, & O; K & Na (environmental silicates)
Rare particles Ti, Fe & Cr (possibly steel) Slide46
What is the Diagnosis?
RB-ILD
CB
DIPSlide47
What is the Management?
RB-ILD
CB
steroids,
macrolides
DIP
+
steroidsSlide48
Summary/Takeaways Case #2
High
Resolution CTAssess lung parenchyma for fibrosis
Constrictive
BronchiolitisRare disease
Irreversible (steroids may help)
? Clinical course in diagnosed soldiers
Lung
Biopsy
Gold standard for interstitial lung disease
? Benefit/Risk
ratio
B-ILD and DIP
Related to smoking
Rx: STOP SMOKINGSlide49
Airborne Hazard Concerns
Iraq & Afghanistan War Veterans
Many combat Veterans have airborne hazard exposure concerns.
Have high index of suspicion for upper & lower respiratory problems & a low bar for further evaluation.Identify physical /behavioral health co-morbidities
early and treat.Case management services to support change in lifestyle interventions.Slide50
THANK YOU !Slide51
Questions?
New Jersey War-related Illness and Injury Study Center
http
://www.warrelatedillness.va.gov
/
omowunmi.osinubi@va.gov
1-800-248-8005
anays.sotolongo@va.gov