1. Study of Active Duty Military for Pulmonary Disease Related to Environmental Deployment Exposures (STAMPEDE) PI: LTC Aaron Holley MD Presented by: Charles Stahlmann DO, Capt, USAF Pulmonary and Critical Care Medicine Walter Reed NNMC

2. Co-PIs & Acknowledgements Michael J. Morris, MD LTC John H. Sherner, MD LCDR Andrew Philip, MD LT Donovan Mabe, MD CPT Michal J. Sobieszczyk, MD Karen Sheikh

3. Disclosures No disclosures or conflicts of interest The views expressed in this presentation are those of the presenter and do not necessarily reflect the official policy or position of the Department of the Air Force, Department of the Navy, Department of the Army, or the Department of Defense, nor the U.S. Government

4. Study Background / Rationale Respiratory symptoms post deployment to Southwest Asia Higher rates of newly reported respiratory symptoms (14% vs. 10%) in deployed vs. nondeployed personnel Deployments are longer, more frequent

5. Study Background / Rationale Variety of exposures during deployment Burn pits Close proximity to living/working conditions Desert dust (particulate matter) Dust storms 20-50 days per year severe enough to obscure visibility Industrial fires Al-Mishraq Sulfur Fire Exhaust IEDs Desert climate JAMA 2004; 292: 2997-3005 Allergy Asthma Proc 2010; 31: 1-5 N Eng J Med 2011; 365: 222-230 Military Medicine 2007; 172: 1264

6. Study Background / Rationale Prospective data lacking. Guidance on targeted work up lacking. Chronicity? Predictors? Confounding factors? JAMA 2004; 292: 2997-3005 Allergy Asthma Proc 2010; 31: 1-5 N Eng J Med 2011; 365: 222-230 Military Medicine 2007; 172: 1264

7. Research Question(s) / Hypothesis Do SMs with respiratory symptoms post-deployment have a different distribution of disease? Can we predict clinical course using data collected at initial presentation?

8. Design & Methodology Design: Prospective clinical evaluation of deployed military personnel Objective: to establish whether deployment to Iraq or Afghanistan is associated with respiratory abnormalities, define the frequency at which any identified abnormalities occur and provide an accurate description and natural history. Relevance: This study is critical to allowing the Department of Defense (DOD) to define the prevalence of post-deployment respiratory symptoms, identify specific risks and define any associated abnormalities within the respiratory system.

9. Design & Methodology Inclusion: Active duty or retired military personnel 18 years of age or older with prior deployment to Iraq or Afghanistan and primary complaint of dyspnea Exclusion: Age less than 18 years, history of chest trauma or acute inhalational injury, documented history of lung disease prior to deployment

10. Study Design

11. Impulse Oscillometry

12. More sensitive than standard spirometry for obstructive disease, correlate well with QOL scores in asthma and copd. 2007 Friedman et al identified 473 controls without respiratory symptoms exposed to inhalation from the World Trade Center on 9/11 and 180 cases with symptoms Cases were more likely than control subjects to have abnormal spirometry (19% vs. 11%; P<0.05), Spirometry focus is on LARGE airways, may not detect early small airway

13. Preliminary Spirometry Results 267 patients All with basic spirometry; 82 with DLCO Median Number of Deployments: 1 (1-2) Median Number of Days Deployed: 352 (209-583)

14. Preliminary Spirometry Results 83 (36.6%) with abnormal spirometry 53 (63.9%) with abnormal FEV1/FVC 1 (1.2%) with abnormal DLCO 104 with post-bronchodilator testing 6 (5.8%) with positive response by ATS criteria

15. Preliminary Spirometry Results No relationship between lung function and time in theatre, deployment location, deployment frequency, or land-based deployment. Dyspnea and enlisted rank are associated with tobacco use and lower FEV1 Cough is associated with number of deployments

16. Current and Anticipated Challenges Time/work limits for verification SMs discharged from active service Participation after contact

17. References Sobieszczyk M, Holley AB. Lung function testing in soldiers serving in Iraq and Afghanistan and returning with dyspnea. ATS 2013 (podium presentation); ID 43530. Holley AB, Sobieszczyk M, Sherner JH, Perkins MP. Respiratory symptoms in service members returning from Afghanistan and Iraq. Am J Respir Crit Care Med 2014; 190: 1076-1077. Sobieszczyk M, Perkins MP, Liotta R, Holley PR, Sherner JH, Holley AB. Lung function abnnormalities in active duty members returning from deployment to Southwest Asia. CHEST 2014; 164: 683A. Morris MJ, Dodson DW, et al. Study of active duty military for pulmonary disease related to environmental deployment exposures (STAMPEDE). Am J Respir Crit Care Med 2014;190:77-84. Friedman SM, Maslow CB, Reibman J, et al. Case-Control Study of Lung Function in World Trade Center Health Registry Area Residents and Workers. Am J Respir Crit Care Med 2011; 184: 582-589.

18. Questions?

19. NEJM 2011; 365: 222-230