Deep Breaths
By Claudia Stahl
Radiology Today
Vol. 25 No. 3 P. 8

New diagnostic technology offers hope for veterans who were exposed to burn pits.

Kevin Burger knew something was off after his return home to the United States in 2004. Following a year-long deployment to Iraq, the young Army veteran could barely run a quarter mile without stopping to cough and catch his breath.

“Prior to Iraq, I had excellent PT [physical training] scores,” Burger says in a podcast from 2021. He was referring to the rigorous physical fitness tests, including a two-mile run, that soldiers must pass while in service. CT scans and a pulmonary function test showed only mild airway obstruction, however, and he was diagnosed with asthma.

Around that time, 80 soldiers from Fort Campbell, Kentucky, who had served in Iraq and Afghanistan, could no longer pass the fitness requirements to remain in active service. When diagnostic tests showed no apparent abnormalities, they were referred to Robert Miller, MD, a pulmonologist at Vanderbilt University Medical Center, for further evaluation. It took lung biopsies to confirm the source of their breathing difficulties: constrictive bronchiolitis (CB), a serious, irreversible condition that causes narrowing in the airways of the lungs.

An uncommon disease in the general population, CB affects disproportionate numbers of veterans who were exposed to burn pits while deployed in Iraq and Afghanistan. These open-air garbage fires, set ablaze with jet fuel and containing all manner of waste— medical, munitions, computers, tires, lithium batteries, plastics—burned day and night, sending up plumes of toxic smoke within yards of military outposts. The burn pit in Balad, Iraq, covered 10 acres.

In 2011, Miller and colleagues from Vanderbilt published a case series about the Fort Campbell soldiers in The New England Journal of Medicine that began to bring widespread attention to the issue. Meanwhile, for more than a decade, untold numbers of veterans would continue to suffer from the aftereffects of their service— declining health, job loss, depression, and death—as the VA department denied medical and disability claims.

The turning point finally came in August of 2022, when—after decades of advocacy from veteran groups, physicians, and television host Jon Stewart— Congress passed the Sergeant First Class Heath Robinson Honoring Our Promise to Address Comprehensive Toxics Act, commonly known as the PACT Act. The legislation grants veterans of the post-911 era conflicts, an estimated 3.5 million people, the right to receive insurance and disability compensation for any “presumptive conditions” related to toxic exposure without having to prove that their service caused the condition.

At a cost of $280 billion, PACT represents the biggest expansion of benefits in the VA’s history. As of February 2024, the VA has approved 764,443 claims and provided 5,214,951 toxic exposure screenings, a PACT benefit, since the start of the program, according to the VA PACT ACT Performance Dashboard (See Figure 1 online).

For veterans who have been grappling for decades with unresolved health issues, PACT represents the next phase of an already long battle. The journey forward will begin with an accurate diagnosis of conditions that are complex and chronic.

Unmasking DRRDs
CB, one of several deployment-related respiratory diseases (DRRDs) on PACT’s list of presumptive conditions, is also one of the most challenging to diagnose. Patients typically report unexplained “shortness of breath” during exercise or everyday activities, “which is an extremely difficult symptom to explain to someone else or to prove,” says Greg Mogel, MD, a radiologist, veteran, and medical director of 4DMedical, a global medical technology company that focuses on respiratory diseases.

Standard noninvasive tests for pulmonary function, such as pulmonary function tests, chest X-rays, and high-resolution CT scans, fail to detect deployment-related CB (DCB), a disease characterized by inflammation and narrowing of the small airways, or bronchioles, in the lungs, Mogel explains. Total breathing volume looks normal in these patients, but sections of the lung where airflow is impaired go undetected.

As a result, patients may spend years on therapies intended for management of asthma and mild respiratory ailments while their health deteriorates from a progressive, unnamed condition that leaves them too breathless to work, play with children, or walk a dog. Even when DCB is suspected, lung biopsy is the only way to confirm it, leaving veterans with the choice of undergoing an invasive surgical procedure that often leads to pain and scarring or living with uncertainty.

Multiple studies are underway involving noninvasive methods of detecting DCB and other DRRDs in veterans. In a collaborative research project, the Nashville VA Medical Center, Vanderbilt University Medical Center, and the Vanderbilt University Institute of Imaging Science are exploring whether 4DMedical’s lung X-ray velocimetry (XV) analysis software, called XV LVAS, can pinpoint ventilation abnormalities in veterans with biopsy-confirmed DCB.

The technology uses an imaging algorithm that analyzes CT and fluoroscopy scans for ventilation patterns in the lungs, creating a 4D picture that identifies regional differences in pulmonary function during tidal breathing. Researchers hope the software can enhance their understanding of factors that cause DRRD and improve their ability to diagnose DRRD noninvasively.

Bradley W. Richmond, MD, PhD, principal investigator of the study and a staff physician at the Nashville VA, says, “[It] allows us to evaluate lung function in real time, while comparing those results with the more detailed structural analysis we derive from CT scans.” Preliminary outcomes of work with XV LVAS are reported in the American Journal of Respiratory and Critical Care Medicine 2023 abstracts.

Another article in the American Journal of Respiratory and Critical Care Medicine shows that parametric response mapping, a chest CT image analysis technique developed by the University of Michigan, can identify air-trapping patterns in the lungs characteristic of CB/DRDD in veterans who have had normal pulmonary function tests and high-resolution CT scans. Commercially available as part of a lung density analysis product from Imbio, a subsidiary company of 4DMedical, parametric response mapping provides a functional picture of the lung, making it useful for assessing conditions like CB and COPD. The findings also reveal that severity of DCB is worse than that of a patient with mild to moderate COPD, explaining shortness of breath and exercise fatigue.

Pulmonary fibrosis, or lung scarring, has increased in prevalence among the veteran population over the last decade and is associated with high morbidity and mortality. Timely identification and subspecialty referral to pulmonologists are key to improving long-term outcomes for these patients.

Current research being led by Bhavika Kaul, MD, a pulmonary/critical care medicine physician at the Houston VA and a core investigator at the VA Center for Innovation in Quality, Effectiveness, and Safety, is examining whether quantitative CT analysis tools such as lung texture analysis can improve timely detection and access to care for veterans with pulmonary fibrosis. Lung texture analysis transforms CT scans into detailed maps of lung textures (eg, normal, ground glass, reticulation, honeycombing). The hope is that these tools may help facilitate care triage to ensure that at-risk veterans are connected to prompt pulmonary care in the future.

AI for Lung Screening
Lung cancer is the leading cause of cancer death in the United States, and the incidence of lung cancer is higher in veterans than the general population. Annually, the Veterans Health Administration diagnoses and treats 8,000 veterans for lung cancer each year, and an estimated 900,000 veterans are at risk due to factors such as age and smoking, in addition to service-related toxic exposures such as those specified in the PACT Act.

To address this challenge, the VA established the Lung Precision Oncology Program to expand the tools and resources available for managing lung cancer in veterans. The program places an emphasis on screening high-risk veterans for early-stage lung cancer and providing veterans with advanced lung cancer access to genetic testing and precision oncology clinical trials.

“The VA has done a fantastic job in establishing baseline criteria for highquality lung cancer screening, as well as a system for care coordination throughout the country,” says Patrick C. Malloy, MD, executive director of the Veterans Health Administration’s National Radiology Program.

Using a hub-and-spoke model, the VA has established 22 regional locations across the country to coordinate services such as screening, genetic testing, and clinical trials with 87 local VA hospitals. Part of these initiatives involves equipping the facilities throughout the VA’s integrated services network with technology that can improve diagnostic accuracy.

For thoracic imaging, radiologists use ClearRead CT, an AI-powered software by Riverain that uses deep learning to remove vascular structures and machine noise from CT images to identify lung nodules “that are important indicators of early cancers,” Malloy says.

In an interview in 2023, Malloy told Federal News Network, “We currently have close to 100 facilities that are now certified to do lung cancer screening and are looking to expand this to all of our facilities across the country. This will be a significant aid to the radiologists and in scaling up those efforts to meet the needs of the program.”

When treatment is necessary, Malloy says, the VA offers a comprehensive range of precision options, including robotic-assisted surgery, percutaneous ablation for small nodules, and stereotactic body radiotherapy, a precision treatment that causes minimal damage to healthy tissues.

Marching Forward
On March 5 of this year, Congress extended eligibility for VA health care to all veterans who were exposed to toxins and other hazards while serving at home or abroad. The expansion covers those who served in the Vietnam War, the Gulf War, Iraq, Afghanistan, or any other combat zone after 9/11, in contingency operations for the Global War on Terror, or who were exposed to toxins or other hazards during military service.

Rosie Torres, cofounder of the advocacy organization Burn Pits 360, expects the recent announcement to prompt even more outreach from veterans and their families. Since the PACT Act was passed, Torres receives daily calls and emails from veterans “who are still being told that their breathing problem is related to anxiety or asthma, or that there is no diagnostic code for their condition. A lot of delay [and] deny … continues,” she says. “I really thought that once PACT was passed, everything was just going to fall into place. We’re far from it.”

Torres founded Burn Pits 360 with her husband, Le Roy, who deployed to Balad, Iraq, from 2007 to 2008 with the US Army. After returning to the United States, Le Roy struggled with symptoms that, years later, would be attributed to DCB and brain injury related to toxic exposure. The organization’s numerous accomplishments include the establishment of an independent burn pit registry and advocacy work that contributed to the passage of the PACT Act.

For millions of veterans affected by toxic exposure, the future means care, not cure. Knowing what’s ahead, “understanding of what’s happening in your body … preparing yourself for what your life is going to look like from now on, matters,” Torres says.

For Burger, it took 19 years and a lung biopsy to receive the correct diagnosis: DCB. In 2023, he flew from his home in Highland Township, Michigan, to Miami, where he received a scan using XV LVAS at the University of Miami Health System.

“Unlike a lung biopsy, the scan was painless. There was no recovery time, and the images came back quickly, pointing towards the disease that the biopsy confirmed was constrictive bronchiolitis,” Burger wrote in The Detroit News. “If this technology was more readily available to veterans suffering from burn pit exposures, they could be quickly diagnosed and put on a path to treatment. This is not only a win for veterans but it is a win for the VA as an efficient and cost-effective screening tool.

Technologies such as XV LVAS, which weren’t available until a few years ago, can serve as a starting point for physicians and patients to begin the conversation. Mogel, who has used XV LVAS to administer scans to hundreds of veterans, says the validation is transformative for everyone involved.

“Radiologists are often removed from the experience of discussing a diagnosis with people. … I can’t even explain the power of sitting down with someone who, for 15 years and after multiple pulmonary function tests, has been told there’s nothing wrong with them. Then we show them the results of our tests, and realization breaks across their face. It’s understanding that their physician ‘gets it.’ It’s one of the most powerful things to happen in my career.”

— Claudia Stahl is a freelance writer based in Ambler, Pennsylvania. She specializes in writing about the health of people and the planet.