Environmental Exposures and Asthma in Active Duty Service Members

  • Robert H. Wauters
  • Brian E. Foster
  • Taylor A. BanksEmail author
Allergies and the Environment (M Hernandez, Section Editor)
Part of the following topical collections:
  1. Topical Collection on Allergies and the Environment


Purpose of Review

Reports of respiratory symptoms, including asthma and hyper-reactive airway disease, have been more numerous in the media and medical literature since active duty service members (SM) began to support campaigns in South West Asia (SWA). Numerous environmental exposures have been reported and this review assesses the available evidence surrounding exposures, confounding conditions, and attempts to develop screening mechanisms.

Recent Findings

While particulate matter exposures and particularly exposure to burn pits have garnered much attention, a 2010 Armed Forces Health Surveillance Center report and 2011 Institute of Medicine publication did not identify a link between exposure to particulate matter with SM respiratory disease. The “Study of Active Duty Military for Pulmonary Disease related to Environmental Deployment Exposure,” (STAMPEDE) and STAMPEDE II have not identified effective forms of routine screening and these and other sources point to the importance of other factors in SM respiratory disease. These include higher than anticipated rates of tobacco use in deployed settings, impacts of obesity, recurrence of childhood asthma, and of confounding conditions such as Paradoxical Vocal Fold Motion.


As with the general population, a complex set of clinical inputs and environmental exposures surround asthma and similar respiratory processes in SM. Concrete relationships and mechanisms for assessment continue to be assessed and refined, but clear associations and pathways have remained elusive.


Asthma Burn pit Paradoxical vocal fold motion Vocal cord dysfunction Deployment-associated lung disease Environmental exposure Hypersensitivity Military 



Global War on Terrorism


Improvised explosive device


Particulate matter


Paradoxical vocal fold motion


Service members


South West Asia


Compliance with Ethical Standards

Conflict of Interest

The views expressed in this article are those of the authors and do not reflect the official policy of the Department of Army, Navy, Department of Defense, or US Government.

Additional Notification

I am a military service member. This work was prepared as part of my official duties. Title 17 U.S.C. 105 provides that “Copyright protection under this title is not available for any work of the United States Government.” Title 17 U.S.C. 101 defines a United States Government work as a work prepared by a military service member or employee of the United States Government as part of that person’s official duties.


Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.
    •• Morris MJ, Skabelund AJ, Rawlins FA 3rd, et al. Study of active duty military personnel for environmental deployment exposures: pre- and post-deployment spirometry (STAMPEDE II). Respir Care. 2019;64(5):536–44 Large, recent study evaluating potential screening mechanisms for pre-/post-deployment service members.CrossRefGoogle Scholar
  2. 2.
    Rivera AC, Powell TM, Boyko EJ, et al. New-onset asthma and combat deployment: findings from the millennium cohort study. Am J Epidemiol. 2018;187(10):2136–44.CrossRefGoogle Scholar
  3. 3.
    Morris MJ, Lucero PF, Zanders TB, Zacher LL. Diagnosis and management of chronic lung disease in deployed military personnel. Ther Adv Respir Dis. 2013;7(4):235–45.CrossRefGoogle Scholar
  4. 4.
    Parsel S, Riley C, McCoul E. Combat zone exposure and respiratory tract disease. Int Forum Allergy Rhinol. 2018;8(8):964–9.CrossRefGoogle Scholar
  5. 5.
    Smith B, Wong CA, Smith TC, Boyko EJ, et al. Newly reported respiratory symptoms and conditions among military personnel deployed to Iraq and Afghanistan: a prospective population-based study. Am J Epidemiol. 2009;170(11):1433–42.CrossRefGoogle Scholar
  6. 6.
    Sudhakar D, Clagett CL, Zacher LL. Military service and lung disease. J Occup Environ Med. 2014;56(S10):S13–7.CrossRefGoogle Scholar
  7. 7.
    Armed Forces Health Surveillance Center. Epidemiological studies of health outcomes among troops deployed to burn pit sites. MD: Silver Spring; 2010.Google Scholar
  8. 8.
    • Institute of Medicine. Long-term health consequences of exposure to burn pits in Iraq and Afghanistan. Washington, DC: The National Academies Press; 2011. Robust investigation of possible links between PM and burn pit exposure and respiratory symptoms, did not identify an association. Google Scholar
  9. 9.
    Morris MJ, Rawlins FA, Forbes DA et al. Deployment-related respiratory issues. US Army Med Dep J 2016. 173–178.Google Scholar
  10. 10.
    •• Morris MJ, Dodson DW, Lucero PF, et al. Study of active duty military for pulmonary disease related to environmental deployment exposures (STAMPEDE). Am J Respir Crit Care Med. 2014;190(1):77–84 Significant initial work regarding rigorous assessment of respiratory symptoms in service members returning from deployment. CrossRefGoogle Scholar
  11. 11.
    Fuchs O, Bahmer T, Weckmann M, et al. The all age asthma cohort (ALLIANCE) from early beginnings to chronic disease: a longitudinal cohort study. BMC Pulm Med. 2018;18(1):140.CrossRefGoogle Scholar
  12. 12.
    • Hirano T, Matsunga K. Late-onset asthma: current perspectives. J Asthma Allergy. 2018;11:19–27 A review of adult-onset asthma and associated predisposing factors in the general population, offers parallels to affected service members. CrossRefGoogle Scholar
  13. 13.
    Wenzel SE, Schwartz LB, Langmack EL, et al. Evidence that severe asthma can be divided pathologically into two inflammatory subtypes with distinct physiologic and clinical charateristics. Am J Respir Crit Care Med. 1999;160(3):1001–8.CrossRefGoogle Scholar
  14. 14.
    Fajt ML, Wenzel SE. Asthma phenotypes and the use of biologic medications in asthma and allergic disease: the next steps toward personalized care. J Allergy Clin Immunol. 2015;135(2):299–310.CrossRefGoogle Scholar
  15. 15.
    Wu W, Bang S, Bleeker ER, et al. Multiview cluster analysis identifies variable corticosteroid response phenotypes in severe asthma. Am J Respir Crit Care Med. 2019;199(11):1358–67.CrossRefGoogle Scholar
  16. 16.
    Szema AM, Peters MC, Weissinger BA, et al. New-onset asthma among soldiers serving in Iraq and Afghanistan. Allergy Asthma Proc. 2010;31(5):67–71.CrossRefGoogle Scholar
  17. 17.
    Engelbrecht JP, McDonald EV, Gillies JA, et al. Characterizing mineral dusts and other aerosols from the Middle East—part 1: ambient sampling. Inhal Toxicol. 2009;21:297–326.CrossRefGoogle Scholar
  18. 18.
    King MS, Eisenberg R, Newman JH, Tolle JJ, Harrell FE Jr, Nian H, et al. Constrictive bronchiolitis in soldiers returning from Iraq and Afghanistan. N Engl J Med. 2011;365(3):222–30.CrossRefGoogle Scholar
  19. 19.
    Weese C, Abraham J. Potential health implications associated with particulate matter exposure in deployed settings in Southwest Asia. Inhal Toxicol. 2009;21:291–6.CrossRefGoogle Scholar
  20. 20.
    Abraham JH, DeBakey SF, Reid L, et al. Does deployment to Iraq and Afghanistan affect respiratory health of US military personnel? J Occup Environ Med. 2012;54(6):740–5.CrossRefGoogle Scholar
  21. 21.
    Szema A, Mirsaidi N, Patel B, Viens L, Forsyth E, Li J, et al. Proposed Iraq/Afghanistan war-lung injury (IAW-LI) clinical practice recommendations: national academy of sciences’ institute of medicine burn pits workshop. Am J Mens Health. 2017;11(6):1653–63.CrossRefGoogle Scholar
  22. 22.
    Saers J, Ekerljung L, Forsberg B, Janson C. Respiratory symptoms among Swedish soldiers after military service abroad: association with time spent in a desert environment. Eur Clin Respir J. 2017;4(1):1327761.CrossRefGoogle Scholar
  23. 23.
    Murray CK, Wilkins K, Molter NC, Li F, Yu L, Spott MA, et al. Infections complicating the care of combat casualties during operations Iraqi Freedom and Enduring Freedom. J Trauma. 2011;71(Sup 1):S62–73.CrossRefGoogle Scholar
  24. 24.
    Del Vecchio SP, Collen JF, Zacher LL, et al. The impact of combat deployment on asthma diagnosis and severity. J Asthma. 2015;52(4):363–9.CrossRefGoogle Scholar
  25. 25.
    Prezant DJ, Weiden M, Banauch GI, McGuinness G, Rom WN, Aldrich TK, et al. Cough and bronchial responsiveness in firefighters at the world trade center site. N Engl J Med. 2002;347(11):806–15.CrossRefGoogle Scholar
  26. 26.
    Duplessis C, Gumpert B. Inhalational diesel exhaust exposure in submariners: observational study. Mil Med. 2008;173(7):671–6.CrossRefGoogle Scholar
  27. 27.
    Borander AK, Voie OA, Longva K, Danielsen TE, Grahnstedt S, Sandvik L, et al. Military small arms fire in association with acute decrements in lung function. Occup Environ Med. 2017;74(9):639–44.CrossRefGoogle Scholar
  28. 28.
    National Wildfire Coordinating Group. Wildland Fire Safety. Available online at: ; last accessed June 13, 2019.
  29. 29.
    Aldrich TK, Vossbrinck M, Zeig-Owens R, Hall CB, Schwartz TM, Moir W, et al. Lung function trajectories in World Trade Center-exposed new York City firefighters over 13 years. Chest. 2016;149(6):1419–27.CrossRefGoogle Scholar
  30. 30.
    McCreanor J, Cullinan P, Nieuwenhuijsen MJ, Stewart-Evans J, Malliarou E, Jarup L, et al. Respiratory effects of exposure to diesel traffic in persons with asthma. N Engl J Med. 2007;357(23):2348–58.CrossRefGoogle Scholar
  31. 31.
    Sibanda E, Makaza N. Health effects of diesel engine exhaust emissions exposure (DEEE) can mimic allergic asthma and rhinitis. Allergy, Asthma Clin Immunol. 2019;15:31.CrossRefGoogle Scholar
  32. 32.
    Riedl M, Diaz-Sanchez D. Biology of diesel exhaust effects on respiratory function. J Allergy Clin Immunol. 2005;115(2):221–8.CrossRefGoogle Scholar
  33. 33.
    Shykoff B, Peteryszyn J. Stability of pulmonary function in U.S. Navy Divers. Undersea Hyperb Med. 2004;31(4):385.PubMedGoogle Scholar
  34. 34.
    Tetzlaff K, Thomas P. Short and long-term effects of diving on pulmonary function. Eur Respir Rev. 2017;26(143):160097.CrossRefGoogle Scholar
  35. 35.
    Centers for Disease Control and Prevention. Current cigarette smoking among adults in the U.S. Available online at: ; last accessed June 13, 2019.
  36. 36.
    Centers for Disease Control and Prevention. Burden of tobacco use in the U.S. Available online at:; last accessed June 13, 2019.
  37. 37.
    Meadows SO, Engel CC, Collins RL, et al. 2015 Department of Defense Health Related Behaviors Survey (HRBS). Rand Health Q. 2018;8(2):5 Published 2018 Oct 11.PubMedPubMedCentralGoogle Scholar
  38. 38.
    Brown JM, Anderson Goodell EM, Williams J, Bray RM. Socioecological risks and protective factors for smoking among active duty US military personnel. Mil Med. 2018;183:e231–9.CrossRefGoogle Scholar
  39. 39.
    King CS, Moores LK. Clinical asthma syndromes and important asthma mimics. Respir Care. 2008;53(5):568–82.PubMedGoogle Scholar
  40. 40.
    Bernstein A, Gherasim A, Dao A. Confounders of severe asthma: diagnoses to consider when asthma symptoms persist despite optimal therapy. World Allergy Organ J. 2018;11:29.CrossRefGoogle Scholar
  41. 41.
    Morris MJ, Christopher KL. Diagnostic criteria for the classification of vocal cord dysfunction. Chest. 2010;138(5):1213–23.CrossRefGoogle Scholar
  42. 42.
    Gurevich-Uvena J, Parker JM, Fitzpatrick TM, Makashay MJ, Perello MM, Blair EA, et al. Medical comorbidities for paradoxical vocal fold motion (vocal cord dysfunction) in the military population. J Voice. 2010;24(6):728–31.CrossRefGoogle Scholar
  43. 43.
    Mikita JA, Mikita CP. Vocal cord dysfunction. Allergy Asthma Proc. 2006;27(4):411–4.CrossRefGoogle Scholar
  44. 44.
    Morris MJ, Oleszewski RT, Sterner JB, Allan PF. Vocal cord dysfunction related to combat deployment. Mil Med. 2013;178(11):1208–12.CrossRefGoogle Scholar
  45. 45.
    Hoy R. Work-related laryngeal syndromes. Curr Opin Allergy Clin Immunol. 2012;12(2):95–101.CrossRefGoogle Scholar
  46. 46.
    Haden JR, Khan DA. Psychiatric syndromes that mimic asthma. Adv Psychosom Med. 2003;24:72–85.CrossRefGoogle Scholar
  47. 47.
    Lev-Tzion R, Friedman T, Shochat T, Gazala E, Wohl Y. Asthma and psychiatric disorders in male army recruits and soldiers. Isr Med Assoc J. 2007;9(5):361–4.PubMedGoogle Scholar
  48. 48.
    Slatore CG, Falvo MJ, Nugent S, et al. Afghanistan and Iran war veterans: mental health diagnoses are associated with respiratory disease diagnosis. Mil Med. 2018;183(Issue 5–6):e249–57.CrossRefGoogle Scholar
  49. 49.
    Moore WC, Meyers DA, Wenzel SE, Teague WG, Li H, Li X, et al. Identification of asthma phenotypes using cluster analysis in the severe asthma research program. Am J Respir Crit Care Med. 2010;181:315–23.CrossRefGoogle Scholar
  50. 50.
    Ross MK, Yoon J, van der Schaar A, van der Schaar M. Discovering pediatric asthma phenotypes on the basis of response to controller medication using machine learning. Ann Am Thorac Soc. 2018;15(1):49–58.CrossRefGoogle Scholar
  51. 51.
    Shorr AF, Scoville SL, Cersovsky SB, et al. Acute eosinophilic pneumonia among US military personnel deployed in or near Iraq. J Am Med Assoc. 2004;294(24):2997–3005.CrossRefGoogle Scholar
  52. 52.
    Brooks SM. Occupational medicine model and asthma military recruitment. Mil Med. 2015;180:1140–5.CrossRefGoogle Scholar
  53. 53.
    Svenningsen S, Nair P. Asthma endotypes and an overview of targeted therapy for asthma. Frontiers in Medicine. 2017;4:158.CrossRefGoogle Scholar
  54. 54.
    Samitas K, Zervas E, Gaga M. T2-low asthma: current approach to diagnosis and therapy. Curr Opin Pulm Med. 2017;23(1):48–55.CrossRefGoogle Scholar
  55. 55.
    Esteban-Gorgojo I, Antolin-Amerigo D, Dominguez-Ortega J, Quirce S. Non-eosinophilic asthma: current perspectives. J Asthma Allergy. 2018;11:267–81.CrossRefGoogle Scholar
  56. 56.
    Howard R, Rattray M, Prosperi M, Custovic A. Distinguishing asthma phenotypes using machine learning approaches. Curr Allergy Asthma Rep. 2015;15(7):38.CrossRefGoogle Scholar
  57. 57.
    Pellegrino R, Viegi G, Brusasco V, Crapo RO, Burgos F, Casaburi R, et al. Interpretative strategies for lung function tests. Eur Respir J. 2005;26:948–68.CrossRefGoogle Scholar
  58. 58.
    Fretzayas A, Moustaki M, Loukou I, Douros K. Differentiating vocal cord dysfunction from asthma. J Asthma Allergy. 2017;10:277–83.CrossRefGoogle Scholar

Copyright information

© This is a U.S. Government work and not under copyright protection in the US; foreign copyright protection may apply 2019

Authors and Affiliations

  • Robert H. Wauters
    • 1
  • Brian E. Foster
    • 2
  • Taylor A. Banks
    • 3
    Email author
  1. 1.Allergy/Immunology/Immunizations ServiceWalter Reed National Military Medical CenterBethesdaUSA
  2. 2.Pulmonary Medicine DepartmentWalter Reed National Military Medical CenterBethesdaUSA
  3. 3.Division of Allergy/ImmunologyNaval Medical Center PortsmouthPortsmouthUSA

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