Burn Pit Exposure Linked to Earlier Sleep Apnea Diagnosis in US Veterans

Key Takeaways

• Veterans with high burn pit smoke exposure (BPSE) were diagnosed with sleep apnea (SA) earlier, but did not have higher overall SA prevalence.
• In a cohort of more than 17 000 US veterans, the highest BPSE group had a 16% higher adjusted hazard of earlier SA diagnosis.
• Findings support earlier screening and surveillance for sleep apnea among heavily exposed post-9/11 veterans receiving VA care.

Burn pit smoke exposure during military deployment has been associated with chronic respiratory and cardiovascular disease, but its relationship with sleep apnea has remained uncertain. A large retrospective cohort study using Veterans Health Administration (VHA) electronic medical records and the Airborne Hazards and Open Burn Pit Registry evaluated whether BPSE influences sleep apnea prevalence, severity, or timing of diagnosis among US veterans.

Study Findings

The study analyzed 17 064 veterans enrolled in the Airborne Hazards and Open Burn Pit Registry who also had objective sleep study data available in the VHA electronic medical record. Participants had a mean age of 40.2 years, were predominantly male (89.6%), and had a high prevalence of post-traumatic stress disorder (58.3%). Obesity was common, with a mean body mass index of 31.4 kg/m².

Burn pit smoke exposure was quantified based on self-reported cumulative days of exposure during deployment and categorized into quartiles, ranging from no exposure to ≥245 days. Sleep apnea was defined using the apnea-hypopnea index (AHI) extracted from polysomnography or home sleep apnea testing reports via a validated natural language processing algorithm.

In unadjusted analyses, veterans in the highest BPSE quartile had higher odds of sleep apnea compared with unexposed veterans (OR 1.13). However, after adjustment for age, sex, body mass index, smoking status, PTSD, and comorbidity burden, this association was no longer statistically significant (adjusted OR 1.10; P=0.058). BPSE was also not associated with greater sleep apnea severity as measured by AHI.

Time-to-event analyses showed a different pattern. Veterans with the highest BPSE were diagnosed with sleep apnea significantly earlier than those with lower exposure. Median time to diagnosis was 8.8 years in the highest exposure group versus 11.1 years in the lowest. After multivariable adjustment, the highest BPSE quartile remained associated with earlier diagnosis (adjusted hazard ratio 1.16; 95% CI, 1.10–1.22), demonstrating a dose-dependent relationship.

Implications for Sleep Apnea Screening in Veterans

Sleep apnea is highly prevalent among US veterans and is associated with substantial cardiometabolic morbidity and health care utilization. Although this study does not support BPSE as an independent risk factor for developing sleep apnea, it suggests that heavily exposed veterans are identified and diagnosed earlier.

Possible explanations include BPSE-related airway inflammation accelerating symptom onset or increased healthcare engagement among exposed veterans. Regardless of mechanism, the findings highlight the importance of proactive screening strategies. Clinicians caring for post-9/11 veterans, particularly within the Veterans Health Administration, may consider prioritizing sleep apnea evaluation in those with extensive burn pit exposure histories.

Conclusion