Citation Nr: 0211137 Decision Date: 09/03/02 Archive Date: 09/09/02 DOCKET NO. 94-48 468 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Phoenix, Arizona THE ISSUE Entitlement to a rating in excess of 30 percent for lower left lobectomy for bronchiectasis, with asthmatic bronchitis. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD C. Eckart, Counsel INTRODUCTION The veteran had active military service from November 1952 to November 1954. This case comes before the Board of Veterans' Appeals (Board) from a rating decision of March 1994 from the Chicago, Illinois, Regional Office (RO) of the Department of Veterans Affairs (VA), which denied entitlement to a rating in excess of 30 percent for service-connected left lower lobectomy for bronchiectasis. The veteran also appealed the March 1994 rating decision's denial of claims for service connection for other disabilities, including chronic obstructive pulmonary disease (COPD). These claims were favorably resolved by a January 2001 rating decision: however, as for the claim for COPD, the RO granted service connection for asthmatic bronchitis and added that diagnosis to the rating for the service-connected left lower lobectomy for bronchiectasis. The percentage rating for the pulmonary disability remained the same and is still on appeal. In September 2001, the Board remanded this matter to afford consideration of this case under the Veterans Claims Assistance Act (VCAA) and for additional development. The remand also directed the RO to ask the veteran whether its grant of service connection for asthmatic bronchitis satisfied his claim for service connection for coronary obstructive pulmonary disease (COPD). In a November 2001 letter the RO asked the veteran to state whether the grant of service connection for asthmatic bronchitis satisfied his service connection claim for COPD. The veteran replied in a December 2001 letter that he wished to continue the appeal of his COPD claim. The RO did not address this matter in its April 2002 supplemental statement of the case. The issue of entitlement to service connection for COPD will be addressed in the remand below. FINDINGS OF FACT 1. The duty to notify and assist the veteran has been satisfied and all the evidence necessary for an equitable disposition of his claim has been obtained by VA. 2. Active bronchiectasis is not current shown. 3. The primary component of the veteran's service connected pulmonary disability is asthmatic bronchitis, manifested by no more than moderate symptoms of asthma or moderately severe bronchitis; pulmonary function tests show forced expiratory volume in 1 second (FEV-1) of greater than 70 percent predicted, FEV-1/forced vital capacity (FVC) of greater than 70 percent, and Diffusion Capacity of the Lung for Carbon Monoxide by the Single Breath Method (DLCO (SB)) of greater than 65 percent predicted. CONCLUSION OF LAW A rating in excess of 30 percent for residuals of left lower lobectomy for bronchiectasis with asthmatic bronchitis is not warranted. 38 U.S.C.A. §§ 1155, 5107(a) (West 1991); 38 C.F.R. §§ 4.96, 4.97, Diagnostic Codes 6600, 6602 (1996); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.41, 4.96, 4.97, Diagnostic Codes 6600, 6602, (2001). REASONS AND BASES FOR FINDINGS AND CONCLUSION Factual Background Service medical records reflect that the veteran was repeatedly treated in service for respiratory problems. In December 1952 he was diagnosed with bronchiectasis, left, cause unknown. From January to June 1953 he was treated for pneumonia of the left lung. An April 1953 bronchogram report showed a bronchiectasis and obstruction and the summary showed a provisional diagnosis of persistent pneumonitis after 3 months and questionable bronchiectasis. Tests for coccidial infection were negative in February 1953. He was placed on profile in May 1953 for bronchiectasis. He was treated again from July 1954 to August 1954 for left lobe pneumonia. The record reflects that service connection for bronchiectasis was granted by the Des Moines, Iowa, RO in a February 1955 rating decision, which rated this disease as 30 percent disabling from November 19, 1954. VA hospital records reveal that the veteran was hospitalized from March 1955 to April 1955, and underwent a left-sided lobectomy for bronchiectasis. By a May 1955 rating decision the veteran's respiratory disability was recharacterized as left lower lobectomy for bronchiectasis and, following the assignment of a 100 percent rating based on hospitalization and convalescence, a 30 percent rating was resumed as of June 27, 1955. The veteran continued to receive treatment for respiratory problems. Private clinic records reflect that the veteran was referred to Carle Clinic in September 1988 for evaluation of his respiratory problems, with complaints of a "pleurisy type" pain every morning, and chest tightness aggravated by wood smoke and other irritants. He used Proventil daily to relieve the tightening sensation in his chest. He indicated that except when "plugged up" he didn't feel short of breath compared to other people. He gave a history of an emergency room visit for an asthma shot after driving through fields. His chest had scattered rhonchi bilaterally, more left than right, with loose large airways secretions and no expiratory wheezing sounds, and more rhonchial than a classic wheeze in character. The impression was underlying bronchiectasis without much auscultatory or X-ray evidence of major residuals. He had noted to have a bronchitis wheeze, and a question was raised as to whether this was due to minimal residual bronchiectasis or due to minimal asthma or just idiopathic bronchitis. He was also tuberculin positive. He was also noted to have had treatment for heart problems in the 1980s, and had undergone a coronary catheterization in September 1989, which yielded findings of coronary artery disease in one vessel and normal left ventricular function. The veteran was treated repeatedly in the early 1990s for recurrent respiratory problems with varying diagnoses. In February 1990, he was diagnosed with sinusitis/bronchitis. The following month, the diagnosis of bronchitis was noted to be questionable, and he continued with complaints of fatigue, cough and "sore diaphragm." In April 1990, the symptoms of cough and congestion had persisted for one month, with green sputum and fatigue still noted. The diagnosis in April 1990 was questionable Mycoplasma. He was also noted to be using a four season Proventil inhaler in April 1990. In February 1991, the veteran was seen for sinusitis/bronchitis. In November 1991, he complained of recently increasing wheezing and chest tightness. Bilateral rales and rhonchi were noted as was a prolonged respiratory phase with cough. The assessment was asthma and secondary infection. He was treated again for bronchitis in November 1992, with complaints of continued coughing and tiredness noted. In early December 1992, he was doing much better, with findings of a clear chest. The assessment was acute bronchitis, improved. On follow up later in the month he had complaints of fatigue, chest rattles and some clear sputum and was bronchitis was diagnosed. In January 1993, he again showed noisy bilateral rales on examination, and was noted to not be responding well to antibiotics, with a recurrence of bronchiectasis considered. A January 1993 chest X-ray showed no evidence of acute pathology. A March 1993 letter from D. Skilrud, M.D., a private pulmonary specialist, reflects that he had seen the veteran over the past six weeks in pulmonary consultation. He reviewed the veteran's medical history, which included his military history as well as a smoking history of smoking 2 packs a day on and off for 30 years, until he quit smoking 15 years earlier. Dr. Skilrud reported that examination revealed scattered quiet wheezing and rhonchi in both inspiration and expiration with slowing on forced expiratory maneuvers. Office spirometry reportedly suggested mild to moderate obstruction. Dr. Skilrud noted that he showed the veteran how to use an extender tube with Proventil and treated him with a tapering prednisone course. On follow up the day the letter was written, the veteran felt greatly improved, and spirometry showed some improvement in flows, but still showed a mild obstructive component, to the extent that Dr. Skilrud felt there was a mild COPD with a bronchospastic component. The veteran was advised to continue with Proventil as needed. According to medical records that appear to be from the office of Grant Zehr, M.D., the veteran was seen in September 1993; there was a notation of bronchiectasis and he was found to have noisy respirations. His medications included Azmacort, prednisone and Proventil inhaler. In September 1993, the veteran filed a claim for an increased rating for his service- connected bronchiectasis. On October 20, 1993, the veteran was admitted to a private hospital with persistent audible bronchospasm after about 2 months of worsening symptoms, despite "aggressive outpatient therapy." On the day of admission he had called Dr. Skilrud and reported doing much worse so he was hospitalized, with Dr. Skilrud the attending physician. It was noted that the veteran had required frequent courses of prednisone over the last year and that on about October 15 he had been given parenteral Solu-Medrol in Dr. Skilrud's office. On admission he was treated with parenteral steroid and underwent a bronchoscopy that revealed thick viscous mucoid secretions. He was also placed on antibiotics after sputum culture yielded micrococcus. After the bronchoscopy the veteran seemed to improve quickly and prednisone was instituted in place of the parenteral steroid. He remained hospitalized for about nine days and at discharge his medications included Azmacort inhaler, Masacort, Keflex for another three days and Proventil inhaler. The final pulmonary diagnoses were known COPD with prominent bronchospastic component and current exacerbation, retained secretions, promoting bronchospastic exacerbation, now greatly improved, status post bronchoscopy, mild global reduction in left ventricular systolic function and echogenic left ventricular apical mass. In November 1993, the veteran underwent a VA examination for non-tuberculosis diseases and injuries. He related a history of pneumonia and bronchiectasis in the service, followed by a period of relatively good health for the next 30 years, and more recent problems with respiratory infections within the past five years. He complained of becoming winded from walking three blocks. He said he coughed some days more than others, and indicated that sometimes he coughed up a tablespoon of light green sputum within 24 hours. He took Proventil inhaler with an extender. On physical examination, the veteran's chest excursion was average, with soft coarse rales scattered throughout both lung fields. There was no evidence of any consolidation. His lower lobectomy scar was noted to be well healed. He reported having occasional sharp pains throughout his whole left chest lasting about a second, ever since his surgery. He indicated this might happen for a few days then not recur again for a few weeks to a month. He also stated that they pain subsided if he rubbed Ben Gay on his chest or was taking antibiotics. The diagnosis was chronic obstructive pulmonary disease and history of lower lobectomy. A November 1993 VA X-ray report shows an impression of COPD and residuals of prior surgery. VA pulmonary function tests of November 1993 were interpreted as showing normal airflow and with the exception of residual volume, normal volumes. A December 1993 letter from Dr. Skilrud confirmed that he had seen the veteran in his office that day, with coarse rhonchi and wheezes present in inspiration and expiration, diffusely and bilaterally. Dr. Skilrud restarted the veteran on 40-mg prednisone for a period of four days, then down to 10 mg. The veteran was also asked to continue on Proventil, Azmacort, and Nasacort, as well as other medications for non- respiratory problems. The veteran was scheduled to undergo a Mayo Clinic evaluation. The March 1994 rating decision on appeal confirmed the veteran's 30 percent rating for the left lower lobectomy and denied service connection for COPD. That rating decision also awarded a separate zero percent rating for resection of the left sixth rib from November 19, 1954. A March 1995 report from the Clinic for Chest Diseases reflects that the veteran was seen by John Donaldson, M.D., who reviewed the veteran's pulmonary history, including bronchiectasis in the 1950s, with more recent evidence of asthmatic bronchitis rather than bronchiectasis. The veteran reported having had frequent "colds" over he last several years treated with antibiotics, and it was noted that he was on prednisone in 1993. The veteran complained of coughing up a tablespoon to 1/2 cup of mucus every morning. Examination revealed quiet respiration, with what appeared not to be full excursions, and mild to moderate wheezing. In pertinent part, Dr. Donaldson noted that the veteran had had a CAT scan at the Mayo Clinic in December 1993, and that it did not show bronchiectasis but did show findings diagnosed as asthmatic bronchitis, with which Dr. Donaldson concurred. He also believed that there was an additional sinopulmonary syndrome from sinus infections creating a good deal of lung problems. He stated that any cold was likely to set off the veteran's lung condition and hospitalize him. Dr. Donaldson also recommended that the veteran try to stay off steroids due to potential diabetic problems. It was noted that pulmonary function tests showed FEV-1 of 62 percent of predicted and FVC of 57 percent of predicted. Dr. Donaldson considered the veteran to be "disabled." VA treatment records from 1995 to 1996 reflect that the veteran was seen in the pulmonary clinic in May 1995 with multiple diagnoses that included COPD and bronchiectasis status post left lobectomy. He complained of "pleurisy like" pains on the right side, with light green sputum, about 1/2 cup a day. In June 1995, he complained of "pleurisy" for 10 days, with symptoms of increased cough with sputum and occasional night sweats. He was diagnosed with pleurisy and COPD. He was seen in primary care clinic in October 1995 with complaints of chest congestion. An allergy clinic note also from October 1995 reflects that he had asthma, which was generally under control but with some flare-ups. In a March 1996 VA pulmonary clinic record the veteran's multiple medical problems were listed and included bronchiectasis, status post left lower lobectomy. It was noted that things were under control, although he had some coughing and rare wheezing. He could walk within limits. The assessment was improved. In April 1996, he was seen in endocrinology and was noted to have taken prednisone in 1993 for 6-7 months for COPD and sinusitis. A June 1996 rheumatology clinic note reflects a diagnosis of COPD/bronchial asthma. A September 1996 pulmonary clinic treatment note reflects that his symptoms were variable and dependent on the weather, and that he could often walk within limits. He still coughed up 1/4 cup of sputum per day. He had not been on any antibiotics in six months and was assessed as stable overall. He was advised to use postural drainage regularly. The VA treatment records reflect that between 1995 and 1996, his medications included Azmacort, Albuterol, Beconase, AeroBid, Serevent, TMP/Sulfa, Salmeterol, Captopril, Naproxene, beclomethasone and flunisolide. In May 1997 the veteran underwent a VA pulmonary examination. A history was taken of the veteran having had a left lower lobe resection in 1955 for bronchiectasis. His symptoms were noted to have cleared with this surgery. About 15 years prior to the examination the veteran developed symptoms of asthmatic bronchitis and began requiring Azmacort, prednisone and bronchialdilators by metered dose inhalers (MDIs). The veteran's pulmonary complaints were sputum production, with the need for postural drainage, multiple pulmonary medications and multiple courses of antibiotics, particularly in the winter, and early morning awakenings with sputum production. He was said to be allergic to cat dander and tree pollen. His current pulmonary medicines were albuterol, Salmeterol, flunisolide, beclomethasone nasal spray, pseudoephedrine, antihistamine. The last three medications were for allergic rhinitis. A CT scan from the Mayo Clinic in 1993 was noted to show no bronchiectasis. The examiner observed that the diagnosis at the Mayo was asthmatic bronchitis, with which he concurred. The pertinent past history was described as childhood pertussis followed by multiple pneumonia in service. The examiner noted that bronchiectasis commonly followed a severe childhood exanthem complicated by a bacterial infection, with the veteran's history noted to definitely suggest a severe precipitating pulmonary infection during basic training. It was noted that negative sinus films in 1955 and 1993 were indicators that he did not have an old cilia syndrome or some variant of Kartagener's syndrome. The veteran was noted to have moved to Arizona from Illinois because of frequent pulmonary problems for 15 years, which had improved after the move. He was shown have a positive reaction to tuberculin and coccidioidin. He was noted to have a mild ventricular dysfunction for which he received Coumadin. The examiner noted that a review of the pulmonary function tests indicated that the veteran's disability was not reflected in the degree of abnormality in the laboratory. The examiner said this was typical of bronchiectasis and also typical of asthmatic bronchitis, wherein the pulmonary function tests might be normal or nearly normal on any given day. Physical examination findings on the May 1997 VA examination revealed a well healed thoracotomy scar on the left and bilateral course rhonchi heard in the lung fields, more prominent on the left. Cardiac examination was unremarkable. The veteran was of normal weight and well developed. He continued to be employed as an accountant. The examiner noted that according to information in the record the veteran had stopped in smoking in 1978, after smoking 1 to 2 packs a day. This was said to be pertinent, in that asthmatic bronchitis was characteristically precipitated by smoking with or without complicating major infection at the outset. Review of chest roentgenograms was noncontributory. The veteran said he could walk three or four blocks on a good day. There were days he was breathless with much less exertion and nights when he struggled to raise sputum and he would sometimes have to do postural drainage for up to two hours. The impressions were left lower lobe resection for bronchiectasis, remote; asthmatic bronchitis; and coronary artery disease. Pulmonary function tests of April 1997 revealed the following scores. Forced expiratory volume in one second (FEV-1) of 77 percent of predicted pre-bronchodilator and 77 percent of predicted post-bronchodilator; FEV-1/Forced Vital Capacity (FVC) of 79 percent pre-bronchodilator and 77 percent post- bronchodilator; and Diffusion Capacity of the Lung for Carbon Monoxide (DLCO) of 97 percent predicted. The computerized interpretation was that spirometry was within normal limits. Lung volumes were within normal limits as was diffusion capacity. VA treatment records dated from 1997 to 2000 reflect that in May 1999, the veteran was taking the following for respiratory problems such as shortness of breath: Salmeterol inhaler, Albuterol inhaler, Flunisolide inhaler and sulfa. The assessment was mild COPD. In September 1999, the veteran was seen for a productive cough with yellow-green sputum and slight increase in shortness of breath. He had had a recent slight episode of sweating, with no rigors or chest pain. On examination there was bilateral wheezing without consolidation. The assessment was COPD. The veteran's list of respiratory medications in September 1999, continued to be the same as those shown in May 1999, with the exception of Salmeterol and sulfa, which were no longer on the list. Private treatment records from 1997 to 2000 reflect that Dr. Donaldson saw the veteran in March 1997 for mucus in his chest, although he was not really wheezy. Dr. Donaldson opted not to change much of his medication, but did prescribe one month of Accolate. In November 1998, the veteran was seen for bronchitis and a little pneumonitis, and was put on Cipro. He was also given a shot of Kenalog. The following month, he was still coughing up a bit, and was continued on Cipro. Dr. Donaldson thought he was doing well at this point. In March 1999, he was seen by Dr. Donaldson and was noted to still have some congestion. Physical examination showed some bronchitis and postnasal drip, and the assessment was sinusitis and bronchitis. Dr. Donaldson was going to put the veteran on a Z-Pac and gave him Kenalog only because the veteran was going on a trip to Hawaii. It was noted that in the future the veteran might need an aerosol steroid, although he was doing well overall. On follow up in April 1999, it was noted that the veteran had had a shot of Kenalog. Dr. Donaldson noted the veteran's blood pressure was a little high due to "white coat syndrome" and his chest was almost clear, with some little congestion. Dr. Donaldson felt the veteran was doing very well, and opted not to change anything, but gave the veteran a shot of Kenalog and planned to see him in four months. The veteran was noted to do much better with the weather change. The assessment was chronic bronchiectasis with an asthmatic component. On follow up in July 1999, a review of systems was negative and the veteran's only complaint was of coughing up a bit of mucus. When the veteran was seen by Dr. Donaldson in November 1999, his chest was clear, and he was doing well. In January 2000, the veteran was given Kenalog. In February 2000, he was seen with complaints of having gotten sick the day before, and was wheezing a bit. His chest was fairly clear and he was given a shot of Kenalog which the doctor noted "should help." He was advised to receive another shot before leaving on a trip to Hawaii in March, which was described as a long trip with dirty air. In March 2000, the veteran was noted to be planning a trip east and then one to Illinois. He was said to be doing well, although he complained of getting a little short of breath when he went out to empty the trash. He was given a shot of Kenalog. When the veteran was seen in July 2000, his lungs were noted to be doing well. Dr. Donaldson gave him some antibiotics because he was going away, to be used in case he had trouble. In November 2000, he was placed on Pulmicort for wheezing and some Serevent. He was noted to be doing well and not wheezing, but felt tight at times. In November 2000, the veteran underwent a VA respiratory ratings examination. The claims file was reviewed by the examiner, who noted the history of respiratory problems, beginning with pneumonia in service, followed by a 20 year period in which he did well, then began having recurrent respiratory problems again in the 1970s. His symptoms beginning from the 1970s were recurrent sinus infections that seemed to go into his chest, causing soreness and pleuritic type pain in his chest, some increased sputum, headache consistent with sinus infection and nasal discharge. He also developed a chronic slight cough, bringing up some green sputum on an almost daily basis. His worst problems were always during cold weather, which was why he moved to Arizona from Illinois in 1994 and after which he seemed to do better for a while. However, even when the weather turned cool he began to develop (respiratory) problems to the extent that during cold weather, he required an antibiotic injection and a week of antibiotic therapy, about once every six weeks. He was said to have asthmatic bronchitis, although he was unaware of wheezing. He had not required any hospitalizations or emergency treatment for respiratory distress. His shortness of breath was worse during an episode of infection, although to some extent it lasted year around. Even at his best, any strenuous activity such as walking more than a mile, or sexual intercourse tired him out. During times when he was having problems, or when the air quality was poor, he could be so short of breath that he could not walk around the block. Other than walking, he was not very active and he did not need to use stairs. His chest was said to tighten when he was exposed to wood smoke and other odors, especially perfumes. He was said to be mildly allergic to cats and dust and was noted to have a 1993 CT scan from the Mayo Clinic that was negative for bronchiectasis. Pulmonary function tests were said to show only mild abnormalities. His current medicine regimen included Albuterol inhaler, salmetrol inhaler, pseudoephedrine, flunisolide, cortisone inhaler for his lungs and beclomethasone spray for his lungs. A period of prednisone treatment in 1994 and 1995 was noted to have lasted for 6 months and was stopped because he developed hypoglycemia. He was noted to have no unexplained fevers and no weight loss. On physical examination, the veteran was noted to be hypertensive with blood pressure of 170/100, respiration was 18 and pulse was 80. He was well nourished and well developed. He was in no respiratory distress and was not using any accessory muscles of respiration. There was no cyanosis, clubbing or ankle edema. The appearance of the chest was normal, with a well healed thoracectomy scar noted. Breath sounds were intact throughout the lung fields, except for diminution of breath sounds at the left base, along with the lower lobectomy. The right chest was entirely clear, with no rales, rhonchi or wheezes. There was a broad area of crackles on the extreme lateral base. There was no evidence of right ventricular hypertrophy, and no significant murmur or gallop. The diagnoses were chronic bronchitis and sinusitis with a history of bronchiectasis, status post left lower lobectomy, and probable element of asthmatic bronchitis. An opinion as to the etiology of the veteran's lung disease was that the lobectomy did not cause his lung problem, although the absence of the left lower lobe would contribute to any ventilatory impairment. The bronchiectasis was viewed as more likely part of the same process still causing problems. The examiner noted that the veteran's tendency toward chronic bronchitis and chronic or recurrent sinusitis was probably why he developed bronchiectasis in the first place. Pulmonary function tests of November 2000 revealed the following scores. Forced Expiratory Volume in one second (FEV-1) of 91 percent of predicted pre-bronchodilator and 92 percent of predicted post-bronchodilator; FEV-1/Forced Vital Capacity (FVC) of 79 percent of pre-bronchodilator and 74 percent post- bronchodilator; and Diffusion Capacity of the Lung for Carbon Monoxide (DLCO) of 161 percent predicted. The computerized interpretation reflects that spirometry, lung volume and diffusion capacity were within normal limits. FVC was changed by 8 percent, which was interpreted as an insignificant response to bronchodilator. The physician's handwritten interpretation was in agreement. Chest X-rays of November 2000 showed no cardiomegaly or congestive change. Postoperative changes of the left posterior sixth rib were shown, as was blunting of the left costophrenic angle which was chronic. There was no definite acute infiltrate, effusion, consolidation, mass, cavitary lesion, congestive change or significant change in appearance as compared to the prior available chest film of April 1997. An addendum to the November 2000 report reflects the examiner's opinion that there was no evidence that the lobectomy had caused a significant problem or that the veteran currently had bronchiectasis. The examiner also noted that the diagnosis of chronic bronchitis and the probable asthmatic bronchitis episodes were probably related to the veteran's tendencies toward bronchitis, which were exhibited in the service. In light of the findings from the November 2000 VA examination, the RO granted service connection for asthmatic bronchitis in the January 2001 supplemental statement of the case. The RO then rated the bronchiectasis and asthmatic bronchitis as one disability. Private treatment records through 2001 reflect that the veteran continued to be seen by Dr. Donaldson and continued to do well overall. In May 2001, he was noted to have asthma but his chest was stable, his lungs were doing well, and he was advised not to golf during days when smog obscured the view of the mountains. It was noted that he had not been hospitalized in over a year. He would be traveling and was given Ceftin to take if he did not do well. In September 2001, his chest was doing fairly well. It was noted that he was on two Pulmicort and that he had periods of time "where he feels it." He was tried on Q-Var 80, two per day, and was told to taper down to one if he improved in a month. In December 2001 he returned for follow-up, and was doing well. He reported that he watched the mountains for air quality and mentioned playing golf with his wife. He was on AeroBid, and had not switched to Pulmicort yet. He was again to try Q-Var 80 to see if this helped. The assessment was stable COPD, and follow-up was scheduled for three months. In December 2001 the veteran underwent a VA respiratory rating examination. A claims file review was conducted, in which the examiner noted the veteran's history of bronchiectasis following "double pneumonia" in service and subsequent development of a chronic productive cough, further episodes of pneumonia, and a lobectomy in 1955. He was noted to have developed recurrent respiratory infections around 15 years earlier, and had moved to Arizona where he was said to do well in the dry summer months. Some days he was not short of breath at all and there was no limit to walking. During the summer months he coughed very little, with very little sputum. During the cold weather, he would cough up to two teaspoons a day, sometimes purulent in appearance. He would also become short of breath and develop infections that usually required antibiotic treatment. For the past two winters, he was noted to get a Kenalog shot once a month. Also, he had to use AeroBid, Seravent and albuterol on a very regular basis. His shortness of breath was such that any heavy exertion, such as briefly pushing a golfcart or walking two blocks, would cause shortness of breath. He had no activity induced wheezing. Chest tightness was triggered by a variety of environmental factors such as wood smoke, tobacco smoke, farm dust and perfumes. His allergy skin tests were only mildly positive. His weight was stable and appetite was good. He had no unexplained fevers or night sweats. A past history of pleuritic pain was noted, as were the CAT scan findings from Mayo Clinic in 1993 that were negative for bronchiectasis. He had no systemic symptoms such as anemia, weight loss or hemoptysis. Objective findings shown on the December 2001 VA examination were a weight of 184 pounds, blood pressure of 160/92, respiration of 20 per minute and pulse of 90 per minute. The veteran demonstrated tachypnea but did not use the accessory muscles of respiration, did not appear chronically ill and was not cyanotic. There was no clubbing or peripheral edema. Examination of the chest and lungs revealed a left thoracotomy scar. The diaphragm moved well and the chest was clear to percussion, except for some hyperresonance. The precordium was not hyperresonant. Breath sounds were intact through all lung fields. There was some left basiliar asymmetry consistent with the lower left lobectomy, that was a dullness and diminished breath sounds at the left base probably related to a higher diaphragm. There were no rales, rhonchi, wheezes or pleural friction rub. The impression was chronic asthmatic bronchitis and history of left lower bronchiectasis, now status post lobectomy. The December 2001 examiner commented that the veteran's dominant problem was chronic bronchitis with an asthmatic component, worse in the winter, with frequent infections, sometimes to the point of chronic infection all winter. At the time of this examination, it did not appear that the veteran had residual bronchiectasis or symptoms associated with chronic severe bronchiectasis. The examiner suspected that, despite past pulmonary function studies showing an element of asthma or bronchospasm, the veteran did not seem to have one or more attacks of severe asthma weekly or the equivalent of such, since his symptoms were characterized more by chronic dyspnea during winter, with some attacks brought on by specific irritants. It was noted that further comments would be made after review of CAT scan and pulmonary function test results. Pulmonary function tests of December 2001 revealed the following scores. Forced Expiratory Volume in one second (FEV-1) of 90 percent of predicted pre-bronchodilator and 89 percent of predicted post-bronchodilator; FEV-1/Forced Vital Capacity (FVC) of 77 percent pre-bronchodilator and 77 post- bronchodilator; and Diffusion Capacity of the Lung for Carbon Monoxide (DLCO) of 120 percent predicted. The results were interpreted as showing no obstructive defect or evidence of restriction despite the left lower lobectomy. Diffusing capacity was normal, and no significant change from November 2000 was shown. Thereafter the clinical examiner commented that a CT scan of the veteran's chest supported the impression that there was very little residual of any bronchiectasis, with extremely minimal bronchiectatic change in the lower lobes. The examiner noted that the pulmonary function tests suggested that there was no restriction or obstruction but that with increased FRC and residual volume, his interpretation of the results was that there was obstructive disease and that there was mild COPD with episodes of asthmatic bronchitis. The examiner stated that the predominant respiratory difficulty was the obstructive disease, with little evidence of residual bronchiectasis. The obstruction was described as "mild" and aggravated in the winter by infections. A probable asthmatic component was also noted. The examiner concluded that the veteran did not have severe ventilatory impairment and did not have severe dyspnea on exertion between attacks. In March 2002, the December 2001 examiner reviewed the claims file and the prior examination. The examiner concluded that the veteran's obstructive lung disease was not likely to have been a progression of the service-connected left lower lobectomy for bronchiectasis; based on history and examination, the veteran did have chronic asthmatic bronchitis, which was not just a change in nomenclature for the veteran's service connected respiratory disease, and no separate diagnosis of obstructive lung disease. The examiner concluded that the diagnosis was chronic asthmatic bronchitis, and this condition was responsible for what obstruction was evident; thus, the obstructive lung disease did not represent a new entity. It was noted that these conclusions were based on the history of the veteran's symptoms having cleared after his lobectomy, without recurrence until 15 years ago. The veteran's smoking history was another major factor noted. Finally, there was little evidence of any residual bronchiectasis on CT scan. The examiner's summary was that the veteran had chronic asthmatic bronchitis with little evidence of obstruction or restriction by pulmonary function studies, except that he had increased residual volume percent indicative of some mild obstruction, consistent with chronic asthmatic bronchitis. The examiner further noted that the term obstruction or obstructive disease merely referred to the changes of asthmatic bronchitis. Legal Criteria Disability evaluations are determined by the application of a schedule of ratings which is based on average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4, § 4.1. Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbation's or illnesses proportionate to the severity of the several grades of disability. 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4 (2001). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability more closely approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. When, after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability, such doubt will be resolved in favor of the veteran. 38 C.F.R. § 4.3. In the evaluation of service-connected disabilities the entire recorded history, including medical and industrial history, is considered so that a report of a rating examination, and the evidence as a whole, may yield a current rating which accurately reflects all elements of disability, including the effects on ordinary activity. 38 C.F.R. §§ 4.1, 4.2, 4.10, 4.41. The United States Court of Appeals for Veterans Claims (Court) has held that, where entitlement to compensation has already been established, and an increase in the disability rating is at issue, the present level of disability is of primary concern. Although a rating specialist is directed to review the recorded history of a disability in order to make a more accurate evaluation, the regulations do not give past medical reports precedence over current findings. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Where regulations change during the course of an appeal, the Board must determine, if possible, which set of regulations, the old or the new, is more favorable to the claimant and apply the one more favorable to the case. Karnas v. Derwinski, 1 Vet. App. 308 (1990). The regulations regarding evaluation of the respiratory system were changed effective October 7, 1996. The provisions of 38 C.F.R. § 4.96(a), in effect prior to October 7, 1996, state that when rating coexisting respiratory conditions, ratings under diagnostic codes 6600 to 6618 will not be combined with each other. A single evaluation will be assigned under the diagnostic code which reflects the predominant disability picture, with elevation to the next higher evaluation where the severity of the overall disability warrants such elevation. 38 C.F.R. § 4.96 (a) (1996) Under 38 C.F.R. § 4.96 currently in effect, ratings under diagnostic codes 6600 through 6817, and 6822 through 6847 will not be combined with each other. Where there is lung or pleural involvement, ratings under diagnostic codes 6819 and 6820 will not be combined with each other or with diagnostic codes 6600 through 6817 or 6822 through 6847. A single rating will be assigned under the diagnostic code which reflects the predominant disability, with elevation to the next higher evaluation where the severity of the overall disability warrants such elevation. See 38 C.F.R. § 4.96 (2001). A review of the rating schedule shows that under the prior regulations, Diagnostic Code 6816 provides a minimum 30 percent rating for a unilateral lobectomy. A maximum 50 percent rating is warranted when the lobectomy is bilateral. Regarding residual lung impairment, Diagnostic Code 6844 addresses post surgical residuals of a lobectomy. Under this code, a 30 percent rating is assigned when Forced Expiratory Volume in one second (FEV-1) is 56 to 70 percent predicted, or when the ratio of Forced Expiratory Volume in one second to Forced Vital Capacity (FEV-1/FVC) is 56 to 70 percent, or when; Diffusion Capacity of the Lung for Carbon Monoxide by the Single Breath Method (DLCO (SB)) is 56-65 percent predicted. A 60 percent evaluation is assigned under this code when FEV- 1 is 40 to 55 percent predicted, or; with FEV- 1/FVC of 40 to 55 percent, or; with DLCO(SB) of 40 to 55 percent predicted, or maximum oxygen consumption of 15 to 20 ml/kg/min (with cardiorespiratory limit). A 100 percent evaluation is warranted when the FEV-1 less than 40 percent of predicted value, or; the FEV-1/FVC is less than 40 percent predicted or; DLCO (SB) is less than 40-percent predicted, or; maximum exercise capacity less than 15 ml/kg/min oxygen consumption (with cardiac or respiratory limitation), or; cor pulmonale (right heart failure), or; right ventricular hypertrophy, or; pulmonary hypertension (shown by Echo or cardiac catheterization), or; episode(s) of acute respiratory failure, or; requires outpatient oxygen therapy. 38 C.F.R. § 4.96, Diagnostic Code 6844 (2001) Under the prior regulations for Diagnostic Code 6601, a 30 percent evaluation is warranted for moderate bronchiectasis manifested by persistent paroxysmal coughing occurring at intervals throughout the day and by abundant purulent and fetid expectoration, but with slight, if any, emphysema or loss of weight. A 60 percent evaluation is warranted for severe bronchiectasis with considerable emphysema, impairment of general health manifested by loss of weight, anemia, or occasional pulmonary hemorrhages; occasional exacerbations of a few days duration with fever, etc., are to be expected, demonstrated by lipoidal injection and layer sputum test. A 100 percent rating is warranted when the disability is pronounced, with symptoms in aggravated form, marked emphysema, dyspnea at rest or on slight exertion, cyanosis, marked loss of weight or other evidence of severe impairment of general health. 38 C.F.R. § 4.97, Code 6601 (in effect prior to October 7, 1996). Under the amended version of Diagnostic Code 6601, a 30 percent evaluation is warranted for bronchiectasis when the disability is manifested by incapacitating episodes of infection of two to four weeks total duration per year, or; daily productive cough with sputum that is at times purulent or blood-tinged and requires prolonged (lasting four to six weeks) antibiotic usage more than twice a year. An incapacitating episode is defined as one that requires bed rest and treatment by a physician. A 60 percent rating is warranted for incapacitating episodes of infection of four to six weeks total duration per year, or; near constant findings of cough with purulent sputum associated with anorexia, weight loss, and frank hemoptysis and requiring antibiotic usage almost continuously. A 100 percent rating is warranted when there are incapacitating episodes of infection of at least six weeks total duration per year. For rating purposes, an incapacitating episode is one that requires bedrest and treatment by a physician. 38 C.F.R. § 4.97, Code 6601 (2001). Additionally, the amended version of Diagnostic Code 6601 further provides that bronchiectasis can also be rated according to pulmonary impairment as for chronic bronchitis (Diagnostic Code 6600). Under the prior rating criteria for bronchial asthma, a 100 disability rating is warranted if the symptoms are pronounced, with asthmatic attacks very frequently with severe dyspnea on slight exertion between attacks and with marked loss of weight or other evidence of severe impairment of health. A 60 percent rating is warranted for a severe disability, with frequent attacks of asthma (one or more attacks weekly), marked by dyspnea on exertion between attacks, with only temporary relief by medication and more than light manual labor precluded. A 30 percent evaluation is warranted when the condition is moderate, with asthmatic attacks rather frequent (separated by only 10-14 day intervals), with moderate dyspnea on exertion between attacks. Note: In the absence of clinical findings of asthma at time of examination, a verified history of asthmatic attacks must be of record. 38 C.F.R. § Diagnostic Code 6602 (1996). Under the current criteria of Diagnostic Code 6602 for bronchial asthma, a 30 percent rating is warranted for FEV-1 of 56 to 70 percent of predicted, or; FEV-1/FVC of 56 to 70 percent, or; where daily inhalational or oral bronchodilator therapy, or inhalational anti-inflammatory medication are required. A 60 percent rating is warranted for FEV-1 of 40 to 55 percent of predicted, or; FEV-1/FVC of 40 to 55 percent, or; at least monthly visits to a physician for required care of exacerbations, or; intermittent (at least three per year) courses of systemic (oral or parenteral) corticosteroids are required. A 100 percent rating is warranted for FEV-1 less than 40-percent of predicted, or; FEV-1/FVC less than 40 percent, or; more than one attack per week with episodes of respiratory failure, or; the requirement for the daily use of systemic (oral or parenteral) high dose corticosteroids or immuno-suppressive medications. In the absence of clinical findings of asthma at the time of examination, a verified history of asthmatic attacks must be of record. 38 C.F.R. § 4.97, Diagnostic Code 6602 (2001). Under the prior criteria for chronic bronchitis, 38 C.F.R. § 4.97, Diagnostic Code 6600 (1996), a 100 percent rating is warranted for pronounced bronchitis with copious productive cough and dyspnea at rest; pulmonary function testing showing a severe degree of chronic airway obstruction; with symptoms of associated severe emphysema or cyanosis and findings of right-sided heart involvement. A 60 percent rating is warranted for severe bronchitis with severe productive cough and dyspnea on slight exertion and pulmonary function tests indicative of severe ventilatory impairment. A 30 percent rating is warranted for moderately severe bronchitis with persistent cough at intervals during the day, considerable expectoration, considerable dyspnea on exercise, rales throughout the chest, and beginning chronic airway obstruction. Diagnostic Code 6600 (for chronic bronchitis), in effect since October 1996 (2001) provide that an FEV-1 less than 40 percent of predicted value, or; the ratio of FEV-1 to FVC (FEV-1/FVC) less than 40 percent, or; DLCO by the Single Breath Method (DLCO (SB)) less than 40-percent predicted, or; maximum exercise capacity less than 15 ml/ kg/min oxygen consumption (with cardiac or respiratory limitation), or; cor pulmonale (right heart failure), or; right ventricular hypertrophy, or; pulmonary hypertension (shown by Echo or cardiac catheterization), or; episode(s) of acute respiratory failure, or; requires outpatient oxygen therapy warrants a 100 percent rating. An FEV-1 of 40- to 55-percent predicted, or; FEV-1/FVC of 40 to 55 percent, or; DLCO (SB) of 40- to 55-percent predicted, or; maximum oxygen consumption of 15 to 20 ml/kg/min (with cardiorespiratory limit) warrants a 60 percent rating. An FEV-1 of 56- to 70- percent predicted, or; FEV-1/FVC of 56 to 70 percent, or; DLCO (SB) 56- to 65- percent predicted warrants a 30 percent rating. 38 C.F.R. § 4.97, Diagnostic Code 6600 (2001). Under the old rating criteria, chronic obstructive pulmonary disease was rated as emphysema under Code 6603 which provides a 30 percent evaluation for moderate pulmonary emphysema with moderate dyspnea occurring after climbing one flight of steps or walking more than one block on a level surface and pulmonary function test results which are consistent with finding of moderate emphysema. A 60 percent evaluation requires severe pulmonary emphysema manifested by exertional dyspnea sufficient to prevent climbing one flight of steps or walking one block without stopping, ventilatory impairment of severe degree confirmed by pulmonary function tests and a marked impairment of health. 38 C.F.R. § 4.20. Diagnostic Code 6603 (1996) Under the current criteria, chronic obstructive pulmonary disease warrants a 60 percent rating when there is FEV-1 of 40- to 55-percent predicted, or; FEV-1/FVC of 40 to 55 percent, or; DLCO (SB) of 40- to 55-percent predicted, or; maximum oxygen consumption of 15 to 20 ml/kg/min (with cardiorespiratory limit). A 30 percent rating requires FEV-1 of 56- to 70-percent predicted, or; FEV-1/FVC of 56 to 70 percent, or; DLCO (SB) 56- to 65-percent predicted. 38 C.F.R. § 4.97, Diagnostic Code 6604 (2001). Analysis There has been a significant change in the law during the pendency of this appeal. On November 9, 2000, the Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (2000) (codified as amended at 38 U.S.C.A. § 5100 et seq. (West Supp. 2001)) became law. This law redefined the obligations of VA with respect to the duty to assist and included an enhanced duty to notify a claimant as to the information and evidence necessary to substantiate a claim for VA benefits. This change in the law is applicable to all claims filed on or after the date of enactment of the VCAA, or filed before the date of enactment and not yet final as of that date. VCAA, § 7(a), 114 Stat. at 2099-2100 ; see also Karnas v. Derwinski, 1 Vet. App. 308 (1991). Additionally, VA has issued final rules to amend adjudication regulations in order to implement the provisions of the VCAA. See 66 Fed. Reg. 45,620 (Aug. 29, 2001) (to be codified as amended at 38 C.F.R §§ 3.102, 3.156(a), 3.159 and 3.326(a)). The intended effect of the new regulations is to establish clear guidelines consistent with the intent of Congress regarding the timing and the scope of assistance VA will provide to a claimant who files a substantially complete application for VA benefits, or who attempts to reopen a previously denied claim. In this case, when the veteran claimed entitlement to an increased rating for his pulmonary disease, he identified the private medical care he had been receiving and the RO wrote to Drs. Zehr and Skilrud for the veteran's medical records. Subsequently, the extensive private medical records, along with medical reports and correspondence, were received from the veteran's treating physicians, including Dr. Donaldson. The RO also obtained the veteran's VA medical records and afforded him multiple rating examinations. Additionally, the veteran was provided with a copy of the rating decision on appeal explaining the RO's decision in his claim and statement of the case and supplemental statements of the case. The Board remanded this matter in September 2001 to allow the RO to comply with the new notice and duty to assist provisions under the VCAA. The remand advised the veteran of the provisions of the VCAA. Pursuant to the remand, the RO sent the veteran a letter requesting that he identify all recent records of treatment for his service connected disability, and provided him with medical release forms. The veteran returned a release form identifying records from Dr. Donaldson who treated him between 1994 and 2001. As noted above records from Dr. Donaldson have been obtained and are associated with the claims file. Thus, VA's duty to notify and assist the veteran has been satisfied and there is sufficient evidence of record to decide the claim. The veteran contends that he is entitled to an increased rating for his service connected lower left lobectomy for bronchiectasis, with asthmatic bronchitis. His representative specifically argues that although pulmonary function testing has overall been normal, the veteran's shortness of breath on exertion and his need to take multiple medications for his symptoms warrant an increased rating. During the pendency of this appeal, the Rating Schedule provisions pertinent to rating respiratory disorders were revised, effective October 7, 1996, as set out in the pertinent laws and regulations, above. The Board shall consider this claim under the pertinent codes that are most favorable to his claim. Karnas, supra. The veteran was originally service connected for a left lower lobectomy for bronchiectasis in 1955. His 30 percent rating has been in effect since that time. He subsequently received treatment during the pendency of this appeal for respiratory problems, diagnosed at different times throughout the 1990s as bronchitis, COPD, bronchiectasis, pleurisy, asthma and history of the lower left lobectomy. He was shown to have been treated for possible bronchitis as early as the 1980s, with recurrent bronchitis shown in the early 1990's. Asthma was also diagnosed in the early 1990's and he continued to carry a diagnosis of bronchiectasis and residuals of left lower lobectomy. Over the course of time, the evidence has shown a history of recurring respiratory infections which in October 1993 required hospital tretament. The evidence has shows the veteran to have had a steady course of medication therapy, primarily consisting of inhalant bronchodilators and inhalant steroid treatment throughout the years. Only on occasion does the evidence show that the use of systemic steroid treatment was required, such as during the October 1993 hospitalization and essentially as precautionary measures during the wintertime in 2000 and 2001. While the overall medical and industrial history of the veteran's disease is to be considered, his most recent level of disability is of primary concern in this increased rating case. Fransisco, Supra. The most recent evidence reflects that the primary component of the veteran's service-connected pulmonary disability is asthmatic bronchitis. This is reflected in the diagnoses in the May 1997, November 2000 and December 2001 VA examinations. The examiners in May 1997 and December 2001 diagnosed asthmatic bronchitis, and also diagnosed a history of left lower bronchiectasis, status post lobectomy. The examiner in the May 2000 examination diagnosed chronic bronchitis and sinusitis with a history of bronchiectasis, status post lobectomy and probable element of asthmatic bronchitis. This examiner thought that the veteran's bronchiectasis was part of bronchitis process, while the examiner in the December 2001 examination regarded the asthmatic bronchitis as a separate entity from the bronchiectasis. The November 2000 and December 2001 examiners determined that there was no current evidence of residual bronchiectasis. These diagnoses and conclusions were drawn following a review of all the available medical evidence in the claims file, in addition to examination of the veteran, and therefore outweigh any other conflicting recent diagnoses. In respect to asthmatic bronchitis, which, as noted, currently appears to be the predominant component of the pulmonary disability picture, the evidence does not show that the old or new rating criteria for a 60 percent rating for bronchitis, or for asthma, have been met or more nearly approximated. Pulmonary function tests on the three most recent VA examinations (1997, 2000 and 2001) have demonstrated results that do not meet the criteria for a 30 percent disability rating, under the revised criteria of Diagnostic Codes 6600, 6602, or 6844. All of these codes provide a 30 percent rating when pulmonary function results show FEV-1 of 56- to 70- percent predicted, or FEV-1/FVC of 56 to 70 percent, or DLCO (SB) of 56- to 65- percent. None of the pulmonary test results from the three most recent VA examinations meet those criteria. The evidence also does not show that the veteran's disability more closely approximates the revised criteria for a 60 percent evaluation for asthma under Diagnostic Code 6602. He is not shown to require monthly visits for required care of exacerbations, or three or more courses a year of systemic (oral or parenteral) corticosteroids. Although he has been followed by Dr. Donaldson between 1997 and 2001, and was administered Kenalog (steroid) injections on occasions in 1998, 1999 and 2000, on some of those occasions the medication was prophylactic in nature, such as in preparation for a long trip. Additionally, the evidence does not reflect that the veteran has required courses of systemic corticosteroids at least three times a year. Additionally, his visits were not shown to be monthly visits for exacerbations of symptoms. Overall he was found to be doing well, particularly by 2001, when Kenalog injections apparently were not administered and had not been hospitalized in over a year. The December 2001 VA examiner noted that the Kenalog shots were only administered in the winter. Additionally, the evidence does not show that the veteran's pulmonary disability warrants a 60 percent evaluation under the criteria of Diagnostic Code 6602 in effect prior to October 7, 1996, for asthma. The evidence shows that he does not have a severe disability with frequent asthmatic attacks one or more times a week, marked by dyspnea on exertion, with only temporary relief by medication and more than light manual precluded. To the contrary, in the more recent private treatment records from 1997 to 2001, he was often noted to be doing well overall, and was able to play golf and travel on long trips. His symptoms were noted to be aggravated from time to time by irritants and by cold weather, but in general he was described as doing well and at times his physician was quite pleased with his status. The December 2001 examiner noted that it did not seem the veteran had one or more attacks of severe asthma per week or the equivalent of such, since his symptoms were characterized by dyspnea during the winter, with some attacks caused by specific irritants. As noted above, the veteran does not meet the criteria of a 30 percent evaluation under the revised criteria for bronchitis, Diagnostic Code 6600, as shown on pulmonary function testing. Under the criteria of Diagnostic Code 6600 in effect prior to October 1996, a rating in excess of 30 percent is not warranted. The veteran's disability is not shown to be consistent with severe bronchitis, with persistent cough at intervals during the day, considerable expectoration, considerable dyspnea on exercise, rales throughout the chest and beginning chronic airway obstruction. The record overall reflects symptoms of such severity were usually temporarily due by factors such as weather or irritants, and not chronic in nature. His private treatment records reflect that in 2001, he was generally doing well, with a clear chest noted in September 2001. The December 2002 VA examination also did not reveal the veteran to appear chronically ill or cyanotic. His breath sounds were intact, with no rales, rhonchi, wheezes or pleural friction rub. If the veteran's disability were to be rated under the current or prior code for chronic obstructive pulmonary disease, he would not meet the criteria for a 60 percent rating. The current criteria are the same as those for bronchitis and require the same pulmonary function results. Under the old rating criteria, a 60 percent rating under the code for emphysema required a severe pulmonary disorder manifested by exertional dyspnea sufficient to prevent climbing one flight of steps or walking one block without stopping, ventilatory impairment of severe degree confirmed by pulmonary function tests and a marked impairment of health. In this case, pulmonary function tests have not shown a severe degree of impairment and there is no competent evidence of marked impairment of health. To the contrary, the medical records do not show a picture of significant impairment of the veteran's health due to his pulmonary disability. Rather, he generally has been shown to be doing well. Thus, his pulmonary disorder does not meet or more closely approximate the rating criteria for 60 percent under Diagnostic Code 6603 (1996). Regarding whether the veteran is entitled to an increased rating under either the old or new criteria for bronchiectstasis, the November 2000 and December 2001 VA examiners determined that there was no current evidence of residual bronchiectasis. However, even if the Diagnostic Code governing bronchiectasis were for application, the veteran's symptoms clearly do not rise to the level of a 60 percent evaluation under either the old or new Diagnostic Code 6601, set forth in the above legal criteria. He was consistently shown to be of a healthy weight, he was not anemic, he did not cough up blood, he did not have incapacitating episodes of infection of four to six weeks total duration per year, he did not have near constant findings of cough with purulent sputum and he was not shown to require almost continuous antibiotic usage. Likewise, entitlement to an increased rating is not shown for the residuals of a lobectomy, as he is already receiving the maximum for this disorder under the old criteria, Diagnostic Code 6816. His recent pulmonary function tests were not shown to meet even the criteria for a 30 percent rating under the revised Diagnostic Code 6844. A separate evaluation for the surgical scar from the lobectomy is also not for consideration as it is shown to be well healed, and not tender and painful. See Esteban v. Brown, 6 Vet. App. 259 (1994). Additional Consideration With respect to this claim, the Board observes that in light of Floyd v. Brown, 9 Vet. App. 88 (1996), the Board does not have jurisdiction to assign an extraschedular rating under 38 C.F.R. § 3.321(b)(1) in the first instance. The Board, however, is still obligated to seek all issues that are reasonably raised from a liberal reading of documents or testimony of record and to identify all pertinent theories of entitlement to a benefit under the law or regulations. In Bagwell v. Brown, 9 Vet. App. 337 (1996), the Court clarified that it did not read the regulation as precluding the Board from affirming an RO's conclusion that a claim does not meet the criteria for submission pursuant to 38 C.F.R. § 3.321(b)(1), or from reaching such conclusion on its own. In the veteran's case at hand, the RO considered the provisions of 38 C.F.R. § 3.321(b)(1) but did not find that an extraschedular rating was indicated. In the unusual case where the schedular evaluations are found to be inadequate, an extraschedular evaluation may be assigned commensurate with impairment in the average earning capacity due exclusively to the service-connected disability or disabilities. 38 C.F.R. § 3.321(b)(1). The veteran's service-connected respiratory disability has not been reported to markedly interfere with his employment, nor has it required frequent inpatient care. In fact, in December 2001it was noted that he had not been hospitalized for any lung disorder for over a year and the last documented hospitalization was several years ago. Additionally, the evidence shows that in May 1997, the veteran was working as an accountant at the age of 64. There is no evidence showing that the service-connected pulmonary disability results in "marked" interference with employment or otherwise presents an unusual or exceptional disability picture as to warrant referral of his case for consideration of extraschedular evaluation under the provisions of 38 C.F.R. § 3.321(b)(1). The Board has considered all pertinent sections of 38 C.F.R., Parts 3 and 4 as required by the Court in Schafrath, supra, but finds no other provision upon which to assign an increased evaluation. ORDER Entitlement to an evaluation of in excess of 30 percent for lower left lobectomy for bronchiectasis, with asthmatic bronchitis is denied. REMAND As noted in the introduction to this decision, the veteran perfected an appeal of the RO's March 1994 denial of service connection COPD. Subsequently, in a January 2001 determination, the RO awarded service connection for asthmatic bronchitis and informed the veteran that this grant resolved his claim for service connection for COPD. In the September 2001 remand the Board determined that further clarification was needed to determine whether the veteran's claim for entitlement to service connection for COPD was actually resolved by the grant of service connection for asthmatic bronchitis. The remand asked the RO to clarify the matter and to readjudicate the issue service connection for COPD if it remained on appeal. In a November 2001 letter the RO asked the veteran to state whether the grant of service connection for asthmatic bronchitis satisfied his claim for service connection for COPD. The veteran replied in a December 2001 letter that he wished to continue to pursue the appeal of his COPD claim. Thereafter this matter was returned to the Board without a clear readjudication of the issue of service connection for COPD. Although the criteria for COPD were discussed in the April 2002 supplemental statement of the case in evaluating entitlement to an increased rating for the service connected bronchiectasis, the "issue" and "decision" pertained only to the pending issue of an increase and the claim of service connection for COPD was not specifically readjudicated. The law requires full compliance with all orders in the Board's remand. Stegall v. West, 11 Vet. App. 268 (1998). Accordingly, this case is REMANDED to the RO for the following: 1. The veteran has the right to submit additional evidence and argument on the matter the Board has remanded to the RO. Kutscherousky v. West, 12 Vet. App. 369 (1999). 2. In regard to the issue of service connection for COPD, the RO should review the claims file and ensure that all notification and development action required by the VCAA is completed. 66 Fed. Reg. 45,620 (Aug. 29, 2001) (to be codified as amended at 38 C.F.R §§ 3.102, 3.156(a), 3.159 and 3.326(a)). In particular, the RO should ensure that the new notification requirements and development procedures contained in sections 3 and 4 of the Act are fully complied with and satisfied. Thus, if any additional development is indicated it should be accomplished. 3. Thereafter, the RO should review the record and if service connection for COPD remains denied the RO should issue to the veteran and his representative a supplemental statement of the case on the issue of entitlement to service connection for COPD. Thereafter, the case should be returned to the Board for further appellate action. The Board intimates no opinion as to the ultimate outcome of this matter. The veteran need take no action until otherwise notified. This claim must be afforded expeditious treatment by the RO. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See The Veterans' Benefits Improvements Act of 1994, Pub. L. No. 103-446, § 302, 108 Stat. 4645, 4658 (1994), 38 U.S.C.A. § 5101 (West Supp. 2001) (Historical and Statutory Notes). In addition, VBA's Adjudication Procedure Manual, M21-1, Part IV, directs the ROs to provide expeditious handling of all cases that have been remanded by the Board and the Court. See M21-1, Part IV, paras. 8.44- 8.45 and 38.02-38.03. JANE E. SHARP Member, Board of Veterans' Appeals IMPORTANT NOTICE: We have attached a VA Form 4597 that tells you what steps you can take if you disagree with our decision. We are in the process of updating the form to reflect changes in the law effective on December 27, 2001. See the Veterans Education and Benefits Expansion Act of 2001, Pub. L. No. 107-103, 115 Stat. 976 (2001). In the meanwhile, please note these important corrections to the advice in the form: ? These changes apply to the section entitled "Appeal to the United States Court of Appeals for Veterans Claims." (1) A "Notice of Disagreement filed on or after November 18, 1988" is no longer required to appeal to the Court. (2) You are no longer required to file a copy of your Notice of Appeal with VA's General Counsel. ? In the section entitled "Representation before VA," filing a "Notice of Disagreement with respect to the claim on or after November 18, 1988" is no longer a condition for an attorney-at-law or a VA accredited agent to charge you a fee for representing you.