Citation NR: 9736889 Decision Date: 10/31/97 Archive Date: 11/05/97 DOCKET NO. 97-20 132A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUE Entitlement to an increased rating for bronchial asthma, currently evaluated as 60 percent disabling. ATTORNEY FOR THE BOARD T. Mainelli, Associate Counsel INTRODUCTION The appellant had active service from May 1977 to June 1980, and from April 1982 to November 1988. This case comes before the Board of Veterans’ Appeals (Board) on appeal from an April 1996 rating decision, in which the St. Petersburg, Florida, Regional Office (RO) of the Department of Veterans Affairs (VA) declined to increase a disability rating of 60 percent for bronchial asthma. An additional issue which was developed for appeal was withdrawn by the appellant in his VA Form 9. CONTENTIONS OF APPELLANT ON APPEAL The appellant contends that he requires a high dosage of corticosteroids on a daily basis to treat bronchial asthma. DECISION OF THE BOARD The Board, in accordance with the provisions of 38 U.S.C.A. § 7104 (West 1991 & Supp. 1997), has reviewed and considered all of the evidence and material of record in the appellant's claims file. Based on its review of the relevant evidence in this matter, and for the following reasons and bases, it is the decision of the Board that, by a preponderance of the evidence, the appellant is entitled to an increased schedular evaluation of 100 percent for bronchial asthma. FINDINGS OF FACT 1. All relevant available evidence necessary for an equitable disposition of the appellant’s appeal has been obtained by the RO. 2. Treatment of the appellant’s bronchial asthma requires daily high dosages of corticosteroids. CONCLUSION OF LAW The schedular criteria for an evaluation of 100 percent for bronchial asthma have been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991 & Supp. 1995); 38 C.F.R. §§ 4.97, Code 6602 (1996). REASONS AND BASES FOR FINDINGS AND CONCLUSION As a preliminary matter, the Board finds that the appellant’s claim is “well-grounded” within the meaning of 38 U.S.C.A. § 5107(a). That is, he has presented a claim which is plausible. See Proscelle v. Derwinski, 2 Vet.App. 629, 631 (1992). Furthermore, the claims folder contains complete records of the appellant’s VA medical treatment and the appellant has undergone a recent VA examination. The record does not reveal any additional sources of relevant information which may be available concerning the present claim. The Board accordingly finds the duty to assist him, mandated by 38 U.S.C.A. § 5107, has been satisfied. In July 1988, a Medical Examining Board Report indicated that the appellant was treated for, and diagnosed with, bronchial asthma in service. His symptomatology included difficulty breathing, wheezing and coughing with mucoid expectoration. He had been hospitalized numerous times and had underwent surgery of the maxillary sinus. Although he took daily dosages of 20 to 25 mg of Prednisone, the asthma remained very difficult to control. He was medically discharged for bronchial asthma. Thereafter, he was granted service connection for bronchial asthma and was assigned a 10 percent disability rating in December 1988. Outpatient treatment reports, dated from April 1990 to December 1990, reveal treatment for bronchial asthma and sinusitis. Complaints included wheezing, constant coughing and production of yellow sputum. It was noted that the appellant had asthma with a steroid dependency. Throughout this time period, his prescription of Prednisone alternated between 6 to 60 mg per day. VA examination, dated January 1991, noted the appellant’s complaints of shortness of breath, wheezing, coughing and swelling. He took 20 mg of Prednisone daily in order to control his bronchial asthma. Diagnosis was chronic bronchial asthma, steroid dependent. Treatment included alternating dosages of 15 to 20 mg’s of Prednisone. Pulmonary function testing (PFT) revealed readings of FEV-1 of 39 percent of predicted value. Thereafter, his 10 percent disability rating was increased to 30 percent in April 1991. The appellant was hospitalized in March 1993 due to complaints of nausea, vomiting, fever, shortness of breath, cough and white sputum. He was given emergency room nebulizer treatments and started on intravenous steroids. He was kept on nasal cannula oxygen. He responded to treatment and was discharged with a prescription of Prednisone 60 mg a day to be tapered down to 30 mg every three days. Diagnosis was of asthma exacerbation, chronically steroid dependent. VA bronchial examination, dated May 1993, revealed that the appellant had been on Prednisone since 1988. Attempts to wean him off the corticosteroid had been unsuccessful. He experienced daily problems with asthma. While lying down at night, his symptomatology was exacerbated with shortness of breath. He claimed to have broken three ribs due to his attempts to expectorate sputum. He reported complications arising from the Prednisone use, which included painful joints, headaches, cataracts and a poor appetite. Examination revealed wheezes in the entire right lobe and some in the upper left lobe. He was negative for cor pulmonale or infectious disease. PFT showed mild to moderate obstruction with good bronchodilator results. Impression was of a ventilation defect with mild emphysema, possibly with a small reversible component. It was suggested that pulmonary vascular disease might be involved. Diagnosis was of severe asthma, steroid dependency. Thereafter, his 30 percent disability rating was increased to 60 percent in June 1993. Outpatient treatment reports, dated February 1993 to August 1993, revealed continued complaints of daily asthma attacks. Excluding his treatment in March 1993, his daily intake of Prednisone during this time period varied from 15 to 40 mg per day. It was noted that attempts to wean the appellant off Prednisone had been unsuccessful and that he had not been successfully below daily dosages of 30-35 mg of Prednisone since approximately four years earlier. PFT conducted in March 1993 showed FEV-1 readings of 56 percent of predicted value and FEV-1/FVC of 85 percent of predicted value. In August 1993, it was noted that his asthma was barely treatable despite “high dose steroids” consisting of 35 to 40 mg of Prednisone daily. VA examinations in February 1994 opined causal connections between the appellant’s cataracts, organic anxiety disorder and arthralgia of the knees and hips and his steroid usage. At this time, the appellant reported taking 60 to 100 mg of Prednisone a day. Thereafter, the appellant was granted service connection for cataracts, pain of the hips and a nervous condition, all secondary to steroid use, in May 1994. On VA examination, dated March 1996, the appellant complained of shortness of breath at all times. He had shortness of breath almost all night long and was unable to sleep at night. He indicated that he had shortness of breath from a walk of approximately 100 to 200 feet in distance. He arrived at work early so that he could relieve his shortness of breath after walking to the work area. He exhibited a dry cough most of the time with productive yellow or greenish sputum during episodes of sinusitis. Physical examination revealed that the appellant developed an increasing shortness of breath upon talking. His lungs were clear with good and symmetrical ventilation with increased expiratory phase. His extremities showed very mild clubbing with mild cyanosis of the nail beds. X-ray examination revealed normal to slightly increased lung volumes bilaterally without evidence of consolidation, masses or cavitary lesions. PFT revealed FEV- 1 of 47 and 51 percent of predicted value, pre and post- bronchodilator, respectively. FEV-1/FVC was 74 and 69 percent of predicted value, pre and post bronchodilator, respectively. Diagnosis included bronchial asthma with moderate obstructive lung disease with mild hypoxemia and chronic corticosteroid use due to his bronchial asthma. Thereafter, his 60 percent disability rating was continued in April 1996. Outpatient treatment reports, dated June 1995 to June 1996, show continued treatment for asthma and recurrent sinus problems. Symptomatology included dyspnea on exertion, wheezing, tightness in the chest, productive cough with dark sputum and yellow nasal discharge. Physician comment, dated June 1995, indicated that that the appellant had been on a “hi dose” of 40 mg of Prednisone. It was commented that the appellant had been steroid dependent for the last ten years and that he did not tolerate less than 30-40 mg of Prednisone per day. His asthma was considered resistant to multiple medications other than steroids. In April 1996, he exhibited a decreased diffusion capacity of carbon monoxide and his dosage of 30 to 40 mg of Prednisone was considered a “high dose” of steroids. In June 1996, the appellant experienced shortness of breath after walking 1 flight of stairs or 50 feet. He experienced tightness and wheezing. VA hyperpituitarism examination, conducted in August 1996, revealed the appellant’s complaints of daily asthma attacks and constant Prednisone use for the last ten years. He indicated that his asthma worsened with decreased Prednisone use. He complained of easy fatigability. Physical examination revealed lungs with decreased ventilation and scattered rhonchi. The appellant developed shortness of breath just from talking and getting up from the table. PFT showed expiratory flows 74.1 percent of predicted value and expired volume 62.3 percent of predicated value. Diagnosis was of bronchial asthma with moderate and restrictive chronic obstructive pulmonary disease with daily exacerbation and Cushing’s syndrome secondary to chronic corticosteroid use. Thereafter, the appellant was granted service connection for Cushing’s syndrome as secondary to Prednisone use in September 1996. By rating decision dated December 1996, his 60 percent disability rating was continued. Outpatient treatment reports, dated August 1996 to February 1997, showed continued treatment for bronchial asthma. In August 1996, the appellant was alternating dosages of Prednisone between 20 to 40 mg per day. In November 1996, he claimed to have pulled a rib muscle and cracked a rib due to coughing. In February 1997, the appellant claimed to have hurt his back due to coughing. In April 1997, the appellant was taking 20 mg of Prednisone a day alternating with 40/30 mg a day. Disability ratings are based on the average impairment of earning capacity resulting from disability. 38 U.S.C.A. § 1155 (West 1991); 38 C.F.R. § 4.1 (1996). Separate diagnostic codes identify the various disabilities. Where there is a question as to which of two evaluations shall be applied, the higher evaluations 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 (1996). The determination of whether an increased evaluation is warranted is to be based on a review of the entire evidence of record and the application of all pertinent regulations. See Schafrath v. Derwinski, 1 Vet.App. 589 (1991). The severity of a respiratory disability is ascertained, for VA rating purposes, by application of the criteria set forth in VA’s Schedule for Rating Disabilities, 38 C.F.R. Part 4 (1996) (Schedule). Currently, the appellant is rated under Diagnostic Code 6602 which contemplates bronchial asthma manifested by FEV-1 of 40- to 55-percent 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. A rating greater than that in effect would be appropriate for the disability at issue under the Schedule bronchial asthma manifested by FEV-1 less than 40 percent predicted, or; FEV-1/FVC less than 40 percent, or; more than one attack per week with episodes of respiratory failure, or; requires daily use of systemic (oral or parental) high dose corticosteroids or immuno-suppressive medications. In its evaluation, the Board must determine whether the weight of the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either event. However, if the weight of the evidence is against the appellant’s claim, the claim must be denied. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet.App. 49 (1990). In this case, the Board has reviewed the entire record, including the statements of record and medical evidence. This evidence shows that for many years, the appellant has suffered from steroid dependent bronchial asthma. Attempts to wean him from daily high levels of Prednisone have been unsuccessful. The current evidence shows, and there is medical opinion to the effect, that he is requires a high dosage of Prednisone (corticosteroid) on a daily basis. This being the case, he meets the criteria for a 100 percent rating under Diagnostic Code 6602. ORDER A 100 percent schedular evaluation for bronchial asthma is granted, subject to the criteria which govern the payment of monetary awards. NANCY I. PHILLIPS Member, Board of Veterans' Appeals NOTICE OF APPELLATE RIGHTS: Under 38 U.S.C.A. § 7266 (West 1991 & Supp. 1997), a decision of the Board of Veterans' Appeals granting less than the complete benefit, or benefits, sought on appeal is appealable to the United States Court of Veterans Appeals within 120 days from the date of mailing of notice of the decision, provided that a Notice of Disagreement concerning an issue which was before the Board was filed with the agency of original jurisdiction on or after November 18, 1988. Veterans' Judicial Review Act, Pub. L. No. 100-687, § 402, 102 Stat. 4105, 4122 (1988). The date which appears on the face of this decision constitutes the date of mailing and the copy of this decision which you have received is your notice of the action taken on your appeal by the Board of Veterans' Appeals. - 2 -