Citation Nr: 1224829 Decision Date: 07/17/12 Archive Date: 07/20/12 DOCKET NO. 06-25 200A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Nashville, Tennessee THE ISSUE Entitlement to service connection for a respiratory disorder, to include emphysema and chronic obstructive pulmonary disease (COPD), as a result of asbestos exposure. REPRESENTATION Veteran represented by: The American Legion WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD K. A. Kennerly, Counsel INTRODUCTION The Veteran served on active duty from February 1957 to March 1967 and from August 1972 to July 1982. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an October 2005 rating decision of the Nashville, Tennessee, Regional Office (RO) of the Department of Veterans Affairs (VA), which, inter alia, denied the Veteran's claim of entitlement to service connection for a respiratory disability. The Veteran submitted a notice of disagreement with this determination in January 2006, and timely perfected his appeal in June 2009. In March 2010, the Veteran presented sworn testimony before the undersigned Veterans Law Judge during a Board video conference hearing. A transcript of that proceeding has been associated with the Veteran's VA claims file. In May 2010, the Board denied the Veteran's claim of entitlement to service connection for a respiratory disability. The Veteran subsequently submitted a notice of appeal to the United States Court of Appeals for Veterans Claims (Court), indicating his disagreement with the denial of his claim. The Court issued a January 2011 Order vacating, in part, the May 2010 Board decision and remanding the appeal for readjudication consistent with the parties' Joint Motion for Remand (JMR). In June 2011, the Board remanded this claim for additional evidentiary development, consistent with the findings in the January 2011 JMR. Such development having been accomplished, the claim again comes before the Board for adjudication. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2011). See 38 U.S.C.A. § 7107(a)(2) (West 2002). FINDING OF FACT The preponderance of the evidence is against a finding that the Veteran currently suffers from a respiratory disorder, to include emphysema and COPD, which is the result of a disease or injury in active duty service or any incident thereof, to include asbestos exposure. CONCLUSION OF LAW A respiratory disorder, to include emphysema and COPD, was not incurred in or aggravated by active duty service. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1116, 1131 (West 2002 & Supp. 2011); 38 U.S.C.A. §§ 3.303, 3.304 (2011). REASONS AND BASES FOR FINDING AND CONCLUSION The Board has thoroughly reviewed all the evidence in the Veteran's claims file. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the evidence submitted by the Veteran or on his behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claims. The Veteran must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to the Veteran). The Board must assess the credibility and weight of all evidence, including the medical evidence, to determine its probative value, accounting for evidence, which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the Veteran. Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claims or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claims, in which case, the claims are denied. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). I. Duties to Notify and Assist With respect to the Veteran's claim decided herein, VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2011). When VA receives a complete or substantially complete application for benefits, it is required to notify the claimant and his representative, if any, of any information and medical or lay evidence that is necessary to substantiate the claim. See 38 U.S.C.A. § 5103(a) (West 2002); 38 C.F.R. § 3.159(b) (2011); Quartuccio v. Principi, 16 Vet. App. 183 (2002). In Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004) (Pelegrini II), the Court held that VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. Prior to initial adjudication of the Veteran's claim, a letter dated in June 2005 fully satisfied the duty to notify provisions. See 38 U.S.C.A. § 5103(a) (West 2002); 38 C.F.R. § 3.159(b)(1) (2011); Quartuccio, at 187. The July 2006 statement of the case also informed the Veteran of how VA determines the appropriate disability rating or effective date to be assigned when a claim is granted, consistent with the holding in Dingess/Hartman v. Nicholson. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Thereafter, the Veteran's claim was readjudicated in June 2009 and October 2009. See Prickett v. Nicholson, 20 Vet. App. 370 (2006). All the law requires is that the duty to notify is satisfied and that claimants are given the opportunity to submit information and evidence in support of their claims. Once this has been accomplished, all due process concerns have been satisfied. See Bernard v. Brown, 4 Vet. App. 384 (1993); Sutton v. Brown, 9 Vet. App. 553 (1996); see also 38 C.F.R. § 20.1102 (2011) (harmless error). In view of the foregoing, the Board finds that the Veteran was notified and aware of the evidence needed to substantiate his claim, as well as the avenues through which he might obtain such evidence, and of the allocation of responsibilities between himself and VA in obtaining such evidence. Accordingly, there is no further duty to notify. The Board also concludes VA's duty to assist has been satisfied. The Veteran's service treatment records and VA medical records are in the file. Private medical records identified by the Veteran have been obtained, to the extent possible. The Veteran has at no time referenced outstanding records that he wanted VA to obtain or that he felt were relevant to the claim. The duty to assist also includes providing a medical examination or obtaining a medical opinion when such is necessary to make a decision on the claim, as defined by law. The record indicates that the Veteran participated in a VA examination in September 2011, the results of which have been included in the claims file for review. The examination involved a review of the claims file, a thorough examination of the Veteran, and an opinion that was supported by sufficient rationale. Therefore, the Board finds that the examination is adequate for rating purposes. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007) (affirming that a medical opinion is adequate if it provides sufficient detail so that the Board can perform a fully informed evaluation of the claim). Given the foregoing, the Board finds that the VA has substantially complied with the duty to obtain the requisite medical information necessary to make a decision on the Veteran's claim. Additionally, the Board finds there has been substantial compliance with its June 2011 remand directives. The Board notes that the Court has recently noted that "only substantial compliance with the terms of the Board's engagement letter would be required, not strict compliance." See D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); see also Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (holding that there was no Stegall (Stegall v. West, 11 Vet. App. 268) violation when the examiner made the ultimate determination required by the Board's remand.) The record indicates that the Appeals Management Center (AMC) obtained outstanding VA treatment records, requested private treatment records, and scheduled the Veteran for VA respiratory examination, which he attended. The AMC later issued a supplemental statement of the case in April 2012. Based on the foregoing, the Board finds that the AMC substantially complied with the mandates of its remand. See Stegall, supra, (finding that a remand by the Board confers on the Veteran the right to compliance with its remand orders). Therefore, in light of the foregoing, the Board will proceed to review and decide the claim based on the evidence that is of record consistent with 38 C.F.R. § 3.655 (2011). As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of this case, the Board finds that any such failure is harmless. See Newhouse v. Nicholson, 497 F.3d 1298 (Fed. Cir. 2007). Importantly, the Board notes that the Veteran is represented in this appeal. See Overton v. Nicholson, 20 Vet. App. 427, 438 (2006). The Veteran has submitted argument and evidence in support of the appeal. Based on the foregoing, the Board finds that the Veteran has had a meaningful opportunity to participate in the adjudication of his claim such that the essential fairness of the adjudication is not affected. Accordingly, the Board will proceed to a decision on the merits as to the issues on appeal. II. The Merits of the Claims The Veteran contends that he currently suffers from a respiratory disorder, to include emphysema and COPD, which is the result of a disease or injury in service, including as due to asbestos exposure. Specifically, the Veteran contends that he was exposed to asbestos during his time aboard ships in the United States Navy. Governing Law and Regulations A disability may be service-connected if it results from an injury or disease incurred in, or aggravated by, military service. See 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. § 3.303 (2011). In order to establish service connection for the claimed disorder, there must be (1) medical evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) a causal connection between the claimed in-service disease or injury and the current disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999); see also Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). There is no specific statutory guidance with regard to asbestos-related claims, nor has the Secretary of VA promulgated any regulations in regard to such claims. However, VA has issued a circular on asbestos-related diseases. DVB Circular 21-88-8, Asbestos-Related Diseases (May 11, 1988) provides guidelines for considering compensation claims based on exposure to asbestos. The DVB circular was subsumed verbatim as § 7.21 of Adjudication Procedure Manual, M21-1, Part VI. (This has now been reclassified in a revision to the Manual at M21- 1MR, Part IV, Subpart ii, Chapter 2, Section C.) See also VAOPGCPREC 4-00 (Apr. 13, 2000). The adjudication of a claim for service connection for a disability resulting from asbestos exposure should include a determination as to whether or not: (1) service records demonstrate the veteran was exposed to asbestos during service; (2) development has been accomplished sufficient to determine whether or not the veteran was exposed to asbestos either before or after service; and (3) a relationship exists between exposure to asbestos and the claimed disease in light of the latency and exposure factors. See M21-1MR, Part IV, Subpart ii, Chapter 2, Section C, Subsection (h). In this regard, the M21-1 MR provides the following non-exclusive list of asbestos-related diseases/abnormalities: asbestosis, interstitial pulmonary fibrosis, tumors, effusions and fibrosis, pleural plaques, mesotheliomas of pleura and peritoneum, lung cancer, bronchial cancer, cancer of the larynx, cancer of the pharynx, cancer of the urogenital system (except the prostate), and cancers of the gastrointestinal tract. See M21-1 MR, part VI, Subpart ii, Chapter 2, Section C, 9 (b). The M21-1 MR also provides the following non-exclusive list of occupations that have higher incidents of asbestos exposure: mining, milling, work in shipyards, insulation work, demolition of old buildings, carpentry and construction, manufacture and servicing of friction products such as clutch facings and brake linings, and manufacture and installation of roofing and flooring materials, asbestos cement sheet and pipe products, and military equipment. See M21-1 MR, part VI, Subpart ii, Chapter 2, Section C, 9 (f). In Dyment v. West, 13 Vet. App. 141, 145 (1999), the Court found that provisions in former paragraph 7.68 (predecessor to paragraph 7.21) of former VBA Manual M21-1, Part VI, did not create a presumption of exposure to asbestos. Medical nexus evidence is required in claims for asbestos-related disease related to alleged asbestos exposure in service. See VA O.G.C. Prec. Op. No. 04-00. Analysis With respect to Shedden element (1), current disability, the Veteran has diagnoses of emphysema and COPD. See, B.A.H. Treatment Records, generally. Shedden element (1) has therefore been demonstrated. See Shedden, supra. The Board notes, however, that the Veteran has not been diagnosed with asbestosis. "Asbestosis is pneumoconiosis due to asbestos particles; pneumoconiosis is a disease of the lungs caused by the habitual inhalation of irritant mineral or metallic particles." See McGinty v. Brown, 4 Vet. App. 428, 429 (1993). M21-1 MR provides that a clinical diagnosis of asbestosis requires a history of exposure and radiographic evidence of parenchymal lung disease. Symptoms and signs include dyspnea on exertion, end-respiratory rales over the lower lobes, compensatory emphysema, clubbing of the fingers at late stages, and pulmonary function impairment and cor pulmonale that can be demonstrated by instrumental methods. See M21-1 MR, part VI, Subpart ii, Chapter 2, Section C, 9 (e). With respect to Shedden element (2), the Veteran and his representative have argued that the Veteran was exposed to asbestos during service. As noted in the law and regulations section above, asbestos exposure is a fact to be determined from the evidence. See Dyment, supra. Review of the Veteran's service treatment records is completely negative for any respiratory complaints or treatment. Additionally, his military occupational specialties (MOS) included being an equipment operator and an air controller. These types of MOS are not typically associated with asbestos exposure, as noted above. The Board accordingly finds that the Veteran did not have any respiratory complaints in service, nor was there any evidence that he was exposed to asbestos in service. Thus, element (2) of Shedden has not been satisfied. See Shedden, supra. The Board notes that in August 1996, A.J.S., D.O. reviewed a single chest x-ray for the Veteran. Dr. A.J.S. stated that this film showed pleural thickening, noting that this type of thickening was seen following asbestos exposure and was consistent with the diagnosis of pleural asbestosis. See Private Treatment Record, A.J.S., D.O., August 23, 1996. In December 1996, S.L.A., M.D. reviewed the Veteran's records and noted that he had served aboard ships while in the United States Navy. The previous x-ray report was noted (indicating bilateral pleural thickening) and Dr. S.L.A. opined that the Veteran suffered from asbestos-related pleural disease due to his "seafaring employment." See Private Treatment Record, S.L.A., M.D., December 19, 1996. In December 2001, a chest x-ray performed by VA indicated that the Veteran's heart was not enlarged and his trachea was midline. No adenopathy was seen, no air space disease was noted and there were no significant interstitial findings. There was hyperaeration of the lungs with flattening of the hemidiaphragmns, but there was no evidence of pleural thickening or pleural plaquing. It was noted that if further evaluation was necessary, a computed tomography (CT) scan would be useful. The overall impression of the Veteran's chest x-ray included evidence of hyperaeration and no evidence of asbestosis-related disorders. See B.A.H. Treatment Record, December 11, 2001. In January 2002, based on the aforementioned chest x-ray, physical examination and Pulmonary Function Testing (PFT), it was noted that the Veteran did not suffer from any bilateral pleural lung disease. See B.A.H. Treatment Record, January 2, 2002. Subsequent PFT in February 2002 again revealed normal spirometry. See B.A.H. Treatment Records, February 28, 2002. In March 2003, for the first time, chest x-rays revealed possible COPD and emphysema as well as probable bibasilar interstitial lung disease. See B.A.H. Treatment Record, March 5, 2003. Private treatment records from J.A.W., M.D., in July 2005, indicated that the Veteran participated in low dose CT as part of the National Lung Screening Trail for lung cancer detection. This testing was negative for lung cancer but the Veteran's diagnoses of emphysema and bronchiectasis were continued. See Private Treatment Records, J.A.W., M.D., July 7, 2005. In a January 2006 lay statement, the Veteran stated the ships he served on were old, had "miles of wire that collected tons of dust, some of it from asbestos that filled the air with flying dust every time the guns were fired." The Veteran also stated that he spent time chipping paint and sanding while aboard these ships. Specifically, when his ship was in the Navy yard for repairs, he stated that he had to "put up with the dust, the dirt filled the air..." See Veteran's Statement, January 11, 2006. The Veteran was afforded a VA respiratory examination in September 2011. At the time of the examination, the Veteran's chief complaint was progressive dyspnea over the prior 15 years. The dyspnea was exertional with no other identifiable aggravating or precipitating factors and no apparent seasonal variation. The Veteran noticed significant acceleration in the progression of the dyspnea with an attendant decrease in the exertional threshold over the prior two to three years. He noted that he could only walk approximately half of a block before he became uncomfortably dyspneac. He had an occasional cough that was periodically productive of clear sputum. Additionally, he experienced fleeting, sharp, sub-costal chest pain that was aggravated by coughing, but did not appear to be associated with the dyspnea. See VA Respiratory Examination Report, September 22, 2011. The VA examiner noted an August 1996 communication from A.J.S., D.O. to the Maritime Asbestos Legal Clinic Division of the Admiralty Law Firm, describing his findings on the aforementioned chest x-ray. Dr. A.J.S. stated that "[t]he film shows bilateral pleural thickening. Pleural thickening of this type is seen following asbestos exposure and is consistent with the diagnosis of pleural asbestosis." Upon physical examination, the Veteran was noted as profoundly centrally obese with reduced but symmetrical expansions of the chest. Examination of the lungs revealed diminished breath sounds to the bases, bilaterally, with no adventitious sounds or disturbances in conduction. PFT revealed mild to moderate restriction with no evidence of associated obstruction. Chest x-ray findings noted the Veteran's heart, pulmonary vessels, lungs and pleura were unremarkable except for aortic valvular replacement. Specifically, the VA examiner stated there was no evidence of asbestosis. The impression was no active cardio-pulmonary disease. A May 2011 chest CT scan (provided by the Veteran from V.U.M.C.) determined the Veteran to have centrolobular emphysema minimally increased since his last examination. There was a conglomerate of two noncalcified nodules in the periphery of the right upper lobe. Id. With respect to the Veteran's complaints of dyspnea on exertion, the VA examiner stated that more likely than not, this condition was multifactoral. Contributing derangements most likely included coronary artery and vavular heart disease, atrial fibrillation, morbid obesity with deconditioning, and COPD. The VA examiner noted that it was not possible to sort out precisely the relative contributions of these derangements to the Veteran's dyspnea. PFTs revealed mild restriction. The pattern of restriction was non-specific and could be due to intrinsic or extrinsic pulmonary disorders. Possible extra pulmonary disorders included obesity-related sub-diaphragmatic restriction and "effort artifact." There was no evidence of obstruction on spirometry or volumes assessments (i.e. air trapping). Id. With respect to possible asbestos exposure, the VA examiner stated that there were no radiologic findings recognized as sufficiently specific to support a presumptive diagnosis of asbestos-related pulmonary injury. "Despite the August 23, 1996 letter from the D.O. claiming such, no official radiologic report in the records presented make any mention of identified pleural thickening or plaques. Whatever the D.O. observed it was, more likely than not, was not asbestos related. Asbestos related pleural and interstitial disease does not appear then disappear." The VA examiner also determined that the Veteran's diagnosed emphysema-dominant COPD was based more on the radiologic findings and extensive smoking history than actual PFT derangements. This condition was considered more likely than not representative of a smoking-related injury and was unrelated to any claimed asbestos exposure. Id. With regard to Shedden element (3), nexus, the heart of the Veteran's claim appears to be his contention that he has suffered from a respiratory disability nearly continually since service. The Board is aware of the provisions of 38 C.F.R. § 3.303(b) relating to chronicity and continuity of symptomatology. Although the Veteran is competent to testify as to his symptoms, supporting medical evidence of a respiratory disorder, to include emphysema and COPD, is required to sustain a service connection claim based upon continuity of symptomatology. See Voerth v. West, 13 Vet. App. 117, 120-121 (1999) [there must be medical evidence on file demonstrating a relationship between the veteran's current disability and the claimed continuous symptomatology, unless such a relationship is one as to which a layperson's observation is competent]. Such evidence is lacking in this case. The Board is free to favor one medical opinion over another, provided it offers an adequate basis for doing so. See Evans v. West, 12 Vet. App. 22, 30 (1998); Owens v. Brown, 7 Vet. App. 429, 433 (1995). Here, the Board finds that the 1996 medical statements in support of the Veteran's claim lack credibility. While each statement purports to connect the Veteran's time in service to asbestos exposure, the subsequent evidence of record does not support this contention. Chest x-ray reports from B.A.H. dated in 2001, made no mention of pleural abnormalities. It was also noted that subsequent chest x-rays and CT scans dated in March 2003 and December 2003, respectively, also made no mention of pleural plaques. Further, the September 2011 VA examiner noted that a January 2000 B.A.H. discharge summary indicated that the Veteran smoked as many as three packs of cigarettes per day for the prior 50 years. Records from a July 2010 admission to V.U.M.C. also noted treatment of an extensive bibasilar pneumonia and specified a 50 pack per year smoking history. Id. Additionally, the September 2011 VA examiner provided a medical opinion based on a thorough review of the Veteran's claims file, an examination of the Veteran, and an explanation of the disabilities in question. Whether a physician provides a basis for his or her medical opinion goes to the weight or credibility of the evidence in the adjudication of the merits. See Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998). Other factors for assessing the probative value of a medical opinion are the physician's access to the claims folder and the thoroughness and detail of the opinion. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000). While the Board is aware that the September 2011 VA examiner was unable to provide a specific opinion as to the nature and etiology of the Veteran's diagnosed COPD, it is clear from the medical evidence of record that he does not suffer from this condition, or emphysema, as a result of exposure to asbestos in service. Accordingly, the Board affords the VA examination significant probative value. Further, there are no other competent medical nexus opinions of record. The only remaining evidence of record consists of the Veteran's lay assertions that he currently suffers from a respiratory disorder that is the result of asbestos exposure in active duty service. In essence, lay testimony is competent when it regards the readily observable features or symptoms of injury or illness and "may provide sufficient support for a claim of service connection." See Layno v. Brown, 6 Vet. App. 465, 469 (1994). See also 38 C.F.R. § 3.159(a)(2) (2011). In this regard, the Court has emphasized that when a condition may be diagnosed by its unique and readily identifiable features, the presence of the disorder is not a determination "medical in nature" and is capable of lay observation. In such cases, the Board is within its province to weigh that testimony and to make a credibility determination as to whether that evidence supports a finding of service incurrence and continuity of symptomatology sufficient to establish service connection. See Barr v. Nicholson, 21 Vet. App. 303 (2007). See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. Sept. 14, 2009) Medical evidence is generally required to establish a medical diagnosis or to address questions of medical causation; lay assertions of medical status do not constitute competent medical evidence for these purposes. See Espiritu v. Derwinski, 2 Vet. App. 492, 494 (1992). However, lay statements may serve to support a claim for service connection by supporting the occurrence of lay-observable events or the presence of disability or symptoms of disability subject to lay observation. See 38 C.F.R. § 3.303(a) (2011); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); see also Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006) (addressing lay evidence as potentially competent to support presence of disability even where not corroborated by contemporaneous medical evidence). In the present case, the Board finds that the Veteran is certainly competent to report on the fact that he was exposed to dust particles during service. See Davidson, supra; Buchanan, supra; Jandreau, supra. However, as there is no evidence of record to establish (a) that the aforementioned dust particles were actually asbestos and (b) that the Veteran suffers from a medically determined asbestos-related respiratory disease, the Board must find the Veteran's lay statements lack credibility. Further, asbestosis and other asbestos-related respiratory disorders are complex conditions and do not lend themselves to lay observation. As such, the Veteran's lay statements do not provide sufficient support for a claim of service connection." See Layno, supra; see also 38 C.F.R. § 3.159(a)(2) (2011). Based on the evidence detailed above, the Board finds that the Veteran's claim fails on the basis of Shedden elements (2) and (3). While the Board certainly empathizes with the Veteran's current condition, and does not doubt that it causes him significant hardship, the evidence simply does not support his contentions that he was exposed to asbestos in service and currently suffers from a respiratory disorder as a result thereof. In summary, for the reasons and bases expressed above, the Board concludes that the preponderance of the evidence is against the Veteran's claim of entitlement to service connection for a respiratory disorder, to include emphysema and COPD, as a result of asbestos exposure. The benefit sought on appeal is accordingly denied. ORDER Entitlement to service connection for a respiratory disorder, to include emphysema and COPD, as a result of asbestos exposure, is denied. ____________________________________________ J. A. MARKEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs