Citation Nr: 1722366 Decision Date: 06/15/17 Archive Date: 06/29/17 DOCKET NO. 12-29 357 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Houston, Texas THE ISSUES 1. Entitlement to service connection for chronic obstructive pulmonary disease (COPD), to include as secondary to service-connected lung cancer or allergic rhinitis. 2. Entitlement to service connection for restrictive lung disease, to include secondary to service connected disease or injury. 3. Entitlement to service connection for asthma, to include secondary to service connected disease or injury, REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD J. Juliano, Counsel INTRODUCTION The Veteran served on active duty from August 1954 to April 1958, and from August 1958 to July 1977. He had prior service in the New York Air National Guard from August 1953 to August 1954. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a February 2010 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Houston, Texas. In June 2016, the Veteran testified before the undersigned Veterans Law Judge at a videoconference Board hearing at the RO. A transcript of the proceeding has been associated with the claims file. In October 2016, the Board remanded the Veteran's claims for further development. These matters are now returned to the Board for further review. In light of the discussion and directives set forth in the October 2016 Board remand addressing both COPD and asthma, and in light of certain post-remand medical evidence, the Board has more properly recharacterized the issue on appeal to include service connection for both COPD and asthma. See Statement, November 2015; Hearing transcript, June 2016; VA medical opinion, December 2016. This appeal was processed using the VBMS paperless claims processing system. Accordingly, any future consideration of this appellant's case should take into consideration the existence of this electronic record. This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2016). 38 U.S.C.A. § 7107(a)(2) (West 2014). The issue of entitlement to service connection for asthma is addressed in the REMAND portion of the decision below and is REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. COPD was not manifest during service. COPD is not related to his active service. 2. COPD is not caused or made worse by a service connected disease or injury. CONCLUSIONS OF LAW 1. COPD was not incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.304 (2016). 2. COPD is not proximately due to or aggravated by a service-connected disease or injury. 38 C.F.R. §§ 3.102, 3.310 (2016). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Veterans Claims Assistance Act of 2000 (VCAA) The Board finds that VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C.A. §§ 5102, 5103(a), 5103A, 5106 (West 2014); 38 C.F.R. §§ 3.159, 3.326(a) (2016). The Board finds that notice letters dated in October 2009, March 2011, September 2011, March 2013, and July 2015 fully satisfied the notice requirements of the VCAA. See 38 U.S.C.A. § 5103(a). Regarding VA's duty to assist, all of the Veteran's service treatment records, VA treatment records, and private treatment records are all in the claims file. The Veteran has not identified any outstanding records for VA to obtain. VA's duty to assist also generally includes the duty to provide a VA examination or obtain a medical opinion when the record "(A) contains competent evidence that the claimant has a current disability, or persistent or recurrent symptoms of disability; and (B) indicates that the disability or symptoms may be associated with the claimant's active military, naval, or air service; but (C) does not contain sufficient medical evidence for the Secretary to make a decision on the claim." 38 U.S.C.A. § 5103A(d)(2); see also McLendon v. Nicholson, 20 Vet. App. 79 (2006); 38 C.F.R. § 3.159(c)(4) (2016). The Board finds an October 2009 VA examination report, and December 2016 VA medical opinion, taken together, to be adequate upon which to base a decision on the claim. The Veteran was examined, a history was elicited from him, the claims file was reviewed, and the examiners provided adequate rationales for their conclusions. While the Board also acknowledges July 2016 and October 2016 VA examination reports, these examinations did not address the Veteran's claim for COPD on appeal herein. In October 2016, the Board remanded the claim so that a VA medical opinion could be obtained because the October 2009 VA examiner did not address secondary service connection (or asthma), and because a July 2016 VA examination addressed the lung cancer only. Pursuant to the Board's remand directives, a December 2016 VA medical opinion was obtained, which examiner answered all of the questions posed by the Board relating to the Veteran's COPD. Also, the Veteran's more recent VA treatment records were obtained. Therefore, the Board finds that there has been substantial compliance with the Board's remand directives. While the Board acknowledges that the Veteran's representative recently alleged in the brief that the most recent December 2016 VA medical opinion was inadequate, the representative did not explain any particular inadequacy, and for the reasons explained above, the Board finds that the December 2016 VA medical opinion was in fact adequate, and no inadequacy is shown or indicated. In June 2016, the Veteran testified before the undersigned Veterans Law Judge at a videoconference Board hearing. A transcript of the proceeding has been associated with the claims file. At the Board hearing, the undersigned VLJ clarified the issues on appeal, explained the concept of service connection, elicited testimony on the elements necessary to substantiate the appeal, identified potential evidentiary defects, suggested the submission of certain additional evidence, and held the file open for 60 days to provide an opportunity to submit additional evidence. See 38 C.F.R. § 3.103(c)(2). Neither the Veteran nor his representative identified any shortcomings in fulfilling VA's duty to notify and assist. See Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). Therefore, for the above reasons, the Board finds the duties to notify and assist have been met, all due process concerns have been satisfied, and the appeal may be considered on the merits. II. Analysis Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131 (West 2014); 38 C.F.R. § 3.303(a) (2016). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d) (2016). To establish service connection, the evidence generally must show: "(1) the existence of a present disability, (2) in-service incurrence or aggravation of a disease or injury, and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service" - the so-called "nexus" requirement. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). "For claims received after June 9, 1998, a disability or death will not be considered service-connected on the basis that it resulted from injury or disease attributable to the veteran's use of tobacco products in service," including "cigarettes." 38 C.F.R. § 3.300(a) (2016); see also 38 U.S.C.A. § 1103 (West 2014). A veteran who "during active military, naval, or air service, served in the Republic of Vietnam during the period beginning on January 9, 1962, and ending on May 7, 1975, shall be presumed to have been exposed during such service to an herbicide agent, unless there is affirmative evidence to establish that the Veteran was not exposed to any such agent during that service." 38 U.S.C.A. § 1116(f) (West 2014); 38 C.F.R. § 3.307(a)(6)(iii) (2016). COPD is not, however, among those diseases listed in 38 C.F.R. § 3.309(e) for which service connection may be presumed due to herbicide exposure. The Veteran may nevertheless show entitlement to service connection for COPD on a direct basis, including as due to herbicide exposure. See Combee v. Brown, 5 Vet. App. 248 (1993). The Veteran served on active duty from August 1954 to April 1958, and from August 1958 to July 1977. He had prior Air National Guard service, as well as a period of inactive duty from May 1958 to August 1958. See DD Forms 214; AF Form 7 (inactive duty - uploaded May 2016 at p.40 of 44). The Veteran claims that he has COPD due to exposure to herbicide and secondhand smoke in service in Thailand and Vietnam. See Claim, January 2011 (claimed as "bronchitis"); Form 21-526, November 2015 (alleging herbicide exposure); Statements, October 2009 (secondhand smoke), March 2011 (claim to include COPD), and November 2015 (COPD due to secondhand smoke); August 2011 (TDY in Vietnam and Thailand). The Board will also address any implicit alternative theory of entitlement as secondary to his service-connected lung cancer or rhinitis. See Board remand, October 2016. Regarding his herbicide exposure, the Board acknowledges that the Veteran's personnel records show that he had service in Thailand, and in the Republic of Vietnam. See, e.g., TDY Order to Vietnam, November 1972 (received June 2016); STR, Thailand, August 1972 (received June 2014 at p.81 of 100). Based on his Vietnam service, herbicide exposure is presumed. See 38 C.F.R. § 3.307(a)(6). COPD is not, however, among those diseases listed in 38 C.F.R. § 3.309(e) for which service connection may be presumed due to herbicide exposure. The Veteran may nevertheless show entitlement to service connection for COPD on a direct basis, including as due to herbicide exposure. See Combee v. Brown, 5 Vet. App. 248 (1993). Prior to the Veteran's active service, an August 1953 letter from the Erie Health Department to the Veteran's Air National Guard unit shows that a chest x-ray revealed his pneumonic process had completely resolved and the Veteran's lungs were clear. See STRs, received June 2014 at p.37 of 84. The Veteran's service treatment records show he was hospitalized three times for pneumonia during his active service - in November 1954, from November 1956 to February 1957, and from June 1968 to July 1968. See STRs, received January 2010 at p.2, 19, and 24 of 87, and at p.30 of 91. With regard to his first period of active service, his pneumonia in November 1954 was noted at that time to be secondary to measles. During the second pneumonia hospitalization from November 1956 to February 1957, an abscess was shown on an x-ray (and it was noted to be healing or resolving). See STRs, received January 2010 at p.82 of 91; see also Board hearing transcript. A February 1957 chest x-ray revealed "complete resolution" of his pneumonia. See id. at p.80 of 91. A later November 1957 chest x-ray revealed no acute parenchymal process. See STRs, received January 2010 at p. 79 of 91. His April 1958 discharge examination report shows examination of his throat and lungs was normal, and he checked the boxes on his report of medical history denying any chronic cough, asthma, or shortness of breath. See id. at p.23-25 of 91. During his second period of active service, a January 1959 record shows he complained of a cough and purulent green sputum, and rule-out pneumonia was diagnosed. See STRs, received June 2014 at p.31 of 100. A January 1959 chest x-ray showed no significant abnormality. See STRs, received January 2010 at p.77 if 91. An October 1959 chest x-ray, however, revealed bronchopneumoniae in the left lower lung. See id. at p.76 of 91. A subsequent October 1959 chest x-ray revealed moderate, but not complete, clearing of the bronchopneumoniae process in the left lower lung. See id. at p.75 of 91. An April 1961 record shows the Veteran reported a productive cough after a cold for a week, and bronchitis was diagnosed. See STRs, received June 2014 at p.47 of 84. An April 1961 chest x-ray to rule out bronchitis and pneumonia showed increased bilateral or bronchovascular markings. See STRs, received January 2010 at p. 74 of 91. A subsequent April 1961 chest x-ray showed mild clearing of bilateral or bronchovascular markings, and no infiltrate. See id. at p. 73 of 91. A January 1965 chest x-ray showed no evidence of disease. See id. at p.70 of 91. June 1968 and July 1968 records show the Veteran was admitted for seven days for pneumonia. See STRs, received January 2010 at p.2 and 24 of 87. His September 1968 periodic report of medical history shows the Veteran denied a chronic cough or asthma, but did report shortness of breath and chest pain or pressure. See id. at p.41 of 87. A September 1968 periodic examination report shows examination of the Veteran's throat, and lungs and chest, was normal, although the examiner did note the Veteran's reported history of experiencing episodes of shortness of breath and chest pain since February 1968; and his episode of pneumonia in June 1968 with a "full recovery" was noted. See id. at p. 28 and 49 of 87. An April 1969 chest x-ray was normal. See STRs, received January 2010 at p.51 of 91. A February 1971 chest x-ray for a cough was negative. See id. at p.50 of 91. A January 1976 shows he was treated for an upper respiratory infection. See STRs, received June 2014 at p.62 of 100. His May 1971 and October 1975 periodic examination reports show examination of his throat, and lungs and chest, was normal, and chest x-rays were negative. See STRs, received January 2010 at p.45 and 47 of 87. His February 1977 retirement examination report shows that examination of the Veteran's throat, and lungs and chest, was normal, and a chest x-ray was negative. See STRs, received January 2010 at p.29 of 87. On his February 1977 retirement report of medical history, the Veteran checked the boxes indicating he experienced ear, nose, or throat trouble, and chest pain or pressure, but denied experiencing any chronic cough, asthma, or shortness of breath. Regarding his ear, nose, and throat, the clinician noted the veteran had hearing loss and allergic rhinitis. Regarding his reported pain or pressure in his chest, the clinician noted the Veteran reported he experienced sharp chest pains due to uncontrolled blood pressure. See id. at p.35 of 87. Post-service, an April 1996 chest x-ray associated with private treatment records of Dr. J.F. was unremarkable. See PTRs, received December 2009 at p.69 of 78. An August 1999 record from Dr. J.F. shows the Veteran complained of shortness of breath for four months since starting Hytrin medication for his hypertension, along with heart palpitations or racing and lightheadedness. See PTRs, received December 2009 at p.17 of 78. A stress echocardiogram test was performed, and diagnoses were recorded including "four-month history of light-headedness and dyspnea, most likely secondary to high-grade cardiac dysrhythmia." See id; see also San Angelo Community Medical Center, August 1999 (received March 2011 at p.9). An August 1999 chest x-ray showed no cardiopulmonary disease. See PTRs, received December 2009 at p.65 of 78. A January 2000 record shows Amiodarone (Cordarone) was prescribed. See id. at p.29. A March 2000 record shows the Veteran reported a nonproductive cough for four months. He was diagnosed with a nocturnal cough (primarily), "most likely an ACE inhibitor side reaction." See id. at p.31 of 78. Dr. J.F. noted the Veteran reported he quit smoking in 1983. See id. at p.37 of 78. A March 2000 chest x-ray showed his lungs were clear. See id. at p.67 of 78. An April 2000 record shows the Veteran reported a history of a cough for four months, that testing revealed severe restrictive lung disease, and that Dr. J.F. suspected the Veteran had "Cordarone-induced pulmonary disease with cough." See id. at p.43 of 78. An April 2000 chest x-ray showed the lungs were clear, and a plan to discontinue the Caradone was noted. See id. at p.41 of 78. A May 2000 record shows he reported still experiencing a little cough, but nothing like it was, which he attributed to allergies. See id. at p.37 of 78. A March 2000 Tricare record shows the Veteran reported a chronic cough, and he was referred to pulmonology. An April 2000 follow up record shows the pulmonologist, Dr. J.F., thought that the Veteran's Amiodarone medication was contributing to the cough and that it should be discontinued, which had not been done yet, and that he was told he had restrictive lung disease with only 40 to 50 percent of his lung capacity. It was noted that he quit smoking about 20 years prior. Diagnoses of restrictive lung disease, rule-out COPD/emphysema were recorded. See Tricare, received October 2009. A June 2009 private treatment record from Dr. D.G. shows diagnoses including COPD, most likely due to history of smoke exposure especially second hand smoke (around 23 years); also diagnosed was a chronic cough due to oak season allergies. A July 2010 VA treatment record shows the Veteran complained of shortness of breath and wheezing, a history of smoking for 20 years was noted and of using inhalers was noted, and an impression of COPD was noted. See VA treatment records, received April 2013 at p.58 of 85. A December 2011 letter from Dr. D.G., an asthma and allergy doctor, shows he wrote that he was treating the Veteran for COPD and allergic rhinitis since June 2008, and that the Veteran had "bronchial hyper-responsiveness" caused by his allergic rhinitis. An April 2013 private treatment record notes a nine to 10 year reported history of progressively worsening shortness of breath. He also reported frequent persistent coughing episodes, and significant nighttime coughing, and that it was aggravated by allergy season. Pre-bronchodilator spirometry revealed a mild restrictive pattern with FVC of 78 percent predicted. Lung volumes by single breath gas dilution and plethysmography revealed air trapping, noted as confirming obstructive lung disease as well. Diffusion capacity was 100% predicted. Diagnoses were recorded of shortness of breath, cough, and asthma unspecified (later noted as "significant bronchial asthma"). See PTRs, received November 2015 at p.2 of 36. A November 2013 private chest CT revealed a right lung nodule. See PTRs, received June 2016 at p.1. September 2015 private treatment records show the Veteran was diagnosed with adenocarcinoma of the right lower lung and that he underwent a right lower lobe resection or lobectomy . See PTRs, received November 2015 at p.9-12, and 24-25. He underwent a repeat procedure in June 2016, and a bronchoscopy and endobronchial valve placement and lavage in August 2016. See PTRs, received February 2017 at p.1; VA treatment records, received October 2016 at p.2 of 47; PTRs, received December 2016 at p.11 of 17. The Veteran was afforded an October 2009 VA examination, and a December 2016 VA medical opinion was obtained. The Board notes that July 2016 and October 2016 VA examination reports did not address the Veteran's COPD. The October 2009 VA examiner recorded a diagnosis of COPD, and noted it was recently diagnosed by a private physician after the Veteran sought treatment for a persistent cough. The examiner noted the Veteran's reported history of smoking for approximately 20 years (from 1957 to 1977) up to one pack per day, and that he "quit 5 times" during that time and ultimately quit in 1977. The examiner also noted his report of exposure to secondhand smoke in service. The examiner opined that the Veteran's COPD is not caused by or related to his active service. The examiner reasoned the COPD is most likely the result of the Veteran's history of smoking for 20 years. The examiner reasoned that the most common etiology of COPD is smoking, which is the case for the Veteran. While the examiner again acknowledged the Veteran's concerns about secondhand smoke, and while the examiner acknowledged that secondhand smoke can be a contributing factor of pulmonary conditions in non-smokers, the examiner opined that the effects of secondhand smoke are insignificant as compared to the direct effects of smoking. The December 2016 VA medical opinion (by a different examiner than the October 2016 VA examination report) shows the examiner noted an extensive review of the medical evidence, and opined that it is less likely than not that the Veteran's COPD is related to his active service, reasoning that there was no indication of any service related event or injury that would have caused his COPD. Rather, the VA examiner opined that it was due to the Veteran's history of smoking. The examiner had also noted that chest x-rays in 1996, 1999, and 2000 were unremarkable/normal or clear. Regarding secondary service connection, the examiner opined that it is less likely than not that the COPD is related in any way to the Veteran's service-connected lung cancer. The examiner reasoned that the COPD diagnosis predated the Veteran's lung cancer, and that it was his restrictive lung disease that likely bore a relationship to his lung cancer, not obstructive. The examiner further reasoned that there was no evidence in the record that his COPD was adversely impacted by his lung cancer, including the fact that there was no change in pulmonary function test results that implicated a worsening of his COPD after his lung cancer was diagnosed. The December 2016 VA examiner further opined that the COPD was not proximately due to or the result of his service-connected allergic rhinitis. The examiner reasoned that it is not possible for rhinitis to cause any COPD disease process, and that the Veteran had COPD long before allergic rhinitis was diagnosed. Regarding aggravation, the examiner opined it is less likely than not that the Veteran's allergic rhinitis aggravated his COPD. The examiner acknowledged that there was one doctor note (May 2011, Dr. D.G.) in which the doctor felt the bronchial hypersensitivity was making the COPD more symptomatic, and the examiner acknowledged that literature does indicate individuals with asthma may have an increased hypersensitivity in the bronchial airways due to rhinitis. However, the examiner noted that the literature is not as clear regarding any relationship to COPD. The examiner added that COPD gets worse with aging. In light of the above evidence of record, the Board finds that the preponderance of the evidence is against finding that the Veteran's COPD is related to his active service, or caused or aggravated by his service-connected lung cancer or allergic rhinitis with symptoms of bronchial hypersensitivity. The Board finds the opinion of the October 2009 and December 2016 VA examiners, taken together, to be the most probative evidence of record regarding the etiology of the Veteran's COPD based on the detailed rationale provided in the report. While the Board acknowledges that the June 2009 private treatment record of Dr. D.G. noted a diagnosis of COPD "most likely due to secondhand smoke exposure," the Board finds this notation regarding the etiology to be by far outweighed by the probative value of the December 2016 VA examiner, again, based on the level of detail in the examiner's opinion. Dr. D.G. provided no analysis or other rationale in that June 2009 treatment record, including failing to address the Veteran's history of smoking for 20 or more years, including during his active service (depending on the Veteran's varying reports of his quit date as in 1977, 1979, or 1983), and failing to address the lack of record of complaint and normal chest x-rays for over 20 years after his active service. The Board acknowledges the Veteran's contention that his COPD is due to Agent Orange exposure or secondhand smoke exposure in service, or to the lung abscess shown on x-ray in service. See Statements, October 2009 (secondhand smoke), December 2012 (Agent Orange); Board hearing transcript (abscesses). The Board also acknowledges the October 2009 buddy statement from D.R. in which he reported he served in three units with the Veteran between 1967 and 1975 and that there was secondhand smoke in poorly ventilated buildings. The Veteran and his buddy are certainly competent to facts, such as exposure to secondhand smoke and symptomatology, within their personal observation. See Layno v. Brown, 6 Vet. App. 465, 469 (1994). Ultimately, however, the Board finds the medical opinions of the October 2009 and December 2016 VA examiners, who attributed the Veteran's COPD to his history of smoking, to be by far more probative than the Veteran's lay opinion regarding etiology based on the detailed rationale provided with the VA examiner's opinion. Furthermore, the Board finds the Veteran's opinion that his COPD was incurred in service or otherwise is directly related to his active service to be incongruent with the contemporaneous medical evidence at the time he separated from both periods of active service, which contemporaneous, objective medical evidence the Board finds is by far more probative. At separation from both periods of active service, examination of his lungs was normal. It is also contradictory to the Veteran's own self reports at separation. At separation both times, he denied asthma or shortness of breath on his report of medical history. The Board adds that there is no medical evidence tending to link his COPD to his conceded herbicide exposure in Vietnam, or to the abscess shown on x-ray in 1957 (then-noted as healing or resolving). While the Board acknowledges that on his February 1977 retirement report of medical history, the Veteran checked the boxes indicating he experienced ear, nose, or throat trouble, and chest pain or pressure, the clinician elaborated that these complaints related to the Veteran's hearing loss, allergic rhinitis, and chest pains due to uncontrolled blood pressure. See STRs, received January 2010 at p.35 of 87. The Board notes the Veteran's January 2011 statement that he experienced respiratory symptoms since service. The Board, however, finds the credibility of this report is diminished by the normal separation examinations, the lack of any record of treatment for over 20 years after service, and by his own self report on his February 1977 report of medical history in which he specifically denied experiencing any asthma or shortness of breath. The Board also acknowledges the Veteran's report that he was told by a physician that his COPD is due to his bronchial problems or bronchial disease. See, e.g., Statement, January 2012. The Veteran is competent to relate what he has been told by a medical professional, such as a contemporaneous medical diagnosis, see Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2006). But, this lay/medical recounting is conclusory and is far less probative than the opinion that the Veteran's COPD is due to his history of smoking for around 20 years, including between 1957 and 1977. Regarding a recent July 2016 medical opinion by Dr. D.D., who wrote that the Veteran's lung adhesions are related to his pneumonia in service, the Board emphasizes that Dr. D.D. did not relate the Veteran's COPD to the adhesions, and there is otherwise no medical evidence of record linking the Veteran's COPD to the adhesions. In summary, the Board concludes that the preponderance of the evidence is against granting service connection for COPD; the benefit of the doubt rule is not for application. ORDER Entitlement to service connection for COPD is denied. REMAND The Board acknowledges that some treatment records indicate a possible relationship between the Veteran's restrictive lung disease and his hypertension medication or lung cancer. See, e.g., VA examiner's opinion, December 2016; PTR, April 2000 (received December 2009 at p.43 of 78). As discussed in the October 2016 Board remand, the Veteran has alleged that his COPD diagnosis was changed to asthma, and the Board remanded the claim to obtain a VA medical opinion to address the nature and etiology of his asthma (see April 2013 private treatment record), including to address direct service connection, and whether it may be secondary to his service-connected lung cancer or allergic rhinitis. Subsequently, an October 2016 VA examination was performed, which examiner diagnosed asthma but provided no etiological opinion. A December 2016 VA medical opinion by another VA examiner did not address the etiology of the Veteran's asthma except to note that literature does indicate individuals with asthma "may" have an increased hypersensitivity in the bronchial airways due to rhinitis, which is speculative. In that regard, the board also acknowledges that a December 2011 letter from Dr. D.G., an asthma and allergy doctor, shows he wrote that he was treating the Veteran had "bronchial hyper-responsiveness" caused by his allergic rhinitis. Therefore, the Board finds this matter should be remanded so that the December 2016 VA examiner may be asked to clarify whether the Veteran's asthma is directly related to his active service, including his reports of secondhand smoke, or whether it is caused or aggravated by his service-connected lung cancer or allergic rhinitis. Any relationship to the December 2011 notation of "bronchial hyper-responsiveness" should also be explained. Accordingly, the case is REMANDED for the following action: (Please note, this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2014). Expedited handling is requested.) 1. Ask the same VA examiner who provided the December 2016 VA examination report to review the entire claims file, including a copy of this remand, and to address the nature and etiology of the Veteran's asthma. The claims folder must be provided to the examiner for review in conjunction with the examination. The examiner should indicate whether it is "at least as likely as not" (meaning likelihood of at least 50%) that the Veteran has asthma that is related to his active service, including his reported history of secondhand smoke exposure in service. Also please ask the VA examiner to opine whether it is "at least as likely as not" (meaning likelihood of at least 50%) that the any asthma was caused or aggravated beyond the natural progress of the disease by his service-connected a) lung cancer, and b) allergic rhinitis. Please direct the examiner's attention to the December 2016 VA medical opinion that medical literature indicates that individuals with asthma may have an increased hypersensitivity in the bronchial airways due to rhinitis. Also, please ask the VA examiner to address any relationship between asthma and the December 2011 (Dr. D.G.) notation that the Veteran had "bronchial hyper-responsiveness" caused by his allergic rhinitis. A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. 2. Address the issue of entitlement to service connection for restrictive lung disease. 3. The AOJ should explain why that SSOC considers the rating criteria for asthma, when addressing the severity of lung cancer residuals. 4. Then, adjudicate the Veteran's claim. If the claim remains denied, the Veteran should be provided a Supplemental Statement of the Case (SSOC), and then the claim should be returned to the Board for further review. The Veteran has the right to submit additional evidence and argument on that matter. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. 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 38 U.S.C.A. §§ 5109B, 7112 (West 2014). ____________________________________________ H.N. SCHWARTZ Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs