Citation Nr: 1753985 Decision Date: 11/27/17 Archive Date: 12/07/17 DOCKET NO. 10-20 658 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUE Entitlement to service connection for asthma disorder, to include severe early emphysema. REPRESENTATION Veteran represented by: The American Legion ATTORNEY FOR THE BOARD B. Garcia, Associate Counsel INTRODUCTION The Veteran served on active duty from September 1969 to July 1971. This matter is before the Board of Veterans' Appeals (Board) from an October 2008 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). In February 2016, the Board reopened the Veteran's previously-denied claim for service connection for asthma and remanded the matter for development. Following the Board's remand order, a VHA medical opinion was obtained in May 2017. The Veteran was afforded a copy of the VHA opinion, and he submitted his response in October 2017. The Veteran specifically waived initial consideration of his response by the RO. As such, the Board may proceed to adjudicate the Veteran's claim. See 38 C.F.R. §§ 20.903, 20.1304. FINDINGS OF FACT 1. The preponderance of the evidence of record is against a finding that the Veteran has a current diagnosis of emphysema. 2. The Veteran's asthma disability clearly and unmistakably pre-existed his active military service, and it clearly and unmistakably was not aggravated beyond the natural progression of the disease during the Veteran's active military service. CONCLUSION OF LAW The criteria for service connection for asthma have not been met. 38 U.S.C. §§ 1110, 1111, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.306 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. Veterans Claims Assistance Act of 2000 (VCAA) and Stegall Compliance VA's duties to notify and assist claimants in substantiating a claim for VA benefits are found at 38 U.S.C. §§ 5100, 5102, 5103, 5103A, 5107, 5126 and 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). VA's duty to notify was satisfied by a letter dated in May 2008. See 38 U.S.C. §§ 5102, 5103, 5103A; 38 C.F.R. § 3.159. In a December 2015 brief, the Veteran's representative suggested that there were outstanding service treatment records (STRs) that were pertinent to the Veteran's claim. In February 2016, the Board remanded the Veteran's claim for the RO to attempt to obtain any outstanding STRs and personnel records. As noted in the Board's remand order, the record contained June 1969 reports of medical history and examination, a November 1974 VA memorandum providing that searches for the Veteran's STRs were otherwise unsuccessful, and a May 20008 PIES response reflecting that all available service treatment records had been sent to VA. The Board also remanded the Veteran's claim to afford him a VA examination. Following the Board's February 2016 remand, the RO requested outstanding STRs and personnel records. All available records were associated with the claims file in March 2016. These records did not contain additional STRs, and the Veteran was informed of such in the July 2016 SSOC. The Veteran was afforded a VA examination in April 2016. In a December 2016 brief, the Veteran's representative asserted that the examination was inadequate. As will be detailed below, the Board subsequently obtained a VHA opinion from a VA pulmonologist in May 2017. In light of this background, the Board finds that there has been substantial compliance with its February 2016 remand directives. 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 violation under Stegall v. West, 11 Vet. App. 268 (1998), when the examiner made the ultimate determination required by the Board's remand). Moreover, neither the Veteran nor his representative has raised any other issues with the duties to notify or to assist with respect to the instant claim. See Scott v McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board . . . to search the record and address procedural arguments when the veteran fails to raise them before the Board."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to duty to assist argument). II. Entitlement to Service Connection Legal Criteria Service connection may be granted for a disability resulting from disease or injury incurred in, or aggravated by, service. See 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). To establish a right to compensation for a present disability, a veteran must generally show: (1) the existence of a present disability; (2) the 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. E.g., Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). In general, a veteran is considered to have been in sound condition when examined and accepted for service, except as to defects, infirmities, or disorders noted on his entrance into service, or when clear and unmistakable evidence demonstrates that the disability existed prior to service and was not aggravated by service. See 38 U.S.C.A. § 1111; 38 C.F.R. § 3.304(b). The burden falls on VA to rebut the presumption of soundness by clear and unmistakable evidence that the disability was both preexisting and not aggravated by service. See Wagner v. Principi, 370 F.3d 1089, 1096 (2004). A preexisting injury or disease will be considered to have been aggravated by active service where there is an increase in disability during such service, unless there is a specific finding that the increase in disability is due to the natural progress of the disease. 38 U.S.C.A. § 1153; 38 C.F.R. § 3.306. Determinations regarding service connection are based on a review of all of the evidence of record, including pertinent medical and lay evidence. 38 U.S.C.A. § 1154(a); 38 C.F.R. § 3.303(a). Under certain circumstances, lay evidence may be sufficient to establish a medical diagnosis or nexus. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); see also Layno v. Brown, 6 Vet. App. 465, 469 (1994). When considering evidence and determining its probative value, VA considers both the competency and the credibility of the witness. See Layno, 6 Vet. App. at 469 (providing that "competency" is a "legal concept determining whether testimony may be heard and considered by the trier or fact" and that "credibility" is a "factual determination going to the probative value of the evidence"). To deny a claim for benefits on its merits, the preponderance of the evidence must be against the claim. See Gilbert v. Derwinski, 1 Vet. App. 49, 54 (1990) ("A veteran need only demonstrate that there is an 'approximate balance of positive and negative evidence' to prevail."). Factual Background The Veteran contends that he is entitled to service connection for asthma disorder, to include severe early emphysema. As reflected in his April 2008 informal claim, October 2008 notice of disagreement, May 2010 VA Form 9, and statements dated in October 2003, May 2008, and October 2017, the Veteran essentially maintains that his pre-existing asthma was aggravated by his military service. The Veteran provides that during his service aboard the USS Howard Gilmore, he worked in the laundry room, where the temperature exceeded 100 degrees, the air was not well-ventilated, and there was exposure to harsh chemicals. In an October 2003 statement, the Veteran maintained that he had a severe asthma attack in 1970 while aboard the ship. In an in October 2017 statement, the Veteran wrote that asbestos was placed around the pipes to control some of the heat coming from the pipes, and that asbestos was also used on the bulk head as a fire breaker. He maintained that there were days when he was kept in sick bay because he was short of breath and dehydrated, and nights when he could not sleep because he was having an asthma attack or was sick. He wrote that there were times when he spent two to three days sick in the laundry room because he was not allowed to go to sick bay. The Veteran also wrote that on one occasion, he went to sick bay, was given a shot, put on an I.V. for three days, and told that he was "very sick." The Veteran noted that he currently keeps an inhaler with him all times and that he has a "Pulmo-Aide" compact compressor that he uses three times per day. A November 1954 discharge report from the Lloyd Noland Hospital provides that the Veteran, then four years old, was a "known asthmatic." In a July 1969 letter, Dr. C. Goral wrote that the Veteran had been a known asthmatic since the age of four and that he had numerous visits to the clinic at Lloyd Noland Hospital due to asthma attacks. It was noted that his last visit was in June 1969, when he was given a prescription for a bronchodilator. In a June 1969 pre-induction report of medical history, the Veteran affirmed a history of asthma and shortness of breath. In the corresponding report of medical examination, the summary of defects or diagnoses includes a notation of "claims asthma, not documented." Following service, a May 1973 treatment record from Lloyd Noland Hospital provides that the Veteran had an asthma attack. On physical examination, his lungs exhibited scattered wheezes, but no localizing sounds. A February 1974 emergency department note from Mercy Hospital provides that the Veteran had infrequent attacks of asthma and that he awoke at 3 a.m. with wheezing and coughing. An April 1974 emergency department note from Mercy Hospital indicates that the Veteran woke up with shortness of breath and wheezing. On intake, the Veteran stated that he had asthma "all of his life." A chest X-ray was normal. The provisional diagnosis was acute asthmatic attack. A May 1986 emergency department note from Carraway Methodist Memorial Hospital indicates that the Veteran had a history of asthma and some recent episodes of shortness of breath. It was noted that he recently ran out of his inhaler. He was assessed with asthma. A July 1987 emergency department note from Carraway provides that the Veteran complained of a productive cough and flu symptoms. His lungs were clear, and the diagnosis was bronchitis and viral illness. A January 1995 treatment record from Dr. Moyo indicates that the Veteran's lungs revealed some rhonchi bilaterally and that a chest X-ray showed no acute infiltrates. The assessments included bronchitis, and the Veteran was asked to stop smoking. A May 1996 treatment record from Dr. Moyo provides that the Veteran complained of a headache, sore throat, body aches, and a dry cough. His chest was clinically clear. A chest X-ray showed no bony abnormalities, and lung fields appeared well-aerated with no acute infiltrates. The X-ray was normal, and there was no interval change from the January 1995 X-ray. The assessment was pharyngobronchitis. An April 2002 treatment record from Dr. Moyo provides that the Veteran tried to go back to work after a motor vehicle accident and had an asthma attack. He went to the emergency room and was given some "breathing treatment." He still had some chest tightness and shortness of breath. The impression was acute exacerbation of COPD, asthma, trauma to chest from motor vehicle accident. The plan was to continue bronchodilators and analgesics. A May 2002 treatment record from Dr. Moyo indicates that the Veteran complained of a cough. The impression was acute exacerbation of COPD, asthma, and multiple painful areas secondary to motor vehicle accident. The treatment plan included avoiding dusty environments. A May 2002 VA emergency department note provides that the Veteran recently quit smoking after many years and that he presented with his second asthma attack in three weeks. His primary symptoms were wheezing, shortness of breath, and cough, and they were partially relieved with his albuterol inhaler. It was noted that he recently returned to his welding job one month prior and that there were no new exposures. A chest X-ray showed mild hyperexpansion but no infiltrate. The diagnostic impression was asthma flare, possibly related to welding. Less than two weeks later, the Veteran was admitted to the Birmingham Baptist Medical Center for four days. The discharge report indicated that the Veteran did not currently smoke but that he worked in a welding plant, which seemed to trigger some of his breathing problems. A chest X-ray showed no active processes. The discharge diagnoses included acute exacerbation of COPD, status asthmaticus, and respiratory failure. At a June 2002 visit with Dr. Moyo, the Veteran still had a cough, but less shortness of breath than he did prior to his admission. The Veteran stated that he had not had any asthma attacks since 1993. He believed that the accident had something to do with the recurrence of asthma attacks. The impression was acute asthma, resolving. A July 2002 treatment record from Dr. Moyo provides that the Veteran's breathing was much better and that his asthma attacks were triggered by his work environment as a welder. The Veteran's lungs were clear, and the impression was acute exacerbation of COPD, much better after he stayed away from work environment. A July 2002 VA pulmonary clinic note provides that the Veteran had a history of childhood asthma that had waxed and waned throughout his life. It was noted that the Veteran was previously a welder, which exacerbated his symptoms, but that he quit this job two months prior. The Veteran was using flovent daily, and he used albuterol multiple times during the day. He would often awake at night with wheezing that responded to bronchodilators. He had a history of tobacco use, but quit earlier in the year. On examination, the Veteran's lungs were clear to auscultation bilaterally with quiet breathing, with end wheezes noted on forced expiration. The assessments included moderate persistent asthma with mild obstruction and hyperinflation, currently on flovent/albuterol. A September 2002 VA primary care note indicates that the Veteran worked as a welder, which affected his breathing. He had been started on an inhaler and felt that his breathing had improved. His lungs were clear to auscultation bilaterally, and the assessments included asthma, continue current regimen. An October 2002 VA discharge note provides that the Veteran was admitted for asthma exacerbation. The Veteran experienced shortness of breath after smoking a cigarette. He was dyspneic with conversation and hypoxemic on admission, and it was noted that he ran out of some of his asthma medication. He received an IV and nebulizer treatment and was held overnight for monitoring. On discharge, he was doing well and was ambulating and conversing without dyspnea. His O2 saturation was 97 percent on discharge. A chest X-ray showed no infiltrate or edema. The principle diagnosis was asthma exacerbation, and the secondary diagnoses included history of tobacco abuse. It was noted that the Veteran had a 30 pack/year history of smoking and that he had stopped smoking at the beginning of the year. Based on a February 2003 VA pulmonary progress note, the Veteran's last exacerbation was six days prior. He typically had "attacks" when the weather was dry. He was using albuterol once daily and was occasionally awaking at night. The Veteran was afforded a VA general medical examination in March 2003. The Veteran reported that he first noted wheezing in or around 1970, when he was in the military. He stated that his wheezing had some allergic components and that pollen aggravated it. He also reported waking up at night short of breath and coughing. It was noted that he had pulmonary function tests in June 2002, which showed FEV1 at 70 percent of predicted value, and peak expiratory flow at 41 percent of predicted value. He had repeat pulmonary function tests after being on albuterol and advair in July 2002, which were normal, except for an elevation of the residual volume to 139 percent of predicted value. The Veteran reported being hospitalized at the Baptist Medical Center and the Birmingham VAMC during the preceding year for wheezing, but other than those episodes, he reported that he did not wheeze very frequently. He stated that he worked as a welder, which aggravated his wheezing, and he quit working in May 2002 as a result. On examination, he exhibited normal breathing. His lungs were clear with some faint wheezes and crackles on coughing. The diagnosis was asthma, severe with early emphysema, apparently not too-well controlled by history, with apparently an allergic component. An April 2003 VA treatment note indicates that the Veteran reported marked resting shortness of breath for three weeks. He reported that pollen was causing the exacerbation. The Veteran's past medical history included history of tobacco abuse. A chest X-ray showed no active disease, and the diagnostic impression was asthma exacerbation. A July 2003 VA treatment record notes that the Veteran had no further asthma flares since April 2003 and that he relied on inhalers. The assessments included asthma, continue inhalers, stop smoking. As set forth in an October 2003 VA treatment record, the Veteran reported that he was using his inhaler a little more regularly due to weather changes, but that it was relieving his symptoms. It was noted that the Veteran reported quitting smoking. The assessments included asthma, continue inhalers. A June 2004 VA treatment record indicates that the Veteran felt his inhalers were helping. There were no complaints of chest pain or increased shortness of breath. The assessments included asthma, continue current inhaler regimen, get nebulizer machine today. A December 2004 treatment record indicates that the Veteran started smoking again after a friend died. Otherwise, his breathing was doing "great." There were no complaints of chest pain or shortness of breath. The assessments included asthma, continue inhaler regimen, Advair helping a lot. In an April 2008 letter, J.S., who worked aboard the USS Howard Gilmore with the Veteran, wrote that he remembered the Veteran going to sick bay aboard the ship on many occasions and complaining about asthma. In May 2008, the Veteran's brother, E.H., submitted a letter in which he wrote that he was eight years older than the Veteran and had been an observer of the Veteran's health throughout his entire life. E.H. did not remember the Veteran being afflicted with asthma as a child. Instead, the Veteran first began to suffer from asthma during service, and it seemed to have gotten worse as the years passed. Despite using medication, the Veteran had asthma symptoms. A May 2013 VA primary care note indicates that the Veteran was not using his nebulizer regularly, as he had misplaced it since he and his wife divorced last year. The Veteran's lungs were clear to auscultation and percussion, and the assessments included asthma, continue albuterol nebulizers, chlorphineramine. The Veteran was afforded a VA respiratory conditions examination in April 2016. According to the examination report, the Veteran's diagnosis was asthma, and it required the daily use of inhalational bronchodilator therapy and inhalational anti-inflammatory medication. It did not require the use of oral or parenteral corticosteroid medications, oral bronchodilators, antibiotics, or outpatient oxygen therapy. The Veteran did not have a history of any asthma attacks with episodes of respiratory failure in the twelve months preceding the examinations, and he did not have any physician visits for required care of exacerbations. PFT testing was performed. The Veteran took an albuterol treatment on his own just prior to PFT testing, and therefore there were no pre-bronchodilator results. On initial testing, the Veteran's FVC was 72 of predicted value, his FEV-1 was 72 percent of predicted value, his FEV-1/FVC were 70 percent of predicted value, and his DLCO was 96 percent of predicted value. On repeated testing, his FVC was 71 percent of predicted value, his FEB-1 was 77 percent of predicted value, and his FEV-1/FVC was 76 percent of predicted value. The FEV-1/FVC results most accurately reflected the Veteran's level of disability. The Veteran did not have multiple respiratory conditions. The examiner opined that the Veteran would not be able to do very physically demanding work due to his respiratory condition. With respect to the question of whether the Veteran's asthma was clearly and unmistakably present prior to military service, the examiner highlighted that the Veteran reported asthma as a child at his enlistment physical. Additionally, numerous medical records from the 1970s and 1980s indicated that the Veteran told treating providers that he had asthma "all of his life," or, since childhood. The examiner noted that following the military, the Veteran worked as a welder and smoked tobacco. His asthma waxed and waned over the years, but was less active after exposure to welding was stopped and after the Veteran stopped smoking. There did not appear to have been any aggravation of his asthma, as he was able to complete military service and thereafter tolerate exposure to welding and tobacco use with only intermittent exacerbations of asthma. However, the examiner was unable to provide a medical opinion because she was unable to review STRs. Because the April 2016 examiner failed to provide an opinion on whether there was clear and unmistakable evidence that the Veteran's disability was both pre-existing and not aggravated by service, the Board obtained a VHA opinion in May 2017. The May 2017 VHA examiner thoroughly discussed the medical history noted above. She also discussed lay statements of record, including the statement from the Veteran's shipmate, J.S., and the statement from the Veteran's brother, E.H. The examiner discussed post-service medical records from Lloyd Noland Hospital and Mercy Hospital dated in 1973 and 1974, which, as noted above, provided that the Veteran was treated for an "asthmatic attack" or acute asthma symptoms. The examiner wrote that the February 1974 note from Mercy Hospital, which indicated "infreq attacks of asthma," suggested that the Veteran's asthma was well-controlled prior to that specific episode. The examiner noted the Veteran's treatment records from Carraway Hospital and Dr. Moyo. He stressed that X-rays from Dr. Moyo showed no radiographic evidence of emphysema and that notation was made regarding the Veteran's profession as a welder, including the fact that on several occasions, it was noted that the Veteran's work environment triggered his respiratory symptoms and/or asthma specifically. Dr. Moyo had also advised the Veteran to avoid dusty environments. The examiner also detailed records from the Birmingham VAMC dated between 2002 and 2015, in addition to the March 2003 and April 2016 VA examination reports. As documented above, the records noted childhood asthma that had waxed and waned throughout his life, that the Veteran's previous work history as a welder exacerbated his symptoms, and that he had a documented history of smoking. The examiner wrote that chest X-rays indicated no infiltrate or edema and did not document emphysema. The examiner noted that the March 2003 examiner and April 2003 VA treating physician both wrote that pollen aggravated the Veteran's symptoms. The examiner highlighted the fact that multiple subsequent VA primary clinic notes dated in 2003, 2004, 2006, 2007, and 2008 did not report acute asthma exacerbations requiring oral systemic glucocorticoids. His medication regimen was noted to include high-dose inhaled corticosteroids, inhaled long-acting beta-adrenergic agonist bronchodilator via nebulizer, Leukotriene receptor antagonist and anti-histamine agents, in addition to intra-nasal corticosteroids for sinusitis/seasonal allergies, and anti-reflux gastric acid suppression therapy with a proton-pump inhibitor. The examiner did not find documentation of attempts at "step-down therapy" for asthma or any reasons precluding it. The examiner highlighted that in a May 2013 VA treatment record, it was noted that the Veteran had not been using his nebulizer regularly over the past year and that there was no documentation that the Veteran reported any worsening of asthma symptoms without nebulizer use. However, worsening allergy symptoms were documented. Multiple primary care notes from 2013, 2014, and 2015 did not report persistent, clinically significant or worsening asthma symptoms or acute asthma exacerbations. Multiple progress notes dated during this time period stated that the Veteran's allergies were slightly worse, and that his inhaled medication regimen was changed from only a scheduled short-acting beta-adrenergic agonist twice daily to addition of a combination of low-dose inhaled corticosteroid and long-acting beta adrenergic agnostic bronchodilator in May 2015, but no documentation was noted of worsening or sub-optimally controlled asthma symptoms that may have prompted the change. The examiner found it was significant that primary care notes dated in March 2015 and May 2015 stated that the Veteran had been working out at the gym, which suggested no significant functional limitation due to asthma. The examiner referenced the Veteran's medication regimen, as reflected in a June 2015 primary care note, and did not note documentation of attempts at "step-down therapy" for asthma or any reasons precluding it. The examiner also detailed the April 2016 VA respiratory conditions examination, including PFT results. Based on the medical evidence noted above, the examiner opined that the evidence clearly and unmistakably showed that the Veteran's asthma disorder existed prior to his entrance into active duty military service. The examiner opined that E.H.'s contention that he did not remember the Veteran being afflicted with asthma as a child was contradictory to pre-service medical evidence noted above. The examiner also opined that there was no clear and unmistakable evidence that the Veteran's asthma disorder was aggravated by his period of active service beyond the natural progression of the disease. The examiner acknowledged that there was some ambiguity as to how many episodes of acute severe asthma exacerbation the Veteran had during active service. Specifically, in his August 1974 initial application for service connection, he noted that he began to have asthma attacks in January 1971. Under "dates of treatment," he wrote "sick bay 3 or 4 days." According to the examiner, it was unclear whether the Veteran was treated for three or four days in January 1971, or a total of three or four days during his entire active service. However, in a January 2003 consent form, the Veteran wrote that he had been treated for asthma in the Navy, "not sure when, 70 or 71," and in an October 2003 statement, he stated that he had a severe asthma attack aboard ship in 1970. As a result, it appeared to the examiner that the Veteran had only one episode of acute, severe asthma exacerbation in service, during which he sought medical care and treatment. The examiner opined that this was contradictory to the lay statement by the Veteran's former shipmate, J.S., in which he wrote that he remembered the Veteran going to sick bay aboard the ship on many occasions complaining about asthma. According to the examiner, available medical evidence did not show that the Veteran's asthma condition suffered identifiable, incremental, permanent worsening because of his period of service. The examiner opined that, if any exacerbation of symptoms occurred during service, it was more likely than not that such exacerbations were temporary or intermittent flare-ups of symptomatology. As explained by the examiner, various inhalational exposures can result in "reactive airways disease syndrome," expressed as an acute (i.e., within minutes to hours after exposure) and severe respiratory reaction (i.e., severe bronchial constriction manifested as difficulty exhaling air out of the lungs). Other than the Veteran's own statements, the available record provided no objective evidence of an inhalational-type exposure, and no objective evidence that an acute and severe respiratory reaction had occurred during his military service. The examiner also opined that the lay statements provided by the Veteran in support of his claims were unreliable because they did not provide any objective evidence in support of their statement and also stated information which appeared to be contradictory to either available medical evidence, or the Veteran's own documented statements. The examiner wrote that the Veteran's clinical course of asthma symptoms after discharge from active service was not characteristic of a disorder that had been incrementally and permanently worsened, which would, more likely than not, be expected to present as symptoms with progressively increasing frequency and progressively worsening severity. Instead, available medical evidence showed intermittent and infrequent exacerbations of asthma symptoms (often documented to be associated with a specific identifiable trigger which would itself be an independent risk factor for asthma and worsening asthma symptoms), interspersed with periods of stable or no documented asthma-related symptoms. The examiner highlighted that during 1980 oral testimony regarding VA educational benefits, the Veteran reportedly stated that as a part of one of his work/training experiences after discharge from service, he was made to perform "manual labor" for "most of the time" during almost the entire year in 1977, which, the Veteran specifically stated that he always performed as instructed. The Veteran did not make any statements noting difficulties performing the assigned manual labor due to asthma symptoms, which, according to the examiner, suggested that the Veteran did not have any functional limitation because of asthma at this time. The examiner stressed that pulmonary evaluations from 2002 stated that the Veteran's symptoms had "waxed and waned throughout life," which was the typical characteristic natural progression of asthma. The examiner also maintained that the Veteran's and his brother's contention that the Veteran's asthma worsened in the years following service was not corroborated by available medical evidence. Per review of available medical records, the Veteran did not appear to have had a documented asthma exacerbation since 2003, and based on the last available review of primary care clinic notes dated in June 2015, his symptoms were well-controlled on a stable maintenance regimen of a combination low-dose inhaled corticosteroid with inhaled long-acting beta-adrenergic agonist bronchodilator and short-acting beta-adrenergic agonist bronchodilator. The examiner noted the Veteran's contentions regarding adverse occupational environmental conditions on the ship during active service, including his assertion that they aggravated his asthma. According to the examiner, the lay statements of record, including those of the Veteran's, his brother, and his former shipmate, did not provide any details or evidence regarding the specific occupational environmental conditions during active service which could have potentially aggravated the Veteran's asthma. According to the examiner, there was clear and unmistakable evidence that the Veteran's asthma disorder was aggravated by multiple factors and exposures after his period of active service. Multiple records from physicians at different time periods have documented direct correlation of his symptoms (including episodes of increased symptoms and acute exacerbation) to one or more factors or exposures that are well-known independent contributors to the development or worsening of obstructive lung disease (such as asthma or COPD). These factors or exposures, which are unrelated to active service, include cigarette smoking, his occupation as a welder, seasonal allergies, and gastric acid reflux. Thus, it was more likely than not that any subsequent aggravation of the Veteran's symptoms after service were, in fact, due to factors unrelated to his period of active service. Because there was no clear and unmistakable evidence that the Veteran's asthma disorder was aggravated by his period of service beyond the natural progression of the disease, and clear and unmistakable evidence that his asthma disorder was aggravated by multiple factors and exposures after/unrelated to his period of active service, the evidence clearly and unmistakable showed that his asthma disorder was not aggravated by his period of active service beyond the natural progression of the disease. The examiner also opined that it was less likely than not that there was any other current respiratory disorder that was incurred in, or otherwise related to, his period of active service. According to the examiner, there was no radiographic evidence of anatomical emphysema based on multiple chest X-rays and limited evaluation of the lungs on an abdominal CT scan. As explained by the examiner, emphysema is a type of chronic obstructive pulmonary disease (COPD), and the Veteran's 2002 and 2016 PFTs did not meet the Global Initiative for Chronic Obstructive Lung Disease criteria for a diagnosis of COPD, which requires a post-bronchodilator FEV1/FVC level of less than 70 percent predicted for a confirmed diagnosis. The fact that the Veteran's diffusion capacity on both PFTs was within normal limits argued against emphysema. The examiner added that if the Veteran had confirmed "emphysema," it was more likely than not due to his history of smoking or occupational exposure to welding fumes, and less likely than not due to any inhalational exposures during active military service. As noted by the examiner, cigarette smoking is the most common cause of emphysema in the population. The examiner also opined that the evidence argued against a diagnosis of severe asthma. The examiner detailed that based on peer-reviewed medical literature, "severe persistent asthma" is defined when a patient has persistent asthma symptoms throughout the day, often has night-time awakening seven times a week, short-acting beta-agonist use for symptom control (not prevention of exercise-induced bronchospasm) several times per day, extreme limitation and interference with normal activity, FEV1 less than 60 percent predicted or FEV1/FVC reduced greater than 5 percent from normal, or two or more acute exacerbations per year requiring oral systemic glucocorticoids. The examiner wrote that multiple primary clinic notes since 2003 have not documented any of the above, nor have they shown significant, consistent, incremental or permanent worsening of asthma symptoms over time. The Veteran has been documented to have functional limitation with only "very physically demanding work," and there is no documentation of consistent or permanent limitation or interference with normal activity due to asthma. His medication regimen does include scheduled use of a short-acting beta-agonist twice daily, but that appears to be per prescription, and there is no documented, consistent, additional short-acting beta-agonist requirement for symptom control. There was no documented acute asthma exacerbation requiring oral systemic glucocorticoids since 2003. Based on PFTs from 2002 and 2016, there appears to have been no significant worsening of his FEV1 over time. In fact, there appeared to be improvement. According to the examiner, worsening of FEV1 is an expected feature of an asthma disorder that has been incrementally or permanently worsened over time. In terms of other asthma maintenance medications, the Veteran was currently on a lower dose of inhaled glucocorticoids than previously, and he was not on a Leukotriene receptor antagonist that he was previously taking, which was indicative of de-escalation of therapy over time. Legal Analysis As noted above, to establish service connection, there must be evidence of a current disability. See Shedden, 381 F.3d at 1167. Existence of a current disability must be shown by competent medical evidence. See, e.g., McClain v. Nicholson, 21 Vet. App. 319, 320-21 (2007). Here, the weight of the evidence of record is against a finding that a diagnosis of emphysema/COPD currently exists or has existed at any time during the course of the appeal. While the Board acknowledges that the March 2003 examiner's diagnosis included "early emphysema," other, more probative evidence indicates otherwise. As stressed by the May 2017 examiner, available records, including multiple chest X-rays and limited evaluation of the lungs on a CT scan of the abdomen, provide no radiographic evidence of anatomical emphysema. Moreover, as explained by the May 2017 VHA examiner, the fact that the Veteran's 2002 and 2016 PFTs did not meet the Global Initiative for Chronic Obstructive Lung Disease criteria for a diagnosis of COPD, and that diffusion capacity on both PFTs was within normal limits, weighs against a finding of emphysema. Contrary to the March 2003 examiner, the May 2017 examiner consulted X-rays, Global Initiative for Chronic Obstructive Lung Disease criteria, and multiple PFT reports in determining whether the Veteran had a diagnosis of emphysema. As such, the Board finds that the May 2017 examiner's opinion is fully-informed and reliable, and that it outweighs the diagnostic opinion of the March 2003 examiner. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301-04 (2008). Even though the evidence weighs against a finding that a current diagnosis of emphysema has existed at any time during the appeal period, the Shedden element is met given the noted diagnosis of asthma throughout the appeal period. See Shedden, 381 F.3d at 1167. However, particularly when relying on the May 2017 VHA opinion, the Board concludes that service connection is not warranted. When no pre-existing condition is noted on examination upon entry into service, a veteran is presumed to have been sound upon entry. 38 U.S.C.A. § 1111; 38 C.F.R. § 3.304(b). Here, the above-noted evidence rebuts the presumption that, with respect to any respiratory conditions, the Veteran was in sound condition on entrance into service. See 38 U.S.C.A. § 1111; 38 C.F.R. § 3.304(b); see also Wagner, 370 F.3d at 1096-97. First, the evidence clearly and unmistakably shows that the Veteran's asthma existed prior to service. As documented above, in his June 1969 pre-induction report of medical history, the Veteran affirmed a history of asthma and shortness of breath, and in the corresponding report of medical examination, the physician wrote that the Veteran claimed asthma. As highlighted by the May 2017 VHA examiner, consistent with these June 1969 notations regarding asthma, the Veteran was described as a "known asthmatic" at the age of four in a November 1954 discharge report from Lloyd Noland Hospital. Additionally, in a June 1969 letter from Dr. C. Goral, it was noted that the Veteran had been a known asthmatic since the age of four and that he had numerous visits to the clinic at Lloyd Noland Hospital due to asthma attacks. Moreover, an April 1974 treatment record from Mercy Hospital provides that the Veteran reported having asthma "all of his life." The Board acknowledges that the Veteran, at his April 2003 VA examination, stated that he first started wheezing in 1970 while in the military, and that Veteran's brother, E.H., wrote that he did not remember the Veteran having asthma as a child and that he first began to suffer from asthma during military service. However, the contemporaneous medical evidence noted above heavily outweighs these statements, as they provide multiple documentation of a history of asthma since at least the age of four. See Curry v. Brown, 7 Vet. App. 59, 67-68 (1994) (providing that contemporaneous evidence can have greater probative value than inconsistent testimony provided at a later date). Second, the evidence also clearly and unmistakably shows that the Veteran's asthma was not aggravated beyond its natural progression by service. As explained by the May 2017 VHA examiner, available medical evidence does not show that the Veteran's asthma condition suffered identifiable, incremental, permanent worsening because of his period of service. The examiner considered the Veteran's contention regarding adverse occupational conditions aboard the naval ship but found that there was no evidence of specific conditions which could have potentially permanently worsened his asthma. As explained by the examiner, the available record provided no objective evidence of an inhalational-type exposure, or of an acute and severe respiratory reaction, during the Veteran's military service. Moreover, if any exacerbation of symptoms occurred during service, it was more likely than not that such exacerbations constituted temporary or intermittent flare-ups of symptomatology. Crucially, temporary or intermittent flare-ups during service of a pre-existing injury or disease are not sufficient to constitute in-service aggravation. See Davis v. Principi, 276 F.3d 1341, 1345 (Fed. Cir. 2002) (distinguishing mere recurrence of manifestations of the preservice condition from increase in disability); see also Hunt v. Derwinski, 1 Vet. App. 292, 297 (1991). The examiner also highlighted the fact that the Veteran's clinical course of asthma symptoms after discharge from active service was not characteristic of a disorder that had been incrementally and permanently worsened. Instead, available medical evidence shows intermittent and infrequent exacerbations of asthma symptoms interspersed with periods of stable or no documented asthma-related symptoms. Moreover, these intermittent and infrequent exacerbation of symptoms were often associated with a specific identifiable trigger, such as cigarette smoking, welding, or seasonal allergies. Additionally, in 1977, only several years after discharge from service, the Veteran did not have any functional limitation due to asthma, as he was able to perform manual labor with no noted difficulties related to asthma. As detailed by the examiner, the fact that the Veteran's symptoms have "waxed and waned throughout life," is indicative of a typical natural progression of asthma. In addition, although the Veteran and his brother have maintained that the Veteran's condition has continued to worsen since service, the May 2017 examiner provided that the available medical evidence did not support such a conclusion. As the examiner highlighted, the Veteran did not appear to have had a documented asthma exacerbation since 2003, and based on the last available review of primary care clinic notes dated in June 2015, his symptoms were well-controlled on a stable maintenance regimen of a combination low-dose inhaled corticosteroid with inhaled long-acting beta-adrenergic agonist bronchodilator and short-acting beta-adrenergic agonist bronchodilator. As noted by the May 2017 examiner, there is no documentation of consistent or permanent limitation or interference with normal activity due to asthma. At his April 2016 VA examination, the examiner provided that the Veteran's asthma would only limit him from performing very physically demanding work. Further, as stressed by the May 2017 examiner, the fact that the Veteran was documented to be working out at the gym in March 2015 and May 2015 suggested there was no significant functional limitation due to asthma. Moreover, medical evidence does not support a diagnosis of "severe asthma," and instead, reflects "moderate persistent asthma." While the Board acknowledges that the March 2003 examiner provided that the Veteran's asthma was "apparently not too well controlled," this characterization was based on the Veteran's reported history and is outweighed by the May 2017 examiner's opinion, which is based on a thorough review of the Veteran's medical records dated since 1954. See Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993). Based on the May 2017 examiner's report, any aggravation of the Veteran's symptoms following service was clearly and unmistakably due to multiple factors and exposures that are unrelated to his period of active service. Consistent with the May 2017 examiner's findings, records from multiple physicians have documented direct correlation of his symptoms to one or more factors or exposures that occurred or were otherwise unrelated to his period of active service, such as cigarette smoking, his occupation as a welder, seasonal allergies, and gastric acid reflux. Further, as stressed by the May 2017 examiner, these factors are well-known contributors to the development of obstructive lung disease, including asthma. The Board has considered the Veteran's statements about the conditions in the laundry room, in addition to his contentions regarding spending three days in sick bay due to shortness of breath, feeling ill in the laundry room, and experiencing sleepless nights during service because he was having an asthma attack or feeling sick. The Board also recognizes that the Veteran's shipmate, J.S., wrote that he remembered the Veteran going to sick bay for his asthma on "many occasions." The Board also acknowledges the Veteran and his brother's assertion that the Veteran's asthma has progressively worsened since service. In this regard, the Board acknowledges that the Veteran, E.H., and J.S. are competent to offer statements regarding observable symptomatology and medical history. See Layno, 6 Vet. App. at 469-70. However, based on the May 2017 VHA examiner's opinion, these reported in-service incidents, at most, appear to reflect mere intermittent and infrequent exacerbation of symptoms as opposed to a permanent worsening of the Veteran's condition. Further, J.S.'s representation that the Veteran went to sick bay on "many occasions" for his asthma appears to be contradictory to the Veteran's own statements, which suggest a single several-day admission to sick bay. Finally, as explained by the examiner, the lay statements regarding post-service worsening are not corroborated by available medical evidence. Thus, the lay contentions of record are significantly outweighed by the May 2017 examiner's opinion, and there is no objective medical evidence of record that otherwise supports the Veteran's claim. See Caluza v. Brown, 7 Vet. App. 498, 506 (1995). Accordingly, service connection is not warranted for the Veteran's asthma. To the extent that the Veteran's October 2017 statement raises an assertion that his asthma was worsened beyond its natural progression due to asbestos exposure, the Veteran's military occupational specialty (MOS) was laundering, which is not identified as an MOS that involves minimal, probable, or highly probable exposure to asbestos during service. See VBA Manual M21-1, IV.ii.1.I.3.d (last accessed November 21, 2017). There is also no indication that this MOS involved mining, milling, work in shipyards, insulation work or manufacturing, demolition of old buildings, carpentry, or construction, which are some of the major occupations that involve exposure to asbestos. See VBA Manual M21-1, IV.ii.2.C.2.d. Moreover, even if the Veteran might have been exposed to some degree of asbestos during service, there is no evidence of record which tends to suggest that his asthma was aggravated by, or otherwise related to, such exposure. Multiple chest X-rays show no indication of asbestos-related disease, nor does the objective evidence otherwise suggest the presence of asbestos-related disease. Attributing a pulmonary condition to asbestos exposure requires specialized training and is beyond the scope of lay observation. See Jandreau, 492 F.3d 1372, 1377 (Fed. Cir. 2007). As such, to the extent that the Veteran asserts that his asthma was aggravated by exposure to asbestos, his assertion does not constitute competent evidence, nor does it warrant an award of service connection or an additional medical opinion. See 38 C.F.R. § 3.159(a)(1), (c)(4); Layno, 6 Vet. App. at 469-70. In summary, the competent medical evidence of record clearly and unmistakably shows that the Veteran's asthma pre-existed service and that it was not aggravated beyond its natural progression by service. In reaching these conclusions, the Board has considered the applicability of the benefit-of-the-doubt doctrine. As the preponderance of the evidence is against the claim, that doctrine does not apply, and the claim must be denied. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. ORDER Entitlement to service connection for asthma, to include severe early emphysema, is denied. ____________________________________________ MICHAEL LANE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs