Citation Nr: 1741072 Decision Date: 09/20/17 Archive Date: 10/02/17 DOCKET NO. 11-19 919 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to service connection for a respiratory disorder, to include asthma, chronic obstructive pulmonary disease (COPD), emphysema, and asbestosis. 2. Entitlement to service connection for obstructive sleep apnea claimed as secondary to a respiratory disability. REPRESENTATION Appellant represented by: Paul Burkhalter, Attorney WITNESSES AT HEARING ON APPEAL The Veteran, his spouse, and his son ATTORNEY FOR THE BOARD J. Setter, Associate Counsel INTRODUCTION The Veteran served on active duty from October 1957 to January 1962. This matter is before the Board of Veterans' Appeals (Board) on appeal from a February 2013 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas. By way of background, the Veteran originally filed separate claims for asthma, emphysema, COPD, pulmonary hypertension, asbestosis, in addition to sleep apnea. The Veteran eventually withdrew his pulmonary hypertension claim, and the separate claims for the remaining respiratory disorders were recharacterized as a claim for a respiratory disorder, to include asthma, chronic obstructive pulmonary disease (COPD), emphysema and asbestosis. See Clemons v. Shinseki, 23 Vet. App. 1 (2009). The issues on the title page have been recharacterized as such. The Veteran has provided testimony before hearings before a Decision Review Officer and before the undersigned. Transcripts of the hearings are of record. At the March 2016 Board Video Conference hearing the Veteran's attorney stated that the Veteran wished to waive RO consideration of any additional evidence they submitted to the Board. In February 2015 the Veteran submitted a new VA Form 21-22a on which he indicated that his attorney was his sole representative, for all issues, without limitation. In a July 2016 Board decision, the claims for a respiratory disorder and obstructive sleep apnea were remanded for a new VA examination and opinion. The requisite development having been completed, the directives have been substantially complied with as to the issue decided herein and the matter again is before the Board. D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); Stegall v. West, 11 Vet. App. 268, 271 (1998). 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). FINDINGS OF FACT 1. No currently diagnosed respiratory disorder was first manifest during active duty or is shown to be etiologically related to any injury, disease, or event in service, including a highly probable exposure to asbestos. 2. The Veteran's obstructive sleep apnea is not related to his military service and is not due to or aggravated by any service-connected disability. CONCLUSIONS OF LAW 1. The criteria for service connection of a respiratory disorder, to include COPD, are not met. 38 U.S.C.A. §§ 1101, 1131, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303 (2016). 2. The criteria for service connection of obstructive sleep apnea, to include as secondary to a service-connected disability, are not met. 38 U.S.C.A. §§ 1101, 1131, 5107 (West 2014); 38 C.F.R. §§ 3.303, 3.310 (2016). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. Duties to Notify and to Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2016). As to the Veteran's claims for service connection for respiratory and sleep disorders, the Veteran was provided notice in February and December 2012, prior to the unfavorable adjudication of February 2013, which satisfied the duty to notify provisions. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1). This letter informed the Veteran of the evidence necessary to substantiate his claim, the evidence that VA and the Veteran were respectively responsible for obtaining, and of the elements of service connection. Relevant to the duty to assist, the Veteran's service treatment records, post-service VA, and private treatment records have been obtained and considered. The Veteran has not identified any additional outstanding records that have not been obtained. Over the course of the appeal period, the Veteran underwent VA examinations in October and November 2016 pertinent to his claimed respiratory disorders and obstructive sleep apnea. A VA opinion was obtained in November 2016. The Board considers the results all of the examinations and opinions to be adequate for rating purposes. The Veteran was provided a hearing before the undersigned VLJ in March 2016. As there is no allegation that either of the hearings provided to the Veteran were deficient in any way, further discussion of the adequacy of the hearing is not necessary. Dickens v. McDonald, 814 F.3d 1359 (Fed. Cir. 2016). For the foregoing reasons, VA's duties to notify and to assist have been met. All necessary development has been accomplished, and appellate review may proceed without prejudice to the Veteran. II. Service Connection Claims Legal Framework Generally, to establish service connection a Veteran 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." Davidson v. Shinseki, 581 F.3d 1313, 1315-16 (Fed. Cir. 2009); Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may also be granted for disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303(d). For secondary service connection, it must be shown that the disability for which the claim is made is proximately due to or aggravated by a service-connected disability. See 38 C.F.R. § 3.310 (2016); Allen v. Brown, 7 Vet. App. 439 (1995) (en banc). VA is required to give due consideration to all pertinent medical and lay evidence in evaluating a claim for disability benefits. 38 U.S.C.A. § 1154(a). Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). The credibility and weight of all the evidence, including the medical evidence, should be assessed to determine its probative value, and the evidence found to be persuasive or unpersuasive should be accounted for, and reasons should be provided for rejecting any evidence favorable to the claimant. See Masors v. Derwinski, 2 Vet. App. 181 (1992). 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. Lay evidence cannot be determined to be not credible merely because it is unaccompanied by contemporaneous medical evidence. Buchanan v. Nicholson, 451 F.3d 1331, 1336-37 (Fed. Cir. 2006). However, the lack of contemporaneous medical evidence can be considered and weighed against a Veteran's lay statements. Id. Further, a negative inference may be drawn from the absence of complaints or treatment for an extended period. Maxson v. West, 12 Vet. App. 453, 459 (1999), aff'd sub nom. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). After the evidence is assembled, it is the Board's responsibility to evaluate the entire record. See 38 U.S.C.A. § 7104(a). When there is an approximate balance of evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each issue shall be given to the claimant. See 38 U.S.C.A. § 5107; 38 C.F.R. §§ 3.102, 4.3. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). In making that decision, the Board must determine the probative weight to be ascribed as among multiple medical opinions, and state the reasons and bases for favoring one opinion over another. See Winsett v. West, 11 Vet. App. 420, 424-25 (1998); see also Evans v. West, 12 Vet. App. 22, 30 (1998), citing Owens v. Brown, 7 Vet. App. 429, 433 (1995). This responsibility is particularly important where medical opinions diverge. The Board is also mindful that it cannot make its own independent medical determinations, and that there must be plausible reasons for favoring one medical opinion over another. See Evans at 31; see also Colvin v. Derwinski, 1 Vet. App. 171 (1991). In Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990), the United States Court of Appeals for Veterans Claims (Court) stated that "a veteran need only demonstrate that there is an 'approximate balance of positive and negative evidence' in order to prevail." To deny a claim on its merits, the preponderance of the evidence must be against the claim. See Alemany v. Brown, 9 Vet App. 518, 519 (1996), citing Gilbert, 1 Vet. App. at 54. Respiratory Disorder(s) and Asbestos Although the Veteran's service records do not specifically confirm that he was exposed to asbestos during service, the Board finds that the Veteran's service as a pipe-fitter in the Navy from October 1957 to January 1962, assigned to USS Monrovia (APA-31), a ship constructed in 1942, could have exposed him to asbestos. In cases involving asbestos exposure, the claim must be analyzed under VA administrative protocols. Ennis v Brown, 4 Vet App 523 (1993), McGinty v. Brown, 4 Vet App 428 (1993). Although there is no specific statutory or regulatory guidance regarding claims for residuals of asbestos exposure, VA has several guidelines for compensation claims based on asbestos exposure M21 1, VBA Adjudication Procedure Manual M21 1, part IV, Subpart ii, Ch 2, Section C (November 4, 2016). In this regard, the M21-1 provides the following non-exclusive list of asbestos-related diseases/abnormalities: asbestosis, interstitial pulmonary fibrosis, tumors, pleural 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, part IV, Subpart ii, Chapter 2, Section C, 2 (b). The M21-1 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, part IV, Subpart ii, Chapter 2, Section C, 2 (d). The M21-1 provides that a clinical diagnosis of asbestosis requires a history of exposure and radiographic evidence of parenchymal lung disease. Diagnostic indicators 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, part IV, Subpart ii, Chapter 2, Section C, 2 (g). Additionally, the Board should consider whether military records demonstrate evidence of asbestos exposure during service, whether there was pre-service, post-service, occupational, or other asbestos exposure, and whether there is a relationship between asbestos exposure and the claimed disease. The Board finds that the Veteran's contentions regarding potential in-service exposure to asbestos are plausible. However, mere exposure to a potentially harmful agent is insufficient to be eligible for VA disability benefits. The question in a claim such as this is whether disabling harm ensued as a result of any such asbestos exposure. The medical evidence must show not only a currently diagnosed disability, but also a nexus that is, a causal connection, between this current disability and the exposure to asbestos in service. There is evidence that the Veteran suffers from a respiratory disability and had highly probable chance of exposure to asbestos while working as a pipe-fitter during his active service. The question then turns to whether or not the Veteran's respiratory disorder and/or his sleep apnea was caused or related to his active service. Based on the following, the Board finds that the weight of the evidence demonstrates that the Veteran's respiratory disorder and his obstructive sleep apnea are not related to his active service. Contentions - Respiratory Disorder The Veteran contends he is entitled to service connection for a respiratory disorder, to include asthma, COPD, emphysema and asbestosis due to his service in the United States Navy as a ship-fitter. He reports that his shipboard duties included repairing asbestos covered pipes and PVC pipes. He maintains that he has current lung disability due to in-service exposure to asbestos, exposure to glue for repairing PVC pipes, and exposure to zinc welding fumes. Additionally, he is claiming service connection for obstructive sleep apnea claimed as secondary to a respiratory disability. A review of the Veteran's STRs is negative for complaints or findings related to any pulmonary disorder. The Veteran did not report chronic shortness of breath, wheezing, or other symptoms associated with a lung condition. While in service, the Veteran's service medical records indicate he was treated for several colds, to include one episode of bronchitis in August 1961 that resolved with bed rest. The remainder of his service medical records are silent for any mention of asthma, COPD, or any exposure to any noxious chemical or material exposures, including asbestos. The Veteran's medical records and lay statements note he was a long-time smoker, consuming 2-3 packs per day, with different starting and ending points noted at different times. The beginning of the Veteran's smoking was noted either at ages 14-16, or at age 20 at the latest when he joined the Navy, and the ending period varies from the middle 1980s to 1998. The Board notes, therefore, at a minimum, based on the Veteran's own statements in his lay statements and statements to his medical providers, that he was a 2-3 pack per day smoker for at least 25 years. The Veteran first received notice of a pulmonary disorder in October 2010 when he was seen by VA after noticing symptoms of shortness of breath and difficulty climbing stairs. The Veteran was scheduled for a computed tomography (CT) scan of the chest. The first record in the Veteran's file pertinent to a formal diagnosis of a respiratory condition is a December 2011 VA pulmonary treatment note indicated the Veteran had diagnoses of obstructive sleep apnea and chronic obstructive pulmonary disease, with subpulmonary nodules 2-4 millimeters in size, numerous, scattered, and consistent with old granulomatous pulmonary disease. No pleural effusion, pleural mass, or pneumothorax was noted. The pulmonary nodules were noted as stable and considered benign. The treating physician sent a letter to the Veteran notifying him of the COPD diagnosis and opined it was likely from the Veteran's smoking history, even though he had quit smoking in the 1980s. A January 2012 VA treatment note indicates there are no findings consistent with asbestosis, referencing an October 2010 CT scan. No fibrosis, pleural "thicking," or calcifications were noted. Some apical bullae consistent with emphysema were noted, and there were scattered "sub cm" pulmonary nodules which were stable when compared to previous films. This physician also noted that the adenopathy was not consistent with asbestosis. A private treatment note from the Veteran's civilian pulmonologist, also from January 2012, noted COPD and obstructive sleep apnea as diagnoses, and remarked from his CT scan that he had enlarged lymph nodes, emphysema, and peripheral scarring. This physician remarked about the history of the Veteran's smoking, having quit in the mid 1980s, his exposure to asbestos in the Navy as a pipe-fitter, and that his shortness of breath with difficulty climbing stairs and decreased exertional distance had begun sometime in the last 5 to 10 years. A follow-on visit in March 2012 with the same private pulmonologist noted the Veteran's pulmonary mass was stable over the previous two years and further CT scans were therefore unnecessary. COPD and chronic bronchitis were diagnosed, and the Veteran's obstructive sleep apnea was noted. The Veteran was also noted as having been exposed to asbestos while in service, but this and a subsequent visit with this physician in May 2012 do not indicate a specific diagnosis of asbestosis, asthma, or any other respiratory disorder other than COPD. A VA pulmonary treatment note from March 2012 indicates the Veteran has a history of multiple pulmonary nodules, mediastinal nodes, and a history of smoking and in-service asbestos exposure, though with no evidence of asbestosis. In August 2014, the Veteran's private pulmonologist provided an interrogatory on a form to the Veteran's attorney saying the Veteran's interstitial lung disease is most likely caused by or is the result of his exposure to asbestos while working on ships during his service in the Navy. The Board notes that the Veteran has not been diagnosed with interstitial lung disease by this pulmonologist or by VA on the basis of any medical record in the claims file. In October 2016, the Veteran received a VA examination for his respiratory disorders. The examiner diagnosed COPD and noted that the lungs were clear to auscultation with no wheezes or crackles heard. The Veteran displayed no respiratory distress from walking from the lobby back to the exam room. The examiner discussed the Veteran's CT scans, noting no presence of any diffuse interstitial changes, though some biapical pleural scarring was noted. No pleural plaques were present, which the examiner noted that if present, would suggest asbestosis. The examiner performed a full slate of pulmonary function testing and noted there was no other respiratory condition besides the diagnosed COPD. This examiner commented on the other possible respiratory disorders that are part of the Veteran's claim, pointing out that emphysema is not a separate disease but rather a component of the Veteran's already diagnosed COPD. The examiner noted the Veteran has never been diagnosed with asthma, and the Veteran denied during his examination that he had ever claimed so. The examiner then discussed the potential of asbestosis, noting it is primarily a restrictive interstitial lung disease, while COPD is characterized by a predominance of airway obstruction, which shows different patterns on the pulmonary function testing. The examiner did note that there can be some degree of accompanying interstitial disease seen with the pulmonary function testing done on patients with smoking-induced COPD. However, the examiner concluded, the normal diffusion capacity noted on the October 2016 pulmonary testing argues against any significant interstitial disease, and that the Veteran has COPD of the emphysema variety. The examiner compared his testing done with that of previous pulmonary function testing done in December 2011 and noted the latter showed moderate airway obstruction, decreased vital capacity consistent with obesity, lung volumes that were normal, and diffusion capacity that was mildly reduced but was normal in proportion to alveolar volume, all of which were consistent with COPD due to smoking and not consistent with restrictive lung disease due asbestosis. The examiner discussed the medical literature related to asbestosis and also pointed out in detail that his findings from the examination of the Veteran indicated no presence of pleural plaques, a "hallmark" of asbestos exposure. The examiner discussed the presence of the pleural scarring from the CT of the Veteran's chest, but also noted the literature hypothesizes that pleural thickening in the lung apices may be related apical ischemia and gravitational stress due to upright posture. In any case, the examiner noted, no medical professional, VA or private, who had examined the Veteran, saw the necessity or utility of performing bronchial washings or a lung biopsy that would have documented asbestosis of the lung. The examiner mentioned the Veteran's military service made it reasonable that he was exposed to asbestos, and that there was no way to quantify that exposure reliably. The examiner also commented on the Veteran's cumulative exposure to tobacco smoking from cigarettes to between 60 and 90 pack-years, which he indicated to be a "very significant" exposure. This examiner also addressed the Veteran's assertions that his exposure to zinc fumes during welding was unlikely to cause lung disease, noting that zinc toxicity up to ten times the recommended daily intake produces no symptoms and that the medical literature shows no nexus of causation between zinc fumes and chronic lung disease. The examiner also discounted the possibility of fumes from working PVC piping and associated glues as having a causative factor in the Veteran's COPD, noting again the medical literature shows no nexus of causation between PVC or associated glues and chronic lung disease. This examiner concluded that it was less likely than not (less than a 50 percent probability) that the Veteran's COPD is due to asbestos, zinc welding fumes, or PVC glue exposure. The examiner directly remarked "[t]he available evidence supports that the Veteran's COPD is a consequence of cigarette smoking." The Board acknowledges and notes the private pulmonologist's checkmark on a form that the Veteran's interstitial lung disease is related to asbestos exposure in service. However, the Board notes that the Veteran has never been formally diagnosed by this pulmonologist or any VA medical practitioner with interstitial lung disease. This private pulmonologist has diagnosed the Veteran with COPD and obstructive sleep apnea, and has discussed the possible relationships of the COPD back to possible asbestos exposure in service but also to the Veteran's considerable smoking habit of at least 25 years duration at a rate of 2-3 packs per day. The Board finds the private pulmonologist's opinion that the Veteran's interstitial lung disease "is most likely caused by or is the result of his exposure to asbestos" to be of no probative value by itself. First, the Veteran has never been diagnosed with interstitial lung disease by this or any other medical professional. This pulmonologist has consistently diagnosed the Veteran with COPD, an obstructive lung disease, and obstructive sleep apnea. Further, this opinion was provided on a form drafted by the Veteran's attorney and are not necessarily the words of the pulmonologist herself. It is well established that medical opinions that are speculative, general, or inconclusive in nature do not provide a sufficient basis upon which to support a claim. McLendon v. Nicholson, 20 Vet. App. 79, 85 (2006). The remainder of the medical records from this pulmonologist contains diagnoses and treatment of COPD and sleep apnea consistent with VA's own diagnoses and treatment. The Board finds the October 2016 VA examination report to be the most probative evidence of record. A medical opinion is most probative if it is factually accurate, fully articulated, and based on sound reasoning. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). After completing necessary testing, the examiner found that the Veteran suffered from obstructive lung disease, which is not caused by asbestos exposure, but rather the Veteran's long history of cigarette smoking. In summary, the evidence against a finding of asbestos-related disease of any kind outweighs the evidence supporting such a diagnosis. The Veteran has a current diagnosis of COPD from both VA and his private pulmonologist, and the Board concedes the Veteran's possible exposure to asbestos during his military service. However, as noted by the October 2016 VA examiner, COPD in its emphysema form is an obstructive lung disorder and not one usually associated with asbestos exposure, a restrictive interstitial lung disease. The Board acknowledges the Veteran's lay statements and that of his family members contending that his COPD is related to his asbestos exposure. The Veteran is competent to report his symptoms of breathing problems and their onset. See Layno v. Brown, 6 Vet. App. 465 (1994). However, the Board finds that the Veteran is not competent to provide such an etiological opinion relating a self-diagnosis back to service. In that regard, there is no evidence that he possesses the requisite medical expertise to diagnose COPD in particular or provide an etiological opinion. COPD was diagnosed from various respiratory tests and the October 2016 examiner assessed the Veteran's COPD and ruled out any connection to the Veteran's asbestos exposure. Based on the above, the Board finds that the preponderance of the evidence is against the claim. The claim for entitlement to service connection for a respiratory disability must be denied. There is no reasonable doubt to be resolved. See 38 U.S.C.A. § 5107 (b) (West 2002); 38 C.F.R. § 3.102 (2015); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Contentions - Obstructive Sleep Apnea The Veteran has asserted that his obstructive sleep apnea is secondary to his respiratory disorder. The Veteran noted that in 2002 he developed shortness of breath with fatigue, and "a couple of years after that," he was diagnosed with obstructive sleep apnea, and started on a CPAP machine, which he continues to use. VA medical records first show a diagnosis of obstructive sleep apnea in 2004. The Veteran's service treatment records are silent for any mention of sleep problems or sleep apnea in particular through his discharge in January 1962. The first indication in the claims file about the sleep apnea is a January 2012 VA pulmonary treatment note mentioning a sleep study done in 2004, and a diagnosis of sleep apnea at that time. A negative inference may be drawn from the absence of complaints or treatment for an extended period. See Maxson v. West, 12 Vet. App. 453, 459 (1999), aff'd sub nom. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). The Veteran received a VA examination in October 2016 for his sleep apnea. The examiner noted and confirmed the previous diagnosis of obstructive sleep apnea, noting the tongue and pharynx were normal, with normal nasal passages. The examiner opined that repeating the sleep study was not necessary at this time, as it is not clinically indicated for the Veteran's current condition. The examiner opined that the Veteran's obstructive sleep apnea was less likely than not (less than 50 percent probability) incurred in or caused by an in-service injury, event, or illness, or is caused by or aggravated by any service-connected disability. The examiner discussed the possible relationship between COPD and sleep apnea, noting that the factors for the latter are advancing age, male gender, obesity, and upper airway soft tissue abnormalities. Additional risk factors from some studies include smoking, nasal congestion, and family history, and that rates of sleep apnea increase in association with some medical conditions, to include chronic lung disease. However, the examiner pointed out, such an association does not state or imply a nexus of causation, even if the Veteran were service-connected for COPD. The examiner noted that the Veteran has not required repeat CPAP titration since his original 2004 diagnosis of obstructive sleep apnea, and there is no evidence in the records of that being necessary. The Veteran's private pulmonologist has also diagnosed obstructive sleep apnea but the applicable medical records are focused on treatment of the Veteran's COPD. This private physician noted in 2012 that the Veteran had been using his CPAP for over 5 years and may need a future sleep study. No mention is made as to the etiology of the obstructive sleep apnea. The Board again acknowledges the Veteran's statements that his obstructive sleep apnea is tied to his claimed respiratory disorder, and again points out that while the Veteran has the ability to observe and note symptoms, he does not have the medical background to self-diagnose or examine the etiology of his claimed conditions. See Layno, 6 Vet. App. 465, 469. In summary, the evidence is against a finding of a nexus of the Veteran's diagnosed obstructive sleep apnea directly with his military service or secondary to his diagnosed COPD. The Veteran has a current diagnosis of obstructive sleep apnea, and the Board concedes the Veteran's possible exposure to asbestos during his military service. The medical literature does not support a direct relationship between possible asbestos exposure and obstructive sleep apnea. Furthermore, the VA examiner points out that while there may be a statistical relationship between the presence of COPD and obstructive sleep apnea, that causation is not a medically supported inference, and even if it were directly related, the Veteran's COPD is not service-connected. Based on the above, the Board finds that the preponderance of the evidence is against the claim. The claim for entitlement to service connection for a respiratory disability and claim for entitlement to service connection for obstructive sleep apnea, to include as secondary to a respiratory disability, must be denied. There is no reasonable doubt to be resolved. See 38 U.S.C.A. § 5107 (b) (West 2002); 38 C.F.R. § 3.102 (2015); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). (CONTINUED ON NEXT PAGE) ORDER Service connection for a respiratory disorder, to include asthma, chronic obstructive pulmonary disease (COPD), emphysema and asbestosis, is denied. Service connection for obstructive sleep apnea, to include as secondary to a respiratory disability, is denied. ____________________________________________ MICHAEL A. PAPPAS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs