Citation Nr: 21065990 Decision Date: 10/28/21 Archive Date: 10/28/21 DOCKET NO. 13-15 184 DATE: October 28, 2021 REMANDED Entitlement to service connection for a respiratory disorder, to include asthma, chronic bronchitis, and reactive airway disease, is remanded. REASONS FOR REMAND The Veteran served on active duty from November 1980 to November 1984. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an August 2010 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). In June 2016, the Veteran testified at a Board videoconference hearing before the undersigned. A copy of the transcript of that hearing has been associated with the claims file. By way of background, this matter was initially before the Board in September 2016 and December 2017, when it was remanded for additional development. See September 2016 Remand BVA or CAVC; December 2017 BVA Decision. Thereafter, in a March 2020 decision, the Board, in pertinent part, denied the Veteran's claim, and the Veteran appealed that decision to the U.S. Court of Appeals for Veterans Claims (Court). See March 2020 BVA Decision. In December 2020, the Court granted the parties' Joint Motion for Partial Remand (JMPR), which vacated the portion of the Board's decision that denied entitlement to service connection for a respiratory disorder and remanded the matter for readjudication. See December 2020 CAVC Decision. This matter was last before the Board in May 2021, when it was remanded for additional development. See May 2021 BVA Decision. Entitlement to service connection for a respiratory disorder, to include asthma, chronic bronchitis and reactive airway disease, is remanded. In May 2021, the Board remanded the Veteran's claim to obtain an addendum medical opinion. Specifically, the Board asked the VA examiner to identify all current diagnoses pertinent to the Veteran's claimed respiratory disorder and to opine as to whether any diagnosed respiratory disorders were etiologically related to the Veteran's active duty service, to include as due to stress associated with being awakened by a non-commissioned officer after he fell asleep during guard duty, bringing in new warheads, and crawling through a field that had been recently sprayed with manure. In addition, the Board advised the examiner that the Veteran was presumed sound upon his entrance into service as to respiratory disorders, despite his reported history of asthma during childhood, and noted that an opinion stating that a respiratory disorder preexisted service was inadequate. See May 2021 BVA Decision. The Board notes that VA obtained the requested addendum medical opinion in August 2021. After performing a review of the evidence of record, the VA examiner opined that it was less likely than not that the Veteran's diagnosed respiratory disorders, to include asthma, chronic bronchitis, and reactive airway disease, were incurred in or caused by the claimed in-service events, to include as due to stress associated with being awakened by a non-commissioned officer after the Veteran fell asleep during guard duty, bringing in new warheads, or due to crawling through a field that had been recently sprayed with manure. In support of the opinion, the examiner explained that the medical literature clearly showed that certain exposure events triggered, but did not cause, an Immunoglobulin E (IgE) mediated response in an individual's body that was already present and waiting to occur. In this regard, the examiner indicated that the in-service events reported by the Veteran were likely triggers of his asthmatic response but were not the underlying cause of the symptoms of asthma, chronic bronchitis, and reactive airway disease. Rather, the examiner explained that asthma was a multifactorial disease with involvement of family history/atrophy IgE antibody response to many environmental factors, while reactive airway disease was a term commonly used when asthma was suspicioned but not diagnosed. The examiner further determined that all of the Veteran's diagnoses, to include asthma, chronic bronchitis, and reactive airway disease, and associated symptoms pointed toward an inflammatory process of the bronchial tree with evidence of atrophy in the Veteran that included a diagnosis of allergic rhinitis. To this end, the examiner explained that atrophy, defined as the genetic predisposition to develop specific IgE antibodies directed against common environmental allergens, was the strongest identifiable risk factor for development of asthma. In this regard, the examiner noted that the Veteran's post-service treatment records clearly showed allergy symptoms or atrophy to environmental triggers. The examiner also cited an UpToDate article which indicated that airway biopsies obtained by bronchoscopy demonstrated that inflammation in asthma generally involves the same cells that play permanent roles in the allergic response in the nasal passages and skin, regardless of whether the individual is atrophic, and indicated that a variety of genetic, environmental, and infectious factors appeared to modulate whether affected individuals progress to asthma over time. In addition, the examiner cited Pathophysiology of Asthma, which states that environmental triggers such as manure would trigger a cascade of IgE antibodies, as mast cells release cytokine and histamine, prostaglandins, and leukotrienes, which in turn contact the smooth muscle and cause airway tightening. With regard to the Veteran's diagnosed chronic bronchitis, the examiner cited a Hopkins Medicine article, indicating that chronic bronchitis was considered a form of chronic obstructive pulmonary disease (COPD) and commonly caused by smoking, air pollution, or working environment. In this regard, the examiner acknowledged that the etiology of the Veteran's chronic bronchitis was not fully explained in the medical evidence of record, as he was a non-smoker and worked as a truck driver for multiple years post-service. However, she also noted that the Veteran was diagnosed with chronic bronchitis with hemoptysis in February 2003, after a bronchoscopy showed that his bronchi were somewhat inflamed and injected; as such, the examiner opined that there was no objective evidence showing that the Veteran's chronic bronchitis was caused by in-service events that occurred approximately 20 years prior. See August 2021 Medical Opinion. After a review of the evidence of record, the Board finds that 38 C.F.R. § 3.380 has been implicated by the facts of the appeal, and as such, that a remand is required to obtain an addendum medical opinion addressing whether any of the Veteran's current respiratory disorders had their onset in, or are otherwise related to, his active duty service. Pursuant to 38. C.F.R. § 3.380, seasonal and other acute allergic manifestations subsiding on the absence or removal of an allergen are generally to be regarded as acute diseases, healing without residuals. However, 38 C.F.R. § 3.380 also instructs that some diseases of allergic etiology may not be disposed of routinely for compensation purposes as constitutional or developmental abnormalities. Service connection must be determined on the evidence as to the existence prior to enlistment and, if so existent, a comparative study must be made of its severity at enlistment and subsequently. Additionally, increase in the degree of disability during service may not be disposed of routinely as natural progress nor as due to the inherent nature of the disease. Determination as to service incurrence or aggravation must be on the whole evidentiary showing. See 38. C.F.R. § 3.380. Here, the August 2021 VA examiner based her medical opinion, at least in part, on her finding that atrophy, which seems to be the genetic predisposition to develop specific IgE antibodies directed against common environmental allergens, was the strongest identifiable risk factor for the development of asthma and indicated that the in-service events reported by the Veteran likely triggered his asthmatic response but were not the underlying cause of the symptoms of asthma, chronic bronchitis, or reactive airway disease. See August 2021 Medical Opinion. Thus, the Board finds that it is not clear whether the Veteran's diagnosed respiratory disorders might be of allergic origin (in whole or in part) as defined in § 3.380. VA has a duty to ensure any medical examination or opinion it provides is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). Thus, the Board finds that a remand is necessary to obtain an addendum medical opinion to determine the nature and etiology of the Veteran's diagnosed respiratory disorders. See Bowling v. Principi, 15 Vet. App. 1, 12 (2001) (emphasizing the Board's duty to return inadequate examination report). The matter is REMANDED for the following action: 1. With any necessary identification of sources by the Veteran, request all VA treatment records not already associated with the file from the Veteran's VA treatment facilities, and all private treatment records from the Veteran not already associated with the file. 2. After completion of the above development, obtain an addendum medical opinion by an appropriately qualified examiner to determine the nature and etiology of the Veteran's diagnosed respiratory disorders. It is up to the discretion of the examiner as to whether an in-person examination is necessary. The examiner should provide the following opinion: Is it at least as likely as not (50 percent or greater probability) that the Veteran's diagnosed respiratory disorders, to include asthma, chronic bronchitis, and reactive airway disease, had their onset during service or are otherwise etiologically related to the Veteran's active duty service, to include as due to stress associated with being awakened by a non-commissioned officer after falling asleep during guard duty, bringing in new warheads, and crawling through a field that had been recently sprayed with manure? Please explain why or why not. In providing a response, the examiner should specify whether any current respiratory disorders are more consistent with seasonal and other acute allergic manifestations subsiding on the absence of or removal of the allergen healing without residuals. The examiner is advised that the Veteran is presumed sound upon his entrance into service as to respiratory disorders, despite his reported history of asthma during childhood. An opinion stating that a respiratory disorder preexisted service is inadequate. Reasons should be provided for any opinion rendered. If the examiner is unable to provide an opinion without resort to speculation, an explanation as to why this is so should be provided and any additional evidence that would be necessary before an opinion could be rendered should be identified. S. HENEKS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board K. Justis, Associate Counsel The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.