Citation Nr: 21011729 Decision Date: 03/02/21 Archive Date: 03/02/21 DOCKET NO. 09-36 299 DATE: March 2, 2021 ORDER Entitlement to service connection for asthma is granted. FINDING OF FACT The Veteran's asthma is at least as likely as not related to his active duty service. CONCLUSION OF LAW The requirements to establish entitlement to service connection for asthma have been met. 38 U.S.C. §§ 1101, 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had active duty service in the United States Navy from August 1967 to May 1971. This matter comes to the Board of Veterans’ Appeals (Board) on appeal from a September 2008 rating decision. In decisions dated in July 2013 and May 2016, the Board remanded the case to the Agency of Original Jurisdiction (AOJ) for additional development and adjudication. The case has since been returned to the Board for appellate review. The Board finds that the AOJ substantially complied with prior remand directives, to the extent possible, and no further action in this regard is warranted. See Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (concluding that a remand is not required under Stegall v. West, 11 Vet. App. 268 (1998) where there was substantial compliance with the Board's remand instructions). The Veteran testified at a Board hearing before a Veterans Law Judge in March 2013. In March 2016, a letter notified the Veteran that the Veterans Law Judge who conducted the March 2013 hearing was no longer employed by the Board. The letter also advised the Veteran of his right to request another Board hearing. The Veteran then requested another Board hearing in March 2016. Although the record indicates that the Veteran later testified at a Board hearing in November 2016, a subsequent February 2018 letter informed the Veteran that the Board was not able to record and produce a written transcript of that proceeding and offered him the opportunity to testify at another hearing. In January 2019, the Veteran responded that he wanted another Board hearing. The Veteran subsequently testified at a Board hearing before the undersigned Veterans Law Judge in December 2020. Transcripts from both the March 2013 and December 2020 Board hearings are associated with the claims file. 1. Entitlement to service connection for asthma. Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). To establish a right to compensation for a present disability, 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-the so-called "nexus" requirement. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 38 F.3d 1163, 1167 (Fed. Cir. 2004)). The absence of any one element will result in denial of service connection. Service connection may also be granted for any disease initially diagnosed after service when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Every veteran is presumed to have been in sound condition upon entry into service except as to defects, infirmities, or disorders noted at the time of such entry. 38 U.S.C. § 1111; 38 C.F.R. § 3.304(b). Only conditions recorded on examination reports are considered "noted" at entry into service. 38 C.F.R. § 3.304(b). In order to rebut the presumption of soundness, it must be shown with clear and unmistakable evidence that a disorder preexisted service and that the disorder was not aggravated by service. Id. Clear and unmistakable evidence" is an "onerous" evidentiary standard, requiring that the preexistence of a condition and the no-aggravation result be "undebatable." Cotant v. Principi, 17 Vet. App. 116, 131 Ca (2003); Quirin v. Shinseki, 22 Vet. App. 390, 396 (2009) (noting that clear and undebatable means that the evidence cannot be misinterpreted or misunderstood). The Veteran contends that he has asthma that his related to his exposure to fumes from JP5 fuel and jet exhaust that occurred in the course of his duties as a plane captain while he was on active duty at Cecil Field in Jacksonville, Florida from 1967 to 1968. See, e.g., December 2007 Statements; March 2013 Board Hearing Transcript. The Veteran’s service treatment records (STRs) show that in the November 1966 Report of Medical History, the Veteran reported a history of asthma. The Veteran also reported that he had been a sleepwalker. The physician's summary noted that the last attack occurred at age 12 or 13, none since. However, the November 1966 pre-induction examination noted that the Veteran's lungs and chest were normal upon clinical evaluation. The examination also did not indicate that any abnormalities were present in the November 1966 chest x-ray. Under the section related to the summary of defects and diagnoses, the report noted that a local medical doctor (LMD) letter stated that "the applicant never has had asthma or has been a sleepwalker." A stamp on the report further reflects that a physical inspection in February 1967 did not reveal any additional defects, and the Veteran was found fit for military service. In November 1967, an STR noted that the Veteran was suspected to have the flu for two days. His throat was inflamed. Later in February 1968, the Veteran complained of a sore throat for two days, but there was no complaint of a cough. His chest was clear. In July 1968, an STR reported that the Veteran had fainted and had been feeling sick. In July 1968, an STR related to the Veteran’s admission for infectious hepatitis reported that the Veteran had a history of pneumonia as a child. The STR also stated that the Veteran smoked cigarettes. His chest x-ray was noted to be normal. The Veteran sought treatment for a sore throat again in August 1969. The impression was flu syndrome. In September 1970, the Veteran complained of tonsillitis. In the Veteran's April 1971 separation examination, his lungs and chest were found to be normal on clinical evaluation. His chest x-ray was negative. Nothing was noted under the summary of defects and diagnoses section. During the March 2013 Board hearing, the Veteran clarified that he had experienced bronchitis prior to service rather than asthma, and he outgrew it. The Veteran also indicated that although he did not report having any asthmatic episodes while in service, he did experience intermittent episodes of shortness of breath after breathing in jet fumes following plane takeoffs that required him to take a moment to collect himself. The Veteran indicated that he had not sought treatment for shortness of breath as he believed that these events were part of the job. The Veteran additionally remembered that he was 24 years old when he left service, and first sought treatment for asthma when he was 39 or 40 years old. He did not recall having any interim episodes of shortness of breath that were notable. During the December 2020 Board hearing, the Veteran testified that he did not have any breathing issues prior to active service. Consistent with his March 2013 testimony, the Veteran recalled needing to cough while working on the flight line following jet takeoffs as a result of the exhaust fumes. The Veteran also indicated that as many as 18 jets could line up to take off in succession. In addition to being exposed to exhaust fumes after takeoffs, the Veteran indicated that he also received exposure when he was constantly going underneath planes to check the struts and wheels while the planes were still running. In addition, it was his duty as a plane captain to inspect planes to make sure they could fly as well as to fuel the planes. These types of duties occurred four out of five days for approximately four to five hours. The Veteran reported that although he was given ear protection, he did not receive a mask. The Veteran only experienced episodes of shortness of breath when he was working. The Veteran also reported that he first began to experience asthma problems after service when he was in 30's. The Veteran's DD 214 lists his specialty number and title as AK (8000), and the civilian equivalent was noted to be stock clerk. In March 2013, the Veteran e-mailed a buddy from his period of active duty service asking whether the buddy remembered that they had been plane captains between 1967 to 1968 at Cecil Field in Jacksonville, Florida. The Veteran also asked his buddy whether the job had entailed filling the planes with JP-5 fuel. The Veteran's buddy responded in a March 2013 e-mail that he did recall checking planes that came into pits; including checking the tires, fueling the planes, and towing the planes away. The Veteran's history of assignments in his military personnel records also shows that he was received for duty at the Naval Air Station - Cecil Field in Florida on October 27, 1967, and he continued to serve in this location until he was transferred to the Naval Hospital in Jacksonville for treatment on July 9, 1968. A Report of Enlisted Performance for the period from October 27, 1967 to March 16, 1968 noted under the description of assigned tasks that the Veteran was assigned to the line as a TA4F plane captain. He was a new TA4F plane captain who worked hard in performing his assigned duties. A subsequent Report of Enlisted Performance for the period from March 16, 1968 to September 16, 1968 noted under the description of assigned tasks that the Veteran was a plane captain on TA-4F aircraft. The report noted that he had been in the hospital for the past month. However, the report indicated that the Veteran had taken exceptionally good care of his assigned aircraft during this period. He was hardworking and had the initiative to foresee things that needed to be done. As the Veteran’s described exposure to fumes from JP5 fuel and jet exhaust is consistent with the recollection of his buddy and the information noted in his military personnel records, the Board accepts the Veteran's reported in-service exposure as credible and consistent with his service. 38 C.F.R. § 1154(a). Regarding the Veteran’s reported history of in-service and post-service respiratory symptoms, the Board notes that the Veteran is competent to report his history of observable symptoms such as shortness of breath and coughing. Layno v. Brown, 6 Vet. App. 465 (1994); Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). The Board also finds the Veteran's reported history to be credible as his reports have been largely consistent throughout the appeal period. In addition, the Veteran provided an explanation for the lack of in-service documentation of these complaints as the Veteran did not believe that the events were significant enough to warrant seeking treatment. As indicated by the July 1968 STR, the record also shows that the Veteran has a smoking history. In April 2000, a VA treatment noted that the Veteran denied that he currently smoked cigarettes. The record noted that it had been 12 to 15 years since he last smoked regularly, and his smoking history was "-1" pack per day for “-20" years. In February 2002, a VA treatment similarly described the Veteran as an ex-smoker. During the December 2020 Board hearing, the Veteran clarified that he smoked no more than one pack a day while he was smoking cigarettes, and he stopped smoking once he found out that he had asthma. The Veteran reported that it was difficult to smoke more than one half pack per day as no smoking was permitted on the flight line where he worked during service. He also indicated that any prior records suggesting that he smoked more than this amount were based on a misunderstanding. The Board notes that this timeline of when the Veteran stopped smoking is consistent with the history noted in the April 2000 VA treatment record. The Veteran is also competent to attest to his smoking history, and the Board finds the Veteran to be credible in light of his explanation for any discrepancies in the record. The Veteran was initially provided with a VA examination in connection with his claim in May 2008. Regarding the date of onset of the Veteran's asthma, the examiner indicated that the Veteran placed the date as occurring while he was on active duty. He did not remember the exact date. The examiner observed that there was related medical documentation of an asthma condition noted once on the pre-induction examination and never again in his STRs. The examiner added that the disorder was a pre-active duty onset condition and was never an active duty issue/condition in the entire four years of active duty. The private treatment records indicated that the Veteran only became symptomatic in the early 1990's, leaving more than 19 to 20 years of long temporal gap since the Veteran left service in 1971. There was no documentation of any asthma or related symptoms such as chest tightness, wheezing, shortness of breath, dyspnea on exertion, etc.; or any upper or lower respiratory pulmonary symptoms during service. There was also no documentation of any treatment for asthma or any related pulmonary conditions before the 1990’s. The examiner also highlighted that the Veteran had a history of 10 to 12 years of smoking 1 to 2 packs per day by the time he was symptomatic with asthma. The examiner also found it significant that the Veteran had never undergone any pulmonary function testing/spirometry before the May 2008 VA examination. The examiner noted that the Veteran currently had mild to moderate, chronic, stable asthma. The examiner found that there was no evidence of any worsening in the Veteran's asthma. He had no history of frequent emergency department visits for any asthma exacerbation in the last few years. He also had no history of recurrent respiratory infections (requiring frequent antibiotics) or frequent asthma exacerbations requiring systemic prednisone oral or intravenous steroids (which are the usual indicators for worsening asthma) in the last few years. The Veteran also never had any history of respiratory failure, he had never been on a ventilator or oxygen therapy, and he had never been incapacitated by asthma. The examiner also opined that the Veteran had a probable coexisting chronic obstructive pulmonary disease (COPD) secondary to smoking. The examiner found that overall, there was no evidence in the claims file that any of the Veteran's current asthma and related respiratory/pulmonary condition was caused by, incurred in, or aggravated or permanently worsened by service beyond its natural course. Given the known history of pre-active duty asthma symptoms, and the subsequent history of smoking, the Veteran's asthma would most likely have happened and worsened with time even without military service. The examiner opined that the Veteran's asthma was less likely than not cause by, or a result of, the Veteran's active service. In April 2014, a VA examiner provided another medical opinion regarding the Veteran's claim. The examiner stated that he had reviewed the conflicting medical evidence and opined that it was less likely than not that the Veteran has a current asthma condition related to his military service. The examiner noted that on the pre-induction November 1966 Report of Medical History, the Veteran checked “yes” to asthma history and the physician wrote "asthma - last attack age 12 or 13 - none since;" and then there was another note saying "LMD letter states applicant never has had asthma..." The May 2008 VA examiner had also reviewed the records and found no evidence of any respiratory problems while in service or after service until the 1990s. In the April 2014 VA examiner’s opinion, the pre-induction physical records concluded that the Veteran did not have a definite diagnosis of asthma as a child. However, the examiner did not think that there was any relevance to the question of asthma at age 12 if the Veteran then had no pulmonary symptoms in the service and then was diagnosed with asthma over 20 years later. The examiner opined that in either case, it was less likely than not that the Veteran's current asthma was related to his military service. In an April 2013 letter, Dr. Z. noted that the Veteran was her patient, and he had experienced asthma since his 30's. It had recently become much more disabling. The Veteran was taking albuterol/ipratropium, formoterol, mometasone, and zafirlukast. He had also been hospitalized twice for exacerbation of asthma in 2013. He was going to see a pulmonary specialist later that month. Dr. Z. also noted that during the Veteran's miliary career, he was a Navy plane captain and received exposure to JP5 fuel fumes as well as fumes from jet exhaust. In April 2013, a private pulmonary office note from Dr. L. noted that the Veteran was seen for a follow-up after an inpatient admission 2 weeks ago for an asthma exacerbation. He reported having a history of asthma as a child when he was 4 to 5 years old, but he never had any symptoms after his early childhood. He started becoming symptomatic in his 30's. Dr. L. noted that the Veteran felt that the onset of asthma in his 30's was related to his exposure to fuel fumes and jet exhaust while he was a plane captain during his military career. The Veteran reported that his asthma was difficult to control, and he usually had an attack once a year with two episodes of exacerbation each year. Triggers included exercise, cold air, dust, trees, and cutting the grass which could bring severe episodes of tightness and shortness of breath. The Veteran had been told by an allergist almost 10 years ago that he had different allergies, including allergies to dog dander and pollen. Dr. L. noted that his past medical history was significant for COPD/asthma. The impression noted that the Veteran had a longstanding history of asthma, initially diagnosed during childhood. Dr. L. also observed that the Veteran's physician at VA had commented on the Veteran's exacerbation and deterioration in his 30's, which was felt to be related to occupational exposure to jet exhaust. In June 2014, an additional VA medical opinion was obtained. The examiner opined that was less likely than not that the Veteran’s claimed asthma was incurred in, had a nexus to, and/or was aggravated by service because there was no pre-existing event involving an asthmatic attack occurred in his childhood; and the examiner also indicated that the pre-induction examination and/or active duty STRs did not include medically-based, clinical evidence to support clinical signs and symptoms for chronic respiratory distress. The examiner also found that it is as least as likely as not that tobacco is a toxin that was related to, and exasperated, COPD and/or asthma. The examiner indicated that he had reviewed the claims folder and current medical literature in reaching an opinion. The examiner noted that the Veteran had reported in the November 1966 Report of Medical History that the last attack of asthma was at age 12 or 13 and none had occurred since, and the November 1966 pre-induction examination noted the report from his private physician that the Veteran “never” had experienced asthma. Therefore, the Veteran’s acceptance into the military was granted on the basis of no asthmatic condition. Thus, it was less likely than not that the Veteran’s claimed asthma was incurred in, had a nexus to, and/or was aggravated by service because there was no pre-existing event involving an asthmatic attack in his childhood. The examiner added that second, the medical community agreed that asthma is medically defined as a “chronic respiratory disease that manifests as a syndrome of episodic and reversible airflow obstruction. Asthma is characterized on pathologic examination by chronic airway inflammation, with prominent eosinophilic infiltration, with or without evidence of airway remodeling.” The examiner cited to a medical article in support of this definition. Therefore, it was less like likely than not that the Veteran’s respiratory event was asthmatic but similar to bronchitis, allergies, bronchitis, croup (laryngotracheobronchitis), or acute hyper-reactive airway involving the upper respiratory tree. Third, the April 2014 VA examiner had reviewed the service records before concluding that there was no evidence of any respiratory problems during the Veteran’s active duty service, and no evidence of asthma until the 1990s. The examiner agreed with the May 2008 and April 2014 VA examiners’ findings that was no evidence of relevant respiratory symptoms during the Veteran’s active service. Regarding the Veteran’s report that he had bronchitis as a child and outgrew it, the examiner cited to a medical article on acute bronchitis to note that “[a]cute bronchitis is a self-limiting inflammation of the large airways of the lungs, usually due to a viral infection.” Current medical literature stated that “[v]iruses are the most common causes of acute bronchitis, accounting for more than 56% of cases.” In the alternative, “[b]acterial pathogens associated with 'atypical pneumonia,' including Mycoplasma pneumoniae and Chlamydophila pneumoniae, may cause acute bronchitis. Bordetella pertussis and related species are recognized increasingly as causes of acute bronchitis in adults as well as children. Collectively, these bacteria account for 5% to 20% of cases.” In addition, fungal infections were rare and usually associated with an immune compromised individual. Therefore, it was less likely than not that bronchitis is “grown out of” rather than acquired. Furthermore, acquired bacterial, viral, or fungal infections were often self-limiting and resulted in “an inflammation of the mucous membranes of the bronchial tubes, resulting in cough that usually resolves within 3 weeks” when treated with appropriate medication. Therefore, it was at least as likely as not that if the Veteran experienced an acute infectious upper respiratory event, it was self-limiting, acute, and transient rather than outgrown. Lastly, the active duty medical records were silent for an acute upper respiratory event while in service or over the presumptive period. Therefore, it was less likely than not that the Veteran had bronchitis in service because of the lack of medically-based, clinical evidence to support an upper respiratory infection while on active duty or over the presumptive period. In addressing the Veteran’s smoking history, the examiner noted that the May 2008 VA examination indicated that the Veteran had a 10 to 12 year history of smoking 1 to 2 packs per day by the time he was symptomatic with asthma. However, the claims folder was silent for pulmonary function testing to differentiate asthma from COPD and/or other types of pulmonary fibrotic conditions. The May 2008 chest x-ray observed “lungs grossly clear.” The examiner quoted a medical article for the proposition that “[t[he development of chronic obstructive pulmonary disease (COPD) is multifactorial, and the risk factors include both genetic and environmental factors. Although tobacco smoking is an established risk factor for COPD, many other associated factors remain underappreciated or neglected. Up to 50% of cases of COPD can be attributed to nonsmoking risk factors. This article describes the role of tobacco smoking and the various environmental risk factors associated with the development of COPD.” Therefore, it was as least as likely as not that the Veteran’s tobacco abuse was related to, had a nexus with, and aggravated his current upper respiratory condition. Regarding the onset of asthma, the examiner noted the Veteran’s report in an April 2014 statement that his asthma started in the early 1990’s and was worsening. The Veteran also reported that he was hospitalized three times for asthma in 2013. The examiner again noted that the STRs were silent for any evidence of asthma. Therefore, it was less likely than not that the Veteran’s asthma was incurred in, was caused by, had a nexus to, and/or was aggravated by service because of the approximate 20-year delay in symptomatology. In the alternative, it is as least as likely as not that the Veteran’s tobacco abuse was related to, had a nexus with, and aggravated his current upper respiratory condition. Regarding the Veteran’s reported exposure to jet fumes and toxins during active service, the examiner acknowledged Dr. Z.’s April 2013 letter and stated that although “many epidemiologic studies have suggested that the prevalence of allergic disease, especially asthma, has been increasing in developed countries over the past 30 years,” the active duty clinical file was silent for medically-based, clinical evidence to support an occupational exposure and/or need to seek medical care for an upper respiratory event related to jet fumes and toxic exposure. In the alternative, the Veteran had a past medical history of tobacco use. Therefore, it was as least as likely as not that tobacco is a toxin that was related to and had exasperated his current diagnoses of COPD and/or asthma. The examiner added that it would be mere speculation to assume the credibility of the Veteran with regard to asthma in service based on a review of the claims folder. In the alternative, there was no medically-based, clinical evidence, to include appropriate levels of exposure to toxic material and/or jet fumes, to support an asthmatic condition or event while in service. Therefore, it was less likely than not that the Veteran’s claimed respiratory condition, to include asthma, was incurred in, had a nexus to, was caused by, and/or aggravated by his time in service. In the examiner’s opinion, the credibility of the clinical files and claims folder supported an asthmatic condition that started in the 1990’s and was exacerbated by the Veteran’s smoking and civilian lifestyle choices. Thus, it is as least as likely as not that the Veteran’s claimed asthma had a nexus to, was related to, and aggravated by his smoking and civilian lifestyle choices. The Board first notes that the record has raised the question of whether the Veteran's current asthma preexisted service. Although the Veteran reported a history of childhood asthma in the November 1966 Report of Medical History, the presumption of soundness applies as no asthma was documented in the November 1966 pre-induction examination or during the subsequent physical inspection in February 1967. 38 U.S.C. § 1111; 38 C.F.R. § 3.304(b). Indeed, the examination report noted that a local medical doctor had confirmed that there was no history of asthma. Although the Veteran has reported a history of pre-service asthma at times in the post-service records, he clarified during both Board hearings that there was no history of asthma or any relevant respiratory symptoms prior to service. As to the Veteran’s report of bronchitis prior to service, the June 2014 VA examiner provided a detailed rationale to support the conclusion that the Veteran’s report was indicative of an acute infectious upper respiratory event rather than evidence of the existence of a respiratory disorder prior to service. As the report of childhood asthma from the November 1966 Report of Medical History is the only evidence of asthma prior to service, the Board does not find that the record contains clear and unmistakable evidence that the Veteran's asthma existed prior to service. Therefore, the presumption of soundness has not been rebutted. The claim will consequently be considered on the basis of direct service connection. After reviewing the above opinions, the Board finds that the May 2008 VA medical opinion provides minimal probative value. The examiner’s rationale reflects that the opinion is based in part on the examiner’s conclusion that the Veteran’s asthma had existed prior to service without evidence of worsening during service. However, as the Board has determined that the Veteran is presumed to have been sound at entry, the relevant question is whether the disorder manifested during, or is otherwise related to, service. There is also no indication that the examiner elicited a medical history from the Veteran as to whether he experienced any relevant respiratory symptoms during service and instead relied on the lack of in-service documentation of any complaints. Furthermore, the examiner believed the Veteran’s smoking history to be more significant than the amount of packs per day which the Veteran reported having actually smoked. The examiner also highlighted the time gap between service and the period when the Veteran first required treatment for asthma without explaining the significance of any delayed onset of the disorder. See 38 C.F.R. § 3.303(d). The opinion from the April 2014 examiner similarly has reduced probative value as the examiner highlighted the lack of relevant findings in the STRs and appeared to be unaware of the Veteran’s reports in the record indicating that he did experience intermittent symptoms of shortness of breath during service. See March 2013 Board Hearing Transcript. To the extent that the examiner disregarded the Veteran’s competent and credible reports, the Board notes that the lack of contemporaneous medical evidence does not warrant a conclusion of a lack of nexus. See Buchanan v. Nicholson, 451 F.3d 1331, 1336-37 (Fed. Cir. 2006). The April 2014 examiner also pointed to the time gap between service and the onset of the Veteran’s symptoms without addressing why the symptoms were not otherwise related to the in-service exposure to fumes from JP5 fuel and exhaust. In addition, the June 2014 VA examiner’s opinion is not entitled to much probative weight as the examiner’s rationale was often inadequate to support the provided conclusions. At one point, the June 2014 VA examiner provided the opinion that the Veteran’s asthma was not incurred in or related to service due to the lack of pre-service evidence of asthma without providing any further explanation for this logic. Although the examiner appeared to determine that asthma did not manifest during service by explaining that the Veteran’s in-service symptoms were inconsistent with the definition of asthma, the examiner nevertheless failed to adequately address the potential significance of the Veteran’s reported respiratory symptoms following incidents of exposure to fumes from jet fuel and exhaust in the manifestation of the Veteran’s asthma after service. The examiner mirrored the prior opinions in highlighting the delayed onset of asthma without providing any explanation as to why such a delay was relevant. The examiner also cited to medical literature that appeared to support an association between the development of asthma and aspects of the developed world such as the Veteran’s in-service exposure events before disregarding the Veteran’s occupational exposure due to the fact that he did not seek treatment for relevant complaints following exposure events. As previously discussed, the Veteran has provided competent and credible evidence to support the conclusion that he experienced periods of exposure to fumes from jet fuel and exhaust for several hours a day during a regular five-day period of work. The Veteran also explained that he did not seek treatment for the temporary respiratory events that followed these exposures as he believed the symptoms were common to his job. Regarding the June 2014 VA examiner’s opinions attributing the Veteran’s asthma to his smoking history, the examiner did not provide a supporting rationale. The examiner cited to medical literature addressing whether tobacco use is a risk factor for COPD without citing to any similar article to support the conclusion that it was risk factor for asthma. Moreover, the June 2014 VA examiner based his conclusions regarding the etiological role of the Veteran’s smoking history on the information reported by the May 2008 VA examiner which the Board has found to be inaccurate. The Board observes that in discussing the Veteran’s current asthma in the April 2013 letter, Dr. Z. acknowledged that the symptoms had only been present since the Veteran’s 30’s, but Dr. Z. still found it worth noting that the Veteran had been a Navy plane captain and received exposure to JP5 fuel fumes as well as fumes from jet exhaust during his military career. Although Dr. L. understood the Veteran’s asthma to have been diagnosed during childhood in the April 2013 private treatment record, Dr. L. was nevertheless aware that the Veteran had not experienced symptoms of asthma until his 30’s. Dr. L. additionally noted the Veteran’s theory that the manifestation of symptoms in his 30’s was related to his in-service exposure to fuel fumes and jet exhaust while he was a plane captain during his military career. The Board finds that it notable that although Dr. L. was aware of the delayed onset of symptoms and identified different triggers for the Veteran’s current symptoms of asthma, he did not point to any clinical findings or medical principles that would contradict the Veteran’s theory that the onset of his asthma was due to the prior occupational exposure to fumes from jet fuel and exhaust during service. Dr. L. instead appeared to accept this theory. The Board has considered the Veteran’s competent and credible reports of in-service respiratory symptoms following his exposure to fumes from jet fuel and fumes, the fact that the June 2014 VA examiner appeared to acknowledge the possibility of an association between the type of the Veteran’s occupational exposure and asthma by citing to an article’s report that asthma has been increasing in developed counties over the past 30 years; and Dr. L.’s April 2013 record suggesting that the Veteran’s theory of entitlement was valid. There is also no probative evidence that any other potential risk factor from the Veteran’s medical history played a greater role in the development of asthma than his in-service occupational exposure. Based on this evidence, the Board finds that the most probative evidence establishes a nexus between active service and the Veteran's current asthma. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. As such, service connection is granted for asthma. See 38 C.F.R. § 3.303(a) (service connection must be considered on the basis of the places, types, and circumstances of his service as shown by his service records, the official history of each organization in which he served, his medical records, and all pertinent medical and lay evidence); see also Buchanan, 451 F.3d at 1335 (Fed. Cir. 2006) ("[N]othing in the regulatory or statutory provisions [relating to evidence to be considered] require both medical and competent lay evidence; rather, they make clear that competent lay evidence can be sufficient in and of itself"). GAYLE STROMMEN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board K.C. Spragins, 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.