Citation Nr: 21027884 Decision Date: 05/07/21 Archive Date: 05/07/21 DOCKET NO. 17-50 279A DATE: May 7, 2021 ORDER Entitlement to an increased rating of 60 percent prior to August 7, 2019 for chronic obstructive pulmonary disease (COPD) with chronic bronchitis and recurrent pneumonia is granted. Entitlement to an increased rating of 100 percent from August 7, 2019 forward, for COPD with chronic bronchitis and recurrent pneumonia is granted. Entitlement to a total disability rating based on individual unemployability due to a service-connected disability (TDIU) is granted. FINDINGS OF FACT 1. Prior to August 7, 2019, the Veteran's chronic obstructive pulmonary disease (COPD) was manifested by pulmonary function testing showing Diffusion Capacity of the Lung for Carbon Monoxide by the Single Breath Method (DLCO) (SB) between of 40 and 55 percent predicted. 2. From August 7, 2019, forward the Veteran's COPD was manifested by pulmonary function testing showing Diffusion Capacity of the Lung for Carbon Monoxide by the Single Breath Method (DLCO) (SB) of less than 40 percent predicted. 3. Prior to August 7, 2019, the Veteran was service-connected for COPD rated as 60 percent disabling and left breast scar and left breast mass rated as noncompensable; for a total disability rating of 60 percent. 4. Resolving reasonable doubt in the Veteran's favor his service-connected COPD has been shown to render him unable to secure and follow all forms of substantially gainful employment. CONCLUSIONS OF LAW 1. Prior to August 7, 2019, the criteria for a 60 percent evaluation, but no higher, for COPD have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.97, Diagnostic Code 6604 (2020). 2. From August 7, 2019 forward, the criteria for a 100 percent evaluation for COPD have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.97, Diagnostic Code 6604 (2020). 3. The criteria for TDIU have been met. 38 U.S.C. §§ 1155, 5107; (2012) 38 C.F.R. §§ 3.340, 3.341, 4.16, 4.19 (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the U.S. Army from January 1956 to December 1957. Previously, the Veteran's claims were before the Board in February 2020, and were remanded for additional development. Additional development including obtaining a supplemental VA examination and additional treatment records have been associated with the claims file, and as such there has been substantial compliance with the prior remand directives, and the appeal is again before the Board. See Stegall v. West, 11 Vet. App. 268, 271 (1998). Increased Rating Disability evaluations are determined by the application of the facts presented to VA's Schedule for Rating Disabilities (Rating Schedule) at 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and the residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.321 (a), 4.1. In evaluating the severity of a particular disability, it is essential to consider its history. 38 C.F.R. § 4.1; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Separate evaluations may be assigned for separate periods of time based on the facts found. In other words, the evaluations may be staged. Staged ratings are appropriate for any rating claim when the factual findings show distinct time periods during the appeal period where the service connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). Here, staged ratings will be considered and discussed, as warranted. Entitlement to a compensable rating prior to August 7, 2019 for COPD with chronic bronchitis and recurrent pneumonia and a rating in excess of 60 percent from August 7, 2019. The Veteran contends that an increased rating is warranted for his service-connected COPD with chronic bronchitis and recurrent pneumonia. Herein, the Board will consider the entirety of the Veteran's symptomology associated with his COPD, chronic bronchitis and recurrent pneumonia and for the sake of brevity will refer to such as his COPD. The Veteran's COPD has been rated as noncompensable prior to August 7, 2019 and as 60 percent disabling from August 7, 2019 under Diagnostic Code 6604. As discussed in greater detail below the Board is granting an increased 60 percent rating prior to August 7, 2019 and an increased 100 percent rating from August 7, 2019 forward. Under Diagnostic Code 6604, a 10 percent disability rating is assigned for forced expiratory volume in one second (FEV-1) of 71- to 80-percent predicted, or; forced expiratory volume in one second to forced vital capacity (FEV-1/FVC) of 71 to 80 percent, or; Diffusion Capacity of the Lung for Carbon Monoxide by the Single Breath Method (DLCO) (SB) 66- to 80-percent predicted. A 30 percent disability rating is assigned for FEV-1 of 56- to 70-percent predicted, or; FEV-1/FVC of 56 to 70 percent, or; DLCO (SB) 56- to 65-percent predicted. A 60 percent disability rating is assigned for FEV-1 of 40- to 55-percent predicted, or; FEV-1/FVC of 40 to 55 percent, or; DLCO (SB) of 40- to 55-percent predicted, or; maximum oxygen consumption of 15 to 20 ml/kg/min (with cardiorespiratory limit). A 100 percent disability rating is assigned for FEV-1 less than 40 percent of predicted value, or; the FEV-1/FVC less than 40 percent, or; DLCO (SB) less than 40-percent predicted, or; maximum exercise capacity less than 15 ml/kg/min oxygen consumption (with cardiac or respiratory limitation), or; cor pulmonale (right heart failure), or; right ventricular hypertrophy, or; pulmonary hypertension (shown by Echo or cardiac catheterization), or; episode(s) of acute respiratory failure, or; requires outpatient oxygen therapy. 38 C.F.R. § 4.97. 38 C.F.R. § 4.96 (d) explains that "special provisions for the application of evaluation criteria for Diagnostic Codes 6600, 6603, 6604, 6825-6833, and 6840-6845" includes a provision requiring pulmonary function tests (PFTs) to evaluate respiratory conditions except in certain situations. When the PFTs are not consistent with clinical findings, evaluation should generally be based on the PFTs unless the examiner states why they are not a valid indication of respiratory functional impairment in a particular case. 38 C.F.R. § 4.96 (d)(3). Post-bronchodilator results are required "except when the results of pre-bronchodilator [PFTs] are normal or when the examiner determines that post-bronchodilator studies should not be done and states why." 38 C.F.R. § 4.96 (d)(4). Additionally, post-bronchodilator results are to be used when evaluating the severity of the respiratory disability, "unless the post-bronchodilator results were poorer than the pre-bronchodilator results. In those cases, use the pre-bronchodilator values for rating purposes." 38 C.F.R. § 4.96 (d)(5). The Veteran contends that he has had ongoing increased and worsening symptoms associated with his COPD including episodes of pneumonia, hospital visits and use of steroids and antibiotic medication. Additionally, the Veteran has reported increased difficulty with shortness of breath and use of a wheelchair at times to reduce his exertion, in particular when attending VA appointments and examinations due to long distances he would have to walk. The Veteran submitted a Respiratory Conditions Disability Benefits Questionnaire (DBQ) in September 2014. The private physician noted the Veteran has COPD and chronic bronchitis and recurrent pneumonia. The examiner noted asbestos exposure during the Veteran's service. The private physician noted that the Veteran's respiratory condition does not require the use of oral or parenteral corticosteroids medication, use of inhaled medications, use of oral bronchodilators, use of antibiotics or use of oxygen therapy. The physician noted the Veteran experiences bacterial lung infections and cardiopulmonary complications. The examiner noted no asthma attacks or episodes of respiratory failure in the past 12 months, and noted no cardiopulmonary complications such as cor pulmonale, right ventricular hypertrophy or pulmonary hypertension were noted. A chest X-ray noted increased AP diameter. Pulmonary function testing (PFT) had been performed and the examiner noted pre bronchodilator testing of FVC 64 percent predicted, FEV-1 of 71 percent predicted and FEV-1/FVC was 112 percent predicted. The private physician did not provide post-bronchodilator testing and failed to indicate if such was completed. The physician noted that the Veteran's disability is most accurately reflected by FVC and FEV-1 percentage predicted. The physician failed to provide reasoning as to why the post-bronchodilator testing had not been completed. The examiner noted that the Veteran's respiratory condition does not impact his ability to work as he is retired. The Board has considered the private DBQ in evaluation of whether an increased rating is warranted; however, as noted above 38 C.F.R. § 4.96 provides that PFTs are required to evaluate conditions under Diagnostic Code 6604, and the private physician failed to specify why post-bronchodilator values were not provided and indicated, only providing pre-bronchodilator values. As a result, these are not sufficient for rating purposes under the provisions of 38 C.F.R. § 4.96 (5). The Veteran was afforded a VA examination in September 2017. The examiner noted COPD, chronic bronchitis and a history of recurrent pneumonia. The Veteran reports he is not taking any current treatment for lung problems and has not had any excerebration in the past year. The examiner noted that the Veteran's respiratory condition does not require use of oral or parenteral corticosteroid medications, inhaled medications, oral bronchodilators, antibiotics or outpatient oxygen therapy. PFT was performed and currently reflected the Veteran's pulmonary functioning. The examiner noted that the Veteran's FEV-1/FVC most accurately reflects his level of disability and post-bronchodilator was 79 percent predicted. The Veteran's FVC was 63 percent predicted and his FEV-1 was 60 percent predicted post-bronchodilator. The Veteran's pre-bronchodilator DLCO (SB) was 41 percent predicted. The examiner noted no other significant diagnostic test findings or results. The examiner noted that the Veteran's respiratory condition does not impact his ability to work. Then as a result of the January 2019 remand the Veteran was afforded a VA examination in August 2019. The examiner noted COPD. The Veteran reported he had pneumonia in the past but denied any symptoms or signs of pneumonia since 2018 and denied the use of any inhalers. The Veteran reported his current medications does not include any inhalers or parenteral corticosteroid medications. The examiner noted the Veteran's respiratory condition does not require the use of oral or parenteral corticosteroids, inhaled medications or oral bronchodilators, antibiotics or oxygen therapy. The Veteran has a history of pneumonia in service which has resolved, and his bacterial lung infection is inactive. No COPD attacks with episodes of respiratory failure were noted in the past 12 months and the Veteran denied being on any inhalers for COPD or bronchitis at this time. A chest X-ray noted cardiomegaly and pulmonary hyperinflation suggesting emphysema. PFT was performed. The examiner noted that the Veteran's FEV-1 predicted most accurately reflects his level of disability. The Board notes that the previous examiner had reported that the Veteran's FEV-1/FVC most accurately reflected the Veteran's level of disability. The examiner in August 2019 considered the prior examiners testing and found that FEV-1 percent predicted most accurately reflects the Veteran's level of disability. The examiner noted that the Veteran's respiratory condition does not impact his ability to work. PFT testing noted the Veteran tolerated testing with no coughing, wheezing or dyspnea and appeared very fatigued throughout testing. Albuterol treatment was given with no side effects seen and repeatability was not met. PFT testing noted FEV-1 post-bronchodilator was 51 percent predicted. FVC was 51 percent predicted and DLCO (SB) was 37 percent predicted pre-bronchodilator. Then the Veteran was afforded a VA examination in June 2020. The examiner noted chronic obstructive pulmonary disease with chronic bronchitis and recurrent pneumonia. The examiner noted that the Veteran was prescribed Keflex 500 mg for 10 days due to a urinary tract infection (UTI) in January 2018. The Veteran was seen at the emergency room in April 2019 after a fall the day before with bilateral arm pain, and denied shortness of breath. The Veteran was prescribed Keflex, Cipro and Medrol Dosepak but the conditions for the medications was not listed. The examiner noted that treatment records in November 2019 note the Veteran was prescribed steroids (Decadron) for cervical spine degenerative joint disease with stenosis and radiculitis. Additionally, the Veteran had new onset atrial fibrillation with pacemaker insertion in March 2020 and was prescribed Keflex. No documented steroids, inhalers or antibiotics were noted to be prescribed for a respiratory condition since. The examiner noted the Veteran's respiratory condition does not require use of oral or parenteral corticosteroids medication, use of inhaled medications, use of oral bronchodilators, antibiotics or outpatient oxygen therapy. The examiner noted that the Veteran has had recurrent pneumonia since service, with no documented episodes since 2018. The examiner noted that the Veteran does not have any other pertinent physical findings, complications, conditions, signs or symptoms related to his respiratory condition. A March 2020 chest X-ray noted cardiomegaly with mild pulmonary congestion and bibasilar atelectasis/consolidation. Interval changes were noted since the May 2011 Chest X-ray status post coronary artery bypass grafting and placement of a cardiac conduction device. It was also noted that previously demonstrated peripherally inserted central catheter had been removed. PFT was last done in August 2019 and the examiner noted the Veteran's FVC percent predicted most accurately reflects his level of disability at 51 percent post bronchodilator. The examiner noted that additional PFT was not done due to the Covid-19 pandemic and to protect the Veteran from further harm, additional PFT or exercise capacity testing were not able to be performed. The examiner noted that the Veteran has multiple respiratory conditions and his COPD is predominantly responsible for the PFT results, additionally he has recurrent pneumonia and chronic bronchitis. The examiner noted that that the Veteran's respiratory condition impacts his ability to work in that he lost up to one week of work time in the last 12 months and he experiences dyspnea on exertion and hs a limited ability for prolonged walking, climbing or strenuous exertions, lifting, carrying due to respiratory conditions which would limit the Veteran to sedentary work. The Veteran was scheduled for a VA examination in October 2020, which he failed to appear and then was scheduled for a VA examination in December 2020, which was canceled by the Veteran's spouse. The Veteran's spouse indicated that he did not need or want this appointment. Then, the Veteran was afforded a VA respiratory conditions examination in January 2021. The VA examiner noted a thorough review of the Veteran's claims file, VA electronic health record and a review of the medical literature relating to COPD. The examiner noted the Veteran has COPD with a history of pneumonia, which has resolved at this time. The examiner noted that based on a review of the Veteran's treatment records and prior examiners reports he was not on any inhalers for his COPD until recently and is prescribed Symbicort. The Veteran denied being treated for pneumonia in the past few years and denied any recent COPD exacerbations. The Veteran had new onset atrial fibrillation with pacemaker insertion at a private hospital in March 2020. Treatment records did not show any use of inhaler, steroids or antibiotics at that time. The Veteran has reported shortness of breath, and that he recently had cardiac stents placed in November or December of 2020. The examiner noted that the Veteran's respiratory condition does not require the use of oral or parenteral corticosteroid medications. The Veteran's respiratory condition does require the use of inhaled medications daily, inhalation anti-inflammatory medications. His respiratory condition does not require use of oral bronchodilators, antibiotics or outpatient oxygen therapy. The examiner noted that the Veteran has not had any COPD attacks with episodes of respiratory failure in the past 12 months and has not had any physician visits for required care of exacerbations. The examiner noted that PFTs have not been completed during the examination as the Veteran recently got out of the hospital for a cardiac condition and is status post stents. Thus, to avoid further harm to the Veteran during the Covid-19 pandemic additional testing including PFT testing was not performed. The examiner noted that the Veteran's respiratory condition impacts his ability to work in that he is short of breath for multifactorial reasons including his cardiac history. The examiner noted that the Veteran's decreased Diffusion Capacity of the Lung for Carbon Monoxide by the Single Breath method (DLCO) (SB) testing which was noted in PFT testing is related to his COPD and can at least as likely as not cause shortness of breath and limit strenuous activities. The VA examiner provided a clarification opinion in February 2021. The examiner noted that PFT testing was obtained in 2019, and the Veteran's pre and post bronchodilator findings for FVC and DLCO (SB) remained the same. The examiner noted that the Veteran's FVC was 40 percent predicted and FEV-1 was 51 percent predicted, and a DLCO of 37 percent predicted both pre and post bronchodilator. The examiner noted a review of the prior PFTs which noted severely reduced DLCO (SB) testing with severe restrictive ventilatory defect. The examiner noted that the DLCO (SB) testing is attributed to the Veteran's current COPD and accounts for his worsening symptoms. A chest X-ray from 2019 showed pulmonary hyperinflation suggesting emphysema (decreased DLCO also indicates emphysema). COPD and emphysema are interchangeable terms and have the same pathology and based on a review of the medical literate COPD can lead to restrictive lung disease as noted in the PFTs. As noted in the Veteran's history, review of his medical records and PFTs including his decreased DLCO the examiner found that his service connected COPD at least as likely as not impacts his ability to obtain and maintain substantially gainful sedentary employment. The examiner noted that a review of the Veteran's medical records noted that he was on antibiotics for a bladder infection in January 2018 and was discharged on Keflex which is a different and unrelated condition than his COPD. Additionally, the Veteran has new onset atrial fibrillation with a pacemaker insertion in Mach 2020. Treatment records during this time did not show any use of inhaler or steroids or antibiotics for any respiratory conditions. Additionally, a VA contract examination done in June 2020 also documented that the Veteran is not on any inhalers, steroids or antibiotics. There was no evidence of pneumonia as per the chest X-ray from August 2019. Additionally, the Veteran in the current examination denied being on any antibiotics or steroids for COPD. The Board notes that the VA examiner in February 2021 clarifying opinion found that the Veteran's pre and post-bronchodilator findings for PFT remained the same. Additionally, the VA examiner found that based on a review of the Veteran's PFT testing his decreased DLCO (SB) testing is indicative of a severe restrictive ventilatory defect. As the VA examiner in February 2021 has attributed the Veteran's reduced DLCO (SB) to his COPD, the Board finds that the examiner has clarified that DLCO test most accurately reflects the Veteran's level of disability. The examiner noted that a review of the Veteran's PFT testing indicates severely reduced DLCO (SB) with a severe restrictive ventilatory defect, and a chest X-ray showed pulmonary hyperinflation suggesting emphysema. Decreased DLCO is also an indication of emphysema, and COPD and emphysema are interchangeable terms with the same pathology. The examiner noted a thorough review of the medical literature noting that COPD can lead to restrictive lung disease as noted in the Veteran's PFTs. Thus, based on the VA examiners clarification the Board will consider the use of DLCO (SB) results based on the Veteran's PFT testing to find that such most accurately reflects the Veteran's level of disability. The Board finds the VA examination in January 2021 and February 2021 clarifying opinion are entitled to significant probative weight. VA and private treatment records have been associated with the claims file. Treatment records note use of antibiotics on several occasions, but it is not clear that such was attributed to the Veteran's COPD. The Board has considered the Veteran's representative's contentions and specifically that an increased rating is warranted for the Veteran's COPD due to worsening symptoms and residuals of having COPD, bronchitis and pneumonia. In January 2020 correspondence the Veteran's representative contends that the Veteran was hospitalized and on oxygen due to his residuals of COPD, bronchitis and pneumonia and thus and increased rating is warranted. The Board notes that the representative is not a competent authority to determine what information may be found probative to a competent examiner. Lastly, the benefit of the doubt rule is for application when the evidence is in equipoise, which occurs only when there is an approximate balance between the positive and negative evidence. 38 C.F.R. § 3.102. That evidence must be both competent and credible. Here, there is no such balance of evidence. Based on the lay and medical evidence of record the Board finds that prior to August 7, 2019 an increased 60 percent rating is warranted. The Board notes the Veteran's and associated lay contentions regarding his ongoing COPD symptomology and limitation on his activities with difficulty breathing, increased shortness of breath as well as a worsening of his symptoms during the appeal. The Veteran and associated lay statements are competent to testify to such lay observable symptomatology. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Prior to August 7, 2019, the Board finds that an increased 60 percent rating is warranted, as the February 2021 VA examiner has clarified that DLCO testing most accurately reflects the Veteran's level of disability, and September 2017 PFT testing noted DLCO testing of 41 percent predicted. A 60 percent rating is warranted under Diagnostic Code 6604 for DLCO of 40 to 55 percent predicted. As such herein the Board has granted an increased 60 percent rating prior to August 7, 2019. However, the Board finds that prior to August 7, 2019, an increased 100 percent rating is not warranted. Even, in consideration of the Veteran's and associated lay statements the medical and lay evidence of record does not establish that an increased rating is warranted during this period on appeal. An increased 100 percent disability rating is assigned for FEV-1 less than 40 percent of predicted value, or; the ratio of Forced Expiratory Volume in one second to Forced Vital Capacity (FEV-1/FVC) less than 40 percent, or; Diffusion Capacity of the Lung for Carbon Monoxide by the Single Breath Method (DLCO (SB)) less than 40-percent predicted, or; maximum exercise capacity less than 15 ml/kg/min oxygen consumption (with cardiac or respiratory limitation), or; cor pulmonale (right heart failure), or; right ventricular hypertrophy, or; pulmonary hypertension (shown by Echo or cardiac catheterization), or; episode(s) of acute respiratory failure, or; requires outpatient oxygen therapy. 38 C.F.R. § 4.97. The VA examiner in January 2021 clarified that the Veteran's PFT is indicative of severely reduced DLCO and is attributed to his COPD. Prior to August 7, 2019 PFT testing in September 2017 the Veteran's pre-bronchodilator DLCO was 41 percent predicted. The Board notes a September 2014 DBQ noted PFT testing had been performed but the private physician did not provide post-bronchodilator testing and failed to indicate if such was completed. As noted above such is not sufficient for rating purposes under the provisions of 38 C.F.R. § 4.96 (5). Thus, based on the evidence of record the Veteran's COPD has been manifested by PFT showing DLCO of 41 percent predicted warranting the current 60 percent rating, granted herein. During the period on appeal, VA examinations and treatment records are absent indications of PFTs warranting an increased 100 percent rating. As such prior to August 7, 2019 an increased 60 percent rating, but no higher is granted. Then from August 7, 2019, the Board finds that an increased 100 percent rating is warranted. The VA examination in August 2019 found PFT showing DLCO (SB) of 37 percent predicted. The February 2021 examiner has clarified that the Veteran's DLCO testing pre and post-bronchodilator has remained the same and is attributed to his increased COPD symptomology. As there has been a clarification and indication that the DLCO testing most accurately reflects the Veteran's level of disability the Board finds that herein a 100 percent rating is warranted from August 7, 2019 forward. Additionally, the Board has considered whether the Veteran's COPD is most appropriately rated under Diagnostic Code 6604, or whether an alternative Diagnostic Code under the respiratory system is warranted. Under 38 C.F.R. § 4.96, ratings under Diagnostic Codes 6600 through 6817 and 6822 through 6847 will not be combined with each other. Instead, a single rating will be assigned under the Diagnostic Code which reflects the predominant disability with elevation to the next higher evaluation where the severity of the overall disability warrants such elevation. 38 C.F.R. § 4.96. The Board notes that the Diagnostic Codes for COPD, emphysema and bronchitis have identical rating criteria, and no other Diagnostic Code may be employed to rate the Veteran's disability. See Copeland v. McDonald, 27 Vet. App. 333, 337 (2015) (when a condition is specifically listed in the rating schedule, it may not be rated by analogy and should be rated under the diagnostic code that specifically pertains to it). The Veteran's service-connected pulmonary disease is evaluated under the provisions of 38 C.F.R. § 4.97, DC 6604, which specifically contemplates the Veteran's diagnosis of COPD. The Veteran also has a diagnosis of emphysema which is subject to the same rating criteria as COPD under Diagnostic Code 6603. As the rating criteria in DC 6604 specifically contemplates the Veteran's service-connected COPD, and the Veteran is not service-connected for emphysema, no other Diagnostic Code may be used to rate the Veteran's disability. See Copeland v. McDonald, 27 Vet. App. 333, 337 (2015) (when a condition is specifically listed in the rating schedule, it may not be rated by analogy and should be rated under the diagnostic code that specifically pertains to it). All potentially applicable Diagnostic Codes have been considered. See Schafrath v. Derwinski, 1 Vet. App. 589, 593 (1991). The preponderance of the evidence is against finding an increased rating in excess of 60 percent prior to August 7, 2019. Herein, a 60 percent rating is granted prior to August 7, 2019. Herein, from August 7, 2019 forward an increased 100 percent rating is warranted. As such, the benefit-of-the-doubt doctrine is inapplicable. 38 C.F.R. § 4.3. TDIU The Veteran contends that he has been unable to secure and maintain employment due to his service-connected COPD. Specifically, his COPD has increased in severity and he is unable to secure or maintain substantially gainful employment during the period on appeal. Herein, the Board has granted a 100 percent disability rating from August 7, 2019 forward, and as such the Board will consider whether entitlement to TDIU is warranted for the period in which the Veteran was not in receipt of a total disability rating which is prior to August 7, 2019. It is the established policy of VA that all Veterans who are unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities shall be rated totally disabled. See 38 C.F.R. § 4.16. A finding of total disability is appropriate "when there is present any impairment of mind or body which is sufficient to render it impossible for the average person to follow a substantially gainful occupation." See 38 C.F.R. §§ 3.340 (a)(1), 4.15. TDIU may be assigned where the schedular rating is less than total and it is found that the disabled person is unable to secure or follow a substantially gainful occupation as a result of either (1) a single service-connected disability ratable at 60 percent or more, or (2) two or more disabilities, provided at least one disability is ratable at 40 percent or more, and there is a sufficient additional service-connected disability to bring the combined rating to 70 percent or more. 38 C.F.R. §§ 3.340, 3.341, 4.16(a). For the purposes of determining rating level, disabilities resulting from a common etiology or affecting a single body system are considered a single disability. 38 C.F.R. § 4.16 (a). When two or more disabilities are treated as one, the ratings for those disabilities are combined using the combined ratings table. 38 C.F.R. § 4.25. If a sufficient rating is present, then it must be at least as likely as not that the Veteran is unable to secure or follow a substantially gainful occupation as a result of that disease. See 38 C.F.R. § 4.16 (a). The central inquiry is, "whether the Veteran's service-connected disabilities alone are of sufficient severity to produce unemployability." Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). The issue is not whether the Veteran can find employment generally, but whether the Veteran is capable of performing the physical and mental acts required by employment. Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). Consideration may be given to the Veteran's education, special training, and previous work experience, but not to his age or to the impairment caused by nonservice-connected disabilities. See 38 C.F.R. §§ 3.341, 4.16, 4.19; see also Van Hoose, 4 Vet. App. at 363. In this case, the Veteran does meet the threshold criteria for TDIU. See 38 C.F.R. § 4.16. Prior to August 7, 2019, the Veteran was service-connected for COPD rated as 60 percent disabling and left breast mass and scar rated as noncompensable for a total disability rating of 60 percent. Thus, the Veteran met the threshold criteria for TDIU prior to August 7, 2019. The Veteran served on active duty in the U.S. Army from January 1956 to December 1957. The Veteran's Army occupational specialty was as an auto maintenance helper. Post-service the Veteran worked in skilled maintenance for Budd's automotive from 1962 to 1995. The Veteran's employer was purchased by ThyssenKrupp in 1978. The Veteran reported completing ongoing training through his employer and attending 2 years of college. The Veteran reported retiring in 1995. The Veteran submitted VA Form 21-8940, Veteran's Application for Increased Compensation Based on Unemployability in January 2020. The Veteran reported that he has been unable to work due to his COPD, chronic bronchitis and recurrent pneumonia. The Veteran reported last working in 2010, when he became too disabled to work. The Veteran contends that he has been unable to work since 2010 due to his worsening service-connected COPD. Specifically, the Veteran contends that his COPD made it difficult for him to work due to difficulty breathing and difficulty on exertion. The Veteran and his wife report that he regularly uses a wheelchair when going to doctor appointments or must walk long distances due to his shortness of breath and COPD. The Veteran reported while working he frequently missed work due to his COPD. There are conflicting opinions of record as to whether the Veteran is unable to secure or follow substantially gainful employment for his service connected disabilities during the period on appeal. The Veteran was afforded a VA respiratory conditions examination in September 2017. The examiner found that the Veteran's respiratory condition did not impact his ability to work. Then the Veteran was afforded a VA respiratory conditions examination in August 2019. The examiner found that the Veteran's respiratory condition does not impact his ability to work. In addition, the Veteran was afforded a VA respiratory examination in June 2020. The VA examiner noted that the Veteran is at least as likely as not (a 50 percent probability or greater) able to perform sedentary work in a normal workday. The examiner noted the Veteran is able to exert up to 10 pounds of force occasionally and/or a negligible amount of force frequently to lift, carry, push and pull. Sedentary work involves sitting most of the time but may involve walking or standing for brief periods of times. Jobs are sedentary of walking and standing are required only occasionally and all other sedentary criteria are met. Then, the Veteran was afforded a VA respiratory examination in January 2021. The VA examiner noted that during the period on appeal the Veteran's respiratory condition has impacted his ability to work. The examiner noted that although the Veteran is short of breath for multifactorial reasons including his cardiac history, his decreased DLCO noted in PFT related to COPD can at least as likely as not cause shortness of breath and limit strenuous activities. Then in a February 2021 clarifying opinion the VA examiner found that the Veteran's service connected COPD at least as likely as not impacted the Veteran's ability to obtain and maintain substantially gainful sedentary employment. The Veteran has experience working as a skilled machinist and mechanic. The Board finds that the VA opinions in January 2021 is entitled to significant probative weight which noted that the Veteran's service connected COPD impacted his ability to obtain and maintain substantially gainful sedentary employment. The VA examiner noted that the Veteran's shortness of breath and limits on strenuous activities is at least as likely as not caused by his service connected COPD. The January 2021 VA examiner found that considering the impact of the Veteran's service connected COPD he was unable to secure or follow substantially gainful occupation as a result of his service connected disability. The entirety of the Veteran's work experience is working as a skilled machinist and mechanic. The Board finds that the Veteran's COPD results in shortness of breath, difficulty on exertion and a limitation of his activities Given the Veteran's education, training and employment background primarily working as a skilled machinist and mechanic it is unlikely, he could find substantially gainful employment in his area of experience and training. The Veteran completed two years of college, but it is unclear what this coursework was in, additionally the Veteran completed ongoing training through his employer which was related to his work as a machinist. Further, even with consideration of basic computer skills it is not clear that the Veteran's knowledge and experience could translate into an online only occupation. As such the evidence of record indicates that based on the Veteran's training and experience working as a skilled machinist and mechanic the Veteran's COPD adversely impacts his ability to perform substantially gainful employment in a physical or sedentary capacity. Although the opinion as to the nature and severity of the Veteran's occupational impairment individually and in combination are not all supportive, the Board finds that the evidence of record is in relative equipoise as to whether the manifestations of his service connected disabilities combine to render him unable to secure or follow substantially gainful employment during the period on appeal. Resolving reasonable doubt in the Veteran's favor the Board will grant the claim. As such the Board finds entitlement to TDIU is warranted. J.W. FRANCIS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board K.R. Kardian, 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.