Citation Nr: 22010559 Decision Date: 02/24/22 Archive Date: 02/24/22 DOCKET NO. 18-53 704 DATE: February 24, 2022 REMANDED The issue of service connection for a respiratory disorder (claimed tightness in chest diagnosed as emphysema) is remanded. REASONS FOR REMAND The Veteran served on active duty from December 1985 to January 2008. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an April 2017 rating decision issued by the RO. The Veteran testified before the undersigned Veterans Law Judge in a virtual hearing in June 2020. A transcript of the hearing is of record. 1. The issue of service connection for a respiratory disorder (claimed tightness in chest diagnosed as emphysema) is remanded. The matter is REMANDED for the following action: 1. BACKGROUND FOR THE RO ADJUDICATOR: The March 2016 VA Gulf Ward General Medical Examination report documents assessment of moderate to severe chronic obstructive pulmonary disease (COPD) secondary most likely to smoking and heterozygote alpha-1 antitrypsin deficiency syndrome. The March 2016 VA respiratory conditions examination report documents diagnosis of tightness in chest diagnosed as emphysema. The physician explained that the Veteran's disability patten was a disease with a clear and specific etiology and diagnosis, namely, COPD secondary to alpha-1 antitrypsin deficiency and smoking. The physician opined that it was less likely than not that the diagnosed disorder was related to a specific exposure event experienced by the Veteran during service in Southwest Asia because the Veteran's service treatment records were silent for ongoing respiratory issues following his period of service in Southwest Asia and the Veteran was diagnosed with COPD at an age consistent with his smoking history and alpha-1 antitrypsin deficiency. The April 2017 VA medical opinion reflects the physician's opinion that claimed emphysema was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The physician explained that emphysema was also known as COPD (emphasis on the C for chronic) and there was no documentation that the Veteran had chronic respiratory issues during his period of service or for many years thereafter. The physician stated that the intermittent complaints during service were less likely than not the first manifestations of the current emphysema because the Veteran was diagnosed after service with emphysema/COPD, at an age consistent with his smoking history and alpha-1 antitrypsin deficiency. The September 2018 VA medical opinion reflects the physician's opinion that the claimed emphysema/COPD was less likely than not incurred in or caused by the claimed in-service injury, event, or illness because the Veteran's lay assertions (and buddy lay assertions submitted on his behalf) do not counterbalance the overwhelming medical facts and documentation that weigh against causation and/or directly contradict the years old recollections of the Veteran (and buddies). The physician noted that the Veteran was competent to recall his medical history but noted that in past recollections of his medical history, the Veteran denied having any chronic respiratory problems. The physician noted that the Veteran's recollections of respiratory disorder were recent recollections and not recollections from many years ago. The physician explained that the Veteran's recollections fit with the anticipated age of onset of symptoms from combined smoking and alpha antitrypsin deficiency (factors with known strong causative association with emphysema). In addition, the physician explained that even if the Veteran's recollection history was discounted, his post service occupational exposure to welding fumes was more strongly associated with causing chronic respiratory disorders than were the aviation-related exposures to hydrocarbons and/or de-icing fluids (i.e., chemical exposures in service). A March 2020 statement from the Veteran's treating pulmonologist reflects that the Veteran had at least nine documented healthcare visits during service, all with characteristic and presentation consistent with persistent asthma. The treating pulmonologist noted that the Veteran received additional treatment after service for those persistent symptoms. The pulmonologist noted that during service the appropriate diagnosis was not rendered even though the Veteran had prescription inhalers for breathing problems as well as decreased oxygen saturation which were not indicative of asthma alone. The pulmonologist explained that after service the Veteran was diagnosed with severe, persistent asthma and COPD/emphysema with alpha-1 antitrypsin carrier status with deficiency requiring alpha-1 antitrypsin replacement therapy with Prolastin-C (alpha-1 proteinase inhibitor). The pulmonologist explained that as a matter of course any patient with persistent asthma symptoms should have a deep diagnostic process initiated, including serial pulmonary function testing, radiologic imaging, bronchoscopy with bronchoalveolar lavage (if indicated), serologic testing for environmental and seasonal influences, blood work for secondar causes for exacerbations as well as genetic testing for alpha-1 antitrypsin deficiency which could induce and cause persistent asthma symptoms later becoming COPD and/or emphysema with permanently sustained damage without treatment. Further the pulmonologist noted that the Veteran did not receive the appropriate diagnostic investigation during his period of service. In addition, the pulmonologist noted that the Veteran had several occupational related exposures which could have potentially accelerated his asthma-COPD symptoms as well as potentially induce alveolar damage which was less repairable secondary to his underlying alpha-1 antitrypsin deficiency because he was an aircraft mechanic and had exposure to aircraft deicing fluid concentrate, poly-propylene glycol, jet fuel, and turbine engine oil, known respiratory irritants. The pulmonologist concluded because of the misdiagnosis in service, the Veteran developed COPD and emphysema. An August 2020 statement from the Veteran's treating physician reiterates that when a patient has ongoing symptoms of asthma or developed an early diagnosis of COPD, unresponsive to traditional therapy, further investigation was needed to occur as underlying alpha-1 antitrypsin deficiency can be a cause of early onset COPD, emphysema, and poorly controlled asthma. Alpha-antitrypsin deficiency is a cause of early onset COPD and emphysema in individuals with or without the underlying influence of nicotine dependence and use. The pulmonologist explained cigarette smoking can increase and accelerate the pace of development of symptoms, however patients with alpha-1 antitrypsin deficiency can go on to develop COPD and asthma without the influence of nicotine dependence and use. Thus, cigarette smoking was a cofactor in the development of early onset COPD and emphysema in alpha-1 deficiency but was not the primary cause. In addition, the pulmonologist explained that the Veteran had multiple occupational-related exposures which also may have accelerated the Veteran's asthma with COPD with a "preponderance" of those exposures occurring during his period of service in the Air Force. The pulmonologist explained that if cardiac concerns was the primary concern of the military treatment that issue could have been resolved by standardized testing including echocardiography and cardiac stress testing. The pulmonologist stated that the Veteran received deficient treatment for his underlying lung disease, including alpha-1 antitrypsin deficiency during his period of service. The pulmonologist concluded that the Veteran's alpha-1 antitrypsin deficiency was the cause of his underlying respiratory symptoms with smoking as a secondary influence as well as occupational-related exposures during his period of service. Given the conflicting medical opinions supporting the claim (March 2020 and August 2020 statements from the treating pulmonologist) and opposing the claim (March 2016, April 2017, and September 2018 VA medical opinions), remand is needed to reconcile the conflicting opinions described above by obtaining a new etiological opinion that takes into consideration the supporting rationale provided by each physician in support of their respective medical opinions. 2. Obtain an addendum VA medical opinion TO DETERMINE IF THE VETERAN'S ALPHA-1 ANTITRYPSIN DEFICIENCY SYNDROME MANIFESTED DURING HIS PERIOD OF ACTIVE MILITARY SERVICE. If the requested opinion cannot be provided without examination, schedule the Veteran for VA examination. The examiner must review the evidence and express a fully explained opinion as to whether the Veteran's alpha-1 antitrypsin deficiency syndrome manifested during his period of active service. The examiner is advised that the courts have imposed a requirement on the board to evaluate any medical opinions by examinations of multiple factors, including but not limited to: whether the examiner conducted a personal interview of the veteran; whether clinical testing was conducted and the results; whether a comprehensive review of the claims folder and other medical and factual evidence was considered, including other medical opinions; the conclusions reached and whether they are based on the state of medical knowledge. the examiner is also advised that by law, the mere statement that the claims folder was reviewed the examiner has expertise is not sufficient to find that the examination is sufficient. The examiner must review the record as found in VA treatment reports and the electronic file. However, the record in substance indicates the following: The Veteran served on active duty from December 1985 to January 2008. His service treatment records reflect he received treatment of multiple occasions of symptoms associated with a cardiac condition. May 2000 service treatment records document the Veteran's complaint of chest pain. On examination, the assessment was noncardiac chest pain. An October 2002 service treatment record reflects that the Veteran had an 18-year history of a half pack per day cigarette habit. A December 2003 treatment record reflects the Veteran received treatment for complaints of heart palpitations. Holter monitor findings showed normal sinus rhythm throughout recording. There were no findings of arrhythmia symptom correlations. An undated service treatment record reflects that the Veteran received treatment for respiratory difficulty lasting a couple of hours that worsened in the evening, The Veteran experienced associated chest tightness, and headaches. On examination, the diagnosis was restrictive airway disease (RAD) questionable environment versus "GER." He was discharged from active duty in January 2008. A March 2009 VA treatment record reflects that the Veteran quit smoking after 20 years and started chewing tobacco instead. A December 2015 pulmonary noted documents diagnosis of moderate to severe COPD secondary most likely to smoking and heterozygote alpha-1 antitrypsin deficiency syndrome. The March 2016 VA respiratory conditions examination report reflects the physician's opinion that it was less likely than not that the diagnosed disorder was related to a specific exposure event experienced by the Veteran during service in Southwest Asia because the Veteran's service treatment records were silent for ongoing respiratory issues following his period of service in Southwest Asia and the Veteran was diagnosed with COPD at an age consistent with his smoking history and alpha-1 antitrypsin deficiency. The April 2017 VA medical opinion reflects the physician's opinion that claimed emphysema was less likely than not incurred in or caused by the claimed in-service injury, event, or illness because there was no documentation that the Veteran had chronic respiratory issues during his period of service or for many years thereafter. The physician stated that the intermittent complaints during service were less likely than not the first manifestations of the current emphysema because the Veteran was diagnosed after service with emphysema/COPD, at an age consistent with his smoking history and alpha-1 antitrypsin deficiency. The September 2018 VA medical opinion reflects the physician's opinion that the claimed emphysema/COPD was less likely than not incurred in or caused by the claimed in-service injury, event, or illness because the Veteran's lay assertions (and buddy lay assertions submitted on his behalf) do not counterbalance the overwhelming medical facts and documentation that weigh against causation and/or directly contradict the years old recollections of the Veteran (and buddies). The Veteran's recollections fit with the anticipated age of onset of symptoms from combined smoking and alpha antitrypsin deficiency (factors with known strong causative association with emphysema). Regardless, even if the Veteran's recollection history was discounted, his post service occupational exposure to welding fumes was more strongly associated with causing chronic respiratory disorders than were the aviation-related exposures to hydrocarbons and/or de-icing fluids (i.e., chemical exposures in service). A March 2020 statement from the Veteran's treating pulmonologist reflects that the Veteran's presenting disorder was misdiagnosed even though the Veteran had prescription inhalers for breathing problems as well as decreased oxygen saturation which were not indicative of asthma alone. The Veteran did not receive the appropriate diagnostic investigation during his period of service and had several occupational related exposures which could have potentially accelerated his asthma-COPD symptoms. The pulmonologist concluded that the misdiagnosis in service, led to the development of COPD and emphysema. An August 2020 statement from the Veteran's treating physician reiterates that when a patient has ongoing symptoms of asthma or developed an early diagnosis of COPD, unresponsive to traditional therapy, further investigation was needed to occur as underlying alpha-1 antitrypsin deficiency can be a cause of early onset COPD, emphysema, and poorly controlled asthma. Alpha-antitrypsin deficiency is a cause of early onset COPD and emphysema in individuals with or without the underlying influence of nicotine dependence and use. The pulmonologist found that the Veteran received deficient treatment for his underlying lung disease, including alpha-1 antitrypsin deficiency during his period of service and concluded that the Veteran's alpha-1 antitrypsin deficiency was the cause of his underlying respiratory symptoms with smoking as a secondary influence as well as occupational-related exposures during his period of service. After review of the file, the above summary of the evidence, and any examination and clinical testing, the examiner must express a fully explained opinion as to whether the Veteran's alpha-1 antitrypsin deficiency syndrome manifested during his period of active service. 3. The RO will then readjudicate the claim of service connection for a respiratory disorder (claimed tightness in chest diagnosed as emphysema). Vito A. Clementi Veterans Law Judge Board of Veterans' Appeals Attorney for the Board G. Jackson The Board's action is binding only in this case. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.