RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXX						CASE:  PD-2014-00043
BRANCH OF SERVICE:  AIR FORCE	SEPARATION DATE:  20060418

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-5 (Dental Lab Technician) medically separated for chronic dyspnea [shortness of breath].  The condition could not be adequately rehabilitated to meet the physical requirements of her Air Force Specialty (AFS).  She was issued a temporary P4 profile and referred for a Medical Evaluation Board (MEB).  The “chronic dyspnea related to history of acute respiratory distress syndrome [ARDS]” was the only condition forwarded to the Physical Evaluation Board (PEB) IAW AFI 48-123.  The Informal PEB adjudicated “chronic dyspnea associated with resolved [ARDS]” as unfitting, rated 0%, citing application of DoD and Veterans Affairs Schedule for Rating Disabilities (VASRD).  The CI made no appeals and was medically separated.

CI CONTENTION:  The CI elaborated no specific contention in her application.

SCOPE OF REVIEW:  The Board’s scope of review is defined in DoDI 6040.44, Enclosure 3, paragraph 5.e. (2).  It is limited to those conditions determined by the PEB to be unfitting for continued military service and when specifically requested by the CI, those conditions identified by the PEB, but determined to be not unfitting.  Any conditions outside the Board’s defined scope of review and any contention not requested in this application may remain eligible for future consideration by the Board for Correction of Military/Naval Records.  Furthermore, the Board’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate.  The Board’s assessment of the PEB rating determinations is confined to review of medical records and all available evidence for application of the VASRD standards to the unfitting medical condition at the time of separation.  The Board has neither the role nor the authority to compensate for post-separation progression or complications of service-connected conditions.  That role and authority is granted by Congress to the Department of Veterans Affairs, operating under a different set of laws.  The Board gives consideration to VA evidence, particularly within 12 months of separation, but only to the extent that it reasonably reflects the severity of the disability at the time of separation. 

RATING COMPARISON: 

IPEB – Dated 20060302	VA* (2 Mo. Post-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Dyspnea ... ARDS	6699-6604	0%	Chronic Dyspnea with History of ARDS	6699-6602	10%	20060629	
Other MEB/PEB Conditions x 0 (Not In Scope)	Other x 26	
RATING:  0%	RATING:  10%	
*Derived from VA Rating Decision (VARD) dated 20070307 (most proximate to date of separation [DOS]).  

ANALYSIS SUMMARY:   

Respiratory Condition.  The service treatment record (STR) corroborates the history in the narrative summary (NARSUM) of an onset of persistent dyspnea following a serious illness complicated by ARDS (requiring ventilator support) in October 2002 (3 years pre-separation).  No STR entries documented the presence of dyspnea at rest or with routine activities, but did note exertional limitations to walking a quarter mile.  There is no STR (or NARSUM) documentation of a history or presence of bronchospasm (wheezing) related to the symptoms.  In addition to various other ancillary investigations, there are four pulmonary function tests (PFT) in evidence, including one referenced in the NARSUM, and one in the interval between the NARSUM and separation.  These were all essentially normal, and none of the VASRD ratable criteria (FEV-1, FEV1/FVC ratio, and DLCO [diffusion capacity]) meet the 10% threshold.  The STR medication history, to the extent it is probative to rating, is as follows.  There is a remote entry (2000, 2 years prior to the development of ARDS) which listed the use of albuterol (inhaled bronchodilator) as needed, but albuterol is not mentioned again prior to separation; and, other than a notation of a Singulair (oral bronchodilator/anti-inflammatory) prescription (with no indication of ongoing use), there is no other STR evidence for either the daily or intermittent use of inhalational or oral bronchodilator agents.  This includes medications listed in several outpatient entries preceding separation and the NARSUM; although, there are no pharmacy records in evidence for corroboration.  

The NARSUM (pulmonology) was conducted 29 January 2006 (3 months pre-separation), and documented that the CI “continues to have significant dyspnea with exertion and occasionally at rest.”  Listed medications (Zyrtec and Flonase) were indicated for allergies, not the pulmonary condition.  The physical examination recorded normal measured oxygen saturation and clear lungs.  The only medications recommended for continuing treatment were the above allergy prescriptions. 

 A VA Compensation and Pension (C&P) examination was conducted 29 June 2006 (2 months post-separation), and documented “has suffered from dyspnea with exertion after walking one mile,” adding that she was prescribed “albuterol as needed for dyspnea.”  There was no further elaboration regarding compliance, frequency, etc.; and, there are no VA records in evidence establishing whether albuterol was prescribed after separation.  The VA PFT evaluation documented normal values for FEV-1, FEV1/FVC ratio, and DLCO.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB’s 0% rating was compliant with VASRD §4.97 criteria for the chosen code, analogous to 6604 (chronic obstructive pulmonary disease).  Rating under this code is based solely on PFT criteria.  The VA coded analogously to 6602 (asthma), and invoked the intermittent use of albuterol per the C&P for supporting the 10% criterion “intermittent inhalational or oral bronchodilator therapy” under that code.  The Board deliberated whether application of code 6602 was justified IAW VASRD §4.7 (higher of two evaluations); and, if 6602 was conceded, whether the isolated VA evidence regarding albuterol use was sufficiently probative for conceding that 10% criterion.  With regards to coding choice, the clinical features of this case are best aligned with the Service coding.  The phenomenon of persistent dyspnea by ARDS survivors is well established, although the pathophysiology is not clarified.  ARDS itself is classified as restrictive lung disease, but that cannot be conclusively extrapolated as the same mechanism for the post-ARDS syndrome.  The §4.97 criteria for restrictive lung disease are separate from, but identical to, those for obstructive disease (PEB code).  On the other hand, there is no medical support for bronchospasm (as rated by 6602) as an etiology of the condition under consideration; nor, is there any clinical evidence that it was ever present.  Members agreed, therefore, that the PEB coding choice was best supported by the clinical features of this case and the evidence at hand.  Furthermore, it would require undue speculation to concede probative value to the VA medication evidence (given the great preponderance of conflicting Service evidence) to achieve a compensable rating even if the more favorable code were conceded; and, it is noted, there would be no practical benefit to the CI for doing so.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication of the respiratory condition.

BOARD FINDINGS:  IAW DoDI 6040.44, provisions of DoD or Military Department regulations or guidelines relied upon by the PEB will not be considered by the Board to the extent they were inconsistent with the VASRD in effect at the time of the adjudication.  The Board did not surmise from the record or PEB ruling in this case that any prerogatives outside the VASRD were exercised.  In the matter of the respiratory condition and IAW VASRD §4.97, the Board unanimously recommends no change in the PEB adjudication.  There were no other conditions within the Board’s scope of review for consideration. 

RECOMMENDATION:  The Board, therefore, recommends that there be no re-characterization of the CI’s disability and separation determination.  

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 201312321, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAF/MRB
1500 West Perimeter Road, Suite 3700
Joint Base Andrews, MD  20762

Dear XXXXXXXXXXXX:

Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2014-00043.

After careful consideration of your application and treatment records, the Physical Disability Board of Review determined that the rating assigned at the time of final disposition of your disability evaluation system processing was appropriate.  Accordingly, the Board recommended no re-characterization or modification of your separation.

I have carefully reviewed the evidence of record and the recommendation of the Board.  I concur with that finding and their conclusion that re-characterization of your separation is not warranted.  Accordingly, I accept their recommendation that your application be denied.

Sincerely,

Attachment:
Record of Proceedings