RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXX		CASE:  PD-2014-00617
BRANCH OF SERVICE:  AIR FORCE		 SEPARATION DATE:  20070604

Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty, E4, Aircrew Egress System Journeyman, medically separated for “asthma,” with a disability rating of 10%.   

CI CONTENTION:  The CI stated he was given an higher rating by the Veterans Administration.  The applicant’s complete submission is at Exhibit A.

The Board’s scope of review is defined in DoDI 6040.44.  It is limited to those conditions determined by the Physical Evaluation Board (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 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 Veterans Affairs Schedule for Rating Disabilities (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:  

SERVICE PEB - 20070418	VARD - 20130607	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Asthma	6602	10%	Asthma	6602	0%	20120823	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:  

Asthma Condition.  According to service treatment records (STR), and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI was treated for allergic rhinitis (hay fever) with an antihistamine (Zyrtec) and a leukotriene receptor antagonist (Singulair).  Approximately 4 months prior to referral for MEB, the CI was assessed to have reactive airway disease (any of several conditions characterized by reversible bronchospasm, wheezing, and allergic reactions).  An allergy clinic evaluation was performed 11 months prior to referral for MEB.  The allergy immunotherapy request screening form listed two years of seasonal rhinitis symptoms of sneezing, itching, congestion, clear watery rhinorrhea (nasal discharge), frequent nose blowing, post nasal drip, and itchy, watery, and swollen eyes.  Specific triggers listed cats, dusting, vacuuming, sweeping, and mowing grass.  The asthma portion of the screening form was crossed out.  
The review of systems listed “No pulmonary symptoms.”  The assessment listed allergic rhinitis and skin testing (allergy percutaneous tests - allergenic extracts) were ordered.  The plan was to follow-up after skin testing to discuss whether immunotherapy was indicated and to continue the Zyrtec and Singulair after skin testing.  At a family medicine encounter, 4 months prior to referral for MEB, the CI reported that he had been told he had “borderline” asthma a year prior and had been given an inhalational bronchodilator (Albuterol).  He had a history of allergic rhinitis and indicated he had previously been taking Singulair.  The CI complained of wheezing, chest tightness, and light chest pain when exposed to jet fuel, jet exhaust, spray paint, various chemicals at work, and running.  He denied any emergency room (ER) visits for pulmonary symptoms.  The CI had rarely used the Albuterol until 5 months prior, and used it once every 2 days at the time of examination.  The CI was not taking any other medications.  The assessment listed reactive airway disease and the plan was to refer to pulmonology, obtain a chest X-ray, and add a combination inhalational bronchodilator/anti-inflammatory (Advair) medication.  The inhalational bronchodilator (Albuterol) was converted to another (Levalbuterol) and the leukotriene receptor antagonist (Singulair) was resumed.  Pulmonology performed baseline pulmonary function tests (PFTs).  The baseline spirometry (measuring lung function in terms of volume and/or flow of air inhaled and exhaled) was reported as “Flow volume loop prior to Methacholine Challenge was fairly normal except for minimal reduction in flow volume loop at the lower lung volumes.”  The FEV-1 was 80% predicted and the FEV-1/FVC was 91%.  A pharmacologic (Methacholine) challenge (provocative test to trigger bronchoconstriction with inhaled provocative agents to assess for asthma) was performed and interpreted as “This Study is suggestive of reactive airway disease.”  At a family medicine follow-up the CI complained that working in his shop and running aggravated his asthma.  He desired allergy testing, a fitness profile, and a job change with desk duty preferred.  The CI reported that his work environment was too unpredictable and that common triggers for his pulmonary symptoms were paints, sealants, varnish, exhaust fumes, jet fuel, hydraulic fluid, pollen, perfumes, horses, cats, and running.  Depending on the level of exposure, he stated that he had to use his Albuterol inhaler several times per days.  The encounter documented that he was currently taking Levalbuterol, Advair, and Singulair but ran out of Zyrtec.  The CI denied a history of childhood asthma and there were no ER visits for asthma.  The physical examination revealed the lungs were clear to auscultation and respiratory movements were normal.  There were no wheezes, rales (abnormal crackling, rattling, bubbling respiratory sounds from fluid accumulation), rhonchi (abnormal rumblings or whistling respiratory sounds from airway secretions), or decreased breath sounds.  The assessment listed mild intermittent asthma, exercise-induced asthma, and allergic rhinitis.  The examiner refilled the Zyrtec.  The NARSUM, 2 months before separation, reported that the CI’s asthma was controlled on rescue and maintenance medications (Levalbuterol, Advair, Singulair, Zyrtec) unless he was exposed to triggers at work or running.  He complained that he was compelled to use his rescue inhaler several times per day depending on the type/duration of exposure.  The vital signs documented 99% oxygen saturation by pulse oximetry.  The physical examination revealed no nasal discharge, nasal flaring, pursed lip breathing, mouth breathing, air hunger, or abnormal respiratory excursions.  The lungs were clear to auscultation and respiratory movements were normal.  There were no wheezes, rales, rhonchi, or decreased breath sounds.  The examiner recounted the findings from the baseline PFTs by pulmonology.  The diagnosis listed bronchial asthma.  The examiner opined that the CI had a good prognosis with avoiding known asthma triggers, a change in work environment, and adherence to medication regimen/asthma action plan.  The chest X-ray was unremarkable.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating under the 6602 code (asthma, bronchial) based on the evidence of the STR.  The VA assigned a 0% rating under the 6602 code based on the VA compensation and pension (C&P) exams 5 and 6 years after separation.  The Board assigned little probative value to the C&P examinations because of the remote temporal relationship to time of separation.  

The STR contained 10 medical encounters, which captured the medication reconciliation in the electronic medical record, after the initial prescription of a 2-month supply of the inhalational anti-inflammatory (Advair).  The encounters spanned a 6-month period from 2 months after the initial prescription until a month after the PEB.  The active medication reconciliation in the electronic medical record showed no refills of any of the medications after the initial prescriptions.  While the CI confirmed that his active medications included Advair and Levalbuterol, had he taken the medications as prescribed, he would have been without Advair for the three months preceding the PEB.  There was no evidence of medication refills up to the time of separation.  The CI reported use of the intermittent inhalational bronchodilator (Levalbuterol) as needed for symptomatic relief with environmental triggers and exercise.  While the CI had been prescribed Advair, evidence suggests that it was used for a maximum of 2 months.  The baseline PFTs (FEV-1 of 80% predicted and FEV-1/FVC of 91%) were “fairly normal” and the overall clinical picture and medication use were consistent with the 10% rating (FEV-1 of 71- to 80-percent predicted, or; FEV-1/FVC of 71 to 80 percent, or; intermittent inhalational or oral bronchodilator therapy).  The constellation of findings did not approach the 30% rating (FEV-1 of 56- to 70-percent predicted, or; FEV-1/FVC of 56 to 70 percent, or; daily inhalational or oral bronchodilator therapy, or; inhalational anti-inflammatory medication).  Although it was determined that the CI was prescribed Advair for daily use, the evidence makes clear that the CI did not engage in the daily use of the medication.  The Levalbuterol was prescribed for use as needed and was used intermittently with triggers.  Members agreed, therefore, that only the criterion of “intermittent” use (as specified in the 10% rating description) was satisfied in this case.  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 for the asthma condition.

BOARD FINDINGS:  In the matter of the asthma condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  There were no other conditions within the Board’s scope of review for consideration.  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 20140125, with attachments
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 XXXXXXXXXXXXXX:

Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2014-00617.

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