RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX                                                                            CASE:  PD-2015-00352
BRANCH OF SERVICE:  Army 	
DATE PLACED ON TDRL:  20050701
DATE REMOVED FROM TDRL:  20070417

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E3, Transportation, medically separated from the Temporary Disability Retired List (TDRL) for “history of asthma,” with a disability rating of 10%.

CI CONTENTION:  “Review All Conditions”. The CI’s complete submission is at Exhibit A.  

SCOPE OF REVIEW:  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 based upon a 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 –20050603/20070327	VARD – NO VA Claim	
Condition	Code	Rating	Condition	Code	Rating
Proximate	
		TDRL
Placement	TDRL Removal			TDRL
Placement	TDRL
Removal	
History of Asthma	6602	30%	10%	No VA Claim in Record	
COMBINED RATING:  30% → 10%	COMBINED RATING OF ALL VA CONDITIONS:  N/A	

ANALYSIS SUMMARY:  

History of Asthma.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s asthma condition began 2 weeks after an allergic reaction to a yellow fever vaccine, which was marked by difficulty breathing as well as tightness in his chest and a closing sensation of his throat in August 2004.  Initial pulmonary function studies (PFTs) were normal (FVC 99% predicted ad FEV1/FVC 114% predicted) as were chest X-ray series in October and November 2004.  He was diagnosed with exercise induced asthma and a methacholine challenge test was positive in November 2004.  In December 2004 the CI was diagnosed with moderate persistent asthma and treated with albuterol (an inhaled bronchodilator), fluticasone (a steroid inhaler), and loratadine (an antihistamine).  A note in January 2005 indicated the CI had a long history of exercise induced shortness of breath and he used albuterol daily, but “no current inhaled steroid Rx.” In February 2005 the CI reported persistent asthma symptoms even with Flovent (fluticasone) and albuterol twice daily and he had an Emergency Room visit on 9 February 2005.  A note in March 2005 indicated he had fair control of non-exertional symptoms with Advair Diskus (fluticasone/salmeterol, an inhaled steroid and a long-acting beta 2 adrenergic receptor agonist combination).  

Despite treatment, the asthma condition could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty and the CI was referred for MEB.  The MEB forwarded “moderate persistent asthma (exercise induced)” for PEB adjudication.

At the MEB examination on 3 May 2005, 2 months prior to TDRL placement, the CI reported being treated for pneumonia and bronchitis during basic training and had chest pains which made it hard for him to breath.  The examiner checked normal for the lungs and chest on the clinical evaluation.  At the NARSUM physical examination dated 3 May 2005, 2 months prior to TDRL placement, the CI’s nose revealed no rhinorrhea or pink turbinates and his lungs were clear to auscultation bilaterally with no wheezing and normal chest expansion.  Other than the methacholine challenge test, PFTs in December 2004 and February 2005 were within normal limits.  On 12 May 2005 the CI was treated for asthma in the Emergency Room with albuterol and an Azmacort (triamcinolone, a steroid) inhaler.  

No VA claim was filed proximate to TDRL placement; therefore, no VA Compensation and Pension (C&P) examination was performed.

A pulmonary evaluation on 24 October 2006, 15 months after separation and less than 3 months before TDRL removal the CI’s breathing was essentially unchanged since placement on TDRL.  He was unable to do little to no exertional activity and had to stop many jobs due to heat and exertion that was rough on his breathing.  He used albuterol prn (as needed) and avoided exertional activity.  He coughed during the night and wheezed worse with cold and exercise.  He reported a previous Emergency Room visit for a flare-up 5 months earlier.  On examination his lungs were clear to auscultation without any wheezing or prolonged expiratory time.  His PFTs revealed FVC 78% predicted, FEV1 86% predicted, and FEV1/FVC 91.  The examiner opined “moderate asthma unchanged from previously.  Prognosis is unchanged could not perform on active duty.  Cannot tolerate heat or exertional activity to any degree.”  PVT studies in March 2007, 2 months after separation were reproducible but not acceptable because the CI had early termination at expiration (<8 seconds), which would tend to underestimate the FVC, which was 54% predicted and the FEV1 was 62% predicted, while the FEV1/FVC was 94.  On 17 March 2007, the CI had an Emergency Room visit for “diff[iculty] breathing/throat swollen” where his current medications listed Advair and albuterol.  However, treatment consisted of albuterol and Zyrtec (cetirizine, an antihistamine) No VA claim was filed proximate to TDRL removal; therefore, no VA Compensation and Pension (C&P) examination was performed.

The PFT examinations in evidence, which the Board weighed in arriving at its rating recommendation, with documentation of additional ratable criteria, are summarized in the chart below.  

Pulmonary Examination	Pulm ~5 Mos. Pre-TDRL Placement
	EB ~3 Mos. Pre-TDRL Removal
	PFT~ 2 Mos. Post-TDRL Removal
	
FEV1 (% Predicted)	114	86	62*	
FEV1/FVC	91	91	94*	
Meds	Advair, albuterol	Albuterol prn	Medications not reported; *reproducible but not acceptable spirometry data	
§4.97 Rating	30%	10%	*30%, but not acceptable	

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the asthma condition 30%, coded 6602 (asthma, bronchial), citing normal spirometry on daily inhalational therapy for TDRL placement.  For TDRL removal the PEB, which convened on 27 March 2007, rated the asthma condition 10%, coded 6602 (asthma, bronchial), citing “Soldier had been using prescribed medications intermittently.  Physical exam notes lungs clear to exam.  FEV1 was 86%.”  Board members agreed that the PEB rating of 30%, which requires “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,” but no higher, for TDRL placement was justified on the basis of daily inhalation bronchodilator therapy.  Additionally, although not cited by the PEB, the CI was also on inhalational anti-inflammatory medication.  While the TDRL removal examination, approximately 3 months prior to TDRL removal, was limited and cited only albuterol prn, the CI had an Emergency Room visit 10 days before the PEB convened to adjudicate his disability status and reported his current medications as Advair and albuterol.  Furthermore, the PEB cited the FEV1 as 86% predicted; however, 2 months after TDRL removal, PFTs, although reproducible, but not acceptable as spirometry data, nevertheless demonstrated an FEV1 of 62% predicted as a result of a short expiration time.  However, the Board will not base a rating on unacceptable data, but did note that the CI reported taking Advair (an inhaled anti-inflammatory medication), which is not specified as a daily requirement under the 30% rating provision, prior to TDRL removal.  Other than the sole annotation of Advair at the ER visit, there is no mention of it having been prescribed or used following TDRL placement.  To the contrary, only albuterol was listed as a medication at the pulmonary examination prior to TDRL removal.  Therefore, Board members agreed that the VASRD §4.97 threshold for a 30% rating was not reasonably satisfied in this case on the basis of inhalational anti-inflammatory medication, the use of which was insufficiently supported by the preponderance of objective medical evidence.  However, an inhalational bronchodilator was used as needed (prn), which is too imprecise to meet the requirement of daily use.  Furthermore, the PFTs reported in the pulmonary consultation prior to TDRL removal do not rating higher than 10%.  Since the CI did not have at least monthly visits to a physician for required care of exacerbations, or intermittent (at least three per year) courses of systemic corticosteroids, a 60% rating in not feasible.  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 with VASRD §4.97, the Board unanimously recommends no change in the PEB adjudication of the TDRL entry rating or the permanent rating at TDRL removal.  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 20150527, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAMR-RB						

MEMORANDUM FOR Commander, US Army Physical Disability Agency 
(AHRC-DO), 2900 Crystal Drive, Suite 300, Arlington, VA  22202-3557

20 DEC 2016

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for 
XXXXXXXXXXXXXXXXXX, AR20160018692 (PD201500352)

I have reviewed the enclosed Department of Defense Physical Disability Board of Review (DoD PDBR) recommendation and record of proceedings pertaining to the subject individual.  Under the authority of Title 10, United States Code, section 1554a, I accept the Board’s recommendation and hereby deny the individual’s application. This decision is final. The individual concerned, counsel (if any), and any Members of Congress who have shown interest in this application have been notified of this decision by mail.

 BY ORDER OF THE SECRETARY OF THE ARMY:

Enclosure

CF: 
(  ) DoD PDBR
(  ) DVA