“I have chronic asthma, and I use two inhalers to manage my asthma. How much will the VA rate me for my asthma?”
This is a common enough question. The VA’s rating schedule has been well-equipped to address all possible disorders of the nose and throat. There are so many kinds of respiratory conditions, however, and the severity can vary so greatly, that the VA most often uses pulmonary function tests (PFTs) as a basis for its rating criteria.
Pulmonary function tests are commonly performed by the veteran’s doctor when initially diagnosing the condition, and then periodically afterwards to gauge the severity of the condition. PFTs can determine whether an obstructive or restrictive disease is present, and also determine the location of a defect. PFTs measure three kinds of lung function: spirometry, lung volumes, and diffusion capacity. To summarize it briefly, a pulmonary function test measures how much air can be inhaled and exhaled, and how much carbon monoxide can enter the bloodstream within a certain period of time.
What can I expect from pulmonary function tests?
The most common form of pulmonary function tests is spirometry. Spirometry is the easiest, fastest, and most readily available method of function testing in outpatient clinics. The VA rating system depends mostly on spirometry results when evaluating a respiratory disorder.
A spirometer is a hand-held device into which the individual breathes. Usually a clip is placed on the nose to prevent any air from entering the nasal passages. The patient takes a deep breath, and then exhales as hard as he/she can for at least 6 seconds (10 seconds being ideal). The strength of the exhalation is recorded on a small machine attached to the device. Because the validity of the test depends on the participation of the patient, the test is repeated two to three times in order to obtain accurate results.
A spirometer does two things. It measures the forced vital capacity (FVC), which is the amount of air that can be forcibly blown out after deep inhalation. It also measures the forced expiratory volume in 1 second (FEV1), which is the amount of air that is forcibly blown out in the first second of the exhale. When expressed as a percentage of the “normal” averages, the FEV1 determines the degree of obstruction (if any) of the air through the lungs – mild, moderate or severe.
How correct breathing affects the test
The participation of the patient is incredibly important for spirometer testing. It is a natural reaction to be hesitant about taking as deep a breath as possible or exhaling as hard as possible when taking the test. The assumption can be that the weaker the breath, the more accurate the test will be. However, this is not the case.
Here is why. If the patient does not inhale deeply enough, the FVC and FEV1 will be underestimated, and the test results may mimic a restrictive disorder (such as pleural effusion or fibrosis). If the patient does not exhale hard enough, the FEV1 may be underestimated, and the result may mimic airways obstruction (such as a false positive for COPD or asthma).
In order to ensure that spirometry test results are interpreted in an accurate diagnosis, it is imperative that the patient inhale has deeply as possible, and then exhale as hard as possible for at least six seconds.
Types of Respiratory Disorders
Pulmonary function disorders are grouped into two main categories: obstructive and restrictive. Routine spirometry testing measures two basic components: (1) air flow and (2) volume of air out of the lungs. Putting it simply, if the air flow is impeded, the defect is obstructive. If the volume of air is reduced, the defect is restrictive. Most respiratory disorders are grouped under one of these two categories. However, there several respiratory disorders do not fall under either of these categories, such as:
- Pulmonary vascular disease
- Bacterial infections of the lungs
- Mycotic lung diseases (fungal)
Obstructive disorders make it difficult to exhale all the air in the lungs. Damage to the lungs, or narrowing of the airways (bronchii) inside the lungs, cause air to be exhaled more slowly than normal. This is due to reduced elasticity of the lung airways, or some kind of obstruction (like mucus or inflammation). Obstructive lung diseases make it more difficult to breath, especially with increased activity of exertion. As the rate of breathing increases, there is less time to breathe out all the air before the next inhalation.
Common obstructive disorders include:
- COPD, including emphysema and chronic bronchitis
- Cystic Fibrosis
Restrictive disorders make it difficult to fill lungs with air. This is a result of the lungs being restricted from fully expanding. Usually restrictive diseases occur when there is stiffness in the lungs themselves. Sometimes this can occur when there is stiffness in the chest wall, weak muscles or damaged nerves that restrict the expansion of the lungs. In some cases (interstitial lung diseases), autoimmune or rheumatologic diseases can cause progressive scarring of the lung tissue that lies in between and supports air sacs. Scarring causes stiffness in the lungs.
Common restrictive disorders include:
- Interstitial lung disease (such as pneumonia)
- Neuromuscular diseases, such as amyotrophic lateral sclerosis (ALS)
- Pulmonary fibrosis
- Sleep Apnea
What should I be looking for in my PFT results?
Once you have completed pulmonary function testing, your results should be available to review. However, they will be difficult for you to understand without a medical professional to interpret them for you.
Spirometry results commonly look like the example below:
The VA rating schedule for respiratory disorders chiefly utilizes the numbers circled in the above example of a spirometry test. The last three columns in the image above are the ones that we are concerned with.
Let’s break this down. And to make it easier, let’s call the patient “Bill.”
PRED = the predicted value. This is the anticipated test result that a normal person (with no respiratory dysfunction) would have.
BEST = the most accurate reading of the spirometry test. Usually the patient will take the spirometry test three times in order to obtain the most accurate representation of his/her condition.
% PRED = a percentage representation of Bill’s test results relative to those of “normal” individuals with his ethnicity, height and build. For example, 85 % PRED would mean that Bill breathes 85% “normally.”
Below is the rating schedule for Bronchial Asthma.
|6602 Asthma, bronchial:|
|FEV-1 less than 40-percent predicted, or; FEV-1/FVC less than 40 percent, or; more than one attack per week with episodes of respiratory failure, or; requires daily use of systemic (oral or parenteral) high dose corticosteroids or immuno-suppressive medications||100|
|FEV-1 of 40- to 55-percent predicted, or; FEV-1/FVC of 40 to 55 percent, or; at least monthly visits to a physician for required care of exacerbations, or; intermittent (at least three per year) courses of systemic (oral or parenteral) corticosteroids||60|
|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||30|
|FEV-1 of 71- to 80-percent predicted, or; FEV-1/FVC of 71 to 80 percent, or; intermittent inhalational or oral bronchodilator therapy||10|
Let us break down the 10% rating:
|What It Says||What You Need to Look At|
|FEV-1 of 40- to 55-percent predicted||Line 2, Column 5|
|or||FEV-1/FVC of 40 to 55 percent||Line 3, Column 4|
|or||Intermittent inhalation or oral bronchodilator therapy.|
In Example 1, Line 2/Column 5 says “105”. To get a 10% rating, this number would have to be between 40 and 55. Likewise, Line 3/Column 4 says “85”. To get a 10% rating, this number would have to be between 40 and 55. Therefore, according to the first two criteria, Bill would not qualify for a 10% rating. However, if he is being prescribed a bronchodilator inhaler and uses it every now and then, Bill would meet the last criteria for the 10% rating.
My breathing test results were normal, but I still have asthma. How is this possible?
Sometimes, spirometry test results create the appearance of a normal respiratory system. In the example case described above, Bill’s high spirometry test results indicate that he can breathe perfectly well. However, Bill suffers from asthma, needing an inhaler to manage periodic asthma attacks and shortness of breath. So how is this possible?
Asthma is considered a reversible obstructive defect. This means that the use of a bronchodilator (such as albuterol) can usually open up the airways and make it easier to breathe. Most people with asthma can breathe fairly well unless they are having an active asthma attack. Consequently, a spirometry test is more likely to be taken during a period of normal breathing, and will most not reflect a patient’s breathing pattern when having an asthma attack. Therefore, when a diagnosis of asthma is suspected, the patient will be asked to participate in other tests that can more accurately pinpoint the problem.
What happens if my pulmonary function tests are outdated?
Some doctors may not require regular or extensive pulmonary function tests. This can be a problem in terms of VA claims, since most of the rating schedules for respiratory disorders depend heavily on pulmonary function testing. An outdated test will likely not be an accurate representation of the respiratory condition. A similar problem exists in cases in which spirometry results indicate little or no respiratory dysfunction. More advanced methods of pulmonary function testing, such as the measurement of lung volumes and diffusion capacity, may not be readily accessible in outpatient clinics and therefore not available the VA examiner’s review.
However, in the event that pulmonary function testing is not available or reflective the veteran’s actual condition, the VA offers another point of reference in the rating criteria—the use of medications for management of the condition. Specifically, the rating criteria identify the use of corticosteroids (inhaled or oral), as in asthma cases, or the use of oxygen therapy, antibiotics, and immunosuppressives as reference points for the severity of the condition. For example, if a veteran with asthma requires daily use of a bronchodilator inhaler to manage his asthma, he would be entitled to a 30% rating.
Whichever the case may be, the VA tries its best to cover every possible situation by the thoroughness of its Disability Benefits Questionnaire (DBQ) for respiratory disorders. On examination of the patient, VA examiners are requested to indicate whether or not pulmonary function testing was performed, and if the testing accurately reflected the actual state of the veteran’s respiratory condition. The DBQ also devotes a section for use of medications, bronchodilators, corticosteroids, antibiotics, and oxygen therapy that the veteran may be prescribed for the management of the respiratory disorder. This questionnaire can also be completed by the veteran’s treating physician, as additional evidence in support of the veteran’s claim in the event that the C&P examiner was not sufficiently thorough or accurate.