sleep apnea secondary to COPD

[ballistics-guy]

I have obstructive sleep apnea (diagnosed by the VA)  I think the VA will deny my claim regardless of the evidence I present.  This post is lengthy, but I thing is may be helpful to others in the same situation.

I have COPD determined to be service connected by the VA

I find a BVA case that identical to my circumstances:

In Citation Nr: 1228135 Decision Date: 8/15/12  , the Board of Veterans Appeals found that sleep apnea was aggravated by the veterans service-connected COPD and that service connection for the Veteran's obstructive sleep apnea was warranted.  In this case:
- The VA determined the veteran had service-connected COPD with emphysema, (that's me)
- There was no evidence that the Veteran suffered from this sleep apnea during his active service. (mee too)
- The veteran was a former cigarette smoker and had mild dyspnea on climbing two flights of stairs (one flight for me)
- A C&P exam concluded that the Veteran's obstructive sleep apnea is less likely than not related to his in-service dyspnea and other respiratory complaints. (me too)
- Despite that, the board rules that since the veterans OSA was exacerbated by his service connected COPD, and therefore, OSA was service related.

Also, I find this case and show it to the C&P examiner:

In another case: BVA9415915 DOCKET NO. 93-01, the board of Veterans Appeals found “Obstructive sleep apnea is causally related to service-connected chronic obstructive pulmonary disease“. They found the veteran to be entitled to service connection for obstructive sleep apnea as secondary to service-connected chronic obstructive pulmonary disease.
-  In this case, the veteran had been previously granted entitlement to service connection for chronic obstructive pulmonary disease. The VA found that obstructive sleep apnea, which presented only after the veteran was discharged, was causally related to service-connected chronic obstructive pulmonary disease and granted entitlement to service connection for chronic obstructive pulmonary disease. 

I showed this case to the C&P doc. She ignored it. I got a decision letter. I'm not considered service connected. Is there anything I can do?

I point out that the VA’s own web page suggests a deleterious link between OSA and COPD

 The VA/DoD “Clinical Practice Guideline for the Management of Chronic Obstructive Pulmonary Disease” indicates that:
“Patients with COPD may also have a longer latency to sleep onset, more frequent disruption and stage changes, and decreased sleep efficiency than in the general population”. 

“Sleep disorders also seem to increase as patients with COPD age”

Patients with signs or symptoms of a sleep disorder should be referred for a diagnostic sleep evaluation, which may include diagnostic tests and diagnostic interviews. 

Congestive heart failure, cardiac ischemia, or gastroesphageal reflux are listed  on the VA’s own web page as comorbidities of COPD.

 

I show these articles from the medical literature:

1. Marin, Jose M., Joan B. Soriano, Santiago J. Carrizo, Ana Boldova, and Bartolome R. Celli. "Outcomes in patients with chronic obstructive pulmonary disease and obstructive sleep apnea: the overlap syndrome." American journal of respiratory and critical care medicine 182, no. 3 (2010): 325-331.
2. McNicholas, Walter T., M.D., "Chronic obstructive pulmonary disease and obstructive sleep apnea: overlaps in pathophysiology, systemic inflammation, and cardiovascular disease." American journal of respiratory and critical care medicine 180, no. 8 (2009): 692-700. COPD is a major risk factor for cardiovascular morbidity and mortality, even after adjustment for confounding risk factors such as age, smoking, and body mass index (BMI) (7, 11).
3. Owens, Robert L., and Atul Malhotra. "Sleep-disordered breathing and COPD: the overlap syndrome." Respiratory care 55, no. 10 (2010): 1333-1346.
4. Weitzenblum, Emmanuel, Ari Chaouat, Romain Kessler, and Matthieu Canuet. "Overlap syndrome: obstructive sleep apnea in patients with chronic obstructive pulmonary disease." Proceedings of the American thoracic society 5, no. 2 (2008): 237-241
5. Chaouat A, Weitzenblum E, Krieger J, Ifoudza T, Oswald M, Kessler R. Association of chronic obstructive pulmonary disease and sleep apnea syndrome. Am Rev Respir Dis 1995;151:82-866. 

What I got back was "With regards to whether the veteran's COPD caused his sleep apnea , we can look to the experts. Recent articles on this subject make the point that COPD and sleep apnea are common and thus, by chance alone , some individuals will have both diagnoses . Result from the Sleep Heart Health Study showed that sleep apnea and hypopnea syndrome (SAHS) was not more prevalent in those mild COPD than in those without COPD."

My response (which I'm still working on) is 

COMMENT: This same study, these same experts showed that even for patients without atrial fibrillation, the risk for ischemic stroke was very significantly increased in the population of patients with OSA. 

The most cited research that indicates that "There is no relationship between chronic obstructive pulmonary disease and obstructive sleep apnea syndrome” is from Bednarek et.al.  First, and very significantly, this was a very small population study (N=365 males) of randomly selected people from voting rolls in WARSAW, POLAND.   Among the population,  16% of the population were diagnosed with OSA; 10.7% were diagnosed with COPD.   Conclusions from that paper were drawn from statistics for roughly five males among a random selections of voters in  WARSAW, POLAND.  

Conclusions from Bednarek et.al. were drawn from statistics for roughly five males among a random selections of voters  WARSAW, POLAND.

In Warsaw, Poland, roughly 11% of the population were diagnosed with COPD; in the United states, the number of people diagnosed with COPD is roughly HALF OF THAT.  

One need to be careful in the application of statistics.  Meaningful statistics concerning American veterans can not be drawn from these data.

FOOTNOTES

Bednarek, Michal, Robert Plywaczewski, Luiza Jonczak, and Jan Zielinski. "There is no relationship between chronic obstructive pulmonary disease and obstructive sleep apnea syndrome: a population study." Respiration 72, no. 2 (2005): 142-149

Mannino, David M. "COPD: epidemiology, prevalence, morbidity and mortality, and disease heterogeneity." CHEST Journal 121, no. 5_suppl (2002): 121S-126S.

The veteran is not a medical doctor, but he is an MIT educated engineer and he is qualified to apply statistics to data.

 

 

BOTTOM LINE APPEARS TO BE  THIS FROM THE C&P EXAM SUMMARY: "Given the veteran's other risk factors, there is insufficient evidence to say that COPD caused the veteran's OSA. "
COMMENT:

“Given the veteran’s other risk factors” is assumed to mean weight and neck size.  However, as shown below, neck size and weight are critically flawed indicators, the probative value of this statement must be decreased.

According to the Mayo clinic(http://www.mayoclinic.org/diseases-conditions/obstructive-sleep-apnea/basics/risk-factors/con-20027941), risk factors for OSA include
"Being Overweight. Around half of people with obstructive sleep apnea are overweight."
COMMENT:
Half. Meaning fully 50% of people with OSA are overweight. Therefore, since 40% of American men are overweight (Nguyen Dang M., and Hashem B. El-Serag. “The epidemiology of obesity.” Gastroenterology Clinics of North America 39, no. 1 (2010): 1-7.), as a risk factor, patient weight is useless. 

More to the point, the probative value of these assertions of risk is actually proven to be negligible by the statistic presented.

 

To further illustrate the difficulty of citing this statistic, consider the study conducted by Lettieri et.al. where it was shown that among patients at the Walter Reed Army Medical Center, Washington, who had  undergone bariatric surgery at Walter Reed and who had significant weight reduction over a period of one year, only 4% of them had resolution of OSA.  Lettieri shows that if the supposed cause is removed, the result remains.  That, is confounding, from a statistical perspective.  One could say “without resorting to mere speculation, it’s not possible to say what it means when (an already dubious) risk is removed, and nothing happens”.  On the other hand one might conclude if the (an already dubious) risk is removed, and nothing happens”, “it’s time to reconsider the risk.”

Having a Large Neck. The size of your neck may indicate whether you have an increased risk. A Thick Neck may narrow the airway and may be an indication of excess weight. 
COMMENT: Here, neck thickness is stated irrespective of stature. Clearly, however, a 17” neck circumference on a 5-foot tall person should be expected to have different ramifications for airway restriction than a 17-inch neck circumference on a 6-foot 5-inch person.  More significantly, since a thick neck is stated to be “an indication of excess weight”, the probative value of neck circumference (stature notwithstanding) should be assumed to have precisely the same probative weight as being overweight (NAMELY, ZERO).

One early and well cited study found that neck circumference was an indicator of OSA grouped metrology data  for men and women TOGETHER.  They found the mean neck circumference of non-OSA patients to be 39.1±3.7 cm and for OSA patients to be 41.2±3.5 cm.  For those of us who buy our shirts in the U.S. the non-OSA group ranged from 14”-15.4 in, and the OSA group ranged from 16.2 -17.6 in.  A 6-foot 5-inch tall man who wears a size 14 or 15 shirt is dangerously underweight.  The statistic is seriously flawed because it fails to recognize that men and women have different stature, and grouping metrology data for them together is frankly, stupid. Failure to account for stature makes the result incredible; to suggest that a 6-foot 5-inch man like myself should have a neck circumference of 14-inches is simply incredible.

 Finally, I point out:
The combined disease of COPD and OSA is so well known it has it’s own name among clinicians.  A simple Google search for ““Overlap Syndrome” OSA COPD” yields 10,400 hits about sleep disordered breathing and COPD.   Overlap syndrome is well known to exacerbate the pernicious diseases of COPD and OSA, beyond what might occur if either existed alone.

I'm at the RO-level now.  Is there anything I can do to get the VA to consider the evidence?

 

[Berta]

What I gathered from the BVA decision:

http://www.va.gov/vetapp12/Files4/1228135.txt

Is that the C & P exam was flawed,  prompting the BVA to obtain a VHA opinion.

The VHA examiner did not diagnose the SA as directly due to service but instead diagnosed it  as secondary to the veteran's COPD.

It is always possible to attack a lousy C & P exam,.ASAP.

And any IMO doctor would want to have a copy of it anyhow.

I had a case at the BVA years ago........direct SC death due to DMII. (my husband was a Vietnam vet.

BUT the DMII was never diagnosed nor treated by VA.

I shaped it as a direct SC DIC claim because they had already awarded his death under 1151, death by VA.

I did have 3 IMos but that isnt my point here.

I knocked down the two C & P reports and Dr. Bash did as well.

Since I had 3 ( the third was a 2 sentence freebee from a former VA neuro that co-oborated my claim ( and Dr B loved it)

I asked the BVA for a remand because my VCAA rights had been violated. They agreed,  but remanded for a third VA opinion from a cardiologist.

I was thrilled because my background on this claim involved a lot of cardio work. But I got an opinion from a PA instead and immediately rebutted it medically and sent my rebuttal to the VA. It was, I proved, too speculative. to have any merit.

BVA agreed and awarded direct Service connected death ,contributed to by untreated and undiagnosed DMII from AO..

Can you scan and attach the C & P exam you got from the VARO?(Cover c file #,name, address prior to scanning it.)

Did you get one yet on the SA COPD claim?

Unfortunately many claims like yours DO need IMOs but often a vet can rebutt a C & P exam in many ways themselves. Even if the RO doesn't buy what you rebutt, and issues a SSOC , the BVA will consider the rebuttal thoroughly..

You did your homework:

"To deny a  claim on its merits, the evidence must preponderate against the claim" (see Alemany v. Brown, 9 Vet.App. 518, 519 (1996))

However, you might well need a strong IMO and the IMO doctor might also be able to cover other issues as well that you have pending now.

The IHD,....... are you an incountry Vietnam veteran? If so , you dont need an IMO for that claim at all.

You mentioned the Duty to Assist regs,....I think they should be amended to say the veteran must assist themselves as much as possible because we, the VA, wont really assist them at all..

Let's face it, if the VA really wanted to assist us, they would provide and pay for  an IMO in every case that warranted one,instead of making us put up with C & P docs who may have no expertise whatsoever in the disability the veteran has claimed, and their exams are a conflict of interest because we don't pay them, the VA does..

Personally I consider many C & P s I have read here over the years as downright malpractice, because that same doctor might be treating veterans medically in an inaccurate way,too  if they cant prepare a proper C & P ....I still believe that last C & P I got was prepared by the guy who fills the paper cup dispenser at their water  cooler.

I cant appeal it because when I forced them to read my medical evidence,under 38 CFR 4.6 CUE,filed right away,  then 5 weeks later after the denial ,they  awarded the claim.   If a real doctor prepared that C & P they must have graduated at the bottom of their class.

 

 

 

 

 

 

 

SVR Death Show March 18,2009.doc

Edited September 22, 2015 by Berta

[lotzaspotz]

Watch, soon we'll be seeing podiatrists and dermatologists doing C & P's for sleep disorders.  If they're an M.D., one size fits all, if you manage to, in fact, get an M.D. to conduct the exam.

We are currently challenging a C & P that should have been conducted by an endocrinologist regarding residuals of a service connected adrenal disorder.  Instead, it was conducted by an anesthesiologist.  We challenged this through the RO as soon as we got the copy of the C & P, and then challenged it again when we filed the Board appeal after the RO denial.  We have yet to receive anything from the VA that directly addressed this particular issue.

We have to throw the BS flag when this happens. 

[ballistics-guy]

On 9/21/2015 at 8:01 PM, militarynurse said:

Is it even possible to be separately rated for both obstructive sleep apnea, (OSA), and another lung condition, ( like COPD ),?

I heard both were respiratory disorders and hence only the highest rating for one is what the VA allows.

 

I believe you are correct except that the VA picks a condition they claim to be you main pulmonary condition, and INCREASES it one notch.  That's your combined rating.  I have the reference fo 38 CFR for that if you need it, but a google search of

 

veteran multiple pulmonary next highest

 

works too