(cell phone 240-506-1556)

To: All veterans

Date: 2015

From:

Topic: Pulmonary disease TB vs COPD

Independent Veteran Medical Opinion (IMO)

Veteran Medical Nexus Opinion (VMNO)

for Veteran benefits

Craig N. Bash, M.D.

Neuro-Radiologist
www.veteransmedadvisor.com

Pages: 2
NPI or UPIN-1225123318- lic #--D43471
4938 Hampden lane, Bethesda, MD 20814
Phone: (301) 767-9525 Fax: (301) 365-2589
E-Mail: drbash@doctor.com

Pulmonary disease TB (tuberculosis) vs COPD (choric obstructive pulmonary disease)

Many patients historically have been exposed to repository diseases such as TB in service due to the
close quarters associated with boot camp and deployments. Often these patients have ling damage
(scarring) from the TB but the also may have a smoking history which is also well-know cause of lung
damage. The VA will normally reflexively say that the lung diseases are all due to the smoking history if
the patient has a smoking history. But this incorrect because lung disease on the first estimation is split
into restrictive and obstructive lungs diseases processes as described below:
Restrictive lung disease (restrictive ventilatory defects): a form of lung scarring (honeycomb)- that can
occur following TB- also known as fibrosis and reduces FEV-1 and total lung capacity.
Obstructive lung disease: often due to smoking also called COPD also reduces FEV-1.
A typical example is the flowing:
Mr. Smith had a severe case of TB in service with a collapsed right lung treated with a right-sided chest
tube. He, on follow-up imaging, had residual TB scarring of his right upper lung and left lower lobe. On
my film review I estimated that this scarring compromised his lung function by 30-40%. His historical
PFTs showed a low FEV-1 consistent with both COPD and TB but the PFTs did not capture the full extent
of his restrictive lung disease scarring. He is pulmonary cripple (His Metabolic equivalent of task = a
MET of 1- he was only able to walk short distance even in 1940s following his TB treatment. No diffusion
scan called DLCO had been done which would have helped determine that his lung disease was
significantly due to TB. The VA on CP exam in 1997 stated the following:
3/1997-Veteran was evaluated by pulmonary service. Obstructive airway was diagnosed. It is
uncertain how much of this might be related to his past history of cigarette smoking and how much is just
reactive airway disease of unknown etiologyrestrictive disease possibly caused by the lung
damage from the TB

His case has lingered until now. It important to note that his smoking history was minimal compared to
his TB (restrictive type) loss of lung function in the early and late 1950s. His spouse had known him
since 1957 and she stated that he could not even walk a short distance without being short of breath (1
MET) and could not dance or do anything physical even when they first met in 1957- again due to his
shortness of breath.
METs are defined as follows:
1. 1 MET = Eat-dress use toilet- standing at rest or oxygen uptake at 3.5 mls per kg of body wt per
minute
2. MET = walk around
3. MET = walk 2 blocks on level 2-3 miles/hr
4. MET = wash dishes, dust
5. MET = climb a flight of stairs
6. MET = run a short distance walk briskly >4 mph
7. MET = scrub floors, lift heavy furniture
8. MET = dance, play golf or tennis
9. >10 MET = swimming, basketball, skiing
His daughters stated that their Dad never played sports with him due to his poor pulmonary function. He
had been smoking for about 15 years at this point as a casual smoker and the time lag for significant
pulmonary damage from smoking is my experience longer than 15 years. METS are normally used for
cardiac dysfunction in the rate schedule but his dysfunction over the years is best described using the
MET system, which encompasses both cardiac and pulmonary dysfunctions.

Recommendations:
1. All patients with lung diffusion that is not solely due to one pulmonary disease should get a DLCO test
along with PFTs.
2. All patients should get good lay statements to support their cases as the above statements clearly show
that this patient had severe lung disease early in his claims process.
3. All patients should consider the METs system to help establish disability if they are not able to do
cardiovascular demanding type work or recreation.
Craig Bash M.D. Associate Professor

drbash@doctor.com cell 240-506-1556

Independent Veteran Medical Opinion (IMO)

Veteran Medical Nexus Opinion (VMNO)
based on Veterans medical records for veteran benefits