11.

LUNGS, CHEST WALL, PLEURA, AND MEDIASTINUM

a. Current abnormal elevation of the diaphragm (either side) 756.6). Any nonspecific
abnormal findings on radiological and other examination of body structure, such as lung
field (793.1) or other thoracic or abdominal organ (793.2). [ Many many things can cause this from
conditions of the lung, abdomen, or hernias and trauma of the diaphragm itself or its nerves. Things such as
lobectomies or pulmonary fibrosis, splenomegaly or a distended stomach, or infections or abscesses (subphrenic or
splenic abscesses). This is why any unexplained diaphragm elevation or other nonspecific abnormality of the lungs,
and other thoracic and abdominal organs is disqualifying. If you cannot explain it and prove it is not a potential
problem, then they cannot be qualified]

b. Current abscess of the lung (513.0) or mediastinum (513.1).

c. Current or history of recurrent acute infectious processes of the lung, including but
not limited to viral pneumonia (480.x), pneumococcal pneumonia (481), bacterial pneumonia
(482.xx), pneumonia due to other specified organism (483.x), pneumonia infectious disease
classified elsewhere (484.x), bronchopneumonia (organism unspecified) (485), and pneumonia
(organism unspecified) (486). [Any type of lung infection that has occurred more than one time is
disqualifying. Very few young healthy adults will ever get a viral pneumonia more than one time while growing up
without some significant underlying reason - unless this is fully explained, it might be disqualifying]

d. Airway hyper responsiveness including asthma (493.xx), reactive airway disease,

exercise-induced bronchospasm (EIA) (519.11) or asthmatic bronchitis (493.90, reliably
diagnosed and symptomatic after the 13th birthday. [Pulmonologists clearly separate EIA from
allergy-based asthma, the DoDI now uses different ICD codes them. 519.11 and 493. Also remember there is a
significant incidence of allergic rhinitis, GERD, and psychiatric disorders that can accompany asthma – look for
them]

(1) Reliable diagnostic criteria may include any of the following elements: substantiated
history of cough, wheeze, chest tightness, and/or dyspnea which persists or recurs over a
prolonged period of time, generally more than 12 months. [This includes a dry night cough, any lung
tightness/twitchiness after exposure to cold air and/or exercise. EIA symptoms can occur up to 9 hours after
exercise - an example would be a jogger in the afternoon that develops a dry cough during the night.
In any recurrent bronchitis (more than once) after age 13, underlying asthma should be ruled out.]

(2) Individuals MEET the standard if within the past 3 years they meet ALL of the
criteria in subparagraphs 11.d.(2)(a)-(d). [Could an applicant be disqualified for asthma symptoms one
or two years ago, simply wait until he meets the 3 years and then be qualified? It looks that way ]

(a) No use of controller or rescue medications (including, but not limited to inhaled
corticosteroids, leukotriene receptor antagonists, or short-acting beta agonists).

(b) No exacerbations requiring acute medical treatment.

(c) No use of oral steroids.

(d) A current normal spirometry (within the past 90 days), performed in accordance
with American Thoracic Society (ATS) guidelines and as defined by current National Heart,
Lung, and Blood Institute (NHLBI) standards. [Order all spirometry (PFT) done with bronchodilators. If
possible, order Exercise PFT (EPFT) with EIA, never order MCT for EIA. MCT can only be used to evaluate
allergy-based asthma. If you are not sure, order a pulmonology consult for help after consulting with your Branch
Surgeon-see more explanation below]

In a PFT, the most useful number in assessing the risk of future asthma attacks is the “ratio.” This is FEV1/FVC,
and tells you if there is restrictive (fibrosis), or obstructive (asthma) airway disease present. Using a ratio of 0.80
(80%), it it goes up, there is restriction, if it goes down, there is obstruction present. A ratio below 0.80 is beginning
to show obstruction, and a ratio down to 0.70 or lower is definite obstruction with a high risk of future reactive
airway exacerbations. Repeating the test after inhalation of a short-acting bronchodilator will further confirm the
reversibility of this obstruction if the FEV1 increases 12% or more from the baseline, or by an increase over 10% or
more of the predicted FEV1 , then you have reversible airway obstruction consistent with asthma.

The MCT (Methacholine Challenge Test) is the gold standard for diagnosing bronchial airway hyper-
responsiveness. The drug, methacholine is a strong bronchial irritant and will cause spasm in anyone in high
enough doses. It is like breathing-in ammonia fumes. So it is given in small doses up to 4 mg/mL. If it causes
bronchospasm at this level (increase of 20% of their baseline FEV1), it is likely reactive airway disease. Higher
doses up to 16mg/mL are used, but might give a false positive since doses this high can cause bronchospasm in
normal people. Incidentally, cold air and exercise do the same thing, this is why MCT is never used in EIA, it could
cause an exaggerated response and even be fatal.

See more at: www.nhlbi.nih.gov/guidelines/asthma/04_sec3_comp.pdf

In a nutshell, any history of asthma up until the previous 3 years can be qualified if you can prove that the applicant
has not had any asthma symptoms of any kind in the past 3 years and has not used any medications whatsoever for
any asthma-like symptoms in the past 3 years. The burden of proof is too make sure you get every medical visit of
any kind for the past 3 years. Even if the applicant stubbed his toe, get the records!]

e. Chronic obstructive pulmonary disease (491).

(1) Current or history of bullous or generalized pulmonary emphysema (492).

[The alveolar are minute in size, there are 170 alveoli in one cubic millimeter of lung tissue. If they
rupture, they form slightly larger air spaces called blebs, like tiny blisters, smaller than 1 cm, usually seen in the
apices of the lungs in 6% of healthy people. However, blebs are more frequent in lower BMI <22 smokers. This
might be the very first step in developing emphysema and chronic lung disease (COPD). When blebs rupture, they
form larger bulla >1 cm (pl bullae), forming bullous disease which is the first step in developing emphysema, and
increasing the risk for spontaneous pneumothorax. They are easier seen by CT scans. Large upper zone bullae have
been reported in marijuana smokers (bullous emphysema)]

(2) Current bronchitis (490), acute or chronic symptoms over 3 months occurring at least
twice a year (491). [Asthma has to be excluded in recurrent bronchitis, particularly after the age of 13]

f. Current or history of bronchiectasis (494). Bronchiectasis during the first year of life is
not disqualifying if there are no residual or sequelae.

g. Current or history of bronchopleural fistula (510.0), unless resolved with no sequelae.

[This is a fistula between the pleural space and the bronchial tree, usually from a lung abscess or empyema
draining through a bronchus. This condition is rare and most commonly due to a complication after lung surgery]

h. Current chest wall malformation (754.89), including but not limited to pectus
excavatum (754.81) or pectus carinatum (754.82), if these conditions interfere with vigorous
physical exertion. [For any pectus that appears more than mild to moderate, order a Haller Index by CT or
CXR. An indes of 3 or higher is severe and is disqualifying. You need to evaluate their exercise tolerance, as most
of them cannot run at normal speeds over 1 ½ miles, they just run out of steam, although applicants often will tell
you that they “ran cross-country” in high school. It helps if their recruiter can submit their time from a AFPT 2-
MILE run test, they need a score of 60 or higher to pass. Otherwise, consider a pulmonology consult with a CPEX
(Cardiopulmonary exercise testing) Otherwise, document in the 2807-1 history box a detail account of their stated
exercise capabilities, obtaining any supporting documentation from their school and coaches]

i. History of empyema (510.9).

j. Pulmonary fibrosis (515).

k. Current foreign body in lung (934.8, 934.9), trachea (934.0), or bronchus (934.1).

l. History of thoracic surgery (32-33), (CPT 32035-32999, 33010-33999, 43020-43499) including open and
endoscopic procedures. [In any hx of a tracheostomy, always document the reason for the trach. Also, we are
assuming this does not include insertion of chest tube for a pneumothorax]

m. Current or history of pleurisy with effusion (511.9) within the previous 2 years.
[Pleurisy or pleuritis is an inflammation of the lung lining, and often has a little effusion, and both are symptoms of
an underlying disease process. A viral infection is by far the most common cause in MEPS applicants. 50% of
pneumonias will have some effusion. Pleural effusions come thick (exudates) and thin (transudates). Thick exudates
are generated from a local disease process, and thin transudates are systemic in origin, i.e. heart, liver, or kidney
failure and will be rarely seen in MEPS. Any history of pleural effusions in MEPS applicants are highly likely to be
(local) exudates from bacterial or viral infections, and much less likely due to a cancer like a lymphoma. Your
auscultation of the lungs will not pick up any signs of effusion unless there is at least 500cc or more. Since 50% of
pneumonia has some pleural effusion, correlate these findings with rule 11c. above]

n. Current or history of pneumothorax (PTX) (512) occurring during the year preceding
examination if due to trauma (860) or surgery, or occurring during the 2 years preceding
examination from spontaneous (512.8 ) origin. [If it is a traumatic PTX, the wait is only 1 year, if it was a
spontaneous PTX, then the wait is 2 years. Always get a CXR before qualifying. If a PTX does not resolve or
respond to a needle aspiration or chest tube, then a “pleurodesis” (chemical or surgical obliteration of the pleural
space) is done before a bullectomy or lung resection is done, The farther along this treatment chain, the more
serious the PTX was]

o. Recurrent spontaneous pneumothorax (512.8). [To assess the risk of reoccurrence, there are
several factors involved. There is a genetic predisposition that comes into play, seen mostly in young slim males that
smoke (r/o Marfan syndrome). “Slim” is usually a low BMI <22. 57% of this group has a “sharp rib.” See 11 e.(1)
above. Other commoner things to look for are a history of asthma, TB and a previous pneumonia ]

p. History of chest wall surgery (34-34.9), including breast (85-85.9), during the preceding
6 months, or with persistent functional limitations. [This includes breast augmentation or
reduction]