Although we agree with their observations, we know that dyspnea on exertion is not the only symptom that interferes with the quality of life of these patients. As shown in previous studies,3–5 orthopnea, choking sensation, intractable cough, inability to clear secretions, and recurrent infections are important symptoms in this patient population. We believe that these symptoms may be related directly to central airway collapse or indirectly from secondary complications. We hypothesize that when secretions are not cleared effectively, these patients are predisposed to superinfection. This will trigger local inflammatory mediators resulting in frequent bouts of bronchospasm, bronchitis, and pneumonia. Future studies need to address the underlying pathophysiology of this process.