I started doing fiberoptic bronchoscopies in the mid 1970’s. I was in training in Philadelphia and this was a brand new technique being used by pulmonary specialists. Looking in to the airways of a patient to help diagnose or treat a problem with this specialized technique was one of the reasons I went into the special- ty of pulmonary medicine. Many of the observations we had with this instrument were new and never previously described.

One of the observations I made early in my carrier could have put my name in the annals of medi- cine if I had only written about it. What I observed in some patients was a collapse of the central airways (trachea and main stem bronchi) when the patient would exhale or cough. Later the phenomenon was called hyper dynamic airways collapse and is now referred to as expiratory central airways collapse (ECAC). ECAC is seen in patients with COPD and is more severe when the COPD is more severe. It is also more common in patients that are overweight and who have more cough and symptoms of chronic airway irritation (chronic bronchitis).

The diagnosis of ECAC in the past was made by observation during fiberoptic bronchos- copy. Now it is said that inspiratory and expiratory CT scans of the chest can be used, but I think that direct observation is still the best technique. ECAC may explain the shortness of breath some patients with COPD have that is out of proportion to their breathing tests.