A 56-year-old man was admitted to hospital with a 1-week history of worsening cough and dyspnea on exertion. He also complained of pleuritic chest pain with fever and chills of 2 days in duration. He had a history of chronic cough with clear-to-yellowish sputum turning purulent with infection. His exercise tolerance had been diminishing over the years, currently less than a city block. He had three-pillow orthopnea but no paroxysmal nocturnal dyspnea. He denied any hemoptysis or weight loss. His medical history was significant for COPD and multiple upper airway procedures including a temporary tracheostomy with biopsy (Fig 1) in 1989, and a right upper lobectomy for adenocarcinoma in 1994. He was a 100–pack-year smoker and admitted to occasional cocaine use. Both his father and sister were heavy smokers and had lung cancer.