67 y.o. male smoker with end stage COPD on home oxygen, tracheobronchomalacia, s/p RUL resection for squamous cell carcinoma. Y-stent placement was complicated by cough and copious secretions requiring multiple therapeutic aspirations. Patient reports decreased appetite, 50 lb wt loss in 6 months.  Decreased activity tolerance.  PET scan revealed some FDG avid nodes concerning for recurrence.  Pt. presents with worsening SOB with R shoulder pain and weakness.