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OK. So uh can you hear me now? Can we start? We can Yeah. OK. Uh How many people here? I could not see events to a stage roughly. Yeah. 13. OK. So uh II need the, the how I can see the people in and with me people. OK. Yes. OK, good. So um hi um I'm Ahmed 36 in, in Ne uh Diana. Uh invited me to be, to give you some hits and how to see the chest x rays. Uh It's my pleasure to be with you. Uh If you have any questions, please answer. Uh I uh I think it needs to be um discussion more than just giving you an and um uh a lecture. So I will ask one by one for questions and uh to interpret the uh x-rays one by one. Uh Happy with that. If anyone could not just say I can't um uh like in, in a place or uh who could not uh answer or does not have a microphone. OK. Happy. The only trouble is that the, the participants they can't actually speak but they can type things in the chat and I'm very happy to read as they go. OK. So OK. So uh OK, so I will ask her, ask her questions, yes or no or multiple questions in the uh in the um uh like the images and please answer me. OK. Now I will start with a, with a presentation uh been done by um Diana to help me actually because I'm, I'm very lazy man. So we are going to do the X rays. Uh OK. How's this goes? Oh yeah. OK. So I know of all of you has been with the X rays and uh seen and having s for the x-rays. Uh but just an f physiology of these things. First of all, this is inspiration and this is expiration with inspiration, the diaphragm going down, pushing the abdomen and will help and uh help the lung to expand well and inflate. So that's why we asked the patients during the x-ray to the radiographer, ask them to and have a deep breath. So we can have a more a better image for the um x rays we see with the inspiration, expiration, the intercostal spaces between the uh ribs is increasing and have a better um alignment done with uh expiration. Uh That's in, in as introduction uh the projection. I'm not sure if you are aware of the production. It's ap or pa usually um most of our x-rays is uh pa um it depends on where, where, where is the patient actually. So if the heart shadow will be larger in uh patient with uh intraprocedure beam than the uh PA beam, which is uh that's why some of the patients or why he has uh cardiomegaly. But no, we you have to uh to see if it's AP or P this is the AP film and the PA film. So they've been coming from anterior. So the heart will have a larger um or a a uh the angry will be uh acute, more acute. So uh it has a more be uh taken by the uh the heart. OK. So with the chest x rays, uh there's a multiple things to do. Uh a lot of like pneumonics to, to, to, to say uh Diana did this one or like uh choose this one to be for uh what we are going. It's air air, we were checking the trachea. So it, we were checking the trachea, checking uh checking the, the whole mediastinum. Can you see my pointing? Yes, we can. OK. So uh the uh trachea usually as the air pi we see, is it centralized or not? Some, some uh pictures we see a stea nosed one in old people will see uh a calcified uh airway. Uh So, so the airways, OK. The trachea uh be breathing, would you see the lung is um how, how is the, is the, the l any shadowing uh his v marking or uh any pneumothorax, circulation, checking about the heart and the the the disability of the patient with the disability of any fracture of the uh chest X ray uh of the uh ribs, um a hint chest xray, the chest X ray in that the rib fracture is not that uh useful. You can diagnose. Uh there's an uh rib fracture. Most of the fracture will appear in the chest X ray or like the, the apparent one would be a displaced fracture uh from the, the alignment will be, the ribs will not be aligned to each other. But in the same time, uh it's a good for a follow up things if you check any um pneumonia, blood infusion, uh pneumothorax. Uh Yes, that's a good uh thing. But usually we uh rely on the CT about the amount of displacement. Uh Is it uh causing any problem where is exactly beca anterior or posterior? Because if it's posterior, usually not going to do anything because there's a lot, the muscle mass is larger. Uh We usually keep to do the uh the electron fracture. Is it behind the scapula? We don't do them. So, uh the X ray itself is just giving you an idea but not an actual, they will not give you. OK. I'm taking the patient to say that because of fracture only. No. So uh small effusion, uh the body always perfuse uh uh secretes and uh fluids between the pa and basal pleural which is in and out help the sliding of the lung. Um So uh what's the, what's the mean fluid effusion is the fluid inside the chest in between the parietal and the pleura which prevent the v lung to uh inflate or uh like move uh in a better way. OK. Does not always uh collapse. As we uh Diana wrote, uh the lung collapse usually is as, as as a collapse lung. The cola lung collapse is a broad term which from inner side or outside, the blockage can goes along collapse or pressure from outside, which is the pneumothorax, air pushing it or fluid in the pleural effusion. If it's minimal effusion, effusion, the lung can inflate, deflate but not in a proper inflation. But it's not causing uh in the degree to, to cause uh effusion. OK. So this image I will share my slides. Uh OK. So, but this is the middle one I want to just because she has a picture of the images. Uh I did not include it in my presentation. This is a pacemaker in the heart. We can see it here and those this is muscle. Uh this is aortic valve. We can see the metallic valve which p usually, but we see the the stitches of uh of it. And uh this is the sterno incision. This is the sterno usually after, after se and after finishing the surgery, uh we have a large wire um be in between the, each, each edge of the sternum and been approximated by the meals. OK. And now can I uh now share my? OK. Can I stop sharing now here? And I need to share, share your screen will be OK. Can you see my window? Can you see it on this one? Yeah, yeah. If you just click on share full screen this one like this. Yeah, perfect. OK. Good guys. Uh So this is a chest drain. This is the surgical chest drain. Uh They told me that will be covered by another uh teaching by um Nikki, one of the my marvelous colleague. So just a hint for that, this is the um the blue line is really opaque. So this is what exactly te tell us is with the chest X ray where the drain is OK. And the drain usually has opening, the opening needs to be within this blue line. So we can see where is exactly the blue li the uh the uh the opening inside the chest. I will show you uh with um with the next big images. So you will need b more. This is another type usually set by the respiratory doctor. It's so called Seldinger. If you want to put a small drain, minimal invasive one, but uh it needs um uh what we call it. Uh um we, it's need a space inside the, if the lung is very just in the chest wall, just beside the chest wall, the the needle will uh puncture the lung. So this is need like, uh uh some, uh most of the people who do it with the, with the sound to see if, uh, the, the needed where it goes. Uh This also will, will be covered by Niki. And this is the Pleurx drain, which is long term drain also usually been with the um, chronic pleural effusion usually with the cancer patients. Um, this is like a tap patient could operate, evacuate when he feel, feel like shortness of breath. Uh And it's a long term catheter because the opening and closing not in the same. This is in the skin like five c 10 centimeters. Then this is inside the chest, so uh called the tunneled one. And it has a calf here which uh prevent uh the infection from outside to inside. Ok. So uh this is a chest X ray. I need to say uh is it uh this is a normal chest X ray? OK. Or like satisfactory, normal chest X ray. Uh What's they are not uh giving me the, the pneumonic which is airway, the air is the air coming from here, we have the left and here we have the right uh uh bronchus. It's centralized, there's no stenosis and it's patent here. OK. The bronchovascular marking of the lung is apparent, no vascular or the breathing. The lung tissue is uh within the chest wall. We cannot see any air here, no apparent. Uh OK. Le let us continue with the pic? Ok. Uh then see with the with the cardiovascular uh this is the heart the the ratio is fine there's no cardiomegaly and the cost angle is clear and no fracture could be seen. Ok, so next so uh who uh can can anyone just describe with with with one word? Ok, can anyone just uh could you write please? Could you comment anyone have any comment guys? I'll tell you if there's any message in and chat. We're just waiting for people to write, I think. OK. Is the one message here? Oh OK. This is from the, from the surgery from the uh program itself, right? So someone said patchy, especially on the right base. OK. OK. OK. What else? OK. At least one responded. That's good. So, um uh sure. So with this one, yes, this is a patchy, right and left, the right is more than left. This increased M VS marking. Uh This patient has a high CRP and uh there is a suspicion of uh pneumonia uh mostly in this right, lower side. OK. So diagnosis. Mhm. Tell me guys answer. So you said pneumothorax, OK. Tension. Mhm OK. Uh It is a pneumothorax. But what anyone could write the, the usual stigma of pneumothorax on the chest X ray. Usually another person's attention pneumothorax as well. OK. Deviation of trachea. Mm. Not that much but OK. OK. So let us uh carry on. Uh this is a pneumothorax. Yes. But we can go with the, with the, with the ABC things because you may sometimes forget things. Uh patient maybe have a trauma, maybe have, you don't have any history. This patient came with uh an sudden onset of shortness of breath and chest pain. Uh There's no, no uh no trauma. So he uh with the airway is the airway actually, according to the angle, I cannot say if it's shifted, it's not massively shifted. Uh B breathing right lung is fine, increased, bronchovascular marking. Yes. But in the left side, um there is an pneumothorax. This is the pneumothorax, right? You have, you can like, OK, see it's pneumothorax or not. This is a black and this is out, the screen is also black. The air is black usually. And the gluco vs marking is the, this is a very small one. Is it tension or not? I can see, I can say it's bending tension because uh there's no like not that massive shift or not that shift on the uh the trachea d disability. Uh there's no history of trauma. So sometimes OK, you can't uh you can uh check if there's any fracture or any, any, any fractures. Uh If the patient did not tell you a trauma, some people came lying, there's a trauma. Uh there was a trauma but they did not mention that. Um But um you need to see the chest X ray according the clinical diagno the clinical picture also. Uh it's easier for you where to hit the uh to see. This is a pneumothorax. Yes. Uh But I anyone can spot anything in the, in the, in the shape of this his chest. Anyone hyperinflated. Someone said. Mhm OK. What's the uh usual stigma of spontaneous pneumothorax? Guys? The usual like when you see them? That's OK. This will, will, will have a a pneumothorax. Someone said, uh barrel probably to say what it looks like someone else had tall patients. Tall patient. Yes, exactly. This patient is high, uh very tall. No more than 222 m actually. But uh this is a ripple shaped mediastinum. Usually the patient told smoker young when cough or sneeze, they have a bulla whose which is uh ruptured and causing pneumothorax with a chest X ray. You usually see a report shape, uh very small, very tight. The pneumo the the the mediastinum is just behind the vertebrae. It's not. And the heart is so small. And the patient, the patient actually, this patient actually told. So we will go to the next one. This is the same patients. This is after drain incision. OK. Anyone uh is it satisfactory or not? Yes or no question. We have one. Yes. Mhm OK. So uh it's yes and no. Yes. Uh the patient's not in emergency. Now, the chest pain, if you could see it, we have a few more answers. So maybe I can see a small airline in the apex. Exactly. Yes. Some space left, still left towards the apex. Yes, that's good. Ok. That's great. So, the drain is like this, this is the drain. This is a small drain. This is for pneumothorax just to drain air. So we prefer small drains. And the drain is, um, uh, uh, this is Seldinger drain, which is like the guidewire one that, that, uh, that I show you on the previously, uh, there's a space, yes, the lung inflated. Ok. Good. There's some space. There's a continuous air leak. The, the P is not healed. It's just like we remove the air from the chest and continue to cause air leak, continue to cause if it's underwater seal will be a bubbling. If it's a, the uh, the fancy technology one will give you the number of how much air mil per hour air per minute is going out. It is produced. So this is the leak. Uh, and this is a space. So this is space. Can we treat it or not? It's maybe just wait and see to, um, to see, to give the, the lung much time to. It's because it's like a sponge. So I give it more time breathing exercises to the, to the, to the lung to inflate properly or we can apply suction on the drain. So can let the lung to uh uh like to, to inflate more. Uh This is usually for two reasons. Either the air coming from the lung, of the whole of the port from the lung, larger amount than the brain can accommodate or the lung have some adhesions um in the chest wall. So could not um like reach the apex or another thing. It can be in CT but not, not in this patient. Usually, maybe the bulla is here with full of air with thin wall. So you can just see, ok, there's an uh pneumothorax ct maybe see this is a big bulla maybe, I don't know because the patient is, he is waiting for a ct until now. OK. So can anyone describe this big effusion, massive pleural effusion slash hemothorax? Mhm OK. OK. Uh That's a right. Yes. This patient has a shortness of breath. They put a drain, drain drained about 200 ml this a drain and but the fluid is more and uh this is opacity, white opacity. So it's uh mostly fluid. You can just say obesity uh on describing things because OK. Who said that it's fluid? Who said it's hemothorax, who said sometimes the lung is just um a blackout, but this is uh like homogeneous opacity and massive. I think the lift back to go to the basics A BCA, the airway is little bit pushed along the, the trach is a little bit pushed uh be breathing the right side. All the lung is white. There's, we cannot see a lung tissue and uh cardiac. She had a bit of cardio because uh, the, the heart is on the left side is maybe just because it also is pushed and, uh, on the right side cannot be seen on the left side. Um, is ok. And the patient has no history of trauma. She came nontraumatic. And uh, if you can see there's no, the um, ribs are aligned. Ok. So then this is the same patient they called us because the uh why the drain was blocked? The small drain was blocked and the patient still has increased oxygen requirement. And uh oh, let's back here. Increased oxygen requirement. Um And the patient in distress. Ok. And the X ray as it is. So what is the causes? Why, why it's not drained? I will let you know, I tell you because this is a small drain inserted by the radiology and it's blocked. Ok. What's the options? Now, what we need to do? Any answers? Someone said flush or change the drain maybe. Ok. Surgical drain. Yes. Flush. Maybe that's uh uh uh easier like primitive or like primary thing to do. You need to do it. And there's um aseptic technique. You need to clean out everything because we don't need to give infection to this effusion and uh surgical drain. We you can put a larger drain or put a surgical drain. Ok. We put a surgical drain and it rained 1000. Any comment on this image. This is the same patient actual actually this is the same patient. So any comments please? Mhm Diana. Could you read or still thinking? So we just got one reply. It said one of the openings outside the pleura question mark. What's his name? Who said that? Cameron? Nice job. OK. Any anyone else? OK. Uh That's right. That's what I told you in the beginning. There's an uh the radiopaque and the opening needs to be in inside a um us, the, with the factory things or the uh uh the opening needs to be within this uh blue line that we saw in this, in this one, the blue line in this one. This is what we are seeing this line and this is opening. So this is, it actually, I put the drain in this patient and I inserted it. I've been distracted by amount of fluid, the massive amount of fluid getting in clam. It. I think it's a little bit pulled before I uh fix the drain with the suture. That's what happened with the patient. OK. And we did the X ray I saw this, then I positioned it, just push it a little bit more and we did another x-ray. That's the x-ray. OK? The, the both line, the both opening or holes are inside the chest. OK. So what would happen if this is skipped as it is anyone has any clue because the drain is draining is draining the fluid very much patients feel better. But if I get it for another day like this emphysema. Someone said, OK, what else? Emphysema? Yes, in case of it's an um and air coming out uh from the lung. Ok. And the air coming from this to this. And we will also escape to this cause the surgical emphysema in air under the skin, surgical emphysema in the same time, in the same manner, fluid will come there and you will feel uh pockets of fluid here that needs to be drained and, and or in between like uh around the drain itself will be a massive one. Uh In addition, if this opening was a little bit outside or the this or allow uh like just at the edge of the wound, you are making the air to come inside the lung because the lung usually on a positive or negative pressure. Can anyone answer? And relative to the air? Oh the atmosphere, negative, negative. Yes, it's sucking. That's why we are breathing because we are sucking air from mouth or the nose from um a zero level to minus to, to negative pressure. So it's the same, the same thing here. So if this opening little bit out, you are sucking air from the atmosphere inside the lung which cause open pneumothorax. Ok. So I pushed in re another suture and we did an x-ray to make sure that's it's in a place. So this is one of the causes why we are putting the X ray and doing an X ray after the chest drain in session? Ok. Mm. Mm. Two. Anyone can comment on this. It's been, been done two days ago. Very fresh new. Any comments? Not yet? Ok. It's, uh, to be honest, it's a little bit, um, tricky one. I don't know. Actually I put it exactly, uh, cured. Ok. Do you see the, uh, right diaphragm. That's a little bit up. This is, I think this patient had the uh had the surgery and he had a trauma to his um to the dia to, to the phrenic nerve. So it caused increased the high phrag. I know it's, it's not that obvious to be honest. Uh But there's a wide differences, you usually see it because pre op and POSTOP chest X ray, we see the there is, is higher than it was previously. And anything else I can, I can comment on that is there is a here at lactoses. But actually, ah OK. Actually, I have another thing I would show you uh it was more apparent on the X ray uh and the uh screen itself screen. Uh But anyone can comment, I remember, sorry, I was uh me also confused. Anyone can comment. Someone said right side, reduced air entry, reduce R nt uh on the exa on the the cult. Yes, you will, you will feel like this but we are not auscultating. Now, actually, there is a space here. Epic pneumothorax on the right side and there is a drain here already. Surgical drain. This patient POSTOP the surgical drain here. So this is space. So usually this is just the uh lower lobe and the upper lobe has been removed. So we think the patient and uh we're giving a time for the patient to uh to the lower lobe to just inflate to accommodate the space. Some of them, some of the consultants like to apply suction or some other people just give patients the uh breathing exercise who let the lung to inflate, just give it a time. So usually next day, chest X ray and see and depends on the air leak. If there is an air leak uh after the operation, anyone has any question and this is your atyla if you can see any question. OK. So any comment here on this slide? Bye. So cophosis, OK. He's a patient 82 year old. So he may have OK. And look at the aorta here, aortic here, there's a classification. Also you can see it. So it would be good. OK. Another mhm. Just description anyone like f it's this is normal uh compare right and left side of the lung, right side is more exposed, likely due to rotation, maybe OK. This patient, we did something called endobronchial valve to him. OK. So this patient has AC O PD. So you will see the, the uh uh what is it? The uh it's like a bar shaped and the um lips are more straightened. Thank you. And this patient has something called intrarenal valve in, in, in the left upper lobe. So we can see that it's a little whitish, more ossification here than the other parts of the lung. And this is the idea of the surgery. It's called lung volume reduction surgery into broken valve insertion. We put uh uh uh went there the upper lobe, uh bronchus, we put a valve that allow the air coming out of the, of the upper lobe and not getting in. So it will shrink. And what's exactly or this is what happened? This is a collapse. This is a left upper lobe collapse. But if you don't know anything about the patient, OK. There is a left upper uh side opacification, maybe mucus blood, maybe a a pneumonia on this, this upper lobe. So, but the, the history or clinical history of this patient, he had an uh a valve. I'm not sure if you can see it here. I could not see it here actually. But in the, the actual screen, the uh p we can see it. Ok. So, mm OK. I'll go with this one. So anyone can comment on this. I would make it larger. Anyone comment can comment on this. Someone said right sided effusion with a drain in place. Ok. Actually, right. How many uh do you the the drain site satisfactory or not? No, why? Uh they said should be towards the base. Ok. Actually, there's a two drains, not one drain. This is one blah, blah, blah, blah, blah, blah, blah, blah blah. And this is true. So this is the base. This is drains are postop. This patient has a uh empyema or had empyema and we did a uh clearing the clearance of the this empyema and we put the drainage to any fluids to came out the lung will, you will see it like this because it's POSTOP usually any, any tr like it's the, the surgery is a trauma. The body will uh uh see this as a trauma. So this is a trauma. Uh The, the lung is not a healthy lung. And if this is a drain, you usually put somewhere something epical because if there is any air will go, uh we will go so we can drain it. And this is a basal one. Um Just thinking you, that's how to, to recognize the two drains or three drains or one drain. Uh So that's the, the issue. The cost of drink and get is a little bit clear, but it's not clear. There's a fluid here and uh also the ossification is still there. So this is still infection. Ok. So those are both drains and the opening is inside, opening is inside and why anyone could see this drain. And this is the diaphragm. How is that anyone could answer? Which is which any answer drain? Could be tunneled. No, actually, just to be aware of the of the anatomy. Uh you we you are seeing two dimension and the body actually is a three dimension. So the a diaphragm is a, a dome shape. So this is anterior yearly or so usually this is posterior, sorry, posterior to the diaphragm. So this is inside the pocket between the diaphragm and the chest wall. Uh So the diaphragm, the api apix ther is very high, but the the size of the diaphragm will be low like this and the liver will be here pushing the diaphragm up. So we'll go next. OK. Diagnosis for this patient, please. Or any comments and my left side, any others? Ok. Let me give you a history for this patient. This patient, an old age, 90 year old guy who had a trauma. Then he had a clinic laceration underwent sorry ahmed. You cut out a little bit. He had what? Sorry, he had trauma. Yes. And he had a multiple rib, uh undisplaced rib fractures and he had splenic laceration. So he underwent splenectomy on the beginning of the rib, uh rib fracture. And this place we did not say anything. Uh We did not uh recommend any, any intervention. We say just pain management, allow patient to cough, please and just physical therapy. OK. And you can see the X ray. Uh I could not see an an an actual rib fracture. Can we be seen here? Like any, any um displaced or not aligned ribs. The patient has an increased oxygen requirement, feeling unwell. They did X ray see this, OK. Usually the fluid or uh empyema or whatever anyone said that you can see like a fluid lid. OK. We can see a con uh it will be an a convex shape here like this of a fluid level with the eu effusion. Can anyone see this? Yes or no? OK. So the, actually the general surgery guys said this is a pleural effusion and they put a chest drain, it's drained only 200 ml which is, if I put it in myself, it will drain the same chest X ray, chest vein inserted. I just like this. OK. What we have to do next? OK. Any suggestions, any suggestions. Uh this is from a question for me. Is this the only image that you had POSTOP, POSTOP we have uh uh the, the lung was fine on the post postectomy. But actually they did not do a POSTOP uh x-ray unless uh until the patient has uh increased of requirements. And was there a ct before to compare city was a city and the city was normal was fine. Oh, the chest waves. Ok. Any suggestions to what to do nothing. Wha what's your impression, what to do or how to like to, to, to find your depression or how to see like uh to find a diagnosis? Ok. Ok. Let us finish this. This is when they asked us, please, could you see this patient's uh oxygen requirement increased and he reached the 15 L of oxygen and we requested act, the CTI could not uh share it now. But the CT showed a blockage of the left main bronchus. The so uh this is a co lung collapsed. OK. Sometimes it's very hard to, to, to see if, if it collapsed or effusion lung collapse due to blockage of the uh main, this is the main bronchus. Then it's blocked. It's also hard to see on the X ray. But uh this is an uh lung collapse due to a blockage. We knew that with a CT. So anyone could uh so just what's the management for this? Someone just asked, what was the etiology of the blockage? Like what was the reason for it? OK. So what's the next step to know with his, to answer his question? Bronchoscopy? Someone said, yes, absolutely right. We did the bronchoscopy for this patient, this or he was a very thick uh ha he had a very thick mucus plug. Maybe we removed a, a whole cup of mucus from his uh only left lung. It was upper, lower. Uh everything was blocked. So we just go suction and it's producing more, more and more and more and more. This is directly after the bronchoscopy. And the next day was the lung was so I could not find it. I did not put it. Uh but the um it was uh totally the lung will it after that. So just, it's a clinical information. Not, not the information even after laparotomy, even after uh uh uh the patient has two things. He has a major seizure, laparotomy. And the same thing he had uh uh uh unspecific fracture, but he had was in pain that could not uh breathe in and out. So, thon accumulated the mucus mucus plug and that's what happened to him. All of his left lung was not functioning. Usually after doing the bronchoscopy, we actually we intubated the patient and then we did the bronchoscopy while the patient intubated. But, uh, uh, if we did the bronchoscopy after that, the patient did uh aggressive chest physiotherapy with positive pressure, physiotherapy to help the lung to aate. So I think it's eight o'clock, but I need to finish things. Ok. So the image on the left side, there's a patient had the surgery, uh, decortication. She had, uh, she had emphysema decortication. And, uh, there was an, um, this is the surgical drain one and the surgical drain two is here. I'm not sure if you could see it. It's just above the diaphragm or like just like even between at the base of the diaphragm. Actually, if you can see it here, um, the patient has HP drug and it's, it's in the, uh, as if on sun, uh, on Thursday, the patient has output fluid of 1 L. OK. Then the next day, the patient has output of 200 mL. Wow, that's great. That's fantastic. But the patient has HP drop. OK. Where's the blood come? We did an X ray. Anyone can see anything in the X ray. Someone said a pacification on the right side. Yes. Actually, uh this uh this drain was blocked by uh blood clot and um this is ossification. The right side was a small here and it's began be larger and larger and this is was hematoma uh or hemothorax. We sent uh we went to the theater, we cleared out things to check if there is any actual active bleeding points. Maybe just it was uh actually it was just uh oozing from all over the, the, the place and of uh the lung and chest wall and cleaned out things, put under drains and uh support the patients. OK? Anyone can come to this patient. There is 12 or three things I need you to comment on it. Aequs, not yet. For me, I saw four findings until now d or trachea, um opacity and chest strain and then query air fluid level. OK? And the 51. Yeah, you get it all. Uh Let let us go to the, all of the airway airway division of the, of the trachea. Yes, there is. Uh we deviated but then coming centralized. OK? But the left lung is not uh it's, it's OK. So it's not, there's no like uh fluid here or air here to push this. So this deviation, traction from this opacity from the inflammation. Ok. This is pulling effect, not pushing effect. OK. This is the deviation of the trachea. The first things that we are uh that's right opacity on this lower zone. Uh just to be aware, this is all the lower lobe, the patient had upper bilobectomy, the upper lobe and middle lobe removed and this is the whole upper lobe. Then the patient after a couple of weeks came with COVID. So this is like scarring, POSTOP and scarring from the COVID itself. OK. Drain in a place because there's air leak, air fluid levels outside the cost of angle is not free. This is the cost of angle. And what else? We've also got someone saying fibrosis. So this is the obesity. OK. We said ABC is the pulling effect. Also look at the heart, it's like more pulse. OK? D I can't see any fracture above the D there is something above the D. Look at this. All of this. All of this. The patient has a surgical emphysema. This is the air under the skin. Look how bad is it. And if you see the patient, if you see the patient clinic, this breast is much, much, much larger than this one. But because uh we are seeing this is an an AP uh RR pa a Coronal section, not sagittal. If you're seeing from the side, you will see a, a very big breast. So the patient has a surgical emphysema. Uh Why is this? Because it's the catheter stayed for more than two weeks. And uh the amount of fluid produced amount of the air produced from the lung is more than the drain itself. So it will find a place in between. And this is the, the, the drains usually chest drains, abdominal drains, JFA drains, whatever are they are and they, they, they are a plastic, the body cannot accommodate it, they cannot stuck with it. So you, you will find later on s um space a small space between each drain or like leakage between the drain and the, the, the skin. So the air will you uh like uh escaped under the subcutaneous tissue and caused all of this subcutaneous emphysema. Usually what we do with this, with this patient. I know it's uh uh something your specialty to do. We some increase the suction to let the uh drain accommodate the amount of air is produced by the lung. So uh this is will decrease. Some people like to put, stick a knife on the skin, put a vacuum dressing. So all the air under the subcutaneous uh subcutaneous tissue will be evacuated if it, it's, it depends on the consultant or if he's like to be more aggressive or just wait and see. Ok. Anyone can comment on this. This is the last one. Air under the diaphragm. Ok. And then someone said, biggest bully or biggest bully? Ok. So to be honest, I, this pa this is, I get it from the Google. I did, I didn't know exactly, uh, what's the clinic? What's the clinical picture of this patient? But it's on the diaphragm. That's right. What's, uh, usually if you see air on the diaphragm on the left side, what is exactly? Ok. Usually diaphragm is, uh, like the gastric pulp on the left side in the fundus. Ok. And the right side, do you, you don't need to see a diaphragm. It's pneumoperitoneum. So this patient has an, a large, large gastric pulp pushing the uh the diaphragm. This is the diaphragm actually, this is the lung and this is we here in the ab we are in the abdomen. This is called evisceration of the diaphragm. The diaphragm is very laxed, very stretched and the abdomen is pushing the, the, the bowel and things you can some, sometimes you find can spleen here pushing uh uh upwards. So you'll, this, this patient will have some distress. Usually old patients uh if they have a trauma to, to the uh to nerve uh a long term one, so they will can cause this was the treatment of this either from up or down. It's easier to do it from up. We go through here, put an uh pushing the diaphragm down there and stitch it like plication of the, of the diaphragm. Some people like do it from uh the abdomen. Uh but it's like a lot of stuff in the abdomen. So you need to pull them a lot. The here is just the lung. You can just push it away and pull the diaphragm down. Uh Anyone has any question? It's actually 6 to uh 6 past eight. We had one question from before which was um if you could explain a bit more about atelectasis, OK? Atelectases. OK. Oh I, as a picture of atelectases, we can see, OK. This one, this is the line of the lactoses. OK. The lung is are multiple numerous balloons. So when one of when you are not breathing well, so usually cause the basal axis, not in the epical heart, the basal axis. So use these uh small collapsed uh alveoli. Usually if the patient has a pain, usually POSTOP not bleeding, well, have some an lactoses on the basal side and it caused a fever due to due to the body reaction that does not need an antibiotic. Usually in day one, it's the why the lung is uh blackish than the other tissues because there is air inside. Would you see the white line? Uh the white lines because this alveoli does not have an air inside or very mini minimal amount. So we like a a small collapse one or with little bit collection of fluid inside this alvelius physical therapy, pain control, make the patient breathe well and open opening the uh these at the, this uh small alvei and the hylax will go. It may increase to the infection. It may because more pain, less, less inspiration, more fluid collection inside those um albu and then will cause the uh causing infection in another dilemma. Ok. Thank you so much, Ahmed for uh your presentation. Uh Thank you so much, everyone for attending. Um We will be back next week on Thursday, hopefully, maybe Friday, uh, potentially the week after. Ok. Um As, as always, I'll hang back for a little bit if you've got any questions, but otherwise please fill in the feedback form that'd be greatly appreciated. And then you can get your certificate and claim it for non-core hours if you're a UK trainee. Um, thank you so much, um, again to Ahmed and I hope everyone's learned something today. I hope so and thank you so much. Uh, to be honest, one, direct feedback. Uh, I would like things to be a direct feedback from the audience to make it more, um, non boring or like if anyone has, uh, I to say or, uh, to answer directly. Uh, but otherwise you try to help as much as you can with this. Uh, I can share this after it's for you. I, uh, I can send the email, I send you this email, the, um, the presentation so you can share it to anyone. Yeah, we will, um, uh, share the recording as well. Ahmed. Sound good. Yeah, it's fine. And if anyone would like any case of those, uh he needs the the hospital number, I'm happy to give it to him. So he just contact me if he wants like more thorough or like serial um imaging or the ct of the lung uh collapse one and I'm happy to give it so. Yeah. Thank you so much for this opportunity and I hope I not boring and beneficial to you. Thank you. Thank you.