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This. Ok. Fantastic. So we've got some viewers that are written now. Um So we can go ahead and start. Hi, everyone. My name is Suleiman. I'm one of the f two doctors. I, along with my colleagues, um, Aidan and Bush, um, we've put together this teaching series called Radiology and Focus. And um the idea is um just um we are junior doctors and we've designed um teaching in radiology for junior doctors um across three months. Um So it's going to be across August, September and October. Um And I'm sure you've seen the posters and you followed our page as well. That will tell you about all our events that are happening today's events, um is on um chest x-ray interpretation and we have Doctor Usman Janjua, um who's joining us and he's a radiology registrar and ST four. So without further ado, I'll let him take over apologies. His video isn't working, but he'll be able to share the slides and explain everything to you if you have any comments, um, they'll be answered at the end um of the um presentation, but feel free just to pop them in the chat box. Ok. Thank you? Hello everyone. Uh Yeah, said I'm, I'm one of the radiology registers. I'm based in Western Scotland. So just going to uh talk about chest X ray interpretation. So like was saying uh if can have questions at the end, but there will be some interaction in between. So I might just ask. So um yeah, feel free to chime in about those points. So today, what we're gonna try and do is recap systematic uh a systematic approach to interpreting a chest x-ray, reviewing image quality and what things you should be looking for, recognizing chest anatomy on a chest x-ray. So things like, you know, lung, lung fields, lines, uh heart go through some pathology as well. So consolidation collapse, edema, COPD, fibrosis and pneumothoraces and then support line or support apparatus checks and some complications with that. I, I believe you guys are all sort of junior doctor level as well. So I'll try and get on to the pathology bit because that will probably be more interesting and more relevant to you guys. So um just a re quick recap of approaching a chest x-ray, things that you would have done in medical school. So have an ABC D approach. Um So that includes airway to look at the trachea, uh the carina. So where the trachea bifurcates that splits the hilar breathing. So look at lungs, look at the pleura, so look around the edge of the lungs and look at some review area which I'll go into in a minute cardiomed. So that's see. So look at the heart size and borders, um anything on a pa chest x-ray. So, uh I'll come on to what, how you do pa A P and all of that, but anything on a pa chest x-ray, if your heart size ratio is more than 50% then it's enlarged. But that depends on the quality of the x-ray as well. And then D is looking at the diaphragm. So look below the diaphragm for free gas or any other sort of abnormalities. You can sometimes find medical devices there um and then ease for everything else. So always look at the bones. So not just the ribs, look at the shoulders, look at the clavicles, look for, look at the breast tissue as well. If it's a female patient, um look to see if there's symmetry in the breast as well. So some, you know, if a patient has had a mastectomy, you'll notice a difference um foreign bodies as well, such as support devices, clothing, you'll be very surprised to see how many hair bubbles and whatnot you'll see. So it's always good to keep an eye out and just have a systematic approach when you're looking at a chest x-ray, if you're presenting any chest x-rays start with an obvious abnormality. So see if, if you see a consolidation, talk about the consolidation and then try and go through the rest of your ABC D approach, you don't see anything obvious, just go through the ABC approach. The idea is to acknowledge obvious, don't miss any other relevant findings. And that's kind of true to every other sort of modality with um radiology as well. So as I mentioned earlier, um couple of review areas that you should really focus on, uh they're really easy to miss. So it's always like, have a conscious effort and looking at these are the lung A P CS, you can find all sorts of things such as subtle pneumothoraces, cancers, whatnot, the retrocardiac area. So that's the yellow circle, um certain types of consolidation. So certain lobar consolidations or masses can be there or even hiatus, hernias, you can sometimes see an air fluid level at that level, but we'll come to some of the a little bit later and then like I mentioned earlier below the diaphragm. So look for free gas there. So just talking about image quality. So as I mentioned, there's two really main ways that you take a chest x-ray. So A P A which is pretty much what we call the gold standard of taking. One is where the patient foot stands upright. So it's an erect chest x-ray and the x-ray beams are shot from behind the patient. Um So that's the ideal way that you wanna do it, but you don't always get the opportunity to do that because you know, patients might be lying down. So or you know, they just can't tolerate it if they're on a wheelchair, for example. So the other projection is A P um The reason why it's important as well is on pa chest xrays where, how you would accurately measure the heart size. Whereas in the A P, the heart size can be artificially enlarged and I'll show you a picture and you can sort of see, get a representation on that. Um But as you can see on this picture that I'm showing you the heart is closer to the x-ray beams. Um So therefore, that's why there's an artificial sort of enlargement that you see. Um One thing to note on A P is um you should not comment on any borderline enlarged heart on an A P projection. If it's grossly enlarged, then fine. But if it's borderline, it's best not to comment on it. Last thing just before I move on to the next slide is all Pss x-ray is done standing up, but A P can be done standing up or lying flat and that has important consequences for certain image findings. But I'll show you some of those in a bit. So as I mentioned on the left, you can see the cardiothoracic ratio. So the way you do that is you measure if you see that blue arrow, so you measure the widest point of the heart and you measure, you compare that to the widest point between the left and right rib and lungs. So once you do that, uh you, you wanna see what the ratio is. So anything below 50% on a pa chest x-ray as normal as I mentioned. But as you can see between these two pictures, the A P is like a 0.1 increase in the ratio between A PA and an A P. So it's quite a significant difference which is why you should, shouldn't really comment on it. The other thing that you can know is the scapula is also more prominent on the A P as well. So a couple more things on image quality. So we talked about projection. So the other three things I would mention are or think about are I use the acronym R IP um bit morbid that kind of uh fits in. So rotation. So you're looking at the spinous processes. So in that middle picture that you can see there, um you want to look at the spinous processes and how they compare to the they should be in the middle and compa when you're comparing them to the medial end of the clavicles inspiration. So on a PST x-ray, it's about 5 to 7 anterior ribs. So if you look at that far, right image and you can see the anterior ribs are the the ones that are curving because you, you remember if you're taking your ribs anteriorly curve, so you should see between 5 to 7 and they should intersect that midclavicular line as well and penetration as well is looking at the spine behind the heart. So these are three things you should also keep in mind as well. So that was just a quick recap er, of some of the things that you should like in terms of presenting what things to look out for and er image quality. So move on to a bit of anatomy here. So, on a pa projection, you can see how there's the way the lung lobes are there as well. But on a chest x-ray, you're getting a two D representation of a 3D structure. So whenever you're describing any sort of pathology or like you or where something is, it's better to describe it in zones. So you can, as you can see there, it's really just divide it into upper zones, mid zones and lower zones where you get some, for example, if you're getting a pacification. So if something's a bit quite bright on one area that can indicate or if you've got a zone of pathology, you can indicate what lobe is involved or what part of what anatomy is involved. But I'll come on to some of those things later. But yeah, whenever you're describing anything, try and think of it on a chest x-ray, think of things as long zones rather than lobes, to be honest. Uh we rarely do lateral projections. So um usually the main sort of reasons is to sort of confirm pacemaker lead placements or sometimes if you're not really sure about like some local pathology, but it's quite rare that we do that. So, moving on to some anatomical lines. Um So here's some of the sort of normal cardiomed contours and some of the lines I'll come go through some of these as well. But as you can see, you've got the right heart border, left heart border as described there, you've got the descending aorta sort of going behind the heart as well. Um You've got a couple of knuckle aortic, knuckle aortic po window, the paratracheal stripe. So these are a couple of things, you should just keep an eye out, but the contours are created by the difference in density of the anatomical structures. So between like gas and something that's a bit soft, soft tissue. So anything that's a bit more dense, it can be brighter than xrays. That's probably that. So visibility of all of these lines and areas depends on technical factors. So if something, if an x-ray is rotated, that can skew what you're looking at or it could be pathology. So keep these areas in mind whenever you're looking at an x-ray. So couple of uh important lines to think about are so the first one I'm gonna go through is what we call the anterior junctional line. So it just sits below the cream as you can see there. And it's essentially the result of the parietal and visceral lump pleura meeting anteriorly and medially. So as you can see on the CT there, so it's essentially just a line where the two bits of lung meet, uh bits of pleura meets, right. Uh usually just contains a bit of fat more than anything else. And it's variable thickness depending on the patients. Uh especially if, if this patients quite uh fat, then there can be a lot of fat there as well. But the reason why it's a really important structure to think about is if you can't see that line properly, it usually indicates there's an anterior mediastinal mass. Um So things I don't know if you guys have ever heard of the terrible fives. So teratoma, thymus, thyroid, um disrupted thoracic aortas and terrible lymphoma. Um The these sort of things can impact the uh anterior junctional line. But essentially, as you can see that it runs obliquely across the upper two thirds of the sternum. Um and doesn't really go down past the mane joint super. So that's anterior. So we've got the posterior junctional line which is higher up. Um and that's formed by the pleocytosis posteriorly essentially. Um And it's adjacent structures are gonna be the Zygo vein as you can see. Um and the esophagus and whatnot. So, essentially, um if you've got disruption of that line, um it's usually posterior medias are the masses that are gonna cause it, things like esophageal malignancy, uh enlarged lymph nodes, um aortic disease as well. And some neurogenic diseases and sometimes you can get register goiters that can disrupt it as well. So usually, as you can see on x-ray, it's like a thin line that's higher up from the carrier. Um So remember, anterior junction line goes goes inferiorly below the creer where uh posterior junction line is higher. So here's, here's an it image that just basically shows a representation of that. So the blue line is the um anterior junctional line, red line is uh posterior. So as you show on the initial images of the lines that I was showing you paratracheal stripe, particularly on the right side, um is also an important line to think about. And it's essentially just a bit of tissue between the lung and the media sign in there. Um Obliteration of this line is really important. So it can be sort of cancers and whatnot. So you should always keep an eye on that. Um Just to make sure that line is visible and you can see the celiac between the lung and that paratracheal stripe on a PST x-ray, you shouldn't be more than 2 to 3 millimeters if it's more than that and it's not rotated or anything like that, you should, you should be thinking about pathology or should alarm bells should be ringing in your mind. So one of the last few lines I'm just gonna quickly go through is the Zygo esophageal line. So essentially, it's just, it's almost like a space actually the top behind the heart. Um and it's encapsulated by the esophagus and the Zygo vein as well. Um It's pretty much pre verbal space here on the actual ct as you can see, it's just that space there. Um deviation of that line on the chest x-ray could be either middle or posterior, mid side. It's almost similar to what we were seeing with the posterior uh junction, the line as well, but because it's slightly lower down, um and it's next to the heart. So you should think about heart left atrial heart enlargement, uh sub lymphadenopathy. Um if there's anything in the esophagus as well, that can cause it. Um any sort of bronchogenic cysts and hiatus, hernias can also disrupt it. So just moving on, we're gonna go to some heart and mediastinal anatomy as well. So this is just a quick recap of how blood moves through and sort of the anatomy on a, on a chest x-ray. So just going to go to the right side first. So you've got the superior infe vena cava, as you see in that far left image they meet at the right atrium. Um And then you've got deoxygenated blood going through into the right atrium. This is pumped out into the right ventricle via the tricuspid valve. And then from the right ventricle, it's pumped out um into the respective pulmonary veins um through the pul uh valve there and then essentially one second sorry. Um Yeah. And then as you can see, yeah, it's pumped out into the p the uh sorry palm of the arteries, not ply veins. And so this is important because uh the space between the particularly the left p the artery and the aortic knuckle. So I'll show you that earlier. Images go back a second. This aortic poly windows. Yeah, as you can see on the left side, um if you get disruption there, it's also not an important place to look for enlarged lymph nodes or malignancy or aortic disease as well come back. Um So that's the right side. So going through the left side, as you guys know, oxygenated blood enters the left atrium um through the four pulmonary veins. Um and the left atrium and ventricle is separated by the mitral valve. Oxygenated blood is pumped into the body via the uh aorta and it goes past the aortic valve. Um Just note that the left ventricle is lower down on the left. All right. Um Probably the most the thing that you probably don't see too much of um at med school, which actually is important is trying to think of where the valves are on the chest x-ray. Um So the best way I would say is try and draw an bleak line, intersecting the and I imagine line there. So you can imagine it or going across between the atria, dividing the atria and the ventricles. So anything above and superior is going to be palm and aortic valves. Anything below is going to be mitral and tricuspid valves. Um Usually the one that's the most, the one that you can see the ring, most face on is gonna be a mitral valve as you can see there. So this is just kind of uh recapping all of that together as you can see. So, but when you're looking at a chest x-ray, trying to imagine these structures here. Um Yeah, so that was kind of recapping sort of the normal anatomy and whatnot, but we'll move on to some pathology now. So we'll start off with consolidation. Um Essentially, airspaces are consolidation is just air filling of air spaces with multiple things, but usually it's gonna be fluids, pus, blood or tumor. And what you get is loss of the normal silhouette sign. So you lose the sort of difference between the, the lung. Uh You lose essentially lose the sort of definition of the lung. Uh And you can see air bronch which show you now. Um But as I was mentioned about silhouette. So essentially, it's just as I was describing, it's the radiographic densities, uh the difference in radiographic densities of structures that lie together. So you can see that. So example, like the heart and the adjacent lung. So talking about consolidation, as you can see here, um as you mentioned, when the airspace is filled with alveoli and the air pacify, uh it becomes dense, you lose that interface between the lung. Uh or because of that, you can't really see the lung that well. However, because it's so dense, you can actually make out the bronchi. So that's what an air bron is. Um So as you can see in those images there, you can see the dense consolidation and you can see the air bronch. Um So you can see the bronchi just tracing through um and consolidation could be pneumonia, it could be edema. As you mentioned, there could be tumor sometimes you don't know, but it's all about clinical context and history. So, as I was mentioning with pneumonias, key things you want to look out for are cavitation. Um So if there's, if it's forming the ring and there's like, you know, there's gas fluid levels, for example, if there's effusions as well and if there's actually resolution after treatment and that's really important. Um So, for example, uh on the scalp view of AC T here, you can see there's consolidation in the left low lobe. But um is it actually infection or not? I don't know. So, um patient had essentially was given a follow up. X-ray didn't clear up after having treatment, they had a CT uh still looked the same. So they did a biopsy and it showed it was an adenocarcinoma. Um So it's really important to think about have that in the back of your mind. But if you're not sure you can do. So if you the clinical context or the clinic history doesn't really fit, you can always do a repeat chest x-ray following appropriate treatment such as antibiotics, have them resolved, get a CT and you can take it from there. So speaking of like um consolidation and sort of collapses and whatnot, that's the next thing I'm gonna talk about. So quick note as sometimes you, you hear these terms collapse and at Alexis, um essentially, they are pretty much the same thing. They just refer to an incomplete expansion of lung parenchyma. So usually the terms are kind of used interchangeably, but some people prefer to use the terms to kind of describe a spectrum. So, atelectasis is more describing smaller areas of incomplete expansion. So like it might be a small sub of a lobe that's just collapsed. Um But some people call that as partial collapse. So it can be confusing or sometimes people prefer to use collapse more to describe er larger areas. So it might be a low bar collapse from Loar at Leis. Um But as you can see there, those pathologies can cause a collapse of A P Leis. So consolidation as we saw tumors that clog up the airways and compress or can externally compress pleural space pathologies like effusions, pneum, and fibrosis which scar the lung and stop it from expanding and pull on it as well. Essentially, anything that stops your airways or lungs from moving. Essentially. So just gonna to touch on the segmental areas of collapse. And it's kind of touching on what I was talking about earlier in terms of um zones and certain area, certain pathologies can sort of help you pinpoint what lobe is affected. So we'll start with upper lobe uh collapse. So as you can see here, um the upper lobe on a frontal chest x-ray takes up quite a lot of space. And uh on the lateral, you can see it's separated by the late fissure. Um but on the frontal x, so you predominantly what face on, that's what you're seeing. So left upper lobe collapse, uh when it does collapse, as you can see, it goes anteriorly. So that's the orange lines on that left image there. Um And consequently, on the frontal radiograph, you can see it's almost like the left side is a bit more hazy and what we call veil like just because it's collapsed and it's causing, it looks a bit more dense in that area just because the tissue is compacted together the lung tissue that is um and you can see that, that dotted blue line there, there's loss of the left heart board and the mediastinal contour. Other thing is you can see that the, the left hemidiaphragm is raised when it shouldn't er usually the right one is more raised than the left. And that's because if you imagine the collapse, that area is uh now need to be, needs to be filled up. So that left he diaphragm is pulled up as a result. So we got left up, that was left upper and left. This is the left lower. So as you can see on the frontal x-ray, it's that tiny little triangle area that you can really make up the left lower lobe on a frontal x-ray. But as you can see, there's quite a bit of space spot underneath or inferior to the oblique fish on the left. So um one whenever you get left low lo collapse, um as I was mentioning earlier, right at the start is think about looking behind the heart as a review area because with left lower lobe collapse, you can't, as you can see there, you can't really make out the behind the heart as well. And it's something called what we call the sail sign. So that's that dotted blue line in the middle image there. Um So it's almost you can't see behind the heart and um it's more pacified there as well. So sometimes if it's not completely collapsed or there's a little bit of lung lower of the lung still remaining. Um You can get what you call a double lung, heart contour. So those are the on the far right image, the red arrow as you can see like the heart contour is a bit more lateral and you can see it's a bit more defined whereas just me where the red arrow heads are pointing to, that's where the actual collapse is. So it's always worth just looking behind the heart if your ST for collapse of the lower left lower lobe, uh this is just a tool, lateral view of that as well. Just to give you an idea of what you're seeing. So you can see the um with left low lo collapse as well, it's projected, it's displaced posteriorly as well as you can see whether there's orange arrows. Um Yeah. Um This is sort of ct representation of that. So you can see on the CT, obviously, it's a lot more clearer, but the extent of that is if you can see it's behind the heart, um It's that triangular opacity um behind the heart there as well. So, moving on to the, that's all the left side done gonna move on to the right side now. So, um you can see again similar to the uh left side, the right um upper lobe takes up a fair bit but less. So because you've got the middle lobe um that's covering there, which we'll, we'll come into in a minute. But yeah, so I, so as you can see here um with the right upper lobe collapse, um you can see that that right, upper zone is really opacified um and it's quite dense compared to the left. Um And you can see that on the CT as well, there's something called what we call the golden S sign. Um I have got another image of it which I'll show you, but essentially the outer bit of that consoled or collapsed, it creates, er, you can see there's demarcation on, there's the silly weather there. Um what we call the golden S but I will show you an image of that. So here we go. So in this case, um there's a, there's right upper lobe collapse, but as you can see where that ringed dotted orange area is on the far right image, um There's a mass that's blocking the bronchi, right upper lo bronchi there. And the that dotted blue line on the right is what is the golden s line that you're looking for? Um All right, so that was up, right up lobe, gonna go on to right middle lobe. So as you can see there, the right middle lobe covers a fair bit of space. Um So main things to think about whenever you see a right middle collapse is the loss of the right heart border contour. So it's the dotted blue line that you're looking for. So if you lose that, think about right middle lobe collapse. However, one thing I would say is um look at the patient's ribs as well. Um because if the patient's got pectus excavatum, so that's what, you know, like pigeon chest, the right heart border can be lost. So it can mimic a right middle lobe collapse. Um But the way you can sort of differentiate is obviously if you know the patient that's fine. But if you're just looking at a chest x-ray, look at the ribs if the posterior ribs are very horizontal and the and when the anterior bits curve uh thing, if it looks like a seven, so remember poster flat and it curves uh anteriorly and it looks like a seven think about uh pectus excavatum, especially if they haven't got a history of any sort of chest infection as well. So this is just the lateral view as you can see here. Um Just to give you an idea of what the uh the right middle lobe collapse looks like. Um if you're looking on the lateral, but you probably will get a CT at that point. Um And finally, of the collapses, we've got a right lower lobe. So you can see there's that triangular er blue area in the bottom right corner near the costophrenic angle on frontal, but just like on the left side, it covers a fair bit of space. So when you get right low lo collapse, um you get a triangular opacity that curves up as you can see without that orange um line there and you get lose the contouring of the right hemidiaphragm. So there's blue dotted lines. Um sometimes you get um shift of the media signum as well and trache to the right. Um And you can get elevation just like on the left side as well just because you're losing space. And this is just the lateral view as you can see here. So you can see there's collapse and uh densification where there's orange arrows are. So just come, this is just to give you a bit more of a another of the right lower lobe collapse. Um just wasn't made particularly clear on the other one. Um You can see that there's dense consolidation on that right lower zone and there's just loss of that right heart border uh right contour there. So, so yeah, we'll move on to acute pulmonary edema. Um So once you get a poorly functioning heart, um there's back pressure that causes the blood vessels to dilate and then you get fluid that leaks out into different spaces. So the main sort of spaces you're gonna get are interstitial spaces. So that's what we call, you know, the curly B line. So they'll be horizontal to the rest of the vascular markings. You can get Frank Pulmono edema. So it looks like it's consolidation essentially. Um But the distribution of it is what kind of points you to more of a um p edema rather than an infected course. Um And also you get that pressure into the vessels. So you get what they call azygos or sorry, not a, you get um phal is what they call. So the you'll see what they call a, a Aler sign as well, but I'll show you some pictures. So, so here as you can see in this patient. Um Does anyone wanna shout out what they see or I don't know if you can chat but um just tell me where you can see, you can pop it in the chat box, right? OK. I don't see any chats so I'll, I'll just crack on. Um, so you can see there's dense consolidation on that chest x-ray on the right uh left. Oh, that was a question. Blunting of the cross phrenic angle. Uh Let's have a look. I probably wouldn't, I mean, it's probably hard to see just because we haven't got to the bottom of that image. I, I probably wouldn't say there's blunting there. I think it's just the image is cut off. Um Yeah, I would say there's lots of patchy consolidation. But where is the consolidation? What is it more central or is it more peripheral? I think the CT probably gives you a clue. I think on the che chest x-ray probably is a bit more, it looks more like it's right, middle zone. Um But actually, I would say it's probably right if there's some on the right upper zone, middle zone and low zone uh on that chest x-ray. Um And then on the CT, you can actually see comfort on the, on both sides. I think the reason why you probably can't see it on that, on that x-ray there is there's a bit of rotation. So you can't really see the left central consolidation as well just because it's rotated. So the right side is a bit more prominent. But if you squint a little bit, I, I do promise you, you can make it out. It's probably just a bit hard to see. Right, just coming on to upper lobe venous diversion, um, or Phal as it's called. Um, so if you get a playing radio golf in an upright position, as we were saying earlier, cardiomegaly on a pa if it's greater than 0.5 on uh on a good quality EPA, then you should be thinking about um cardiomegaly and you should be looking at the upper lobar veins um if they're at least as prominent as the low lower lobar veins um and in an appropriate clinical context. So, you know, if you're thinking it's heart failure, then you should be thinking about um venous diversion. So, on the x-ray, you can see that the upper the veins are sort of the upper lobar veins are quite dense and it's what we call the Aloin as I was mentioning earlier. So it's usually an earlier sign of palm edema rather than later. Um And then as I mentioned earlier, so you got curly bee line on the left, the image there is a normal lung, you can see the vascular markings sort of sc in and around the lung, you know, they're not like in a horizontal line. Whereas on the right that image, they're kind of perpendicular to the vascular markings there. So if you're seeing that always look at the peripheral view of the lung or the peripheral bits of the lung for curly bee lines and they're suggestive of just basically fluid leaking into that interstitial space. So, yeah, just to give you a bit more of an idea. And on the CT, you can see the interstitial lines of the spaces there are quite thickened. Uh It's just fluid just leaking in, leaking out. Uh Yeah. So just this is just another ct of uh upper lobe venous diversion. But you can see on an axial ct here. So you can see the upper lobe venous uh veins are quite dense there. Um So like you were saying, it's just early sign of pulmonary edema. So, uh the other thing to look for is as we saw on that earlier x-ray was sort of the consolidation that we were seeing that's more central and it's perihilar as you can see. So those red a kind of give you an indication. So on the left, it's back to normal. On the right, you can just see it's harder to make up the the upper lobe venous veins compared to the lower lobe venous veins, uh pulmonary veins, sorry. And you can see that there's just a bit more pacification, it's a bit more dense than that you can see on the right. There's that what we call back winging or dense consolidation, that's just in and around the hilum. So it's much more central. So if you're seeing it both, both sides and it's more central. Think about palm edema rather infection. Um Like you, like I show you here, you can see that there's that perihilar ba wick back wing consolidation. So that was P edema. We're gonna go on to COPD. So can anyone shout out what the, what you can see on this x-ray compared to what we were seeing on a normal x-ray? Yeah. Flattened diaphragm, barrel chest. Yeah, hyphenated chest. Um Yeah. So on the CT A, you can see the bulla. Yeah. So you guys are all right, well done. Um Some sort of main things are you're looking for that flat and height came down from like you're saying, there's a lo increased lucency of the lung as well compared to a normal x-ray. Um And on the CT, you can see there's bullous changes as well. Um But when you're thinking about what constitutes hyperinflation as well, if there's more than six anterior or 10 posterior ribs above the level of the diaphragm in the mid of the line, think about um hyperinflation. So to give you an idea what that looks like. Yeah. So you can see if you're counting the ribs, there's more than 11 that go past the midclavicular line here. So you can see it's quite hyperinflated. Um You can see it like as we were mentioning, is flattened hemi diaphragms. So, uh next up is uh pulmonary fibrosis. So anyone wanna shout out what they can see on these images? So, if you start off, uh in fact, yeah, start off with both, both of them. What do you see? Yeah. Well done. Yeah, definitely diff articulations. So on the left, it's probably more subtle than it is on the right. It's on the left. You can just see the long markings just low, quite, um, quite prominent and they're just widespread. There's no sort of zonal sort of area. So there's nothing in the right left. So that's kind of diffuse. You can get zonal areas, zonal fibrosis. I'm not gonna really go into that. It's more of a like radiology exam sort of thing, but just try and look for the thickened lines as well. Sometimes it can be really hard depending on like you say on the project. So just keep it in mind. But that image on the right, you can make out the reticulations um a bit more. So someone mentioned that there's consolidation. So sometimes it's quite hard to wake, work out if it is consolidation or not. Um So the one thing I would always say is if you're not sure this, this is a radiology tip for everyone look at previous imaging because if it's, if it is something that's new and look at the time frame as well and the history. So if they're coming in with like Pyrexia and whatnot and they've had x-rays and there's something new, it could be a superimposed infection or an infection on top of the fibrosis. But on that right image, um I probably wouldn't, I mean, it's hard to say without a previous x-ray, but one thing to make out is the heart outline is quite shaggy. Um So it's quite fuzzy looking. Um And there's just diffuse coarse lung markings all over. So she's in keeping with fibrosis. Um But yeah, if you're not sure, try and look at previous x-rays as well and look at, take the history into account if you're thinking about consolidation, you probably see in reports when you do practice, if you have seen them is superimposed, infection cannot be excluded. So it's classical like, so going on ti pleural effusions. Uh One thing to know is just the two pleural layers that you've got. So you've got the parietal pleura, which is the pleura that attaches to the chest wall. And you've got the visceral pleura that's attached to the lung edge. So anything that goes into that space is going to cause compression and can collapse the lung. So, effusions, new authorities and whatnot. So as you can see here, there's just a sort of schematic diagram of an effusion um in that space. So this x-ray is just to kind of give you an idea of areas that you should be looking for. Uh I can see your question there. Um I'll answer that question now, actually, um, it depends on the history that they can do. Uh, and the, yeah, it depends on the history, to be honest with you in terms of reticulations. Um, but yeah, if you've got, in terms of COPD then, yeah, usually it's more permanent and it's more progressed COPD changes. Um, if you, if you are seeing fibrosis than it is progressed, fibrosis, um, to be honest, II, I think ILD is probably a worse diagnosis than getting um and certain other things as well, just because it's so progressive and there's not really much in the way of treatment that you can do. It's just you can just sort of hold the for more than anything else. But yeah, coming back to this uh x-ray. Yeah. So in terms of fusions, main sort of area that you should look for for subtle fusions is the costophrenic angle, which is that dotted line there. So just keep an eye on that. So on this x-ray, you can see on the left, the red dotted line there's blunting. So you can see there's just that curving of the costophrenic angle, whereas on the right, you can see it just dips down, it makes that sort of triangular shape. Whereas on the right, uh on the left, you can't see that. So this is an effusion that's a bit more prominent and it's a bit more obvious. So you can see there's a meniscus there. So there's a fluid level. Um on this x-ray and that's just progressed. And as I was mentioning earlier, any a an effusion or anything in the pleural space can cause lung collapse. So it is something to bear in mind. So this is really important because I was mentioning earlier about w why it's, it's important to recognize pa and A P x-rays, particularly for certain pathologies and effusions is one of them. Um So when you're upright, if you imagine if you're standing upright, all the fluid is gonna sink to the as low as possible because of gravity. But if you're lying flat on your back, that fluid is just gonna go towards your back, isn't it? So the fluid is just gonna be distributed all across uh the back of your, your pleural space rather than all sinking to the bottom. So, as I, as I'm mentioning here on the li on this left side here, you can see there's that haziness um compared to the right. Um So you can see that the, the fusion just kind of redistributed and made that lung look a bit more hazy. So it, the one thing to bear in mind is, you know, as I was mentioning earlier about um upper lobe collapse, the reason why you get that is just because there's increased density. So it's a similar sort of uh imaging quality that you're getting here. It's just the effusion is just redistributed. So that's why there's an increase in density there Um So it's just something to bear in mind. So, always look at symmetry as well. Um And yeah, like as I was mentioning, yeah, this is just sort of give you that schematic diagram. So, does anyone want to shout out what they can see here? Yeah. Total. Yep. Both of you guys are, right? So there's collapse of that left lung. Yeah. Yeah. All you guys are right. So there's massive pleural effusion causing a white out. Um And there's tracheal deviation towards the right. Um So yeah, it's just something to bear in mind whenever you can get an infusion, it's big enough. Uh It's not, no, it's not a new uh neomy. Well, we don't know because of the history, but yeah, main thing like when you're looking at that is a massive effusion. So, so last sort of pathology we're gonna look at um is pneum. So just to recap again, that pleural space is between the parietal and visceral pleura. So anyone want to shout out what they see here? Yeah. So it's the left sided pneum thorax. And what, how do you, how can you tell? Yeah, exactly. There's lots of lung markings on that left side. So, on the right, you can see the bronchovascular markings on the left. It's completely lucent. Um Yeah. So just keep that in mind. This is on a PHS x-ray. Anyone want to tell me what they see here. So I said the pa the last one was a Phx x-ray. This is an A P Yeah, you're right. I uh I'll come to that question in a bit, but you're right about the right-sided pneumothorax. Why do you think there's a right-sided pneumothorax? Yeah, there's haziness as well. But why? Ok. Yeah. Why do you think the right side is hazy in the middle zone? Particularly on that right side? You whoever is Joshua, you're right about right sided pneumothorax. But does anyone remember this is an A P chest x-ray? Can anyone tell me why they think it is? Yeah. So you're right. It's loss of markings in the right low zone. But the reason why it's important that, that why I'm showing you guys this is because on a pa chest x-ray, you'll lose the lung markings more often than not, you'll see the loss of lung markings higher up. Whereas on a ap if you imagine someone who's supine or like lying flat that remember I was talking about redistribution with gas, um fluids, gas is kind of gonna be similar as well in this regard. So you can see on that right costophrenic angle, it's just way, way more deeper than it is on the left and that's just because the gas is just pooling there as well. So it's something called the um deep scal sign. So always whenever you're worried about a pneumo thinking about pneumothorax, always look at the projection. Um sort of give you an idea of where the Yeah, exactly guy could be. Supine. Yeah. Um Always think about the projection, right? And this is just to show you on the ct essentially what we're looking at. So you can see the, the left apical knee thorac is, is a different patient. Um Can anyone tell me what they see on this one also that uh if, if you could remind me about the fluid um effusions and differential diagnosis, um I'll just main thing is I'm not going to touch too much on that. But the main thing is if it's uh exudate or transudate, uh so it could be infected pus or it could be like like tumor and whatnot. So it depends on the clinical history as well. So you can, you can always take a fluid sample and work out from there. Um But yeah, so coming back onto the this, yeah, you guys are right. So it's all on the right side. There's a pneumothorax there. So spot on anything else that you see as well aside from the pneumothorax. Yeah. But why do you think the in terms of loss of the silhouette sign? Why do you think that might be? You're right. So right. I'll uh oh there we go. Yeah, there's a bit of Atis because if you pneumothorax is there, you're right. There's gonna be a bit of collapse and yes, spot on butcher um subcut emphysema. So remember we were talking about ABC D. So E is, look everywhere else. So look at outside of the lungs as well. So look at the soft tissue. So on that right side, you can see there's gas in that fat plane. Um So, I mean, we don't know if it's COPD or not. Um But yeah, you can see there's a bit of partial collapse but there's just subcutaneous emphysema there all tracking all over. So we don't know if there's just been a, if there's trauma or whatnot. So it's just something to look out for if you see subcutaneous emphysema and just be like, oh why, why is that and try and look at the media saa contours for gas in the me Stal spaces. So just a couple of more things in terms of new authorities look for tension. So that's displacement or deviation of the mediastinum, look for rib fractures because you're looking for something called flail ribs. So that's rib fractures in more, in three or more ribs, in two or more different places in those ribs. Um So if you've got a 10 flail rib, they can puncture the lung essentially or yeah, cause a puncture and cause a pneumothorax, sur surgical emphysema, as I mentioned. And so those are pathologies. So here's the support lines. Um I think pathology guys probably see a lot of that in terms of support lines. I I think depending on where you guys practice some, some of you will be expected to like sort of look at G checks overnight and whatnot if you're an FT or, and above um some will have to go to a senior and whatnot. So it's always just worth knowing, learning how to actually look for them. Er, it just depends on where you are but it's always just a good skill to have. So just coming on to s um main thing is to check that the NG passes vertically in the midline or near the midline and it goes below the level of the carina. Excuse me, what you can see it's that red ring on that image on the left. Um And it shouldn't go into any of the bronchi on the right or left. So it should just go vertically down as you can see there, cut across to the left um into the stump gastric space. And usually anywhere between 8 to 10 centimeters. 10 centimeters is the like gold standard area. But usually if you get it us, if it's six or 10 centimeters, it's fine as long as it's not close to the gastroesophageal junction, which is the that junction between the esophagus and the stomach. So right. So can, oh uh I'll come on to the sale sign. So I said I'll just quickly mention this. Um So the sale sign is essentially a indicates a left lower lo lobar collapse. So you get a triangular opacity behind the heart. So if you see a triangle opacity behind the heart it's indicative of a left lower lobar collapse and that's the sale sign. Um Right. So just starting coming back to the NG complications. Um So if we start from the image on the left and then work our way across. So can you anyone tell me what's wrong with the image on the left and what you would do? Yeah. Exactly. It's right. Bronchus. So, what, what would you do? You're at risk of aspiration. Yeah. Take it out. Exactly. Yeah, it needs. Exactly. So don't feed, take it out. All right. Second one, the middle image. Yeah, it's coiled. Exactly. So, same as before needs repositioning. Exactly. Yeah. And then the last image on the right. Push it a bit forward. Exactly. Yeah. So it's quite close to the, it is in the stomach but it's very close to the gastroesophageal junction. So it's quite easy for it to just be displaced and pulled back up. Um So it just needs, like you guys say, needs advancing. Yeah, exactly. Uh As David is saying there, right? So that's s um other thing is et checks, uh endotracheal tube checks. So ideally should be between T three and T four. So you count the sort of spinous process that's the easiest way to try and figure out what um where you are and it should be about 3 to 5 centimeters depending on the projection and the rotation, all of that image quality um from the creer. So it should lie above the Creer. Um, and you should see it between the two medial ends of the clavicles. So, try and use the spinous processes as kind of a guide if it's rotated. Um, if the E TT is too high, you won't get good aeration. If it's too low, it can cause some other complications. So, just like last time, um, if we start from the left and work our way across. So what's wrong with the tube on the left? Yeah, it's beyond the Creer. And where is it? It's, well, it's probably just at the Creer touching the right Bronchus. Um, so luckily the lungs are still aerated on both sides. Um, so there hasn't been any collapse yet but they're at risk of it. So, yeah, you'd have to pull it back up. Right. What about the middle image? Exactly. Yeah. Spot on Thomas. Er, well done. So, just like last time you'd wanna pull that up. Um, because you've blocked, essentially it's gone into the right Bronchus. So it's blocked off the la air is not getting through it or passing into the left main Bronchus. So you're getting collapse and then finally on the image on the right, uh not into the uh esophagus, not, not too high. This one's probably a bit more tricky. Um I'll give you a clue if you're going ABC de look at E, so if you look at just above the right clavicle, there's subcu emphysema. Yeah, Exactly. So what's happened is they probably, they probably put too much pressure through and cause rupture. Er, and there's essentially just perforation as well. Um So it's hard to make out on this image to be fair because it's quite small but there is a new movie to sign in. Um But yeah, so it's just be aware if you're seeing subcutaneous gas, even though the ET tube looks fairly. OK? Cause I think that positioning is actually looks OK just on the x-ray uh is projected, looks, it looks like you're projecting. OK. But there's subcutaneous gas and there's emphysema there as well. Uh subcutaneous emphysema, right? Uh just coming on central lines, there's different types of central lines. You can get, you can get picc lines that go peripherally into, into you. Um more centrally, you can get jugular lines, tunnel lines, all sorts. But the idea is that they, you, they should be going in normal a anatomy, they should be going down the SVC and they should light the tip or the end of the SVC just entering the right atrium. Um So on that image, there do a annotated point where the arrowhead is where the tip is. That's what we call the cava atrial junction. So where you can tell where that is is you look at where the pulmonary um where the hilar is and the pulmonary arteries at that level. So you can see them right next to it. So you should, if that is next to it, that's the atrial junction, that's kind of the level that you want. So anyone tell me what they can see you here. Yeah, exactly. Pneumothorax. So what's happened is they've puncture through the vein, hit and hit the pleural space and cause a pneumothorax. Yeah. Spot. So, just because we're, we're coming to the end. So this is just some other complications that you should be thinking about. Um if you've got a left side in the internal juggle line, um if it's too short and if it's in the left brachiocephalic vein, you can get uh it is advancing uh for the previous one you said, yeah, I would say it's probably too short. You're right. I think it's probably too high up as well. Swan. Um But yeah, coming on to some of the other complications. Uh So if it's too short as you can see there, it, you know, need advancing if it's too far in, um it can cause dysrhythmias, particularly if it's contacting the sort of a VN and whatnot. So that's why you don't want to push a central lining too far. So you want to try and get it in that sweet spot of the K atrial junction and then finally, yeah, you wanna make sure it's actually going in the right vessel and not just going in completely the opposite way. So if the catheter tip is like completely off, um it that needs reciting uh urgently. So uh that's the end of the talk. So just a summary gone through systematic approach a to e approach, thinking about image quality checks. So projection rotation, inspiration, penetration, um uh chest anatomy as well. So the lung zones, whenever you're looking at a chest x-ray, remember it's a two D image of a 3D structure. So think about lung zones and divide the lungs into thirds when you look at a chest x-ray to describe it, some of the lines. So like we were talking about paratracheal stripe poly window, uh junctional lines, uh cardio ano contours where the valves are, you know, where the sort of blood have the blood flow and whatnot. Think about those sort of things, pathologies that we went through consolidation, collapse, edema, COPD fibrosis and no th and then just some support line checks, uh NG ST CVC S and the complications, right? Thank you very much. Uh Any questions. Uh Yeah. So what thoracic foreign bodies and devices compromise chest x-ray quality? Um When you say chest x-ray quality, do you mean like the projection whatnot? I, I guess probably the main ones I would say if you've got things like um pacemakers and whatnot, I didn't cover it here. But um if pacemakers they sit in the subcutaneous tissue point in the anterior chest wall generally, so you can't see what's behind them. Um So that can impact what you're looking at. Um So you wanted to try and, but the one thing I, I haven't mentioned is look at the leads as well, make sure the pacemaker leads are in the right place. Um It's probably in the whole other topic as well for that. So I don't want to try and get, get too much into it. So I'd say things like pacemakers if you're talking about on the patient as well, things like hair clips and whatnot if they've got even nipple. Um What do they call them piercings and whatnot? So, yeah, essentially tho those can cause artifact anything that's high density, it can block your view of the lungs, can, can uh preclude your assessment. Um But if you're talking about how do they affect your choice of image modality? I mean, it depends on what you're looking for in terms of pathology. If you're looking at a chest like infection still worth doing an x-ray, it's a quick, easy test to do. If you can get the answer in an x-ray, then you're saving the patient radiation time. Uh Contrast if you get, if you wanted to do AC T. Um And yeah, so it's something to think about. Um So usually getting an x-ray in the first instance, for lung pathologies is a good, good first step. Uh Yeah. Any other questions? All right. Um Thanks Doctor Roman for that session. It was honestly so great. Um Do you mind going on to the next slide? Uh Oh Yeah. Uh You guys are welcome. Yeah, yeah. So, so guys, it would be really, really great if you can fill back, fill in a feedback form. So I've just sent the link in the chat and you can also use this QR code to send. It'll be really beneficial for Doctor Man's portfolio um and just to get some feedback. Um Another thing is we've got a couple more sessions coming up, you can see on the right hand side, our next one is next week on abdominal imaging. So please join us for that. All right guys, thank you very much. Have a good evening. Appreciate. It's quite a long topic to talk about, but yeah, thanks for persevering. No, honestly, your top was so great. Honestly. Oh, you're welcome. Right. All right. Bye. Cheers. Bye Roly.