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Hello, everyone. Uh It's lovely to have you. Welcome to our first me education event of the uh the New Year. Hope you had a rest filled time over Christmas. Um Today we're joined by Bobby and he is gonna chat about a guide expert chest X ray interpretation. I know lots of you are really interested in this. So what I'm gonna ask you to do is as we go through, do put your questions in the chat. We have a new feature on the platform now which um if Bobby can't answer the question there and then what we'll do is we'll highlight it and then at the end, he will answer that question. If it's relevant to the, what he's talking about at that moment, he may then answer it right there and then, but otherwise it'll be queued and it'll be asked later on. OK. So um at the end of this event, er in an hours time, you will have a feedback form in your inbox, please complete it. We're really keen to get your feedback. It'll all go to, to Bobby. He will get a copy of this feedback ma it's, it's mainly about his teaching, er, and what you want to see going forward. Bobby has actually agreed to do some more teaching with us. So that's brilliant. So do let us know what it is you're missing out on where you are and we'll see if we can fill that gap for you. Ok. So without any further ado I'm gonna hand you over. Thank you very much, Bobby. Uh Thank you Sue and uh happy New Year to everyone and welcome to this teaching session on er chest X ray interpretation now in sort of 45 minutes or so, obviously, I can't talk about every um area of chest X ray. So I'm gonna start sort of reasonably basic and we're gonna move through using uh a number of cases to talk about uh different aspects of chest X ray interpretation. And then as I say, well, you said we can follow up on this at some point in the future if there are specific things that people want to know, um Please put your questions in the chat uh as Sue said, and I'm gonna turn my video off just to, er, conserve a bit of bandwidth for everyone. So, um, but I'll be here and I'll be talking, put your questions in and we'll uh have a good Q and A session towards the end. OK. So hopefully you can all see the slides and er, whatever I've got, er, no declarations of interest with regards to this talk. So what I'm planning on doing is talking a little bit about uh the techniques in chest radiography, just at a, a relatively basic um level, some bit of anatomy, how to look at a film um or an image. So you uh get the most out of it introduction to the various patterns of lung disease will very briefly mention some other techniques and then we'll have a summary. So if you look at techniques that I'm not gonna talk about lateral films, um because we're doing those less and less. So it's less important. The, the first thing that you need to know really is that we do our frontal view uh either in the pa projection. So it's posterior to anterior or in the AP projection, which is anterior to posterior. And that what that really depends on is how sick your patient is. And so if we're doing mobile radiography and the radiographers or technicians are coming to your patient, then almost always the film will be ap and it will be marked as such. Whereas if the patient comes to us in the department and we uh have them standing up as I'm gonna show you in a moment um for the film, then it will be a pa a projection. And certainly in the UK, there will be no markers apart from the side marker. So here we have the, the left here to say that this is the left side of the patient, um other places will use the right instead or maybe put both on. But if there are no other markers, then it's generally safe to assume that it is a pa a film. Now, the reason this is important um is er done with this rather complicated fiber, I'm gonna, I'm gonna talk through it. So in apa projection, we have the patient standing with their back to the x-ray source and the er detector, whatever sort of detector you're using uh in front of the patient and the X ray beam comes from posterior to anterior. And what that gives you is this arrangement at the bottom, so that the heart which is an anterior structure is as close to the detector as possible. And what that means is that there is almost no magnification of the heart. You can see that the beam is diverging. So there's virtually no magnification and it means you can measure the heart size on your film and compare it to any other film that's been done in the same projection and the distance between the X ray source and the detector is standardized across the world. And so you can compare a film from done anywhere else that's in APA projection and measure the heart size and say whether it's got bigger or smaller or what have you when you have an AP projection. So now our patient is sitting or lying down on their back and you're shooting from front to back, you can see that the heart is now much further away from the detector. And that means that because of our divergent beam, the heart appears magnified what you can't control is the distance between the source and the patient. And so as that distance varies, the degree of magnification varies. And so you can't objectively measure the heart size from one film to the next. If they're ap you could, you can sort of estimate whether the heart is bigger or smaller, but you can't actually measure it. And so that's the main difference between the PA and AP projection. So where possible, we will always try and do APA projection. Another important thing to realize is that on a chest X ray, on any X ray, really, there are only five densities of material that you can see. So air and a vacuum appears black fat is a sort of dark gray, soft tissue. And when I say soft tissue, I mean anything that's water density. So any soft tissue will all appear as, as a growly, light gray bone is almost white and then dense metals are white. And that means it's quite easy to differentiate bone, soft tissue and fat from each other. But it's very difficult or impossible to differentiate different types of soft tissue cos they all appear as a single density. And we'll see how that works as we go on. The other really important sign is the so called silhouette sign. And it is the basis of finding most abnormalities on a chest X ray or any radiograph. And essentially what the silhouette sign says is that if you have two structures, the 12 the same density. And let's just for the sake of this slide, call them lung nodules. So you've got two lung nodules if they are separated by something of a different density. So let's just say normal lung then on your X ray, even though the X ray is a two dimensional image of a three dimensional patient, they will appear as discrete separate structures. You'll be able to draw around both if you like. And that means that they are separate from each other. However, if the two nodules are touching each other, like in this view, they will appear as a single structure. And it may not be possible to easily differentiate whether this is a bi lobe nodule or two nodules or a normal structure with a nodule next to it for instance. And again, we will see examples of this as we go on and I will point out the silhouette sign. So if we just think about a little bit of basic anatomy, just to make sure that we're all on the same page as to what we can see on a, on a radiograph. And I'm not gonna talk through all of these, we can spend uh a long time just looking at this one side. But in essence, there are a lot of anatomical structures that you can easily see on a chest X ray. So, although the heart and the media tym essentially looks like a triangle, each part of it outlines a different structure. And you can see those listed here and there are many others and you can see with act correlation um what you are seeing. So for instance, here we have the um aortic knuckle, which you can see here labeled as number two. You've got the left heart border uh made up of the left ventricle and so on. So there is a, there are a lot of anatomical structures on the chest X ray, uh which we're all, which we're gonna need to look at and we're gonna talk about that as we go forwards, an important thing to do is just to assess the expansion um of the chest. And there are various ways of counting uh or looking at how big the lungs actually are. Er, and one method is to look at the number of ribs that you can see. So you can look at anterior rib ends. So you can see the anterior aspects of the ribs here on the other side. Uh and you should be able to see six anterior ribs above the diaphragm and that tells you that the patient has taken a good breath in and we do need our patients to take a good breath in to be able to see all the structures properly. Sometimes it's inevitable that the patient is going to have an expiratory radiograph where there are fewer than six anterior rib ends visible. There are times when you may want to do that deliberately. And also sometimes this number will change with time with some types of lung disease. So for instance, in fibrotic lung disease, the lungs gradually get smaller and over a number of years, even with the best breath in this number of ribs will decrease. And so you can assess that going er as you move forward through time. There are also of course, er anatomical other anatomical variants that you can see. So this is the azygous fissure, which is quite a common variant. So you will see a curved, very thin line uh in the right upper zone, uh terminating in a sort of teardrop uh structure. And that teardrop structure is the azygous vein and embryologically, it drags itself through the lung in these patients dragging some pleura with it. And this is the pleural reflection that you're seeing and the bit above forms the so called azygous lobe. And this is an entirely benign normal uh variant. And there are many of these. So again, when you're looking at the X ray and you're looking at it systematically, just look out for any anatomical variants that you see some are more important than others, sometimes it is really difficult. So here is a patient er, with er morbid obesity. I can't remember exactly what they weighed, but it's probably in excess of 200 kg. Um, you can see that the best we could do was to do it ap, and semi erect. We couldn't even really sit the patient up properly. And you can see that the lungs are largely obscured by all the soft tissue overlying the patient. And this line here is the, uh, the large, er, ab abdomen, which is now overlying the chest, uh making the interpretation very difficult. So sometimes no matter what you do, no matter uh the best will in the world of the technicians and radiographers and whoever's interpreting it is very difficult. So a little bit more anatomy, um this is from CT now, uh you hopefully you're all aware that the right lung has three lobes. So an upper lobe, a middle lobe which is anterior and the po the lower lobe, which is predominantly posterior uh and the left lung essentially has two lobes. So the upper lobe, which you can see goes from apex pretty much to the diaphragm and the lower lobe which is almost goes from apex to diaphragm. Um And sometimes these fissures which I've outlined in yellow here, which are the uh borders between the lobes are also visible on chest x rays. Now, the important thing about that is here is to realize that the lobes of the lung overlap each other. So if you take the left lung for instance, as I said, the upper lobe goes from apex to diaphragm and the lower lobe from about two thirds of the way up the chest all the way to the diaphragm. So there is a large area on a frontal view where they are overlapping similarly with the right lung where it's split into three lobes. And this means that it can be very difficult to position something in either the upper lobe or the lower lobe. For instance, on the left, if it is in the middle, because it could be in either lobe. So my suggestion to you is when you talk about where you know, a nodule, for instance, is if you imagine that my red cursor is a nodule is just specify whether it's in the upper zone. So the upper third of the lung in the mid zones, the mid third or in the lower zone, the lower third. And that way you don't have to commit yourself to which lobe it is in, but everyone will be able to find it. If of course, you have another view, for instance, here in this lateral view, then you'll be able to much more easily uh suggest where it is because you can see all the lobes in a different orientation. So just bear in mind that there is a lot of overlap um of these structures. Now, just to mention the the heart border. So on a frontal film, the right heart border is made up of the right atrium and the left heart border is made up of the left ventricle because they have interfaces with the lung. So the only reason we see the left heart border is because it's got lung next to it. Similarly, the only reason we see the right heart border is cos it's got a lung next to it. Now, the left atrium, which is a posterior structure and the right ventricle, which is an anterior structure have no lung next to them. And so they are not visible on the chest X ray when they're normal in the frontal position. And this ct uh rendering illustrates that. So here is our right atrial border. This is the right atrial appendage. And you can see that's up against some free space that will be lung similarly with the left ventricle. But this triangular structure here, which is the right ventricle has no lung uh around it. And so he is invisible uh in its normal structure and the left atrium is at the back here and you can't see it at all. So remember the things you are seeing are the things that have an interface with the lung. And again, we're gonna look at that as we go. So how do we look at a film? There are some really important things to bear in mind that um sound very, very simple, but it's where people go wrong quite a lot of the time. So you you know, you're all going to be busy people. You've all got lots of patients that you need to see. There are probably lots and lots of x rays that need to be looked at. But it is very important whether you're using uh sheets of film or you're using an electronic system that you make sure you have the correct patient uh in front of you. So always check the name and the date of birth and the hospital ID number. However, you id them in your part of the world to make sure you've got the right patient because there will be patients who have similar names, there will be mix ups in which film is in which packet, there will be all sorts of problems. So it's up to you to make sure you've got the right patient to keep the patients safe. Some patients will have multiple films taken in quick succession. So make sure you've checked the time and the date on the film which your technicians will always add to the corners of the films. Usually to make sure that you've got the film you actually want to look at, just check that it's the right way round and we'll, we'll come to this. I'll show you an example. But um the side markers on the film are very important because there will be patients who have congenital abnormalities who have dextrocardia, um who've maybe had uh thoracic surgery where knowing which side is which is very important. And then remember you need everything you want on the film to make a proper interpretation. So for instance, if you're looking for a pneumothorax and the lung apices, the very tops of the lungs have been omitted, then you can't necessarily exclude a pneumothorax and you should get another film. So don't make a diagnosis or try to make a diagnosis on an inadequate er data set, make sure you have all the information that you require. Um And II, you know, we've got delegates here from all over the world. So maybe not everyone is using packs an electronic data storage system, but even a manual system which I grew up on with films in, you know, in envelopes, in packets is not infallible. Mistakes can be made pack films end up in the wrong packet or are labeled incorrectly in packs on an electronic system. So just always make sure you are absolutely looking at what it is. You want to look at other things when you're assessing the patient, the phase of inspiration. So we I said before that you need to see six anterior ribs. Now this is the same patient. Uh and there these x rays are just uh a minute or so apart. So we deliberately did inspiration and expiration imaging. Um And you can see an inspiration, the film is normal. OK. Uh in expiration. However, you can see the lung volumes are much smaller. There's a lot of haziness around the hila of the lungs which look a little bit like mild pulmonary edema. The heart appears larger because it's squashed now in the ap direction in, in the. And so it goes from being completely normal to having the question. Is it slightly enlarged and so on. So there can be some really big differences in patients between inspiratory and expiratory films. And so it is absolutely vital that you make that assessment of is this inspiratory or expiratory? Almost always, the radiographers will aim to get an inspiratory film for you, as I said before, always check side markers. So here we have our left labeled uh and you can see that this patient is uh has sinus inversus. So the stunt bubble is to the right and the uh apex of the heart is also to the right. So there is reversal, the aortic knuckle is to the right. So there is dextrocardia here uh with Sinus inversus and this patient actually had caragin syndrome. So they've got mild bronchiectasis and obviously, they've, you can't see the sinusitis. Now, it would be very easy if you were not looking at the side markers simply to look at this film and go oh and just turn it around so that it faces the other way into what you think is normal. So it's absolutely vital that you check the side markers each time. Now, how you look at a chest X ray. It is a very difficult thing to teach because we all view um visual information differently. We, you know, we're all, all our brains are slightly different and we all look at the world in slightly different ways. Um So one method that is worth thinking about, particularly if you're relatively inexperienced is to think about it in the way you would think about trauma or resuscitation in a sort of airway breathing circulation uh methodology. So make sure you look at all airway related structures, for instance, say the trachea carina, the bronchi, the hila structures and then lungs and pleura for breathing and so on and so forth. So the list is here with e for everything else. I mean, there is a lot of information on the chest X rays and I'm gonna come to you in the next couple of slides um when you've done all of this and you've checked all the iatrogenic things, anything that, you know, as medical professionals we put into patients, all the lines and tubes and valves and everything else. Then you need to think about review areas. Now, radiologists have review areas for oh slides are frozen. Here we go. Um have review areas for virtually everything. So uh in my head, for every type of examination I look at, there are places I go back and have a second look because I know those are places where you may miss things or I might miss things. So on a chest X ray those places are behind the heart. Remember I said that this is a two dimensional image of a three dimensional patient. The heart is very anterior, there's lots of lung behind the heart. Make sure you look through the heart. If you like check the gospic angles, they should be nice and sharp. Um you should be able to draw a pencil round them. Any er blunting or change in those core angles is important. Look under the diaphragm, uh exhaust lots of uh organs under the diaphragm and most important of all, maybe is to look up in the apices. The apex is just a bit above the clavicle. All sorts of pathological processes can hide up here and then remember that the chest X ray is just that not only have you got the heart and lungs, you've got the cervical spine, you've got most of the thoracic spine. If not all of it, you might have the upper lumbar spine. You've got all the ribs, both shoulder girdles and so on and so forth. So there's lots and lots of stuff to look at important things to remember when you're doing this. If you have any old studies for that patient, then make sure you look at them and just ask yourself three simple questions. Does it look better? Does it look worse or is it just different in some way? Symmetry is really important? Although the lungs are not symmetrical, anatomically, radiologically, they are essentially symmetrical. So you can look from one side to the other and make sure everything looks the same, lots of abnormalities, all look the same as we will see. The body only has a limited number of ways of reacting to a different, to different insults and chest radiography. Uh A lot of them will look identical. So it's important that you look at the film in the context of the patient. So what is the patient's history? What symptoms do they have? What signs do they have? What's been done to them and so on. And that will help you review uh the patient appropriately. Ok. So there are only a few basic patterns of lung disease. I'm not talking about pleural disease. I'm just talking about lung disease. So you can have consolidation, which means that the airspaces are full of something. And we'll see that for real in, in the next uh slide, there could be an interstitial process. So this is al stuff filling the alveolar spaces, the airspaces, this is a disease of the scaffolding if you like of the lung. So it's not really an airspace disease. It's all the interstitium that's affected atelectasis is just a technical term for collapse. And it just means loss of volume in some or all of the lung. And then the difference between a nodule and a mass is simply size and it just depends which book you want to read. But somewhere between 2.5 centimeters to three centimeters, it'll get called a mass and anything below that, it'll be a nodule and of course, nodules can be solitary or there can be multiple nodules. So they are the basic patterns of lung disease. So, with regards to um consolidation. So here we have a chest X ray and we have a corresponding um er ct er computed tomography image. So what you can see is this branching pattern of airways. Now, remember the silhouette sign I talked about, normally, you can't see the airways because they're very thin, they're full of air and essentially surrounded by air and so they're invisible. But now because the alveoli are full of something fluid, pus blood tumor cells, whatever it might be, then the alveoli sorry, the airways are now highlighted by that because they're surrounded by something of a different density. And so you can see them and this is called an air bronchogram. And if you see an air bronchogram, then that means that that patient has consolidation, it doesn't tell you what the cause of the consolidation is. You need to do other tests to establish that and look at the history of the patient and so on, but they have consolidation. So air bronchogram are the hallmark sign of consolidation. In this case, the consolidation is in the left upper lobe and of course, it can be multifocal uh as in this patient. Um and you know, the differential diagnosis will vary because of that. So that's consolidation. This is uh an example of something different. This is an example of a collapsed lobe and it's a, it's a absolutely sort of classic as you studying for radiology exams. If any of you are, this is an absolutely classic example of a left upper lobe collapse. So if we just start with the right lung, the right lung is essentially normal. So it's uh nicely aerated. Um It's pretty much the same density gray throughout. You've got a normal branching pattern. There's a little bit of calcification, that's fine. But if you look at the left side, this is where all the abnormalities are. So you can see that the left heart border is no longer sharply defined. You can see that the left hemidiaphragm is raised. Normally, the right hemidiaphragm is highest. And if you look at the distance between this pair of ribs and this pair of ribs, then it's greater on this side. So these ribs are crowded together, we call this rib crowding. And you can see there's a sort of general haziness over the left hemithorax. So this is the class um sorry. And the last thing is the mediastinum. Normally, you expect to see about um a third of the heart to the right of the midline. And here there is virtually nothing to the right of the midline. So all of this is telling you that the left hemithorax has got smaller and that's because there is loss of volume in this left upper lobe and the left upper lobe collapses anteriorly. So it collapses up against the chest wall er to the front. So there, so this haziness is called by some of the bridal veil sign. And then you can see everything else is a product of decreased volume. And uh there is our left up leg clubs. Now, here are all the other collapses. Um I'm not gonna go through them all individually. Th this is just to illustrate that one, they collapse in characteristic ways, but more importantly is to illustrate this silhouette sign to you again. So here on the right, we've got this haziness here in the lower zone, you can't really see the right heart border and hopefully, you'll all know or remember that the right heart border, the thing that is up against it is the middle lobe. So you see the right heart because the middle lobe is aerated and if the right heart disappears almost always, it will be because of a middle lobe problem. So this is middle lobe collapse. Similarly, if you look at this patient, you can see the right heart border now, but you can't see the diaphragm. And the only thing up against the right hemidiaphragm is the right lower lobe. So this has to be right lower lobe collapse and so on. So it's quite easy to work out. So long as you remember what lies next to what and also bear in mind that when you look at an X ray, it's as much about the things you can see as the things you can't see. So both are important. You need all the positives and the negatives to make a diagnosis. Ok. Moving on. Now, here, here is our chest X ray. Um We can say this person with the symp symptomatically, they've got a cough and I hope you can see that behind the heart there is a much increased density. If you look at the right heart and look at the, the level of grayness there, this is much whiter because it's increased density and what this turned out to be, I mean, it, it follows the contour of the heart almost exactly. And what this turned out to be was the lung cancer. So this is the mass on CT the patient is now in the prone position, we're biopsying the mass uh via this needle inserted posteriorly and you can see how the mass sits behind the heart. So the heart is this anterior structure here. And this brings us uh neatly onto lung cancer and lung cancers can be really difficult to see. They can be really easy to see. So here are three examples. Unfortunately, we don't have polling and things set up on this. We'll, we'll try and do that next time. But these patients all have similar symptoms you can see here in the right hand frame, this ill defined mass in the right, mid and upper zones. So that's easy. It, in this view, in the middle, different patient, it's this asymmetry here. So you can see the right pulmonary artery hanging downwards like an arm, the left pulmonary artery less easily visible as usual. But next to it is this ill defined rounded structure. So it shouldn't be there. There isn't one on the other side. So if we're gonna use our rules about symmetry, we should see one here if it was normal, but it isn't. So that's our lung cancer. And then in this patient where the X ray looks virtually normal, the cancer is this slight increased density here, which is projected right over this rib. So again, you're looking at the symmetry, you can't see that increased density on the other side in the same way. So you need to be really mindful of how um subtle the findings can be. And you need to make sure you look at the X ray in a very systematic and logical manner to pick up the abnormalities. OK? You, you can't just look at it by having a glance at it. You've got to be absolutely systematic when you do it. And the more you do, the quicker that systematic analysis becomes OK. And sometimes it's really easy. So these are multifocal and I can see there's nodules all over the place, all sorts of different sizes. Um quite, all, quite smooth. This is the ct of that same patient. So you can see the various nodules in all lobes. And this turned out to be uh renal cell carcinoma metastases. Now, I think with masses I'm not, you know, we, we, we can't go through every single mass, but in general benign masses tend to have smooth walls. They may be calci calcified, they may have cavitation. But if they are a cavity, they'll have a very smooth, thin wall attached to them. And they're commonly things like granulomas and Hamartomas, pulmonary um uh atrial arterial venous malformations and so on. So, if they're smooth and calcified, they're almost certain to be benign. And of course, malignant nodules just have the opposite sort of features. So they're often irregular, they're spiculated. So they're spikey. If they are calcified, it's often not in the middle. And if they have a cavity, it'll be thick with an irregular wall. So you can see they're just the opposite of each other and then almost always, it's gonna be some type of lung cancer. Although of course, um there are some infections that can cause thick walled cavities for instance. So it's not 100% that this is gonna work, but it'll point you in the right direction almost always. Ok. Um pleural effusions. So hopefully, you've seen uh re gras in patients with pleural effusions before. So this is a, a typical appearance where you've got this so called meniscus where the fluid appears to rise up between the lung and the chest wall. And of course, the meniscus can be quite small or the lung could be full of fluid. Uh sorry, the thoracic space could be full of fluid. But here we have our um uh hydrothorax in this case and it could be a transudate or it could be an exudate. You can't tell from the film. It, that's gonna be about sampling it and taking your history. It could be an empyema or a cholothorax that could be pus and it would look exactly the same. Again, history is key or it could be blood with a hemothorax or fat with chylothorax. So, what I'm just trying to get over to you is that the X ray appearance is going to be the same. The X ray appearance does not tell you what the diagnosis is necessarily, it goes back to what I was saying before that many, many things all look identical. So what you need from here is information about the patient. What's the history? What are the examination findings? What are the lab tests and so on and so forth. And ultimately, you may need to put a needle into this and sample this fluid to actually get a diagnosis. I pleural effusions have different appearances depending on whether the patient is um in the erect position, standing up, sitting up or lying down, uh so erect, you've got our meniscus. That's easy, supine, more difficult cos the fluid is gonna layer out at the back and form a sort of dense layer for the X rays to go through. And so the side with the fluid is going to look a slightly lighter gray than the side without the fluid. And I hope you can see that um this lung is just slightly lighter gray than this side. And if you were gonna look to sort this out, of course, you could change the position of the patient, you could just sit them up and do another X ray or you could use ultrasound. Um just put the probe on and you'll be able to see fluid. Sometimes the effusions can be uh quite large as in this case, um and actually bulge and sort of push the fissures over. Um and sometimes that will change the diagnosis. But again, you can't really tell what's going on without a history here. Now, how much fluid do you need? If you're doing a lateral film, then as little as 50 mL of fluid will blunt the posterior costophrenic recess and you will see it. But on a frontal film, Rome, we're not talking about laterals, you need about 200 mL of fluid even to just slightly blunt this costophrenic space. And as much as 500 mL, half a liter might go unnoticed. So chest X rays are not particularly sensitive for small effusions. If you're worried whether your patient has a small effusion, you're going to need to do some other imaging technique. And ultrasound is the most uh is the easiest to do um in in many settings because you can bring the equipment to the patient. And if you have access, then you can use CT scanning as well to do this. But uh and of course, you can use clinical techniques like uh percussion. And uh as I've said, there are loads of different types of effusions, but the two major types are transudates often from heart failure or hepatic failure or exudates from infection or malignancy. And there are endless causes. I mean, this is by no means an exhaustive list um of courses of effusion. But as I said, the key thing from a radiographic perspective is they can all look the same. So you need to uh to go further and here's AAA large fusion causing er what some people might call a white out or what most radiologists would cause called complete opacification of a hemithorax. And it's pushed mediastinal structures across and you know that this is fluid um that he is not reducing the volume, this is fluid that's filling that space and pushing the mediastinum across. And on CT you can see that. So here's this sort of mid gray is our effusion. This bit of light gray is the lung and you can see the media has been pushed across when it was subsequently drained with the chest drain. It's left a pneumothorax in unfortunately not great technique. But I put this up deliberately to show you uh two things, one that it was an effusion. And second that you've got this horizontal line here. Now, the chest has almost no absolutely straight lines. So if you see a straight line like this, you need to think about an air fluid interface or an air fluid level and clearly with this pneumothorax above and the fluid here, this is why there's an air fluid level here. This is a hydropneumothorax. This is a, a different scenario. So this is a patient who's had a pneumonectomy. So they've had this left lung removed for cancer. You can see the chest drain in and the skin clips where they've had the thoracotomy with time that space starts to fill with fluid. And again, you get an air fluid level because there's fluid above and uh sorry, air above and fluid below. When it's completely opacified, you'll notice that the mediastinum has not been pushed across this time. In fact, it's been pulled across. Remember we said a third of the heart should lie to the right. Um So this is the thoracic cavity getting smaller after a pneumonectomy. So when you see a complete white out, if you like, you need to be asking yourself the question, is it something pulling the mediastinum in or pushing it away or keeping it in the same place cos that changes the diagnosis. So you have to ask yourself, is it a pleural problem. Is it a problem of lung? Is it an airway problem or have they had a pneumonectomy? So, always consider the options. A white out does not always mean fluid. Ok. That brings us, er, on to pulmonary edema and heart failure. Now, this is a, a sort of classic appearance of heart failure. Patients had cardiac surgery. They're in intensive care. They've got, they're intubated, they've got a nasogastric tube in and you can see this sort of fluffy airspace consolidation per permanently in a perihilar distribution. So the peripheries are spared relatively and this gives the so called bat swing appearance that people talk about. I'm not sure I've seen many bats that look like this, but that's what it's called. The thing with heart failure though is it can have numerous appearances. Peri hilar haziness and batwing or fluffy airspace consolidation. Like someone's put cotton wool all over the chest are just two manifestations. It may be something very subtle like the upper lobe veins are just a bit more prominent than they would be otherwise. Or you might get so called curlies lines. These horizontal lines from the chest and the X ray appearances don't always correlate to the severity of the patient's symptoms. So you might have a person with upper low blood diversion who is very short of breath and hypoxic. You may have someone with curly lines who sat there really not too bad. By the time you get to this stage, then they're likely to be pretty sick. But the in between stages, the x-ray doesn't always correlate with the patient's symptoms. So, remember, you need to treat your patient and not the X ray. And so heart failure and pulmonary edema again, lots and lots of causes. Not all of them are due to heart failure. You can get pulmonary edema from neurogenic causes, um fluid overload, some inhalational er things such as smoke inhalation, for instance, uh near drowning, rapid reexpansion and so on. So there's all sorts of causes. Um And again, the history is key, right? I'm just gonna talk quickly. I've got about five minutes left before it's meant to be question time. Um So air collections. So clearly, this person has a big pneumothorax and we know it's pneumothorax because you can see the edge of the lung as I'm outlining here and you can see there are absolutely no lung markings beyond this edge. And you need both of those things to definitively say that this is a pneumothorax and there are lots of different types of gas collection. So, pneumothorax, I've just talked about, you need a long edge and an absence of markings. Tension, pneumothorax is of course, where the pressure builds with each breath and pushes the mediastinal structures across. And these are often life threatening conditions. You don't always get an x-ray, sometimes you just treat them clinically. But uh it is the variant pneumopericardium is where air starts to sit between the heart and the pericardium. And you sometimes see it in asthma, you can see it postoperatively as in this case. And it's another example of our silhouette signs. So remember, we don't normally see the pericardium cos it's right up against the heart. But if you put just a tiny bit of air into that space, then it becomes a separate structure because there's air on both sides of the pericardium. And so you can see it and then pneumomediastinum is where air is diffusely infiltrating through the soft tissues of the mediastinum. And again, you see in asthma, you see in bronchial injuries from trauma, uh what of whatever kind um and so on. So again, it's just a matter of carefully. First of all, realizing there is air and then looking at the configuration of the air and seeing, working out where which anatomical space it is in. And this is just to illustrate how far the mediastinal structures can be pushed across. So this is a massive tension pneumothorax in a critically ill patient, all of that doesn't matter. But this tube here is in the S VC, in the superior vena cava and then in the IVC in the inferior vena cava, it's deliberately going all the way through. And normally this tube would lie here to the right of the midline and you can see how far it's pushed across. So the mediastinum is quite a mobile structure. If the pressure is high enough. Ok. Pneumoperitoneum. So this is gas under the diaphragm. So patient with a hollow viscous perforation, possibly trauma, um air is leaked out into, into the peritoneum and now you can see it under the diaphragm and that's easy. In this case, it's AAA really huge one. And this is the CT where you can see all this free air which appears black on CT and then air contained within the loops of bowel. So easy to diagnose I talked about cavitation. So here is um a, a, an ovoid cavity within the lung and he's got an air fluid level within it and it's fairly thin walled. So we're gonna think it's probably benign. So it's not going to be um a cavitating tumor, for instance, such as squamous cell carcinoma is probably a small lung abscess or sorry, a big lung abscess. Uh And the key thing is these air fluid levels, you shouldn't see this sort of interface in the chest. So if we just move away from plain films, I mean, obviously there's loads of other things we could have talked about on plain films and er, maybe we'll do that er, at a later date if I'm invited back by Sue. Um but remember when looking at the chest, there are plenty of other imaging modalities available to us. So we've been talking about plain films today. Er, this is MRI of the heart, this is uh cardiac CT and an anomalous uh coronary artery. We've got nuclear medicine techniques such as Mibi and Pet. Um This is invasive coronary. Uh Again, looking at coronary artery disease, the E CG can be considered an image. Uh and there are plenty of other techniques out there. So, again, when you're thinking about the chest, you need to think about what other imaging might I need, what imaging is available to you because not everywhere has everything. Um and how you're gonna make that diagnosis. Um So to close really, um when you're whe whether you're writing a report as a radiologist or whether you're um a clinician, just looking at your patient, you need to think about how I'm gonna interpret all of this information because there's lots of it. So first of all, list all the findings that you have. So go through and systematically note down everything you think is wrong with that X ray or right with that x-ray, try and summarize it um into a, you know, a few sentences, maybe make sure you correlate it with the clinical history and the examination findings. And of course, any other tests that you've done lab tests and what have you compare it with previous imaging. And then when you've done all those things, all those four things trying to come to some sort of conclusion is not always possible by any means. Um The radiology department is there to help you in your local hospital um to come up with this sort of thing but try and put it all together. Uh, it's a problem solving exercise and, uh, almost always you will come up with the right or somewhere near the right diagnosis. Now, this was written a little bit for my, uh, my UK, er, students but I think there's a ply, so make sure you look at the radiology, imaging of your patients. It's part of the clinical record, w which whatever method you use in your countries to, to record the patient's information, whether it's in writing or on an electronic system or whatever it might be, the imaging is just part of that record. So make sure you look at it. If you have the opportunity, go to your local radiology department, sit with radiologists. Um If you have multidisciplinary team meetings where you discuss complex patients, then go try and visit those because you will see the imaging in, in the correct clinical context. And of course, as a radiologist, I would always say you should consider radiology as a career. It's fascinating. It's fast moving. It's technologically always on the go. And if you like problem solving, then radiology is definitely the place for you. Now, these websites should all be accessible wherever you are in the world. Uh So the Royal College of Radiologists in the UK has quite a lot of information on radiology careers and undergraduate training. Uh These two websites, Radiology, masterclass.co.uk and Radio Pia have thousands of cases of all body parts, all sorts of pathologies free to access. Er, so you can learn. Um, and then there's this, er, so called unofficial guide to Medicine website and they do one for radiology and it's brilliant. So if you're looking for a book, um, er, or a website, then that, that is another uh resource that I would encourage you to, to go to and, er, with that I'll close and take any questions. So, thank you very much for your attention. Perfect. Yes, thank you very much. Um So we do have some questions coming up. I do believe there's one that was asked uh a while back about long COVID patients. Are you able to answer that one? Bobby or uh what's the best time to do a chest X ray? Well, that, that's a really interesting question. I mean, we, we would only x-ray them on a symptomatic basis. So if, if they are still short of breath, for instance, you know, a, a month or two after their episode of uh COVID, then that is a good time to X ray them, but sometimes the findings are really subtle. Uh and CT may be necessary. Um, but I would certainly leave it a little while. Uh Otherwise they're all going to have, er, x-ray changes and you're just gonna have to x ray them again. So, you know, treat them symptomatically, er, in the first instance. Perfect. And I go on to the next question that we've got. Uh hopefully you should see it on your screen. This is a new feature for metal. So if people can see the questions uh there it's on your screen. Um Do you feel A I will take over C XR reporting? No, no. Well, it depends on what time scale you're talking about one day. Yes, absolutely. You know, 1015 years in the future maybe right now and in the foreseeable future and with the A I solutions that are out there, they are generally very good at looking for one thing. So you, you, you'll use an A I and it'll tell you if there's a long nodule, you'll use a different A I. And it might tell you if the nasogastric tube is in the right place. You use a third A I and it tells you if there's a rib approach, there are some experimental systems that are meant to do more than one thing. But as a radiologist, I'm looking for 100s of different things all at once. That's what you will be doing in your normal clinical practice. And at the moment, there is no A I that comes anywhere close to that. So, yes, one day, but not by any means in the immediate future. So, any of you thinking about being a radiologist, I think your, your careers are safe. Yeah, brilliant. So, our next question. Let's have a look. Uh Thanks, Doctor Bobby. I always struggle to spot fibrosis on C Xr. What is the best approach? It's really hard and the subtle fibrosis will be missed by even the most expert radiologists um on a chest X ray. Again, you have to correlate it with clinical findings. So, you know, have they got crackles and all that sort of thing? Are they short of breath? What's their respiratory function test like? But in the end, if you suspect your patient has fibrotic lung disease, they need a CT because you will only spot it quite late on a chest X ray. Wonderful. Next question. Uh oh, is esopha is esophagal? A? Yeah, a recess line helpful in assessing large effusions. Um Well, I'd say from personal experience. No, it's not, it's not something I look at uh or look for specifically. Um I think once you have a large effusion, um then you're really looking for what the cause of that might be. And the fact that, you know, one anatomical line or other may or may not be visible is not necessarily gonna help you with that. What you need to do is sample it to find out what's going on and take a history. Of course. Perfect. Next question. Why are lateral C XR views not done routinely with pa views? Well, they, they contribute relatively little um for, for most people so well for most patients. So the the time we do them is preoperatively. So our cardiac surgeons like a lateral view to make sure that there is a nice gap between the deep surface of the sternum and the anterior surface of the heart. So when they open the chest, they can do it safely. Yes, you can look at the thoracic spine in appropriate patients. But in the main, it doesn't actually contribute anything useful. So and it's quite a large radiation dose to the patient. So if you've got young patients, you don't wanna keep doing lateral views. So if you suspect an abnormality on CT, on a plain film, on APA film, like a lung nodule, depending on the facilities you have, you would either go directly to CT because then you can position it, you can look for other associated findings and so on or you might do a lateral view at that stage to help identify its exact position but just doing laterals, er all the time has really gone out of fashion. OK. We have our next question from Chris. Chris would be uh a user actually uh that he is, he belongs to an organization on the platform. Chris, please do pop your uh profile link to the organization in our chat just in case any of our middle education delegates are interested in coming along to one of your events. But Chris has a question here. Do you have a good crib sheet or checklist when reporting plain chest radiographs? I often see lungs and pleural spaces clear, normal cardio. Yeah. And um, II think you have to, um, you have to sort of trust if I answer the question in reverse, you have to sort of trust your reporter. So, when I write something like that, I'd like to think that the people reading it, the people who refer to me in general know that I've looked at everything else because I said it's normal. Um, and you kind of have to trust the radio radiologist to do that as far as a checklist goes. Um, I don't, I don't know of anyone certainly in sort of UK European practice who comments on absolutely everything and, you know, says normal, right heart border, normal, left heart border and normal, this normal, that normal, whatever. Um, because that's just gonna take a long time. Now there may be other parts of the world where it's, it's much more formalized in that sense. I think when you're looking though, um, that sort of, if I can flip back to the right slide, yeah, this, this, you know, this sort of thing where, um, you just check these review areas and if you think they're normal, just say they're normal. Um, yes, it's a difficult question to answer but II would suggest it's about, uh gaining that trust of your, your radiologist. Um, that when they say in a few sentences that many, many structures are normal, they have actually looked at them hope that answers the question, Chris. But I mean, yeah, message me uh separately if you, if you want more information. Perfect. Uh We have our next question. Is there anything more we have to look for? Except cardio. Yep, Bobby, you know that I'm not medical. So these words, I, I'll read the questions. It's fine. Yeah, you read the questions, you pop them up and I'll read them. Um Well, the first thing to say which II really should have put, put in my talk is cardiomegaly is not necessary for heart failure and pulmonary edema. So you can have a completely normal sized heart and have florid pulmonary edema. So you can't use cardiomegaly as a differentiator of our changes due to fibrotic lung disease or some other reticular process or pulmonary edema. I think you can view the chest X ray and you have to view it in the context of the patient's symptoms and history. Uh When you're talking about very subtle changes um with pulmonary edema, of course, the more florid, the pulmonary edema becomes, the easier it becomes to make a diagnosis. But in that very subtle phase, um then it is more about examination and history than how big is the heart because the heart may be completely normal. Brilliant. Um That's fantastic. Does anyone else have any questions or uh Bobby's already said he would love to do some more teaching for us and I can see that lie has actually said by far the best session on chest radiology. So is there anything you want to pop in the chat? Is there anything within Bobby's, um, expertise area? Is there further education that you want that Bobby can take a look at and say? Right. Ok. Yeah, I've got that. I can do that and then I can check with Bobby and we can sort something out for a few weeks time. So, load the chat up with whatever you would like. Um, whether it's questions or er oh can we have chest c session? What's that? What do you mean by that? You? Mm. Oh CT. Yeah, we can do CT we can do, we can do a session on CT. Perfect. I thought we were going to be cutting up chests then. Well, we can do a postoperative session if you want. I mean that's easy enough too, but it may not have wide applicability. The CT. Absolutely. Yes. Perfect. Perfect. So yes, we can do that. There's, you know, this, I would love if, if um sorry Bobby, but if our delegates have any, if you've had teaching from someone that's been amazing and you've got their email address or something like that, please email them and tag me in and I can approach those consultants or teachers or whoever to get them to uh come to the platform to do some teaching for you. This platform, this organization on our platform is for you, for you to get the teaching that you want. So, and, and I don't know what teaching you want or need. I need you to tell me. So please let me know what you want. Let you know, put it in the feedback. We'll review that. Um Brain MRI. Is that under your remit? Uh No, I know where the brain is. But apart from that, um you need to, you need to find one of my colleagues to do that. I sometimes wonder where mine is but hey, but lie, we will, we will take that on board and we'll see if we can uh find anyone or if anyone has any ideas who could, who could do that. We want more interventional radiology things. Brilliant, brilliant, brilliant. We will do what we can. Like I said, this platform, I'm not medical. I don't know what you need. I don't know what gaps you have in your uh learning. So I need you to tell me so that we can try and find people. Yeah, the feedback link will be in your email uh in about two minutes time. It will be directly sent to you. And once you fill that out, you'll get your attendance certificate on your medical account. OK. Does anyone else before we go? You're welcome. Does anyone else before we go have any questions whatsoever for Bobby to answer? Um But II promise you, I will get him back. I have a question. Go on then w with regards to, I mean, with regards to S et again, it's a massive topic. So, um, if you wanna, um, in the chat or with Sue later or whatever, just sort of maybe chunk it up a little bit. If you have a specific thing you want to know about, then we, we could concentrate on that. Otherwise, you know, we could do one on cardiac CT or lung ct or whatever it might be. But, you know, the, these are big, big topics in 45 minutes and I don't want you just to like skate over, um, a huge topic very superficially. Um, if that's not what's needed lung ct. Yeah, we can do that. Bobby. I think I could have you every, every week for the new year employee. If you're gonna do topics, if you could pop in, we'll get Bobby every week. We'll make it a running thing with him, right. Like I said, pop it in the feedback. I pop all of these, er, er, ideas in the feedback. Obviously, Bobby can see them here, pop them in the feedback. I will pass them on to him. I'll give you a week to fill out the feedback and then I'll pass it all on to Bobby. He, we can then get together and we can decide what, um, dates and times events, um, that we can set up for you and if you're following me, er, medical education then you will be emailed with regards to those, uh, new events that are coming up. Um If not just keep an eye on the platform. Ok? Um So I don't think there's any more questions so I am going to stop us going live. Uh Thank you Yusuf. I'm going to stop us going live now and hopefully I will see you at our next event. Ok. Everyone. Thanks everyone. Do you do lung biopsy intervention, Bobby. Uh I used to uh not anymore. Sorry, Chris, right. Take care everyone. All right. Bye.