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CRF 16.05.23 Basics of Chest Radiology, Professor Elizabeth Dick, Consultant Radiologist and Professor of Practice at Imperial College London

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Summary

This medical session invites healthcare professionals to an interactive learning experience on how to analyze chest x-rays. Through real-time voting and engaging with live visuals, participants will learn a step-by-step system on how to describe radiographs when taking exams or on the ward. From analyzing the inspiration, rotation and angle to the details on left and right mediastinal contours, this session will teach healthcare professionals the anatomy, terminology and techniques needed to review crisp digital images.
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Learning objectives

Learning Objectives: 1. Understand the anatomy of a normal chest X Ray 2. Recognize different structures on the left and right sides of the mediastinum as observed on a chest X Ray 3. Describe the technical aspects of a chest X Ray, including penetration, rotation, and PA or AP orientation 4. Demonstrate skill in using a system to analyze a chest X Ray 5. describe the unique characteristics of the right ventricle when analyzing a chest X Ray
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The following transcript was generated automatically from the content and has not been checked or corrected manually.

I want to do to do next week. Um So we'll take our time um and kind of do the first half this time and then the second half next time. So I'm going to be talking to you about chest X rays and um all about kind of how you analyze those. This is going to be an interactive session. So, what I would like you to do please is you either um scan the QR code which you can see on the right or you can enter this address into your phone browser. So Paul F dot com forward slash Edick 900 and um all of the votes that we're gonna do today is completely anonymous. I can't see who's voted what uh so vote freely. And what I would like you to do is um to take part if you can because that kind of really helps with your learning. So let's start off. And the first um the first vote I'm going to ask you to do is this one and this is um where do you call home? So hopefully you should be able to put on your screen where you call home and by the way, there could be more than one place while you're doing that. I'm just having a quick look in the chat to see if there's any comments coming up. I know, um Moussavi, you're going to do all the kind of um, moderating, aren't you? So here we go. So you can see at the top the address that you can, you can enter on your phone to say what you call home And here's the QR code very big. If you want to look at the QR code and take a photo of that, try that if you want apologies, doctor, is it possible um if you could show back the link, the other link? Yeah, of course. Yeah. Yeah. Yeah. So the link is at the top here. I'm hoping this is projecting for you Paul F dot com forward slash Edick 900. Lovely. Thank you very much. Oh, I think on this map you can actually zoom in by the way. So uh if you're in a country, it's very, very small. Um you can zoom in on it. Okay. So it looks like we're getting a nice range of um answers, aren't we? Um So in fact, this is a tiny bit of a test in my geography. Um Can you actually help me with geography? In fact, uh is this Sudan? Yes, it is great. Okay. Thank you. I feel very embarrassed. I don't know that. Um And then also we can see, obviously that there are quite a few people who are in the Middle East. Again, lots of people from Ukraine. Um and then also some around the rest of the world. Okay. Great. The next thing I'd like to know um is to find out a little bit about your background. So what I'm planning on doing is to build your basic knowledge of chest x rays so that you basically have a kind of system. But looking at chest X ray's not just when you're doing an exam, but also when you're on the ward. Um Now, the other thing I was going to say is sometimes this happens, has happened before actually where people were able to draw on the screen. We, I think we managed to disable it last time. Um If we don't, doesn't matter, but if we can say that would be great. OK. So, um the, the reason why I've asked this question is I kind of want to know how to pitch the training um that I'm about to give you. Uh and I can see lots of people are answering their names, uh answering whether where they are in the chat as well, which is great. So it looks like uh sorry, the majority of you are actually fifth years. Um which makes me wonder if you would actually like to kind of, since you're very senior, would you like to kind of skip the normal and then go straight to the pathology or would you still like to go through normal chest x rays and how we look at a normal chest X ray? And I'm just going to get you to vote because there are people in went 2nd and 3rd and 30 years. So for their sake, I think we should continue with the normal experiences. Okay, perfect. Thank you. That's great. Okay. So what I'm gonna do is teach you a system and you're going to apply this system with every chest X ray you look like. So we start off with a normal chest X ray and um then basically we start, I usually start on the left side. And so that's what we're gonna do right here. So I start off at the top on the left and I start tracing the normal structures of the left media steinem. So I'm looking at the arch of the aorta, I'm looking at the left pulmonary artery uh and then the left atrium and left ventricle and all of these things should come up here. Um And um uh and then I kind of worked my way up the right side of the mediastinum. And then once I've done that, then I look at the lung fields as well. So usually when they put chest X ray up in an exam, for example, there's a moment when you think, oh my gosh, I can't see anything. And what I would advise you to do is to use a couple of seconds to mention some technical details about the chest X ray because that makes you start talking, which makes you sound good. And it also just builds up your confidence. It gives you a little bit more time to look at the film. So the technical kind of details that I would mention would be things like this is a male patient or a female patient, they look elderly or they look like and you know, they're an adult, they're young. And then I basically talk about um what the inspiration is like. And the way that you measure that is you look at the anterior edge of the ribs. So we can see the anterior edge of the ribs here. And this is the sixth rib. If you've managed to get your diaphragm, at least below the sixth rib, then that's a good um inspiration, good penetration. That means that the X ray, you know, got enough X ray beam. And the way you assess that if you look behind the heart, can you see the vertebral bodies um and the intervertebral disc spaces, if you can, then that's good. And if you can't um then it's under penetrated. And then the next thing I think about is rotation. And the way that we assess rotation is by looking at the spine is processes and the medial ends of the clavicles. And really you want the medial ends of the clavicles to be midway to have the spinous process midway between. So if I just flick on to the next page here, here are the spinous processes. Here are the medial ends of the clavicles and it's about halfway and halfway again. So this patient is not rotated. Whereas if, if, for example, this medial clavicle was much closer than this one that would imply that it's rotated. And the final thing I want to say is um talking about P A or A P and people tie themselves in terrible knots about. Um Should they say it's a pa film or an AP film? And I'm going to give you a tip. So the tip is, don't mention that, just say it's a frontal radiograph and then that way you avoid that whole discussion. So um oh yes, here we go. So, first patient, we're going to look at and what I'd like you to do with this please is to show me where you think the medial ends of the clavicle are. Uh so you can touch on the screen, you can touch more than once. Where do you think the medial ends of the clavicle are on this patient? Okay. Very good. This is great. Thank you. So, um it's lovely that you put your names in, but I cannot follow. I won't be able to trace back who's, who's so, don't worry. Oh my gosh, we're getting some terrible scribbles now, aren't we? Uh Let's see what happens. Oh, dear. Okay. So what we can see here is that the mediums, the clavicles are rotated and the majority of you were absolutely right when you pointed to the clavicle. So there's one here and there's one here. Um And then if you look at the spine, the spine is in the midline, it's right down here. So it's actually very close to this middle end, the clavicle and far away from this one. And that's a sign really that the patient is rotated, isn't it? Um Okay. And so I put rotated patient up next to the normal one and you can see the difference. So you're opening phrase would be uh this is a frontal chest radiograph of a young male patient or maybe an elderly female patient. And you can say the patient's taken a good inspiration, they're not rotated or they are rotated, the film is well penetrated. And you've already said things that make it sound like, you know what you're talking about. Uh And you've had a little bit more time to look at the film. So this is good. So now what we're gonna do is we're going to look at the structures at the left side of the mediastinum. And I'm hoping that you're going to be able to label these for me. So there are four structures to label the aortic arch, the pulmonary artery, the left atrium and the left ventricle. And let's see. Oh, no, I decided not to do this in the end. Okay. Uh Never mind, I will label them for you. So the first thing we see is the aortic arch and then underneath it is this structure here, which is coming out branching. This is the left pulmonary artery. And um don't forget, of course, that you've also got a right pulmonary artery, which is this branching structure here. Then underneath it, we have the left atrium and then the left ventricle. So those are all the things that you see on the left side of the mediastinum. Um Oh yes, that's right. I was going to get you to click on the structures, never mind, we won't do that. Um Okay. Then on the right side of the heart, um the first thing to say is that when you're looking at the heart and you're looking at it in the midline, you want to have about one third on the right side of the spine and two thirds on the left. And if you, if you see kind of half, half, so half the heart on one side, half on the other, that's not good. That means that there may be some kind of problem with the lungs. Um So you really want it to be the majority of the heart is on the left side. And when we go down the right mediastinal contour, you see the right atrium, you don't see the right ventricle because the right ventricle is very anterior, which is a bit of a trick question. They like to ask you that in exams. So we've got the right ventricle, we then have the right pulmonary artery, which is this branching structure here. And then we come to the SPC which you may or may not see as a kind of soft tissue and then this is the edge of the trachea. So those are the structures you're going to see on the right. Okay. Um So just to remind you, the normal hilum consists of the pulmonary artery, which we see here. And the which because it contains blood is a kind of white density. Also the main bronchus, left and right, main bronchus and they contain air. So they're black. And then in theory, um you could also have lymph nodes or even a primary tumor at the right hilum. And so in the normal circumstances, you don't see lymph nodes, but if they're abnormal, you will see them. So the next thing I do is I look at the lungs and the way I look at the lungs is the way that I used to examine the chest. So I start at the A P C's and I compare one side with the other side going all the way down. And there's a few areas that it's important to remember to look at. So one of the areas is behind the heart, another area is to look right out to the periphery. So check that these little branching structures which are the pulmonary arteries check that they're dividing all the way to the periphery. Um And the reason why we're checking for that is because if you have a pneumothorax, um the easiest way to see it is by looking at these branching vessels and thinking, oh my gosh, suddenly they've stopped. You also need to remember that actually, the the chest particularly posteriorly extends um inferior, so it's inferior to the hemi diaphragm. Um So, in fact, you can see the lung markings here. Can't you in fear is the hemi diaphragm? So look behind the hemi diaphragm, of course, always look for free air under diagram as well. So if we just zone in for a moment on the APC, I remember I was talking about how you get these branching structures and these are the normal blood vessels. So the normal pulmonary artery and pulmonary veins and they go all the way to the periphery. And that's how, you know, there's no pneumothorax. Okay. So this is what I would say. Um if I thought everything was normal, I would say the trachea is central, the mediastinum is not displaced, the mediastinal contours and highlight appear normal. The lungs are clear with no pneumothorax. There's no free air under the diagram, the bones and soft tissues are normal. So that's my kind of standard uh spiel or when I'm looking at a chest X ray. And obviously, quite often, if they're showing you a chest X ray and an exam, one of those things would be abnormal. So, um but if genuinely everything is normal, then the next thing I do is I say look, I haven't identified an abnormality yet. So I'm going to look at my review areas and it always sounds exciting, doesn't it? When you say I'm gonna look at my review areas, it sounds like you know what you're doing. So um would you like to show on the screen where you think the review areas are, you can touch anywhere on the screen for me? Good. So quite a lot of people are reviewing at the hilum, which I think is a great idea because there can be things hiding there can't there, where else can things hide someone's looking at the trachea, which is a good idea. Yeah. So by review area, what I mean is an area where sometimes there will be pathology and you won't see the pathology unless you actively look for it. So I think you're absolutely right to look at the hilum. All of you very happy that some of the people are looking in the apices because that's definitely a review area, isn't it? Then some people are looking down here in the costophrenic angles. I like the fact people are looking under the hemi diaphragm and then quite a lot of people are looking behind the heart as well, which is fantastic. Great. Okay, good. So yeah, so the review areas like I said it just sounds good when you talk about review areas. So my review areas, I look at the apices, I look at the periphery of the lung. I look underneath or below the hemi diaphragm and I look behind the heart so well done. All of you. Very good. Okay. So now we're going to be thinking about this. I want to get you to answer a question about mediastinal shift. So we kind of looked at normal. Now, now we're going on to our pathology and the first pathology we're going to think about is mediastinal shift. Um Can I ask a question? Um Misra, am I speaking too fast? Um For me, I could, I can totally understand everything but I just, I don't think you're speaking too fast to be honest, I'm a far speaker. I know that. So um if anyone thinks would like me to just slow down a little bit lovely. If anyone just writing the comment, then I'll get you as soon as possible. I will not be offended. Yes. No, everyone is saying is quite fine. Okay. Good. All right. Well, shout out if they're not. Okay. So about mediastinal shift, which of the following are true. And I'll read these out while you're boating. A right sided pleural effusion pushes the mediastinum to the left. So to the opposite side, a right sided tension, pneumothorax pushes the mediastinum to the left, a right sided tension, pneumothorax pulls the mediastinum to the right, a right sided collapse pulls the Mediastinum to the right and a right sided collapse pushes the Mediastinum. So let's see what you've all voted, by the way, you can have more than one answer, correct. Uh And there's a spread of answers which is good. Okay. So let's look at the correct answers here. So the correct answers are these. Um So basically this is all about volume. If you think about it, the mediastinum is in the center, right? And any process that pulls it one way will shift it. So that um kind of um basically, then it affects the opposite side. And then there are also processes which will push the mediastinum. So um the processes which push the mediastinum are a pleural effusion because that's increased volume in one hemi thorax and a tension pneumothorax, which lots of you picked up on a tension pneumothorax will also increase the volume in a hemi thorax. So it pushes the mediastinum to the opposite side. Now, there's one process which will pull the mediastinum and it pulls it to the same side. And that's the process where you lose volume and that process is collapsed. So when you have a collapse of a lung or even just a segment, you lose volume in that hemi thorax. And so the mediastinum moves to the spot where, where you lose um volume. So here we go. I think I've summarized all this again. So the trachea can be the trachea and the mediastinum can be pushed or pulled. There's two processes which push, which are the pleural effusion and the pneumonia tension, pneumothorax. And there's one process which pulls and that is the collapse. Okay. Very good. So I think most of you got that right. So let's have a look at this patient in this patient. Um They have got a white out on the right side. And what do you think has happened to the trachea? Do you think it has been pulled to one side? Pushed to one side? What do you think is going on here? So I can't remember how I asked this question. Oh Yeah, I asked the question here. So what has happened? Key? I think you can just enter your answer um on the screen type it. Um I'm hoping it's still activated while you're typing. Tell me if it isn't. So here's the tricky a we can see this airfield structure coming down. Um This patient isn't rotated. They're pretty much in the midline. So you don't have to worry about that. We've got a white out on the right lung and a white out is a nonspecific sign, isn't it? You can get white out from collapse, you can get white out from, you know, consolidation. We'll talk about that more in a moment or you can get it from a pleural effusion. So it's not a very specific sign. Okay. Let's see what people have said someone's written, pushed, pushed. Oh, that's interesting. So definitely it's collapsed. The lung has collapsed on the right, push to the left hold to the right, getting a variety of answers. I'm glad I've asked you this question. Pull to the right hold. It may be that the earlier questions are actually the earlier answers actually relate to an earlier question because actually everyone now is saying pulled to the right, which is great news. Okay. So let's move on to it. So everyone is correct. Basically, the trachea is here, obviously, it should be in the midline. And at this point, it's pulled over to the right side. And, and so given that we've got a white out in the right lung and the process has pulled the trachea, it has to be loss of volume on the right. So it has to be right lung collapse. Um And in fact, this patient, I think had a proximal tumor in the lung and that had caused complete collapse of the right lung which had pulled the media style. Um so very good, everybody great. The next one is um actually very similar looking patient um in that the trachea is pulled over. But I think what's more remarkable here is that the mediastinum is also pulled over, isn't it? Whereas on the previous patient, we didn't see that so much. And this is another example of right lung collapse and that's pulling the heart and the mediastinum. And the trachea to the right? Okay. Very good. Now, in this patient, they have got a left sided pleural effusion, which you can kind of tell because there's a fluid level here, can't you? And I'm hoping I can convince you that the heart is shifted to the right. Do you agree that um kind of more than or about half of the heart really has seen on the right of the midline. Whereas as we all know, we like to see only one third of the heart seen on the right. So this is a process effusion which has shifted the heart to the right. Okay. Um This is a different patient but very similar appearance, isn't it? Where the pleural effusion has pushed the mediastinum to the right? So the pleural effusions on the left mediastinum has been pushed to the right. Now. Here's someone who's got a tension pneumothorax. And what's happened in this patient is that the left lung has completely collapsed. And instead of seeing two thirds and one third of the heart, we're actually seeing half, half and you can see the long edge here. So the lung is completely collapsed down. And all of this black air here is air within the pleural space within the left hemothorax. And actually, it's getting on for tension because it's now pushing the mediastinum across. Okay, very good. So, here's another patient and I'm hoping you're going to be able to tell me what the diagnosis is, please. Um, same again. I'm going to get you to vote. So take a look at the both lung fields. Um, you can kind of look at them however you want, but remember how we had our normal kind of looking out to the edges to check that the lung fields are okay. Have a little think about what you think about the mediastinum. I'm just gonna see. Have I? Oh, yeah, here we go. Uh I think people are boating already, which is fantastic news. So keep boating, keep boating. Okay. Let's see what you've answered. Uh What is the diagnosis? Right? Tension you said? Fantastic. And some people have said mediastinal shift to the left, which is making me very happy. Thank you. So, what we see here is that there is a right pneumothorax, almost all the lung has collapsed, isn't it? This is the edge of the right lung. It's tension and you can know it's tension because if you look here, you can see how the mediastinum is kind of pushed across and you can kind of really get the impression, can't you that all of that air in the right full spaces pushing across? And if you look at the mediastinum, now, do you remember how we said we wanted two thirds of the heart to be on the left and one third to be on the right. Well, there's barely any of the heart on the right side of the spine. The majority of the heart has moved across. And so here there's a tension pneumothorax on the right, which is pushing the mediastinum to the left. So very good everybody. Great. So we've talked about uh pushing and pulling. Um The next thing we're going to think about is when you have an enlarged heart. And what I'm hoping going to tell me is the causes of cardiomegaly mean and you can enter all your answers now, any cause that you know of. Um So what are people said? I like it. There's a lot of um there's a lot of uh variety. So a lot of people have said heart failure, cardiac tamponade. Yes, that's right. If you've got any kind of cardiac pericardial effusion, hypertension. Yes. Hokum, hypertrophic cardiomyopathy. In fact, any cardiomyopathy VSD and heart failure. Yep, genetic or pathological cause yet. So I can see that person is using the so called surgical sit where you classify things, don't you say? Uh it could be congenital or acquired etcetera. Very good. Okay, great. I'm glad to see all those answers. Thank you. Okay. So the most common causes that we see are congestive cardiac failure. Uh But as you said, there are other causes, things like cardiomyopathy, pericardial effusions. So, what are the signs of left ventricular failure on X ray? There are kind of four main signs. The curly be lines are the most obvious sign and these are where you've got tiny little horizontal lines extending from the pleural edge. You can get a batwing perry hill, a haziness, you can get al viola shadowing and I will discuss that with you. And then my least favorite sign. In fact, to be honest, I think I don't really like it as a sign is so called upper low blood diversion. I find it very hard to identify that. So let's take a look at an X ray and see all these signs that we're looking at. So this patient has got left ventricular failure. They've got a big heart but more almost more obviously around the hilum on both the left and the right. There's this kind of butterfly shape of haziness, okay, which is a sign of left ventricular failure. And then the other thing that you can see in this patient is can you see these branching um black structures? So these are air filled Salvio lie um and little bronchioles and they're surrounded by this patchy white um airspace shadowing. And what that is is the Alvesco light are full of fluid and then the bronch, I are around the Alvie oh Lie and there and they still contain air. So they stand out and I'm just looking to see, I'm hoping it's going to project on your screens. Can you see um if you look down on the right here, for example, that um there are these horizontal lines here. These are the curly be lines there named after a radiologist called curly. So let's take a look. Let's zoom in here a bit more. These are the branching airspace, um, bronchioles that I was talking about. Um And so, yeah, just to kind of explain the anatomy basically where you've got the bronchial coming down to the alveolus. The bronchial keeps having air within it, but the alveolus will fill up and the alveolus can fill up with fluid like in Pompano edema. But in other, like, for example, in infection, it could fill up with pus, it could even fill up with hemorrhage if you've got some kind of lung contusion. Um but the most common things that it fills up with our fluid or pus and then what happens is the Alvesco light or white because they contain solid material, whereas the bronchioles still contain air. So they're black and they stand out against the white Salvio lie. So you can see those branches that I've drawn on here and then here, let me zoom in here. Hopefully, that's a little bit better for you to be able to see these horizontal lines. The more you look, the more you see these horizontal lines and what these are are. So you've got the alveoli, but around the alveoli, you have the interstitial space which is like a potential space around it. And that interstitial space can fill with fluid. And when that filled with fluid, it will stand out as white lines like this. So those are the signs of left ventricular failure. And now next patient, this is a very old film, but it's a good film. Um So this is a patient who came in in the morning and they had the chest X ray on the left. And then two hours later, they had the chest X ray on the right, which is normal. So what happened to the patient in between? You have to tell me what treatment do you think they received? So this is about thinking a bit laterally. Uh So they went from having cardiomegaly to having a completely normal heart. What other people said uh a lot of people have said diuretic. Ah but now someone said something that I really like. So I think a diuretic, I mean, it would be quite impressive if a diuretic um bought your heart from very, very big right down to normal. Because if you had left ventricular failure, causing your heart to be that big, you would even if you managed to treat the left ventricular failure, you would still expect to have a big heart, wouldn't you? And then the other thing about this patient, which I'm just going to go back to for a moment to notice. And this is quite challenging. I maybe would only expect the 50 years to notice. This is, although there's a big heart here, there aren't many signs of heart failure. So, do you remember how in the previous patient we saw this? Um butterfly pattern. We're not really seeing a butterfly pattern here. Um So it's like a big heart, but there aren't really the signs of heart failure. So that's why I was kind of thinking about, that's why I was talking about, sorry, I'm lost all your response. Now, that's why I was talking about thinking laterally. And that's why I'm very excited about people who said pericardiocentesis iss because basically this patient had a pericardial effusion. And when once that was drained, the heart size went back to normal so well done for all of those people who work that out. Okay. Good. So let's move on now, let's think about the highlight. I'm just looking at timing. We're doing okay. Um Let's think about the normal structures that lie at the highland. And I'd like you to tell me that. Now, please. Um So just tell me the normal structures that lie at the hilar. Someone said pulmonary arteries. That's true. Hyler Lymph nodes. Exactly right. Yeah. Very good, Bronk. I very good. Main Bronchus, agree. Pulmonary veins and Bronchi lymph node is exactly right. Perfect, well done. So those are the structures that lie at the hilar. Um So you've got the vessels, pulmonary artery and vein, you've got the main Broncos and you've got lymph nodes which may or may not enlarge. So what can happen to all of these structures? Well, the pulmonary artery can get bigger if you've got pulmonary artery hypertension and there are a variety of causes of pulmonary hypertension aren't there. You can get that with mitral valve disease. You can get that with chronic pes and you can get it with a primary pulmonary hypertension. What about the Broncos? Well, you can develop a carcinoma there. So that would be another reason why you might have a big hilum and finally, what the lymph nodes, um you know, it's a common site for lymph nodes to enlarge and they might enlarge for multiple reasons. So, infection of any cause uh malignancy of any cause uh and then always put sarcoidosis in there too. Okay. So let's look at some examples. I'm just looking in the chat to see um just interrupt me. By the way, if there's anything that you want that is coming up in the chat or I can see lots of people are saying the chat, which is fantastic if there's anything coming up in the chat that I'm not covering Muestra. Thanks. Yeah. Lovely, Miss Moussa. Mostly. Sorry, I touch your name wrong. Sorry. No problem. Okay, great. So next one is um this patient and I put the normal in for you just to compare. So, um patient on the on the right um has very, very enlarged, soft tissue mass is here and these are lymph nodes. And what I'd like to draw your attention to is the fact that you can still see the normal pulmonary artery. But um kind of through those lymph nodes. And that's how I know these have, these can't be arising from the pulmonary artery itself. So you've got two structures, you've got the artery, but you've got the lymph nodes kind of next to it, but they're separate structures if that makes sense. Okay. Very good. Here's a patient who's also got enlarged Tyler, but here you cannot separate out the pulmonary arteries. And here we've got, this is a pump. So this is pulmonary artery hypertension. And what happens is the pulmonary arteries come out and then they twirl around like this. Um So they look like these huge round masses, but all they are is just very big pulmonary arteries, very good. Um And one of the things that you might notice, so this is a different patient who's got pulmonary artery hypertension as well. It's often easier to see the right side than the left side because the left side almost gets hidden by the heart contour. But the right side you can see here it's very big approximately and then it kind of narrows down distantly. I don't know why it does, but it does okay. Very good. Uh This is a patient who's got a normal looking right highland, but they've got a mass here on the left and this was a primary tumor. Um And you can kind of identify that the pulmonary artery is separate from that, can't you? And now this patient um has got not just Hyler lymph nodes you can see these rounded structures here, can't you, which are separate from the blood vessels? But also, do you remember at the beginning, I was talking about the edge of the trachea. So you've got the edge of the trachea here and instead of having lung next to it, you've got this kind of like almost like a wall of soft tissue. And this is um parrot, so called paratracheal lymphadenopathy. So this patient's got lymphadenopathy all kind of through their mediastinum. Okay. Let's move on to the lung spaces now and remember how we looked at the lung spaces, we kind of, you know, uh looked at it in an organized fashion a bit like when you listen with a stethoscope. So you've been called to see someone he's breathless. Um its A and E and you need to be telling me what's going on with this patient just looking to see what have I put the answer. Okay. Yeah. Uh So why don't you put the answers here into the chat? And then I'll have a look at the chat. So young man breathless. First of all, which side do you think the abnormality is on blue? Which side is um darker? I met it. I better actually have a look at the chat. It's got a little right side. Right. Right. Right. Everyone is saying right. Which is great. Okay, perfect. I agree. The right side is darker, isn't it? OK. Good. And I can see some people are already writing the answer, which is fantastic. People are saying it's the right side of pneumothorax. And that's exactly right. So your first clue to the fact that this is the right side of pneumothorax is the fact that the right side is darker. So that should alert you to the fact that the lung vessels are not going all the way to the edge, they're not producing the same density as you would normally have. So this is the right side of pneumothorax. And I'm hoping that the edge of the lung, if you couldn't already see it all of a sudden, it appears to you, doesn't it? So you can see the edge of the lung, not just superior lee here, but actually, you can follow it all the way down. Okay. Good. So, um pneumothorax, we've already talked about this. You look at the periphery of the lungs you're looking for in the pleural space. It's a great clue if you see that one side is blacker than the other even better if you can see the lung edge. And so what would I say? What's my spiel for pneumothorax? I say there's no shift in the mediastinum. So no tension or I say there is shift in the mediastinum which indicates a right or left tension pneumothorax. And then I would say, and this is one of things that I think you have safer final exams. Uh Certainly in the UK, I would say this is a medical emergency. I would treat this immediately by inserting a large bore cannula into whichever pleural space it is. So you need to have all of your medical emergencies. Uh kind of ready at the top of your head or finals? Okay, great. So what else? I'm just looking at the time cause I don't want to wear you out. Um The next thing to think about is surgical emphysema and this patient, the more you look, the more you see all of this black air outside of the chest wall and there's so much black outside of the chest wall, I can't actually see the lungs but because he's got all the surgical emphysema, he's got to have a pneumothorax because the air has to come from somewhere. Um So when you see surgical emphysema like this and in a way, it's almost easier to feel clinically, isn't it? You feel that kind of poppy thing on the under the skin? Then you um then you have to assume there's a pneumothorax and this is a different patient who's got a pneumothorax. Uh You so you can see the pneumothorax edge on the right. And then what you can see is all of this air going through all of the soft tissues of the neck and into the mediastinum as well. Okay, I think I like this picture so much. I took several copies of it. So again, here you can see the pneumothorax. So you can see the edge of the lung here. This is the mediastinal contour, blending with the pericardium. So, can you see all of this? This is AARP, which is tracking down the mediastinum as well. And then here he's got aired tracking through the muscles of the chest wall. Would anyone like to help me identify what muscles these are in the chest wall? You can write that in the chat if you like two others. Yes, it's Victrelis music's. I can hear someone answering. That's great. And let's see if anyone else wants to answer the pectoral muscles. Yeah, just pop it in the chat. So, thank you. That's great. I think everyone got that. Everyone's very good at the pecs I've seen to remember. It's one of the first things I learned in medical school. So. Exactly. Right. And I think that the reason why this man had a fracture. So he had a pneumothorax was because he had a fracture of his first rib and just bearing that in mind for a moment. Even more anatomy to look at. What is this rounded structure that we see um within the neck trachea? Yeah. Just pop your answers in the chat. That would be great. Thanks. Uh Very good. So, Trachea. Exactly. Right. And then this structure behind the trachea. What's that? It feels like you've got to be really quick typist here, doesn't it? Very good? I think lots of people are getting that. So, yeah. This is the esophagus, isn't it? And then here we have the great vessels um which are coming off the arch of the aorta as well. Fantastic, well done everybody. Good. Now, this is a really important patient for you to learn about. Um So this is a patient who's got Bullis lung disease. And what happened was they were involved in a road traffic accident and they, which obviously makes us think about pneumothorax and they had a flail chest, which means that they've got multiple rib fractures. Um In fact, the definition of a flail chest is when you have two ribs, sequential ribs. So one next to the other with fractures in more than one place. And what that means is that when the patient breathes in the chest wall, um instead of kind of opening out like this, it then gets sucked in. So it's so called paradoxical inspiration. And that makes it very hard to ventilate the patient and then they get all kinds of problems. In fact, someone's written paradoxically perfect. So, um and he's also got surgical emphysema. I hoping now you're all experts on surgical emphysema. You can see all of this air within the soft tissue. But the problem is he's also got bullets, lung disease. He's got multiple bull i in his lungs and I'll just show you that now. So here we can see all of the surgical emphysema, right? Uh We can see some of the rib fractures Um, but if you look at his lungs, can you see all of these black circles within the lungs and these are all bully, um, from his bullets lung disease. So, it may just be that one of these has popped and that's been the cause of the air in the pleural space and air in the chest wall. And the problem is, is if you put whoopsie, the problem is, is what is the risk of putting a chest drain into that pleural space? And I'm hoping you'll be able to tell me the answer. This is actually quite hard. I would only expect the 50 years to know this. Um So you've got essentially, instead of putting it into a plural um to a pneumothorax, like we were on the previous patient, we are now putting it into a Bullis within the lung, which is an airspace kind of ball of air within the lung. So you have to think laterally here about what it could be causing. Quite a few people are saying infection, which is absolutely true. Great, uh unwanted collapse. Yeah. I mean, certainly in general, whenever you put, put, put things um into the chest wall next to the lung, it can cause collapse. Can't it? Okay? I'm really glad I asked this question because so far I don't think people have got the answer and I didn't know this until I was well into my junior doctor days. So the answer is that what happens is you fuck, you create a fistula. So a fistula between the bullous and the pleural space. So you've effectively created a hole between the pleural space and the Buller and you never conceal it up because obviously the lung is quite pathological. Anyway. So essentially, if you ever see a patient who's got the kind of lungs that look like this and they've got a pneumothorax, um think very, very carefully before putting a drain in. And if I was you, um I would basically ask a very senior person for their opinion on what's going on because of the risk of bronchopleural fistula. Okay. I'm just thinking, I think that might be a good spot to end it all. So shall shall we end there? Are there any questions that people want to ask me? Um Before we finish our Yeah, go on a visual marking. Yeah, sorry. So I was going to say there are some questions in the chat but is all right. Thank you. Can continue. Okay. Cool. Let me read out the first one from Taiwo are visible lung markings normal. Um Yes. So it is normal to see the branching vessels which are the pulmonary arteries and pulmonary veins. Uh So that is normal. Are there any other questions? Um Moussab I didn't see them all. No, I think that's the only one I've seen right now. Why did we intend to do a chest train in the first place? So, basically, as soon as people have a pneumothorax, uh which we assumed because they had rib fractures and they had surgical emphysema. We tend to put new method, we tend to put chest trains in. In fact, I would say our trauma patient's quite often when they come into us in our emergency department. If the ambulance crew think that they may have a pneumothorax, they're so concerned about missing a tension pneumothorax. They will quite often just do a decompressive thoracostomy. So just put a little drain in just to make sure that there is an attention. Someone says, are there conditions that increase land markings? That's a good question. Well, uh certainly if you have pulmonary hypertension, like we saw, then you see that the proximal pulmonary arteries are bigger and more prominent. I don't think there's any other conditions that make the vessels more prominent now. And that's a great question. How can you know if a picture is PA or a P? Well, it doesn't usually it's written on actually pa or a P but my tip for you is it doesn't matter. So don't worry about whether it's PA or A P, just say it's frontal. What is the importance of review points? So I guess the importance of the review points is number one in general, when you're looking at a chest X ray, you kind of look at it. You're like, okay, there's nothing going on here. Hang on. Let me just double check. So, you know, as in life, you know, before you walk out the door of your house, you check. Have I got my keys? It's the same kind of thing. Second of all, when you're doing an exam, uh if you haven't seen anything and you're in a panic, um, if you say I'm going to look at my review areas, it sounds like, you know what you're doing, it sounds like you've got a system going and that's always good. How do we know about the presence of air Bronchogram? So we'll come back to those uh next week as well. I'm hoping I am next week. I'm pretty certain I am. Um Basically, if you see a branching black structure surrounded by whiteness in the lung, that is the air Bronchogram. And what it is is the bronchial which contains air surrounded by alveoli which contain pus or fluid. But we'll look at more of those next week. Tell you. Um mhm I think that's the end of the questions. Is that right? Yeah, I don't see no more questions. They're perfect. Great. OK. Thank you very much professor for such an amazing presentation in lecture. Thank you. I'm looking forward to seeing you all next week. I think it's pretty much the same time and thank you, Mr especially for bearing with me. Well, I found myself on saying lovely. That's no problem. Actually. I hope you have a lovely evening professor and I hope everyone has a lovely evening. Thank you very much and um see you next week. See you then. Bye, you too. Bye bye.