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from my friend. Uh huh. Going to go following last week. I'm just going to go over the, um the details about some of the cases I showed you and I want to discuss pulmonary edema, which is obviously, uh, really important. Let me take you back to the anatomy. The anatomy is very logical, is that the lobule is political, and it's about 1 to 2 centimeters in diameter. Each secondary pulmonary lobule has a bronchus and an accompanying pulmonary artery and the pulmonary veins, the lymphatics run in the space between secondary pulmonary lobules. Just here in what's called the inter lobular scepter. Now, when you get fluid in the interlocutor sector, as you will do with pulmonary venous hypertension or lymphangitis carcinomatosis, this gives you the curly be lines. And so the curly be lines in the situation where you've got a sudden onset of breathlessness. This is likely to be interstitial pulmonary edema. Okay, now, we've only got about 28 people at the moment, and I'm conscious of the fact that the link that I post won't be visible to future participants. So if the moderator could intermittently just repeat, uh, that link, um, by posting it. That'd be That'd be very good. Thank you. And so when we get interstitial pulmonary edema, these interlocutor sector get filled with fluid. And if you turn this at right angles, you can see that these represent the curly be lines, which you can see on the chest X ray. And here are the curly bread lines and the curly. Be lines represent interstitial pulmonary edema. Yes, Yes. Okay, so the et tube here Anyone comment on the ET tube in this particular X ray? Yeah. Just put something in the chat. Any thoughts about that UTI tube? Is it? Is it okay or is it too low? It is too low, isn't it? Because it should be approximately 2.5 centimeters away from the Carina. And that's because there is a significant risk of intubating the right main bronchus with that et tube. But this patient has got interstitial pulmonary edema, which is the prelude to Al Viola pulmonary edema. Okay, but the patient will still have the same symptoms. That is is, they'll be very breathless. And this is due to heart failure which causes left atrial hypertension which leads to pulmonary venous hypertension. in a different patient. Here's another case where we've got curly be lines. I hope you can all see them, these horizontal lines. And in addition, we've got some alveolar a change because this patient is, uh, having interstitial and alveolar pulmonary edema. So this is a case of heart failure. Another great case of curly be lines you can see here nice perpendicular lines to the chest wall. And this patient has got upper lobe blood diversion. And this is heart failure. Now, this should be recognized clinically. But if it's not recognized clinically or the patient then goes on to have a chest X ray, you can pick up these signs. The only other cause of this would be lymphangitis costly Victoza. But that tends to be unilateral secondary to a malignancy in the hilum. But this is due to heart failure, and I've I've turned the diagram at 90 degrees for you. And when you get fluid in these scepter here and you x ray the patient, you get the curly be lines. So this is a patient who then goes on to get pulmonary edema, which is the bat swing of your pulmonary edema. So it's the next stage from that interstitial pulmonary edema. So the interstitial pulmonary edema as that becomes more pronounced, it leads to al Viola pulmonary edema, and although it's a little asymmetrical here, it does resemble a batwing, and it's called batwing pulmonary edema. You can also see there's a little bit of blunting of the costophrenic angles now. It's quite subtle on the right, a little less subtle on the left, and that means that the patient has almost certainly got coexisting. Pleural effusions. Yeah, here's another example of battling pulmonary edema. Again, it's a symmetrical bit more pronounced on the left. It's in a periosteal a position and is less marked on the right. The pacemaker is circumstantial evidence that the patient has got cardiac disease. Here's a patient who not only has a bat swing pulmonary edema, but they also have a misplaced nasogastric tube. And the nose of gastric tube is clearly going down down the right main bronchus and right lower lobe broncos. So it must be in the trachea. And don't forget, the trachea and the esophagus are superimposed on the frontal projection. If you get a rotated film, as we do in this case, It sometimes makes it easier to see that the N G tube is in the trachea, but it's obvious that it's in the trickier because it's going into the lung. But they've also got very nice demonstration of battling pulmonary edema. I can't see the left hemidiaphragm. Can anyone tell me why? What goes with pulmonary edema? Well, they've got a left side of pleural effusion here. Okay, this is the right internal jugular line. This is the ET tube, which is in a good position. That's in a good position. This is in a not very good position, and in fact, the position of the energy tube in this patient can be extremely dangerous, and therefore it needs to be removed immediately. This patient has got what we call a lamella pleural effusion. Note the curly be lines here, but also fluid has spilled out between the lung and the visceral pleura. Okay, and it's a potential space. Normally, a pleural effusion occurs between the parietal and the visceral pleura. But this has occurred between the lung and the visual pleura, and it's trapped fluid which orientate itself vertically at the CP angle. There's also a small amount of alcohol, a pulmonary edema. And here's the schematic diagram to explain what I just described. And there's the lumbar fusion. Now, this is a young guy who was 25 years of age who comes in either with a head injury or with a severe neurological insult. And the severe neurological insult in this particular case is subarachnoid hemorrhage. You can just see here blood in the basal systems, blood in the fourth ventricle and some debilitation of the temporal horns of the lateral ventricles. So this is subarachnoid hemorrhage causing hydrocephalus, and that can actually produce, uh, non cardiogenic or neurogenic pulmonary edema, which was seeing in this case here. So this patient did not have any cardiac disease, but the pulmonary edema was as a result of a significant, uh, pulmonary uh, sorry. A significant neurological insult giving pulmonary edema. I want to briefly discuss lowbar collapse, and then I'm going to go through some of the cases that we are hosting on packs been so low bar collapse. I'll tell you about left lower lobe collapse when the left lower lung collapses. It does so by going towards the back and towards the midline like that and So here is an example of the left lower lobe collapse. You can see the sale shape behind the heart, and we've got a small left hemothorax. So we've lost volume. We've got shift of the trachea over to the left, and the hilum has been pulled down a bit. So the left island is always higher than the right. I'll, um And it's been pulled down. And the CT of this particular patient is this one here, and you can see that the low bar collapse has occurred towards the spine and towards the posterior chest. Okay, the left upper lobe. When that collapses, it does so by going towards the anterior chest wall and towards the midline and the left upper lobe collapse. Looks like this. You don't see the interface of the lung, you only see increased density, and that's because the lung is collapsing towards the anterior chest wall. But it does all so collapse towards the midline in this particular patient. We've got a mass lesion in the hilum, which is responsible for the left upper lobe collapse. And then we've got here a rib destruction. So in this particular patient, the left upper lobe collapse is caused by the hilar mass lesion and results in a metastasis in the rib. Now it's very important to recognize that when you get a low bar collapse in an adult presenting for the first time, the most likely diagnosis is and endobronchial tumor or a highly tumor, which is causing obstruction of the Broncos. And this patient has clearly got a cast name of the Broncos with a mass lesion and a rib metastasis, the left lower lobe collapse that you saw earlier again, this is the left lower lobe collapse, and this was caused by an endobronchial tumor in the left lower lobe. And this is the CT scanner that left upper lobe collapse. The collapse goes towards the midline and towards the anterior chest, and then we've got ripped destruction just here. Yeah, one of the most tricky ones to see on a chest X ray is a middle lobe collapse, and the middle lobe collapse in this particular case is caused by mucus. Plug. Now, because the middle lobe is a smaller lobe, it's much more susceptible to collapsing as opposed to one of the larger lobes, such as the upper lobes or the lower lobes. And so whenever you see a middle aged collapse, it may or may not be due to an endobronchial tumor. But it's probably due to an endo bronchial mucous plug, as it was in this case. Now the key to the diagnosis here is that anatomically the middle lobe abuts the right heart border. And the reason why you can see the right heart border on a normal chest X ray is because the aerated lung has a different radiographic density to the right heart border. But when you've got filling in of those airspaces or a collapse of the middle lobe, the solid lung then has the same radiographic density as the right heart border. And therefore you get this, um, are obscuration or inability to see the right heart border. And it's not until you do the lateral that you can tell that this is a middle lobe collapse. Okay, I want to talk about misplaced nasogastric tubes and misplaced tubes elsewhere. So here is the correct nasogastric tube placement, so we've got a nasogastric tube in a well centered film. It's going down the midline slightly to the left. It doesn't veer off parallel to the left main broncos but keeps on going and then takes a sharp left at the gastroesophageal junction with its tip lying in the stomach. Now, that is a normal position of a nasogastric tube. If you then look at the film on my schedule earlier, the pulmonary edema. You can see that this nasogastric tube is veering off to the right well, before it gets the gastroesophageal junction. And so this is going into the right main bronchus, right? Uh, la la Broncos and into one of the labor bronchi. And the patient's also got pulmonary edema. Somebody asked me, What are the other causes of low bar collapse apart from the tumor? Well, that's a really good question in Children who are crawling about they patient the child. Maybe between 18 months and two years, three years of age, they'll call about and they put things in their mouth and it could be an inhaled foreign body. Uh, and the important thing is that you almost never see the foreign body on the X ray because the foreign body tends to be radio loosened. Okay, so that's that's one important consideration in adults. You automatically think this could be a bronchial cast namer in patients who present in the community, and they come to the hospital for an X ray. It could be a hilar mass, which is pressing the Broncos from the outside. And one of the more benign cause is when I use the term advisedly benign. An inverted commas, uh, is a carcinoid tumor. Now, a carcinoid tumor is not benign, but it's less malignant than a carcinoma, and they can present with the low bar collapse, they tend to be in young people who don't smoke. So here's another example of a misplaced nasogastric tube. Can anyone tell me where the tip of the nasogastric tube is? So here is the nasogastric tube. Yeah, it's in the right lower lobe, and it's been advanced quite a bit. And it's actually gone as far as the CP angle. Okay, now, this patient has also got consolidation consolidation here. Now, that could be pulmonary edema. It could be an infection. It all depends on the presentation of the patient. Okay, Now, if you remove the n g tube, which is obviously the right thing to do, what could be the consequence of removing that tube? Anyone know it's gone right out into the CP angle, so there's a significant risk that that tube has already breached the visceral pleura. And if it's breach the visceral pleura and then you take the tube out, what do you think might happen? They get a pneumothorax. And this patient did have a pneumothorax when the tube came out. Quite a large one, actually. Okay, so always be careful where you see a nasogastric tube going this far down that removing it might actually cause a pneumothorax. In fact, what's happening is the patient has got a defect in the visceral pleura. But that defect has been plugged by the nasogastric tube, and as the nasogastric tube comes out, the plug opens up and they get the pneumothorax. Uh, here's the nasogastric tube, which appears to be, uh, in a reasonable position. It's kind of veering off to the left, but it's not varying off to the left in the left Paris terminal region. It's varying off to the left once it's in a right Paris external position. And so this is actually in the medial right lower lobe broncos and one way of improving the detection of, uh, misplaced tubes is to do a, uh, an edge enhanced film, and it's done at the same time as the standard film. So for the same radio radiation exposure, the Radiographers can manipulate the image, and they can get what's called an edge enhanced film. And the Edge enhance film just shows you that energy tube a bit easier, but it also shows you this lucency projected over the liver. Does anyone know what that might be, given the fact that it's, um, it's gone right down into the posterior costophrenic sulcus. So it's similar to going into the lateral costophrenic circus, but it's just gone into the posterior one. So what? What might that cause damage to the visceral pleura? Yeah, and they can get a pneumothorax. So this is actually a pneumothorax. Now the pneumothorax is fairly stable in that it's of a certain size. But when you remove the tube, guess what happens. The patient gets a pneumothorax with the deep soccer sign tubes gone, but the pneumothorax got bigger. Okay, Okay. The next thing I want to discuss is White House. Now, White out is not the the kind of description and I would give to X ray like this. It's best described as, uh, completed classification of the left Hemi thorax. And when you look at these x rays, the most important thing you need to do is one. Take a clinical history from the patient. Find out, has the patient been unwell recently, or has this been longstanding? And the second thing and this is the most important thing is you must always look at previous X rays because the previous X rays may show you exactly what's going on. No. Okay, so this patient had a white out of the left hemothorax. And so I looked at the previous film, and five weeks earlier we've got a left upper lobe collapse. So the chances are that this patient has got a complete lung collapse from and endobronchial tumor, which is just at the orifice of the left upper lobe bronchus and is so so placed and positioned and of such a size that it's as it grows in the five weeks it causes complete lung collapse by obstructing the left main bronchus. Okay, now somebody's asked, why is it stable until the nasogastric tube was removed? Yeah. So what's happening in the case of a nasogastric tube, causing a pneumothorax. If the nasogastric tube has breached the pleura, the physical presence of the nasogastric tube is providing a plug to the pleura. And once the tube comes out, you get a pneumothorax because there's no longer anything plugging that pleural. Okay, so this white out here is caused by a left upper lobe collapse. Here's another one. Were the white out is caused by What? What's going on here anywhere? It's not a pneumothorax. We've got complete a classification of left hemothorax that nasogastric so that, uh, endotracheal tube. Where is it going? It's not a nasogastric tube, it's and endotracheal tube. And where is it going? It's not in the right place. Where is it going? It's going into the right main bronchus. Okay, so there's the left main bronchus, and the tube is going into the right main bronchus, and it's causing complete collapse of the left lung. And if you withdraw the tube and pull it back to a normal position, the lung will re expand. Okay, so that's a nice example of looking at what else is on the film. And so looking at the endotracheal tube and knowing that this is causing a complete collapse. It's withdrawal will allow the left lung to expand. Here's another patient who has got a white out, and this time it's associated with rib destruction. So the two scenarios that would fit with that X ray are that we've got a malignant pleural effusion which is causing destruction of the rib small pleural effusion on the left also. But this is a malignant pleural effusion with destruction of the rib. Now it's important to look at previous films and take a history from the patient because sometimes a pneumonectomy might look like this, and sometimes you get resections along with a pacification of the authorities. There is a patient who presented with a white out of following an assault, and although you can't see it very clearly, this patient on the CT scan did actually have rib fractures, and one of those rib fractures had lacerated the intercostal artery. And combined with the parietal pleural rupture, the intercostal artery was bleeding into the heavy thorax into the pleural space. Now, clearly you will only arrive at the diagnosis if you know the history and you've looked at previous films and it may be because it's an assault. It maybe the patients first and only film. But this is a cause of, uh, White House so white out of the heavy thorax. You can resolve the problem by understanding the clinical circumstances in which the patient has presented always look at previous films and then look at the film carefully to see if there are any precipitating factors that lead to the, uh the white out for the, um, increased the classification of the heavy thorax Knew my purse name gas under the diaphragm. Now the diaphragm is normally just an interface. And by interface, I just mean you can see where the diaphragm starts because you've got lung above it and soft tissue below it. But when you've got a pneumoperitoneum, you've got lung above the diaphragm and you got gassed below it. So were the pneumoperitoneum abuts the diaphragm. You can see both sides of the diaphragm, and this is a quite large new person name. The commonest cause of a pneumoperitoneum is a perforated duodenal ulcer. Okay, and you're more likely to see this on an erect abdominal film. If you're going to do a supine film, you're going to be looking for a football shaped gas bubble around the umbilicus in a supine patient but indirect patient. It goes up and causes the diaphragm to be seen very clearly in a subtle pneumoperitoneum. You can see small amounts of gas under the right hemidiaphragm and a small amount here, and that's really quite subtle. Okay, I'm going to talk about some special types of X rays that you may encounter in your practice. Does anyone know what a flare of segment is? No. Okay, when we breathe in, the rib cage expands. And when you breathe out the rib cage contracts and this is the, uh, the observation that you see, when you examine somebody from the end of the bed, you see inspiration cause the ribcage to go out and expiration the ribcage contracts. Now, in the case of a flail segment, it happens the other way around. The flail segment goes in during inspiration, and it probably doesn't move actually, during exploration. So everything else moves out during inspiration, except the flail segment and radiologically. A flail segment is defined as two consecutive ribs that are fractured in more than one place. Okay, so there's a fracture there there's a fracture there. There's a fracture there. There's a fracture there. And actually, we've got several ribs about four or five ribs, which have fractures in two places. And this means that this particular part of the chest is going to be under ventilated. Okay, so it's really quite important to recognize this clinically and if not clinically, radiologically. So a flail segment in this particular case is associated with the pneumothorax. And we've got fractures in two places, uh, involving three or four ribs in this situation and we've got associated pneumothorax and left side looks okay, so this needs to be fixed pretty quickly. And in the United Kingdom, anyone who has a rib fracture due to a significant trauma is considered for internal fixation of those ribs. Yeah, Miscellaneous. Here's a very large pleural effusion, which you can see here, and this mimics an elevation of the right hemidiaphragm, but is actually due to a large pleural effusion that sits underneath the lung. And that's called a sub pulmonic pleural effusion. Plural effusions are normally meniscus shaped, but sometimes the infusion gets trapped underneath the lung. Okay, and that's called a PSA pulmonic pleural effusion. Here's another example, so it looks as if the diaphragm is elevated. But the infusion is trapped under the lung. This patient has had to x rays three months apart, and you can see the shape of the heart has certainly changed. Now, it's very unusual for a cardiomyopathy to change that quickly. And therefore you need to think about pericardial effusion. And it goes back to what I was saying earlier, that the single most important thing is that you look at previous films. So understand the clinical context in which you're dealing with, um, but look at previous films, and that will give you the answer. And if you need to confirm this, you can do so very simply by doing an ultrasound or an echocardiogram of the heart foreign body I touched on this earlier on. This is a dental bridge which goes into the right main bronchus. And you can see here there's the dental bridge in the right main bronchus. Okay, so very important to recognize foreign bodies most foreign bodies will not do, uh, will not be seen on the X ray because they already loosened. But when you've got a radio peg for somebody uh, it's fairly straightforward. And here is a foreign body in a child, and I want you to tell me which side the foreign body is on the left or right, Right? Right. Who thinks it's right and who thinks it's left? It's actually on the left hand side. Okay, now, Rule Number one is that we don't see the foreign body in most situations because it's radiolucent. Now consider this. If you're looking at that patient, clinically, the right lung is moving with inspiration and expiration, isn't it? But the left lung has the same volume, whether it's on inspiration or exploration, and therefore it's the side that is not moving very well. Now. The golden rule about chest medicine when you're examining somebody is too. Look at the expansion and the side of reduced expansion or no expansion is almost always the side of the pathology. And so this side is not really moving, whereas this side is getting denser during expiration and smaller, and it's getting less dense and larger during inspiration. So that's the normal side and say what's happened is the foreign body is caused obstructive emphysema of that left lung. Okay, obstructive embassy of the left lung. Right. I'm going to come out of this now, and I am going to show you packs been cases. Okay, so, uh, by now, I think everyone should have had that link. Just post it again. And we did quite a few X rays last time. But I want you to go to number 13, which is it's number 16 in the order. So m s 013. And this is another case of, uh, endotracheal tube going down the right man. Broncos causing a complete collapse of the left lung. Now, can anyone tell me what this tube here is? You've got something that looks like a nasogastric tube, but there's a big balloon on the end of it. Can anyone tell me what that might be? It's a patient who presents with a hematoma, missus. Well, this is a sense taken black, more tube. Okay, I'll put it into the chat and sank steak and Blakemore tube is a tube with a balloon on. They insert the energy tube into the stomach, they blow the balloon, and then they apply traction on the tube to squash the viruses and prevent the virus is bleeding or at least try and reduce the variceal bleeding. Okay, so the patients got to interesting facts. Uh, one the same state stinks taken Blakemore tube, and the e T tube has gone down the right main bronchus. Okay, so number 14, which is number 26. So if everyone clicks on that one, So some of these x rays take a short time to load, by the way, So just be patient. Uh, and then with this link after the lecture, you can look at all of these cases at your leisure. Okay? They are there for your, uh, education. So look at them and take notes of all the answers that I give you. And you look at the X rays. It was This was a bit like the film I showed you, whether the heart suddenly increased in size. Although I don't have a previous film here. And if you put the put it side by side with the coronal CT, you will see that this is caused by pericardial effusion. So the fluid is around the heart. It's superficial to the pericardium, and it gives the heart this globular shape. So if you see the cardiac silhouette, changing its appearance and looking more globular, you must think, Could this possibly be a pericardial effusion? And this can easily be verified by doing an ultrasound of the heart or, uh, an echocardiogram. So number 15, I think I've shown you this on the power point, but it gives you an, uh, an idea of what you're looking for. So go back and have a look at it. You can see nasogastric tube is in the right. Lower lobe Broncos. I can see a lucency here. I can see surgical emphysema here. And if I go into the edge enhanced film again, it takes a little time to load because of the Internet speed. Um, there you go. You can see the pneumothorax here, so this n g tube is actually resulted in a pneumothorax number 16. I want somebody to tell me what the diagnosis is. It's a female patient, and they've got chest pain. So what's going on here? It's a female patient, and she's got chest pain. Any thoughts? Anyone? What would this patient look like from the end of the bed? Breakfast? Possibly sweaty. Right? Do you notice the left breast shadow here? What do you notice? On the right hand side. No breast shadow. So the patient had a mastectomy, and the mastectomy is because of breast cancer. And can you notice the ribs here? What's going on with the ribs? Any thoughts about the ribs? Broken ribs? Yeah, fractured ribs. Are they just broken through normal ribs? So you can see that there's a gap here. And actually, what's happened is you've got a pathological fracture. So there's a metastasis in the rib, and the metastasis has led to fractures of those ribs. Okay? And this is all as a result of breast cancer. So you've got an absent right breast. Got multiple metastases with fractures. Okay, Number 17. I'm going to make this the last one. This is a patient with the right shoulder pain and a chest X ray six months earlier was completely normal. What's the diagnosis on this x ray again? It just takes a little while to load. Can anyone see what the abnormality is? Very short. Costophrenic angles. That's normal. Yeah. When the X ray looks fairly normal, it does. Here I always think about a, B, C and D. A. Reminds me to look at the A P. C. S be reminded me to look at the bases, See? Reminds me to look at the cardiac outlines and in front of and behind the heart and D reminds me always to look below the diaphragm. So let's go back to a A for a procedure. Can you see a difference between the right apex and the left apex? Any thoughts? Well, there's the right apex, increased density. And actually one of those ribs has been destroyed. And if I show you on here, you can see there's there's the mass lesion affecting the spine. Just show you another. There you go. There's the There's the mass lesion in the right lung, which is invading the spine and also the posterior ribs. And that's called a pancoast tumor. So that's called a pankos tumor. Uh, I think I will show you one more, actually, because we've just got 10 minutes for the next lecture. Uh, number 18, which is number 14 in this list. So M s 018. Have a look at this one. Do scroll through these images when you get home. Okay? You've got the link and my first lecture was recorded So the answers to films 1 to 12 are in that first recording, and, uh, this will be recorded also. So this is a nice example of a curly beeline and a curly beeline is either due to fluid in the, uh, inter lobular septum because of pulmonary venous hypertension. Yeah, or because of lymph fluid in lymphangitis, lymphangitis tends to be unilateral, whereas interstitial pulmonary edema tends to be bilateral. Now, this is unilateral, and there's a mass lesion in the high level. So what do you think the diagnosis is anyone unilateral curly be lines with a mass lesion in the hilum. Is that more likely to be lymphangitis or interstitial pulmonary team lymphangitis? Yeah. And so if we look at number 19, number 19 is the CT scan of this particular patient. And let me just let that it might take a short while. There you go. So we've got the lateral lymphangitis, and if you remember the diagram I showed you at the very start where the patient has got curly be lines showing showing you the anatomy, let me just see if I can get that. Um let me see if I can get that presentation back up. Because this is This is quite important, actually. Right. So remember, I showed you the secondary pulmonary lobules. The central portion comprises the bronchus and the pulmonary artery. And in the winter lobular septum, which are the spaces between the lobules you can see on this particular image that you've got all these thickened interlocutor scepter on the right hand side. And that's due to lymphangitis caused by a central tumour which is obstructing the lymphatic return back to the heart. The lymph vessels go into the highland and then into the thoracic duct, which then drains into the left break. Okay, folic vein. So this is a nice example of unilateral lymphangitis. Uh, the patient has also got a small pleural effusion. Okay, so that's, uh that's the presentation over for today. I've got lots more presentations and I'll go through in subsequent sessions. I'll go through abdominal X rays, CT scans of the chest, CT scans of the brain, trauma fractures, Um, those sort of cases. I'd be very happy to show any anything you want, uh, in terms of, uh, what you would find useful that could be going over radiological anatomy or just basic stuff that, uh, you might need to see as a medical student, but as a junior doctor. So please feed back to me about anything you particularly want to see. Okay. Was any of that of any use? Yeah, it was very good. Great stuff I've got about. I think about another five lectures to give you, so I'll go through anything you want. Just let me know what you want me to show you. And I will do it in the format where you can scroll through the images. Uh, yourself. Is that okay? So thanks very much, indeed. If there are no questions, it's just left for me to say, Please, everyone keep safe. And if there's anything we can do for you educationally, just ask, and it will happen. So thank you very much.