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CRF RADIOLOGY LECTURE DR JOHN CURTIS (Term 2, 2022)

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Summary

This on-demand teaching session is relevant to medical professionals and will cover the basics of chest radiology, such as the silhouette sign, pneumothorax and surgical emphysema diagnosis, and the signs and dangers of an attention pneumothorax. Through interactive exercises and cases, you will learn how to identify these phenomena through X-rays and how to manage them. Come and do this medical professional session and improve your knowledge of chest radiology.
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Learning objectives

Learning objectives: 1. Understand basic chest radiology (i.e. discuss the 'silhouette sign', pneumothorax, and attention pneumothorax). 2. Explain how negative intrathoracic pressure is important for venous return to the heart. 3. Recognize symptoms of pneumothorax and different types that can occur. 4. Describe treatment options for pneumothorax, including green cannula insertion. 5. Properly identify and distinguish pulmonary vessels, changes in radiographic density in order to determine lung pathology.
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The following transcript was generated automatically from the content and has not been checked or corrected manually.

and just Sorry. I just started the recording. I'm sorry. I wasn't No, that's okay. That's fine. So I hope everyone can open this if they can't, uh, could they just indicate this in the chat so that, uh, I know that everyone's able to open it. Okay, that's fine. So we've got a patient with left chest pain and distance here. I'm going to close that tab now. Can anyone tell me what the abnormality is? Yeah. Mhm. Yeah. Put it in the chart. I want this to be very interactive. Mhm. Yeah. Can everyone see the chest X ray of Case M s. 001? Yes. Okay. So patients got left sided chest pain. What do you think the diagnosis might be? Yeah, Any thoughts? Put this. Put this down in the chat, not bronchitis. So open the open the chest X ray on your own computers and have a look. This patient who's got left sided chest pain and dyspnea, um, angina pectoris. They may well have angina, but that's not something you can diagnose on a chest X, right? Yeah. Myocardial infarction again. You can't diagnose this on a chest X ray. Can everyone see that there is a lung wedge visible just here. You're all able to see that, and you can see an absence of blood vessels here. Okay. And the long edge and the absence of blood vessels in a patient who's in the erect position means that you have a pneumothorax. Okay, so this patient has got a left sided pneumothorax. Okay, Now, what I'm going to do now is I'm just going to go over some basic chest radiology. I'm going to talk about the silhouettes sign now in radiology when you're looking at a chest X ray, the reason why you can see the heart separate from the lungs is because the heart has a different ability to stop the X ray compared to the lungs. Okay, so we've got lost the heart, which stops the X ray. To a certain extent, the bones stop the X ray to a greater extent, and then the lungs allow the X ray to go through relatively unimpeded. And so when you've got the X ray beam hitting the edge of the heart against the lung, that's called the silhouette sign. So structures of a different radiographic density that lie adjacent to one another can easily be seen separately. So in other words, one structure casts a silhouette against the other. And when you've got her spaces Oh, pacifying as you're doing consolidation, you can get a situation where the silhouette sign is produced between the lung and error in the bronchi. Okay, so I'll show you what I mean. So on this, uh, x ray on the right hand side, you can see that there is consolidation in the right upper lobe, and we've got the into the face of the horizontal fisher. And I hope you can all see, uh, in the bronchi. Yeah, and that's another form of the silhouette sign. Okay, so the reason why I can see the bone against the lung, it's because of the silhouette sign. The reason why I can see that blood vessel in the lung is because of the silhouette sign. In other words, the pulmonary vessel has a different radiographic density from the lung that surrounds it. Okay, And this is a very nice example of the right upper lobe pneumonia. Now, I'm going to encourage lots and lots of interaction here, and I really, really do want people to put things in the chat. If you were to put your stethoscope over this patient's chest in the right upper zone, what might you here, given the fact that they've got consolidation and and bronchogram any thoughts? Yeah, Yeah. Crackling. Yeah. Wheeze pops. Yeah. What about bronchial breathing? Bronchial breathing? In order to get bronchial breathing, you need to have a patent bronchus in Consolidated Lung. And so, in order to have an Arab bronchogram, the in the bronchi can only get there if the bronchus is patent. And so this will cause bronchial breathing and bronchial breathing is is nothing more really than transmitted sounds from the trachea. Okay, right down to the consolidated lung, which sits just underneath the stethoscope. Okay. Now, when I was a medical student in 1986 a long, long time ago the World Trade Center in New York, this is on a similar day, and you can see that the World Trade Center is clearly seen from the sky adjacent to it. And this 18th century church can be seen separate from the skyscraper because it has a different color density to the skyscraper. And if you like the consolidation that you can see on this X ray is similar to the mist that descends over the skyscraper. Okay, And it's obscures the skyscraper. So the first thing to go when you've got consolidation is the absence of the blood vessels. So I can't see any blood vessels here because we've got consolidation surrounding the blood vessel. Okay, over here. And as they have the same radiographic density, I'm unable to see the the blood vessel. But what I can see is the negative contrast of the air in the Broncos. Okay, so this is a right upper lobe pneumonia, and this is a very nice demonstration of the silhouette sign in real life. Now, the first X ray I shared, um S W 01 is a left apical pneumothorax. And what is a pneumothorax? Well, a pneumothorax is air in the pleural space, and it gets there either due to blunt or penetrating trauma, which causes damage to the visceral or parietal pleura. You can also get it in patients who got pre existing lung disease, such as cystic lung disease or emphysema, and in patients who've been ventilated on I t U. So here's an example of pneumothorax. You can see the lung age here, you see lots of vascular markings and these vascular markings, our pulmonary arteries and veins. And the reason that you can see them is that they have a different radiographic density from the surrounding lung. Okay, now where you've got the pneumothorax, you've got no lung markings, obviously, because the lung has retracted. And so you may or may not see the lung edge, depending on whether or not, uh, it's superimposed over a rib or not. But what you will see in a pneumothorax is absence of those vascular markings. And when you do an exploratory view, the lung will get smaller. But the difference in density between the pneumothorax and the, uh collapsing lung gets gets bigger. So in other words, the difference in density between the pleural space, which contains gas and the lung gets greater. Okay, So for those who have just joined, uh, Hannah is going to post a link. Uh, and this will enable you to see the cases, uh, live. Now. I'm going to come out of the presentation, and I'm going to go back into the cases here and good for number two. Open study. Some of these cases may take a short while to open. No. Can everyone see this? Okay, Yeah. Just put something in the chat. Yeah, great stuff. Okay, now this patient is on. I t U. What was this tube called? Come on, guys. Let's have a bit of interaction. What's this tube called here? Uh, not a nasogastric. It's an E T tube endotracheal tube, and they've just had inserted this tube here, which is the right internal jugular line. Okay. And this right internal jugular line has lead to an acute respiratory embarrassment. So, what's happened? Anyone? No bleeding damage to the vessel. Now, What's this here? Uh huh. Yeah. Can we see blood vessels here? No, I can't see blood vessels here. You can see blood vessels here, so this patient has got very large pneumothorax. Okay, Now, what's this here? This is the left hemidiaphragm. And where is the right hemidiaphragm? It's so depressed that I can't see it. Okay, this medicine will shift. So here's the pneumothorax pushing everything over to the left hand side. There's the collapsed right lung. There's the right heart border. This is the pneumothorax. And the pneumothorax is under so much pressure it's pushing down and diverting the right hemidiaphragm. So does anyone know what we call that? Yeah. Oh, yeah. Well, this this is attention. Pneumothorax and attention. Pneumothorax is when the intra thoracic pressure is so high it exceeds the intra abdominal pressure, and it causes the diaphragm to get pushed down and everted. Okay, So what I mean by a version is it's convex upwards is normal. It becomes convex downwards. Okay. In fact, so depressed is it that it can't be seen on this x ray. So this is a detention pneumothorax. Now I want to ask everyone What? Attention pneumothorax producers. What? What? Why? Why do patients die with attention? Pneumothorax Anyone? Yeah. Yeah, well, they they certainly get a collapsed lung. Yeah, Compression of the heart. Yeah. Yeah. Pressure impedes on the heart. Yeah, so? So what happens is, um when we breathe in and breathe out, we are helped in that process by the negative intrathoracic pressure that pulls blood or sucks blood into the right side of the heart. So the venous return to the heart is aided by the changes in intra thoracic pressure. And so the negative intrathoracic pressure pulls blood venous blood from the legs and the body into the right side of the heart into the right atrium and then the right ventricle. But if the pressure inside the thorax is so great that you no longer have a negative intra thoracic pressure, you're then in a situation were you are getting no venous return to the heart. And if you get no venous return to the heart and all of a sudden your heart will start beating because it's got no venous blood going in and therefore you're going to get no cardiac output, and it is a medical emergency, and this is treated by inserting a green cannula. One of these very fine ball cannulas, uh, in the second intercostal space midclavicular line and you hear this whooshing noise coming out because the pneumothorax is under some tension and it's a life saving procedure and it buys you a little bit of time before you need to put a larger chest rain in. Okay, so this position has got attention pneumothorax. Now I'm going to go back to, uh, my PowerPoint presentation. I'm going to tell you a bit more about noon authorities. So here's another example of a patient who's got a pneumothorax. You can just see the lung edge here. I hope you can also see that those the pneumothorax. And here is surgical emphysema. Okay. Yeah, And surgical emphysema. You can see gas in the subcutaneous tissue. Is everyone able to see that? Yeah. Great stuff. Okay, lovely. The left lung is completely normal. Okay, but on the right hand side, we've got a pneumothorax. We've got the absence of blood vessels beyond the lung edge. Got surgical, emphysema, surgical emphysema, and this is a pneumothorax. Sometimes the pneumothorax is not very well seen, and we need to zoom up the X ray and they can see the lung edge. Just that. So this is a zoomed up image of this x ray over here, so that if you suspect some of having a pneumothorax and they are in the erect position, So the standing up you need to look in the offices and you need to look very carefully for a lung edge, which tells you that the patient has got a pneumothorax. Now the situation is completely different If the patients in a supine position because what happens in a supine position is that the patient will have pneumothorax collecting in this region here. Okay, They get a pneumothorax collecting in this region rather than this region here was in the erect position. They'll have a pneumothorax collecting here. So this patient underneath it's an AP film. They've had a pacemaker inserted and they have a pneumothorax. And the lung edge is just here quite difficult to see, but there's absence of blood vessels just up here. Okay, so this is a pneumothorax secondary to put a pacemaker insertion. This is where a supine pneumothorax will collect. And I'm going to show you on the next slide a very nice example of a supine pneumothorax. So if you look at this chest X ray, which is the scout of a CT scan, you can see there's the left costophrenic angle. And if I look the right side, there's the right costophrenic angle, which is much deeper than it is on the right hand side. And we can see a lucency here, and all of this is due to a pneumothorax. And that pneumothorax is because it's going to collect in the anterior basil part of the chest. When the patients in a supine position. If the patient was in a wreck position, you would get the pneumothorax collecting here. And, of course, as you know, when patients go into a CT scan that they do so in a supine position. So this is called the Deep Salt Person, and it's a sign of a pneumothorax in the supine patient. And this is what the CT scan of that patient looks like. They've had a chest rain inserted. But here's the pneumothorax. You got an absence of vessels. There's the lung edge. And there's the cost of the threat sulcus, which is deeper on the affected side compared to the normal side. And most of that pneumothorax is going to collect anteriorly and basically, as you can see here. So here's the pneumothorax. Most of it's going to collect, basically, because the patient is in a stupor in position. Okay, pneumothorax here, pneumothorax here. Any questions on any of this? Anything in the chest? No questions at the moment. That's great. Okay, that's fine. So just another example, really, of somebody who's got a supine, uh, film. So this is again a chest X ray equivalent. It's actually the scout of a chest CT So before all CT scans are done, we live them down in a supine position and they get a scout, and they then have the CT planned. From this. And from this scout film, I can see that the right costophrenic angle is lower than the left costophrenic angle. And that's because the patient has got a pneumothorax, and you can see that the pneumothorax, instead of collecting at the apex, is collecting in the base. And so one of the one of the signs of a super pneumothorax is depression. Of that costophrenic angle, it's called the deep sort of a sign. Here's another example. Patients had an 80 to put in endotracheal tube prior to ventilation. They've also had a nasogastric tube, which is going into the stomach, and you can see that the cost of chronic angle is very deep on the left compared to the right. And that's because the patient has got this deep silk, a sign from a baseball pneumothorax. And this is the extent of the pneumothorax that you can see on the X ray. Now I just want to talk a bit about attention pneumothorax. All new authorities are under some tension because that's the laws of physics. Yeah, but in the situation where you've got a clinical tension hemothorax, the intra thoracic pressure is so great that it overcomes the intra abdominal pressure and it causes the diaphragm not only to depress, but to flip. So instead of being convex upwards, it becomes convex downwards. And so you get what's called a version of the diaphragm. So here's an example of attention Pneumothorax. We've got mediastinal shift and who got depression and ever version of that diaphragm. This was a natural case I was involved in in 1996 at the Royal Liverpool Hospital. Patient has come in with a road traffic accident, head injury. They've already had their head scanned. They've got chest drains already in situ. They've been intubated, so there's a chest draining on the right. There's a chest drain on the left. They've got massive medicine shift over to the right, and can everyone see that the dye from here is depressed? Not only is it depressed, but it is devoted, and that tells me that the patient has got attention Pneumothorax. Now, this looks grayer or whiter than this, and that tells me that because the patient is in a supine position. There must be both air and blood in the thorax, and that's a attention hemopneumothorax. And in spite of the fact that the patients got a chest strain in situ, we don't know what's happening to that chest pain. It may have a blockage in it. Somebody may have clamped it or it's up against the chest wall, and it's not functioning very well. But that thorax is under tension. And so I went into the scanner before we did the CT slices, and I inserted a needle into the left second intercostal space midclavicular line. Can anyone tell me what the sound was? Put it into the chest. How would you describe the sound that came rushing out? Well, it was a wash sound. It was a It lasts about five seconds, and you know that you've successfully treated attention. Hemothorax by the sound that comes out of the needle, okay, and it's a it's a whooshing whooshing noise or whistling noise. Now, this is the chest X ray that I've shown you, and this patient has the right internal jugular line put in and they get some deterioration, and this is my depiction of where the diaphragm is probably gone. It's turned inside out upside down. And we've got this version of the diaphragm, and it's so depressed. It's not even featuring on the film. Okay, so let's have a look at, uh, number three. So I'll go to number three open study. And this is a patient who has been, uh, evolved in a major trauma. Probably a radio traffic accident. 31 year old male. Okay, now, I use this case, uh, for the Royal College of Radiologist Trauma Teaching Day. So this is a proper, uh, trauma case, and you can see on the scout film that the patient is obviously lying down flat because they're in a CT scanner. There's the endotracheal tube. We've got some increased the classification here. This is a very low resolution. I would never use this to make a diagnosis, but can you all see that? We've got depression of the costophrenic angle compared to the other side? And so can anyone tell me in the chat What? I think the diagnosis might be just the very fact that we've got depression of the, uh, costophrenic angle. What sign am I demonstrating? that? Yeah, Yeah. Left sided pneumothorax. Yeah, and it could be a tension hemothorax right now. Where is the stomach bubble? It looks like it's here, doesn't it? And it just so happens that all these E C G leads are just overlapping the stomach. But actually, it's a bit deceiving because the stomach finishers were these e c g leads overlap. And this is actually the lucency of a pneumothorax. And I'm going to show you why If you go into this grid here, asks you to change the layout and I'm going to change the layout in 23, okay? And I'm going to put the axial and the corona image up side by side. Now, if you want to change the windows, you can do so by going into the second tab, which is the the sunshine here. And then press numbers. 12345. And I'm going to press number five. And that changes it too long windows. And you can already see that there is a pneumothorax here. I'm going to change that one to number five. And can you see that the pneumothorax is collecting mainly in the base, but the pneumothorax is so big, it's collecting at the apex and the base, but more so in the base. And as we go further down, we can see that the diaphragm is diverted in the anterior portion drug that across the so as we go across, can you see that the diaphragm has been diverted? Anteriorly. So this is an anterior basil pneumothorax with depression of the diaphragm. And not only if you got depression, the diaphragm, but what have we got in the lungs? What do you think this all this is in the lungs, given the fact that the patient has been involved in major trauma. Yeah, blood isn't it's confusion. Confusion. Yeah, that's absolutely right. So consolidation is often due to pneumonia, but it can also be due to a contusion or hemorrhage. It can be due to pulmonary edema in the case of heart failure. So it's just filling in of the air spaces. And the reason why the radiologist can often get the diagnosis correct is because we listen to the clinical history and the clinical history of road traffic. Accident or major trauma tells me that all of these forced I of consolidation are due to contusion, but this patient did have a attention. Pneumothorax. And it's just a very nice, uh, demonstration of that. So this is this saving patient, and I've got a nice little video, which is, for some reason, not playing. Not to worry. Um, we've got depression of the diaphragm. Okay, so that's, um that's quite, uh, an important case because it allows you as doctors to recognize attention, pneumothorax clinically. And if you don't recognize it clinically, you can recognize it radiologically by the depression of the diaphragm. Okay, so I'm just going to show you another one. And this is a young guy who unfortunately died. He was run over by a car and he presented with a chat secretary. He didn't get into the CT scanner. Unfortunately, this poor patient died, and he's got an endotracheal tube in situ. So this is case 004 endotracheal tube in situ. You can see he's got a deep sort of a sign compared to the other side. He's got contusions in the lung. He's got a new chemo pericardium, stroke gas around the heart in the pericardial space. He's got a pneumomediastinum extending up into the neck and the stupid pneumothorax. Let's go to number five. Well, that's loading. Just going to show you something. Like, uh, this is a patient who's got a pneumothorax. Okay. Showed you this earlier. Can you see that? Where the heart sits on the diaphragm, the diaphragm loses its visibility. Does anyone know why that is? Why does the heart lose its visibility where it sits on the diaphragm? Well, the reason is it has the same radiographic density as the diaphragm. And if it has the same radiographic dances the diaphragm, you won't be able to see the diaphragm over here. Okay, you can see the interface of the diaphragm here and here because the diaphragm has a different radiographic density to the lung that sits above it. Okay? And you lose that diaphragm, even when you've got consolidation in the lung of the diaphragm. But you naturally lose the diaphragm where the heart sits on it because they share the same radiographic density. Okay. And so if I just go back to this, um, I think this is loaded now. So this is a case number five. It's a portable, semi erect film. Got an endotracheal tube. We've got a nasogastric tube just going into the stomach. There's an E c g lead. There's an EKG lead here. There's a left internal jugular line. There's lots of surgical emphysema here. Surgical emphysema. And then we've got these streaks of lucency, which represents pneumomediastinum and a pneumomediastinum has occurred, probably because of the barrel trauma from positive pressure Ventilation. Okay, now this positive pressure ventilation has caused a pneumomediastinum, and you can now see the diaphragm because instead of having the heart sitting directly on the diaphragm, we've now got gas between the heart and the diaphragm, which you can see here. And this is called the continuous staff from Sign. And it's a sign of pneumomediastinum. Okay, so it's one of these signs that radiologists, uh, can look for and tell clinician that we're dealing with the pneumomediastinum. And in this context, it's almost certainly produced by the ventilation, uh, a ventilator, the barrel trauma that occurs. And, uh, the big question that we need to ask somebody presents with this following vomiting is, you know, does the patient have a ruptured esophagus, but in this context, it's probably due to ventilation. Now, if we go for number six, I want to show you this chest X ray, but it's an AP semi erect fill. It's taken on I t u uh, this hour and it's a mobile, and I want you to tell me what's happened here. A tube has been inserted. Can anyone tell me which tube has been inserted and what the problem is? Nasogastric tube. Yeah, very good. And what was the problem with the nasogastric tube? Not It's not reached the stomach. So where is it? It's in the lung, isn't it? Or in the bronchi. So here's the nasogastric tube. It goes into the nose, and then the distal portion of the nasogastric tube is going in the middle line. So everything looks okay so far, and then it takes an acute turn to the left. It's going down the left main bronchus left lower lobe bronchus right down into the a tip of that left lower lobe Broncos. Now there's a little bit of consolidation here. Patient may have a little bit of pneumonia, but what is the problem here? Why is that a problem? What do we need to do about that pretty quickly? Yeah, you need to take it out, because if the nursing staff inadvertently feed that patient. You're going to produce a pneumonia. Okay? And the pneumonia is going to be, uh, essentially, um, food in the lung, Okay. Or, you know, liquidize food in the lung. It's going to drown the patient, so this needs to be recognized pretty urgently and then removed. So this was removed and it was recited. And you can see here that the patient has got a nasogastric tube which comes down here. Okay, there's the metallic tip of that nasogastric tube. Okay? And we've got a different patient, and this again is a nasogastric tube. What's the problem with this one? Yeah, same problem, but it's in the right lower lobe broncos. Okay, so the nasogastric tube should come down the midline down the midline, and then when it gets towards the gastroesophageal junction, it should then veer off to the left. Okay, but this is clearly going down the right main bronchus into the right lower lobe broncos. Now, I want you to look at six b. So we'll skip six a, and we'll go to six b. These can take a little while to load, but the joy of doing it this way is that now you've got the link and you can scroll through these images after this lecture is over. And just have a look at what we've discussed. So it's an AP erect film, and here's the nasogastric tube. And it's going down, down, down, down, down, down. And then it takes a nose dive over to the left. So this is in the correct position. Okay, so this is a nasogastric tube in the correct position, and it's going into the into the stool color. Okay, I'm going to show you, uh, number 10 and number 10 is a patient. I've not put any history in here, but if I told you that the patient has got a fever and a cough, what do you think the diagnosis might be? Pneumonia. Very good. And where is the pneumonia, right? Yeah, Right. Lobe lobe, middle lobe lobe. Right. Lower lobe. Why is it in the right? Lower lobe? What? Anatomical feature tells me it's in the right lower lobe. Okay, let's go back to this chest X ray. Right. Okay. This patient has got a pneumothorax. But why can I see the right hemidiaphragm? Well, I can see the interface of the right hand the diaphragm, because the radiographic density of the diaphragm is completely different from the air related lung above it. Now the right lower lobe happens to sit anatomically on the right hemidiaphragm. The right middle lobe happens to sit side by side with the right heart border. So if I lose the right hemidiaphragm due to consolidation, that tells me that the patient has almost certainly got a right lower lobe pathology. And so I can see that the left hemidiaphragm I can see the right heart border, but I've lost the right hand he died from. So the silhouette of the right hemidiaphragm has been lost because now the lung above it and adjacent to it has the same radiographic density as the diaphragm. And so we're dealing with a right lower lobe pneumonia. Okay, that's the right lower lobe pneumonia. And this patient is most likely to have a pneumococcal pneumonia because they've they've come from the community, and they've got all the signs of pneumonia. They've got a cough sputum, pyrexia, and they've got an X ray, which shows right lower lobe pneumonia. Now I want to show you, uh, number 11. Um, I'm sorry to interrupt, but I just want to encourage everyone to do the feedback before we finish so we can post certificates for the selector at the end. Oh, yeah, that's that's fine. Thank you. Do tell me when to stop. I'm going to carry on. But by the way, so I get some immediate feedback. Put this in the chart. Is this the type of teaching you want to You want to hear? Yeah. Okay, good. So this this patient, um, is so this is number 11 is complaining of breathlessness, and you can see that they've got, um, what's called a lamella pleural effusion. Lamella pleural effusion. Where you've got fluid in between the visceral pleura and the lung. Not actually in the pleural space, but between the visceral pleura and the lung. And can you see these curly be lines Now, curly, be lines are where you've got fluid in the interstitial in between the secondary pulmonary lobules. Okay, so, um, if I can try and demonstrate this to you, heart failure, um, is almost always do two left ventricular failure. It can be due to, uh, cause is, but it's usually due to left ventricular failure. And what happens is that in the interstitial you've got the Broncos in the middle, pulmonary artery in the middle, always close together. And then in the interstitial or the inter lobular septum, you've got pulmonary veins and lymphatics that ruin. Okay. And when you get pulmonary venous hypertension due to heart failure, the fluid in the vein seeps out into this space. And it gives you these lines which are perpendicular to the long access of the chest wall like here. And it's a curly beeline. Okay, so all of these lines here, curly be lines. And it's a very, very sensitive sign that the patient has got interstitial pulmonary edema. Okay, that's called Curly be lines. And it's named after a doctor, Curly, who is a radiologist who first described it. There's another case and yet another case where the currently be lines are seen here. And what I've done is I've turned this diagram that I showed you earlier on its side, and there's a curly be line. There's a curly be line. There's a curly be line, and this is a very, very potent sign of heart failure. Okay, the other sign of heart failure, which you will see with number 12. Case number 12 is batwing pulmonary edema. So this is where the pulmonary edema goes from. Interstitial to Al Viola. Uh, and this is where the patient really, really experiences trouble. They get very, very breathless, and you can see that they've got airspace Pacification. They've got some broncho grams, and this is a patient who's got batwing pulmonary edema. Okay, there's another patient here with batwing pulmonary edema. Can anyone else tell me what the, uh what the other problem is here? They got that swelling pulmonary edema. They've got a small pleural effusion. What's the nasogastric tube doing? And what needs to happen pretty quickly? Yeah, it's in the wrong place, and you need to remove it. Now, if somebody's asked what is a curly be line, I'll go back because this is this is quite important. So the normal anatomy of a secondary pulmonary lobule is You've got this polygon. You've got a broncos in the center, got pulmonary artery. Wherever you see a broncos, you always say pulmonary artery next door to it. Now that's in the center of what's called a secondary pulmonary lobule. The pulmonary vein and the lymphatics run in the periphery of the secondary pulmonary lot of trouble. And so when either the lymphatic is blocked or you got pulmonary venous hypertension, as you do with left atrial hypertension or left ventricular failure, you then get fluid steeping out into these spaces. And when you get, uh, interstitial pulmonary edema, I just turned it on its side. And all of these curly be lines represent fluid in the winter lobular sector. And it's a very potent sign of interstitial pulmonary edema, which is the prelude to heart failure as we know it, which is the battling pulmonary edema, which is case number 12. So let me just show you that again. I'm sorry to interrupt, but we've got another two minutes. That's okay. That's fine. So does Does anyone have any questions for me in the one minute remaining? What I'm going to do in the next session, I'm going to go into a bit more detail with some examples of pathology, and again you'll be able to scroll through the cases in real time. So this is pulmonary edema. Back to doing pulmonary edema. Got some curly be lions pleural effusions. This is heart failure. Okay, so when a nasogastric tube is inserted, do you always do an X ray? Well, the teaching in the UK is to do the litmus test. So you put the nasogastric tube in the stomach, you aspirated. And if the PH is less than six, you know you're dealing with a correct placement of a nasogastric tube. But I have to say it's drifted now into, um, the, uh, situation where everyone gets a chest X ray. So doing a chest X ray is the safe thing for the patient, because you can then absolutely ensure that the nasogastric tube is in the correct position. The last thing you want to do is feed that patient via a misplaced and nasogastric tube. So next time I'll be doing more chest X rays, more CT scans, and by the end of my lecture series, I'll be showing you CT scans the brain's CT scans of abdomen's so that you can understand enough radiology to help your patients as doctors. So thanks for your attention. You guys keep safe and everyone in the UK is rooting for you. So very best wishes. Any questions you have? Uh, please, um, ask the moderators and I'll try and answer them via email. So thank you. Thank you very much. My pleasure. Thank you. Thank you. Okay.

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