Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

Uh Hi, everyone. Uh Thanks for coming. I think we're just gonna wait uh a few more minutes so that people join and then we'll, we'll start. Uh All right, I think we're just gonna start now and that's all right with everyone. So, uh thanks everyone for coming to the first uh Edinburgh University Radiology Society events of the year. Um Today we'll have um Nile who's ast one in radiology here in Edinburgh, uh speak a bit about um the chest X ray and how to um key concepts with it and how to interpret it. Um Just at the end, there will be also a feedback form. So, um if you stay until the end, uh if you complete it. So you also get a certificate. So, uh just keep that in mind for now and I'll just hand it over to you and I'll great. Can you hear me? Ok there for sure. Uh Yeah. Yeah. Yeah, apologies. I think my connection kind of lagged or, or cut off whilst you were doing the introduction. But thank you very much for, for having me. Um Yeah, as, as o'shea said, my name is Niall. I'm one of the radiology registrars locally in Edinburgh. And thank you very much for the invitation to, to give you a little bit of a talk tonight, which will hopefully be relevant for any medical students that are here, particularly those kind of maybe perhaps more in their clinical years. But I guess it's, it's something that you're going to come across quite a bit is the chest X ray. So, um we're just going to talk about some basic approaches and particularly focusing on um collapse and consolidation, which are two of the kind of key um pathologies that will lead to kind of white areas or pacification on the chest X ray. We'll also talk first about about some kind of more basic approaches. But uh what would be really useful um would be if, if you could, you know, interact, uh We'll have the chat open. So there, there are a few questions as we go along. There are obviously in radiology, there are sometimes some wrong answers, but it's, it's not uh it by no means a test this evening. So just, you know, if you, if you think you might know what's going on or, or particularly, there's a few, few questions where we're trying to localize where in the lungs things are going on, please do try and pop in some, some answers for us and we'll chat through your answers as well as we go. So I'll just move on to my sides and get going. So as I said, we'll talk about a chest X ray approach and some key review areas on the chest radiograph. Um We'll talk about alveolar and interstitial patterns of, of um a pacification or pathology on a chest X ray, which are kind of, it's an important thing to get into your head as you, you then kind of look, look at more chest X rays collapse and consolidation. As I said, trying to tell the difference between these two things which you know, you will read often in chest X ray reports but not really know what they mean. And then we'll do a little bit at the end with a white out lung. So this is kind of a common one that does sometimes come up in, in kind of finals. If, if you, you there, uh if you were lucky enough to get one of these in your finals, a chest, a chest X ray, then sometimes the white out lung can come up and just try to think about the differentials for what could be causing that. And there's some cases scattered through as we go as well. So there are a lot of chest chest radiographs in this presentation. All of them taken from radio pia, you'll see the little codes at the bottom. So if you want to find out any more about these um cases, or if there's anything that you're kind of struggling with, the way that I've explained it, then it is worth going on to radio pia and have a look. So yeah, as I said, you do try and interact in the chat as well as we go. And if I'm not checking in on the chat, hopefully, Usher and the, the gang from Eu Rs will, will you can just feel free to, to shout me down and, and ask me any questions as we go as well. So first of all, the, the approach to the chest x-ray and hopefully at this stage, you'll have kind of some sort of an approach when you're looking at your chest X ray. So you're not completely just a uh a rabbit caught in headlights when you see one that you just need something to fall back on that you can kind of like take a breath and just go through a bit of a structured approach. What you should have at the end of that is a, is a feel for whether the chest X ray is normal or abnormal. And it's not so important to know exactly what's going on, but to be able to describe it in a way that's useful I think is, is what they want, at least by the end of medical school. Um So the main thing to say is, you know, usually in clinical practice, at least having a previous chest X ray is very useful, particularly if, if you see something that's grossly abnormal, if you're able to look back at a chest X ray from, you know, perhaps a year, a few years ago and it was there, then it's less likely to be something that's, you know, the patient is going to be acutely unwell with, um, it's more likely a, a more long term process. So, but if you again, equally have a chest radiograph from last week that looked normal and one today that looks very abnormal, then that's obviously uh uh you know, it's going to sway the way you interpret the chest x-ray. So this is the approach that often these kind of, you know, med med school kind of um I think geek emetics and those kind of websites will kind of have different approaches. This is one I came across and is often often used. So the D doctors ABCD E obviously and a good A B eight E is, is something that, you know, is useful to fall back on. If you have a way of somehow battling these kind of approaches into an eight E, it is, it is a useful approach. So the doctor's part of it initially is obviously just kind of that bit where you're taking your breath. And you're just literally saying this is a chest radiograph of a 78 year old female. Um It's taken in apa um projection or an AP projection depending on how the patient is obviously positioned and then just have a quick chat about whether it looks like it's, you know, a well positioned, there's been a good inspiration and whether all the anatomy that you want to see. So from the A PSA, all the way down to the lung basis is included, then you're actually moving on to actually interpreting the, the anatomy and the, the pathology that's going on in the chest X ray. So you'll start often with the soft tissue and bones. So this is kind of an approach. Some people will use this. Other people will use an approach where they work outside in. So they start with the soft tissues, bones, the lungs, the central airways and the mediastinum. This approach goes a little bit all over the place. So some people don't like this, but it is an easier one to remember. So you go for the soft tissues and bones have a look at the airway. So back to the midline and the mediastinum, which is in obviously mid midline as well and the cardiac contour, then you go for your breathing. So this kind of falls back a little bit to your normal at e where you're looking at the lungs themselves, the circulation then. So you're this a little bit more back to the heart and the aortic arch and your diaphragm. So again, your costophrenic angles, anything below the diaphragm, so any free gas um and then the extras. So anything else that's, you know, standing out that you haven't gone through already? So any foreign body. So lines and tubes that the patient may have in, I think personally, this is a, this is a good approach and one that you should think about using, if, if you haven't got one already. And I think what I like to do is generally get lines and tubes out of the way. So if there's a, if there's an NG tube or a central line, I like to kind of comment on that or at least kind of reaffirm to myself that I know what that line is for before I then continue on and look at the the actual patients anatomy. So I look at the kind of more external things or the things that have been placed into the patient first. So that's an approach. So in terms of review areas after you've gone through this approach, this is uh yy, you, you, you should have kind of a good thorough assessment of what's going on. But there are certain areas where pathology tends, tends to hide or areas that are a little bit neglected in terms of reviewing a chest radiograph. And I'd like to know if anyone has come across or if anyone has kind of mentioned any key review areas on a chest radiograph. So if anyone would like to just pop into the chat, any particular areas on a chest X ray where you should go back and maybe have another look at in case you haven't, you know, fully assessed it or you might have missed something. So, we'll go, I'm gonna have a quick look in the chat. So maybe just about 30 seconds. If anyone has any ideas don't be shy. And are you able to see the chart? Now? There's some, if I can see the chat, I think I can see the chest. There's nothing in there yet. Is there? Uh, there's 20, and there, there are a few comments. I don't know if you can see it or not. I can't actually, I can see a few people have put so far the hilar area. Um Someone mentioned the um someone mentioned the retrocardiac area and paratracheal area and apical regions. Yeah, all very good suggestions. So unfortunately, guys, I might need to go back to you again because my chat doesn't seem to be uploading are are kind of keeping up to date. So, but it is great. Thank you very much for kind of interacting the the audience. So there's some very good suggestions there. Somebody said the hilar areas, the retrocardiac um lung is an important one as well. So these are my ones and the top two have already been mentioned or at least sorry, the these middle two have been mentioned already. So we've got the lung A PC. So looking for kind of a subtle pneumothorax up at the AP is one and it can be quite difficult there often when the contour of the lung itself is quite similar to, you know, the, the the you're looking at the kind of 3rd 4th ribs. So if there is a subtle pneumothorax, it can be difficult to see it initially. So going back and having a closer look and making sure you can actually actually see lung markings up in that area. Hilar shadows is a good one as well. So you should be able to see these hilar points, these kind of, you know, inverted triangle areas where, you know, if there's any kind of blunting or any kind of masses in there, they can be very easily missed. Um And then on the so and also just looking right and left. So the left one because the heart is obviously on the left side, this hilar point is usually just slightly higher than the right. Um So if there's any disruption to that, if perhaps the left one is a little bit lower or even in the same on the same level as the right, that can indicate there's been some volume loss and things kind of moving in that direction below the diaphragm and bones as well. Are the other two that I tend to go back at just having a look down there to see what if there's any abnormalities of the partially visualized bowel that you can see there or obviously, pneumoperitoneum we've already mentioned and the bones um particularly in the context of trauma, these, these are quite, you know, can be quite beneficial to go and have a look at the lungs specifically, sometimes inverting the windows. So actually completely flipping the x-ray digitally to to an inverted image. So the bones actually look black and the rest of the, the lungs look white underneath. They can just focus your eyes a little bit more on the bones. So they're my review areas. Now, we're going to move on a little bit and talk about alveolar interstitial patterns. And these are the two most common patterns of pathology that we'll see in the lung. So the difference between the two essentially alveolar is where you have, you know, from, from your basic anatomy that you would have done back in first year. You've got the alveoli, which are kind of the the major kind of functional unit of the lung. And there are these kind of pockets usually filled with air, but they can become filled with other things like, you know, blood pus, water, protein, selbri, all these things that I've mentioned here in the context of pathology. So for example, in the context of pneumonia, there would be pus and cell debris, all of that kind of stuff in it. And in the context of, you know, a pulmonary hemorrhage, you might have blood in the context of pulmonary edema. There might be water. The idea being that if the alveoli are filled with this material that isn't air, you'll give a particular appearance on a chest radiograph the other one is interstitial. So, rather than affecting the actual, you know, filling the alveoli, it's all these structures around the actual alveolus itself. All the supporting tissues that actually are are involved in interstitial processes or an interstitial pattern. We'll come on to the type of pathologies again, that are involved in interstitial um processes, but generally, it's things like fibrosis um that, you know, the, the problem being that there is a little bit of overlap between these two. But I think at medical school level, if you can kind of look at a radiograph and say, well, this is more likely an alveolar pattern or an interstitial pattern. That will be the most useful approach or way forward initially. This is just some images taken from one of the kind of chest X ray made easy books and this is just what I was explaining here. So you have your alveoli which are filled with kind of all this kind of abnormal debris or, or fluid in this one. And then the uh interstitial pattern is more that the actual parenchymal uh tissues are are involved in that process. And as I said, there is a little bit of overlap between those two. So what we, what we see of these on a chest radiograph is and then now the older one, it's usually more kind of patchy or fluffy um because all these alveoli are all beside each other. And you know, in e essentially superimpose on each other. It can look like there's fluffy areas of, of a pacification often with not very well defined margins unless a whole lobe is involved. In which case you can actually see a very well-defined lobe being involved with, you know, a big lot of consolidation. We'll come back to that a little bit later on. Um As I said, yeah, so segmental or lo air bronchogram or something that, you know, if you haven't come across yet, you, you may at some stage, but essentially what it means is because you've got all those alveoli filled with that material. There are kind of some bronchioles that run through it, connecting it. So some of those will still be filled with air. But because they're surrounded by uh fluid or pus filled alveoli, then you'll actually, you'll be able to see those kind of linear bronchioles quite well through. And that's what you get. That's what we call ear bronchogram. Hopefully we'll be able to come back and I'll show you an example of that later, interstitial patterns then is more linear reticular with sometimes these small nodules inside. And as, as you can imagine, because it's more affecting the tissue, you're not going to get that fluffy nature with kind of things coalescing and all those kind of alveoli on top of each other. Some people will talk about honeycomb pattern patterns and because the tissues in fibrosis, for example, are kind of contracting, you'll end up with reduced lung volumes and we'll talk about the application of reduced lung volumes in a few minutes as well. So, the things that are predominantly an alveolar process, we've already mentioned a few of these. So, a lobar pneumonia, for example, or aspiration pneumonia, will anyone tell me there? What would be the most common lung that would be affected in aspiration pneumonia? Has anyone come across this maybe in either in teaching or in clinical practice? So, aspiration pneumonia, is it right or left lung that's most commonly affected? I can actually see the chat now again. Hopefully it will update for me. So if anyone would like to tell me aspiration pneumonia, right. Yeah, perfect. And the reason behind that I won't ask you to, to go explaining it for me. It's because essentially the way that the anatomical structure is of the the right bronchus, it's a little bit more linear um orientated. So if you do get aspiration of fluid down the trachea, it will end up kind of going preferentially down to the right side. Um So that's that one. And then, so the predominantly interstitial processes, sometimes you can get pneumonia that, that affects more of the parenchyma of the lung rather than the actual alveola themselves. TB is one of those that can, can also affect kind of more of the interstitial interstitial, sorry and sarcoid and idiopathic pulmonary fibrosis is the other one. So we've already said fibrosis is kind of the classic example of an interstitial process. But sometimes these kind of more atypical infections can also cause interstitial processes. The one that I the one that I should point out that gives kind of a both of these appearances is pulmonary edema. And obviously, in the context of um congestive heart failure, this is something that we do see quite a bit. So you end up with obviously an increase of fluid in the lungs generally because the heart is obviously failing to kind of move it on and it gets backed up into the lungs. So you get both kind of pulmonary edema. So some fluid within the alveoli, but also the, the, the parenchyma of the lung itself becomes more wet and thus, you kind of will have an increased of an increase visualization of the, the parenchyma in the lungs as well. So, it's both an interstitial and an alveolar process. Um Just a quick one again, a good one to know for finals is the chest radiograph features of congestive heart failure. And this is another a to e so I'm sure I won't go asking you this, but I'll just have a quick look if anyone's gone for it. No. Um So essentially the a to e alveolar edema we've already talked about. So this is pulmonary edema. It's the, the alveoli filling filling with fluid, curly bee lines. So this is interstitial edema. So you can usually see it quite laterally in the lungs themselves. So these kind of like really fine lines where the, the interstitium of the lung has taken on more fluid than it would normally have. Then you've got the cardiomegaly. So that's obviously just the heart enlarged greater than a a cardiothoracic ratio of greater than 50%. Um that's measured on apa chest radiograph cause, obviously, you will get a magnification normally on an ap chest radiograph. So you can't really assess the the cardiac um the cardiothoracic racing on that side, dila dilated upper lobe va vasculature as well, just due to the kind of the changes in the the hemodynamics and the circulation in the the lungs. Obviously, in the, in the context of congestive heart failure, you get kind of more prominence and an increased vascularity towards the lungs that are normally kind of quite blacked out and over exposed, not overexposed, but more exposed than the, the lower um kind of the bases in a normal chest radiograph and pleural effusions as well. So, a lot of these, at least three of them are due to the, the fact that you've got kind of increased fluid in the lung. So we're going to now go through some chest radiographs and again, I'm gonna give about 20 seconds for people to have a quick look at these. And if you have any, if any ideas come to your mind as to what's going on, it'd be great if you could um pop it in or at least tell me what side the, the abnormality is on and we can kind of go from there. So, does anyone want to tell me where the abnormality they think is in this chest radiograph? Not a trick question. Um Right lobe. Yeah, I see one come through there. So Michelle said right lower lobe. So that's a really good you, you've obviously localized it to this area here. So this kind of area of a pacification, which I think you'll agree with me in saying that it's a little bit fluffy rather than it being kind of very reticular or kind of uh honey comb or, or any of those kind of, you know, reticular nodule that we'd normally associate with interstitial process. This is quite fluffy and ill defined and it's down here towards the, the right lower zone. The issue being with saying the right lower lobe is that in this area, we've got both the right middle lobe and the right lower lobe and they're superimposing each other. It sometimes is impossible to really say whether it's in one or the other. In this case, it certainly isn't. There are some tips and tricks that I'll come to in a few moments about that will help you a little bit in terms of deciding whether it's right middle or right lower lobe. So I think the safest thing to say in this case would be that there is right lower zone. So right lower zone, right, middle zone, right upper zone, there's right, lower zone fluffy pacification. Um And obviously, you might get a bit of clinical information if this is given to you in a, in a, in an examination and if the patient was febrile and had a cough, then it's, you know, that's likely to fit with a kind of AAA pneumonia or, you know, some consolidation secondary to infection. So really good. This one a little bit more difficult, but uh it's not really so much where is the abnormality? Because the abnormality is everywhere. But does anyone have any idea what we're looking at here? What the diagnosis might be? Yes, we've got one answer in for pleural effusion. So I think pleural effusion is definitely implicated here. Um So there is, it's difficult to say for definite. There's, there's probably, you can probably see, I'll go back to the slide again for a minute. There probably is a, a line of fluid here. This is a portable chest radiograph. So not the best kind of quality one. But you can see here, there's some fluffy kind of opacification as well, which doesn't really look so much like a a pleural effusion. It looks more like there's some opacification, some alveolar pattern type opacification going on here. Now this isn't a a mobile, so a portable chest radiograph and will have been done kind of ap but this heart just, it kind of strikes me as probably you know, being very, very large and, you know, you can say for sure, but there probably is some cardiomegaly here. We've already said possibly pleural effusions. I think these look slightly dilated, the interstitium just generally looks um a little bit more prominent. So I think this is one of those pictures that you'll probably see quite a bit when you become a foundation doctor of a patient in acute kind of congestive heart failure. And you know, again, you'll be putting this in the context, you know, when you're working on a, on a medical take or an A&E putting it in the context of the patient in front of you. But I think it, it does really fit or more likely to fit here with a patient who's in kind of congestive heart failure and has pretty much all of those of the A to e the only one that you can't really make out that well. And it's just because it's, you know, there's all this opacification down here are the curly bee lines. It's quite difficult to see. So really good. I don't know if there's any more comments there. That's fine. Move on to the next one. So anyone want to say where they think the abnormality is here, no takers so far. This is a little bit more difficult. So what we're looking at here is there's definitely this is the first thing that jumps out at me, certainly. But also on this side I think there's some kind of patchy pacification with also some increased interstitial markings here as well. It's, it's less kind of fluffy and more you can actually see the interstitium is a little bit more prominent this one. If you go to this case, uh, you know, you don't necessarily have to, you can trust me, but it's, it's more of a, an atypical pneumonia type picture where I think there's a little bit of a mix of both alveolar. So you've got this kind of fluffy opacification, but also this kind of bilateral lower zone reticular kind of pattern going on as well. So this is just to show that things aren't always very straightforward and often times the satisfaction of, of looking here and finding this will make you kind of ignore the fact that this looks a little bit odd and even out towards this side as well. And this one finally does any, would anyone like to tell me whether this looks like an alveolar or an interstitial type pattern? Um If you were to kind of be shown this, would you start by describing it as alveolar or, or interstitial? You give five or 10 more seconds to get one answer. If I'm not seeing any answers that have gone up as you can, let me know track of deviation is a good call. Yeah. Um and I think that there probably is a little bit of that, but in terms of so just we'll come back to that in a second. We talked about the two patterns of alveolar or interstitial. So, alveolar being kind of more of a fluffier pacification and the and the interstitial being more kind of linear kind of pattern reticular little nodules do. Which one of those do we think we're dealing with here? Yeah, thanks. S so interstitial. So we can see here, bilateral lung fields increased, kind of, you wouldn't expect to see these kind of interstitial markings as prominent as we're seeing here on both sides. Um We've got banner who mentioned a little bit of racial deviation. There probably is a little bit of tracheal deviation. And this is what I was trying to mention earlier on is that sometimes because if you have a, if you have an interstitial interstitial pattern that's caused by fibrosis. So you can imagine that there's that fibrotic process going on and the the lung tissue is all pulling, you know, uh in the direction of the fibrosis or where it's happening is pulling structures towards it. There probably is a slight shift of the trachea towards this direction because of that fibrotic process. And this is quite a classic appearance, essentially of, of idiopathic pulmonary fibrosis or a or a fibrotic lung disease. So, we're going to come on now a little bit to talk about, which is the main part of this talk is about consolidation and collapse. So these are words particularly when you start reading radiology reports as a junior doctor. Maybe you're doing it already as a medical student. Well done to you. If you are, you'll hear a lot about consolidation and collapse. But no one, at least for me, it took a long time for anyone to kind of explain exactly what they meant. So, is consolidation the same as collapse. And I'm not going to get you to answer that question because the fact that I'm asking it and the fact that I'm talking about differentiating between the two would suggest that they are not the same thing. So, consolidation involves the opacification of the lung. So there's, but there's little or no volume loss. So we've already talked about fibro fibro fibrosis leading to, to volume loss. But consolidation is where you have those alveoli filled with some sort of an abnormal material, it's filling it and replacing the air that's there already. So you're not losing volume, it's just replacing, you know, the air that's in there already. So collapse. On the other hand, we come to it in a moment does involve some volume loss. So consolidation is an alveolar process, we've just said, but it's it. So sometimes, so we, we'll, we'll come to, we'll come to collapse in a moment. So consolidation can be very easy to detect, but sometimes a little bit more challenging and can be a little bit difficult to figure out where it is uh in the, in the chest as well, or even sometimes it can be very subtle. And the only thing that will, that will kind of allude to it happening is something called the silhouette sign. So has anyone come across the silhouette sign? And would anyone like to try and give a really brief explanation in the chat as to what it means? So I'll give 10 seconds and if no one is jumping at that, then I'll go ahead. Yeah, bat bat wing shadowing. So batwing shadowing is usually related to the appearances of pulmonary edema. You get that kind of bat the back hilar batwing kind of appearance of acute um pulmonary edema is usually the batwing shadowing. The reason I've used this as a as a kind of gift in the background here is the idea that it's a silhouette. So maybe that was a little bit of a tricky one to put in. So what I mean by the silhouette sign is I'll come on to it and just explain it on the next slide. So it's when there's something in the lung and it touches a normally an area of the chest X that's normally really sharply defined. So it's got a really well defined silhouette. But if you have something like a little an area of consolidation or a lung tumor or something that, that comes up really close to it, you'll lose that normal well defined boundary between, you know, the, for example, the, the hemidiaphragm or the heart border and the, the rest of the lung and the fact that you've got a miss a missing or a blurred interface where things should normally be really sharp, that is the silhouette side. Um So it's useful in the detection of consolidation and collapse. So we're going to just talk a little bit about this now, and somebody had mentioned that the little focus of consolidation earlier on was in the right lower lobe. And we're going to talk about how we can sometimes tell whether something is in the right middle or the right lower lobe. So these are two chest radiographs that show consolidation or some sort of a pacification in what what I would I would term the right lower zone. So there's some consolidation here and there's some consolidation here. The way that you can tell the difference between whether this is right middle or right lower lobe is by using the silhouette sign. So on this side here, we, we'll just have a look at the normal borders that we should normally have that we should see regularly on a chest radiograph. So we've got the cardiac borders here right and left the hemidiaphragm all nicely defined when we come over here and start to trace the, the hemidiaphragm on this side. Uh On the right side. Can I just confirm with Usher or someone that uh you can see my um pointer? Um Can you show it again? Yes, yes, we can you can great. Perfect. Um So yeah, on this kind of right lower zone but one, so I was just talking about this hemidiaphragm. I'm not really seeing it so we can even compare it to this other side. It's not really that well defined. So this suggests that whatever is going on here, be it a bit of consolidation or pneumonia is coming in close contact with the hemidiaphragm, the hemidiaphragm when we will come to some anatomical pictures in a moment comes in close contact with the right lower lobe. So this which is yes, there is consolidation but it's in the right lower lobe. Whereas if we come over and look at this one again, we can see we've just used it as a as a comparison. The hemidiaphragm is really nicely well defined. But when we're looking at the cardiac border on this side, it's it's lost particularly in this kind of lower portion here. So this would suggest to me that again, this right lower zone consolidation is actually in the right middle lobe because it's coming in close contact with the heart border, which the right middle lobe does. Again, I'll show some pictures which will clarify this soon. So this is a chest radiograph of a younger patient and it's again showing the silhouette sign. So we're looking more here on the the left hand side. So we we've got kind of this kind of ill defined kind of fluffy opacification here and the heart border as it goes out towards the kind of left side, the, the kind of cardiophrenic part of the, the heart border is lost. Does anyone want to tell me what part of the lung that they think this is in? Perhaps based on a bit of anatomical knowledge you might have from previously, it's completely, completely fine to just give a guess. No judgment. We give 10 more seconds, no one taking it. I think. So, the trick was essentially is that there, you know, if we're looking at the cardiac border on this side, it's going to be the right middle lobe, but on the left side, we don't have a right middle lobe. Um It's, it's not going to necessarily, it, it's going, it's, it's going to be the lingula here on this side that's actually affected, which is a part of the, the left upper lobe that's um been involved in this side. So that's the part that comes in quite close contact with the, the cardiac border on this side. I think you could also argue that the hemidiaphragm on this side is not really that well demonstrated as well. So there's probably an element of it extending down to that as well. So we're going to come on to collapse now. So collapse versus elexis. Does anyone know the difference between these two things? This is probably worth somebody trying to answer. Has any anyone, does anyone know the difference between these two Yeah. So we've got, got somebody saying used interchangeably. Um And I think that is fair enough and I think the g maybe, um suggests that as well, they are essentially the same thing and I don't think it's, the radiology is trying to trick you, but I think it's just that there's kind of a preference in different countries for what, what to use. I think generally, what we would say we would use atelectasis for as a sublobar collapse. Um And then kind of a collapse would be of a whole lobe generally. Um And yeah, there's a little bit of Greek there for anyone who's particularly interested. But the main thing to say is because actually the lung is collapsing, it's not being filled with some sort of a material as we've seen and kind of consolidation, it's contracting, it's, it's collapsing in, in itself, there's going to be loss of volume in the lung. Um And sometimes actually even it's so central to the process of lung, there's volume loss is that some people will actually use collapsed atelectases and volume loss. It's kind of all the same thing. So it's just to be aware, don't be afraid by, you know, uh terms that are used, particularly atelectases can sound very intimidating, but essentially it's just collapse. Um And, you know, on a chest radiograph, sometimes if, if people aren't breathing that well or, you know, for example, postoperative chest X rays after kind of people being on, you know, being ventilated for the purposes of a general anesthetic. They kind of, it's not unusual to see just little linear areas in the bottom of the lung that is just kind of some, some little areas of vital lectus. And then as the patient starts to breathe for themselves, and the anesthetic wears off, you know, those things will, will, will those areas of atelectasis will reinflate. So volume loss. So as I was saying, it's, it, it means that kind of the structures that are normally stable can be moved in one direction. We had somebody answer earlier on in the case of the fibrotic chest X ray that they felt the trachea was slightly pulled in one direction. Um in order to interpret volume loss, it's, it's quite important to actually see on the chest X ray, you know, know what, what normal is and where your normal structures are on a normal chest radiograph, which is, you know, it's easier said than done. And it takes quite a while or, you know, to look at quite a few chest X rays to get that. The, the main ones to say are we've got this kind of horizontal fissure here, which is not normally actually seen because it's, you know, it's just a soft tissue kind of interface between the, between the, the lungs, the lobes of the right lung. But normally, you know, if you were to do a CT, it's often easier to see it, but it just runs across here. This will be important. We come back to that in a little while. But other things like the trachea kind of being moved in a particular direction. The hilar shadows, we've talked about the fact that the hilar point is usually a little bit higher on this side, on the left side to the right because it's slight, slightly shoved up by the heart. So collapse is something that causes radiologists and by virtue of that, um the people who are looking after the patients um who have collapsed quite a bit of concern. Does anyone know why? If we see an area of collapse in a chest X ray, why we're quite concerned and would maybe be quite eager to get a patient back again um For another chest X ray after maybe they've been treated with antibiotics and try and get someone in five or 10 seconds or else I'll jump back in again but do feel free to answer if you no takers. So the reason it causes concern essentially is that low? I think there was something Oh Grace. Is it to do with VQ mismatch? There will be VQ mismatch because you're not aerating these, these parts of the lung. So that that can often lead to low saturations. Patients who end up with collapse, particularly like a low bar collapse can end up with low sats. The reason it causes concern is because of the actual etiology of the collapse itself. Because if you whatever is causing this lung to collapse, you've got to kind of think of that a little bit as well. So if there's, you know, an endobronchial lesion of some description, some sort of a tumor growing in the actual bronchus that's causing, you know, the lung beyond that to collapse. That's the major concern. That's the most sinister cause of the collapse. Obviously, a lung collapse, there can be some kind of less sinister ones as we'll come on to in a moment. So tumors are the main one. But also we've talked about kind of fluffy opacification and consolidation in the lungs being pneumonia. But if somebody has a chest infection, mucous plugs and mucous plugs also happening in the context of asthma, all these things can actually block off the, the lumen of the broncho, the bronchus or the bronchioles and cause collapse of the long distal to that. Um foreign bodies are the other one as well, typically. And Children will see, you know, swallowing things that they shouldn't swallow or not, not necessarily swallowing but aspirating them. Um And then beyond that, because it actually occludes the bronchus, you'll get collapsed beyond that. So, yeah, as I was saying, this is where it gets a little bit more confusing because mucous plugs can be seen in pneumonia. So collapse and consolidation can also kind of happen together as well. So I can pull it all apart for you because some of it will come back together. But I think it's good to have a framework in your head as to the differences here. So I think this might be one particular example of a child, um, who's come in for a chest radiograph because, um, they're kind of short of breath and they've got a cough. Anyone want to jump with this one. I think I'll, I'll do this one myself. There's a few more interesting, interesting ones that I can get people to help out with. So essentially what we're looking at here is it is quite subtle, but I think behind the, behind the heart here, it looks like there is a little bit of collapse going on. I think you can see the hemidiaphragm quite well there, but there looks like there's a slight collapse here and this is one of those where the hilar points are quite useful. So we've got this hilar point here on this side and this one, I think that this actually highlights it a little bit better in a moment. So your hilar points. So this one should be higher and it's actually been dragged down. So this is where the volume loss is and this is where the hilum has been pulled down in that direction. So this is a child who's probably inhaled a peanut or something like that or some sort of a aega bit and it's gone, gone down and caused a slight blockage there. So collapse, the main things that we see on a chest X ray are volume loss. Um So things being pulled in the direction of where the collapse is. So we've already seen the hilum being pulled down. In that last example. The other thing that we might see is because obviously the amount of air coming in through the trachea and down to the bronchus is going to be relatively the same. You might get some hyperinflation of the other lobes that aren't collapsed or the other areas of the lobe that aren't of the lung that aren't collapsed. So this is a little bit of a bulky slide and apologies. It's quite worthy and we will try and wrap up in the next 10 or 15 minutes. I want this to be quite snappy. And obviously, if you find it useful to go back to have a look at these cases again, so collapse of a whole long lobe because obviously the anatomy of a chest of the chest and the anatomy on a chest X ray is quite standard. If you collapse a whole lobe of your lung, there's quite specific appearances of that lobe being collapsed across many patients. So if you have, you know, any, any patient with a, you know, left upper lobe collapse should have quite similar appearances, you know, regardless of who the patient is. And this is the the thing to kind of say, and it it is quite if you can kind of burn the images that I'm going to show you into your head, you'll be able to say you'll look quite impressive on the ward round. And when you're a junior doctor, you'll be able to say, well, I know that doesn't look right. And actually, if I think about it, there's some volume loss and that is something that I've seen before being the left upper lobe. So hopefully, these will will stick with you. But essentially by thinking about the basic anatomy, the silhouette sign and where the volume loss is going. So where things are being culled, you can often identify what lobe is involved. So here we go with the first one. So does anyone want to tell me what lobe is involved? And yeah, I think just what lobe is involved, first of all, for this one middle lobe. So yeah, right middle lobe, exactly. There is no left middle lobe. So that is a completely fair answer. Ally. Um So yeah, we've got on this one, we've got this silhouette sign we've already talked about. So the the the cardiac border here is lost, but we've also got, and this, in this case, we had, I think the last one we looked at that had loss of the the border on this side was consolidation. So there wasn't actually volume loss. We're saying that volume loss is, is quite specific to collapse. So the we've got, we've lost this border but we've also got this shift of structures towards the right. So that's suggesting that it's, it's not consolidation, it's collapse. So it's a right middle lobe collapse. This one there is a little bit more difficult, but probably the more the these kind of ill positioned and portable ones are the more common ones you're going to see. Does anyone want to tell me where they think the abnormality is here? Anyone want to take this one? If I miss it when I'm flicking back to my slides, let me know. But essentially this one is a little bit more difficult, as I said, but we're looking here at the cardiac, but we've got this, this, this is the abnormality. So that's the main thing is in your, your initial assessment is to figure out that this is, this is what's wrong. And then you can kind of use these other tools that I'm teaching you this evening in terms of the silhouette sign and volume loss to try and figure out whether it's collapse or consolidation and hopefully what lung it's in. So we're looking at this area here, not really seeing the the hemidiaphragm that well on that side, but the cardiac border, you know, sometimes these don't project very well, but I think you can see that the cardiac border is really well defined here and there's also some volume loss. So you can see that these this cardiac border, you're not really seeing it as prominently or you shouldn't see it as prominent as it is as it is here. So we're actually getting a little bit of pull up structures again towards that direction. Um And probably a little bit of tracheal deviation down that way as well over towards the left or sorry, the right side. So this is AAA, right, lower lobe collapse. Oh, yeah. So some answers came through there. Um So yeah, that's what, that's the one we're dealing with there a little bit more difficult, that one. So again, this is the kind of picture that I like to show in the context of showing this these X rays. So obviously, the cardiac border is going to come really nice and close to the right middle lobe. Whereas the hemidiaphragm is going to kind of mostly come in contact with the right lower lobe. So the fact that we're not really seeing the the hemidiaphragm on this side suggests that it's the the right lower lobe that's involved this one, anyone want to hazard a guess as to where they think the abnormality is. And if anyone can tell me what the classic radiographic kind of term for this finding is that would also be great. OK, we've got who says, left lower lobe. So yes, is the answer. So let's go back to this one for a moment. So the the key finding here is actually this is one of our, our review areas and this is something that people do miss. Unfortunately, sometimes. So we've got this increased opacification. Normally, you should be able to see lung markings in that retrocardiac lung. And you can't see that at all. We've got this kind of triangular density that's going down here and you can see that the mediastinum is being pulled in that direction as well. This is kind of all going that way. I think you can probably see that the trachea has gone slightly, but definitely the mediastinum, there's volume loss, things being pulled in that direction. So this is the sale sign and this is the, the again, one of these that I want you to try and this is what the orange light is for. So it's going to be burned into your, your memory. So we've got a S sign this triangular area and that is a left lower lobe collapse. Next one, I don't want to say what this this one is. Again, just think a little bit about the areas involved. I guess we've already dealt a lot with right middle and right lower lobe stuff. So by process of elimination, you probably realize that we're dealing here with the right upper lobe. So this is a right upper lobe collapse, which is the gold and S sign. So essentially, you can kind of see that this is the S and what this actually is is the horizontal fissure. So the horizontal fissure as we've kind of this is why I've put this little picture in here. So the horizontal fissure is normally kind of, you know, a convex towards the lower part. Um Whereas here, because there's been that volume loss and that whole lung, that whole lobe of the, the, the right upper lobe has collapsed. It's been pulled in that direction. You can see the track has gone that way as well. So, you know, if it, if it was, it'd be quite odd to get it. But if you had a, a right upper lobe consolidation, you wouldn't see this volume loss that we're seeing here, you would just see kind of a, you know, a white out or opacification of the lung up here. But it's the fact that we've got this volume loss in association with this opacification that makes us think that it's, it's collapsed rather than consolidation. And this one, yeah, and some good answers there on the last one there. Uh So this, this next one, anyone want to tell me where they think the abnormality is. I think the answers might be lagging just a little bit for me. But thank you for, for giving me some interaction this evening, left upper lobe and like I said, so, yes, this again is another kind of classic one that I want you to remember and this is called the vale sign. So again, you've got this kind of generally increased opacity across the left lung. Um So if you were to compare it to the right. I think you'll probably agree with me there. But you've got this kind of well defined hemidiaphragm on this side, the hardboard is not so well defined, but then this other thing, so that's the veil sign, the fact that it's, it's not a, a dense consolidation of that side, but it's just a, you know, a slight increased opacification of the other side. And you've also got this kind of linear bit of increased lucency. So a little bit of darker bit in this side. And this is what I was saying earlier about, you've still got a similar amount of air going down the track and into the bronchus. So actually what happens here is the right um lower lobe has a compensatory increase in um obviously, the amount of air that it, that it has in it. So you end up getting this kind of linear bit of, of lucency along the the mediastinum here. This is just a lateral chest X ray, not something you need to worry about so much for, for medical school. But this is just showing essentially that, you know, if you were to take a lateral chest radiograph on somebody with this, you, you, you'd see that kind of the that upper lobe which sits more anteriorly would be opacified or kind of collapsed. This one, this one might be a little bit easy in terms of finding out where the abnormality is, but I think it kind of leads us on to the finish up of, of our talk this evening. So the abnormality quite clearly is going to be on the right. And I don't think anyone was going to get that wrong this evening. We can also see that the trachea on this side is actually quite, it's a lot easier to see here because the whole lung is ified, but you've got shift of the trachea in that direction. Um So that, that indicates there's going to be some volume loss here. Um This can be uh quite a complex thing to try and pull apart. But I think it's again, try to get a bit of a framework in your head. So you've got almost complete opacification of the of the lung field with volume loss. There's a few things that are going to cause a complete opacification of a, of a lung. Um Things like collapse of a whole lung, a large pleural effusion or a pneumonectomy is the other one that we need to be aware of. So if somebody gets a whole lung removed, which is obviously done in the context of cancer, sometimes, um we need to be aware of that the issue being or the the important thing to remember is that particularly in a clinical setting, you're going to have a patient in front of you. Um So what would be very, very beneficial here would be, you know, how unwell is this patient? If the patient is, you know, not saturating very well and has a massive VQ mismatch. Then this is more likely to make me think that, you know, in the context of volume loss, that they've just got a massive lung collapse, a whole lung collapse. And I'd be very suspicious in that case that actually there might be some sort of a bronchogenic tumor that's causing it if this patient had a history of surgery, you know, for of a pneumonectomy a couple of years ago and they were actually sitting in A&E completely well and I'd be less worried about that. So we're just going to talk about the white out lung a little bit now. So the things I've already mentioned can cause a white out lung feel. So a large pleural effusion. Um So there's, there's two different types. So a large pleural effusion that has uh that's causing some compression of the lung beside it. Um And then, you know, a little bit of compression and collapse. And then there's ones that, that causes major collapse, uh and sorry, collapse by compression of the lung. And then we've talked about the a collapse of an entire lung. So that's just where there's some sort of something in the bronchus that's causing the whole lung to collapse and a pneumonectomy. So the three things are a pleural effusion, collapse of the entire lung or a pneumonectomy. And often the clinical will, will help you a little bit with that, I think you can obviously get a, a very large, you know, extensive pneumonia. But I think in terms of, you know, that would be so far down on your list of differentials that it's not really important in this context. Again, if you had a patient who was, you know, very unwell, um and, and febrile and coughing and that was your picture, then you might be shifted in that direction. But a white out lung field in terms of, if you do get one ever in a nosy, it's going to be one of these three things that they're trying to get you to figure out. And we're going to just talk really briefly about how to pick the was apart. So the tools at your disposal are volume loss. So if there's any mediastinal or tracheal shift evidence of previous surgery, so, having a close look at that lung, that's, that's got, you know, uh, the white out lung to see if there's any evidence of any clips or any previous surgery. And obviously, you know, if the clinic, the clinical history is the patient as well and you know, or if they mentioned the previous surgery, that's definitely gonna make you think that it's a pneumonectomy and a previous chest radiograph. So this is one of those important ones where if you have a previous chest radiograph from two years ago and they've had a pneumonectomy or it looks the exact same as before, that's suggesting that it's more of a long term process. So these are three chest radiographs with a white out lung. One of, you know, we're what I want you to do here is try and figure out just have a quick look at these yourself um and try and kind of match them up with those three things. So, one of them is a pleural effusion. One of them is a lung collapse and one of them is a pneumonectomy and I'll just give you about 10 or 15 seconds to just have a quick look, look for volume loss, look for evidence of previous surgery and just deal and we'll talk a little bit about the pleural effusion in a moment and what, why that's different to a collapse. Yes, grand. So hopefully that was enough time to have a quick, uh look through those. We're just gonna quickly kind of talk about the, the findings and all of those and, and figure out why one fits with, with uh collapse. So the main thing, hopefully, this kind of jumped out at you initially is that we can probably make out that there's, there's some uh some staples here or some sort of evidence of previous surgery. So the main thing to say is we've got two white out lungs here with, with volume loss. This one, this uh patient with volume loss has some evidence of previous surgery. So this is going to be the one that's going to be the pneumonectomy. Um This one here is the other. So essentially just by, by, by elimination, this is going to be your your other one. So there's no, I can't see any evidence of, of volume loss here or sorry of, of previous surgery here, but there is volume loss. Um And again, if you were given any sort of clinical context here, the patient would not be well. Um so they obviously be very short of breath, low saturations. Um And this would be somebody who would either get treated in this context with some antibiotics to hopefully clear things up. But if they weren't getting any better, there'd be a very low threshold for doing a CT scan in this patient to actually find out what is causing that blockage of their, their kind of bronchus to, to lead to collapse of all three lobes. This final one then is, you know, white out here, there's no volume loss. And actually what you have is the, the the mediastinal structures being shifted in the other direction. And that is an, that's more indicative here of there actually being fluid within the pleural cavity and you know, it's pushing the lung and the mediastinum in the other direction. So I think it would be on that there was a previous slide, they talked about moderate or major compression, collapse of the lung if you had a pleural effusion that was causing moderate. So maybe not, you know, sorry, major collapse of the lung. So the collapse is obviously working in the opposite direction. So you've got pleural effusion, pushing it away, the collapse is volume loss. So it's pulling it towards it. So there can be some complex ones, chest radiographs with pleural effusions that actually will look like things are quite midline without too much shift. But it's because there's a 22 processes going on at the same time. I think that would be far too unfair to give the medical student at any stage in their, their or even a foundation doctor to be fair. Um So it's, it's just the idea that if you've got a white out lung and the mediastinal structures are being pushed away, it's more likely to represent there being a large pleural fusion. So hopefully that was useful. I've got some, a few more chest radiographs just to kind of have a look through. These are other pathologies that you might come across. Um either on the wards or on your exams. This one is quite, quite a striking one. It, it, it might worry people a little bit. So you've got what looks like a fluid level here behind the heart. Um But actually, it's quite a, quite a benign finding really and something we come across quite a bit, this is just a hiatus, hernia. Um So you just just don't get too worried about that one. Some, some people might think there's some sort of a weird pleural and gas uh or sorry. Uh some sort of a fluid and gas collection in the, in the pericardium or something. But it's actually just a, a new repair to name. This one is the one that we classically say this chest X ray should never have happened. This should be something that you diagnose clinically and I hope you'll agree that there's complete lucency of the, the right lung and there is some tra shift here. So this is a tension pneumothorax. Essentially, we could do a whole different lecture talking about a lucent lung or kind of the darker lung. We focus a little bit more tonight on consolidation and kind of the, you know, um brighter lung or white areas on the lung. This one, we've kind of talked a little bit about this and somebody mentioned earlier on this is that kind of batwing idea. So we've got kind of massive pulmonary edema. The hint here being that there is some sort of a cardiac device with um defibrillators in it as well. So this patient has a, has a cardiac history automatically before we even um go any further. So this is a pulmonary edema type one and this one, does anyone want to try and tell me based on what we've learned this evening, what uh we're dealing with here? Yes, somebody please. The last little bit of interaction, I swear will be away and free anyone. No one's taking it unless I'm corrected. Somebody tell me consolidation. Yeah. Yeah. Yeah. Edema. So this is another difficult one. We're dealing with a patient who's likely is, is in ICU. There's got an intertracheal tube here. They've got a central line, a subclavian central line on this side, multiple chest drains. But this is the area that I just wanted you to pick up on here. So we've got, again, this, this border of the heart is, is is is obscured, got some consolidation there. Fluffy kind of ill defined. It's more of an alveolar type pattern. So we've got um uh some consolidation down here. This is likely secondary and actually there likely will be some collapse in there as well. The volume loss may be a little bit of a shift towards that direction. This is one of those classic ones that you might be shown when you do an ICU rotation. Essentially, it's secondary to the uh intubation. They've knocked a tooth down into the and they've actually aspirated a tooth causing blockage here or some sort of blockage. So there is some collapse, but there is also some consolidation I think. Um it's difficult to say for sure whether there's there's volume loss in this to be fair, but there's definitely some fluffy opacification and this density here is actually the tooth. So do be aware that this is a chest X ray that they might show you when you're on your ICU rotation. And you look um like you're ahead of the game if you can pick that one out. And we haven't talked so much about kind of a more subtle pleural effusion, which are the more common ones that you'll see with that kind of meniscus sign just out towards the edge here indicating that that's kind of the fluid level there. So we've talked about alveolar and interstitial opacification patterns. We've differentiated hopefully between collapse, which involves volume loss and consolidation. Unfortunately, they do overlap a little bit atyp collapse, volume loss, all kind of fitting as part of what the one family sometimes terms are interchangeable, the silhouette signs. So where there's normally a sharply defined border and a chest radiograph and that's lost, you have to be thinking that there's something going on in the lung in that area. It could be consolidation, it could be collapse. And you're using your other tools like volume loss to try and figure out which one of those it is the main thing to say is have a structured approach to your chest radiograph and be able to kind of be confident that if you were to go through that approach, that by the end, you'd be able to say that something is abnormal or abnormal. And then if you're trying to figure out, pick out what you know what exactly the abnormality is, then these tools that we've talked to this evening should hopefully help you with that. And yeah, when you're obviously a foundation doctor. Um Don't be afraid to obviously come and, and ask questions if you or the rest of your team are struggling with what is actually going on on a chest radiograph because often, you know, we do, we do look at quite a few. So getting a little bit of input from us might be useful. So thank you very much for your time this evening. Um I'll stop sharing my slides if anyone has any particular questions for me, I'm obviously happy to happy to take them. Um But thank you very much for being with us this evening and hopefully that was useful. Yeah, thank you very much. Now, I actually had a question myself and I'm just gonna put in the chart. I don't know if you can see that. But yeah, so this is, this is something I think it's, it's better to get it clear in your head. What a what a pneumothorax and a collapsed lung are the a pneumothorax essentially, meaning that there's, there's air within the pleural cavity. A a collapsed lung doesn't necessarily mean that there is, there's that air in the pleural cavity. It just means that a part of the lung has collapsed in, in a pneumothorax. Obviously, if you've got a shriveled up lung, because there's so much air within the pleural cavity, there, there will be lung collapse. There'll be, you know, particularly with a massive pneumothorax, the whole lung will be collapsed. But what collapses. A term or atelectasis is used more for in describing changes. It's more when there isn't a pneumothorax and the lung is still inflated. But we're looking at either a part of a lobe or a lobe being kind of collapsed and volume loss in that direction. Hopefully, that makes sense. But a pneumothorax dull is a collapsed lung. But I think collapse in itself usually is used to talk more about a lung that isn't, you know, shriveled up because of the massive pneumothorax. If that makes sense, that was really helpful. Thank you. Does that answer your question user? Yeah, it does. Thank you so much. It is, it's something that like it does come up with that idea of like a pneumothorax and a collapsed lung. And people will talk about like, you know, more colloquially when a patient has a pneumothorax or their lung has collapsed. So it can make that terminology a little bit more confusing than it already is because people are already using collapsed and NAAS and volume loss to describe that, that whole thing. So, yeah, just a, just a difference. Yeah. Pneumothorax is air within the pleural cavity and then you'll be able to pick the rest out from there. Yeah, great. Thank you so much or any other questions if anyone likes to ask. Um I think B is just posted in the chat or a feedback form for the session. So um if you do have the time please fill it out and then you can get a certificate for attending the session. Great. And, yeah, thanks for, uh, to everyone who, who organized it and also for everyone for giving up their evenings, come along with this. I know, obviously you, you have many other things to be at on a Thursday evening. But, uh, thank you for, for coming along and hopefully it was useful. Yeah, it was definitely useful and I'm sure I can speak for everyone on committee and everyone in the audience when we say we're really grateful for you giving up your time to do this. No worries at all. And yeah, in, in the feedback, obviously, if there's anything else specific that anyone would like to cover, either myself or one of the other registrars can maybe organize to do that over the next few months. So just if there's anything you're struggling with or you're not really understanding in the radiology side of things, just ju just let us know. All right, great. I think that's, that's us. Uh Thanks so much Nile for um coming to speak to this event and thanks everyone else for joining uh as well and I'm just gonna, you here. So thanks for coming. I don't know if there's anything else you would like to say now or all good. I'll leave you be. Yeah, get in touch if you need me. OK? Thanks. Thanks so much.