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Summary

This session is for medical professionals who motivate to learn more about chest X ray assessment and interpretation.It will include basic knowledge on chest X ray elements such as rotation, inspiration, penetration and exposure, as well as what to look for in assessing a chest X ray, including airways, bones, circulation and fluid. Through an interactive environment, attendees will be able to explore the basics, ask questions, and then attempt to assess a chest X ray to practice the skills taught.

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Description

This is the 2023 Radiology Teaching series hosted and organised by Anna. This series will include some high yield exam contents with helpful SBAs and interactive segments to keep everyone engaged. Please find the recordings and slides of these sessions here and we hope you will find them useful.

Please note that these slides and recordings are properties and should be credited to their respective authors. There are no affiliations between these speakers and the St George's University of London teaching curriculum.

Please find the session titles here:

  • Interpretation of Abdominal X-Ray - Dr Mohamed Adam Ali
  • Interpretation of Chest X-Ray - Dr Manjiri Joshi
  • Important signs in surgical radiology - Dr Naren Govindarajah
  • Interpretation of MSK X-Ray - Dr Gabie Reiff
  • Important signs in abdominal CT - Dr Pardis Zalmay
  • Important signs in CT head - Dr Olutobi Meadows
  • Important signs in US - Dr Ashcaan Hajilou

Learning objectives

Learning Objectives:

  1. Identify components of an adequate chest x-ray and assess appropriate documentation (i.e. patient name, date of birth, date and time)
  2. Explain the difference between an anterior/posterior and a left/right chest x-ray.
  3. Describe the technique used to assess rotation, inspiration, penetration, and exposure of a chest x-ray.
  4. Demonstrate the ability to assess patient on a chest x-ray, including diagnosis of airway, bone, circulation, diaphragm, fluid, gut, and hilar abnormalities.
  5. Recognize and explain clinical implications of cardiomegaly on a chest x-ray.
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Computer generated transcript

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

Okay. Can everyone see my slides if I'm flicking through? I'm not sure if that's your, let me just open the chart and see. Yeah. Oh no, I think it's in the brilliant. OK. So should we start? Um So this is gonna be I'm gonna try and make it as interactive as possible just because I think otherwise it's not very interesting. So please shout out, you know, um Don't feel like anyone's judging you or anything. Can I just get an idea of what years people are in? So I know Anna is in third year um into collating. Is that kind of similar for everyone? Yeah, I think so. I think so. OK. Brilliant. All right. So to start with, we're just gonna go into the basics chest X ray teaching. So if you guys are in medical school, you're most likely going to be doing F one F two. Um where the bread and butter of what you come across in radiology is gonna be chest X rays. Um maybe a bit muscular, skeletal as well. Um But this is kind of what we see all the time. So I'm one of the ST ones. Um who's just started training in Georgia's in August. Um So I'm also very new, but please feel free to shout out and ask any questions as we go through the teaching. So just first things first, as we often do in medicine, we like to take it back to the basics, especially when we're thinking about exam style preparation. Um So, does anyone know how we would start off in terms of assessing adequacy of a chest X ray, any acronyms or anything like that at all? Right. Yeah. And what does that stand for? Rotation, inspiration, penetration and exposure. Yeah, fantastic. And even before that, anything else that we might be looking at like maybe a bit of birth in time of the X ray? I'm sorry, sorry. And I think it's just gone. Okay. So I just say that again, like the patient's name and date of birth is correct and the date and time of the chest X ra is correct. Absolutely. So I don't know if you guys are aware, but I think a couple of months ago there was a massive serious incident recently at ST George's because a nasogastric tube was reported. But the ward on the team thought like a different one was reported, the patient was fed via nasogastric tube. It was actually had actually been since moved since that report. Um And there was another chest X ray which they thought was the report when it being put out for. But essentially the patient died because they were fed into their lungs. So it's really, really important. I know that it seems a bit pedantic when we're going through chest X ray teaching. And um normally just assume that what you see on the, on the system is, is what's the most recent. But that is really important, especially when you're thinking about things like N G tubes. So yeah, details, name, date, time direction. So A P or P A, so does anyone know the difference and why we do one versus the other or why would prefer one over the other? Okay. So A P basically refers to anterior posterior. So the chest, so the X rays are coming anteriorly. Yeah, exactly. You can't measure heart size based on A P and that's because it'll be magnified a little bit more on A PPI which means it might look like a really large heart, but actually, there's no cardiomegaly in reality when you do pee. Um So next, in terms of rotation, we're looking at the distance of the medial heads of the clavicles to the spinous processes. Uh okay. Um And that gives us an idea of, you know, roughly was the patient like this or like that where the chest X ray was being performed? So inspiration is how many ribs can we see? So we're thinking maybe 5 to 6 anterior ribs in the middle of ocular line or 8 to 10 posterior ribs behind above the diaphragm penetration is, can you see the vertebrae through the heart and exposure? So have you received, have you looked at all the edges of the films, for example, the costophrenic angles, the ape disease and you can see, you know, to the edge of the film and, and that's really important because sometimes there are findings on the edges of the films um that are really, really crucial. So next, this is basically your bog standard normal chest X ray. I say that both costophrenic angles haven't been properly captured. But you can see the ABC is clearly, this is what we will call basically normal chest X ray. There's no focal consolidation or collapse. Um I can't see any plural effusions, appreciate we can't see the bottom of the film, but broadly speaking, that doesn't look like there is any um and the otherwise the heart looks like it's normal sized. Does anyone have a trick or something that you know that we can assess whether the chest X ray was done A P or P A without it being actually written on, on the film itself? Yeah, exactly. So if you can see the scapula or not, obviously, there's a bit of caveat in day to day life, but here you can see the scapula aren't in the lungs or aren't projected over the lungs. Um And you can assume that this was performed pa so you can assess the heart size, the basics. So we're just gonna go through a way in which we assess chest x rays and what we're looking for. So you might have seen the first one pop up as well. Um But just, just take me through it. So a we can go look for the airways in particular trachea, the right and left main bronch. I um and we can look at the A P C's as well if you want to conclude it in a, basically, it doesn't matter what system you use as long as you're looking at everything. Uh Does anyone want? Shout out what we could be looking for if we are going next sofa B and C and so on, just shout out anything. So be would probably be bones that's like a big one. Um See anything, anything for see, it's quite similar to your A T V assessment. Yeah, circulatory system. So cardiac, can you see the aorta? What does the aortic knuckle look like? Um You can also include costophrenic angles there if you like, why is it assumed to be pa if we can't see the scapula which is posterior? So when someone when we're performing a chest X ray and if the patient is able to follow commands, you know, isn't really old and, and also on with all those caveats, they actually get the person to kind of hug the hug, whatever is in front of them, maybe like they put, you know, over, over the film itself which means that with that movement, you're getting the scapula out of the way, so they're not projected over the lungs. So that's why it's really useful. And in addition, when you've got the X rays passing from here, that way, you've got the heart, which is closer to the film itself. So the magnification is going to be less whereas if you're going this way. So for example, people on I T U or on the wards who are having a portable chest X ray who aren't very well. Um They often can't do that movement and then they'll just be taken a two P which means that there's a bigger distance in this way between the heart and the film, which means you'll magnify a little bit more. So if it's been done correctly, you won't see the scapula in the I projected over the lungs. I hope that answers your question. Um Okay. So we want to see next d any ideas what we might be looking for? Diaphragm. Yeah. Yeah. The honestly, I'm gonna ask really, really bond or questions. So if you think it's too easy, it probably is. So just, you know, just shot up. But yeah, perfect to diaphragm. Can we see anything under the diaphragm? Can we see any air under the diaphragm, which is a worrying sign of pneumoperitoneum? Um And yeah, that's, that's one of the big ones. Uh e I kind of puts everything else. So anything that you missed um F we can think about fluid potentially. So where, where might we be able to see fluid on a chest X ray? What kind of fluid take care of the fusion? Sorry. Say that again. Carol infusion, plural effusions. Yeah. Anywhere else. So plural effusions is in the pleur itself. Exactly. So you often see blunting of the costophrenic angles because just if you think about gravity, that's where it's gonna sit most of the time unless you've got some really weird and wacky lungs. Um, but in terms of actual, actually in the lung parenchyma itself, what kind of fluid might we call that? Yeah, very edema. Exactly. So, pleural fluid, pottery edema, big ones for F G, you can think about gut. So, um, things like nose gastric tubes can come under that. Uh, and you can assess those if they're there and h you can think about hilar, which is still a very tricky topic. Um, but we will be just going to the basic, so just to rattle through. So a airway bone circulation just as we've said. So, e is also for everything else. So anything, anything external that we've put in? So pacemakers, central lines, we need to be able to look at them and say, yeah, they're in the right place and they should be safe to use or no, actually, that central line is not sitting in the central vessel. Um, so you want, probably think about repositioning that things like that. Okay. So does anyone having gone through doctor Ripe? Um and the kind of rough A two G H H assessment, whatever you wanna call it, does anyone want to have a go at it? Sounds like a concern. Oh, really? Yes. Can everyone see the whole image? So can you see up until the humeral, the right humeral head on this film? Because all of my slides look like this, so be useful to know. Okay. So they, so you can see it. Okay. Sounds like they can um fine. All right. I think we'll just carry on unless there's something I can do. You? Sure. Okay. Um Yeah. Does anyone want to have a go at presenting this chest X ray? I might start picking on people. I'm sorry, I'm going to be that person. Raina Sing. Okay. I saw Anna Haddon muted herself for a second. Do you want to give it a go, Anna? Um Yeah. Sure. So, um uh looking at this, I would assume that is pa because I can't see the scapula, I don't think um looking at the rotation, um I'm not 100% sure, like because I don't think the spinous processes are exactly by article or Ecuador distance, the clavicle. So there might be a tiny bit of rotation. Um Inspiration, counting the ribs. Yeah, I can see at least five and then at least seven. All right. Yeah. So they're well inspired and then penetration. I can see the birth of breath through the heart. So that's fine exposure I can see from the ape sees to the costophrenic angle. So that's fine as well. Um Looking at the airways, I don't know if that's a bit of Tokyo deviation, but I can't like particularly tell actually, um looking at the rest of the airways. Um Yeah, I'm not 100% sure. That's fine. That's fine. That's the big abnormality that you might be able to see on this film. Maybe like there's some consolidation on the right or some like a pacification on the right. Yeah, absolutely. And where would you say it's in the right lung? Probably if you had to divide it up into thirds, for example. Yeah, probably the mid zone or the upper zone. Yeah. So it's kind of in that border, isn't it between upper and mid? So another term that we can use to, you know, put it in the middle of that is Perry Hilar because you can see the hilar vessels um around over here. Yeah. So that's where your, basically the highlight is where the lung connect with the rest of the body. So you've got your artery artery upon re vein and your main bronchus going in through here and going in through there. So you can call it a peri highlight of pacification. What kind of shape is it like? I don't know, you may be quite rounded. Yeah, absolutely. It's rounded, it's fluffy. It's sitting there. Can you see anything else grossly abnormal in the lungs? Because I can't really. No, no, no. And if it was consolidation, what other kinds of things can we see in consolidation? What is consolidation? Anyone else can also jump in, like, pneumonias specific or pacification? Yeah. Yeah. So that pneumonia is one of the things that can be responsible for consolidation. But what actually is consolidation? What does it mean? Just like it's hyperdense? So like there's some kind of like like fluid, solid build up. Exactly. There's stuff where there shouldn't be stuff, right? Because because air is black. So if you look around here, yeah, you can see lung markings, you can see some things going down, but I'll tell you that this is broadly this over here is broadly within the limits of normal but consolidation is muck. So pass fluid, whatever you want to call it, sitting in the air space is preventing, you know, basically sitting as an infection or lots of different things. So consolidation doesn't necessarily have to be limited to pneumonia. Although that's a very common one, this looks just a bit too rounded and soft and fluffy. I can't see any air bronchogram through it. That's another sign of consolidation. So air bronchogram is basically means that the small little bronchioles which aren't impacted with fluid and passing all that muck are open. So you can see sometimes little areas of dark tract going through the consolidation. So air bronchogram is a sign that you've got consolidation. I can't, I mean, maybe you can see a little one here, but basically this is concerning for a mass. Um and mass in radiology is bad. Basically, if you call anything a mass anywhere, people automatically assume you're talking about cancer, which most of the time you probably are. So this is most likely some kind of primary bronchogenic malignancy. Um So consolidation will go through and we'll have a look. But thank you for trying. I really, you know, that was really, really good. It was a really good presentation. Um And otherwise, yeah, you're right. There was nothing focally abnormal, but this is concerning and this will trigger us to request a ct thorax. Have a further look and just start that whole MDT process. Yeah. Okay. So this one does anyone else want to give this one a go? This was a little bit harder. Um or there's maybe a bit more stuff going on. So I will always help you guys through it. So, you know, it's no, don't be scared. Basically Reese. Do you want to give it a go? I can attempt to, I don't think it's gonna be great. No, no, that's absolutely fine. Sorry to pick. No, that's, that's all right. All right. So I would confirm the patient's name and date of birth and all of that sort of stuff. Then we can move on to the assessment of what the chest X ray looks like. Okay. So rotation um yeah, is centered in terms of looking at the spine, it's process to the clavicles in terms of inspiration. I, I think I'm finding it hard to tell whether they haven't inspired properly or there's just so much a pacification then it's just like limits in the field. But I don't think I, I'd probably say I don't think this was taken on for inspiration, but that could be wrong just because I think you need like five or six interior ribs and 123 or maybe this five or maybe it's all right then uh on the borderline, I agree. I can see from the top, right. It's A P um um in terms of the penetration, um I can't see the spine ist process. I can't differentiate the spinous processes. So maybe it's not that well penetrated. Yeah. So penetration, we're looking more at the chunky virtual bodies, but I agree they're not very clear through the heart. Um I know. So it's probably a little bit over penetrated. I agree. Yeah. And then exposure wise, yeah, we can see the A P C S, we can see the costophrenic angles cool, okay. And then airway um check it doesn't appear deviated. Um And then in terms of the lung fields themselves as appears like a pacification in the right, throughout the right lobe, throughout the right lung. Yep, I can see the appears on the left lung in terms of just the, like the lung field itself. It's almost seems that like, sounds like a pneumothorax picture where the like of the lung field doesn't go to the for the complete almost thrusted cavity. Is that right? So I think you're talking about here this bit, right? Yeah. So like, yeah, so it goes down, it doesn't seem to fill the whole thing. So I would actually say that that is quite a large pneumothorax. A lot of new authorities that you end up seeing maybe not in teaching, but in day to day life will be a little tiny sliver of air sitting right at the top there. But this, I can see really nicely this lung marking all the way around. And if you look at this area here, for example, compared this, this little square to this little square that is just completely black and there's nothing, there's just airsick thing in there. So I'd say that's a large left side of pneumothorax. Yep. And good talking about the lungs as well. So there's a pacification throughout both lungs. Um If you had to describe some radiological words or describe it using radiological words, what kind of stuff would you call it? You said a pacification, which is correct. Um Well, in terms of that consolidation, that sort of stuff. So it's kind of, yeah, so you can say that these are, they almost look like very, very small dots or scattered all over and they're bilateral, you can get bilateral pneumonia, but often it tends to be, you know, more of a focal process. This could be anything, this could be a fibrotic lung disease where everything is just all really strictured up and fibrosis and is looking like that. Um And we know that people with existing lung conditions are more likely to get a pneumothorax. So that's also what's going on um over here and in terms of the trachea. So I do think this film is a little bit rotated. If you look from where I see the spine is process to be here, medial head of clavicles there, that's the distance and then that's the distance. So there is a bit of rotation, but I would be concerned that maybe this trachea looks like it's shifted over to the right hand side. You see what I mean? And the heart border. No, no, don't apologize. But, you know, it's just to kind of talk things through and, and see what you see and um you know, discuss it, but the, the heart as well, it's really hard to make out. I can't, I can barely make out the cardiac border. And I think the whole mediastinum has shifted a little bit to the right. So I'd call this a large left side of pneumothorax with rightward deviation of trickier and mediastinum, which is concerning. Yeah. Um So we'd be thinking about what the patient's like clinically. I mean, not in radiology and radiology, you get to sit, drink coffee and a report, but the clinicians be thinking, what's it like clinically, what's going on, how we're gonna manage this patient? But brilliant, well done. So basically this is pneumothorax. I'm probably just, you know, going through all of the basics that you guys know really, really well, but just to recap, you've got your visceral pleura that sit right up, flush against the lung, then the parietal pleura that is another sort of lining around the visceral pleura. Um Normally you've got a little small amount of pleural fluid that just helps lubricate it and make sure that, you know, when the lungs are expanding their moving nice and uh in a very like smooth pattern. However, when there's issues, you can get a build up of fluid or the fluid might not be able to be, might not be able to um leave because there's something blocking it, for example, a tumor. Um So you can get a build up. Um Sorry, I'm describing the pleural fluid, but this is essentially the same thing. So pneumothorax is just area in the pleural space. Um And we'll look at that in a little bit more detail. So, does anyone know how we can classify new authorities? Like spontaneous tension? Yeah. Yeah, exactly. So, spontaneous in tension. Um So spontaneous, you can think of that category being more like spontaneous and traumatic because traumatic pneumothoraces are common if someone comes stabbing and you've basically made a whole and the air is just going in through. So every time the egg zale there's less pressure, air goes in and it just gets worse and worse and worse. So that can lead to a tension pneumothorax. You can have a spontaneous pneumothorax and that they don't have any traumatic, blunt penetrating trauma type of injury. Um but that they just rupture something, maybe a bowler and end up with a pneumothorax. Um Another definition that we think about is uh simple pneumothorax. Um So that's in someone that doesn't have any pre existing lung, lung disease um or a secondary or so primary pneumothorax story or a secondary pneumothorax. Does anyone know what kind of lung diseases would predispose you to developing new authorities and therefore classify you as a secondary pneumothorax if you were to get one, just general lung, sorry, fibrosis from the fibrosis. Yep. COPD. Yeah, absolutely. So, asthma TB anything that goes on in your lungs, basically your lung parameter. Bregma is just not doing so well. Um And then it just makes it more liable to burst. So, COPD people get large bully, which is basically an air space that's filled, it's liable to burst and then you might just get air going into the pleural space and ending up with a pneumothorax. So, progress secondary simple um simple vest attention. So what is actually the definition of a tension pneumothorax? What do we worry about in any with works. Yeah. Exactly. And what kind of, um, clinical signs might we see? Trick your deviation. Trivial deviation. Yes, a tricky alleviation, mediastinal shift. Exactly. Because there's just so much pressure in there that it's pushing all the contents to the other side. So, pneumothorax is new authorities. They kill, it's one of the reversible causes of cardiac arrest. So, tension, pneumothorax, you'll get maybe a sudden drop in blood pressure. Um They might become extremely hypoxic and they'll need immediate immediate management where simple new authorities, you can sort of see how they do clinically and decide on management and we'll have a very quick look through that as well. So management. So what, so we've already talked a little bit about the people with lung pathology that are at risk of developing pneumothorax. Anyone know any kind of like stereotype, any demographic then like kind of connective tissue disorders like ma fans. Yeah. Yeah. Absolutely. Um, tall, thin, skinny young men apparently is a demographic. Apparently they're at higher risk of having a pickle bully which can pop and you can get a pneumothorax. Um and any signs and symptoms, we've gone through some of them to just shout out anything really breathlessness. Absolutely big, big one. Do you get chest pain? That's really common. Anyone else? Yeah, exactly. So they can just become really unwell breathlessness, tachycardia, chest pain. Um All of those ones. So this is not going to overwhelm you but basically, this is a way in which you can decide. I think this is on the British Thoracic Society guidelines. Um You can decide what to do with some of the pneumothorax. Um If someone's older and has got some underlying lung disease, then they are more likely to need treatment. Sorry. You okay. Okay. Sorry, sorry. That's right. Um So this can kind of take you through that diagram all through that algorithm to see who needs treatment um and what we should be doing, but basically if someone's unwell, then they probably need a chest drain and they need definitely to stay in. So in terms of needle aspiration or chest rate insertion, do we know? Does anyone know where we would be putting the needle in midclavicular line like second intercostal space? Okay. Yeah. So in an emergency. Yeah, definitely. So that's an emergency needle decompression for sure. What about chest rain? Where are we going to be putting that in? Yeah, triangle of safety. So that's looks a little something like this. Um But actually if you've been to E D, you've been on icu respiratory wards or wherever we don't really tend to use landmark technique anymore. Everything is pretty much guided by ultrasound. So um this gives us a rough idea but everything tends to be ultrasound, guided needle visualization for these procedures. Anyone want to go through this one through the next one, Sharia? Do you wanna give it a go? Do you want to give a goanna, I'll, so I'll talk you through it. We'll skip all the, we'll skip the direction and the rotation and stuff because it seems like you guys are really hot on that and you know that really? Well, what's the big abnormality that you can see on this chest? X ray, the other sky? Yeah. Yeah. Yeah. Exactly. Um What is that, what's speaking out to you here? What do you think this could be? Yeah, exactly. So right sided pleural effusion. Um we can see the meniscus level really nicely over here. It's completely obscuring this entire region. Um And yeah, this is most in keeping with a moderate to large, right sided pleural effusion now for pleural effusions. Um Well, let's go through it. So this is a unilateral pleural effusion. Does anyone have any ways in which we can think about unilateral plural effusions and what they might be due to like, maybe it would be more likely to be like an infective or a malignant cause compared to like um kind of like a like a pulmonary hypertension or simple. Okay. Yeah. So unilateral, I think there's three big hitters infection, TB malignancy, there's loads of little random ones as well. But if you're looking at unilateral large, you know, like a one sided, essentially pleural effusion, that's what you would be thinking about. Um And then if we're thinking about these types of plural effusions, so if you can see appreciate that meniscus line there and another one here or kind of another one there. Um So bilateral pleural effusions. Does anyone know what those might be down to? So, it's generally the failures. So the three big failures are cardiac renal liver, right? Um So exudative, well, sorry, unilateral um is infection TV, malignancy and bilateral, you're thinking some of the failures again, loads more. But heart failure is probably your biggest hitter over here. So we've gone through that, gone through that. We've gone through that. So there's another way that we can categorize plural effusions, which is probably what we should be using in clinical data day context transit native. It's gone very dark in here. Mhm It's okay. Oh, thank you. Sorry about that. So there's a couple more categories that we can think of and that's transit data versus exudative. Does anyone know a little bit about those terms? Just literally shout out anything at all like the protein content of like 37 like trans uh and like kind of splitting them up into the causes as well. So it's kind of similar like infection and malignancy would be the same, but the failures would be the other one. Yeah. Yeah. And someone's put on the team's chat lights criteria. Fantastic. So transit native, why does it occur? It's normally because there's a difference in pressure. Now this is going back to like, I don't know, physiology days, I guess, but there's a difference in pressure between your capillaries coming in. Um And your other interstitial fluid if you don't have enough protein, which you often don't in liver failure because your liver's not making albumin. Um You might not get that fluid coming back and it just kind of sits there. That's one of the causes of transit, native plural effusions. So that will tend to be on both sides because that hydrostatic and oncotic pressure is distributed throughout your body. You know, it's not gonna be preferentially on one side and the other if the liver's not making album and the albumin is not getting kind of anywhere. So, exudative on the other hand, is maybe because there's some localized irritation or inflammation which is causing that capillary barrier barrier to be a bit more leaky. And if it's a bit more leaky, then in that particular place you'll get more fluid that stays. So that's a rough, very rough brief talk about uh about that from a radiology trainee. So don't take what I'm saying is gospel. Um And yeah, just, just as a just I had to look this up as well myself. But how much pleural fluid can we see or how much pleural fluid needs to be there before we can see it on A P A chest X ray. Any guesses it's normally about 200 mills, which if you think is it's not an insignificant amount. Um And if you go back to, for example, this one. So that's gonna be quite a bit that's gonna be causing the patient uh significant shortness of breath um and discomfort. It needs to be a fair amount before we can really talk about it. And as one as um Tammy has put on the uh teams, chat lights criteria. So lights criteria is really, really useful when talking about plural effusions. Um The way we can do it is we can take a sample of the pleural fluid and we can also take a blood sample at the same time and we basically send it off to the lab, look at a bunch of different things and just compare and contrast the ratios. What kind of things are we going to be sending off pleural fluid that we've aspirated? What kind of things are we gonna be interested in? If we've stuck a needle in there? Maybe like LDH LDH? Yeah, that's a big one. Absolutely. What if we think it's effective and if we need to know what kind of bug we're dealing with? So M C N s and if we think about TB, what kind of marker do we maybe send off for? Nickel? The only is insane. So that again, sorry, Ana. Is it zeal niece and stain? Yeah, that's really good. Um That takes off in about six weeks to do so there's another test that we can do called acid fast bacilli. I uh so you can send that one off as well. There's loads you can set of cytology because you want to see is there any malignancy going on in here? Because sometimes these plural effusions can contain cancer cells. Um So, cytology, LDH glucose, P H M C N S um uh acid fast bacilli as another example. So lights criteria is a set of criteria. Basically, if the pleural fluid has got a lot of protein, generally, more than 30 g per liter, I think the unit is, you can assume it's exudative because there's a lot of protein, there's a lot of reaction going on in there. Um And that's the kind of stuff that we're tapping and getting off. If the protein is, I think less than about 20 you can safely assume that it's generally transitive. If you're in that middle ground, say you're 27 26 then you can use lights criteria. So that's why you send off a blood serum level as well. Um to compare these numbers for LDH, for protein. Um And then you can make a mind up about what you think it is. So this is another um pleural effusion, it's a bit tricky to assess because if you can see this patient was completely in some random position when it was taken, the finest processes are here. The left clavicle listing all the way over there. So it's really, really rotated. So it on these studies, it is harder to assess what's going on with the trachea and the mediastinum because this is throwing you all off. But this is a large left sided pleural effusion with, uh, with some trickle deviation, uh, away from the pleural effusion. And, uh, anyone want to take a gamble at this one? Pneumonectomy. Yeah. Absolutely. And what makes you think it's a pneumonectomy rather than a right sided pleural effusion because I can't see like, um, any of the, like bronchi or, like, any of the airways going into the lungs. So it seems like it's been removed. Yeah, absolutely. And what do you think about the trachea and the heart true there deviated as well. So like, yeah, like left shift. So I guess um because there's nothing there, it's like kind of shifted over. Okay. Good, good. So, yeah, this is just another example. Um and this is also similar, this is also a pneumonectomy. So these are some of the common differentials to think about on a total, on a total white out on a chest X ray. Does anyone want to give this one a go just in terms of how you would be describing it safe in a Noski scenario? I don't know if you have radiology based Oskin's. You do? Okay. Um So how would we go about presenting this chest X ray? Yeah. Okay. So it's a P wrecked. Where is the most striking abnormality? What looks the funniest? Yeah. So actually I'd say it's definitely the right you're talking about this region here. So what's this line running along here? Yeah, exactly how many loaves are in the right lung. This is also open to everyone on teams, by the way. Three. Yeah, exactly. So, three lobes in the right lung and then there's two in the left lung. So normally on chest X ray, the main fissure that you're able to see is in the right lung and it tends to be the horizontal fisher. So this here is a horizontal fissure which is why you can see it so clearly delineating it. Yeah, exactly. So this is a low bar pneumonia, mostly focused in the right upper lobe. But generally, radiologists tend to be very pedantic. Um But generally in when you're describing chest x rays, you don't 100% know whether it's a lobe. So normally we go with zone. So you can say this is a pneumonia, you know, looks more likely in the right upper zone. Uh I can see the horizontal fissure really nicely. So it's more likely to be located in the right upper lobe. But it's difficult to say unless you're like directly looking at a CT. So just just a point if you, if you come into the department at any point and you, you start chatting to the consultants, but absolutely low bar pneumonia going on over there. Now, anyone want to give this one a go where do you think the abnormality is, is it on this side? So, is it on the right? Was it on the left? So we're going to be talking about collapses now. It's on the left. Yeah, absolutely. Um And maybe I've given you a bit of a hint, but we've already said that there's two lobes on the left hand side, there's a left upper and there's a left lower. So this to me in this whole left hemithorax looks globally like it's a different capacity to the right. Um I hope you can all see that this just looks, this looks a little bit blacker. This looks a little bit more, little bit denser. And can you see that rim of black air around this structure here? Anyone shout out what the structure here is a, a technical Yep. Um or aortic arch. Yeah, absolutely. So there's a little rim of air sitting above the aortic notch going all the way into the apex of the left lung. Anyone have any idea what this could be? So it's a type of collapse. So, yeah, there is pathology going on in the lobe. This is called a veil sign. So it's referring to fact that there's like almost a veil like capacity over this entire left lung. And that's because your left lobe doesn't just sit in one other like the upper bit of your um left lung, but it extends all the way down over here. So, if that entire thing has collapsed, then you're looking at the entire left upper lobe being collapsed to compensate for that, your left lower lobe then inflates because that's what lungs do because they want to make sure that they're filling up your entire hemithorax. Uh And the way it's extending up means you can see this room of air around here. So that's actually all inflated, um, airfield left lower lobe and this is called the left sickle sign, uh, which is supposed to be German for like a sickle if you can kind of squint and look at it that way that is running over the um over the aortic notch. And this is concerning for maybe there's a bronchogenic malignancy sitting in your upper lobe, rhonchus blocking it off and causing complete collapse of the left. So, uh this is a veil sign you might see it on um on an exam, the right lung otherwise is completely fine. Okay. I don't get whites that upper um like low but not the lower lobe because I can't see that much of a difference between them. Sorry, say that again. How come it's like where is the division that shows it's like the upper lobe rather than the whole thing. So this is just a classical, it's a classical sign. Um It's hard to appreciate we'll go through some more ones and then you can see what the left lower lobe looks like. The left upper lobe is quite big and extends all the way down. And the lower lobe sits a bit more posteriorly. So if you imagine that whole bit is this is all anterior collapsed lung that you're looking at. Does that make sense? And then behind that is your left lower lobe? But the left lobe lobe has now gotten a little bit bigger, gotten a little bit more inflated. And that's why you can see it like this. That's why you can see this more lucent or this black a bit around the collapsed left upper lobe. And that's the veil sign because it's avail like capacity over that entire lung. Does that make sense so much? Yeah, that makes sense. Yeah, no problem. If anyone has any questions, please also shout out. That's absolutely fine. Um OK. Anyone want to give this one a go. Where are the, where is or are the abnormality abnormalities? Okay. Which, which side? Right side? So this one here you're thinking, okay, I can see that stuff. I can see what you mean. Is it? Yeah, I agree. It's both. Um Can you guys see these quite well demarcated capacity's over both lungs? Are you able to see it? So there's another one here, there's another one there, there's another one there. So what kind of things are bright on X ray just generally? Mhm Calcification? Exactly. So that's why your bone is bright cause it's filled with calcium. Um This is a bit calcified, which is why it's brighter. And if you can see here, so you're right and left hemidiaphragm. Can I convince you that? For example, this is a bit thicker than usual. So, these are sitting on your pleura calcified patches bilaterally. Does anyone know what pathology this might be? So, these are calcified pleural plaques. Anyone know where, what we might be concerned about if a patient um has pleural plaques previous exposure to anything in particular? Yeah. Yeah. Yeah. Yeah. Say it with confidence. It's asbestosis. Yeah, exactly. So, pleural plaques, you can get, it might be due to asbestosis. Um But that's a very common one. Um So you'll know that if you uh you know, when you start working and you have people that have been exposed to asbestos and well, if they die in hospital and do their paperwork, that has to be reported, every death related to asbestos exposure has to be reported. Um And people can sit with these calcified pleural plaques for a long time. Um That's something that you might see. Okay. So, uh this one, there's a few different things going on here. Um If anyone would be very kind and very brave to try, otherwise I'll have to pick on Anna and she's not going to like me very much. Okay. Does anyone have any idea what these things are? You see them a lot? Uh This is more, we're talking a bit more anteriorly. This is to patch up your sternum. Why might we crack open someone sternum suges? Yeah. Except these are quite bright. These are quite white. So they are, um, they're kind of metal so most of your teachers won't be metal. But good, good thinking. It's, it's to put your sternum together, basically. So they're called midline sternotomy. Wise, you'll see loads of them. If you look at chest x rays for patients and hospitals, why are we cracking open someone's sternum? Yeah. Very good spot. There's broken bones over here. Now, can you see if you follow it, for example, let's follow this rib down. So, going down. No, no, no, no, no down and it just cuts off there. Can you see that there's a fracture there and it's going all the way around here and when we looked, I mean, I haven't put it on this presentation but when you image the bottom um part of this person's chest and the costophrenic angles, they were just refractures all the way on the left hand side. Um Okay. Any other bones that you're concerned about? Yeah, exactly. Good. Really good. There's a factor here. Yeah. So that's broken off. This person had a trauma. Um, they fell, they've broken all the left side of the ribs that broken this um, this left clavicle. What kind of things do we worry if someone's broken a lot of ribs on one side due to trauma, long puncture? Yeah, absolutely. And that might lead to a pneumothorax. That could be a traumatic pneumothorax because there's injury, um that's causing injury to the pleura. Another thing we worry about is Flail chest. Don't know if you guys have heard of that. Yeah. So Flail chest refers to like paradoxical movement when you're breathing radiologically, it's a little bit different, but it basically refers to two breaks in three contiguous ribs or more. Um And that puts you at risk of getting a flail chest. And also, so we've talked about these wires, the midline sternotomy wires there normally use. And also if you can see these clips over here, these little metallic lines, it's that may be hard to see on this uh screen. But so these are anterior mediastinal wall clips. So these findings, the wires and the clips are most likely uh findings for a previous cabbage. So they've cracked open the sternum to basically give them a cabbage. And if they've had a cabbage, then you know that the heart's not doing too well. Um So what else can we talk about? Well, what else can we see when looking at the lungs here? If their heart's not doing too well, then they've had an injury. A Dema Yeah, absolutely. So there's loads and loads of this a pacification. It's just not looking as black as this lung here, for example, that could be a bit of the penetration, but actually, it's really shadowed around the hilum and especially in the basis where fluid tends to sit and collect. So this is cardiomegaly. I know it's a P but actually, this is an absolutely huge heart. So even we can write in our report, even allowing for a P projection. There is cardiomegaly. They've had a previous cabbage. They've got polymer edema, they've got rib fractures. Um, so that's how you would talk about this chest X ray. What about this one? Uh, yeah. Which side? What's, what side? Okay. Where's pathology left or right left? Yeah. And can you see lung markings on either side? So I can see them here. Yep. They're kind of going all the way down, but here it's just black, isn't it? It's just, it's just air. So this is a left sided pneumothorax. And can you guys see this level here? Yeah. So does anyone know what this is like a classical, it's like a classical picture of this um finding, do we know what we call a pneumothorax with a bit of fluid on that same side? It's hydropneumothorax. So you can see like a really clear sort of um straightening um on that left costophrenic angle and that's just fluid over there and the big left side pneumothorax. Now, this one is probably the hardest one in this entire presentation. Um Should we go through it together? Yeah. So I'm going to look at the right lung and I'm going to tell you that it is broadly normal. There's some prominent bronchovascular markings here, but you can see lung markings all the way I can't see any focal consolidation. Um but moving on to the left lung, I don't know if this is a bit tricky to see, but I think the left lung or the left lung volume is a little bit less than the right. It doesn't look quite the same, it looks just a little bit smaller. Um, so then we have to go looking as to why that is. So we can see the aortic notch here. Normally the left cardiac border sits here and your left hemi diaphragm sits here. Now, I can see the right hemidiaphragm really nice and crisply here. Can you guys see the left? Not really, no. And then what's this behind the heart? Can you guys see this? This should all be, this entire thing is the heart right where it should be the heart. So this entire thing should look the same as this, but it doesn't, this is a bit more, there's a bit whiter, it's a bit more solid looking. Can I convince you of that? Yeah. So this is a left, lower lobe collapse. So left, lower lobe has actually collapsed right down. It's all squished together. Probably something's blocking. It may be a mucus plug. Um And it's just collapsed, write down which is why your volume on your left side is overall less. Um And it can be a really tricky finding because if you're not looking for it, you won't see it because it's literally just sitting in the middle of the heart Um, but again, if you know, you'd be concerned, is there a cancer? Is the mucus? Is there something else that's plugged, plugging it up? Okay. So, how would we describe this? So you can see that? Actually, this is a really nicely smooth demarcated edge. Yeah. So I'm less, yeah, absolutely. I was just gonna say I'm less likely to favor consolidation because it's just so nicely done. And I, I, you know, you're completely right, it's a collapsed, right upper lobe when you've got lung lobes that collapsed down, you think about it, you've lost that bit of lung, you've lost that bit of volume in that space. So the rest of the lung will compensate. This is actually what should be the horizontal fissure, which normally sits like that, as you can imagine, horizontally, it's been pulled all the way up to compensate for the fact that this right upper lobe has shrunken right down. So actually this is all right, middle lobe, which normally starts about here, but that's just had to inflate up to compensate for that upper lobe collapse. Okay. Now, this one we're talking about collapses. We're still on collapses. One of the things that we, one of things that's really hard in radiology is the absence of stuff. If you can see a big white thing sitting over here, then, okay, you can talk about it a little bit, but looking for stuff that should be there, that's not there. That's the tricky bit. So for this, I'll tell you it's something next to the heart. So you can see that this is your sorry, you can see that this is your aortic notch. Yeah, you've got your artery, the aorta coming down. This is all really nicely in view. This is your AP window. So you're a auto pommery window. It should be like a nice little triangle that's all conserved. Your left cardiac border is fine, this bit that looks a little bit fluffy is actually normal. You normally get a bit of fat sitting around your heart. Um So it's called sort of uh cardiac fat pad. That's fine over here, we should be able to see a really nice smooth right cardiac border. It all looks a bit funny and this list try and get a looking thing here. What lobe sits right next to the right cardiac border on a chest X ray? It's not right upper because we just saw that collapse, right middle. Absolutely. So this is the right middle lobe collapse. Oh, sorry. Okay. Um So this is right middle lobe collapse. Um And that's why you've lost your right cardiac border. So it can be a bit tricky to look for stuff that's not there. But if you go hunting, then you then you're more likely to find it. Okay. So this one, there's a few things going on here. Now we'll talk about artefacts. So artifacts is just extra stuff that we've done or put in. Can anyone name a few artifacts you can see on this chest X ray? Just shout leads. Second E C G O. Sorry, E C G leads. Yep. Yep. So you've got this one here, this one, here, this one here, this one here. Yep. Is that essential lion as well? Oh, sorry. I was just looking at the messages there also left pneumothorax in the previous chest X ray. Um No, I don't think so. I think it's difficult to see when you're not on your big pack screen. So sorry for that, but I can just about see lung markings here and here and here just about there and there and often um in practice, you know, most of the new authorities that you see will be small little slivers um and not very obvious if you are maybe not able to see clear lung markings, but you can't see a visible lung edge most of the time. It's not a hemothorax because you should be able to see pleur that has just come away. Um And air sitting in the space sometimes it's like is there any atarax is they're not and it can be really difficult. But if you can't make out a really nice crisp lung border most of the time there isn't. Does that answer your question? No problem. Um So yeah, we were talking about E C G electrodes. Brilliant. Uh Sorry, remind me what the other thing was that someone said N G tube. Yeah. Sorry, say that again. Did she send youtube? You said, don't you to, I know you said central line. That's it. So, yeah, central line. And this is the central line here. Yeah. Where should the tip of the central line sit? It's in the name? Oh, SPC. Yeah, exactly. You want it to be sitting right at the tip of where the right atrium and the SPC meat. Um, and the point of that is because you begin, you're gonna be giving drugs that need to be given in a high volume. If you give them peripherally with Cannulas, um, they can be very, very toxic to that area and you want it to be delivered into a large volume such as stuff like TPN. Um, if you've ever seen people on TPN, they need to be delivered directly. Um, sort of centrally. So, yeah, this is a left sided central line. Uh The tip is kind of sitting in the S P C. So that's fine. Uh What about this structure here? What's this with the little gap in the middle? So it's a left sided chest re yeah. So this patient's got and youtube central line, chest drain, they're not doing very well. What's this thing over here? If you imagine where it is on the patient? So, it's kind of about here, right? Is in the middle of the clavicles. Yeah. Yeah. Truck yours to me. Exactly. Yeah. Brilliant. So you've got lots of different things going on here. You've got some surgical clips maybe from a previous operation. Um And what's this going on in the right? Lotrisone? Do you think it's consolidation? Sorry, ana collapse, maybe. Yeah. Yeah. And which lobe is it likely to be the lower lobe? Yeah. So right, lower lobe collapse along with everything else? Brilliant. Okay. I think this is more of the same. Let's see. That was a H Okay. Yeah. Um So this is another white out. This is a right sided, white out. You can see the trachea has been pulled over. So that means that there's volume loss on this side cause is the volume loss include collapse. When you connect to me, if the plural of um if there was a large pleural effusion, it'll often be pushing um the trachea and the mediastinal contents to the other side. You can see that we've completely lost the heart here is just moved all the way over to this side. So it's marked what he lost on this. So most likely a right side. A pneumonectomy. Yeah. Mm This one. What was wrong with this one? Uh hmm It's been in half. Okay. Fine, cool. Just leave it on this one and then we'll finish off. So we've got this tube sitting over here and we've got all of this muck basically in the same area. What's happened? Hmm. So an N G tube has gone. Look. Yeah. So the N G tube is exactly sitting, not where it should do, which is in the stomach but has gone and sat in the right lower lung. They fed them through it and almost certainly cause this aspiration. Right. Well, thank you.