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If you guys can hear me, then um we are going to start. Um My name is Yeah, thank you. Uh My name is Mazza, one of the junior fellows for the plastic surgery team at Salford Royal Hospital. Um in all this session, um it's two sessions, we will discuss about the basics of the chest x-ray as a junior doctor when we are on a what call or on call commitments. Uh No matter which department you are in, you will always be asked to have a look um at a chest x-ray every now and then. So this session basically aims at junior doctors working in, they would cover on call whenever they are asked of to review a chest x-ray. So in today's um first part, we will discuss about some basics and almost cover half of our topics. So um let's start, let's dig in. Um the first thing that I want to say is that nothing in nature prepares us to see x-ray images like x-rays and the x-ray world. Maybe we were not supposed to um see it. But um despite, but after the discovery of Madam Curie, um we are able to pe behind what, what we call um visual spectrum of raise. And now we can see um what, what lies in the x-ray world. So, since uh we are not naturally um supposed to see, I think the x-rays, so sometimes looking at the x-rays is daunting and it's sometimes a bit difficult to understand what's really going on, especially um the chest xrays. I think they are a two d representation of a 3d world. Um from your anatomy classes. You must remember that the chest is a 3d world, which has got 3d organs. You've got your heart in there, your great vessels in there, your esophagus in there, your lungs, and you see your bones like um your spine and the ribs, all of these are in a 3d world. But when you look at a chest x-ray, it's a two D world. So um sometimes looking at a chest x-ray could be quite daunting and uh you may not understand what's really going on. Um Our, this approach today would be an attempt to understand what to make out of this two D image of an x-ray road, which is basically an image of the 3d world, right? So, um when you look at a chest x-ray, um it is all shades of gray, um there are some whiteness and then you've got different grades of gray, which is we um and what is what we need to kind of bring ourselves, we kind of need to familiarize ourselves. OK. This is the bone, this is the air, this is the soft tissue. This is how different things look on an x-ray. If an x-ray um passes through air and hits the radiographic plate, it would just give you dark jack black color. That's only one extreme of the x-ray spectrum. Um So this jet black color you will get if the rays just pass through pure air. If there is are obstructed. If there's a metallic thing in the way of the x-rays before they hit the radiographic plate, then you will get this whiteness. So you got a reference range, it would be black, total black and the metals would be white all white. And in between you've got soft tissues and fluids which will look like this shade of gray bones, not too white, but still white. But you can't remember these grades and say, OK, I know this much grayness is bone and this much grayness is the soft tissue. So how would you see all this reference range on a chest x-ray? So when you look at the chest x-ray, um there are certain things that guide you. For example, I said the air is totally black. Sometimes you get pneumothorax and there's still some blackness. If you look at this lung or this lung, you've got some blackness there. Is that air or is that lung within the air? How would pure air look like in in there if there was no lung. So how the air looks in a chest x-ray, if you want to have a look at the air, the pure air just look outside the body. So that's your skin ending there, your clavicle, your skin, just if you look outside, that's how the air would look like if it was purely air in the lung cavity in the chest cavity to be precise, how would the fat look like um For your reference point just come inside from that air bed and then you got your skin and then you got just below the skin, you got your fat. So this is the grade of the fat, let's say if you got a lipoma in there. So the consistency of the grayness would be somewhat like this. I'm not saying that there would be a lipoma in the chest, but it's just uh for the reference soft tissue. Uh how would the soft tissue look like? So hard is the soft tissue? Uh That's how the soft tissue should like. Like that's the mixture of whiteness and blackness, which results in a grayness from the absorption of the x-rays by the heart. How would the bone look like? Just have a look at your clavicle? So that's how all the scapula, that's how your bones would like on a, on a chest x-ray that just suppose if somebody swallowed a bone and it's lost in there, um How would you know that it's bone and not something metallic. So you will compare the greatest level would be something like the bones out here. How would matter look like? Um You got some foreign bodies in there. That's how the matters would like, like they're a bit whiter than the bones whiteness. So that's your reference gray, gray scale of the chest x-ray. Look outside. That's how the air would look like. If, if you find air in there in the mediastinum or if you find air in, in in your chest cavity, think of the tics, but it should look like this. The bones would look like clavicle or scapula, soft tissue would look like hard fat tissue would look like just about this gray scale here. And the metals would look like this. So basically simple as you all know um radiographic plate, um the rays come rays get absorbed by your body and then they hit the radiographic plate looking at the chest x-ray. Um You will see why have you got, you will think, why have you got different kind of levels of grayness? Why do you get this line here? Why do you get this line here? Why do you get this line here? Why this line just merges with this line? What does this represent? We will grow? We will go through all of this in bit by bit just to start with the basics. As I said that it's basically um a 3d cavity which has got 3d organs placed in various places and then the radiographic rays come and then they go through them different organs, they absorb different number of ray and intensity and then leave you with an image on a radiographic plate. You'll understand what I mean. Um Let's just imagine if there was just um heart in the chest and no other organ, no lungs whatsoever. You will get a different kind of um shadow of the heart. But as you know, in the Mediastinum, you've got your backbone, uh the vertebra, you've got your heart, you've got your esophagus, you've got your um aorta, all of these run through one place. Although they ju juxtapose each other just like if you imagine if this is your heart, then you've got your um vessels esophagus, then you got your vertebra. Now, the rays pass through all of these through and more and more of the rays gets absorbed and you get a more whiter image. But I'm trying to say that um if it was just hard, it will give you a lighter gray. Um But since many, many structures get behind each other and more rays gets absorbed, you get a more white area, especially in the, in, in the center, we will talk about this more in our next sessions. But this is kind of what I mean. Um in the middle, you see, you got vertebrae, you've got your major vessels, you've got your heart, you got your sternum. So that's why if, if you remember when you look at the uh chest x-ray, the medium kind of looks funny. It's got really white areas. It's got just the heart shadow, it's got heart shadow overlapping the lungs. This is all because 3d structures are placed in the 3d places and sometimes they overlap each other. Sometimes they don't, when they overlap each other, you get a different kind of whiteness. Um The point where they're overlapping each other, just the borders of the overlap. You get those strips and lines which you can use to distinguish OK. This is here here where the aorta ends. This is where the um heart border starts. For example, we'll go through all of this. Um As I said, that it's a 3d um world and uh you got 3d organs in front of each other. If you look at this picture, one and two, the m middle borders are overlapping, we can see slides. It's just you, we can see not the slides. So at the moment, is that so, yeah, so you're not, no, just you not the slide. So initially at the start, you could see your screen. Um But I think you are probably on the window of just your image. Not let me just do it all over again. Yeah. Yeah. Can you see it now? Yes. Yes. So could you go see your projections? Yes, you guys, can you see it now? Yes. Right. So I will just quickly walk through this again. Um Because I think it's important for you to see um this is how the air would look like the metal on the other side. Um The soft tissue gray in a scale here, the bones are white but not that wide. That's what we talked about. So this is the picture I was talking about where you can compare different um grayness scales and you know, OK, which density corresponds to its structure. Um the air outside looks black. Um If this air, this color, this kind of blackness you see inside the chest cavity, think of air in the chest cavity like for pneumothorax. If you walk in from outside inside, when you cross your skin barrier, you see just fat lying under. So that's how the fat should look like in the chest x-ray soft tissue, heart is a soft tissue, that's how the soft tissue looks like. Um And then the bones look like your scapula or your clavicle. And the metallic bodies are really, really white. This is what I was talking about that the rays go through a structure, they get absorbed and then they give you um level of whiteness or grayness on a radiographic plate. The next one you go in is this is what I was saying. It's a 3d structures, different kind of heart lungs, um aorta esophagus, the vertebra, they come in front of each other and then they absorb different strengths of the rays and you get different kind of whiteness and grayness on a radiographic plate. We will try to distinguish what whiteness, what grayness corresponds to which structure and how we can use that to our advantage to in interpret in interpreting the um chest x-ray. The CT scan shows basically what we all know from our anatomy class is that you've got, it's a 3d structure. You've got your heart, you've got your major vessels, you've got your vertebra, you've got your body wall, you've got your sternum, the front body wall, the rays will be passing through all of these structures then hitting the radiographic plate. So you will get different um strings of grayness and whiteness on a, on a chest x-ray. And we will use those whiteness and grayness to say, OK, this whiteness corresponds to this structure and this whiteness corresponds to that structures based on our knowledge of the anatomy of the chest. OK. So this is what I was um talking about. Um is that, so if you see the plate one here is in front of plate two, but the image you get is so this area is overlapping from both of the plates so that this area overlaps uh in both of the plates. This is something what you would see on a chest x-ray are just white area where the both of the plates overlap. And then this border uh between the this grana and this darker gray area. You got this border which tells you OK, this is the overlapping area and then here is the one plate, here, here is the other. And if the plate two is in front of the plate, one, you get sort of same image. So this is what I was saying that it's a 3d world. We based on just an x-ray. If I don't know the anatomy of the chest, I can't say OK, is the heart in front of the um esophagus or the esophagus in front of the heart? Um We can't just say that based on an A P um or one view of the x-ray. Do you know what I mean? Um So we kind of use our anatomy knowledge with the uh what the x rays image are telling us. So we combine the both and with, of course, in any chest x-ray, you also correlate the clinical knowledge if you don't correlate the clinical knowledge, uh you may not get the right answers. We will, we will see how, how that's related. So moving on to next. Um So basically this is the same thing interfaces. Um when the two things overlap, you get um a wider area and then where the overlap ends, you get these lines. So basically you can call them interfaces. So there is interface here, there's an interface here, even there is that interface between this dark area. And this another thing that's important in um chest xrays is something called silhouette sign. Um So basically, these are two plates um which are not overlapping each other, but they're like just kissing each other aligned. So there's no gap between them. So this is basically called silhouette sign reference to the absence of uh depiction of an anatomic soft border. We will see how sometimes in the next x-rays, um the heart border can sometimes be um obliterated by a chest or a consolidation in the lung. So that's what I mean. Sometimes they're not overlapping, but they're just sitting by each side and, and they will the normal borders um which sometimes give you new diagnosis and sometimes make some diagnosis difficult. So like here you see, um this is if this is the normal border of the heart and there's no um other pathologies you see there and then you get this mass or consolidation right there. Can you make out the um heart border in this x-ray? You can't because what has happened is that consolidation is just juxtaposing with the border of the heart and it looks like the heart border is completely obliterated. This is something which is called s sign. It's important to know. So as I said that talking about the interfaces, as I said, there are many, many structures just in the mediastinum. Um For example, what I see in, in this x-ray here is I see the heart, right? You see the heart here and then I see the vertebral bodies then I see the esophagus, then I see the um aorta going down, then I see the um trachea there, the bronchus there. So you see how in the chest, all of these structures are just in front of each other. Um How do I know which is, which um of course, by anatomy, I know there's a hand like structure which sits in the chest, which is hard. What do I mean by the interfaces is that? So here is the lung, the lung has some air in it. So it's got, it's got a different distinct kind of grayness scale to it. So when the air passes through this, you get this kind of grayness, of course, you see the uh the uh ribs as well, but this is how the um a normal lung looks like. But then what you get is the heart dis makes a contact or comes in front or behind the lungs. Now, two structures ab absorb more of the radiation and then you get this whiteness of more white area. So basically, that's how the heart image becomes or shows on a radiographic light. The heart border is where the heart ends and and you just see the lung, then the overlap of the heart. So these are very important interfaces, these, these are what we call interfaces, lung and then heart. And then if you move inside from an knowledge, I know the aorta just comes and makes an arch here right about there and then comes down. So you got three structures here. You got more white area. Um So that's lung heart. And now aorta I move further in it's more white area because by an apnea, I know the esophagus is there. So esophagus comes in front and then there are also vertebra behind. So esophagus, then you got some of your aorta there, then you get your um vertebra and your heart. And so you see this is really, really white because lots and lots of radiographic rays have been absorbed by all, all of these structures together. So you go to your left. Uh So the, now the esophagus and the aorta are out of the picture. You got your vertebra and your heart and your lungs, of course, you got really white area and then you move further, it gets more because now it's just heart and the lung and you move left and then it's just the lung and it's vasculature. Does that make sense? Does, does anybody have any questions? All right, there are no questions. Then I'll, I'll move on. So basically, again, the same thing, we will talk about these in detail, different interfaces. But now we're just talking about on the um upper part. So you got your trachea with air in it, then you got um the paratracheal tissue which makes an interface with the trachea, then you move out and then you got your lungs again, you see same kind of interfaces later on, we will discuss about these in in the section of Mediastinum as well, right? So um we've talked about interfaces, uh how different um interfaces would look like, how different scales of grayness would look like. Now, the next thing in the basics I would like to talk about is assessing the technical quality of a chest uh chest x-ray. Um why is it important? Um if the chest x-ray is not taken in a standard way, um then our interpretation of the chest x-ray and the structures which show up on chest xrays are they become um erroneous and you can make wrong diagnosis. If the quality of chest x-ray technically is not good, then um you will get wrong diagnosis simple as that. So which things are important while we talk uh about the um quality of chest x-ray? Is it rotated? Um inadequate inspiration or the penetration of the um x-ray beams? Is it too much? Is it too less? First, we will talk about the rotation? So basically, uh it's a rotation of the patient in um relevance to the beam of the x-rays. So how can a patient rotate if, if the patient is just standing upright and in a pa film, as you all know that pa film is the gold standard film for the chest xrays. If a patient is just standing there, it gives you a good inspiration, film. Everything is OK. And those are the kind of x-rays which look nice and, and they usually don't have any quality issues. Most of the issues come when the patient is lying in a hospital bed and mostly in the wards when, when you get chest xrays, it's because some patients really sick and it's really difficult for them to go up and get up and go to the radiology department to get the x-ray done. So what you do, you get an A P view um and they're lying in the bed, they are incumbent, you can't move them, you do your best to take the best quality picture, but either the x-ray being or the patient, they end up moving in one of the three axes and you get these technical issues, we will talk about all of these and what issues they can give you. So the three axis basically um XX is I, if you focus focus XX is, is basically when the patient um moves like this or this, uh they're up or down. Um in regards to their shoulder, then the ZX is sometimes they um patient could move forward or left. Um And so on. We'll talk about these in detail and the XX is, as I said that um it's also what we say is known as um right or left lean and the patient is lying in the bed and they're like this and, and they, they take the chest x-ray. What happens is that either you don't get all of the picture of the chest x-ray, like you see the um half of the clavicle is missing from there. Um Or sometimes what happens is that you get your um these phrenic angles gone. So when the costophrenic angles are not visible on either side or one is like too rotated, you know that this patient has been rotated in, in their axes. Um There may be no gastric bubble as you see in there. So y axis is basically um front or backward leans and sometimes or most it happens because of the a ray of the x-ray is not focused at right angle. And either the ray comes from down and looks up or it comes from up and looks down to the um chest cavity. So, in a normal um chest x-ray, what happens is rays come straight, they go through the um your chest and then here's the um radiographic plate. Uh So how do we assess for this is normally what you see is you see your clavicles and you should see lung epis just above the clavicle. If you see some lung epis above the clavicle, then you know, the patient is not rotated in the in the yx is they're not leaning frontwards or backwards or the x-ray beam has not been moved inappropriately. So, um it is another um interesting fact is that sometimes um what you want to do, you actually want to see behind the um clavicles to look for lung pathology there. That's rare, not at a junior level, but um, if you wanna look at the lung epis, so what you do is you intentionally put the rays from downside. So the clavicles, they look um above the APIS and, and then you can look at there and see if there's any lung pathology going on there. So, this view is called TIC view. Sometimes it's because of um an error and sometimes you actually want to see it. So what happens if um um if somebody is rotated in, in A YV or the um advantage is we talked about the advantages that you could see the lung appis that's rare for us to actually go for it. Um The disadvantages are the cardiac silhouette. Um it looks diminished, um lung volumes, they appear falsely low. You see here, the lungs are like looking really small on, on an A P view. So the we will talk about that too. The next um is the Ziac rotation. It's basically one of the shoulder of the patient. It either moves forward like they can bring you the right for uh shoulder forward or the left shoulder forward. What happens is when that happens, the the is rotation, the hila they appear either large. So which side they move right that side with? Yes and hila it really feels big. Um So the lung vasculature on that side could also feel um different and you can make a wrong diagnosis of hilar um lympha, um a adenopathy or, or, or some other, how would you um check if the patient is not rotated in the Z axis? Is you look for the spinal processes just in the middle, the heads of the clavicle should be cod disin from the spin processes on the both sides. Excuse me. Um So what you do is actually um just measure if, if they're equal distant, uh if they are, then, you know, the patient is not rotated in the ZX is. So, um can you tell um which side the patient has rotated MZ XS in this x-ray? Is it right? Or is it left? Just look for the spinal processes? Um and then look for the head of the um medial head of the clavicle and just see it are the both sides equal disin old, are they now? So basically, um the right side is not. So which side the distance is shortened? So the rule of thumb is spinal process is closer to the clavicle head. So it's closer in this side and there's more distance on this side, which side is shorter. Usually the side is, is the shoulder which has been um rotated that the shoulder has come forward. So that's how it would look like in the. So um consequences of um this uh size and shape of the card sul again could be changed. So you can't make a comment on the card silhouette, um Mediastinum, as I said, um the hila um they could look enlarged um disor and the other side of course, will look smaller than um it actually is, right? Um So moving on next, um what's the difference between these two chest x-rays? Uh There are not many uh pathologies. It's not a trick question. There's just one difference. Um If, if any, any one of you can spot it. So, more information is that these x-rays were taken um in the same patient at the same time that the this film was taken before and this film was taken after like a few moments after. Um So everything else is same except just one parameter, anybody. So, um basically, the difference is that um this is inadequate um inspiration and in this x-ray, the patient has inspired adequately. So how would you know which x-ray chest x-ray is, has the adequate inspiration and which doesn't. So basically, we count the ribs. Um Right. Um This is a good picture for, for this purpose. Um You get to, you should, what you should have. Uh What I usually do is I look for the uh right diaphragm, um the anterior ribs, um arch like this and the posterior ribs, they are horizontal. So if you're counting um the posterior ribs, so that's your first posterior rib. It it it's always a different shape um the first rib. So you got your first post rib and then you got 2nd, 3rd, 4th, 5th, 6th, 789, 10. If you look at your anterior posterior, you got your first anterior rib and the anterior ones are, are arched like this. Uh you got your 2nd, 3rd, 4th, 5th, 6th, 7th. So um you could calculate this if the inspiration is adequate or not based on both the anterior and posterior rib. But I find the um anterior rib counting method easy. I just look for the first one and the curve I count seven and the seven rib should be um dissecting the diaphragm. So um if you want to go for the posterior rib, uh then the ninth and 10th, posterior rib um should be visible above the um diaphragm. So if the ninth and 10th is above the diaphragm, uh if you, if you're looking for the posterior rib method, then that's a good inspiration. Um If you wanna look at the anterior ones, then the um seven rib should be dissecting the diaphragm. So if you've done all these three, you have assessed for the quality of the um chest x-ray if it's a good quality or not. Um before moving forward, as I said, uh there are some um uh side effects of inadequate expansion of the um in inspiration when a chess film is being taken, um the lung volumes, they may um appear falsely low, lung markings appear falsely prominent. Um You may think it's a pulmonary edema cardia may appear falsely lost, right? Um Exposure. Um How would you expect? Uh uh how would you um assessed for the exposure? So, basically, um simple rule of thumb is if you can see the, these intervertebral spaces behind the lung, they should be barely visible. If you can see them, then it's a good quality um exposure. But if you can't see them, it's under exposed. If they're really, really um screaming at you that they're there, then probably it's um overexposed. As I said, the summary of the um technical shoes is that to summarize what you do is you first look for rotation is the patient um tilted right or left. If they are tilted right or left, the costophrenic angle won't, you won't see the both of the costophrenic angle. You won't see um equal um clavicle exposure. Um Then you look for the lung apis. Are there any lung abscesses above the clavicle? If they are, then the y axis is OK, then you look for the spinous processes. And the media head of the clavicles are the equidistant. If they aren't, then the patient is not rotated in the x axis. They haven't brought their any shoulder forward. If they're not rotated, then uh you look for all these three things and then you check your boxes like OK, it's not right and left. And I can see the episodes about the clavicle um and the spinous processes that from the both medial heads of the clavicles. Then you move and see for the inspiration. Um What I do is the interior ribs is the same on dissecting the um the diaphragm or the 9 10 above the diaphragm. Then yeah, it's a good inspiration film. Then you go for the exposure and do I barely see the um inter spaces behind the cardiac shadow? Yes, I do. Then it's a good technical quality film. Then I am really confident to comment on the lung volumes. I'm confident to comment on the um cardiac size. I'm confident to comment on the um Hila and the hilar pathologies. I won't say, ok, this is not a good quality film and there is a doubt that the lung volumes will be low or there's a doubt uh There would be the card shadow won't be accurate and things like that. There's another thing that affects the, we will, we will speak about that as well. Um So um there are many, many approaches to um look at the chest x-ray. Um Some people go from the midline outwards. Um And I prefer this ACDF approach. Uh like you would review any um sick patient ABC D approach. There's an A BD approach for chest x-ray as well. So it's easier because um uh it gives you a systematic approach and you don't miss out on anything and it's a demonic as well. Um A is for assessment of quality and airway uh assessment of quality we've done. So far. And then we will see at airway b uh bones and body walls, C cardio and mediastinum D diaphragm e equipment and effusion f fields of the lungs and do for great vessels. We will talk about a few today. So airway um a we have done the assessment um of the quality and then we'll move on to the airway. Um General principal pathologies, we will cover some not all. Um Is it narrowed, is it deviated? Are there any foreign objects in there? So narrowing, um classical exam question, uh you may have encountered this um so far in your journey of clinical practice and medical education, it will come again. So what is this? What do you see here is um narrowing of the airway. Usually this happens in group. Um You get this um sharp um closure and then expansion of the airway. So this looks like a steeple, steeple of a church. Um So that's why this is called a steeple sign. So basically, what you do is you look at the trachea, it should be um of equal size all the way up. But if it's not, if something looks like this, you know, there's a narrowing of the airway. Classical example is here. Next, the airway deviation um that's really important um because you got some major emergencies which can be diagnosed on a, on a chest x-ray, just looking at the deviation of the airway like pneumothorax. Again, we will correlate some things here if you see um you've got your, so, so you see this blackness is just exactly like the blackness outside the um chest x-ray. So this is your guide. So I I told you that this is a, so this is air exactly. There's some in there as well, but you got your tissue as well. It's not jet black like this. So this jet black and this jet black matches. So I know that's the air in the chest. So the the lung, the actual lung, if you see it has collapsed and become this small right there. So that's your lung. All of it is the air. So what's happening unequal intrathoracic pressure is there and the this air, it's, it's it's just pressing over this trachea. And you see the um trachea has shifted towards the left, towards the right and you got your, this total collapse of the um left lung s can due to pneumothorax and, and probably attention and methods as well. So, airway deviation, um it happens uh because of the two kind of pathologies, uh the pathologies which deviate the trachea towards them and away away from them. The pathology that devi a trachea away from the affected side, of course, is the pneumothorax and where the air pushes everything towards the other side. A very large pleural effusion could do the same a very large mass. For example, I've got a very large mass in my left lung it could press um on the, on the right lung to, to press it to the other side. What are the conditions which would bring the normal lung towards their side is at ectasis, which is basically lung collapse. Um Lobectomy, if you removed a lung, a right lung, for example, a cancer patient. So there's an empty space, nothing to keep the balance. What happens is the other side just shifts to the uh to the side which is empty lobectomy, pneumonectomy. If, if, if a lobe is just um removed or, or the whole lung accordingly, the that, but that much of the normal lung could go towards the other side. Fibrosis, fibrosis, basically, um contracts when it contracts, it brings the side towards itself. But it's really that, that the uh if your process happens unilaterally, you see in both sides and both sides contract and except pressure. But if you do see that could be one of the reasons. So we've seen the a deviation. Um So basically, what do you see in here? Anybody? I see there's no landmarking. Um But then, um do you see any air in there? Yes, the lung is not there. The lung has collapsed probably. But is there any air in there? So the air should look like something like this. No, there's no air in there, but the lung is not as well. I don't see any lung markings. So it's no lung there, no air there. So, probably um it's, it's, it looks like something this uh from here or soft tissue, like you see, the heart border is not visible. So i it's something like of a soft tissue. There's no soft tissue that, that fills the uh cavity like this. So what could it be? It could be fluid. So um it could be fluid there but definitely no air. So this is the fluid how the fluid looks like. Uh the fluid will just wipe out everything. So this is hemothorax due to the massive left pleural effusion, the same thing, the lung is gone. Uh Because of the fluid buildup, there's no fluid, there's uh there's no air in there, but the the the lung is collapsed the next day in the airway is CNA. Um Cryer is important in a couple of things. It helps you distinguish between the right and left bronchus. It helps you um distinguish between uh when you, when you are asked to judge for um two to bisect the CNA. So, cry is really important. The normal angle of the cryer. Does anybody know what's the normal angle of the crier? There's the clinical significance like that as well should be less than 90. Um So how do you trace it? You see your trachea, you go down um then you see your right bronchus going there, left bronchus, going there. If you see the lower border of any of the bronchus, you can trace it up uh if you trace it up, then you see your right, it just ends here and then the other one starts here. If you can find the lower border, that's fine, you can look for cry from, from that way as well or just trace it from the trache, it onwards, from trache, it onwards right and left bronchus and cry is right there. The angle should be less than 90 splaying of the um angle of the cryer when it becomes more than 90. Uh So basically, the trachea is sitting just above the heart. If the heart becomes enlarged, it could put pressure on the cryer and just open the um angle more than 90 it's called splaying of the um right and left main bronchus. Um And this is, this happens when you've got extreme left atrial enlargement. So just looking at the crying angle, you could see, OK, um this patient has a bigger heart again, the foreign bodies just because how the um trachea and right main bronchus is made because of this nature of anatomy. It's kind of just a straight, it's, it's at a bit of angle, but not that much as compared to the left one. So if there's a foreign body ingestion, it just tries to fall in the right side and you would mostly find your foreign bodies in the right side. So next, um in R ABC D approach is the bones and the body wall. So what you can look at is the fractures deformed. Um, your spine, um, sclerosis of the bone, late lesions of the bone. Um I won't talk about the sclerosis and lytic lesions of the bones in a, in a chest x-ray. Um, but it's something that you should be aware of. Um, then osteopenia, we can't, I can't um diagnose it on a, on a chest x-ray and it's ok if you, if you don't, that's fine And then, then sometimes you see notched ribs. But again, um it's something for the radiologist for today's purpose. What we're going to do is uh make ourselves familiarize with the um, ribs and rib fractures. But for the rib fractures, the, the one thing that's important is that um the rib fractures, sometimes they're so big and you can see them right away. Um You will see the loss of the normal contour or the lines or the cortices of the, of the ribs. And you can actually appreciate that there is a rib fracture. Sometimes the rib fractures are so subtle. And as I said earlier that um for a chest x-ray, you mostly need the clinical history as well. And without the um clinical history becomes sometimes difficult to give an accurate diagnosis. So, if you correlate the, um what was the trauma, what was the mechanism of injury on your examination? Where is the maximum pain? And then you go and look on your chest x-ray. Ok. The patient is saying the pain is almost here. And then you look closely and on, on that part of the chest x-ray for any rib fractures, you actually see something. Um we'll have a look and as I said, sometimes the refractures are so big that just looking at the normal cortices, you, you, you look at every rib and you look at the normal cortices from the start to the end. Are they continuous? Yes, they're continuous. Is this rib continuous? Yes, this rib is continuous. This rib continuous. This rib continuous look for the um an interiors as well. Everything is continuous. But then you come to this side, you see this is not continuous here and you see this line here, you've got um horizontal fracture there, you've got a horizontal fracture there, you've got a horizontal fracture there there and there and there as well. So sometimes they're big enough. Uh the fractures will result in a discontinuity of the ribs. Um And you see the line separating them. So, you know, OK, there is a rib fracture but sometimes uh does anybody see a rib fracture on this inside? As I said, sometimes they can be so small. Um although you're not gonna do something surgically but still, um you need to make a diagnosis for such a small rib fracture. Um So they basically, when you correlate with the patient, they, they've got pain and everything. This, there's a small crack on the cortis here like a green sick crack, maybe. So, correlating the history with the rib fractures is really, really important and physical examination too. Sometimes you feel the um some of the emphysema just under there. Sometimes the crackling of the bones is felt again. Um the clavicle fractures, although um the chest x-ray is not um something that you rest if you're suspecting a clavicle fracture. But in a polytrauma patient, let's just say you can look and you should look at all of the bones and you see fractures of the clavicle. This is the distal third again, um not, you're not really looking at and sometimes you are um at the spine as well. Uh But as part of our complete assessment of chest x-ray, you look at the backbone too. So you see a collapsed fracture of the, of the vertebrae. And on this lateral view, select view is, is, is um important to look at the vertebrae fractures or collapse because uh because you, you see on the NTV, you got um just so many things in there, it's difficult. The p views um are important to um look at the curvature of the um spine, especially the scoliosis. Uh A view will tell you if somebody's got scoliosis and all and um elect we will tell you about more, give you more information of if there's any collapse of the, of the vertebra or if there are any fractures of the vertebra for any fracture. A general rule of thumb, look for the cortices if they are continuous or not. Remember how vertebra looks from the anatomy. Um Does this something look like that? Then again, chest x-ray um and the curvature of the um spine um in a barrel chest basically. So this is your um transverse diameter and then your anterior posterior dimeter of the chest. Um The anterior posterior dimeter is always smaller than the, your um transverse diameter. Um But sometimes because of the emphysema, um what happens is both of these damages become same and you get something what we call barrel chest. So you see the A P damage really huge here. Um And another thing that you notice is the flattening of the diaphragm. So basically, this is called a barrel chest. Um and you get it in emphysema, five forces to come through that. So, um the body wall, uh what do you look in the body wall in, in a chest x-ray? Um It emphysema sometimes it's subcutaneous emphysema, they call it. Now, it used to be called um surgical emphysema. So if you look here, so you see that's not normal, the normal x-ray that I showed you earlier, you got something going on in there. So it's basically like a small pocket which look like the air from outside. Um So yeah, it shouldn't be there. So it looks like air in there. So you've got surgical emphysema there and of course, look at that and then um what you do is next, these are just the causes of the surgical emphysema. Um How, how you can acquire it some, sometimes accidentally, sometimes it could be because of the our surgical procedures like um post surgical complication of chest tube. The next thing is um have a look at your body wall as well. Do you see any masses, any swellings or anything of the sorts move on to the next session. Uh Section of our ABC D assessment is the cardiac silhouette. Um So normally we get a P uh P A view. So P A view is basically where we stand with our um chest face, just um on the radiographic view on the front, on the radiographic and the x-rays come from our back. So to explain this bit here, uh what I'm gonna talk about, um I'm sure if you um would have done it at some point in your life um is when you get a source of light like a bulb or a candle and then you bring your finger just near it. The, the more you bring the finger near the um source of the light, the bigger the shadow of the finger is. So um just if you keep that in mind, I wanna talk about the cardiac size. So basically the source of the, if the source of the x-ray is here and they're traveling us some distance, then they hit the um heart and then you get a shadow of the heart in there. Even on a pa view, this is not the accurate, exact size of the heart. But because between the heart there is just um anterior body wall and then you hit the radiographic plate, it's I would say pretty much almost the same. But when you get an A P film, anterior posterior, now the rays hit your heart first, then they go to rest of the chest cavity and then hit the play. It's basically like me bringing the um if, if heart is my finger bringing closer to the light source, when I, when I do that, then the, the shadow of my finger becomes bigger. So what happens in an A P film is the cardiac size becomes exaggerated. If somebody asks you to comment on cardiac size on an A P film, just say it's not, it won't be accurate. You will say the patient have cardiomegaly when they don't. So same thing um on uh PF and you got this size of the heart, which should be less than uh 50% of the entire chest gamma D. Um So in a PF film, the same patient and the heart looks enlarged. So um if you don't look which film it is and you could say, oh some at this patient has got cardiomegaly even they don't, it's just because how the image was obtained, we'll talk about this um further in the media section as well. But I want you to know and from the anatomy, you know, um you got your heart there. So this should be your left ventricle just above the left atrium um above you got your pulmonary artery, left sided. We will talk about that. Um In the next section in detail, you got your arch of AOTA, you get your right primary artery and you got your right ventricle again. Um And then you, as I said, they're different interfaces. We will talk about these in detail, we will defy the mediastinum. Um And you get your this um aorta interface as well. The important uh thing um for the cardiac chiva uh that you need to remember is the cardiac ratio, maximum, horizontal cardiac, we should be um till 50% or less than 50% on a pa film. That's very important. If it is 50% or less than 50% it's fine. If it's more than 50% then you got cardiomegaly. So in a, on a P A film, both of these are P films. Um this is the normal heart and if the heart is bigger and you calculate the ratio. So basically, it's the from the interior margin of this chest cavity to the interior margin here. And then you divide it by the uh the cardiac and then you get to your size, right. Uh The splaying of the um ga lale we have talked about um that usually happens in left atrium enlargement um right. Ap tuum enlargement gives you this double density sign. Usually you should see just one border of the heart, but in here you see two different um interfaces. That's because of the enlargement of the right APM. It's something subtle pericard um effusion, um especially chronic um it looks like a water bottle sign. So in olden days, people used to have these leather made water bottles which stored water and if you look at there, it just kind of looks like this. So if you see this kind of thing, then think that I got an infusion especially on it. So that's it about for um these are the basic things. Um Next, we will talk about Mediastinum and the rest of the things. If you guys have got any questions, then hit me. Um Anything at all don't be shy. Um We will take it from there. Yeah, somebody said duck of breath. Um I'm assuming on the comments it was um when I asked, what's the difference? You're right, Michelle. Um It was the inspiration. Any questions at all? If none, then thank you so much for your time and uh attending. Um we will see you next week um with the second part of it. Um If you go um and go through the there's a very good um session on the Elfh um website as well, which talks about these uh normal chest x-ray things. Uh give it a read. Um get some CPD points or something like that as well. It goes into portfolio too. Um Give it a read. Um ef I, I'll put it in the, um, I text you as well. Um If you don't have any um account, make an account, they've got a very good series. Um go through the section with the chest xrays, um read it and then then if you get any questions about this session or you don't understand anything, just bring your questions, we will try to answer next time. Thank you so much, Monica for your nice comments. Um I will see you guys next time then. All right. Thank you for your time.