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Ok. I think we can get started now before the joint as we go along. All right, fantastic. So I hope that's enough time for them to just get settled in. So, hello, everyone. Thank you for joining today's Mela and UK MLA Vision episode. For those who are new. We're essentially aiming to host um ideally host monthly sessions or gear towards the UK MLA. We have the Lovely Oz and far today to help us host today's session, they're second year medical students, University of Buckingham. And just so everyone's aware today's um session will be recorded and post it on our website, um post it on our um partner website meal where people students can watch on demand just before we start. As I always do like to lay out a couple of rules. Ideally, can everyone please have their cameras um off and their mics muted just so um so as I can flow as, as as normal as possible, and if you do have any burning questions, do feel free to raise your hand button on the zoom. But just keep in mind we'll have a questioning session at the end of the, the teaching and I would like to give a hand it over to. Ok. Thank you very much, Kev for the introduction. My name is Jose, I'll be presenting the respiratory system today with far. Um And um roughly it should take roughly 40 minutes to an hour or so. And like Kevin said, please feel free to ask questions at the end. Um And again, this is the respiratory system kind of uh more brief overview of the the high yield um points. So, so let's get started on the session breakdown. Um So we'll be covering. So next slide, please far. Yeah. Ok. So we covering the anatomy of the respiratory system, um the physiology of the respiratory system, including things such as the histology, gas exchange, ventilation and perfusion and acid base balance. Um and then we'll move on to pathology of the respiratory system such as asthma COPD, cancers and other diseases. Ok. So we'll first stop with the thorax, the thorax is made up of three major parts and these parts are the thoracic cage, the thoracic wall and the thoracic cavity. So, of the thoracic cage, it's important to note that the ribs are part of that and, but they're broken into different sections. You have ribs, 1 to 7 known as the true ribs. Um because and they're known as a true rib because they're directly attached to the sternal costal joints. Yeah, ribs, 8 to 10 known as the false ribs where they are not attached directly, but they have um interchondral joints and then ribs. 11 and 12. These are known as the floating ribs because they are suspended by muscles and don't attach to the sternum. So of the thoracic wall, there's three important muscles to be aware of and starting from the outside going in. We have the external intercostal muscle, internal intercostal muscle and innermost intercostal muscle. And what is the purpose of the thoracic cavity? The purpose is to mainly protect vital organs such as the heart, lungs, drea, and the esophagus as well as providing um a passage for structures passing through the head to the abdomen. So, moving on to the diaphragm, diaphragm is very important in regards to breathing and respiratory. Um So, contraction of the diaphragm causes the diaphragm to move down and that leads to inspiration. Whereas relaxation of the diaphragm caused it to move up leading to aspiration. So, diaphragm is very key in helping in helping one breathe. Um and obviously damage to this part can cause respiratory issues and we'll um move on to that later on. So the the main arterial supply of the diaphragm is the phrenic artery. Uh whereas the venous strain is the brachial cephalic vein, ays vein and inferior vena cava, where the innervation is the phrenic nerve. And the diaphragm has specific structures which run through different levels. And these are quite important to know. So at T eight, we have the infra vena cava T 10, the esophagus and T 12, the aortic. OK. So just to make sure that you guys have been paying attention, even though it's only been two slides. Um We've got a couple of questions for you. Um If you want to just put the answers in the chat, um it's up to you or if you want to unmute and just say it out loud. That's also OK. Um So for question one, which of the following is the smallest subdivision um of the bronchial tree. Does anybody have an onset for that one? You can put them on the side fine and we can discuss them in a second. Um Number two, which muscle is primarily responsible for increasing the volume of the thoracic cavity during inspiration. And the third question, which of the following structures is not found within the mediastinum? Um So I'll give you guys a couple of minutes to just jot down some ounces in the chat. Mm I actually can't read the chart. Ca um K can you read the chart out, please? If anybody puts answers in the Yeah, what was I saying? Yeah. So in the chat. Um So do I have some suggestions? Um We have a ab we have a ad and we have a BD. OK. Um So for the ques first question is actually kind of a trick question. So the bronchial tree actually stops at the terminal bronchioles, the respiratory bronchioles and the alveolar ducts are not technically part of the bronchial tree. Hence, the cancer is c for that one. Um question two. Yes, most of you got that. It is the diaphragm. Um The other, the other muscles are very important as well, but they are not primarily responsible for increasing the volume, the volume increases when the diaphragm is um relaxing and moves down. Um So yeah, and then number three, which of the following structures is not found within the Mediastinum. Yes, that is the diaphragm. The others are found within the Mediastinum. OK. So moving on to chest X rays, obviously, this is something very important that will be seen in the future. A lot of the time. Um And it's, it's a lot of information on the X ray and it's important to have a standardized approach. So we don't miss anything. So a nice one that we, that we have here is a CDE. Um And again, it just ensures consistency, making sure things are not missed. So first we look at the airway, then we look at breathing and cardiac and diaphragm. And then everything else. When you look at the airway, you're looking at tracheal deviation, you won't be able to identify the bronchi. Um When looking at breathing, you're looking, how clear are the lungs? Is there any consolidation? Are the lungs collapsed? Are there any opacities and opacities are, are just show up on X ray as more, more white, the more white is the higher the opacity and it's indicative of liquid or solid or anything else. Whereas air is more um gray black on an X ray. Then you look at cardiac, you look at the heart, you look, does it look enlarged? And then you by doing that, you look at the heart, um how large it is compared to the actual um um chest cavity, you'll look at the diaphragm you're seeing, can I see the cost of front angles clearly? Have they been disfigured? Is there perhaps fluid there or anything else? And then you look at everything else. You look at soft tissue, you look at valves, pacemakers, piercings leads anything that will help you come to um, a diagnosis. Ok. So this first x-ray again, you, you'll, you know, we're looking at the, um, the airway, the um is ok. Um The main thing that stands out in this x-ray is on the right side, there's quite a lot of opacification in the lower section of the right lung. And then we can't see the costophrenic angles, whereas we can on the left x-ray, right, if you don't mind pointing out on the le on the left, on the left side where that cost the angle down below. Um And again, we can't see it on the right side, that's indicative of fluid build up in the lungs. On the right, on the right side, the heart borders have also disappeared where it's not present on the um where it is present on the, the left side. Um So this, this chest X ray is as indicative of um plural effusion of the right lung. OK. There on to the next one. So we can see again, looking at the, the airway, there's not much Tokyo deviation here on the right side. Again, there is some opacity, not as much as before, but there is still some. Um and then we call it more like a cloudy appearance. Um And again, we we can see the costophrenic angles in this case. So it's, it's not a liquid like before. Um This one is more indicative of something. It's some, it's consolidation which is, which is like infect due to infections or cancers or other some other reasons on to the next one, please. So again, this one, we we can see somewhat of the costophrenic angles. They're not normal. This whole x-ray is um you see the chest is quite expanded. Um You can let's call it a barrel like appearance due to some inflation. Um The diaphragm is a lot flatter, the costophrenic angles are there, but they're blunted, they're not sharp. And again, we see this X ray um in patients suffering from COPD. Um but you can also see in patients with severe asthma. So again, this is due to the hyperinflation on to the next one, please. Ok. So this last x-ray is just an example of how you can see everything else that can be seen in a normal x-ray. Um So obviously, you have the support here on the spine, you've got ECG leads pins. Um If there were piercings, they will also be evident, they're very hard to miss. Um And a pacemaker would also appear as well. Anything that is a foreign object or as metal will easily show up on an X ray. Um So yeah, that's just an example of what things some things can look like that are not normal body objects. OK. So a couple of questions to just um consolidate what we've just said about x-rays. So the first question is a chest X ray, demonstrate rounded opacity with well defined borders in the right lower lobe. Um What is the most likely diagnosis from those options? The second question, what is the term for the appearance of widened intercostal spaces with flattening of the diaphragm seen mostly in obstructive lung diseases? Uh And on a chest X ray, what can describe the collection of air within a course of the lungs? OK. Yeah, you guys wanna take a couple of minutes to just think about those and put them in the chat. OK. So we have DAA. Are they, are they all daa so far? Only one so far. That's da well, I have another da. Oh Yeah. The old da so far. All right. Yes, you're all correct. It is DAA. So for D um yes, you are correct. The reason that it's a tumor is because it's rounded and it's got well defined borders. So you can see it very clearly. It's not like hazy or cloudy um viral chest for um obstructive lung diseases, like we just saw in CO PD and also in um extreme cases of asthma um due to the hyperinflation. And then a pneumothorax is the term used for air in the pleural space. Ok. So now let's focus on the histology of your lungs. We'll start at the tea and work our way down. So, the type of um epithelium found in the tea is pseudostratified, ciliated columnar epithelium. And obviously, um it's important that this passage remains open for efficient um air to flow through. So there's a ring of highline car cartilage around it for support. As we, as we um go from the trachea to the bronchioles, we lose that cartilage and get a ring of smooth muscle instead and then going down to the alveoli, there's um two main cells that are here and they're quite important. We have type one pneumocytes um which are involved in gas exchange. And these are simple squamous and we have type two pneumocytes which are involved in s pro production. And these are cuboidal. We also um have duct cells and um club cells involved in immune response and these contain certain enzymes. Ok. So, for gas exchange, um obviously, the basic path of oxygen from air into the blood is going from yeah into the lungs. Um and to do that, it has to be used through various layers such as the surfactant epithelium basement membrane and the interstitium endothelium. And then obviously the plasma in the blood red blood cell membranes and finally into the hemoglobin. Um So hemoglobin is a quaternary protein and it's made of four subunits. Um Each subunit has one single iron group inside, hence four oxygens combined at one time. Um There are various factors that can affect the affinity of hemoglobin to oxygen. Um as shown in the table on the left hand side, such as PH temperature 23 B pg, uh carbon monoxide or carbon dioxide and fetal hemoglobin. Fetal hemoglobin is not really an environmental factor, but they do have a different makeup of hemoglobin because they have different subunits. And so it shifts the graft to the left. Um hemoglobin binds um cooperatively and hence gives it that sigmoidal shape on the graft. And it exists in 22 states. The tense which is present in low affinity areas and then relaxed, which is uh um present in high affinity areas. Um And in systemic capillaries, the partial pressure, pressure of oxygen is around 60 so, cells will usually unload their oxygen into metabolizing tissues here. Um So obviously, you can see on the graph, the main line for hemoglobin and then the things that shifted to the left are an increase in Ph. So that's a decrease in the concentration of hydrogens um an increase in carbon dioxide um I mean a decrease sorry in carbon dioxide, a decrease in 23 B PG and a decrease in temperature and then the opposite for the other side. So right shift is an increase in acid acidity. So an increase in hydrogen concentration, an increase in carbon dioxide concentration, an increase in 23 B PG and an increase in temperature as well. So breathing is control. Hello. Yeah. No, sorry. Um breathing is controlled by certain chemoreceptor and each have a different role. So the central chemoreceptor are found in the medulla and these detect ph changes and the partial pressure of carbon dioxide. Whereas peripheral chemo receptors are found in the carotid and aortic bodies. And these detect the partial pressure pressures of oxygen. And it's importance for the body to um detect changes in partial pressures because it allows the body to acclimatize to different environments such as high altitudes which have low oxygen concentrations and that causes the body to increase respiration in response. Ok. So when we're looking at restrictive or obstructive diseases, it's important to know a couple key terms here. Um because these come up over and over again and it's i it's good to have a, it's important to have a good understanding of them. So the first one we'll cover is F EV one and that's the maximum amount of air that can be forcefully exhaled, slash expired over one second following maximal inhalation slash inspiration. Whereas F VC is a total amount of air that can be forcefully exhaled in one breath. So we normally have the formula F EV one over F VC. Um from that, we make a ratio, um the normal ratio is 7 70% which is 0.7. So if this ratio is less than 70% this is indicative of an obstructive issue and, and due to something such as like narrowing of the airway, whereas if this ratio is greater than 17% this a restrictive issue and that can be due to things such as scarring or fibrosis. And if you look on the left hand side, we can see um uh a graph that has the flow and the volume and how and how the we can see the um the, the shape normal vers obstruction versus restrictive. And it's important to just note down that and just be aware of each one and how they work. Ok, go to ventilation perfusion. So obviously, respiration does, I mean, these are the two very important parts of respiration, ventilation that's taking the a and perfusion, that's, that's gas exchange. And if there's an issue with any one of these two, there's gonna be a decrease in efficiency in the overall respiration. So, naturally, the um arterial pressure in the lungs is highest at the base compared to the apex of the lungs and that's just due to gravity. Um So we've gone to definition. So ventilation first to the process of air movement into and out of the lungs, whereas perfusion refers to a circulation of blood within the pulmonary capillaries. And that's important obviously for gas exchange. Now, when there's a mismatch, um that that can be a mismatch when it's either ventilation or perfusion is abnormal. So when ventilation is abnormal, it can be things such as pulmonary edema or bronchoconstriction. Whereas if perfusion is abnormal, it can be due to things such as pulmonary embolism. Um And again, if there's a mismatch, this can lead to types of respiratory failure. And there's two types, more covers a day. So type one resp failure, that's why there's low O2 and the CO2 is normal and type two is where there's low O2 and high CO2. And this can be due to hypoventilation seen in CO PT obesity, pneumonia and fibrosis. It's really important to take note of these two types of breast failure and then take note of the O2 concentration and the CO2 concentration. Um So, acid base regulation, um the body obviously is going to produce a lot of hydrogen um from metabolic processes such as glycolysis, um ATP hydrolysis. And yet, um obviously, if we do not have regulation in place, those numbers would be all over the place. And so we have a buffer system that exists in order to resist changes in Ph. Um So there's a chemical buffer system which controls carbonic acid and protein and plasma and physiologic buffer system, which is categorized into respiratory for the short term and renal for the long term, um carbon dioxide is acidic. And so once it's dissolved into the plasma, um it saturates the red blood cells and it reacts with water um to form carb carbonic acid, which dissociates readily into bicarbonate and hydrogen. And so for the short term respiratory system regulates this. Um if there's an increased amount of CO2, then you're going to increase respiration, eliminating that excess carbon dioxide from building up. And you're also going to be metabolizing tissues with um a high level of CO2 such as an exercise which causes you to breathe more in the renal system. You're gonna have long term regulation and this regulates the amount of bicarbonate present. Um And this can increase excretion and decrease the production of bicarbonate. And it can also increase the production of carbo carbo carbonate if it goes the other way. So, just a couple of questions. Um Oh, sorry, I forgot to just add for metabolic and respiratory disorders. Um These are um like changes in Ph that causes the body to react a certain way. So you have metabolic acidosis which is a low level of carbonate. Um And causes of this are the kidney can't produce enough bicarbonate or increased acid production, reacting with and depleting the carbonate. And you also have metabolic alkalosis, which is a high level of bicarbonate. And this can be from a loss of hydrogen ions such as during vomiting or renal loss or retaining too much bicarbonate. Um On the flip side, there's also a respiratory acidosis which is a high level of carbon dioxide present. And this can lead you to poor ventilation such as in asthma COPD. Um in people with obesity who can't breathe properly. And um respiratory alkalosis is a low pressure of carbon dioxide and this can be caused from hyperventilating such as an anxiety, panic, uh pulmonary embolism, et cetera. And so in the body, there is compensation that occurs and the compensation will always go the opposite way to whichever way the the problem is going. So if you have acidosis, then you're going to increase respiration to reduce the amount of CO2. If you have alkalosis, you're going to decrease respiration to increase CO2 the other way um to help compensate with that. So, um going on to some questions, number one, which component of the respiratory system is responsible for producing surfactants? And then number two is an ABG. So um a patient presents to the emergency department with shortness of breath tachypnea, which is fast breathing and confusion. Um An arterial blood blood gas analysis reveals a ph of 7.3 a partial pressure of carbon dioxide of 60 a partial pressure of oxygen of 60 as well. Bicarbonate is 30. What is the most likely interpretation of these ABG results and then you have normal ranges here for each of them. So I'll give you a few minutes for that one. You don't have to answer both questions together because obviously the second one is gonna take a little bit longer. So if you wanna put them separately, that's also ok. In the chart we have ba ok. I will wait, wait a little bit more to see if anyone else has same or different response. Mhm We have BC. OK. Mhm You have some disparity. Yeah. Yeah. Come on guys. Feel free. Mhm OK. Well, we have, we have two. So if that's OK, we can move on to the the answers if there's some disparaging between a couple of answers. So yeah, whoever put the first, the first answers was correct. So it is B and A. So the component of the respiratory system which produces the fact that is the type two pneumocytes. Type one was involved in gas exchange. Um Macrophages are just involved in immune response and cells was not even mentioned it was club cells. Um Number two. Yes, it is respiratory acidosis. Um whoever whoever put respiratory acidosis, do you want to explain why you chose the answer as opposed to me metabolic acidosis. If not, that's OK. I don't wanna put you on the spot, but that's fine. OK. So Ph is low. If you look at the range at the moment, you can see that the normal range is 7.35 to 7.45. Um And this PH is lower. So that means already you can get rid of options B and D cause this is an acidosis. Um Looking at the other things that are present, you can see that the bicarbonate is high. And so that would increase the um I'm sorry, I lost my spot. The bicarbonate is 30 which is over the range. And so that's increasing the um amount of respiration that needs to take place. And so it's respiratory. If it was metabolic, then this carbon dioxide would be greater than. Um so this carbon dioxide is compensating for um the increased carbonate concentration, which is why it's respiratory and non metabolic. Um I hope that I hope that makes sense. Ok. So, like you mentioned before, restrictive re restrictive diseases and differences, um we're gonna focus now on a obstructive disease known as asthma. Um And again, it's obstructive disease. So thinking back to the graph I showed you um before again, the volume is more or less the same as normal, but the issue is the flow and obstruction. So, with this one called asthma, um it's a chronic obstructive lung disease and it's caused by episodic bronchoconstriction and reversible airway obstruction due to hypersensitivity to environmental factors and these different factors such as things like, mm I don't know, dust. Um and there's several changes that occur to the airways. We have reversible narrowing of the airways, there's inflammation, smooth muscle hypertrophy and double soft hyperplasia. And in between attacks, it's asymptomatic. The person is more or less. Ok. Um, but during an attack, a patient can experience dyspnea, which is shortness of breath, coughing, wheezing, and chest tightness. And it's important obviously for, um, someone with asthma to know what their sudden triggers are, whether it's dust, whether it's things like, um, overexertion, um, just so they know and they're prepared to treat it if um if it, if it ever occurs and it usually presents as the um atopic trend. Um Here we have hay fever, eczema and asthma. Ok. So for asthma, asthma treatment, it can be treated by two main sub types of treatment. And obviously, treatment depends on the severity of the asthma because varies between individuals. Um So, normally, first line treatments are bronchodilators. Um We have short acting beta agonists such as salbutamol long beta agonists such as salmeterol and a Muscarinic antagonist such as um Apium. And then we can move on to anti-inflammatories which include corticosteroids such as glucosone, anti leukotriene, such as monoblast and then management of an acute asthma attack. You're gonna use oxygen high dose nebulizer, salbutamol hydrocortisone irion bromide. Ok. On to the next one, we have um chronic Obstructive Pulmonary Disease also known as CO PD. So again, it's, it's like asthma. This is an obstructive disease. The key difference here is that CO PD is irreversible. Whereas asthma is reversible and CO PD has now went over the airway and encompasses both chronic bronchitis and emphysema. Um Just know that there are factors that influences factors that do influence are heavy smoking and people with um a one and streps deficiency. So, like we said, um emphysema is present along with chronic bronchitis. Um with the emphysema, there's no cough or peripheral edema, edema of the person can be breathless, does very quiet, breathing sounds. Whereas um with the chronic bronchitis, the person has cyanosis, chronic cough for at least three months every year, palpitations and there may be peripheral present. Ok. And um ok, regarding treatment, um so again, obviously, so this is, this is very important to stop smoking or reduce smoking to help with this. The influenza vaccine is important, pulmonary rehabilitation. And if that doesn't help, you can move on to some um high level treatments such as oral theophylline oral anti therapy, you know, cause there lots of mucus that has to be cleared out and then diuretics for the edema to clear out that excess fluid. Um for management of CO PD for acute CO PD again, such as like asthma, either oxygen, either higher dose nebulized bronchodilators, oral or IV steroids and also antibiotics to help prevent or treat um any of the antibacterial infections. Ok. So um we saw before on the X ray, we saw um consolidation, we said it can be indicative of things such as infections. One of these infections that um, it can be is pneumonia and pneumonia is an infection that causes inflammation of the lung tissues and is seen as consolidation on chest x rays. So I just name a co a few of the symptoms and signs that we see, we see shortness of breath. It's a productive cough and chest pain, fever, hemoptysis, tachycardia, tachia. Um, one thing that's important to note here is um, the productive cough and that means that it's productive because it's bringing up something when they cough. Um And please note a few organisms that can cause it. Typical streptococcus pneumonia, atypical myo mycoplasma pneumonia, and there's viral noia and fungal as well. Ok. So regarding pneumonia treatment, obviously, it's important to first get a chest X ray and confirm what the issue is along with the patient's history. Um But also the next step is to get us do some more blood culture to confirm it for sure. Um And then you can also do an ABG to um check for hypoxia. So the basic treatment for pneumonia is antibiotics and that's for the infection. If the person is hypoxic, you can give oxygen. And again, if they're dehydrated, you can give IV fluids. Um if the infection is very bad and the person is in distress, then complete ac 65 score and that covers confusion, uh Urea if it's over seven respiratory rate, if it's over 30 BP, um systolic, less than 90 diastolic less than 60. And if the patient is 65 years or older and it co stores a standardized test that's used more or less everywhere. And each point covered is um a point of one and you add it up and then obviously the higher the score, the more severe the pneumonia is on ac a score of two plus the patients should be admitted to the hospital. Ok. Tuberculosis. So again, tuberculosis is an infection caused by mycobacterium tuberculosis and it forms cavitary lesions in the upper lobes. And uh as a result, granulomas form with caseous necrosis in the center. And obviously, this can be an issue for the patient. Um Tuberculosis can be confused with cancer. Uh That's why again, it's always important to do your X ray, do your history, um do your examination and then use all that information to come to a proper diagnosis. Um So some symptoms that we see are fever, night sweats, weight loss, hemoptysis, live and dey. And um a few risk factors to consider, consider some contact with someone who has TB immigrants from a holiday, retires from atb prevalent country, immunosuppressant and IV drug use. So again, it's really important to do a thorough history, ask the important questions and then narrow it down to um what the actual issue is along with using your diagnostic investigations like X ray. Ok. In the next slide, please. Ok. So for tuberculosis screen and management, um we have for active case of TB. The infection can be identified with a chest X ray sputum culture and NA A. And this is a nucleic acid amplification test. Whereas for latent cases of tuberculosis, the man two test can be used. And that just basically is where um tuber tubercular is injected into the skin. And do you wanna mhm Like assess it and look for the size of the thicken that it causes a positive test shows um of more than five mims, the thickening of the skin. And then to help with remembering the management, you can use um acronym ripe. That's Rifin um isonide, pyrazinamide and ethyl. But OK. And also again, since TB is a notifiable disease, it's very important to notify as soon as infection is suspected and is at that patient until they're fully treated. Again, also notify people they've been in contact with and contact the infected patient. So it's really important that this is all done in a timely manner and efficiently as well. OK. Lung cancers. So on, on the left side, you can just see some histological images of um different types of lung cancers. And again, we'll make these slides, um we'll give you guys these slides afterwards. So you guys can look at it in your own time and just spend in more detail and looking at the differences between these different pathologies. But regarding lung cancer, uh that c right into either small cell or non small cell. So small cell make up around 20% of the cases. Whereas non small cell, they make up around 80% of the cases. And of the nonsmall cells, we have adenocarcinoma, squamous cell carcinoma, and large cell carcinoma. Um, some common symptoms of lung cancers include short of breath, coughing, hemoptysis, club of the fingernails, weight loss, night sweats, fever, and lymphadenopathy. And again, we see a lot of these signs and symptoms overlapping with different lung diseases. So we're really emphasizing the importance of doing that history using your different investigations and narrow it down to a specific cause. Ok. So regarding lung, lung cancer treatment, non small cell carcinomas, they're usually more localized than others. Um So the first line treatment we use is a lobectomy or segmentectomy. Um, radiotherapy and chemotherapy used um in small cell carcinomas. Um, since their prognosis is worse, however, they can also be used in non small cell carcinomas as an adjuvant therapy. And adjuvant therapy is one that's given before surgeries just to help reduce the size of the tumor. Whereas a neoadjuvant therapy is given after surgery to improve the likelihood that the treatment works and also minimize the risk of it of um, reoccurrence. Uh It's important again to use these adjuvant therapies with surgery if necessarily because the risk of lung cancer has metastasized, it can spread. So some common places, it can spread to our brain, the liver adrenal glands and bones. And again, if if it does spread, it makes the prognosis, uh a lot worse than it was previously. Um, lung cancer can also occur as a result of other cancer occurring elsewhere. First, for example, breast cancer. Ok. So we'll cover a restrictive disease now known as IOD in lung disease. So this is refers to um the restrictive conditions that affect the parent kind of the lungs which can lead to inflammation and fibrosis. And again, this is, this is gonna cause issues of expansion um of the lungs and breathing issues. We uh we look at fe VF EV ratio and it's restrictive, it's gonna be greater than 0.7. It's important to look at the CT scan rather more than more so than the x-ray when looking at I LD because the most characteristic appearance of I LD I, you can't actually see on very well. Um Whereas on CT S, you could, it looks like um a distinctive broken glass appearance as you can see on the left hand side here. Um and again, causes of this can be hypersensitivity, pneumonosis, drug induced due to things such as methotrexate and idiopathic sarcoidosis and fibrosis. Ok. So now we're looking at um asbestosis. So, asbestosis is due to the exposure of asbestos, which is a fibrinogenic and oncogenic compound. And again, this is a disease that does not always show up right away. In fact, most of the time it shows up uh quite a few years after exposure. So it's important, it's really important. Again, to look at that history. Um Look at ask questions such as where's their job, what kind of environments were they in? And we'll cover some risk factors now. So, asbestos miners, pipe fitters, roofers and insulation workers and builders working on boats and ships. And it, the inhalation of asbestos can lead to this fibrosis and it can cause pleural plaques which can be seen on X ray which which um present on the left side here. Um Again, the the risk of asbestosis, it it does increase the risk of developing mesothelioma or bronchogenic carcinoma later on in life, right? Ok. So now we'll cover pleural fusion. So we saw that in the e before we saw where there was loss of the costophrenic angles and quite high opacity down in the in the right lung from the previous X ray. So, pleural fusion is characterized as the accumulation of fluid in the pleural cavity. And, but that can be classified as either exudative or translative. And upon examination is gonna be to pression and reduced breath. Sounds, pleural fusion is caused by increased vascular permeability and this is the exit type, whereas the translative type is caused by, you know, high or low hydrotic pressures. So regarding the first one, the increased vascular permeability type, um this causes proteins to leak out of the space and this can be seen in pneumonia, um tuberculosis, lung cancers and a rheumatoid arthritis, whereas translative can be seen as congestive heart failure, hyperal liver cirrhosis. Ok. So just to kind of round off on that, um a couple of questions for you, which of the following conditions is characterized by reversible airflow obstruction and is classified as obstructive uh question two in which respiratory condition is airflow limitation, typically progressive and not fully reversible. And there is also cla um classified as an obstructive lung disease and which respiratory condition is characterized by fibrosis and scarring of lung tissue resulting in decreased lung compliance and classified as a restrictive lung disease. Um So we'll just give you guys a couple of minutes to put your answers in the chat. Yes. OK. We have a DD. OK. Any other, any other options or are they all all the same sulfa add? Ok. Yes, you guys are correct. So, the first one is asthma cause it's reversible. And the diff the biggest difference between asthma and COPD is that the COPD is not reversible. Um It typically manifests much more aggressively and you get productive cough and much harder to resolve the issue. And then the restrictive one in question three is tuberculosis. So, yes. Hold on you guys. OK. Thank you so much guys that completes that concludes the um presentation like we said before, we're gonna give, send you these slides afterwards. We'll make them available from um medical on I believe or I'm not sure we'll sort that out. Um But again, it's just important to use this information. It's quite broad use this information walk backwards such as light we saw what type of tissue is present. Um Think about what kind of collagen type it is, think about the small details. But again, this is quite brief, just use it as a base and work backwards. Think about why things are happening and yeah, thank you for attending. Um If there are any questions, feel free to ask now and we'll cover them. Fantastic. Thank you so much Os Farra. So currently in the chat, I will be sending the feedback form that can be utilized for if you if you have any suggestions on how we can improve uh medical learn. If you also, if you do have any questions now for today's session, please feel free to ask them now. Just feel free to please unmute your mic.