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The chat that majority of people have not attended an x-ray round session before you are muted. Fantastic. So we are going to go over the A ab and CS them for all the new uh individuals. So it should still be fun, but we'll give it one more minute to make sure everyone else comes in. Let me see if I can pull up an oldie but a goodie. Um x-ray rounds uh of our um that we've done before for kind of introduction stuff. So no worries. Sounds good. Should be a fun one too, right? All right. I think I have one to steal. All right, Deanie, I think when I'm ready to rock and roll. Ok. Sounds good. All right. So I'm gonna, so let me, uh, so Dean, you said um, first of all, actually Deanie, introduce yourself, my friend. So people know who I'm speaking to and while you're awesome. OK. Go ahead and introduce yourself then uh Hi everyone. My name is Danny and I help doctor G setting up x-ray rounds and everything like that. So if you all have any questions or any problems, feel free to put them in the chat and I'll answer them as um Doctor G speaks. Uh Deanie is very much underselling herself. She uh is a recent graduate um from the Bloomberg School of Public Health here at Johns Hopkins. Uh just an amazing human being who's done a lot of community outreach with us is published is coauthored um and is uh just destined to be an outstanding physician scientist. So that's who Deanie made in is I'm sorry about that. Thank you for that. Um And Deanie, you just mentioned that a good portion of everyone here. It's their first time. Yeah, around 85% of people are new. All right. So what we will do is uh so let me tell you who I am. I'm a doctor. Uh pa satu, I'm an associate professor at Johns Hopkins. Um I have a uh I'm a pulmonary and critical care doctor. So today's lecture given the good portion of you um are new to this. We're gonna start off with as an introduction of reading an x-ray. Then I'm gonna go into a case, I'm gonna do the case on my own. But Deanie, if you're up for it, um I know you're multitasking but do you wanna just make this conversational m meaning like I would ask you to ask me questions of the x-ray. Um And I can go through that. Does that make sense? You, we, we WW you'll figure out the flow of it. I promise you, I know, I'm throwing you for a loop at the moment. Is that doable for you from your end? My friend do. OK. Um So it's not anything on you. It's just saying. All right. Uh Deanie, tell me, where do you want me to start to how to best interpret this? So that way this can be conversational for all of you knowing that so many of you are new. Next time we regroup, we are, we tend to invite students to join us virtually on stage. Um And you'll read the x-rays with me uh in real time. Um A couple of things. The reason why we do this is uh two fold. One is for many of you, this counts as shadowing. Um I usually say if you attend one session, that's three hours, why is it three hours? Well, it's one hour with me and then two hours of maybe rewatching it and trying to look up everything. I've just said, I go through this efficiently. I, I try to stop for some questions but you know, I I'm coming at this to teach you guys some information. But keep in mind um If you're like, what is the trachea doing? What are, what, you know, how much of it is cartilage? How you know, that would be a question I would say great, great question, explore it, look it up um by all means, seek out the answer um to supplement this. So part of it is virtual shadowing. And then in, in addition to that um being able to uh self direct your own learning experiences. The second part as uh the mission for med all is to reach a international um group of individuals to kind of strengthen their own clinical skills. And that's what we do here for this. So with that in mind, we're gonna launch into uh reading a piece of data that is pretty universal throughout the world in regards to what doctors are asked to do. And that's reading a chest x-ray, I can tell you um I'm also a the um editor in chief for a journal of just for case reports. So I get a large influx of them throughout the world. And what's fascinating is almost every case report always submits a chest x-ray if there's um for the majority of cases. So, meaning what I'm trying to get at is this is a data point that you are always going to see. Uh I would say a close second would be the uh EKG S and electrocardiogram. So as a physician, knowing how to best interpret this piece of data goes a long way. Finally, I'll also say this. Many of you may be saying, well, it's I'll learn from doctor G, then I'll go into medical school and then residency will teach me right answers. Probably no. Um If they kind of just throw you in there and they hope you pick up some skills throughout. But I'm shocked how many times I give uh reading a chest x-ray lecture to medical students, to resident physicians, to pulmonary fellows. And none of them have a standardized approach. So that's what I'm trying to go. Gonna teach you guys here. I'm gonna teach you a standardized approach of how to read a piece of data that has well over 1000 data points and how to do it efficiently. To me it's like reading a book, right? You start off with page one to get all the way to page 500. Now, with that in mind, this is the art of medicine. The way I teach is by no means the same way a radiologist may be learning this or a thoracic surgeon. However, what's great is we all come to the same conclusion even though we may use a different way of getting there. So I say this cause occasionally we'll invite one of our radiology colleagues. Um Doctor Chen has been in here before and he himself reads it a little bit differently though does achieve keep all the same data points that I do. So with that in mind, Deanie, I think I've babbled enough. We're gonna launch into the first reading of a chest x-ray, Deanie. This is, I don't need you yet, but this is me reading what's called a normal chest x-ray. So let me go ahead and share my screen Deanie if you can be awesome. And just let me know that you can see the screen once I hit share and you see it. Yep, I can see it. All right. So we're going to spend the next 10 minutes reading a normal chest x-ray. So you have this chest x-ray right off the bat for all the students out there. Especially for your first time doing this. It is highly important if I ever call on you to recognize what is being asked of you is to tell me the picture with your own words and vocabulary. Nothing more, nothing less. Uh Hold on one second. All right. So um what I'm, what I'm getting at is if I ask you, hey, does this look normal or not normal? All right. So it's one or the other. You will just tell me your clinical gestalt like yes, I think it's abnormal doc or no, this looks normal. If I asked you to describe something, describe it as you see fit like, hey, that looks fluffy. It looks like a circle, it looks square. I just do that. All right. That's where I'm getting at. I don't, you don't, you, you don't know the medical terminology. I'm not asking you to do that. I just want you to interpret something the way you see it. That's it. So think of this no different than picking up a picture and describing it to someone. So let's dive into reading a chest x-ray the way I read x-rays a chest x-ray is first, I make sure that the chest x-ray was positioned well, and then after that, I look at everything but the lungs, the lungs, I look at last and the reason for that is to make sure I don't miss anything that could be influencing the lungs abnormalities. So I look at the mediastinum. The mediastinum is one of the things I would ask you guys to look into what that means. The mediastinum is the space between your right and left lung. It's where the trachea is. It's where the heart is. It's where the esophagus is that anatomical space created between the right and left lungs. So I'll look to see if the mediastinum is normal. And you'll see because it's kind of a negative space. It's kind of created because two things don't meet there. What I usually do is just look for anatomical landmarks and see if that can give you a clue. After that. I look at the pleural space. The pleural space is the space that surrounds the lungs. And I just look to see if there's any fluid in there or any air in there. Then after that, I look at something called a hilum. Hehilum. The hilum is where the blood vessels, the airways and the lymphatic system all take off to go to the whole lungs. So we'll look at that, then we'll look at the heart specifically its size, both left and right. And then after that we finally go into the lungs and we take an inventory of the lungs. So let's start and first, let me find as always the marking. All right, I'm about to mark up. Uh, so first things, first I told you, I look to see if the chest x-ray is positioned. Well, what I mean by that is when a x-ray technician goes in to snap a chest x-ray, she he or she asks the patient to be upright and have their backs flat against a wall that flatness and upright allows me to assure that the patient's not shifted. Why is that important? Well, if their right shoulder is sticking out more than their left shoulder, right, then what ends up happening is their right lung looks bigger than their left lung. And there are diseases out there that can make the lungs look asymmetrical. So, is that what's happening here or is the patient patient just rotated? So how do I make sure they're positioned? Well, God, uh ladies and gentlemen, look at what I'm drawing here, these kind of cylindrical kind of tear shaped shapes. So, what are these? All right, everyone take your hand, put it behind your neck. What you're feeling? Your spine is actually your spinal process. That's what I'm circling here. Your spinal process looks like the beak of a toucan. If you don't know what a two can is, please Google. It's a type of bird. It's also the bird on the uh serial cover of something called fruit loops. So its beak is long. But if you stare right at it, it looks like a tear sheet. If you look at it from the side, it's just nice and long. So I look at the spinal processes. If I can see them looking like tear shaped, they look good. I will erase one just so you can have it for contact. So keep staring at these right the way you know what a normal chest x-ray is is by looking at normal chest x-rays over and over again. Next, I told you we go into the mediastinum. When we go into the mediastinum, I look for one anatomical landmark and that is something called the carina uh drawing on. This is always gonna be a challenge. Let me erase this. So what is the carina, the corona is when this trachea calms down and bifurcates in the mediastinum. This bifurcation right here is because this is going into the right lung and this is going into the left lung, the airways. So what's the trachea? Take your hand, put it in the front of your neck. What you feel there? You may feel the hyoid groin or the hyoid bone or your Adam's apple. But that cylinder in there, that's your trachea and it goes down behind your manubrium behind your sternum and bifurcates into what's called the Rya. The cry is located right here. I'll put a little C for it. So what I look for here is to make sure that the CNA falls right over top of your vertebrae. So in my mind, I'm drawing these vertebrae boundaries, right, the vertebrae making up your spine. If the cry falls in between them, then I can confidently say that nothing is pushing or pulling against the media stum. The next thing I look at is the angle of the cryo right here. Now, if it's an acute angle, that's normal, if the angle is more up two, which we call Slade, that usually means something is underneath the carina and pushing up against it often times it's the heart. So if I was reading this x-ray so far, I'd say patient is not rotated, the media sty does not appear to be shifted. That's it. If the Kina had more of an two angle splayed, then I would say the uh media sign has not shifted. However, the trachea is splayed. That's it. That's all you said to the reader or the listener. Hopefully he or she is understanding what all that means in order to interpret what you're trying to convey. So let's go back. Now, we're going into the pleural space. The pleural space is that space that surrounds the lungs, creates a, a thin amount of uh fluid to lubricate the lungs that allow them to slide with each inhalation and exhalation. So, one bad thing about this um x-ray is that this angle actually both angles are cut off. So I apologize, but we'll just draw what they mean right here. So there's angles that form right at the bottom called costophrenic angles. Costo for bone phrenic, for the nerve that innervates the diaphragm, you get this angle just in a chest x-ray. And if you, these angles look like a nice fang out of dracula like a vampire, it's normal. If you have fluid in here, fluid will be pulled to the base because of the gravitational pull and it will wipe out the pleural space. You need about 300 mL of fluid in there. So I'd say costophrenic angles are present. Next, I look for air and I look up here what are called the apics, the apex of the lungs in the apex of the lungs. I wanna see grayish and to some extent. Um lung markings look, if you stare at your screen, look at the screen like put your head closer to it. You can see these lung markings that are much more prominent, the closer they are to the heart and they kind of fade away as they go out. They're definitely a lot more prominent at the bases than they are at the apex and that has to do with gravity, right. So fluid is pretty heavy, it gets weighed down. So a lot more of your blood circulation in your lungs is at the bases, not at the top. However, I'm just making sure that there's no air surrounding the lungs and that known as a pneumothorax. And so as long as the top part of the lungs that extend a little bit above the clavicle, the clavicle is this bone right here and this bone right here as long as there's no blackness out there. And if you're wondering like, well, it's grayish, yes, black, I mean, pitch black like black as the, as your phone is when it's off that level of blackness. So I'd say costophrenic angles are normal and there's no air in the ac great. Next, we are going to go to the hilum. The hilum is a part that oftentimes gets overlooked when reading chest x-rays. But oh, it has so much to share to you. So it's always good to look at it. Let me get rid of the spinal processes too. So the hilum, there's two of them right and left. So here's the right hilum and here's the left hyalu in the left, you only get a little portion of it because the heart covers up the rest. But this is a normal looking hilum. You need two things. One, you need it to be somewhat translucent if it's as white as this spine as is vertebrae. So there's an abnormality there. And you'd say, you know, there's significant opacification of the high lung. It does not, it's rather translucent. That's a good thing. Remember the hilum is where your blood vessels, airways and lymphatic system take off next, on the right side, it should look like this kind of a kidney shaped, um, or beam shaped. Now, if it gets plump, then you make the case that the hilum appears to be full and it's either full because it's full of blood or the lymphatic system is rather puffy because it's full of uh, white blood cells and so forth. The left one is a little bit harder to interpret if it's plump. Usually, I would say if it's uh if, if it extends out, that gives it away. But the right is a lot more obvious. Can you get unilateral hilar abnormalities? You can sure. Um But I usually see those with pneumonias. Um So usually systemic processes, both of them are abnormal. But if one is abnormal, it's usually because of the pneumonia. So it's usually pretty obvious based on other anatomical readings that you will do. Next. We go into the heart. By the way, guys, I know I'm going fast. I strongly encourage rewatching this and rewatching it so you guys can get a handle of it next. You look at the heart. What you're looking for is two things. One to make sure there's a space between the left ventricle of the heart and the ribs and a two slope. Part one slope here, two slopes here. What does that mean? This space right here means your left ventricle is not big and this divot right there implies that the left atrium is not big, right. So the left side of the heart, the left ventricle being big usually means the heart has been struggling for some time with some high BP or it's suffering a bad heart attack or a myocarditis, a variety of things. But usually the most common reason you get a big left ventricle is because of high BP and elevated. A big left atrium tends to happen without, without a big left ventricle. It tends to happen in uh myocardial infarctions. So that's what we would see here. Uh But this is a normal left ventricle. Next, I look at the right side briefly, the right ventricle over here and essentially I want it's to look almost like a nice triangle as it pops out. Your right ventricle is big. Usually takes on more of a circular border. So that's the heart. All I'm looking for in the heart is for people to say, is it big or not? There's no such thing as a small heart. Are you looking for when, when an x-ray, when a chest x-ray are you looking for, is to say, is it enlarged or not? That's it. Because if it's an enlarged heart, then that could be impacting the lungs, abnormalities and finally the lungs. So the lungs, the way I read them is I zigzag through like this and again, I zigzag through like this and then I zig zag back and forth. So what I'm looking for when I interpret the lungs is I'm looking for uniformity. So, meaning I want the top part of the lungs to look like the bottom part of the lungs. And then I want the right side of the lungs to look like the left side of the lungs. That's it. If they look the same with some allowed differences, right? The blood vessels at the base are gonna be more prominent than at the top. So if you're, if you can appreciate that, then you have a normal lung. So the way I would read this, if I put it all together for you all from the beginning to the end, right. So uh the patient is not rotated, given the use of the anatomical le mark of the spinal process, the media sign of does not appear to be shifted as the trachea seems to be in line with the vertebrae boundaries as well as it is not splay. The costophrenic angles are present and there doesn't seem to be uh appear to be air in the uh apices of the lungs. So the pleural space seems to be rather normal in regards to the hilum, both of them uh right and left appear to be of same size and rather translucent. So they appear to be normal. The heart does not appear to be enlarged or without any uh right-sided enlargement either. So it appears to be not enlarged, that's it. And in addition to that reading the lungs. There doesn't seem to be any opacifications, consolidations or any interstitial markings that uh capture my attention. The last part that I said about interstitial markings means that the markings you see all these lines are, are prominent, the closer they are to the heart and they tend to become less prominent, less obvious. The closer they get to the boundaries that happens because blood right, a lot more of the blood vessels with larger diameters are closer to the heart. The further away they get from the heart, the smaller the diameter. So the uh the lung markings which are made by the blood vessels are harder to see Deanie before I go to the next slide, my friend. So I don't get shipped out of the viewer. Any questions popping up in the chat box that I should tackle. We have two questions. Um a little bit niche. One about subcutaneous emphysema and um one asking if the patient in the x-ray is erect or recumbent. So are the only two questions. Yeah. So the second part of this page, so any time you get a chest x-ray, the the technicians will always ask the patient to be standing. Um The way I can tell if a patient is sitting is sort of like this. So we'll go over what that means because when you're standing, you can get a good pa shot. Um uh The way the uh the uh x-ray beams hit the patient um are a little bit more um uh uh make the heart, for instance, look even much smaller than it is versus this an A P shot on this end. So these patients would be s uh sitting upright um or standing. And then in regards to subcutaneous emphysema, great question where you would see. So what it implies emphysema being air that is just not getting any um blood vessels to it and then subcutaneous, just implying under the skin. And so that tends to appear in skin areas. So you'd see a lot of it. Um If you can see my markings, you'd see a lot of subcutaneous findings usually around the periphery. And it's usually iatrogenic doctors tend to make it uh because we place chest tubes, et cetera at times you can get subcutaneous emphysema here in the mediastinum. Um And again, there would be air and that air usually actually it's pretty cool, goes around the heart. I think I have an old case. I can demonstrate that, but that is rare. Often times you can get it in patients with really bad coughs and the violent nature of the stress of the cough can create a tear um in the esophagus. So, uh but subcutaneous emphysema oftentimes it is tronic something has caused it, either a doctor placing a chest tube or trauma, trauma, a bullet wound can cause it as well. So, great questions. And now Deanie, we're gonna go into the second part and this part is kind of meaty D NNI. So we might only get through a portion of it and then save the rest of it for the next time. Is that OK? Sounds good. All right, Deanie. You've done these with me before. I'm pulling this up. You ask the questions, you fo whatever you want and you, you know, you can start up a simple doctor. G, what's going on with this patient? Whatever you'd like me to begin to answer you. Tell me, hm, what if we start by? Does this patient look rotated? So great question. And I will tell you the patient does not look rotated. So you can see the costophrenic angles here and here. Now you can make the case that the patient is leaning. Yes, I will buy that right? Because you can kind of see, look at, look at his head, right? It's kind of tilting to the right side a little bit, but there's a reason for that. Um And I'll give it away a little bit Deanie if you recall this chest x-ray here, the first one. And now here, do you appreciate this kind of prominent white line right here that I'm drawing? Do you see that? All right. And that white line is obviously not present in this patient, correct? Mhm So that white line, all right, everyone that white line, let me draw this out again, this white line is a breathing tube placed into the patient and it ends right here. You can even make out the threedimensional aspect of it. These white lines have an intentional, I'm sorry, these uh cylinders placed into the airway through the vocal cords into the lungs to put the patient on a breathing machine. All have an intentional white strip that will pop up when x-ray readings. So I say this because Deanie, the reason why this gentleman while he is not rotated, my x-ray technicians properly position him, position him. So his back is flat against a metal plate, but he is rotated in the sense of his head's kind of tilting to the right side. That's happening because we just put a breathing tube in him. He's still a little bit in a medically induced coma. So he is, you know, he's not able to control his uh neck muscles, et cetera. So I I know uh you asked one question and I took it a little bit further. But the reason why looking at a chest x-ray after placing a breathing tube in a patient is important. It because it's all about positioning. So, one of the first things we're discussing in this abnormal chest x-ray cause the patient has a breathing tube is about is the bre is the uh breathing tube positioned appropriately. So, what we look for are two things. One is, does the breathing tube come, does it go under the clavicles? And here's the clavicles, here's the bottom boundary of it. And you can see that the breathing tube does come under the clavicle. So that's checkbox one and next you want the breathing tube to be about almost an um, an inch above the carina. Do you? I'm, I'm putting you on the spot here and I apologize. But do you reme what would happen if I dropped something on your carina? What would you scream out in pain or would you cough extensively? What cough extensively? Oh, Deanie. Can you hear me? Yes, perfect. Thank you, Dana. You're a rock star. Ok, good. So you would, you're right, you would cough extensively. Ladies and gentlemen listening your c your your lungs internally have no pain receptors. It doesn't do you any good evolutionary to have pain receptors inside the lungs, right? Pain is meant to draw your attention to something, right? Or cause you to kind of calm down, right? If your heart's having pain, it's asking you don't overexert it if you have pain receptors in your skin and wants you to draw your attention to why it's hurting pain receptors in your lungs. What are you gonna do with that? You can't look inside your lungs to say what's going on the instead of pain receptors, there's an overabundance of cough receptors and your cryo is an area of your lungs that has one of the highest concentrations of cough receptors which makes sense if something goes down the wrong tube, right? As we say, right. So you swallowed some water but it didn't go down, your esophagus, went into your lungs. What are your lungs gonna do? They're gonna cough it out. So why we want the breathing tube to be about an inch to two inches at the most above the cryo a couple reasons if that breathing tube is touching the cryer. Well, guess what that means? That patient's gonna cough and cough and cough and cough and cough and coughing will mean it's not gonna allow the machine to do the appropriate breathing and could eventually also cause coughing, builds up a lot of pressure in the chest, could also rupture one of the lungs. So you wanna make sure the crying up and the breathing tube are not meeting. But the other reason is if the breathing tube, sometimes what we end up doing is sliding it too deep. So it even passes a cry out and just goes into one of the lungs. It's called main stemming, right? Because you place it in one of the main stems, either the right left stem or the left stem. Well, if that happens, that means you're blowing all the air into just one lung and not the other, which is also a bad thing and the patient doesn't get the optimal treatment. So after placing a breathing tube, which have places countless breathing tubes in the IC U, you reassess and make sure the patient can, um, where the position of the breathing tube is, and to date other than a chest x-ray, there really isn't uh any other gold chest x-ray is or gold standard. Let me put it that way. So the breathing tube is one abnormality that is different than this x-ray here. So Deanie, you asked if this patient is rotated? I told you he is this patient is not spinal processor staring at me. However, he's rotated in a different sense with his head kind of tilting. And I told you why because he was received um what's called rapid sequence uh due to a rapid sequence intubation, he received um medications to put him in a brief medically induced coma. Usually these patients where you tend to push are opioids like fentaNYL and oftentimes some level of anxiolytic. So you can always provide a benzodiazepine. Um in this case, such as diazePAM or LORazepam, oftentimes LORazepam and then you push in a neuromuscular blocking agent. Um oftentimes something called succinylcholine. So together on those, the patient gets into a brief coma and he he or she is not fighting you as you place the breathing tube in them. All right enough. Rambling, Deanie. What's your next question about this patient? So I see some other lines on the screen. Do you know what those are? Yes. Oh, great, great question, Deanie. I'm going to number the lines. OK. OK. I'm going to number this one, this line coming all the way down, down, down my goodness, I hard draw. So this finishes there, but you can actually see it also right here, right? So this line, hold on, let me clean this up just a little bit if I hit this. Oh, so this line comes all the way from the top and finishes right here. So this is line one, then you have this line line two and this line line three. So line three goes like this and line two goes like this. So DNA, your first question, uh are all those the lines you saw or are there other lines as well that you wanted to draw my attention to? Those are the lines I saw. Got it. There is right here. These two lines right here. These, it looks like it's just nasal cannula that was left over. Um We leave that when a patient doesn't put a breathing tube in him or her. So they can get some oxygen because remember when we put breathing tubes in patients, we stop them from breathing and actually momentarily stop their heart from working. So, um it's a scary situation but you wanna get it done as quickly as possible. Anyway, back to this, the lines. So lines two and three have something in common. That line one versus line one, line two and three, I can tell you with great confidence. Line two, lines two and three are outside of the body, right? Because these lines do not follow any internal anatomical pathway whatsoever. So being outside of the body implies, well, what kind of line is it? And I can tell you lines two and three are EKG leads, right? So these are lines that come off of the um padding placed in order to capture the the heart's um electro electricity to uh to be read in it on an EKG. So these so one way to know if lines are in the body or outside the body is you ask, hey, is it following some anatomical internal path versus line one? Which the answer is yes. So line one comes all the way down, a straight shot down and actually loops all the way here, Deanie. Do you see the loop at the end? Uh Here, I'll, I'll erase it. But can you appreciate that loop all at the end? Yeah. So ladies and gentlemen, this is a feeding tube. So this feeding tube goes in the mouth and then into the patient's stomach. This as well. The only way you can assure a feeding tube is in the patient is by snapping an x-ray. So uh the reason why this is so important to say, I know it sounds. Oh, well, you know how um you know, is there any other way you can assure it's going into the stomach? There isn't so well, let me put it this way. When I place breathing tubes into patients, nurses often give me the feeding tube to place at that very moment cause I usually can hold um my, um my blade that I used to lift the, um the patient's mouth opening so I can get through the vocal cords. I, I can slide that under the epiglottis that usually covers the esophagus while I'm intubating. But then I try to lift the epiglottis in order to slide the feeding tube in. So I can, in that sense, say with confidence, I've placed it into the stomach in non intubating times when I don't place breathing tubes in patients, nurses have to place these feeding tubes through the patient's nose and hopefully they swallow it to go into their stomach. But the only way to assure it is you have to snap an x-ray um and be confident it is in the stomach. Why? Because there are times where the feeding tube can go into the trachea and be slid all the way into the lungs, thinking it's in the stomach and these breathing these feeding tubes, you know, they, they're kind of, they're not sharp, but they're rather blunt and they can cause some lung trauma where the lung actually may collapse. Nonetheless, not to scare you too much. All right, Deanie. Back to you. What other questions about this case so far do you have? Hmm um What are your thoughts on the size of the heart? Uh Also a great question. So a couple things in regards to the heart size when a patient is on a breathing machine. So this is tough. So go to let's take into account this patient when you want to take an x-ray of a patient, whether it's an x-ray or even ac A T scan, and we'll cover those. Actually, we'll cover it briefly next time whenever you're getting an x-ray of the lungs. If your patient, it has the capacity to follow some simple instructions. What you ask is if the patient can take a deep breath and hold it and then you snap it. The purpose for that is it allows the lungs to be as ex uh inflated as possible. And it allows the um reader myself to have the best ability to capture the entire surface of the lung in order to comment on it. Right. Look everyone right now, taking a deep breath, put your hands on your chest and take a deep breath. Your hand rises when you exhale, your hand falls, when you exhale the lungs get smaller, right? And it implies less surface area for me to interpret. So you want all your patients to take in a big deep breath and hold it. The other reason you don't wanna do an x-ray on exhalation is cause again, when the lungs exhale, they get smaller, they get, you know, they're scrunching themselves up. Well, that scrunching, it's gonna make all those blood vessels look more prominent. So suddenly I I'm trying to do decide are the blood vessels really fluid overloaded or is there excess white blood cells in the lymphatic system or did I just capture the patient on an exhalation? One way to differentiate the two is by counting ribs. So these are the posterior ribs that go this way and the anterior ribs go this way and you can count them right? So 1234567. So in the anterior ribs, anything more than five, more than six patient gave a nice deep breath and held it. So in this case, well, we got one, an interior rib, we got two, we got three, maybe four, but that's about it. So Deanie in a patient on a breathing machine, here's the tough part, the machine is doing all the breathing. Can you make the machine hold a deep breath? Of course, you can. Yes, you can, you can have your respiratory therapist go and do what's called an inspiratory pause. In this case, we did not do that. In this case, all we wanted was was the breathing tube the um airway positioned well and is the feeding tube positioned well. So in this case, we didn't care at all where we capture this patient's breathing cycle. And I can tell you just quickly glancing at this briefly counting the interior ribs. This patient was captured during exhalation. The other thing about exhalation though is it does tend to make the heart look a little bit bigger cause if you look at this you're like, it looks more plump than that. Does that make sense to you so far? So how can you tell that it was during exhalation from counting the ribs? Yep. So going to the rib counting here. Boom. Pen, remember the anterior ribs come across like this posterior ribs come up like that. So I always count, I, I mean, you can count one or the other but you gotta stay consistent. I count the anterior ribs and we got one, two and we even got three here. And this, I'll give you credit for 1/4 1 up here. So that's all I'm getting for an interior ribs. That's not a lot. I want more than six to feel comfortable that this patient um is an inhalation. The other. Give away, look at the heart here. The right ventricle has a nice space right there and on exhalation that space is lost. Does that make? Do you see that? Yeah, I see that. So those are kind of the cues I take um to kind of tell me I caught this patient in exhalation. There's nothing bad about it. Um especially in the ICU where this patient ended up coming. It's a reasonable gestalt to kind of take on and say, ok, you know, most of the times in the ICU, I'm looking forward and making sure my lines, my tubes are all in the right place and I'll scan the lungs briefly, but I know the way I'm going to interpret the lungs is gonna be influence where we caught the patient's breathing cycle. And I can tell you, could you ask the respiratory technician to go in and push the button for an inspiratory? Hold you could. But it's a bit of a cruel thing to ask. Um because when we snap x-rays, uh your x-ray technician is usually wearing lead and uh everyone else has to vacate the room because you don't want that radiation exposure. Now, you may say, well, what about the patient? Is the patient getting it? They are. But remember the patient's getting it maybe once a day, we're gonna be getting about 20 x-rays in one day. So we're gonna do our best to avoid that exposure. All right. Now, let me stop back to you, Danny. How about this, Danny? One more question and anything you didn't even ask clinically like, hey, why did this patient even need a breathing tube? Any question you want to ask? And then after that, we're going to pause and we're going to regroup on this x-ray next time because there's so much more to say, I think that we should touch on the lung markings between both sides. All right. So with the lung markings we're gonna discuss and then after discussion, ladies and gentlemen, what I love about this, this is gonna be a to be continued. So it is going to be a request to come back in four. We or not four weeks in two or three weeks. So you can understand what we're implying. So, Deanie, don't let your eyes deceive you. Would you say the left lung markings? Doctor G? They're a little bit more prominent than the right lung markings? Yes. Yeah. No. And, and ladies and gentlemen, like I want you to do that, like tell, just tell me what you see with your eyes. I will lead you. All right. And Danny's done this, Tina, you probably read x-rays better than my residents right now. So Deanie spot on, you're gonna get, you're, you're seeing a lot and look at these guys, like remember the markings here. Yeah, they're prominent but you, you can barely see them as they get to the edges here. You look at this, this one marking goes all the way to the rib edge. Yeah, this other marking goes all the way to the rib edge. This other marking goes all the way to the rib edge, all on the left side, the right side. You can make a case that, you know, you got some lung markings also going out pretty prominently, but definitely not as much as the left. Why is that? So, Deanie, I'm gonna walk you through a finding here. OK. We're gonna pause and we're gonna come back to it next time Deanie there is an abnormality here that I promise you every resident w misses, they miss them, miss every, even sometimes a first year radiology resident would miss Subtle. So hear me out, my friend watch what I'm gonna draw and then I'm gonna make it disappear. Look at what I'm outlining right here. All right. You see this line that I just drew? I'm gonna erase it. So, as well, I, I'm keeping this line guys. This is pretty cool. Uh, there's, we're gonna call this, um, side two. I'm gonna call this side one. All right. So I'm gonna erase this line, Deanie in side two. Would you agree? There's a lot more lung markings than side one? Yeah. OK. Side one, like look at this is probably the best space for it right here here. Let me erase the number one actually where the number one is where the number one is, right? You would expect because it, it's so close to the heart you would ex expect, expect to see some ma lung marking, but you don't see any, there's no lung markings, correct? Yeah. Now, ladies and gentlemen, like this is the type of concern that I would have to say. Is this a pneumothorax? Is there air in the lungs outside the lungs in the pleural space with some level of confidence as your attending physician? I would say that's not the case here. It's not the case here because of this line. This line is giving me the confidence cause an air in the pleural space. Usually the lung stops, right? And the air is above it. This isn't the case. The lung here seems to be present because as Deanie mentioned, there are lung markings next to it, but there's none here. There's none there. What's happening here? I'm gonna give it a little bit away, but we're gonna come back to it in two weeks. Is yes. This patient, oh, this patient has what's called an emphysematous boulet. This right here where I'm drawing a star is normal lung. This is still lung but no blood vessels. None, not a milch. It's emphysema but because of its size, it's more than a centimeter big. It's considered a Boula. So what we will do? Oh and by the way, in this little circle right here, that's the patient's breathing tube. When you guys come back in two weeks, we are gonna discuss what the because this is such a cool finding that, you know, the radiologist did not capture this. This is the first time I saw this patient and I'm like something's happening here. So I'll call the radiologist up and you know, we were going over this and I'm like, look, I I this, this isn't because the radiologist, first of all, like, could this be a pneumothorax? Like it can't be, it's not following an anatomical lung position. And so my suspicion here was um was just, that was a bule. And so we got a chest ct and it confirmed it. This is a really cool case because bullet for them is bullet, the differential for that, the medical cause of it. It's not a lot. There's some genetic things choi there's also some non-genetic things and it's something the patient does to himself that resulted in that. So, oh, what a cliffhanger, Dean? Isn't this a cool cliffhanger to leave at? This was, this was a cool case. All right. Any other questions popping in and Deanie? Thank you for popping in and like running it with me, my friend. You are awesome. So guys real quick before I ask Dean Deanie, uh are there any questions? Um No more questions and something new. I added this to our feedback form because we get so many questions at the end of the feedback form, there's a space for you guys to put any questions that you had that went unanswered and then I'll compile them and I'll send them to doctor G so that we can like send them out and answer all of your questions if you didn't get them answered. Perfect. And uh I just happened to scroll to aba uh the right, right. Hemidiaphragm does look elevated. It is more elevated than um expected. Correct? Is that normal? No, it's an abnormality. Um And we'll discuss it more next week. Let me see if there's any other questions. Uh I see a question about the cardiothoracic index ratio. Yeah. So the challenge with that on a mechanical ventilator is the cardiothoracic index ratio in the heart size to the space of the Thora thorax. The heart should always be less than 50%. It's implied for inhalation. Right. It's implied when your patient takes a nice deep breath. If you don't have that, all bets are a little bit off, um, on exhalation. So usually you rely on, is there space between the left ventricle and the rib space? And is there a two slope approach? So, as long as that's the case, you know, I would say the heart is not enlarged, um the right hemidiaphragm will go over. Oh, let me put down. All right, sorry about that. All right. So um the other part, sorry. Uh and then um in regards to the heart space, correct? So less than 50% of the space, but with that in mind reading chest x-rays, if you're gonna read hundreds of them in a day as we do as lung doctors and radiologists read a lot more, you wanna really ballpark it quickly, right? So if you have that space and you have the two slope approach, the heart's usually fine, 99% of the time. Now, if the heart doesn't feel fine, then you can do more accurate measurements to see. Hey, is your clinical suspicion accurate? It's kind of like reading, right? If you come across words, you know, you keep reading. If you come across a word, you don't know, you're gonna spend some extra time, right? Like what is that? Let me grab a dictionary. Same thing here, you're looking for things that pass the clinical gestalt so you can keep going on with the case. And these are anatomical le marks to provide just that there is asymmetry in this patient. But remember the asymmetry is not because the patient is rotated, the spinal process is spot on. There's something happening to the lungs I ever told you it is the bulla that's incredibly important because it results in an excess amount of air, pushing normal lung um into a manner that it creates of one size of the lungs being bigger than in other side. And we'll talk about more of that next week. All right, with that in mind. Do you need anything else? I think those were all the questions. All right, party people, same time, same place. Last comment, go through this. If this is your first time sitting with us, go through this and ni do you remember when we taught how to read an x-ray before? Like our first introduction then? Yeah. So we have our introductory lesson. It's the first one. It's on our on demand content. And in addition to that, one of our students made a really awesome review sheet and I put the link in the chat. If you go to our on demand content, you'll be able to find it again and it's a really good sheet to help you review everything we talked about today. Awesome. Thank you. So much, Danny and guys go through these lectures. Hear them out. We will always present a normal chest x-ray. So the more you guys see a normal chest x-ray, the more you will get clinically suspicious if you see an abnormality. All right, see you guys. Uh, so the next lecture, hold on. I will tell you deny. Just so you're aware we'll do it in two weeks. September 13th, 13th. Yes. All right. All right, everyone see you then. Take care. Bye bye.