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Sorry, and you alive? All right. Hello everyone. Welcome to our x-ray rounds. I know we took some time off in November and, um, and then, uh, in December just things kept getting delayed when you guys, uh may maybe some of you are at this right stage of life where um, you may be having a break for the holidays. But, uh, the biggest thing that occurs is people try to gym four weeks of work into two weeks. So many of us are just running all over the place. But now with that said, if this is your first time, let me tell you who I am and welcome to today's um presentation. Yes. Uh Jayant. There's no, oh, wait, let me turn my camera on. Sorry, no slides yet. So my name is uh Panos. Um Pan Gee is my first name if you wanna call me doctor G whatever you wanna approach me as is fine by me. Um I'm an associate professor at Johns Hopkins. I'm a lung and critical care doctor through med all uh and uh medicine for the greater good. What we've been doing, uh, a little over about six months is providing these x-ray reading rounds with you all. Um So what is, what, what should you take away from this? What we're gonna do is talk about interesting clinical cases for 12. Hopefully reading an x-ray, you'll learn a little bit of that skill set and then for others, it's up to you what this means for you. Like if you are a premed student looking for shadowing hours, this counts at it. Let them know like you do virtual shadowing it 100% counts for those of you who are clinicians in some capacity in somewhere around the world, make sure this can count towards your clinical skill training and you can continue enhancing it. So however, you wanna take this away, it is up to you what I'd strongly encourage and this is where I'm gonna call out my colleague, Danny is with these presentations, even if it's your first time, we continue kind of going and building off the past. So if it is your first time, strongly encourage you reviewing some of our earlier work, do you um can you give him any insight into how to uh look to the prior uh teachings? Yeah, of course. So if you go to our med all page and you press on our on demand content, you should be able to find recordings of all of our past sessions. And on top of that, we'll have one called introduction and we'll also have a PDF called introduction to reading x-rays and that gives a really nice summary and overview for those of you who are new. Perfect, perfect. Um Oh Anila you're not able to hear or see the screen. Um Aila. Can you not hear me? Yeah. Is everyone else? Can you guys hear me? Everyone can hear me? That's like you can see me now. OK, perfect. You it says live at your top, right as well, right? Yeah, it says a lot. Yes. All people are dring. Yeah, there's no slides yet. No slides. So um with that in mind, um what we got. Thank you anyway for the Greek. Um What I would strongly recommend is knowing this um in the in these presentations, we really, we do a really succinct good first time. This is how you read a chest X ray and after that, we just keep diving in. So for those of you for your first time, sit back and relax and enjoy, but strongly recommend going to the prior slides and uh prior presentations as Dean mentioned and reviewing them because we're gonna continue just building on this knowledge over and over again. Um With this case, I'm going to present it, I'm gonna go discuss it. And then for the second part of the x-ray reading, I'll bring some of you on stage if some of you wanna read an X ray with me dive in um you know, by all means uh uh come on in. Um Danny will invite you guys to the stage and you'll read it with me and then I'm gonna go over one last close and few comments. But the big goal of this is to sharpen your clinical skills, get comfortable with reading a data point that we request throughout the world. Almost every healthcare system throughout the world has x-rays. Now let me, I always like to start off with kind of the philosophy about x-rays. So give me two minutes to do that. And at 410, we'll go over the case, the philosophy for a chest X ray, it should be a recognition that you really should be pursuing it for the majority of times for an acute issue. Something happening in the immediate sense. Why? Right? Because there's limitations with a chest X ray. Chest X ray is a two dimensional representation of a three dimensional cavity, right? Our chest area, our thorax is three dimensional chest X rays aren't SMS everything. So with that in mind, it's not gonna pick up a lot of the great granular things that is say a chest CT would do a chest CT is an X ray, but three dimensional um recreation of it. So recognize that aspect of it. The other part for a chest X ray. The reason why I say of you really should pursue it for kind of immediate concerns, for immediate questions that need an immediate answer um where it's good, it's good to kind of evaluate really lifethreatening issues that can happen to the lungs or to the chest area in of itself such as pneumonias or lung collapses. So by all means, it's a really good modality for that. What it can do though is tell me what's going on in the lung circulation. So people are concerned about a say a blood clot in the lungs. This this may give you some like hints at it but no definitive way of proving it on a chest X ray. So why, why I'm saying this out loud to you all is while this is a very common data point that we get on almost every patient admitted to a hospital. It by no means gives you all the answers you would want. It just gives you very quick answers to really quick concerns, right? In other medicine, we like to make sure we can evaluate you for things that are life threatening. So if we think you have a pneumonia, chest X rays are gonna help us if we think you have a lung collapse, chest X ray will help us from that aspect. So just recognize that. So with that in mind, let's go over today's case. Today's case is really new. It was last time I was working in the on oncology, ICU. So a little bit of cat a bag if it's an oncology ICU, it must be a patient with cancer. Um So with that in mind, I'm gonna go ahead and share my screen. I'm gonna read this chest X ray. I'm gonna take it off and we're gonna kind of go over the case a little bit more succinctly. So with that in mind, sit back and relax as I do the initial presentation of this chest X ray. So let me just go ahead and share my screen and Deanie, my friend. You will have to be the one who validates that you can see it. Can you see it? Yes, you're all good. All right. Fantastic. Excellent. All right, love this. All right. So let's go over what is happening in this very, very busy chest X ray. So here we have a 74 year old patient who presented to the emergency department, short of breath, short of breath. So let me read this chest X ray for you all as it flashes before me. Let me tell you what's going on here. So right off the bat, I look to make sure the the position is correct. So the patient does not appear rotated as I can identify the spinal processes and they themselves do not appear rotated. As I go down, I can identify the trachea. The trachea doesn't seem shifted per s and we'll discuss what that means, of course. Um But I could make the argument that it is uh it's not splayed either. So the trach has not shifted and it's not displayed. So the mediastinum overall looks preserved in what's going on. Next, I go to the plural space in the pleural space. I look to see if there's costophrenic angles and if the apices are preserved from that aspect, I cannot see the costophrenic angles at all bilaterally, they are gone. That's the indication that there's gonna be fluid in the pleural space. And I go north, I look at the apices bilaterally they are present. Um And so from my standpoint, I can't appreciate if they have collapsed at all. So the apices look preserved indicating that if something's happened in the plural, it's plural space. It's just an anomaly from fluid and not an indication that air has escaped into it. Next, I look at the hilum and I can tell you um right and left. It's hard to make it out. So no commentary on the hilum just because of some confounding concerns uh likely be happening from the pleural space again for those new new people here just hang tight. I'm just reading it and I'll go over everything I just said in a second. Next, I go over the heart and I can tell you immediately, no comment. Um I can somewhat make out one aspect of a heart border, but the rest of it is lost um in a sea of whiteness. So no comment on the heart size. Now I go through the lungs and so I can only see on the right side, just the upper portion and a little bit of the middle lobe, the rest of it is gone in a sea of white. But what I see in the right upper lobe in the right lung is kind of infiltrations um that really continue extending way beyond um the aspect of it that I would say is reasonable. So, um I would say there's um significant interstitial uh interstitial findings here on the right side and as well on the left side with prominent interstitial. So, uh and we'll again, we'll discuss what that means in a second. So hang tight. So, but no, nothing else, no cons, no consolidations and no um infiltrates. So my big takeaway from this is significant, bilateral pleural fusions um uh in a patient who is presenting that uh they are short of breath. So all that said and done. What did this mean? Let me go ahead and do some markings. Uh Now, it's just a matter of finding where the markings is. So hang tight as I tell you guys what all this means, hide. All right, perfect. Let me get the markings. All right. So pen. So for those of you who are new here, whenever we get a patient with a chest X ray, what we ask is um to make sure that the patient themselves is positioned appropriately. I know that sounds silly, but your technicians have to make sure that they're positioned where their back is flat against the wall, right? If they are turned at all. It's gonna really throw off the measurements and it's gonna be hard to really interpret uh pathologies, right? If their, if their left shoulder is more forward than their right shoulder and then their left lung is gonna look bigger than their right lung. And is that because of their positioning or is that because of true anatomical issues? The landmark that I use here are what are called the spinal processes. Spinal process is what comes off of your spine. You can feel it right now. If you take your hands and you run them against your spine, what you're feeling is your spinal process. It looks like the beak of a bird coming out of the vertebrae. And if you're staring right at it, it looks like a tear drop. If you're staring it from the sides, it it's more obvious that it is a bird's beak. So I stare at it, it looks tear shaped, patient is not rotated next. What I do is I identify the trachea and this patient's trachea takes kind of a unique curve, but that curve just looks more like its own anatomical uh variants rather than any pathology really happening. So what I do with the trachea is I go and identify this part, right? The trachea is your windpipe. You all can feel it right? It's that tubing that sticks out uh in your neck and you can follow it down until you get to your um manubrium and then it disappears behind it, you no longer can feel it. And behind that manubrium, that top part of your uh chest, uh your, your breast bone, right? But the top part of it right behind it where it splits, it's called the Crna. So I always look for that bifurcation right here where I'm putting the seat called the Crna. And I use a CR as another la anatomical landmark. And what I try to see is if the cri of the split falls in between the borders of the spine and if it does, it implies that nothing's potentially, it, it implies that reasonably, the mediastinum, the mediastinum, by the way, is an anatomical landmark that's created between the right and left lung in the mediastinum is your heart, is your esophagus, is your aorta. Many good things are found in the Mediastinum, but it's a space that's created um between the left and right lung. If something's happening there, what ends up happening to the Crna is it gets shifted um depending on what's going on. So the Crna looks in place in between the vertebrae again using that as an anatomical landmark. The other thing I look for is the angle of the Crna. If it's an acute angle, then you say the CRNA is not splayed. If it's more of an obtuse angle, it means it's splayed and something's underneath it, pushing up, spreading the bronchi um that are coming out of the carina. So we're off the bat. So far. I have interpreted that the patient is not rotated. I found the car and I can say, look, the mediastinum looks OK. It's not, nothing's tugging or pulling at it and nothing's really pushing up against the uh carina to make it uh display it right to kind of cause the bronchi to really over extend beyond the acute angle. Next, I look at the pleural space. The challenge for you all, if you've never seen a normal X ray, there's no pleural, there's no costophrenic angles here. Costophrenic angle is exactly what it sounds like. Costo meaning bone phrenic implying kind of the Latin word for diaphragm. And it's ii don't know where it is in this patient. I'm just kind of making it up. It looks like if it was normal, it, the costophrenic angle would look like kind of vampire fangs. Um Finding them will imply that there's likely no significant fluid in the pleural space, not seeing them indicates there's fluid in the pleural space. Just as we're seeing here, we can't see any phrenic angles here that implies there is fluid in the pleural space. Next we go north, we go above the clavicle to look at the apex. And what I'm looking for is if the apex right here is nice and gray, if it's nice and black, that means air is in the pleural space as well. Air travels north because it's lighter in density and it pushes the lung down a little bit, but right above the clavicles, I can see a nice gray area indicating there's no air in the plural space. Next, I'd go to something called the hilum. I can't see it. I'm, I'm making it up where I think the hilum would be, but I have no idea if this is where it's at. The hilum is where the lymphatic system, the blood vessels and the airways all come out together, clustered as they continue spreading out. Um You, you can always see the right, better than the left because the left normally also goes behind the heart. But you kinda just look at the shape if it looks nice and kidney shaped like this, it's normal. If it plumps out, it's abnormal and you just say there's hilar enlargement. Next, I go to the heart cause I just look to see the heart's enlarged. We cannot see the heart at all. All of its borders are lost behind this sea of whiteness. And I'm kind of uh highlighting the meniscus here in this sea of whiteness that's going on. So no clue where the heart is. Um But you look to see if it's large or not. That's all you can really comment on and then you go into the lungs, the lungs, you kind of zig zag back and forth, looking to see what sticks out and there's three things that could always stick out. One is, if the lungs look cloudy, those are called opacities. Two of the lungs look white it out and we'll discuss what white it out means in a second because that's what's happening here or three. If the interstitium, the interstitium is the, is the term for kind of the lung tissue where the blood vessels travel, the blood vessels are thick as it as close, are thicker when they're closer to the heart. But by the time they go out into the lungs, uh to the distant part, it should disappear. But if they still continue looking prominent, like they are here, like I can still trace them out all the way at the top, right? If that's the case, then you just say there's interstitial, there's prominence of the interstitial, right? And that usually implies that the uh blood vessels are really congested, blood is not flowing out of the lungs properly. All right, let me erase this. And before stopping to look for questions or comments, there's something I wanna make a point in regards to waiting out of the lungs. So in this case, whenever in the lungs, you're gonna get one of three abnormalities, either it is the interstitial prominence, like I said here, it's just streaking lines that extend north into the lungs or all the way to the boundaries of the rib cage. That's, that's abnormal. You should get them in the beginning closer to the heart and then they kind of fizzle out two is opacities. Opacities is like if I took a cloud and put it in the heart, right? You can kinda see through it. It looks fluffy. Those are opacities. Opacities can represent anything could represent an early pneumonia. It can represent a resolving pneumonia. It could represent water in the lungs. It could represent blood in the lungs. It could represent autoimmune process in the lungs. Opacities are very nonspecific waiting out of the lungs. You only got four reasons that would occur. That's it. This is waiting out of the lungs. Ladies and gentlemen, right here, what you are seeing is waiting out of the lungs. Four reasons will happen that there's a white out in the lungs reason number one, a bad pneumonia, bad pneumonias will white out the lungs and you will call that a consolidation two atelectasis. For those of you who have been with us before. You may have heard this fun term called atelectasis, atelectasis. Something that makes human lungs really poor compared to the rest of the mammal species because their lungs really don't atelectasis. Ours do atelectasis is lung, self collapsing. Now, I say that but in reality, there are mammals like sea lions that will collapse their lungs and they do that in order to do deep diving. So their lungs uh don't get them bends, don't get kind of this kind of pulmonary edema. Nonetheless, human lungs, you guys can all create atelectasis in your lungs. You go lie down in bed, take short shallow breaths and do that for about 30 seconds. I promise you the bottom part of your lungs have self collapsed. Anyway, atelectasis is reason number two, you can get wiped out. So bad pneumonia is atelectasis. Reason number three, this is funny or I think it's funny but it might not be very intuitive. Say this individual went and got a lung surgery where some of his lung was removed, chopped off. What's gonna happen to that space is one of two things in the immediate sense. In the first six months, that area where the lung was removed will get wid out. And you're like, why is he getting whited out? Well, in the pleural space, the pleural space is a vacuum. It's very negative pressure. So very negative pressure is going to result in things being pulled into it, right? It's a vacuum. So things will get sucked into it. So we'll get sucked into it. It's fluid. So a lung resection in the first six months will get fluid in there. Now, does the fluid stay permanent? It can, it just depends on the patient. If you have a patient that's really committed to exercise and rehabilitation, then their lung will grow and grow and take over that space. And so it just depends on the patient. So four things that can cause white out atelectasis, pneumonia, lung resection. And you're wondering, Laura, what's the fourth thing? The fourth thing is what you're seeing here. This anomaly is known as a pleural effusion. So a pleural effusion, let me stop sharing my screen so I can get back to you guys. Let me put in a pen, let me uh let me downgrade this so I can talk to you guys and let me come back here. Am I still sharing my screen, Danny? No, we're not sharing your screen anymore. Yeah. Perfect. Perfect. So the uh an effusion implies that an infusion implies that there is fluid or an excess amount of fluid in a space that should have excess amount of fluid. Ok. That's the case. That's what it's implying, right? Too much fluid in a space that shouldn't have fluid. That's an effusion. So you can get infusions, you can get them in your knee space, right? If you've ever torn an ACL, you get effusions, right? That's why your knee gets big. So, effusions occur whenever you have excess water, the four things shock pneumonia, pleural fusion, um atelectasis and I'll write that word in there. So you guys are like, well, how do I spell that? And a lung resection? So, pleural effusion means excess fluid in the pleural space. So, excess fluid in the pleural space, right? That's what we're seeing here. This patient has a pleural effusion. So, pleural effusions are fascinating because you gotta figure out well, why is that happening? Why is there pleural fusions? So let me pause here and turn it over to you guys actually. Is there any questions coming up so far? Just let me look. I'm not a uh uh questions. Uh Rsha, you said you mentioned the chronic should be in between the vertebral columns. Yeah. So this is a subjective point to make you're right. So I'm indicating that I think it just fall in between the columns for two reasons. One, the patient is not giving me a good inspiratory breath, right? And I can get that sense just because if you saw the ap they barely come over the clavicle. So I'm gonna give him some leeway that we capturing this leg. Lu an expiration when you're capture on expiration, things get squished up. That's why you're seeing part of the trachea deviate out when Yeah, I see that kind of bulging. It's implied that I'm capturing this one expiration because again, things get shifted up. That happens a lot on patients who are coming in your I uh into your ICU and you're like, I am breathless. I'm breathing like 30 times a minute. I can't pause to take in that deep breath that you want me to take when you're snapping x-, right? If you guys ever get xrays done to your chest in comes the technician and goes taking a deep breath and hold it. Well, if you're breathing three times a minute cause you're breathless, you're not gonna be able to do that. So we're like, all right, do your best and we'll snap it. But the fact that the trachea part kind of bulges out the windpipe. It's applying to me that like we called him and see it was expiring. So that's why I'm giving him a little bit of leeway. So good question. But again, this kind of just reading these over and over again, just takes time from that standpoint. Um All right. So pleural fusions, right? Pleural fusions, Uh you, you can confirm it simply by your chest X ray. It's there. I already got the diagnosis in regards to why I think he's short of breath. He's got two, he's got bilateral fusions or bilateral meanings on the right and left lung. Let me see. Let me ask you guys this. Anyone have an idea or thought of what can put extra fluid into the pleural space? What could be a culprit of this? Anyone wanna take a guess? Heart failure. Yes, malignant infusion blood can occur. Yes. Uh extra pressure differences. All right. Heart failure. Yeah, I love it. You guys are like pneumonias. All right. Let's let's operate. I love this. You're gonna love it, love it, love it, love it. All right. Let's go through a few things. Um that can cause it because you guys are nailing it on the head first. Let me go over infections causing it. 100% infections can pneumonia specifically, right? Because what ends up happening is you get all this pus and starts leaking into the lung. Now, pneumonias w should not cause bilateral pneumonia, really should happen in one section of the lung. You shouldn't get a pneumonia that causes bilateral. Uh, I mean, I'm saying this because there's always like something that like, deviates from it, like a histoplasmosis pneumonia. I get it fine but commonly, commonly not bilateral. The reason why if I think the patient has a pneumonia, I better put a needle in this person's back to get a sample is because what I'm concerned about is did the infection get into the pleural space? An infection getting into their pleural space creates a parapneumonic effusion. If it and if a lot of puss gets into there, it can cause what's called an empyema. This changes my treatment of an infection. If it's a para pneumonic infusion, long course of the antibiotics. A very long course. If it's an empyema, I gotta also put a chest tube in this patient, right? Because empyema will create a lot of fiber. Um A lot of scarring, sorry, a lot of scarring in the lung cap in the total space. So I don't think this is an infection. Just my two cents cause it's bilateral. Heart failure is another common reason for bilateral pleural fusions. Actually, heart failure is probably the leading cause in America of bilateral pleural effusions. Other bilateral causes can be liver and other uh but liver patients also will have uh ascites like their belly should be full of fluid, right. So it's going in the lungs and it's going into the belly too. And then certain kidney diseases can cause it as well. But heart failure, by far the leading cause of bilateral pleural fusions in the US. Now, why are they happening? Happening there? Well, cause the heart is struggling. So it's weak. I'm picking on the heart because I'm a lung doctor. I get to do that. It's weak, can't send blood forward effectively. So a lot of the blood gets backed up. Well, guess what your lungs do? Your lungs look are like, look, I can only back you up so much. I'm overdoing it. I'm congested. So I'm gonna pour some of this fluid into the pleural space and the pleural space sits there with fluid. If I see pleural fusions bilaterally and the patient has heart failure. Here's the other kicker that pleural fluid didn't just happen overnight. That's probably been there for months, if not years. Um Pleural fusions that happen from heart failure, it's a compensation that your body is trying to do, right? It's like I gotta find cavities to put this extra fluid in and one of them is there. So now with that in mind, what do we think is happening here? Actually, I don't, we don't know what's happening here. Like could this be heart failure or could this be his cancer? This patient has um Melanoma metastatic, right? So, skin cancer that has spread throughout his body and so could does um Melanoma cause effusions, of course, of course, does any cancer that's that's able to spread, especially spread into the lungs can cause pleural effusions. But could this also be heart failure? Right? Because he received a specific type of treatment to try to cure his melanoma, but it's got a high risk of it also causing heart failure, right? It's one of the car t cell therapies. So you could have heart failure too. And that because that I brought that up, you know, when we saw this patient, I was like this could be heart failure, it could be his cancer. It could be both, right? Because the challenge that we have here is I pointed out to you guys, the prominent interstitial markings, you see that predominantly with heart failure. So what's the culprit here? So let me show you what we ended up chewing. Let me share my slide to do, let me show my screen. So at the ah so at the top. Ok. So let me before I share my screen, we gotta figure out what's going on here, right? Is this, who's the culprit of this effusion? So what we end up doing at the hall is correct. I'm gonna end up putting a needle in there. I'm gonna send it out. I'm gonna send it out for an evaluation of how much protein and how many cell remnants are in here. If this is a highly protein fluid in here. Too much fluid. We call this an exudative effusion if it's almost no fluid, almost, you know, none, uh no protein. Sorry. If no protein in there, we'll call it more transitive transitive will imply this is likely 100% or close to 100%. Heart failure. Take sedative could be infectious. Could be cancer. I will say though cancers can give you both can give you both exudative and transudative. We really nail the head for this to be caused. Uh for me to say definitively, it's cancer is if we find the cancer cells in there, find them in there. I don't care if it's exudative or transitive. This is a malignancy causing it until proven. Otherwise, the reason it can cause both. It just depends where it's causing the blockage for the effusion to occur. Car T cells can cause heart failure because it's inflammation. Any bad inflammation can cause heart failure, depending on the severity of it or depending on sometimes it can actually cause a, a sense of myocarditis. All right. Now, let me share my screen and go over what we pay. Hold on. All right, let me go back to sharing my screen sheer and de can you see the, can you confirm that you can see this? Yeah, that you're all good. OK. So ladies and gentlemen, if I get a pleural fusion and I'm asked right? Because of the patient's cancer history what the oncology teams ask me is like, I need a sample, right? Can you go to the patient, take some fluid off? So we can see if his meso, if his uh melanoma has gotten into a pleural space, we know it's metastatic, it already spread into the lungs. But we gotta see if it's leaking out into the pleural space after his car t cell or can we blame this all on heart failure? They would love that because it wouldn't change management here. What I end up having to do. So if this was, oh, let me stop sharing real quick. All right. Let me come back to you guys live. All right. If this was 2000 20 years ago, um Well, even 1990 it was 1990. I was giving you this lecture. I saw this xray. I'm like right now, I gotta do a plural. I gotta see if they got a pleural fusion and I gotta put it. I gotta t it, do you guys know? Yes, but the will be up update. No worries. Uh Not right now. But when we send them out, I promise what we used to do as doctor to get this fluid off is I would have the patient turn his back to me and lean over and then I take my fingers and I percuss, right. I'm gonna have my wall here to kinda demonstrate. Well, there you go. This, that's what we do to their back and what we listen, right. What I'm listening is it's loud, it's loud. I start top and I'm coming down, it's loud, it's loud cause I'm, it's like banging on a drum, it's banging on a drum. Right? Because there's air under that, that uh sliver of uh thin paper, right. There's just air underneath it. So I'm banging on the drum until it gets dense. Right. That's where fluid is. So 1990 I just percuss you until I find where I think the fluid is. That's what we used to do kind of blindly in 2023 no longer blindly. What we end up doing is we put an ultrasound probe on you. An ultrasound probe is gonna look like this. This is an example. It's not the patients per se. What we look for is to find the diaphragm. It's already marked here. We find the diaphragm and the way we find the diaphragm is because it's always the top part of the diaphragm that you know where the uh where borders the lungs is always nice and bright. I love that about the diaphragm. I'll find it. Plus the other way to know it's the diaphragm is you got a patient taking in some nice deep breaths and you'll see it sliding and then we find the lung and the lung in a big effusion looks like this, right? A little bit of the lung. The reason why it looks like a little tail just swimming in the fluid is because the fluids collapsing the lung, it's causing atelectasis. Right. It's collapsing the lung. So the lung just looks like it's helplessly swimming in there. And then all this blackness, I promise you, it's much more black here. It's a little bit grayer as you get to the probe of the ultrasound looks nice and black. The thing is, it could be just fluid or it could also be blood, blood will give you the same look of it as well. But that's a pleural fusion. And then the thing is though, I kinda don't wanna be too close to the diaphragm. So I keep sliding my probe up where I can find a reasonably sized pocket, usually about 1 to 2 centimeters deep. And that's what I'll do. And then uh what I end up asking the patient is I position him, him or her, right? They take off their shirt, they lean forward just like this. This is the ideal position. I've done thoracentesis in other capacities where sometimes the patients are laying on their slot side because they're on the breathing machine. But this is where I like them to be right, sitting upright and bending and kind of leaning forward like this. You put a little pillow in front of them. Oh And this is the kicker, right? This is what we spend time positioning the patient doing because what you end up doing is you have to numb that area, right with lidocaine and then you drive a needle. This needle is about 8 to 10 inches long. Hopefully the inches comment can translate into the metric system for you all. I apologize about that. Um It's long. So, um, but uh, nonetheless, so we take this long needle, not all of it goes in at all into the patient. The reason why it's long is because of the catheter is long that we're gonna drop into the patient in order to pull this fluid off. And, but we have to ask the patient that was like he or she's gotta sit still. They cannot move, especially once we mark the area, they gotta sit still and we go on um right above the rib. This is another key part. Let me stop sharing. Uh stop sharing. Let me come back to you guys. When we do a th this is called a thoracentesis. When we do it, we always go above the rib. So if I, my finger is a rib, the needle gotta go above it. Never below it. Oh My gosh. If I catch one of you guys trying to go below it, I'll slap your hand. No, don't do that right? Because all the blood vessels are underneath it. So we go under the rib, you're gonna hit a blood vessel and they're gonna bleed out. So by all means you gotta go above the rib. Now, when they go above the rib after we've lidocain, it's gentle, right? You're constantly pulling back on your needle gently as you enter the space. And once you enter the space, it's like such a great feeling. You can hear, you feel this release of tension and all this fluid starts flowing back. Once it flows back, you move your catheter, drop it all in. You take out this large needle, you show the patient they faint a little bit because of a large needle in their back. And then you start pulling off this fluid. Now, when you pull off the fluid, especially in the lungs, like what we just saw, you're probably gonna get close to half a liter to a full liter of fluid, out full liter just sitting in this patient's lungs. And you do it slowly though, you don't rush it because as the lung re expands, if it re expands too quickly, the patient's gonna get short of breath and cough and be miserable. So you gotta do this slowly. So this procedure, the needle in the patient's back probably takes no more than two minutes. And really like I've done over 1000 of these, I can probably do that in two minutes. The preparation for it takes about 10 minutes, two minutes to stab the patient in the back, get the and drop the catheter in and then probably another 20 to 30 minutes. Now that I'm an attending, I told my fellows. All right, you're in there. I'll see you in 30 minutes. I'm gonna go see some other patients. They're just pulling the fluid, the poor fellows. All right. So now let's go back to the case because now I wanna show you guys what happened invs. So we got the patient here. We stabbed them in the back, right? And now this is their lung afterwards. All right, Danny, I can't see the screen but I need you guys can, if you can read me their comments and tell me which side of the lung now looks better, right? So if you guys can remember, here's the before and here's the after. Remember up here, if you guys can see the letter L next to 38 the radiologist put that there so they can mark less. Lots of people saying the right side. Yes, the right side looks better. Now, there's one more thing though about the right side is right here. What's left is actually this is an opacity right here where my arrow is. I don't, you know, if you guys can see my arrow. So I'm use my pen if you guys were wondering what an opacity looks like. This is what an opacity looks like, right? You can somewhat see through it. The left side is still white it out. All right, let me stop sharing. Now, let me ask you guys a question, by the way, on a side note, um to the commentary earlier about the Crna looking shifted. This patient now is taking a nice deep breath. He is much more comfortable because we just removed. Actually, in this patient, a liter and a half, look how much more, look how bigger the apex is. And here, if you said the crna shifted, you'd get you, you, you'd be correct. And the reason why it shifted here is because all the fluid here is now pushing against it. Here, it wasn't right in the prior picture because there was a nice balance of two things pushing. But here the fluid is pushing. So the the mediastinum is shifted here. But because of the left uh side is pleural fusion. All right, let me stop sharing here and let me go over uh discard, let me now talk to you guys. I wanna ask if you have some questions. All right, you got a patient like this bilateral pleural fusions. Is anyone asking why? Why didn't we drain the left side? Does anyone wanna, is anyone asking that? Let me just see. Yes or no. Is anyone asking? All right, thank you, Abdul Raha. Anyone else? Is it just a is Abdul rm the only person who's thinking about this at the moment? Does anyone else wanna know? Now you're saying right side is bigger? All right, if you get bilateral pleural fusions, we always like to go to the right side because the left side has the heart in it. So it's like I don't wanna muck around with that. So it's less likely I'm gonna hit the heart, so always go on the right side. But why do we do? Right? Or why do we only do one? And it's not size per S ei will always do the right side, even if it's smaller than the left. Right. The reason for it is, I don't wanna take the chance of knowing if my needle hit the lung. If my needle hit the lung, his lung will collapse. I really won't know that for another 12 hours. Right. If I really hit him hard and his lung collapsed immediately, I'd know that. Right. As I get the X ray, the X ray, we usually get within an hour, but then we're gonna repeat it 12 hours later and make sure, hey, things are looking ok. Right. So like if I was like, all right, did it x-ray. All right. Looks good. Let's do the left and then 12 hours later, both lungs collapsed. Uh Not a good position. So I, we don't do, we rarely do two thoracentesis at once. We usually do them a day apart. And if we have to choose one, we always choose the right one, regardless of size. I promise you letting one lung breathe better, the patient's gonna get relief. So even say the left side looks huge, bigger as long as there's some in the right lung that's easier to tap. I'm still gonna do that first. Um Because whatever relief you get to the right lung. I promise you'll start compensating for the left side. But we do it to assure that we didn't cause both lungs to go down. So that's why we tend to do it 24 hours apart. Um Because again, if your needle nicked the lung just a little bit, 12 hours later, that lung has collapsed because enough air has escaped to collapse it. So that's why you get a bilateral pleural fusion and say like I wanna do it. I wanna do two now with that in mind though, bilateral pleural fusions. The other reason we rarely tap both sides is because I said earlier like they're usually caused by the heart. So do you guys if this sick? This, by the way, I apologize. This was cancer. This was all his cancer. His melanoma spread in there. If this was heart, what do you think would happen? 24 hours later? I got a new X ray. What do you think it's gonna, do you think the right side is still gonna look great or is that effusion coming right back? What do you guys think look still looking great or is it coming back? Yeah, it, so this is I love my cardiology friends. They're like, can you just take the fluid out? Yeah, I can take it out. It's coming right back, right? If this fluid is caused by the heart and no one fix the heart, all this fluid comes right back. So whenever I get a cardiology request, like, can you come and tap this? I'm like, are you sure? Like if you guys think it's all heart failure, I'm not gonna do it sometimes I'll do it in heart failure for like palliative reasons to let the patient be more comfortable as he passed away. Fine. Or if they're like, well, maybe there's an infection there fine. I'll do a diagnostic Thora, but I'm not gonna sit there removing a leader only knowing it's coming right back. So if we think this is from liver disease or liver disease, especially like, do your best not to tap it because if you do it, like tends to come back even more violently. Um So you get like, if it's transit, ultimately, it's coming right back. So just an fyi you gotta really fix the organ that's causing it. Um So in this case, even if we thought it was heart failure, I didn't know. So I was like, let me just drain and drain a lot of it and we'll send it off. Um For like, like the fact that this patient had a cancer concern, we took a liter and a half off simply because we need a lot of fluid to see if we can find a cancer cell and it came back with a lot of cancer cells. So we did a thoracentesis on this patient. Um This patient though after this um I remember it was close to midnight. We got the results went and spoke to him. He was very sweet. He just opted after that to go into palliative care. So, uh the next day we um we ran kind of just a palliative care service on him and he passed away peacefully. Um It's tough. Cancer sucks. I don't think I need to te tell you guys that, but he went through a lot of treatments and we could not cure this. And uh and honestly, there was no, nothing more, even his oncologist, there was nothing more we could offer. And even he, he said no more. So you'll, you'll come across patients like this. Um How quickly could the fluid reoccur in the pleural space if it's caused from heart failure within 12 hours? It's all back, right? Cause you gotta understand like the heart's causing it. So me taking the fluid out, it's like it's like having a sin one and the it's this and the the drain is clogged. So you're like, oh let me just keep taking fluid out. The sink is still on. There's no fluids coming right back. I don't care how much fluid you take off quickly. It's coming right back. That's the analogy I would say sink one drain clogged fluid continues to build up in heart failure or uh advanced liver disease or kidney disease. Any questions about this case? Did you guys like this case need to do be all right. How severe is it? Oh, no, this is a great question. Carrie. Yes, it's clinical context. Clinical context. Let me say what? So if a patient comes in, even in their chart, this patient has known heart failure and they got bilateral pleural fusions. But if they're coming in with a fever and they're coming in with a white blood cell count that's elevated, I'll still go and tap it. I'll do what's called a diagnostic tap. I'm not gonna take off that much, right? Because you got heart failure. But I'm gonna tap enough to make sure there isn't an underlying pneumonia in this. Sometimes I can get away with just doing a chest ct and looking at the lung tissue. But the challenge is with really advanced pleural fusions, like we said earlier, they'll cause lung collapse, atelectasis. So then I really can't see if there's a pneumonia hiding there. So I would, it's got, it's the right clinical context carry you're spot on it. It's the right clinical context, right? Even a small effusion. I've seen the old small effusions, right? Barely 200 mL. But my gosh, if it's associated with a pneumonia carry, I'm going after it, I got to and I'll probably will use smaller needles for that because the larger ones are a little bit more clumsy for small effusions. But the reason for it is I gotta make sure that that infection hasn't gotten into the pleural space. If it has, I gotta act on that quickly. But what we commonly see as lung doctors is never let the sun sit on an empyema. Meaning if a patient comes in and I think they got an empyema, I'm tapping it. I have to so longer that infection stays in that part of the lungs, it's gonna scarred up and it's like, uh, the worst thing in the world that the patient has to live with right there will always be breathless. Always be in pain. It sucks. So carry the size, rarely matters in uh, in the tapping of a pleural fusion. It's, it's more of the clinical context, right? If I, I've come, I've seen patients with like fluid would come all the way up to their clavicles and the, the heart doctors are like, no, it's all heart failure. All I'm not happy now. Don't no need. They're coming right back. So it's all about the contacts, all about the contacts. All right guys, Merry Christmas. I'm pumped. You're gonna hear it from me first cause not even. Um, um, hold on, let me look at my calendar. You're hearing from me first, Dan. He's like, oh my gosh, we're gonna find out um, January 3rd January 3rd, 2024 3 o'clock. So new time. So sorry if that's tough on you guys, uh, three o'clock, we'll be back. Um, we'll try to do these always twice a month, um, to do this and I'll tackle this last question from if patient was on unveil later. Yeah, the patients on a vent, we've had these patients. If patients are on a ventilator, what we do is just roll them. So say the effusions on the left side, we roll them on the left side. Let all of it come down and go from that. Right. Right. Let's say you just roll them, the nurse holds them. Those are tougher cases. I will tell you um I've even done it where I had a patient, lift their arm up and I go under their axilla. Those are just tough. You just gotta position them though with that in mind. Sometimes we can, while their breathing tube is out, we can have them and they're, and they're kind of awake and, and they can help you, they can just sit forward, we just help them do that. So if they're on a ventilator, it's always about their mental status. Are they awake enough to follow my convenience to do this for me? That's it. All right. We'll stop there. Listen, you guys enjoy your winter. Um It for those who celebrate Christmas, Merry Christmas, for those who celebrate Kwanzaa Happy Kwanzaa for those who will just enjoy the New Year, Happy New Year. Um I can tell you for DNA and I, this has been really rewarding. So don't hesitate to review the prior cases. Um Someone wrote uh Thank you. Oh, you guys are too kind. Uh Uh, thanks so much. Uh, I've seen them in my ICU in Cleveland Clinic. Yeah, I mean, we, we can do them in the ICU. It's just, it's tough but it's doable. But you guys rock next month, we'll see you guys twice a month. We'll be doing these, uh, January to about May and then over the summer we'll probably cut it back a little bit. But enjoy. Bye guys.