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All right, everyone. Welcome uh to our x-ray rounds. Uh I'm Doctor Gatto. Uh If you, if this is your first time coming. Well, welcome. Uh I'm speaking uh in a low tone. Uh I taught a class and had a late meeting and couldn't get to my next office. Uh So you guys are catching me as I'm in the hallway of our Johns Hopkins University um for the Doctor Abbie, I see that you're here. Welcome. Uh And hopefully, uh everyone else here is having a uh has been here before. Um Deanie. Are you able to unmute and just confirm with me that you can hear me and everything's OK or put in the chat box, whatever is easiest my friend, we can hear you. Perfect. That's it. I always rely on t for the feedback. Um So with that in mind, what we're gonna do in a second is go over today's case given the limitation I have uh at the moment, I may just do the X ray readings, but as you guys questions, so go ahead and put into the chat box. So um as we go through this, just go ahead and put your answers in there. It's good to see so many familiar names already. So what this intention is with uh reading a chest X ray. It, the intention is for you all to learn this valuable clinical skill um that you can use and keep using and reusing over and over again. Um I would encourage if you've never, if this is your first time here, go back to our old lessons. Uh So you can see in real time how we've done uh uh how to approach a chest X ray. And then, you know, we will always do some clinical cases as well. So if you've not done this before, please, I encourage you to go back and take a look at others. If you uh that way you can all be on the same page. So today as a lung doctor, I'm gonna go over a clinical case, but starting it off with reading a chest X ray if you have any questions or concerns, put it into the chat box and I'll try to tackle them one by one. So without further ado, let's dive into today's chest x-ray. I'm hoping that we'll, we'll finish in about 40 minutes reading two chest x rays. So let's do the first case. Go ahead and share. All right, and Danny, can you confirm into the chat box? So you can see, well, maybe now you won't see that screen. But let me put that. Uh could you uh we can see it perfect. Thank you. All right. So let's go here. All right. So here this is a patient of mine. She is 58 years young. This was an X ray that was taken of her after some complaint of shortness of breath. So let me read this x-ray for you all and kind of try to highlight then between this x-ray and the next one, what the abnormality is. So 58 years young, her background medical history is that a COPD? Let me put that into the chat box. So 58 year old female with COPD, she is complaining of shortness of dyspnea. So let me go ahead and read this x-ray for you all. So in regards to this X ray, I'm gonna read it and I'll go over these points. Uh The patient does not appear to be rotated in regards to her mediastinum. It is neither shifted and the crna is not displayed in regards to the pleural space. Uh bilateral costophrenic angles are present and the ap are also present without any hint of fluid or air in the pleural space. In regards to the plum, she has uh a high level on the right side that is of appropriate shape and transparent and on the left side, again, appropriate shape and transparency as well. In regards to the heart, it does not appear to be enlarged, the apex of the heart ends shortly before it ends with a significant amount of space before the chest wall on the left space. And there seems to be a reasonable left atrium, left ventricle slope, um to indicate that the left atrium is not enlarged with any elevated pressures. Then getting into the lungs. It looks like the patient is taking an adequate breath and going from top to bottom on the right. Uh There's an appropriate distribution of the interstitial spaces. They don't seem to be enlarged. There's no opacities, there's no consolidation, the same thing with the left lung, great interstitial markings throughout but not overly expressed, getting to the periphery of the chest wall and there's no opacity to their consolidations. So to you all this, the way I would read this is a normal x-ray. So let me try to let me hide this. Let me go to uh oh, here's the, yeah, just hold on. Let me just make sure we go back to this. No. Hi. Well, let me, I'll use, I'll use this. All right. So the way we started off was highlighting the spinal process right here. These things are appropriate in regards to coming at you looking somewhat similar to, as I always say, kind of a uh um looks like should look like a um uh a tier shape, an oval shape and you guys can see those uh as I draw them out. Next, we go into the Mediastinum and in the Mediastinum, what we're looking for is the parinum and if I circle the parum circle it right here, there's two things about the corinum. We wanted to um go ahead and uh be in between the spaces of the vertebrae. So if I can put the boundaries of this around the vertebrae, the car seems to be falling in there. And the other aspect too is that it uh the angle of it is it's not splayed, right? So it's coming down like that. So let me pause here because this has come up before. In regards to talking about the car shape, the carina shape is meant to be kind of an acute angle. That's it. If it's more obtuse the way you uh read that is that it is splayed and by calling it splayed, it means that something's under the carina and it's pushing against it. You use the Carina as the anatomical landmark of the Mediastinum saying, hey, nothing's moving it, nothing's shifting. It usually implies a healthy mediastinum but not fully. But it's the best you can do in a chest X ray. All right, let's go back to sharing the screen and let's dive into, oh, go ahead and share. All right back to this. Let me go ahead and delete some of the stuff I put in here. So the other aspects of uh trying to here, let me go ahead and let me do this. There we go. All right, Danny, can you sure, can you see the screen that I just put up. Yes, perfect. Thank you, Deanie. All right. So let me go to this pen here. Next, we'll go to the pleural space. Do you see this phrenic angle here? This is a, this is appropriate. This means that there's no fluid in this space. And by capturing that succinctly right here, it implies again, no fluid. So good plural space. And then what we do is we look at the apex up here to make sure there's a nice gray demarcation. And that's what you can pick up no air in the top and no fluid in the bottom. We'll go to the hilum. What we're looking for is kind of this level of a shape on the right side and this level of shape on the left side is actually these are two really good high ones, they're somewhat transparent, you can see through them and they're not consolidated or they're not thickened. And then in the heart, there's a nice space between the left ventricle and then this is the ap uh atrium right here. And you see this kind of one slope down two slopes. So the heart is of normal size. And then what I said earlier, the interstitial spaces, you know, they're zigzagging out but they're not coming all the way to the periphery. So that's a normal distribution of the interstitial. So this is a normal lung. She's 58 COPD short of breath coming in and she has uh what we can identify as normal lungs at the moment or normal chest x-ray so we could stop sharing. Oh, you couldn't see the annotations. Ok. All right. Oh, all right. Nonetheless. Ok. I thought all right, I'm gonna flip it back on but let to the crowd real quick for those of you who have been with us before, you know, that we tend to like to ask some questions. So we have a 58 year old who is short of breath. Any thoughts with COPD, any thoughts from just that one chest X ray of why she's short of breath? I told you it's a normal chest X ray. So anything anything that you can think of what's making her short of breath? Mhm. They have anyone want to take a ok thymectomy. This patient has not had it. So her mediastinum is uh is good, I promise you. Um So, but it's a good thought. Any recent illnesses. Good question Felicia. Um She did have a sick contact uh uh about two weeks ago, her grandson, her grandson runny nose, a little bit of cough. She took care of him. That's it. Two weeks ago. She had a kid, a grandchild that had a sick um I had a sick contact so I'll start there. You wrote anything related to the heart? Remember the heart looked normal and the heart is causing shortness of breath. X-ray things that you're looking for is does the heart look big are there prominent interstitial, uh, markings that would indicate heart failure? Um, that's not the case so far here. Any medications, just her inhalers, just her inhalers. All right. Let's go to the next powerpoint. I'm gonna show it and I'm gonna ask you guys, does it look different from the prior one? All right. You ready? No allergies, no allergies, uh, uh, fungi. Good question though. All right. Let me go ahead and let me share my screen again. Hold on one second. All right, I'm gonna share. All right, here's the x-ray that you all just saw. And now here is the next x next x-ray she left the hospital with shortness of breath comes back in about five hours later. Anything on this x-ray? Take a look at it. I wanna then take it off the screen and see any thoughts about what is different between this x-ray and the one prior, this one versus this one, same patient five hours apart, this versus this. All right. Let me stop sharing. And what do you guys think? What, what stood out potentially is different if you need more time, I'll put it back up. But what stood out different between those two x rays? A brilliant, brilliant, all of costophrenic angles are different. So the heart looks shifted. We'll, we'll come to that. One of the things that I want you guys to take away from in regards to these readings is that I want you to know what's normal and not normal and a lot, you just, you, you, you picked it up, you're like, hey, there's something different with the. So let's go back and look at this. All right. So what I want me to mention is that the angles are different. So look at these angles up here for the costophrenic angles. This is normal. It comes down, right? I keep always saying this, they're supposed to look somewhat like fangs, right? Like a a dracul fangs and so forth. But here they don't look like that, right? They're somewhat flat. This one on the left side almost doesn't look like there's an angle at all compared to this, these look very different. Um And to the person who said the heart has shifted, you're correct. I mean, the heart actually went further to the middle if anything, but the heart is still no normal. I promise you normal heart still have kind of a too slow process happening here. Let me redo this x-ray and then we're gonna come to a point about it. So in this x-ray, she still is not rotated. So good job to the technician. Now, let's go to the medias and in the Mediastinum, right? When you guys are looking at it, it's here's branch off a bit here and here. Yeah, you are. I would still make an argument. It's not shifted and it's not splayed. So the mediastinum is still good and healthy costophrenic angles as ALA pointed out, something is off with them, the apex looks ok. Nothing going on here. Nothing going on here. Hilum. I would still make the argument. It still looks ok. And then we talked about the heart being of normal size and then looking at the lungs actually, again, the interstit looks fine. The interstit looks good. So the blood vessels are not engorged. There's no consolidation, there's no opacity, but this is an abnormal X ray and abnormality has to do with this. This patient is exhibiting what's called a COPD exacerbation. So let's go back to you guys. Let me ask you this. People with asthma or CO PD. If they get into trouble, they can't breathe. The, think about this before we even think about the X ray. I just showed you for someone having an asthma attack and someone having AC O PD attack. What do you think? What are their lungs gonna look like on an X ray? How are your lungs look like on an X ray? Ok. OK. Go ahead and put your answers in the chat box. How will the lungs look like on an X ray of someone having an asthma attack or AC O PD exacerbation? Anyone wanna be brave enough? L let me ask you this, will the lungs look normal or not normal into that? Will the lungs look normal or not normal? Grace says not normal. What do you think that not normal? Um Would be, tell me what you think may be going away and it's a, it's a reasonable question. Do you think there should be a white spot on the lungs for people with an asthma attack? Hypert translucent? OK. Obeyed um flush that idea out a little bit so I can try to make sure I know where you're coming from. What do you mean by hyper translucent grace or you're saying? Is there some tension? OK. Again, this is meant to be a thinking cap conversation. All right. It's a little bit not fair. I get it. I'm asking you guys to try to get into my head. So let me, let me walk you through this, this patient. So asthma and cop a shot, can you look enlarged? Great point. So that tends to be the abnormality. But how do you know the lungs are enlarged? How do you know? Right. So Aah and others, you guys are getting down to the point, they look enlarged, they look hyperinflated. OK. How do you know the lungs are enlarged? Like how do you know they're pathologically enlarged and to get enlarged? Both asthma and COPD are airway diseases like so think of the airways, airways have to get air comes in and air comes out in asthma and COPD is the issue of air coming in or is it the issue of air coming out? Asthma? And CO PD is the issue for air to come in or is it the issue of air leaving the lungs coming out spot on. So that means air can't leave. Air is struggling. So think about it. Each breath you take keeps building on top of the air that's already there. That's why you guys are saying the lungs are gonna look hyperinflated. But how do I know the hyperinflation is pathological? How do we make the case that the hyperinflation biological? OK. You make you said number of costal B that's reasonable. But the case that I will present to you. So this is why when you guys come to x-ray rounds, if you've been taught x-rays by other people, they always tell you to count the ribs. I don't believe in that. And that's the art of medicine. There's nothing wrong. If you wanna count the ribs, people will count the ribs to make sure the patient because if you go get an X ray, they're gonna say, hey fungi take a deep breath and hold it so I can snap x-ray. So we count the ribs. Did they take an adequate a deep breath? That's fair at the same time though. What do you tell patients who are coming in with an asthma exacerbation? Hold your breath. Really? OK. I can't do it anymore, right? It's gonna be hard to do that. So Obeid just hit the, hit the ball, hit it, swt a goal, whatever sports idiom you wanna look at the answer is if you wanna know if the hyperinflation is pathological. You look at the costophrenic angles. So here you go back to sharing the screen. All you said this earlier. You said something is wrong with the pleural space. You're right. Something is wrong with the pleural space. This is why I want you guys to look at thousands of thousands of X rays. These pleural spaces are abnormal, especially when you compare them to the normal. Here's a normal costophrenic angles. These are what we would call flattened. Ok. Flattened cost phrenic angles. Yeah, you might see what it did these a little bit, right? Is it? No, if you've looked at a thousands of these, this is supposed to be normal. Let me erase this real quick. So you can see them. These are normal costophrenic angles. These are not the little bit of an angle that'll take is just because of the way the diaphragm will look over the liver. But I promise you this can get even flatter. These are flattened. Cost phrenic angles, right? The angle is not as deep, right? It should be at least an inch, you know, a few centimeters deep. This is barely, barely touching it. This is pathological hyperinflation. So from my standpoint, well, let me stop sharing real quick. Let me come back. Oh, there we go. Stop sharing. So to you all the number one finding of COPD and asthma exacerbations, it's actually a normal x-ray. Yeah. Can you get pneumonia short? They, they could have a pneumonia and that resulted in their shortness of breath kicking in asthma patients and COPD patients typically have normal x-rays. Actually COPD. You can make an argument, maybe you can find a little bit of emphysema. Sure, asthma normal. The number one finding on an X ray of an asthmatic going through a difficult moment is a normal x-ray. Right? Because it's an airway disease. If there's a pneumonia, that patient has been sick for quite some time, the flattened diaphragm comes on if they're flare really has progressed to where the air is trapped. Here's a kicker. Here's a beautiful thing. Watch this guys. Let's go back to this. Let's go back here. This is the same patient five hours apart, same issue. The other part that you may notice here is nothing's around her neck. Here you have oxygen coming around her neck. Ok. Erin, you are an asthma exacerbation or co PD exacerbate an airway issue where you're struggling to get air out. Do they need oxygen in the beginning? Do they need oxygen? And meaning do they need us to give them oxygen when they're struggling to breathe? Like that patient five hours ago, does she need oxygen? The answer is no, you guys can put that in there if you like. The answer is no, this is never an oxygen issue to begin with, right? We can get air pound. You need to get the CO2 out. You need to get that out. This patient came and left, right, she left because she's like, well, I can just manage this at home. She couldn't, and she came back whenever you see the diaphragms flattening like that because that's the finding, right. It is diaphragmatic. I, whenever you see diaphragmatic flattening, I will bet you the patients needing oxygen if her exacerbation has progressed long enough where so much air is trapped. The reason why she begins to desaturate to fall on oxygen levels is because that new air can't even find in alveoli that has room to take in oxygen from the sky. So one way of doing that is over uh pro providing more and more oxygen in order to compete. Ideally, what she needs at some point is enough bronchodilation where she can get the air out, right? So what she is waiting for is for a nebulizer to start coming on so she can breathe in the bronchodilators to get it out. So let me any questions, anyone wanna ask a question before I wrap up today's lesson. I promised you guys 30 to 40 minutes. So any questions before we wrap up? All right, with no questions. Hold on. Let me just see. All right, let's talk about COPD exacerbations and asthma. So any diseases of the airway and there's others, there's other diseases. What you want to do is try to understand what brought it on. So one of you asked, was there any sick contacts So if there's a context, then yes, what you need to do is recognize is that enough for it to cause the COPD exacerbation. If it's enough to cause a COPD exacerbation or asthma flare, then is it just an airway disease or has it done anything else by anything else? Meaning has it resulted in pneumonia? And I promise you that majority of times it won't, this will result in more of a, it's caused just airway disease or the airways get more and more narrow, right? That's why this is a disease of breathing out when we breathe in our airways, open up when we breathe out, they naturally collapse. And if you have a disease that causes that collapse to be even more pronounced, then they're gonna struggle to get things out. So if you're having a patient with asthma come to your emergency room and they're struggling to breathe just because they have a normal X ray, don't dismiss them, manage them aggressively. Get them on a bronchodilator, get a nebulizer treatment going, get some steroids happening, steroids. Remember, take about 12 hours to kick in. So that's not gonna help immediately. Steroids will help later. Sure, you need that. But get the bronchodilators right now and then you'll try to shut off the inflammation if you got a patient like that coming in with their diaphragm flattened, put oxygen on them. You, we miss a lot of time to help them. So that's what's important. So COPD exacerbations and asthma exacerbations. Those are airway diseases. They won't. X-rays will usually be normal or no acute issues. If you have diaphragmatic flattening, that's a pathological hyperinflation. Often necessitating oxygenation until you can open the airways enough to get air out. Any comments or questions. Sometimes you might have to also do noninvasive ventilation where you'll put them on bipap and so forth. But any questions. So any questions this, then we're propping up the case or anything else. And Alfi good, good job with regards to figuring that out. All right, my friend, this is a quick lesson. Uh, for today, Danny will provide um, any feedback but really good job in regards to picking out the abnormalities. You know, I really appreciate it and uh come back in two weeks and we'll tackle the next lesson. All right. Thank you guys so much and de for next time. Let's go ahead and make it an hour earlier cause I think it sounds like that may have been. Let me just make sure my schedule is ok. Yeah. Next time, 3 p.m. Eastern Standard Time, we'll start this an hour earlier. So thank you guys so much. Take care.