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Um for those of you um first time, sit back, relax. We'll um what the intention of this is to learn to read a chest x-ray. Um If this is your first time, please? Uh Deanie, right. There are prior lessons that are recorded that you can go back and watch introductory stuff. Um However, you never need to stop have those. I'm hoping once you finish this, you're like, oh my gosh, I really wanna, I, I wanna do this again or I wanna, I wanna learn more. Go back to the introductory ones and you can dive in. Um Today we'll start off with a normal chest x-ray. I will read that one to you all and then we'll start off with a case. This one is not gonna be so much a diagnostic mystery for you all. And it's a patient that came to me in my clinic on Monday. So a very fresh case should be a lot of fun to discuss. Um But it's a discussion kind of the complexity of the case. So should be, should be great. Um I will say we, we have a large audience all the time. So if you guys are drop dropping in questions in the chat box. My amazing colleague, uh Deanie, Deanie. Is it all right? If you try to let me know if there's a question I should try to tackle or answer. Is that ok? Yes, of course. Um And if I don't or if we miss it, um just email me your questions. There's my email, my email address is there email me like doctor G or if you guys don't mind, want my first name, I will also say we have a feedback form at the end. Um And we would love it if you fill it out after you guys attend a session. And one of the questions um leaves room for you guys to tell us if there's anything that you had questions about or that we didn't get to talk about so we can answer it that way as well. Yes, the whole, so the the purpose of this is to give a group of individuals access to, you know, uh medical education that hopefully is gonna improve your clinical situations, your clinical diagnostics, your clinical interpretations. And for many others, it actually is the shadowing that you would always have uh that you need to do um for your clinical, right? For premed or for medical school, etcetera. And so come for the hour, stay for the enjoyment and then leave enthusiastic and watch older lectures as well. Um And I say this because reading a chest x-ray really necessitates doing it over and over and over and over again. So with that in mind, we're gonna go ahead and start with the first chest x-ray and let me open it up. Let me put this on present your mode. Let me go ahead and share my screen. As I share my screen. I would like you all to drop in the chat box. I want two or three people to volunteer to come on stage. Um DEA, you're gonna be OK to let me know who's uh asking. Yes, you got it. All right. So I'll go ahead and read this chest x-ray just so you guys can get a sense of the, the reading and uh I'll, I'll do it as if I was put in front of my colleagues and then I'll go over ultimately what this means. So we have here a 48 year old patient. Um her chest x-ray was obtained for the purpose of shortness of breath. So reading this chest x-ray, what I oh let me get rid of this the way I would read it if All right, the patient is not rotated as obvious using anatomical landmarks of the spinal process as I go down the trachea and finding the Carona, uh it does not look splayed and it does not look shifted, implying the mediastinum likely is relatively unremarkable, reviewing the pleural space. First, I go to the costophrenic angles, both of them are apparent and then I go to the top to the ac both of them look present um without any hi or indications of a pleural effusion or a pneumothorax. Next, I go to the hilum um on the right side, it looks translucent. It looks uh normal in size and on the uh left side as well, it looks normal in size and translucent lucent. Next, I evaluate the heart, the left ventricle um appears um uh unremarkable. It is not uh enlarged and the left atrium there seems to be a two slop approach. So a two does not look enlarged. And the right ventricle as well looks relatively unremarkable. So the heart looks of normal size as for the lungs, they look to have an appropriate distribution of of their vasculature. Um much more dense at the bases and much more dense with the closer the proximity to the high lung. So overall, no infiltration, no consolidations, no um uh uh drastic uh pulmonary findings. So overall, this is a normal chest x-ray. So doing that what I go through and again, I really encourage if this is your first time, if this is your first time, go through the prior lectures, right? Don't count on these lectures. Moving forward to be the intro to 101, they're really meant to kind of reaffirm prior discussion. So going through this, the first things I look at are these spinal processes here. What I'm looking for them to be is looking like almost like a tear shape, right? That implies that the patient is standing upright and without any rotation, the reason why you wanna make sure the rotation is not there is. So it doesn't mud the way you interpret a chest x-ray, right. If my left shoulder is sticking out much more forward and more prominent, my left lung will look smaller than my right lung. And so is that a real indication of a pathology or is it just an error on how the chest x-ray was obtained? Next, I travel all the way down until I get to the car. The corona is an anatomical landmark where the right and left bronchi split. What I'm looking for here is a less than 90 degree angle of the carina. So it implies that nothing is underneath it, pushing up against it. So if it's more than 90 degrees more of like an too angle, then you would say the CNA is splayed. The number one thing splaying a cry is usually an enlarged heart. Also, I'm trying to make sure the cry falls in between the vertebrae boundaries. As long as it falls in between that, it implies that nothing is shifting. The c uh the mediastinum, the anatomical space between the right and left lungs, the shift can come from the lungs or can come from the mediastinum. So again, you're using it as an anatomical landmark. Next, the pleural space, the space surrounding the lungs. Well, lubricated with about three mL of fluid and a allowing the lungs to slide with each breath. You take this patient's costophrenic angles are perfect. Everyone take mental pictures. This is exactly how they should look. The costophrenic angles are only seen on chest x-rays, not on chest ct scans. A ct scan as we will get to in later lectures is a three is an appropriate three dimensional representation of our body. Chest x-rays are not chest x-rays are two dimensional. So it takes a three dimensional object and flattens it. And so you get these angles, it's where the diaphragm and the ribs meet. They should look like somewhat like vampire fangs, not like a wall versus tuss. And if they're absent, it usually means there's about 300 mL of fluid in here, blunting it. So and then we gotta discuss how the fluid came next. I go to the top because not only can fluid get into the um pleural space, but so can air, air is less dense than fluid. So it travels up and the way air would present outside of the lung in the pleural space is actually pitch black. It's pitch black as the air out here. So you're looking for something that pitch black to be at the apex, everything looks fine. So as I imply that the pleural space looks unremarkable, next is the hilum, the right hilum is the only one you can see fully and it takes on kind of this kidney shaped beam shape, um anatomical figure and it should be rather translucent. You, you should be able to see relatively through it. The left not you don't get the full hilum just because the heart will eventually block it, but it should still be rather translucent. They both are translucent and look normal shape. Next is the heart left ventricle is here, left atrium is about here and the right ventricle is about here. A normal size heart means there's a space between the heart and the ribs and the slope of the left atrium takes on a different slope than the left ventricle. It's a two slope approach. And I read that as a normal size heart, technically normal size left heart, the right side, if it's enlarged, it's usually gonna balloon out. And usually this angle is not that loses this little divot right here. The right side of the heart, I will tell you guys, it's a little bit more of a nuance of how to read it. So don't feel bad. That's one that I'll bring up. But I'm not gonna put you guys on the spot to try to find the right ventricle if it's enlarged or not. And it's a different pathology if the right side of the heart is big versus the left side. And then finally we go into the lungs and the way I look at the lungs is I zigzag back and forth, back and forth back and forth, I zigzag back and forth, back and forth, back and, well, that's sometimes it's hard to drive this thing and then I zig zag literally across, back and forth, back and forth, back and forth, back and forth. Now let me get rid of everything. I just drew because what I'm looking for in the lungs is a relative uniformity from top to bottom with an asterisk, right? The top part of the lungs are gonna have less obvious blood vessels. That's what these streaks than the bottom parts, right? Cause I said earlier, fluid is heavy. So there's gonna be a lot more blood vessels at the base of the lungs just because gravity pulls that also the blood vessels should be much more obvious back to the middle part of the lungs, right? Cause the closer you get back to the high lung where all of these blood vessels came out of as did the airways, as did the lymphatics, they're much denser just because they're clustered together, right? But as they have the opportunity to branch out further and further away, they, you start losing them by the time you get out here, that's a normal distribution, that's normal. So this patient is a normal chest x-ray. Also, if you're wondering what the heck is below the diaphragm, this is her little gastric bubble. So she may have just eaten, may have some things cooking. She may be ready to burp if you're wondering what these circles are here and here that is part of the patient's bra. So, yeah, in case you're wondering these other findings, what they could be. So with that in mind, let me erase this. And before we get to the me, before I get to the case, I will pause momentarily and see if there's any questions. Is there any questions? Anything immediate to answer? No questions. We do have our volunteers though to join the stage whenever you're ready. All right, bring them on. Who is it? I'm excited. OK. Awesome. I'll go and invite them. Yup. Doctor Addie, you can hear my inspiring voice. That's very kind. Um But yes, watch the recordings later. My friend, I apologize. Um Sometimes II I don't know how to troubleshoot. So, but you will get these recordings and you have my email address if you should ever need me. All right, we got one person. Be a few more. There we go. Oh, all right. So we got Gabriel Maya and Argon Maya. You've done this before with me, haven't you? So I feel confident. Look at you. I remember the first time you did this. You're, you, you always come across confident, but now you're even, you're like, I might as well be a doctor. Um Maya, where are you coming from? Where are you? I'm in Seattle, Seattle, Washington. So it is what, like 2 16 right after school? All right, my friend. Thank you for joining Agum. Where are you coming from? Uh Hello doctor. Uh I am from Jordan. Excellent, my friend. You know, thank you for being here uh for being here, my friend. Thank you. Um No worries Gabriel. And where are you coming from? Yeah, I'm from Georgia. I've actually been on before. I just had to take a big long break because my life got really chaotic for a while, but it's nice to be back. I'm coming from just a couple hours north of Atlanta. Excellent. Excellent. Just because it is an international crowd. Georgia, the state, not Georgia, the country, but good to have you back. Ariel and Maria. Where are you coming from? My friend. Oh, hi, doctor. I am Marlo Shiga and sorry. It's ok. It's ok. I am attending uh first time uh from Hinkley, Ohio in good old state of Ohio. Oh, Ohio has a special place in my heart. Well, welcome Marla. I apologize the way. Oh, please please your first name? Like white lettering and it's where are you? No worries. I'm really excited. Uh because I just graduated from acute care nurse practitioner program. Yes. And I had two rotation in IC U and uh I'm kind of familiar I had awesome preceptor attending, but I am really looking forward to your mentorship and to the lunch, of course. So a couple of things that I wanna make clear, this is a safe space. Everyone here. I don't care if you are a Nobel Prize winner or a senior in high school. This is a safe space. Get them, get things wrong here. Say it out loud, right? And I mean this because you're not here to wow me, you're not. I think the world of you guys already, you guys have my attention. I will always support you guys. I want you guys to wow the people you go out there for, right? Whether it's work or it's shadowing, make your mistakes here, learn from them, go out. So don't feel pressured. And the other thing that I really request um from Agam Tamala to Gabriel to Maya, especially Maya. You've done this with me. What I always ask you guys is don't try to fancy me with any medical lingo if you know it. Great. Don't worry about it. But if you don't then just describe what you see. I don't care if you're really imaginative. Like I just told you costophrenic angles to me look like vampire fangs. I'm hoping that's something you guys know what it means. But just tell me like one of the beautiful things about being a good physician, a good clinician is the ability to describe whether you use the medical lingo or not. Doesn't bother me, right? It's like speaking right? Can you uh get your point across? I don't need you to use like IQ high IQ level sat words, vocabulary just tell me just describe what you're seeing. So when I'm calling you guys. That's it. Just to describe that. Don't feel pressured because this chest x-ray is gonna be busy. So, um let me go ahead and throw it up and then what I'll do is Gabriel, I'm gonna have, I know you've taken some time off, but I'll have you first kind of just tell me where the trach uh the spinal processes are. And you guys are wondering what the spinal processes are. You can feel that just take your hand, put it around your back, that the spine that you feel is your spinal process. That's what we're talking about. If you've ever seen a to can, if you've ever seen it, it's a bird. I've said this before and, and there's plenty of international people who are like, I don't know what that is because in America we have fruit loops, the cereal, but a two can remember it's be goes out like this. And so if I, you stare at it from the front, it looks like kind of this cylindrical shape, kind of a tear. But from the side, it looks elongated and that's what the spinal process is. So if I'm steering it head on, it's nice and uh tear shaped. If I'm staring it at the sides of the patient's rotated, it looks like a two cans beak. So that's it. So Gabriel, you will tell me if the patient is rotated or not and then you're gonna dive into the Mediastinum with me. Maya, you're gonna go over the pleural space and that we'll leave it at that. Ok. Agam I'll come to you to weigh in on the hilum and the heart and then Marla, you and I are going in for an adventure of the lungs. Is that ok? Awesome. This patient we're about to dive into is a 52 year old who's coming to me due to shortness of breath and the oncology team is requesting my services because they're struggling to have the patient relieved of his dyspnea. We just did a procedure on the patient um several days prior to Monday's clinic visit where we placed a pleural um pleural catheter. So let's dive into this and we'll go over the complexity of what this patient represents. Oh, let me just e OK. All right. Let me share. My screen patient has non small cell lung cancer, by the way, not that it's, it's relevant, but it's, you know, either way, let's go into the case. All right, Gabriel. Can you see the screen Gabriel? All right. Let's go to the actual case. This is in it. All right, Gabriel, this is the case. So your first job is to tell the audience if you think the patient is rotated or not. Let me circle the spinal processes for you. What do you think is the patient upright in a good position for us? I think the patient's upright and not rotated. Correct. Yes. Not rotated. Excellent, my friend. Fantastic. Next, you're gonna dive into the Mediastinum with us. So first things first for to the audience for things that are going to be a play of gray versus white, OK, gray versus white, like the trachea in comparison to its background around the mediastinum is a great versus white phenomenon. If you really wanna see it, best, do not lean forward. When you start leaning forward, you lose sight of the grayness and everything kind of blurs as a white thing. So one of the things I love doing on rounds in the intensive care unit is asking the intern to point out the Rya, every intern, every intern leans in, every seasoned resident, every seasoned nurse practitioner, every seasoned fellow leans back. When you lean back, you can get the gray to white. Um differences really becoming much more clear. So I say all this to you, Gabriel, tell me to, to stop drawing when you think I'm at the Carina, right? I'm going down the trachea. Tell me when to stop. I remember the Carona is where? All right. Excellent. Yes. So here is the Carina and I'll draw it out for everyone. All right. Sound good. Yeah. What do you, what do you think of this angle right here? Do you think it's less than 90 degrees? It's acute? Yeah. Yeah. Perfect. It is an acute, it is not splayed. I will tell you though. And this is just my clinical just talk. I'm just saying this out loud to you guys. The left bronchi flattens out much faster than I would expect it to nonetheless. Um That's me just bla it. All right. Next question to you here. Let's round out the bronch, the uh trachea. So you can see the cry. So, do you think the cry right here is staying put in between the boundaries of the vertebrae? Yes, it is. All right. So to everyone here, the Mediastinum is the an anatomical area between the right and left lung. It's a negative space and in it is your esophagus in it, is your heart in it is the thoracic aorta in it is a, is your thymus if you're younger. And so I can't really get a good picture of those really. It's just the heart and the thoracic aorta. I can somewhat see this is the aorta aortic knob right here popping out. But otherwise I can't really tell anything else. Like there's no way I can really tell you what things look like. So what I'm using is the RYA to make sure it's not shifted if it's shifted and it tells me there's something happening to the Mediastinum either as a direct insult or indirectly. The other thing I'm looking for is to see if it's splayed. Like if something's big here pushing up against it, then uh you know, I'm usually thinking there's an, an uh something in the anterior mediastinum doing that oftentimes is the heart, the heart's a horrible culprit. All right, Gabriel. Nicely done, my friend. You're not done where I'll bring you guys, you know, stay on stage but well done on your part. Next. Maya, you ready to go into the plural space with me? Yes, I am. All right. Maya, we'll start, we'll start top down, we'll start top down. Ok? Maya, let's go to the right. We'll start on the right first. OK. All right up here in the apex of the, of the lungs above the clavicle, the clavicle is this bone right here. Do you appreciate that? That apex of the lung is still looking rather grayish, you know, it looks no different than it looks here. Do you agree to that? Uh Yes. Excellent. So no obvious dark blackness to you. You would say no air up in the pleural space on the right side, correct? Excellent. Next, let's look at the costophrenic angle on the right side. Now, the caveat here is, unfortunately, it's a little bit cut off, but you can see the formation of it. You can see, you know, kind of this angle taking off right there. So, Maya, would you agree that you can see the costophrenic angle on the right side? Yeah. Based on what I can see in the picture, I can uh think it's present. Yeah. OK. All right. My friend, can you and this is just a yes or no question. There's not a maybe there's not. It's yes or no. Don't even add a hint of, of, of questioning this. I want confidence. Just dive in with your confidence. If you're wrong, we'll go over it and I'm still high five. You know, I think the world of you, you're welcome to be wrong here. But the left side on the left side. Do you see a core mechanical? No. Awesome. My friend. I agree with you. Now, Maya does the left apex up here. This is just a yes or no question, yes or no question. Does this look the same as this? Um I don't see your markings, but I'm assuming you're seeing the right versus left, the left looks a little bit more opaque, right? So the left more looks more opaque, whiter than the right. It's not even dark black like I would suspect that there's air there. It looks more opaque, looks like more whiteness to it. Correct. Yeah. All right. So this is great, right? And, and if you were my intern, I would expect you to say that like, hey, when I'm reading the apex, there's some abnormality here. It's much more opaque than I I would expect it to be awesome. So right off the bat, you have identified something happening to the pleura both at the base cause the costophrenic angle on the left side is gone and at the top, the right apex is opaque. All right, nicely done. Maya nicely done Gabriel and then next we have it. Let me uh it is uh is it Abram? Yeah, Doctor AAA actually my friend. All right. Let me go back. Hold one. I think I shoot, hold on. All right. Can you still see my screen, my friend. Yes. Excellent. Coming from Jordan. Thank you so much my friend for, for taking the time out of your day to be with us. And um tell me where you're at in your journey of your career. Are you a physician? Are you a student? So, yeah, I have been graduated Vicent. I am doing my internship here and uh yeah, I am doing uh these classes with you with the doctor Sau uh to just uh increase my experience in this field. Excellent, my friend. Excellent. Well, if you love this and if you, we could ever recruit your talents to the States, send me an email, my friend. Happy to help. Thank you. Um Thank you. All right, good, sir. All right, let's dive into the hilum. So tell me again, tell me just from your standpoint, what do you think of the hilum on the right side? Does it look rather translucent? Like you can kind of see through it? Yeah, it's a trans I can see through it and it's not, it's not big. No, right, the right side I, I would say is normal. I'm ok with it now. Good, sir. I'm tricking you here a little bit. This is all you got of the hi on the left side. So if you were my intern, you would just say, look, I can see somewhat of the hilum, but I can't make anything out of it. We are you, I'm, I'm adding words to you. But are you ok with me saying that I, I agree. Yes. Ok. Now here's the kicker. We're gonna talk about the heart and again, still a little bit unfair. but you know, let's, let's do our best because there's a lot happening on the right side. Anything you wanna make a mention on the right side and again, I, I'm putting you on the spot. Keep in mind there's nothing, there's not a wrong answer here. Anything you wanna comment on the right side, like if, if you're on rounds with me and I asked you to come out comment on the right side of the heart, what would you say to me? Ok. The right side, uh looks fine. Um uh Yeah, yeah, I can find the specific lines without any sloops. Yes. And you're getting that little sliver right here. Yep. All right. What do you make of the left side of the heart? Um I can see the border of the left side. OK. So right off the bat, 11 comment might be, you're right. There's so remember this image here, right? There is an obvious space between the apex and the ribs, right. Correct here. There's nothing right. The heart looks like it extends all the way to the ribs. So you 100% could say, should say. And I would say there's a potential for cardiomegaly here. Now. Is, is that, is that fine if I putting, uh I'm putting words in your mouth because you're coming up with these conclusions already. Is that ok? Yeah. Yeah. Yeah, that's ok. All right. Next cause Marla is gonna go into the lungs with us. So we made a comment about the lung, the, the heart. Good, sir. I'd like you to do me a favor and I actually want everyone to do me a favor. OK? We talked about the lean back in order to make grayish things and whist things stand less out or stand, stand out more. Sorry. So don't put your nose to the computer screen. All right, if you pull yourself back a little bit, right? Maybe at an arm's length here, I'm gonna go to the next slide. Oh Hold on me, my friend. Can you begin to see this? Look, I'm gonna kind of outline it for you. There is one border here. It's gonna calm down. Can you see what I'm drawing out? I'm dr this is a tube. Can you? It's, it's very hard to see. It's very hard to see, but this is a tube that I'm outlining for you guys. This is the pleural catheter that I placed in. Can you appreciate that? It's hard, right? Let me get the lines to go away. But on this x-ray, it's there, it's a little bit more obvious above the heart. But these boundaries right here, this one right here and this right here is meant so on a chest x-ray, it could stand out a little bit and you can kind of see even more of the boundary down here. I'll get these right, these lines to go away, but this is a catheter placed in here. Can you appreciate that? Good, sir. Are you still there? Yeah, yeah, yeah. So, yes, perfect. All right. So that's the catheter that I placed in there for this patient. So you're good. You're good. Thank you. Good, sir. So, you know, maya, you already made a case. Hey, there's something happening to the pleura and my, the reason I wouldn't hit this point home is that if you're dealing just with an enlarged heart, you should still somewhat be able to see the costophrenic angle popping out somewhere here. You don't see that at all, right, the translucency you see here is really because of the um catheter that's placed there. So this would be the heart may be enlarged. I don't like honestly the fact that there's so much pleural effusion and there's a pleural catheter in there. I have nothing against someone saying potential cardiomegaly but confounded by clearly excessive pleural effusion, not only excessive Marla will get you to go into the lungs, but what Maya picked up earlier about the apex being discolored is because there is a pleural fusions going actually all the way up. This right here in the apex is actually thickening of the pleural lining. So this cancer has really spread a lot in the left lung. So awesome, nicely done so far, guys, Marla, you're last. Are you ready, my friend. Yes, sir. All right guys, this is a complex case. I get that. So if you're picking up on these things, great, really, what I want your eyes to kind of navigate with this is the ability to at least see the shapes that we're pointing out. Marla stick with the right lung with me real quick. Zigzag zigzag zigzag zigzag zigzag zigzag zigzag. So a couple things with the right lung that I'll ask you. Do you appreciate that the, the streakiness of the blood vessels at the base are much more obvious than the top. A Yes, perfect, my friend. So, with that affirmation though, you still appreciate that there is some level of uniformity of the streakiness of these blood vessels that all tend to look like they're ending mid lung. Is that correct? Correct? Excellent. And they're not going all the way to the border. So the right lung, Marlo, would you agree? No traits, no opacities, no consolidations. Is that correct? Correct? Awesome. Left lung, Marla, you're somewhat at a disadvantage. May and Agum both confirm that there's a pleural fusion with a potential cardiomegaly obscuring here there is pleural thickening up here. That's the opacities up here. And so all you're left with is this liver of a lung correct? To make any comments. So, in that part of the lung, any comment that you'd like to make uh on that part of the lung? I do. I, I can distinguish the blood vessels. Yes. And how they are diminishing as we get to the um sides of the thoracic cavity. Perfect. So that's the liver of the lung you would say is a normal lung, correct? Yes, perfect. So for everyone reading here, putting it all together from Gabriel down to Marla. You know, the way I would read this chest x-ray, you guys have hit it all out of the park, the patient, you know, right off the bat, the patient is not rotated. You can find the Carona does not uh appear to be split and it does not appear to be shifted. The right costophrenic angle is apparent. Even though it's slightly caught off on imaging, the left is obscured. The right apex is present. The left apex seems to have some level of an opacity, opacity present. In regards to the hilum, the right hilum looks fine and normal. The left hilum is there's a sliver of it that's apparent in regards to the heart. The right side, the right ventricle looks normal. The left could have some apparent cardiomegaly. But the confounding picture here is a potential pleural fusion that's poorly drained because of an obvious catheter that is placed in the patient. In regards to the lungs. On the right side, there's no infiltrations, opacities or consolidations and on the left on the piece of the lung that we can see. Same comment, no infiltrations, opacities or com consolidations. Infiltrations just imply streaks of the lines. So uh an infiltration is these streaky lines that you're seeing here, but they go all the way to the end. That's an infiltration. An opacity is, you know, something filling up the lungs, but you can still see through it. And a consolidation is a complete wipe out in the lung. So that's what we got in this patient, right? I outlined the chest tube again. Let me tell you guys what's going on in this patient. And this is a really good case. Um Hopefully for you guys, so you guys can all see me. Mhm Good. So this is a case I'm going to put in here lung entrapment versus trapped lung. Now, look there will be doctors out there, there will be clinicians who will use these turns synonymously and they're really not, they imply potentially the same process, but at different parts of the spectrum, a lung entrapment implies that something in the pleural space or something in the lungs has caused it to collapse and is keeping it from re expanding and that tends to be more of an immediate active inflammation. These are patients experiencing chest pain, not because of pain receptors in the lungs. Remember you've been here in older lectures, the lung itself, the lung has no pain receptors. You drop a needle in the lung, you're gonna cough, you're not gonna say ouch, if you're experiencing pain, it's because of the pleural uh pain receptors. The pain receptors found on the pleural, both against the uh chest wall and the, that's wrapped around the lungs. Those feel pain. So patients with a lung entrapment are having an active process causing discomfort, breathlessness, dyspnea. These are the patients when I put in the chest tube, they get some immediate relief from the drainage. But the frustrating part is the lungs still is struggling to expand in this patient's case. It's not just because the, the cancer has really coated the lung. It's also because there's a tumor in the airway itself. So keeping air from coming in, you know, with a deep breath to help expand lung entrapment, we wanna be as aggressive as possible to help this guy's lung expand. It's tough. The first process is exactly what we are doing. We place a catheter in him. He drains it every day and we snap x-rays to hope and pray it's expanding. This x-ray looked horrible. This x-ray actually looked unchanged from the day we placed the catheter to now. So what we'll end up doing is trying again. So Hussein, a collapsed lung is, is really more of an umbrella word. Of like, well, what's cause it to collapse because you could have a pneumothorax, atelectasis. Sometimes it's called a self collapse. So a collapsed lung is kind of just a umbrella word that lung entrapment and trap lung can be part of. But go apply a more very specific pathology that's happening. Trap lung is the outcome. You're trying to prevent a trap lung is a permanent lung that's stuck, can't get it open again. It's done. And at this point, re it's just the plea, the pleural s the pleural lining, meaning even if I remove the tumor, nothing, nothing is happening inside the lung in a trap lung. It's all about the pleural space, meaning it's so fibrotic, it is keeping the lung from reopening and you can place all the catheters you want in the world in a trap lung because of the chronicity of it. Patients actually don't feel symptoms. They're not coming to me saying I'm so short of breath. No, their lung has just, it's like, all right, look, you lost this part. You gonna start adapting to it. I'm not saying that's a good thing. Hear me out. The pleural space is a vacuum. It's a negative space. So fluid is always constant being drawn in. So guess what happens to that space? Since the lung can't expand there, there's a constant pleural fusion that the patients have. Why? That's a big deal is maya, I'm gonna pick on you, maya, where would you expect to see algae growing on water in a river that's flowing, right? Not, yes, on top. But, but which body of water in a river that's constantly moving or in a pond? That's just sitting. Hi, ladies and gentlemen, bacteria infections. If you want them to grow in your body, they gotta grow somewhere where a pocket of fluid sits and never gets recycled. It just sits there. This patient if we don't, if we're unable to expand his lungs, yeah. He might not feel symptomatic from the trap lung, but he will, with every infection, every infection he gets, that would be a bronchitis will end up getting into that pleural space. We'll tap it, we'll probably pull out some pus. But this is tough too because if you try to put a catheter in a trap lung, that pleural space is so fibrotic. It's tough. Like I've, I, I pounded one in before. It's tough. It's hard to get through. Uh Sometimes I even ask my surgical friends to do it. So, in this case, tonight, what you guys are learning about is the difference between a lung entrapment. It is implying that something could be in the pleural space or something could be in the airway itself or a combination of the two that is keeping the lung from fully expanding during active inflammation, right? It's an acute process. So, meaning I'm not taking this chance. I, I'm hoping we're catching this patient at some point in time to help the lung expand. Now, the catheter itself is not gonna do it. I need that inflammation to shut off. The challenge is that inflammation is brought on by a really advanced cancer that you already saw on imaging traveling up the pleural space all the way up to the apex. He's a stage four nonsmall cell lung cancer patient. So it the odds are not gonna be good that we're gonna shut off this inflammation. So my suspicion is even with the chemotherapies that we're throwing at him as well as the catheter, this is gonna go down the path of a trap lung. Um You know, even with our best efforts, but that's what you always try to prevent. You try to prevent a trap lung, you try to understand the cause of the inflammation and then at the same time you provide the anna uh anatomical interventions necessary to drain the fluid while trying to shut off the inflammation at the same time. That's the lesson tonight guys. Was this good? Did you guys like this case? I'm trying to be a Debbie Downer. Thank you. Thank you so much. Thank you, Arkham. Did you have a good time? My friend from Jordan. Yeah. Yeah. Absolutely. Excellent guys. We're gonna try to be doing these twice a month um for you all and my next one will be October 4th. I'm gonna take the last two Wednesdays off in September October 4th. I'm gonna try to have doctor Tony Chang join us. He's a radiologist. Don't let that scare you guys, right? He's very friendly. And again, for those of you who have met him before on this channel, one thing I always make the case is reading a chest x-ray is art. We all read it in various ways. He's gonna come up with a methodology that's gonna be very different from mine. But we all get to the same outcome, right? So if you all get a painting, you may interpret it differently, but you're all saying the same thing, it's the same concept. Honestly. What we're just trying to do is just not miss anything. So it should be a lot of fun. All right, ladies and gentlemen, I bid you ado Deanie. Is this ok? If we go ahead and end my Yes, of course. I was just gonna say, since you guys have an extra week off, it's a great opportunity to go back and see some of our recordings, especially for those of you that are new. Excellent, excellent. And uh Doctor Addy, I uh this is all I do, but if I do anything else, I'll keep you guys updated. Really appreciate you guys, Mara. Do you have a question? Yes, I do. Sorry, I couldn't, I couldn't find the button to raise my hand up. Um Would you, would we be getting emails and notifications when the next session is to sign up? I apologize. I'm new. No question on med all. If you follow our organization, then you'll get notifications every time we add an event and any changes in everything. Fantastic. Thank you. No worries. All right, good people. Enjoy your September. Take care guys. Bye. Thanks. Bye.