EXPECTATION vs REALITY in RADIOLOGY - How to read a Complicated Chest X-Ray

What is up YouTube? Today we are going to be looking at the expectations versus realities in radiology as they pertain to chest x-rays. So hopefully you guys enjoy and let's get to it. All right guys so this first chest x-ray is the expectation x-ray when most people have when they go into radiology or when you're presented with cases as clinicians or physicians and other specialties you look at a chest x-ray you're able to pick out all the anatomy it's a nice young patient probably mid-20s standing up straight not sick at all just a routine outpatient chest x-ray everyone's able to look at this know it's normal have a nice lateral view to compare you see this you know it's normal you move on to the next one however let's check out the reality in radiology I like to call these kind of studies insta-close studies because usually if you're a first-year radiology resident as soon as you open one of these studies you close out of the study immediately you insta-close the study that way you're a poor upper level or senior resident or attending has to suffer through this kind of study but eventually you feel comfortable reading this kind of difficult study and you don't close it instantly you end up just reading everything that comes across your queue and that's what makes you a good radiologist but let's get back into it okay so this is the reality of radiology most of your patients are going to look like this when they are imaged in the hospital or in a hospital setting especially if you have an ICU we get a ton of x-rays like this per day and they can be very complicated and very daunting to look at to a beginner however search pattern is key and if you don't have a search pattern you can go watch my previous video I'll put a link up here and you can check out that search pattern go watch that one and then come back to this video okay so my search pattern is a little different when I read ICU or portable radiographs than it is when I do a normal outpatient x-ray okay so the very first thing I do is look at the lines and tubes when you have a ton of tubes and a ton of layering EKG leads and everything like this like this patient has it's very easy to miss a line or miss a malposition line or tube and cause the patient harm so that is my number one priority in these in these x-rays so the first thing I noticed here is a right subclavian approach impella device let's see if I can window in right there so as you can see this is the impella device coming from the right subclavian artery since I'm on the right already I'll keep working my way from the right so the next thing I see is a right IJ approach swan gans catheter which I'll try to follow this one down for you so here it is coming in the neck right here coming down it loops around through the right ventricle right ventricular outflow tract into the main pulmonary artery and they can advance these things and push them into the right pulmonary artery as well but this one's in kind of the neutral position all right next I'm working my way to the left we have a left central line so this is a left IJ approach central venous catheter coming down it's very difficult to follow down through here it ends in the right atrium next we notice this inferior approach ecmo cannula which I presume is a right femoral approach ecmo cannula and it is overlying the right atrium as well so next I look at the airway and esophagus so right here we have an endotracheal tube let's see if I can zoom in on this it's terminating right here this is this long radiopathic line coming down it's terminating right just above the clavicular heads next you can sort of see a nasogastric tube coming down you can kind of follow it down let me see if I can zoom in here you can see it coursing down the esophagus through the GE junction which you can't really see uh distally so you won't be able to comment on its location within the stomach all right so now we got the lines out of the way and the airway and esophagus let's go to the lungs over on the right hemithorax we have not one not two but three chest tubes as you can see right here one two three with their respective side ports this side port and this side port on the left you'll notice the left pleural pigtail catheter as well and I think that about concludes all the lines and tubes in this patient okay once I got all the lines and tubes out of the way and I know that they're in correct position I move to the actual lung field so what I do is I will zoom up just like I did on the prior x-ray example I will make sure there's no pneumothorax I can switch to inverted windows if I need to now this patient does have chest tubes in here so if I saw a pneumothorax it would possibly mean that the chest tube that the chest tubes are not working properly but I don't see one in this case and oftentimes it's very difficult to see a pneumothorax in these patients because they're hunched over and not sitting upright so the next thing I do after ruling out a pneumothorax is look at the actual lungs so this patient has really low lung volumes or hypo-inflated lungs you can tell by the elevated diaphragms almost obscuring part of the heart next I will check out the left lung field which looks pretty clear honestly I see no obvious pleural fusion down here moving to the right you can see that there is a nice tracking opacity along the right lateral pleura and into the costophrenic angle down here that likely represents a pleural fusion tracking along the pleura there's also a more focal opacity along the right minor fissure this could just be a loculated portion of fluid or loculated pleural fusion in this fissure or it could be an underlying mass or infection there are a lot of scattered diffuse opacities throughout this lung as well that could be secondary to the pleural fluid tracking the lung making the lung wet there's also probably a nice component of atalexis giving the low lung volume in this area however underlying infection is also a possibility and that depends on how the patient is doing clinically all right so once we got the lines and tubes and lungs out of the way the next thing I do is look at the mediastinum so I want to make sure there's no pericardial effusion or obvious enlargement of the cardiac silhouette make sure there's no pneumomediastinum or pneumopericardium the next thing I do is look at the bones and soft tissues these soft tissues look good I kind of glance around the chest wall and the neck you'll be able to see some soft tissue gas tracking along the chest wall if one of the chest tubes is malpositioned next you want to make sure there's no obvious osseous abnormality so these soft tissues and bones look good in this patient all right guys so that concludes this session of expectations versus reality in radiology I plan on doing this with a few other modalities in radiology as well so if you like it make sure you smash that like and subscribe button leave a comment below if I like it I'll respond to it otherwise I will see you guys on the next video