How to Interpret a Chest X-Ray (Lesson 6 - Diaphragm and Pleura)

A review of how to diagnose a pneumothorax, various forms of pleural effusion, other forms of pleural disease, and pneumoperitoneum. A differential diagnosis for each of these findings is discussed as well.
Video includes the following images (among others):
Right pleural effusion, downloaded from Radiopaedia.org, originally provided by Roberto Schubert
Pleural plaques, downloaded from Radiopaedia.org, originally provided by Jeremy Jones
Presumed mesothelioma, downloaded from Radiopaedia.org, originally provided by Jeremy Jones
Pneumoperitoneum, downloaded from Radiopaedia.org, originally provided by Henry Knipe
Chilaiditi's sign, downloaded from Radiopaedia.org, originally provided by Hani Salam.
Sources for other images may include Wikimedia Commons, radiologypics.com, and Jose Caceres' wonderful radiology blog: Caceres Corner (blog.myesr.org/category/caceres-corner/)

[@shehabcomet]

Thank you Dr. Eric for the very clean organized medical lectures

[@sadmanjaoad6994]

Your videos are too good. Really love how you explain everything with practical examples.

[@sunving]

Thank you very much Dr Eric Strong. I cant thank you enough.

[@lakmaldesilva3864]

A great series of lectures. Truly interesting and beneficial. Thanks a lot.

[@peymangravori1981]

glad to hear you're doing better. thanks for the videos!

[@TCBRCB]

Great series a very good review, and it's sad and shameful if someone tries to prejudice such a useful work.

[@doctordre1979]

Thank you for the great work you do publishing these videos

[@kuhmpashun]

These are great! Thank you very much for taking the time and resources to produce these!

[@xxthunderbird46xx]

Thanks so much for teaching so well!

[@ManishJain-ds8rx]

Chilaiditi's sign, Pneumopericardium Pneumomediastinum.. awesomely explained 👍

[@u2bie1989]

Great videos! Thanks for your time and effort!

[@mynameismarsss]

Greeting from Thailand. Admiring your good work.

[@shrawankumar-tl6ed]

Thanks sir, for real clinically important videoes

[@MestreHoo]

yes, thank you very much sir! excellent teaching videos in general, really admirable work you are doing!

[@sthrallday]

awesomely done! Very informative

[@LittlePurpleBook]

Fantastic lecture.

[@olegalexandrov2167]

absolutely brilliant lectures. thank you very much.

[@doctormunesh1985]

big-big thanks 4 great videos ....

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Thanks a lot doc!

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[@Ani.DR.07]

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Amazing!

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[@malsoud100]

excellent

[@shalicgraw5280]

Ty!

[@davocreative]

I was looking for part 7 Doc. Good videos.

[@StrongMed]

Sorry, a few dozen computer viruses have slowed me down. I wish I had a budget to hire an IT guy! Part 7 (and 8-10) will hopefully be out soon.

[@davocreative]

Eric's Medical Lectures Thanks! They have been very informative. Keep the good work.

[@nawalkishorsingh4500]

Very nice

[@abulc.4996]

This is some next level work Professor

[@shif442]

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[@martindejesushernandezcruz1564]

Faltó hablar sobre la desviación del mediastino en el neumotorax.

[@adnanmalik6390]

pakistan loves you doc

[@somanyallies]

Thank you for this, excellent video. Can I ask, sometimes CXRs are well penetrated and actually you can see the posterior sulcus quite well..is it not possible to see a small pleural effusion in the visible lung below the superior aspect of the diaphragm? So it doesn’t blunt the costophrenic angle but is still visible? Thanks

[@MrStaunfenberg]

8:45 it could be a mass in midlle of posterior mediastinum ?? because these opacities is very well delimited in parenchima of the lung whith sharply and very well definited rims

[@pucka1024]

can you explain why vomitting and ashma causes pneumomediastinum ?

[@explainors5998]

Thanx

[@nastyakvashnina]

Thank you for great video series :) Could you please explain, why there is so significant deviation of trahea in patient with pleura thickening due to the tuberculosis (on 12:10)?

[@StrongMed]

Pleural fibrosis and scarring from any process will lead to an impairment in the ability to expand the affected side, since it decreases compliance of the chest wall/lung apparatus. This restriction will result in low lung volume on that side, which will pull the trachea and entire mediastinum towards it. The restriction might sometimes be balanced by a space occupying pleural effusion which works to push the airway and mediastinum away, but in this case, the restriction is clearly winning the tug-of-war

[@nastyakvashnina]

Thanks foe explanation!

[@manuelmandomo9904]

Hi I' d like to the thank for the videos Could you explain why are there two well defined lines orientated vertically on both lungs in patient with pneumopericardium (15:55) ?

[@dishango74]

seems to me like collapsed lungs, any radiologist opinion ?

[@venkybly]

Tq sir

[@caterscarrots3407]

That pneumothorax with a deep sulcus sign looks like not only a pneumothorax but also the GI tract pushing on the lungs and heart, collapsing it further. I can clearly see the liver and intestines on the chest x ray. Normally those only show up on an abdominal x ray. I can only think of 1 condition that would push the liver and intestines towards the collapsed lung. That is pregnancy. So I do believe that the first x ray that isn't showing just a pneumothorax is that of a woman in the third trimester with a pneumothorax.

[@StrongMed]

I think it has that appearance because of the combination of the fact that the radiology technologist included more of the abdomen in the view, and because it looks like a slightly lordotic film (i.e. one that is shot slightly angled from the feet). Impossible to know if that was done on purpose or not, but it does beautifully demonstrate the deep sulcus sign.

[@nimrahali3796]

Thank you, Sir, for great videos. Which book do you suggest for studying X-rays? Also, videos on Abdominal X-rays interpretation would be of great help.

[@StrongMed]

I have not personally read it, but Felson's Principles of Chest Roentgenology is by far the most recommended book for learning chest X-rays. A video on abdominal X-rays is on my list of topics to cover, but unfortunately I can't offer an estimate of when I'll get to it.

[@farrjaltoallah2293]

Thank you, doctor, for the nice explanation. I have a question. If the patient came complaining about the chest, always do PA and lateral?

[@StrongMed]

In general, if equally convenient, a PA and lateral is always preferable to a single, portable AP view. However, patients requiring chest X-rays are often acutely ill and when in the ED, it may not be clear that they are stable enough to be transported to radiology for non-portable films. And for patients on the hospital wards, it's usually easier to bring an X-ray technologist to them than it is to bring them to radiology. But for ambulatory outpatients, PA/lateral >>>>> AP.

[@bartoszwlodek8144]

Hi, Thanks for the great videos they do make learning internal medicine things easier. I was just wondering about the animation you have on this video (CXR lesson 6) that seem to show an AP position of the patient but you refer to it as PA (e.g. minute 10:25), is this correct or is it just a animation issue? I just want to be clear since I feel that this is exactly the type of thing that a consultant would ask me about. Thanks again.

[@StrongMed]

You're totally correct. The animation is obviously demonstrating an AP film, but the actual film is a PA one. I probably should have used a fully upright AP film instead in order to stay consistent.

[@bartoszwlodek8144]

Eric's Medical Lectures Thanks

[@LU-jz8ci]

Patient in first images has pleural effusion in the left lung as well.

[@Desiqnify]

So should you expire when doing a chest ray to view the pneumothorax better?

[@roshansah7872]

What is the shape of plaque you have mentioned?

[@StrongMed]

The three dimensional shape of asbestos-related pleural plaques are hard to visualize, but here's a description of them from Radiopeadia.org (radiopaedia.org/articles/pleural-plaque): "Pleural plaques exhibit the so called "incomplete border sign" on chest radiograph. The inner margin is often well defined because it is tangential to the x-ray beam and the adjacent lung is a good contrast medium. The tapering outer margin is indistinct as it isen face to the x-ray beam and the chest wall provide less tissue contrast. Calcified plaques is more obvious than non-calcified plaques to be identified. Locations most commonly encountered include posterolateral, mediastinal and diaphragmatic pleural. Appearance has been likened to that of a holly leaf, which thickened rolled and nodular edges."

[@AnithaS-yj3cq]

Sir i guess ribcages not to support i think to hold the heavier lungs in position eventhough alveoli present they are heavy they kept it in a tray in our anatomy hall

[@socaladv2557]

Would the resulting x-ray of the diagram at 4:49 result in an AP view?