 What is going on everybody on YouTube? Welcome back to my channel. For those of you who are new around here, my name is Michael, AKA Dr. Celini and I'm a fifth year interventional radiology resident physician. On today's video, I wanted to discuss the coronavirus and COVID-19 x-ray findings. And I was planning on making this video anyways, but then I saw this video that CNN posted about one of their main correspondents, Chris Cuomo, who is also the brother of Andrew Cuomo, the governor of New York. So it's been very public over the last few days that Chris Cuomo has been diagnosed as positive for COVID-19 and he's kind of been giving an update throughout his course in disease progression. In this particular video I saw a few days ago, they discussed Chris Cuomo's chest x-ray findings and I feel like I could do a better job explaining it than they do. So we're going to go through this video and use it as a way to kind of discuss the chest x-ray findings of COVID-19 or the novel coronavirus and go from there. So let's go ahead, get into it. So like I said before, Chris Cuomo is a CNN news correspondent, which I see him all the time on this channel. He is the brother of the New York state governor, Andrew Cuomo, which I actually didn't put two and two together for a while, but that's a different story. Last week he tested positive for COVID-19 and they've been interviewing him almost daily about the course of his disease and he does a pretty good job of opening up about it. So I'm going to start the video, I'll stop it intermittently when I feel like I need to interrupt. I feel better than I deserve and I now know that I can't just take it from this thing. That when the fever spikes, you just want to curl up in a ball and stay there for the next six, seven hours and you can't. You've got to bundle up your clothes, you've got to start drowning yourself in fluids, you've got to take your Tylenol and you've got to get after it. If you don't want it to get into your lungs, you've got to force yourself to breathe. You've got to get up off your ass, you've got to walk around, it hurts, you don't want to do it, everything in your body is telling you not to do it and it's lying to you. So I really like what he's doing here, he's staying positive, he's staying active and he's mobilizing, which is fantastic. You don't want to just lay in bed and let this disease take a hold of you if you can help it. And it's lying to you and I know that now and the more I do, the more I push myself to do, the better I'm getting. So I'm going to take faith in that for now. I know I'm not through it, but that's good. Let's talk about the collective though for a second going up. So he's actually onto something with this because when patients lay flat in the hospital bed on ventilators, the actual back or posterior of the lungs do not aerate as well because they aren't expanding because that is the dependent portion of the thorax. So as you've seen in many cases with this virus, we actually prone the patients and allow the posterior or back of the chest to expand, which allows those airways to kind of open up. If you don't allow those airways to open up, that lung becomes collapsed or atollectatic and can cause that infection just to kind of sit there and not resolve. So I'm going to fast forward this part because they're just talking about data and whatnot. So I think let's fast forward to the part where he starts talking about his chest x-ray. Now, in terms of where we don't want to go from, if you have coronavirus in most of the cases, your big fear is that it's going to get your lungs. That's what it wants. It wants your lungs, this thing. So this... Yes, this virus does love the small airways of your lungs. This weekend, I had the fever start to go down a little bit and I started to feel it come into my chest. So I went to get a chest x-ray and I want you guys to see this just so you can see what we're looking for and not. Okay? So first and foremost, this is just a normal frontal radiograph, as we call it. It's not labeled PA or AP. Probably a PA radiograph given the way it looks, but let's see what they say about it. Doc, obviously you understand this. What we're looking for in the lungs are big white areas. What are the terms that people will hear? What are they looking for and what do you see in this mighty expanse of chest and front? So first and foremost, Sanjay Gupta is the neurosurgery physician right there. He is the chief medical correspondent for CNN. He's all over this channel and you've probably seen him everywhere. He is neurosurgery trained and has been out of practice, I think, for a little bit now. And I'm willing to bet he hasn't actually looked at a chest x-ray in a very long time because neurosurgeons don't really look at chest x-rays that much. That's not in their specialty. So we'll see what he has to say about the chest x-ray. One of the things that you'll hear is infiltrate. So if you are a longtime subscriber to my channel, I did a video on where I read a normal chest x-ray versus a really complicated ICU x-ray and I said I don't use the term infiltrate and still to this day I did questions about why I don't use that term and this is a perfect example. So I don't use the term infiltrate because it implies infection. When you say there is an infiltrate on a chest x-ray, it's basically saying that there is an infection there or that's how people interpret it. The problem is that many things on chest x-ray look like infection that aren't infection. So if I were to call something an infiltrate implying it's an infection and it was an infection, that would be a misdiagnosis. So in short, anything that opacifies the lung fields on chest x-ray does not always have to be infection. Other things can also opacify the lung fields on chest x-ray such as lung malignancy or cancer. Also fluid can also do the same thing. Hemorrhage, protonaceous material, et cetera. So just remember that the term infiltrate is not used by me or anybody I train with because not everything on chest x-ray is an infiltrate or an infection. Do you have an infiltrate in your chest, in your lungs? That's basically a collection of inflammatory fluid. I would look for those in areas where the black areas are the air in your lungs. I would look for some of those black areas essentially be filled with white spots. And I just want to make it clear for the audience, I'm not diagnosing here from afar. In the middle of the chest x-ray there, you can see you have a little bit of infiltrates and you can see this on. So again, this is really difficult to see because I'm looking at a picture of an x-ray on a news broadcast and then I'm also watching on YouTube so it's not exactly ideal for diagnosing. However, I don't see any infiltrate on this x-ray. This is a lateral projection here. This is the sternum up here. This is the back, as you can see here, the spinous processes and the vertebrae here. This is the side view of the heart or the lateral view. So again, this x-ray is taken from the lateral projection which means the beam is going this way and that's why you can see all the ribs like this right here. So I think what he's seeing is the overlapping ribs and normal pulmonary interstitial vasculature that is causing this infiltrative appearance. But this is pretty clear from what I can see. This is the side view now. You'll see in the sort of middle of this, the film there is your spine. You see those sort of domino looking bones, awfully small I might add. I don't know what he means by small bones. These look like normal vertebrae to me. They actually look pretty good. This is for a big guy like you. In the middle of the spine there and then in front of that is the x-ray of your lungs. So I think what he's saying is in front of the spine is the x-ray of the lungs. But what most people don't realize is that the lungs actually go out well past or well posterior or behind the spine here, as you can see right here. So this is the back of the lung here on both sides and this is the spine column right here. So you can see there's a good distance between the spine and the lung. So you're looking at it from the side here. So the lungs kind of expand posterior to the spine. It looks pretty good. Maybe a little bit of fluid buildup there. I don't see any fluid buildup. If there were to be fluid buildup, there would be some blunting of the caster-fronted angles here and you can't really see all of them. So maybe there is like a scant amount of fluid there but I would never call that. Pneumonia, which is what they're trying to diagnose. Pneumonia is not just diagnosed by a chest x-ray but it's one of the tools that doctors use to diagnose. It looks good and again, just to make it clear, I'm not diagnosing Chris via television here but that looks pretty good and I looked at that more closely on my computer today. Right, look at how different pulmonary people look at it. They take very close readings because it's either really pneumonia or it really isn't and they expect me to have infiltrate because I have the virus and I have to tell you, it is scary to have your lungs go up there and see this stuff and be like, what is that? What is that smoke in there? And they tell you, yeah, it's the virus. So this is exactly why I wanted to do this video in the first place because chest x-rays are not really good at diagnosing COVID-19 or novel coronavirus and this is the perfect example for that because Chris Cuomo has been diagnosed as positive for the virus. However, his chest x-ray is pretty normal and the reason for that is because often in many other disease processes as well, COVID-19 will actually lag on chest x-ray and what I mean by that is it actually takes a while for the virus to accumulate within the lungs and actually show itself on chest x-ray. So as you can see here, you can test positive for the virus but have a normal chest x-ray, which is why chest x-rays are not really that valuable in the beginning stages of the virus. They can, however, be useful in tracking the disease progression. So it looks like Chris Cuomo is doing well so far. I wish him the best. It's no one wants to have this virus and he seems to be doing very well, all things considered. So best of luck to him. So now that we saw Chris Cuomo's normal chest x-ray, let me show you an example of a floridly positive chest x-ray for a COVID positive patient. So this chest x-ray is an example of a COVID-19 positive patient with radiographic findings. So I pulled this from Radiology Assistant, which I love that website. So as you can see on this chest x-ray, it is pretty classic for COVID patients. You have these consolidative bilateral ground glass opacities in the periphery of the lungs, as you can see by these arrows. A chest x-ray that looks like this is not specific for COVID-19 patient. You can see this in a ton of different disease processes. So if I were to see this five months ago, I would have never come down hard on COVID-19 if I even knew about it. I could never come down hard on anything. I would likely just call it some sort of infection because the differential for bilateral peripheral ground glass opacities is pretty broad. So just to name a few things that kind of have this appearance on chest x-ray, you can have influenza can have this appearance, just normal influenza A or B that we're used to, cytometallovirus pneumonia, HSV pneumonia, respiratory syncytial viral pneumonia, an atypical bacterial pneumonia, such as microplasma pneumonia. Also pulmonary edema can have an atypical appearance like this as well. And also you can have many interstitial lung disease processes like chronic eosinophilic pneumonia or cryptogenic organizing pneumonia. So basically what I'm trying to get at with this whole video is that you cannot use chest x-ray for diagnosing COVID-19. Really the only specific way for diagnosing COVID-19 is to get the nasal swab. So that officially concludes this video. I hope you all learned something. If you have any other questions, leave them in the comments below and I will try to answer them. I usually respond within the first hour or so. As always, smash that like and subscribe button and follow me on Instagram if you don't already. If you wanna check out the CT findings of COVID-19, I actually did a pretty good write up on my Instagram page to go over and check that out. Turn on those post notifications so you are notified when I post a new video which is usually about once or twice every week. Otherwise, I'll see you all on the next video.