 Sharing small video of few important paradigm X-rays in day-to-day practice, some are like a squadron and some for the learning purposes. Case No. 1 – 30-Weaker Newborn with a Respiratory Distaste Obviously it is a X-ray of Hyaline Membrane Disease or Respiratory Distaste Syndrome or surfactant deficiency, all are synonyms. What are the X-ray findings here? Ground-glass aprons to the both lung fields, symmetrical reticulonodular opacities, air pankograms, blurring of the cardiac, and diaphragmatic margins. Few important things, it is caused by surfactant deficiency, common in neonates less than 36 weeks, more of the prematurity, more of the severity of HMD, surfactant is produced by type 2 nemocytes. What is the role of surfactant? It lowers the surface tension of aloe lye, and efficiency of surfactant in aloe lye. They lose their compliance, meaning that they remain collapse, and clinically RDS present immediately after the birth. Grading of RDS is important for clinical management. This slide shows all four grades of RDS, film in the centre is normal, X-ray chased. Grade 1, subtle ground-glass aprons, minimal reticulonodular shadows, no much hypoventilation, diaphragmatic and cardiac margins are well seen. Grade 2, significant ground-glass aprons, but still the lungs are fairly ventilated. Air bronchograms seen in the region of the heart and not seen in the lateral aspect of the lung pills. Cardiac and diaphragmatic margins are obscured. Grade 3, findings are same as in Grade 2, but air bronchogram also seen in the lateral part of the lungs. Cardiac and diaphragmatic margins are significantly obscure, get throat, almost opaque lung pills with or without air bronchogram, heart and diaphragmatic margins are not seen at all. Grade 1 and 2 RDS do not need any intubation, no need of ventilatory support and more important, surfactant therapy is not required. They do well just with a oxygen support, whereas in Grade 3 and Grade 4 HMD they need intubation, they need ventilatory support and more important, they need surfactant therapy, which is a magic drug. As I said surfactant is a magic drug. This is the x-ray of the child showing Grade 4 HMD, surfactant was given through the adductracheal tube and have a look at the x-ray which was taken just after the 3 hours of surfactant therapy where both lungs are well expanded, diaphragmatic and cardiac margins are well seen, both lungs are fairly good ventilated. Here, let us go through the causes of respiratory pneumonial distress. Causes can be medical or causes can be surgical. Amongst the medical causes, transient tachypnea of newborn, meconium aspiration, pneumonial pneumonia and more important respiratory distress syndrome or surfactant deficiency among the surgical causes, congenital diaphragmatic hernia, congenital cystic adenomatoid malformation, congelital lobar emphysema or sequestration. In Case number 2, I will like to demonstrate variety of thymic appearances in periodic x-ray chest. One should be familiar with the appearance of the thymus and before that let us see few thymic signs, sail sign where you will see the lateral sharp border as the thymus is medestinal organ and lower margin of the thymus is sharp giving the appearance of the sail of port. Thymic wave sign, it can be seen on right as well as on the left. We all know thymus is located in the superior medestinum anteriorly. It is very soft organ seen on the x-ray up to three years of age. Thymic shadow should not be visible up to three years of age. When its lateral border is indented by anterior ends of ribs, which use undulation to the lateral margin causing a typical wave sign, when inferior border of the thymus interrupts with the cardiac shield out, giving a typical notch, we call it as a notch sign. Notch sign can be seen on the right or the left. Whenever you see both loops of thymus are elevated upwards and laterally we call this as a spinnaker sail sign and this is a sign of pneumo medestinum. There is a complete spectrum of normal appearance of the thymus on x-ray chest. Figure no 1 shows the typical sail sign on right. 2 shows thymus on either side dominantly on the left side with oblatation of the left heart-border. Figure no 3 shows thymus on either side with typical not sign on right. Figure no 4 shows thymus on either side with a typical sail sign on right and figure no 5 shows thymus dominantly seen with the oblatation of left-heart border. This was again a new born, baby had some respiratory distress, someone thought it is a large thymic shadow on left but distress continued on day 2 and baby was sent to us for opinion what we thought a large opacity on left dispensing heart and trachea. As I said normally thymus is very soft organ and do not cause any displacement of normal anatomical mark. In addition there was a small air crescent at the left of diaphragm, we thought some SOL, we took baby for ultrasound where two large cystic lesions were noted consistent with secant type 1 and CT showed two large cysts on left suggestive of secant type 1 which is the most common type where cysts are more than 2 cm size. In secant type 2 cysts are usually less than 2 cm. In secant type 3 macroscopic cysts are seen giving solid most on chest x-ray. 35 wicker baby born to villager complaining of frothing since last 2 days. Pinnacle suspicion of tracheoisophageal picella was made with typical coiling of the riles tube seen in the upper isophagus. Periodic surgeon wanted to confirm before taking for the surgery so diet study was advised we use 1 to 2 cc of non-eulic contrast media which confirms upper blind end and there is a gaseous stomach and bowel loof. So this is the common type of TOF seen in almost 86% of the cases where upper end is blind and lower end is connected to bronchus. This slide shows various combination and permutations of TOF. Both esophageal ends can be blind, upper end connected to trachea and lower end is blind. Upper end is blind and lower end is connected to trachea which is the commonest type which we have seen. Both the ends can be connected to trachea and H-type of picella where small tract of esophagus is connected to trachea. Another new born with a severe respiratory distress ultrasound study was not available. Any obvious case of bobtalic type of congenital diachromatic hernia where we see many cysts like shadows of the bowel loofs with a marked medial senile seep is very distinct because of ifselectral and counter-electral hypoplastic lung. Ifselectral site is collapsed by herniated bowel loofs and counter-electral lung is hypoplastic because of marked medial senile seep. We all know we can alternately diagnose bobtalic type of hernia by identifying herniated stomach in the thorax with a marked medial senile seep. This is bit older child of 3 months complaining of mild respiratory distress and cuff on and off. X-ray shows herniated bowel loofs mostly colon mainly on right, so this is a mortgage type of congenital diachromatic hernia where defect is on right in the entire medial aspect of the diaphragm and commonly colon and momentum are the organs to herniate through this defect. 6. 2 years child presented with a cuff and mild respiratory distress since last 2 days. X-ray shows increased translucency on left, mild medial still shift to right, lowering of leftum of diaphragm, spaling of vessels on left. All these observations are consistent with partial body obstruction in left bronchus, typical ball-hole type of obstruction where air can go in but cannot come out and trap in the lungs. Friends, we cannot afford to miss diagnosis in a given case. This is absolutely life-saving. Pill must be taken without any rotation, both the clavicle must be projected symmetrically on the pill. Sometimes, foreign body obstruction can be complete obstruction giving you appearance of the complete collapse of the lung or loathe with a medial still shift to the same site. Complete obstruction is rare. 7. 2 days old baby had severe respiratory distress and now where is the pathology on this pill? Of course, on left, where you see lot of air in the left neural cavity without any lung marking with a marked medial still shift to right, consistent with tension pneumothorax on left. Here is another case of pneumothorax on right with a typical lateral border of collapsed lung and mild medial still shift to left. You see this sort of a line especially in neonates giving you pseudo appearance of the collapse of lung but look carefully, this line is going below the dome of diaphragm and lung marking are visible lateral to this line also so this is a case of just skin fold causing illusion of pneumothorax. 8. 1 year old child presented with a high grade fever and curbs since last 3 days showing large patches in right upper lobe and both lower lobes fall off x-ray after 2 days shows cavity religions in these opacities here we are dealing with a stapelococcal pneumonia with typical pneumatocyles we should pick up precisely and report because antibiotics for stapelococcal pneumonia are slightly different and moreover other complications of rupture of these pneumatocyles with pneumothorax or hydroneumothorax or amperma are quite frequent. 9. New born child with respiratory distress x-ray shows opaque left upper lobe with marked medial still shift to right x-ray of same child after 10 days shows over expanded left upper lobe with a medial still shift to right so we are for sure dealing with a congenital loba amperma we know this is common in left upper lobe, right middle lobe and right upper lobe and usually not seen in lower lobes. 10. New born child with mild respiratory distress x-ray shows heart on right and liver shadow also on right stomach on left so this is a isolated dextrocardia with cytosolitis. In this situation congenital heart defects are quite frequent if you get dextrocardia with cytos inverses meaning liver on left and stomach on right here heart can be absolutely normal without any CHD.