Well, nothing good, I think you all know me, that it distinguishes grams that are approved, riding arena, I'm from Vigo and well, I'm finishing my doctoral thesis on how García Toral and almost a bit of a geek about this subject, so the truth is I love talking about it because it's a technique that is quite simple and quite useful. One of the things that is most striking about thoracic ultrasound is how a cheap technique that has been in place for years has taken so long to be implemented in the world of thoracic pathology, and this is because we are not going to see an image as clear as we see in, for example, an obstetric echocardiogram, since air does not transmit ultrasound well, so we are not going to see an anatomical image, we are going to see artifacts, the artifacts that ultrasound produces when it interacts with the lung parenchyma depending on the amount of air it has, but well, ultrasound is here to stay and in fact it is already considered the fifth pillar of the physical examination, and until now we were all mistaken, ultrasound is the real Stethoscope, even from the etymological origin of the word, if we go back to this, "tos" means "in the chest" and " escopio" means "to observe." With the stethoscope, we ca n't observe; the only way to observe at the bedside dynamically and without emitting ionizing radiation is thoracic ultrasound. So, all of us who work with this pathology have an obligation to know. To give a little background to the talk, I'm going to talk first about the technique, the equipment, and the modes of examination. Then I'm going to talk about what a normal lung looks like, and then I'll talk about pathologies of the chest wall, the pleura, and the parenchyma. If you want to ask a question, feel free to interrupt me at any time. If not, you can ask at the end, or however you like. Perhaps this will be a somewhat basic talk, but later, if you want us to do another one, we can do it in more depth in some aspects without problems. Regarding the equipment we use for thoracic ultrasound, we mainly use these two probes. The first one is a linear probe; you can recognize it because the image I'm going to obtain is a rectangular image, and it's characterized by being an area of... High frequency in ultrasound provides definition but at the expense of a little depth. So, I'll use this first probe when I want a very clear view of the chest wall or when I want to see the pleura in detail, when I need to see the pleural lines clearly. The convex probe is one I recognize because it gives me a more angular ultrasound image. It's a low-frequency probe and therefore has low definition, but I'll have more depth. So, it's a probe that will be very useful for assessing pleural effusions, pneumonia, and atelectasis with intermediate characteristics. This probe here is the microcombix probe. It has a little more definition than the convex probe and a little more depth than the linear probe. If I could only have one probe, I would stick with this one, but ideally, I would have both. The sector probe, which is the one cardiologists use, will also be useful for assessing the lung parenchyma, especially for what cardiologists want to see, which are the V lines of cardiogenic edema, but it will require us to lose depth. A bit of clarity to see exactly the characteristics of the consolidations, so if I can choose, ideally I'd have a linear probe and a probe with bus modes. There are a lot of ultrasound scan modes, but the ones that will be useful at the bedside are these three I have here: the ver mode, which is the anatomy mode, with which I identify structures; the m-mode, which tells me about movement, will show moving structures as granular and stationary structures as a continuous line; and then the dual mode, the Doppler mode, will color structures that are approaching in red and those that are moving away in blue. There are many more modes in thoracic ultrasound: we have the 3-mode, the insular fold, and elastography, but at the bedside, these three will be fundamentally useful: the m-mode and logic. When we talk about ultrasound imaging, we're talking about echocardiography to assess a grayscale that goes from black to white. Black will depend on the amount of air in our lung parenchyma; if there's a lot of air, the air conducts poorly. In which ultrasound in my lung will not transmit or return echoes, so I will have a black and poetic image. As I lose air in my lung, my lung will become whiter. When will this happen? Well, when I have intracellular fluid in cardiogenic edema, when I have an increase in interstitium. In the case of [unclear text - possibly "due to the] midpoint, I have a gray color, which is generally compared to city." When will I be able to see this city" in the lung? Well, when I have an enlarged lung, in the case of pneumonia, in the case of atelectasis. In that case, I will see that city" with a gray color. How will I be able to explore the pair above the lung? How do I place the probe? Fundamentally, I have two ways to place it: longitudinally, which would be placing the waves, and then I will cut the upper and lower ribs. This would be this image that we have here. By cutting the two ribs, I will find the two acoustic shadows of these ribs. This is the ideal way to start the Exploration because that way I'll orient myself, figuring out what's above and what's below, and from there I'll scan along all the intercostal spaces. When I see something that catches my attention along that line, what I do is turn the probe and place it right between the intercostal spaces. The image I would have would be here. Here I no longer have acoustic shadows from the ribs; I see the thoracic wall, the broad parietal pleura, the visceral pleura, and in the middle a little bit of... The exploration protocol I have to use is the one validated and recommended in the international consensus document on thoracic ultrasound. It's this one you have here: the Volpicelli eight-space assessment, which assesses four anterior spaces and four lateral spaces. With this, you can diagnose most pathologies. This is also the ideal position for assessing a pneumothorax, with the patient lying down, since the air will rise upwards. But our patients aren't always critical; they won't always be lying down, and being able to sit them up and perform a posterior examination will often... To provide more information, if my patient comes in because of a bruise and I suspect a rib fracture, there's no need to assess all the intercostal spaces. Go directly to where it hurts. We do a bedside clinical ultrasound, and having the clinical information will help us perform a targeted examination. So, depending on the clinical suspicion, if I suspect a pneumothorax or cardiogenic edema, it will be much more useful to perform an examination of the anterior chest wall, always scanning along all the intercostal spaces. However, if I suspect my patient has pneumonia, a pleural effusion, or a pulmonary thromboembolism, it's more efficient to start from the posterior aspect. As I said, the general way to start is with the probe longitudinally because that helps me understand what's above and what I'm working on. In this case, here I'm seeing the spleen, a structure that is underdiagnosed, and just above it I see the pleural line. This shadow I have here is the acoustic shadow of the rib. Once... I've oriented myself and I already know what's up and what's down. I'm starting to scan along all the intercostal spaces, following the line of the pleura to detect any slight alteration. We're going to see what a normal lung looks like, starting with the chest wall. Regarding the chest wall, if we start the examination with the probe longitudinally, we've said that I'm going to find the acoustic shadow of the ribs. In this case, it's the typical "bat wing" image. I don't really know where you see the bat here. This is supposed to be one wing and this is another. What I have is the chest wall, one rib, another rib, here's the line of the pleura, and below it, the lung parenchyma. But I 've told you a little lie. This is n't the classic "bat wing" image; this is the "bat wing" image of a young lung. Why young? Because if you look closely, I can see the pleura even below the ribs. I can see the pleura because this rib has cartilage. If it were completely... or if... If we have a sharp point, we would have a complete acoustic shadow. I'm going to see this in children. I'm going to show you the cartilaginous area of ​​the ribs. If I want, I'll use a probe and place it right between the ribs. The image I'm going to get is like this: first, I'll have the skin, then a more complex structure, which is the subcutaneous cellular tissue, then the muscular fascia, and just below that hyperechoic line of the pleura, which will always guide my examination. Below that is the parenchyma. If you use the MS mode, the movement mode I was talking about, the skin and muscles will appear as a continuous line since they won't move during the respiratory cycle, while the lung parenchyma, if our patient is breathing, will appear granular. This is the image of beach sand. The sand would be my lung parenchyma while they are breathing, and the water would be the skin and muscles. How are we going to see the pleura? We can see it with a convex probe. We would see it like this: here it is between the two ribs, this hyperechoic line, and we're going to... Let's look at it in much more detail. If I use a linear probe, it will be a hyperechoic line of less than two millimeters. You'll see in some texts that they say if I use a very high-frequency probe I can see the parietal pleura and the visceral pleura. This isn't actually the case. Often the endothoracic fascia is confused with one of the pleurae. If the pleura is healthy and I don't have any pathology like a pleural effusion separating the two layers, it won't be possible to see the differentiation between the parietal and visceral pleura. I'll only see a single line of indirect data. In dynamic data, I can see the sliding sign. This sign appears when the visceral and parietal pleura are together and my patient is breathing. The visceral pleura will slide around the parietal pleura, and I'll see this dynamic sign, which has to be present if the patient is breathing. There are other signs I can see, like imprints on the pleural line. The pleura extends to the chest wall and transmits the heartbeats. Okay, I can see this in B-mode or M-mode. When will I lose this sign? When I have a pneumothorax (mt), meaning there's a lot of air in the chest wall. Then the transmission of the heartbeats won't reach the chest wall. Conversely, when will I see it much more pronounced? If I have a selective pleural effusion, the heartbeats will be transmitted much better and I'll see it much more clearly. How are we going to see the lung parenchyma? As I said, here we're not going to see an anatomical structure; we're going to see artifacts. The two most important artifacts we're going to find are the lines, which are horizontal lines, and the lines, which are vertical lines. Let's look at them a little more in detail. These lines you have here are equidistant from the pleura and are a reflection of it. This is like when I pick up a stone, throw it into the water, and it makes arcs. Well, in this case, my stone is the one that makes ultrasound waves that hit the... The pleura changes impedance, it starts to see air, then it reflects it to me at a distance. The instant is normal to find this in a healthy lung. In fact, the presence of lines tells us about adequate aeration and rules out congestion or even PIB. These lines you have here are like sunbeams. They start at the lower pleural line, and throughout the screen, without disappearing, they will move along with the sliding motion. As they move, they erase the lines. These are not so common to find. We can find up to two lines within the same intercostal space. When we see three or more lines, it means there is something in the parenchyma above that is causing the ultrasound to bounce back to the pleura, and this sends it back down. So that something could be increased interest. There is an increase in lines. This increase in lines we see today in COB and we see it in respiratory distress. Well, we see it in cardiogenic edema. Then there are some tricks to differentiate if it is due to one cause or On the other hand, in this case, it wouldn't be a normal image; there are a lot of lines. This is the case of a patient with Macario. Now that we know what pulmonary pathology looks like, that is, what a normal thorax looks like, let's see how pathological chest wall pathology looks. Ultrasound is very useful for detecting a rib fracture. Many times, well, I'm in the ER ordering chest X-rays, and today I don't see a fracture anywhere. Ultrasound is sensitive for its detection. All I have to do is take a linear probe and place it longitudinally right over the rib that hurts the patient, and what I'm going to see is an interruption of the cortex. Here I have a healthy cortex, and if you see, at this point it's interrupted. Also, if it's in the acute phase, this will be accompanied by a small hematoma, a small edema around it. When the fracture isn't very large, sometimes I do n't see the separation so clearly, and what I see are indirect signs like this one you have here. This is the chimney sign, like small lines that peek through. Because of the point where the fracture is, and here the small lines are visible, it's also very useful for detecting bone metastases because you'll see complete destruction of the rib's anatomy. The cortical bone is here, and while I see this, it's something variegated that could be a callus, but if I double the scan and see aberrant vascularization, it's probably a metastasis. It's also useful for assessing how the tube is placed in the chest wall. If you see, this tube is completely inside the pleural line, while this one has remained outside. Now, there are many representatives who sell tubes that are accessible for ultrasound, but I don't need any special tube. If I put a little saline solution through the tube, my tube will become echogenic. So it's an ideal way to see how the tube is placed in the wall. Now, regarding the pleura, well, the truth is that pulmonologists started using thoracic ultrasound to assess pleural effusions. We saw that it punctures very low down. What is known as the pleural garbage dump allows us to obtain a sample that is much more cost-effective without the risk of removing a hepatocyte from its function. This is very useful for avoiding iatrogenic effects. If we want to properly characterize a pleural effusion, we have to follow a series of guidelines. The first is to describe how we examined the patient, whether sitting or lying down. We then describe the thickness of the chest wall to where the lung parenchyma begins, measured in centimeters; the height of the effusion in intercostal spaces; and the width from the spine to the mid-axillary line. This way, we have the effusion perfectly defined and can monitor it. Often, people are interested in knowing the amount of pleural effusion a patient has. There are different formulas that have been validated to determine the exact amount of the effusion. Perhaps the most practical is to multiply the thickness of the effusion (if this is the chest wall and this is the diaphragm), the thickness would be the distance from the wall to where the pulmonary parenchyma begins. If we multiply this distance in millimeters by 20, we will have an idea of ​​the volume in milliliters. Regarding the effusion, the RS has now issued guidelines that tell us not to use just one measurement because it can depend on the patient's position and whether they are ventilated or not. They suggest using two measurements: the sum of the effusion height and the distance from the diaphragm to the collapsed lung. We add these two measurements, multiply by 70, and get an idea of ​​the amount of effusion in milliliters. For example, 100 milliliters might be more accurate. But in reality, it doesn't really matter to me if the patient has 1.2 liters or 1.7 liters. What I'm interested in is knowing what to do with this effusion. For that, I have a much simpler technique: observing the intercostal spaces it occupies. If it only occupies one intercostal space, the effusion is small, and the patient probably can't even perform diagnostic traction because they will collapse during inspiration. If it occupies two to three spaces, I can treat patients and diagnose them without problems. With three to four spaces, the effusion is already moderate, and perhaps I need to... Start thinking about evacuation now, and if I already have more than four spaces and more than four spaces with a collapsed lung with that jellyfish sign, my patient in the three and benefits that needs evacuation, the characteristics are taken and the effusion can help us a little to know the etiology of it, so if the effusion is completely black, it probably goes in favor of it being a sweat effusion, if that effusion starts to gain in echogenicity, starts to gain in little dots inside, especially if it is accompanied by a thickening of the pleura or an immobilization of that collapsed parenchyma, it probably goes more towards an exudate, and if I find these septa inside, this is a sign, here there is no need to puncture to see the pH, this will probably have to be done with a tube and fibrinolytics because if I try to get it out just by evacuating, well, maybe it will get stuck in a septum and I won't be able to get it out, there are some other data, like the plankton sign, that help me see if It's a very cellular effusion. I find this sign in malignant pleural effusions. It has motor activity; the blood will appear here as if floating. I've colored it so it's a little more visible, and with respiratory movements, it will appear as if it were plankton. This is a video that Manuel published with us this year because of the number of things it shows, or the number of things you can see. It's an ultrasound. I don't know if you notice, but we see small dots floating; it's the plankton sign. It was a hemorrhagic pleural effusion, a pneumatic pleural effusion, from a Kobe patient. That's why we're monitoring him with ultrasound, because he had a pulmonary thromboembolism. In fact, the image of the inf The pulmonary artery has it here, which coincides with the acoustic shadow of the rib, but also, I don't know if you notice, but little bubbles come out of here when the patient breathes. These bubbles must be from a pneumothorax. The patient had air from a pneumothorax, a hemorrhagic pleural effusion, and also a pulmonary thromboembolism. Besides, Paul Casey says that with an ultrasound, monitoring at the bedside, we can see a lot of things depending on the amount of fluid we have. We can even predict that a pleural effusion will form. This is because a healthy pleura is a smooth stone, but as my lung begins to congest, the pleura begins to wrinkle until it unfolds completely and appears in my pleural effusion. Generally, this wrinkling will be accompanied by an increase in lines, and depending on the amount of effusion, I will have different signs. If I have a very small pleural effusion, then I have a static sign, which is this square, which is nothing more than a flowing effusion. It's tiny, framed between the acoustic shadows of the ribs, the parietal pleura, and the visceral pleura. I also have some dynamic signs, such as the sinusoidal sign. If I put it in M-mode to assess the mobility of my lung (atelectasis), if the fluid isn't very dense, I'll see that the pulmonary parenchyma rises and falls, making a sign similar to the sun sign. If I have a very viscous pleural effusion, the mobility will be quite diminished. With 100, which is a disc effusion, the most well-known sign is the jellyfish sign, which is nothing more than my lung completely floating in a liquid medium. This means I have a massive pleural effusion. This is perhaps a slightly exaggerated video of a jellyfish sign, in which the effusion is already very large. In fact, you only see the lung parenchyma when you can easily take a breath; the diaphragm drops, and that's when the lung parenchyma appears. Otherwise, it seems like everything is a Rand sign. When the effusion is very small, sometimes it can be difficult for me to differentiate it. To determine if it's a true thickening of the pleura, it's very useful to double the ultrasound image because if it's fluid, it will show color, whereas if it's a thickening of the pleura, we won't see the colors. Well, I use this image a lot when I talk to the ultrasound residents because many times when we see this image, they tell me, "Look, they're just blindly injecting fluid, no more than... we need to use ultrasound to drain this. I'm going to zoom in no matter what." And it's true that most of the time when I have this ultrasound image, I'm going to have a large effusion, be careful. However, with a similar image, sometimes I find that what I have is a mass, a consolidation. So, with the ultrasound to guide the procedures, it's very common. And since I'm taking the opportunity to characterize the effusion and to say where I'm going to inject, I take a look at the interstitial fluid. Well, you know much better than I do that sometimes it can play tricks on us. Or, with the linear probe, I point it a little upwards towards the upper rib and identify where it was. This is especially useful when I have to perform procedures very close to the spine, where aberrant vessels sometimes appear. When puncturing or inserting tubes, this can cause problems. It can also help us identify pneumothorax. Furthermore, it has much greater sensitivity than an X-ray. To explore it, I will have the patient lie completely flat so that the air rises. I will use a linear probe, starting on the anterior wall, but I will move it laterally to detect the point where the air ends and the lung parenchyma begins. We must consider some drawbacks: it is not possible to determine the thickness of the pneumothorax. It is said that when the pulmonary point is the point where the wall begins and I cannot find it further laterally in the midaxillary line, this pneumothorax probably requires drainage, but I cannot determine the exact thickness. We must also consider the subcutaneous system, which can sometimes be misleading, thinking that it doesn't have a motor reaching the patient, and then in reality, it's not. So, And then, in obese patients or small pneumothoraces at the mediastinal level, sometimes these can go unnoticed. How am I going to see it? Well, I'm going to see it as an absence of pleural sliding. That is, in this case, the pleurae are not together, so I won't be able to see the slide sign, and the pleura will be completely still. I'll have lines that are sometimes even increased, but I won't be able to see many lines, and I won't have the pulmonary pulse, the transmission of the heartbeats. This would be seen dynamically. Here, in this case, we are seeing it moving the operator, but if you look at the pleural line, it doesn't move. I see lines, but I don't see lines, you see. These are very sensitive signs, as is the mode. In M-mode, here too, the lung parenchyma won't be breathing, so I'm going to lose that granular image, and I'm going to have the image known as barcode markings, and I also won't have the transmission of the heartbeats. As I say, these are very sensitive signs, but they are not 100% specific. To have a 100% specific sign for pneumothorax, I have to go to the point where the healthy parenchyma begins. This is the pulmonary point. If you look, I have characteristics of pneumothorax on one side and characteristics of a healthy lung on the other, like the beach sand. This is dynamic, but it doesn't look like this. Dynamically, it would look like this. If you look closely, here I have pleural sliding; however, here this pleura isn't moving at all. This is the pulmonary point. This point is 100% specific for pneumothorax. And when we fit it together, you see that this moves and this doesn't count. This is the area of ​​the healthy lung that has sliding, and this is the area of pneumothorax. I don't have the sliding of the pleura. I ca n't rely on just one sign to diagnose pneumothorax. I have to follow an algorithm. First, I have to see that there is no pleural sliding. Then I have to see that there are no lines trying to find the pulmonary point laterally. If I find that pulmonary point, I'm 100% sure that I have a pneumothorax. But if I can't find it. I have to check that we don't have a pulmonary pulse. Try using M-mode to see that Batasuna code. It seems a bit scary to do an ultrasound and say, "No motors, scale like a tube, no tube." At least that's what happened to us. We started using ultrasound for things beyond pleural effusion in 2014, and well, we've reported our experience now. We took advantage of the fact that after doing blind posterior bronchial biopsies or plural biopsies, we always had to do one with an X-ray because a pneumothorax occurs in up to 6% of cases. So we said, "Well, after finishing the procedure, when we were starting our learning curve, let's do an ultrasound to see if they really have one and then correlate it with what we see on the X-rays." So our negative predictive value when we started the learning curve, I insist, was 98 percent. In fact, now we don't order control X-rays anymore, we just do the "cobra" (a specific technique), and so it's a simple procedure. The only thing is you have to start doing it carefully. So I encourage you to start. As I mentioned at the beginning, be careful with emphysema because we've said that a pneumothorax can't have lines. Look at this, what we see here coming from the pleura. Yes, these are lines. But these lines coming from here are vertical lines, but they come from the subcutaneous tissue. These are emphysema lines. When a patient has a pneumothorax and air leaks into the subcutaneous tissue, we 'll see it with these lines, which are lines that sometimes play tricks on us. We have to see where they start. They start from above, these are lines, and they start from here below where the pleura is, with its lighting. These are lines that we have to differentiate. Regarding pulmonary pneumothorax, I'm only going to talk about consolidations. I'm not going to get into interstitial syndromes. As for consolidations, they will be accessible to ultrasound when the consolidation is in contact with the chest wall. In this case, I will be able to perfectly identify the consolidation. If the consolidation is not in contact with the chest wall, but the surrounding inflammation is, then yes. In this case, what I'm going to see is an increase in focal lines in the area where this consolidation is located. But be aware that in 8% of cases, neither the consolidation nor the surrounding inflammation is in contact with the chest wall. In these cases, they are false negatives of the ultrasound. I'm not going to see lines giving the appearance of a healthy lung, and I'm not going to see that behind this there is a consolidation. But well, in many cases, we can see it. The most well-known consolidations are those of pneumonia. In this case, what I'm going to see is a pair of areas above that have variable density and consistency inside, which often have some areas of atelectasis, meaning the pleura is fragmented. Characteristically, it has an air bronchogram and a fluid bronchogram. The air bronchogram is air trapped inside the bronchi. So, I'm going to see it as a white area that, in pneumonia, will be dynamic. When the patient breathes, we're going to see how these white areas move with respiration when the bronchus is full of... What I see in secretions is a fluid program, an image, and a hollow space. And here, like a vessel, the fluid bronchogram can be seen in different stages of pneumonia, but its presence over time, even when the pneumonia is resolving, is a criterion for performing a bronchoscopy. Perhaps this consolidation is pneumonia, and it's a tumorous consolidation. There are some other signs, such as the crushing sign, which is this small hyperechoic area you see here, indicating that the consolidation is not localized. This point here shows where aeration begins. If you look, this area is more consolidated, and from here it begins to dilate. That's why we see more of this dynamic area. It would look something like this when my patient exhales; that's when I see pleural effusion. However, I see pleural effusion with the jellyfish sign, while when they inhale, I see this large, aerodynamic bronchogram. You see the white structures that reach the chest wall, and here I have the crushing sign. From here, the aeration would begin. This would be a typical case of pneumonia. Sometimes it's difficult to differentiate whether what I have is consolidation due to pneumonia or consolidation due to a pleural effusion that has produced compressive atelectasis. This is difficult to differentiate, but there is a sign that can be useful to us, which is the air bronchogram. Notice this structure above, which is pneumonia; it has white dots inside that move with respiratory movements, while the Elektra structure, being compressive, doesn't have white areas of air that move with respiratory movements. This would be a false complex, according to the diagram, and this would be pneumonia with an associated stroke. But when I see a consolidation, I have to look very carefully not only at what's inside but also at the margins and what it does outwards. If you notice, this consolidation, which also has a similar appearance, as if it were compressed, has much better-defined margins; it's more of a rounded structure. And notice what it does on the chest wall; it's in the middle, towards the inside. This consolidation is a A tumor, even pneumonia, will never cause this type of invasion. We need to define precisely what's inside, how it behaves dynamically, and then the margins, because if it extends into the chest wall, it likely indicates a tumor. So, I want to tell you that ultrasound is the fifth pillar of physical examination, and its inclusion in management algorithms can reduce the need for additional tests or unnecessary treatments. Ultrasound allows us to decrease iatrogenic effects, improves the convenience of multiple procedures, and enhances diagnostic yield. I encourage you to start using it because it's quite simple and very useful. Listen, I'm swiping. I do n't know if you want to talk about any other pathologies or ask me anything. The questions are welcome. Congratulations, Crisis. I really liked your willingness. And well, I think that to start with this situation, we have plenty of time. I think that if what you say is right, let's start using the ultrasound machine and begin here little by little, with the regret of not having you here, so that when Let's start. You can go see if this happens and we can do something more practical. But if you ever want to send me an image to WhatsApp or email, no problem. Yes, well, yes. Then, regarding the equipment you mentioned, you recommended that it didn't need to be a particularly expensive piece of equipment or one with a lot of technology; any piece of equipment to start with could work. And regarding the waveforms, you recommend, ideally, wouldn't it be ideal if you had a linear and a Condex? The equipment, as I said, doesn't need to be a big piece of equipment. Normally, with the presets configured for the abdomen, it's usually enough to put the scan focus on the line of the stone, which is where we'll have more definition. And then, if you want to make some preset adjustments to improve the pulmonary pathology, I'm sending some instructions. There are some guidelines to make the new equipment look better. As I was saying, they come with harmonics and elastography, which does improve the definition a little in some consolidations, but they aren't necessary. That is, to see pneumonia, effusions, pneumothorax, they aren't strictly necessary. I use them when we're looking through a... An increase in lines is seen, and I don't know if it has plural thickening, but to make a differential diagnosis of cardiac pixels, distress of what is diffuse interstitial syndrome, but for bedside pathology, differential diagnosis, they are not necessary, and in your case, crisis, how long did the echo coexist with the graphy, when did you stop doing ultrasounds, x-rays to confirm the data that will impute, is urban and well, especially for non-motor, for effusions, to see the learning curve of the economy, they are dedicated, it is said that cardiologists, I don't know if it is because they are more adventurous, they say that for the diagnosis of cardiogenic edema, what you have to see are bilateral lines, it's enough with an hour of learning for pneumothorax, we took a year and a half to stop, we saw the results of the study and that we were all well, especially for the detection of the pulmonary point, the pulmonary point is what is hardest to find, you have to visit the probe well, you have to be sure that the patient is breathing, because many times they are scared, so they stop breathing, then it seems to you that they have motor lines everywhere because you never see sliding, so we For a year and a half we've been using X-rays and ultrasound for the diagnosis of pneumothorax and pleural effusion. You'll see it soon. I think that this year you've already done the pleural effusion and the pneumothorax. This year you're abandoning X-rays. Well, yes, the inconvenience of taking more time to explain is a problem, which is that nobody has a question, and now it's not the same to withdraw the good quality of the presentation. And well, I agree with you that I think ultrasound is already a basic tool that should be present in all thoracic surgery procedures, not only for preoperative evaluation but also for postoperative follow-up of our patients. And then, regarding preoperative analysis, do you think ultrasound can have any use, for example, in cases where we have doubts about whether there is any infiltration of the parietal pleura without removal of walls? Many times when we are totally sure, well, with those more sensitive senses, we want to use it. It's one of the things that CT software can give you added value to. Because with compressibility, that area will be colored much better, but with a simple, unfiltered icon, we saw it in this video I showed you, and it will be much clearer than ever before. If you look here, the mass goes into the chest cavity, so it is useful. I would encourage you to use it. And regarding preoperative studies, it's also useful for assessing the airway. If you use a rigid airway, you can measure its caliber with the ultrasound to see what can fit in, whether it's a rigid airway or a stent, to assess the diameter of the stents that need to be placed. I think a very complete study can be done, both preoperatively and for follow-up. Another activity that could have been confirmed would be the identification of pulmonary adhesions. Regarding pleural sliding, I imagine it can't be changed or corrected. You'll see an area that doesn't have pleural sliding, and then, if it's moderated, it will have the barcode. That's also quite useful. And then, finally... Cristina, do you have any experience with intraoperative identification of pulmonary nodules or lesions using ultrasound imaging? Because it is a tool that, well, in some cases, can be used, simple as other techniques we use. It has been documented and used on occasion, but there isn't a definitive guideline. Well, good luck starting with the ultrasound. Thank you so much for everything. We are very grateful that you have been here with us, sharing this time. We will be in touch with you later to share our experience. Perhaps it will affect you. Great, very good. Well, made to withstand nothing. See you later.