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© 2003
Recognizing
Interstitial Versus
Airspace Disease
Many times these patterns overlap
But frequently, recognition of one
or the other helps with the…
Differential diagnosis
Parenchymal Lung Disease
Two Major Types
Alveolar (air space)
Interstitial
Airspace Disease
Soft-tissue opacities
With hazy and indistinct margins
Tend to respect segmental or lobar
boundaries
May contain air bronchograms
Air Bronchogram
Bronchi usually not visible
Walls are thin, they contain air, are surrounded
by air
When something of fluid density fills
alveoli, air in bronchus becomes visible
Pulmonary edema fluid
Blood
Gastric aspirate
Inflammatory exudate
Air Bronchogram
The visibility of air in the bronchi because of
surrounding airspace disease is called an “air
bronchogram”
An air bronchogram most often a sign of airspace
disease
The black branching
structures are the
result of air in the
bronchi, now visible
because density
other than air
surrounds them (in
this case it is
inflammatory exudate
from a pneumonia).
This disease is
fluffy and indistinct
in its margins, it is
confluent and
tends to be
homogeneous. In
both upper lobes,
you can see air
bronchograms.
This is an alveolar
(airspace) disease,
in this case
pulmonary edema
on a non-
cardiogenic basis.
Pulmonary edema
Common Airspace Diseases
Pneumonia – inflammatory exudate
Pulmonary edema – edema fluid
Pulmonary hemorrhage – blood
Aspiration – gastric juices
Airspace Disease
Now referred to as infiltrative lung disease
Discrete particles of disease
Inhomogeneous
Doesn’t respect lobar boundaries
Usually no air bronchograms
Made up of lines (reticular) or dots (nodular)
or both (reticulonodular)
Interstitial versus Airspace Disease
Cancer–1° or 2°
Sarcoidosis
Cystic fibrosis
Asbestosis
Right upper lobe mass is
a bronchogenic
carcinoma. It is sharply
marginated, relatively
discrete, contains no air
bronchograms. It began
in the interstitium of the
lung.
Hematogenously disseminated
metastatic disease, e.g. renal cell ca
Silicosis
Miliary tuberculosis
This CT of the
chest shows
thickened
bronchial walls
with extensive
dilatation of the
bronchi (bronchi
should be
smaller than
their
accompanying
blood vessel).
This interstitial
disease is Cystic
Fibrosis.
Cystic Fibrosis
This is a diffuse
infiltrative
(interstitial)
disease that is
composed
primarily of lines
(reticular disease).
Examples of
mostly reticular
disease include
idiopathic
pulmonary fibrosis
and eosinophilic
granuloma.
Idiopathic pulmonary fibrosis
Interstitial Diseases
Examples of mostly reticular patterns
Eosinophilic granuloma of the lung
Pulmonary interstitial edema
Idiopathic pulmonary fibrosis
Rheumatoid lung
Interstitial lung disease
with coarse, criss-
crossing pattern is
called “honeycomb”
pattern. It is seen in
such diseases as
eosinophilic
granuloma of the lung
and bronchiectasis.
Bronchiectasis
Another diffuse
infiltrative pattern
In the lung is
“ground-glass”
opacification, seen
on CT. Though
non-specific, it is
differentiated from
airspace disease
in that air
bronchograms are
not present and
the blood vessels
are usually still
visible through the
Alveolar proteinosis
disease.
Take Home Points
Though somewhat artificial, lung
disease can be divided into airspace and
interstitial (infiltrative) patterns
Airspace dz is fluffy, confluent with air
bronchograms
Interstitial dz is diffuse, discrete, tends
to occur in lines, dots or a combination
of the two
Which of the following is
airspace disease or
interstitial lung disease?
Click to go forward
Click to go back
Airspace or interstitial?
Go ahead
Airspace or interstitial?
Go ahead
Airspace or interstitial?
Go ahead
Airspace or interstitial?
Go ahead
Correct
This is interstitial disease
There are multiple
discrete nodules in both
lungs. They are well-
defined, do not have air
bronchograms and do
not respect lobar
boundaries. These are
metastases from a colon
cancer.
Go ahead
Correct
This is airspace disease
There is diffuse
airspace (alveolar)
disease which has
somewhat of a “bat-
wing” appearance. The
disease is fluffy,
confluent and is not
made up of discrete
lines or dots. This is
CHF.
Go ahead
Correct
There is interstitial disease
There are multiple
nodules in both lungs
from metastatic
disease of breast
primary. The disease
occurs in a discrete
nodular pattern with no
air bronchograms.
Go ahead
Correct
This is airspace disease
This is localized
airspace disease. It is
lobar and segmental
in distribution, is
confluent, has
indistinct margins. It
is pneumonia of the
right lower and upper
lobes.
Go ahead
Wrong
Look Again
Remember airspace diseases are fluffy,
indistinctly marginated and may have
air bronchograms
Interstitial lung disease tends to be
discrete nodules or reticular densities,
diffuse and inhomogeneous
Go Back
Congratulations, You Graduate
I know an
airspace
disease
when I
see one