5/10/2014 Dr.

Basch's files 1
Recognizing
Interstitial Versus
Airspace Disease
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All Images Retain Their Original Copyrights
William Herring, M.D. 2003
Recognizing
Interstitial Versus
Airspace Disease
In Slide Show mode, advance the slides by pressing the spacebar
All Images Retain Their Original Copyrights
William Herring, M.D. 2003
5/10/2014 Dr. Basch's files 2
Why learn the difference?
Many times these patterns overlap
But frequently, recognition of one
or the other helps with the
Differential diagnosis
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Parenchymal Lung Disease
Two Major Types
Alveolar (air space)
Interstitial
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Airspace Disease
Soft-tissue opacities
With hazy and indistinct margins
Tend to respect segmental or lobar
boundaries
May contain air bronchograms
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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
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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
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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).
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Pulmonary edema
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.
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Common Airspace Diseases
Pneumonia inflammatory exudate
Pulmonary edema edema fluid
Pulmonary hemorrhage blood
Aspiration gastric juices
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Aspiration pneumonia at both bases
Airspace Disease
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Aspiration pneumonia at both bases
Airspace Disease
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Interstitial disease discrete,
inhomogeneous, no air
bronchograms
Airspace disease fluffy,
indistinct, homogeneous,
contains air bronchograms
Interstitial versus Airspace Disease
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Common Interstitial Lung Diseases
Cancer1 or 2
Sarcoidosis
Cystic fibrosis
Asbestosis
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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.
Bronchogenic carcinoma large cell
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Interstitial Diseases
Examples of mostly nodular patterns
Hematogenously disseminated
metastatic disease, e.g. renal cell ca
Silicosis
Miliary tuberculosis
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Interstitial Diseases
Examples of mostly nodular patterns
Hematogenously disseminated
metastatic disease, e.g. renal cell ca
Silicosis
Miliary tuberculosis
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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
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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
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Eosinophilic granuloma of the lung
Pulmonary interstitial edema
Idiopathic pulmonary fibrosis
Rheumatoid lung
Interstitial Diseases
Examples of mostly reticular patterns
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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
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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
disease.
Alveolar proteinosis
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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

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Which of the following is
airspace disease or
interstitial lung disease?
Click to go forward
Click to go back
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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
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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
5/10/2014 Dr. Basch's files 26
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
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Correct
This is airspace disease
Go ahead
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.
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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
5/10/2014 Dr. Basch's files 29
Congratulations, You Graduate
I know an
airspace
disease
when I
see one
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