William Herring, M.D.

© 2003

Recognizing
Interstitial Versus
Airspace Disease

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Why learn the difference?

 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

Aspiration pneumonia at both bases

Interstitial Lung 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

Interstitial disease – discrete, Airspace disease – fluffy,

inhomogeneous, no air indistinct, homogeneous,
bronchograms contains air bronchograms
Common Interstitial Lung
Diseases

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.

Bronchogenic carcinoma – large cell

Interstitial Diseases
Examples of mostly nodular patterns

 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
Go ahead
colon cancer.
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
Go ahead
discrete lines or
dots. This is
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
Go ahead
the right lower
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

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