William Herring, M.D.

© 2003

Recognizing
Interstitial Versus
Airspace Disease

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2/6/2018 Dr. Basch's files 1
 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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 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

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 Common Airspace Diseases

 Pneumonia – inflammatory exudate

 Pulmonary edema – edema fluid
 Pulmonary hemorrhage – blood
 Aspiration – gastric juices

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 Airspace Disease

Aspiration pneumonia at both bases

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 Airspace Disease

Aspiration pneumonia at both bases

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 Interstitial versus Airspace Disease

Interstitial disease – discrete, Airspace disease – fluffy,

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

 Cancer–1° 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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 Interstitial Diseases
Examples of mostly reticular patterns

 Eosinophilic granuloma of the lung

 Pulmonary interstitial edema
 Idiopathic pulmonary fibrosis
 Rheumatoid lung

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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
Alveolar proteinosis
disease.

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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
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 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
 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
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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
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 Congratulations, You Graduate

I know an
airspace
disease
when I
see one

Want to return to the beginning of this module? Click here

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