What does diffuse bilateral dense airspace opacities mean?

Chest x-ray showing dense airspace opacities in the lower right

Your question:  

What does it mean when a chest x-ray shows "diffuse bilateral dense airspace opacities right greater than left which have significantly worsened in the interval?" 

This is what it showed on a patient's  chart. The patient  was admitted to the hospital and was having trouble breathing at the time of the x-ray.  Shortly before this x-ray, the patient was increased from a 6 LPM nasal cannula to an NRB to maintain as sat of 90%. Her last chest x-ray was the day before. 

My humble answer: 

To be honest. I am no expert on interpreting x-rays. Yet I do have some incites that may help you understand what the radiologist meant by this x-ray interpretation. Much of this information was obtained via a discussion I had with a pulmonologist friend of mine. First, let's start with some basic information.

What are some basics?

Opacity. This is the area of an x-ray that appear WHITER or DENSER than the surrounding tissues or structures. 

Interval. This means "since the last x-ray." So, "significantly worsened in the interval" suggests that this was present in the last x-ray, but it is worse on the current one. It means that the condition (whatever it is) has progressed or become more severe since the last x-ray. 

Bilateral. This means both sides of the lungs (the right and the left lung) are affected.

Right greater than left. This means the right side is effected more so than the left, but it is occurring on both sides. 

Dense airspace opacities. This refers to increased density or whiteness in the lung tissue. This can be caused by various factors, such as inflammation, infection, fluid accumulation, or other pathological changes. 

What does this mean?

When an X-ray shows "diffuse bilateral dense airspace opacities right greater than left which have significantly worsened in the interval," it indicates a concerning finding in the lungs. This statement suggests that there are extensive and widespread areas of abnormal opacities (whiteness) on the X-ray images, affecting both lungs (bilateral) but more prominently on the right side.

The cause is probably something going on in the lung parynchema: 

1. Pneumonia. Does the patient have a diagnosis of pneumonia? It may be getting worse.
2. Aspiration Pneumonia. Did the patient aspirate? 
3. ARDS. This causes inflammation and fluid build-up? 
4. SARS. A viral respiratory infection. 
5. Interstitial lung disease (such as pulmonary fibrosis). This causes inflammation and scarring
6. Pulmonary edema. Fluid buildup in the alveoli

Further testing (such as getting a cat scan) may be needed to get a more specific diagnosis. A physician may also make an educated guess as the the cause and potential best treatment based on the patient's history and current admitting diagnosis. 

UPDATE

The person providing me with the question came gave me an update. It was also determined that the patient had clubbing of the fingernails and a diagnosis of ILD. The patient's doctor determined that this was the unlikely cause of the change being that it occurred so fast. If it were ILD, the changes would occur slowly over time. Likewise, the x-ray from the day before was similar to one from 2 years ago. This shows that the ILD was unchanged. 

The patient showed no signs of an infection. White blood cell count was normal. However, until this was further ruled out, a broad spectrum antibiotic was ordered. 

A previously done Cat Scan showed ground glass appearance on the lungs. This is a possible early sign of ARDS. The patient's doctor said this is a possible cause of the change. For this reason the doctor recommended lasix and BiPAP. 

The patient also had a blood transfusion the day before. And so it's possible this ARDS is a result from the transfusion. This usually only happens when a patient has a massive infusion of blood, such as from a trauma. Although, it's possible that it's due to the transfusion. This may explain the sudden development of her symptoms and the sudden change in the x-ray. So, this may indicate the patient may have ARDS. The doctor is hopeful current treatment will fix her lungs. But, if she goes into respiratory failure, the next best step may be mechanical ventilation. But, the goal (obviously) is to avoid this. 

What was the treatment for this patient? Lasix, antibiotics, BiPAP. If the patient does not tolerate the BiPAP, high flow nasal cannula to maintain sats. If the patient's condition worsens, mechanical ventilation is an option. 

If you have a case you would like to discuss, or any question at all about anything respiratory related, please send us an email using the link to the right.