When you look at a chest X-ray, the patterns and shadows reveal more than just shapes—they tell the story of how your lungs are working. Pulmonary fibrosis changes this story by leaving behind visible signs of scarring.
On an X-ray, pulmonary fibrosis often appears as a net-like or reticular pattern, most noticeable in the lower parts of the lungs. These markings show where healthy tissue has been replaced by fibrous tissue that make breathing harder over time.
You might notice the edges of the heart and diaphragm looking less clear, or the lungs appearing smaller than normal. These subtle signs help doctors track how far the disease has progressed and how well treatments are working.
Pulmonary fibrosis causes scarring in the lungs that makes breathing harder and limits oxygen flow into your blood. It develops when normal lung tissue is replaced by stiff, fibrotic tissue, leading to lasting damage and reduced lung function.
Pulmonary fibrosis is a chronic interstitial lung disease that leads to the thickening and stiffening of the lung parenchyma. The interstitium, a thin network of tissue supporting the air sacs, becomes inflamed and later filled with scar tissue.
This scarring disrupts gas exchange, lowering oxygen levels in your bloodstream. Over time, the lungs lose elasticity, and breathing becomes more difficult.
The process begins with repeated injury to lung tissue from infection, autoimmune reactions, or unknown causes. When the tissue tries to repair itself, excess fibroblast activity produces too much collagen and connective tissue.
This abnormal healing response results in fibrosis, which is permanent and progressive. In advanced cases, imaging shows a honeycomb-like pattern, especially near the lower lung zones, reflecting extensive tissue remodeling and loss of normal structure.
Pulmonary fibrosis can arise from many sources. In some cases, no clear cause is found, which is called idiopathic pulmonary fibrosis (IPF).
Other times, it develops from connective tissue diseases such as rheumatoid arthritis, systemic sclerosis, or lupus. Long-term exposure to environmental irritants like silica dust, asbestos, or mold can also trigger fibrosis.
Chronic hypersensitivity pneumonitis, caused by repeated inhalation of organic particles, leads to similar scarring. Certain medications, radiation therapy, or viral infections may contribute as well.
Smoking increases the risk and worsens outcomes.
| Category | Examples |
| Autoimmune causes | Rheumatoid arthritis, systemic sclerosis |
| Environmental exposures | Asbestos, silica, mold |
| Medications | Amiodarone, bleomycin |
| Unknown (Idiopathic) | Idiopathic pulmonary fibrosis |
Age over 60 and a family history of interstitial lung disease also raise your risk.
Pulmonary fibrosis includes several distinct forms with different causes and patterns. Idiopathic pulmonary fibrosis (IPF) is the most common and severe, often progressing despite treatment.
It corresponds to the histologic pattern of usual interstitial pneumonia (UIP). Other forms fall under the broader category of interstitial lung diseases (ILDs).
These include nonspecific interstitial pneumonia, sarcoidosis, and chronic hypersensitivity pneumonitis. Each has unique imaging and biopsy findings.
Fibrosis can also occur as part of connective tissue disorders or cystic fibrosis, where chronic inflammation leads to scarring. Progressive pulmonary fibrosis refers to cases that worsen steadily over time, regardless of the underlying cause.
Identifying the specific type helps guide treatment and predict how quickly lung function may decline.
You can evaluate pulmonary fibrosis using several imaging tools that show how lung tissue changes over time. Each method offers different levels of detail for detecting scarring, assessing disease extent, and guiding treatment decisions.
Chest radiography is often the first imaging test used when pulmonary fibrosis is suspected. It provides a quick and accessible way to view the lungs and can reveal early signs of scarring.
On an X-ray, fibrosis may appear as reticular or net-like shadowing, especially near the lung bases. You might also see reduced lung volume and blurred heart borders, sometimes described as a “shaggy” outline.
Although chest X-rays are less sensitive than CT scans, they remain useful for tracking disease progression and identifying complications such as infection or pneumothorax.
Advantages:
Limitations:
A high-resolution CT (HRCT) or thin-section CT scan provides the most detailed view of lung structure. It uses thin slices—usually 1 to 2 millimeters—to show fine patterns of fibrosis that a standard CT or X-ray cannot detect.
HRCT helps you identify features such as honeycombing, traction bronchiectasis, and reticular thickening, which are hallmarks of pulmonary fibrosis. These findings help distinguish idiopathic pulmonary fibrosis (IPF) from other interstitial lung diseases.
Radiologists use HRCT patterns to decide if a surgical lung biopsy is needed. The scan also helps measure disease severity and monitor response to therapy.
Key HRCT Findings:
| Finding | Description |
| Honeycombing | Clustered cystic spaces, usually at lung bases |
| Reticulation | Network of fine lines from fibrotic tissue |
| Traction bronchiectasis | Airway dilation from lung scarring |
Magnetic resonance imaging (MRI) is less common for lung evaluation because air in the lungs reduces image quality. However, newer MRI techniques can show lung perfusion and ventilation, providing functional information that complements CT imaging.
MRI avoids radiation exposure, which can be useful for younger patients or long-term follow-up. Other methods, such as lung ultrasound (LUS), are being studied for detecting subpleural fibrosis.
While LUS cannot replace CT, it may help in bedside assessments or when CT is not available.
Emerging uses:
Chest X-rays often show a pattern of fine lines, irregular densities, and changes in lung shape that reflect scarring and tissue remodeling. These findings help you recognize how fibrosis alters lung structure and function over time.
You may notice reticular shadowing, which appears as a network of fine, net-like lines across the lung fields. These reticular opacities are usually more visible near the lung bases and along the peripheral zones.
This pattern forms as fibrous tissue replaces normal lung parenchyma, reducing clarity of the heart and diaphragm borders. The edges can look “shaggy” or blurred.
In early disease, you might see ground-glass opacity, a hazy area that still allows visualization of lung markings. Over time, this haziness becomes more defined and coarse as fibrosis progresses.
| Common Findings | Typical Location | Appearance |
| Reticular lines | Peripheral, basal lungs | Fine, net-like pattern |
| Ground-glass opacity | Diffuse or patchy | Hazy, less dense |
| Shaggy heart border | Lower zones | Indistinct outlines |
As fibrosis advances, honeycombing becomes a key sign. It looks like clusters of small, thick-walled cystic spaces, often stacked in several layers near the lung bases.
These spaces represent destroyed alveoli and irreversible scarring. You may also see architectural distortion, where normal lung structures—such as bronchi and vessels—appear pulled or displaced by fibrotic tissue.
This distortion can cause traction bronchiectasis, where airways appear widened and irregular. The combination of honeycombing and distortion signals chronic, established fibrosis, often linked to idiopathic pulmonary fibrosis (IPF) or other advanced interstitial lung diseases.
Fibrosis causes volume loss, especially in the lower lobes. On X-ray, this appears as upward displacement of the diaphragm, narrowed spaces between ribs, and reduced lung height.
You may also notice smaller overall lung volumes, reflecting restricted expansion during breathing. In contrast, patients with combined emphysema and fibrosis may show near-normal volumes despite scarring.
Coronal imaging or follow-up radiographs can help you assess how much lung capacity has decreased. Recognizing these volume changes is important because they often parallel declines in pulmonary function tests and disease progression.
Recognizing fibrotic patterns on imaging helps you understand the type and stage of lung disease. Certain findings, such as reticulation, honeycombing, and traction bronchiectasis, can point to specific forms of interstitial pneumonia and guide further evaluation or management.
UIP is the most common pattern seen in idiopathic pulmonary fibrosis. On a chest X-ray, you often see reticular (net-like) opacities that are more prominent at the lung bases and peripheries.
The lower lobes may show volume loss and blurring of the heart borders due to scarring. High-resolution CT (HRCT) provides more detail.
It often shows honeycombing, traction bronchiectasis, and architectural distortion. These findings usually appear in a subpleural and basal distribution.
The pattern is typically asymmetric and progressive over time.
| Imaging Feature | Typical Location | Description |
| Honeycombing | Subpleural, basal | Clustered cystic air spaces |
| Traction bronchiectasis | Lower lobes | Airway dilation caused by fibrosis |
| Reticulation | Peripheral | Fine linear opacities from interstitial thickening |
NSIP often appears more uniform than UIP. On imaging, you may see ground-glass opacities mixed with fine reticular lines, usually in the lower lungs.
Honeycombing is uncommon, and the lung architecture tends to remain preserved. Compared to UIP, NSIP changes are symmetric and may respond better to treatment.
The fibrosis is more homogeneous, without the patchy scarring typical of UIP. You might also see traction bronchiolectasis, a milder form of airway dilation.
Other fibrotic patterns, such as organizing pneumonia or chronic hypersensitivity pneumonitis, can show overlapping findings. In these cases, a multidisciplinary review that combines imaging, clinical history, and pathology helps clarify the diagnosis.
Early pulmonary fibrosis may appear subtle on imaging. You might notice irregular interlobular septal thickening, intralobular reticulation, or faint pleural irregularity.
These findings can represent an interstitial lung abnormality (ILA) that may progress over time. As disease advances, fibrosis becomes more extensive.
Honeycombing, traction bronchiectasis, and volume loss become more visible, especially in the lower lobes. The lungs may show architectural distortion, where normal structures are pulled out of shape by scarring.
At this stage, the pattern often defines the underlying process. UIP changes suggest irreversible fibrosis, while NSIP or mixed patterns may still show partial reversibility with appropriate therapy.
Accurate diagnosis of pulmonary fibrosis depends on combining clinical findings, imaging results, and expert review. You need a detailed evaluation that includes lung function testing, imaging by high-resolution computed tomography (HRCT), and input from a multidisciplinary team of specialists.
You may first notice shortness of breath, dry cough, or fatigue. These symptoms often develop slowly, which can delay diagnosis.
Your doctor will assess your medical history, occupational exposures, and any family history of lung disease.
Pulmonary function tests (PFTs) measure how well your lungs move air and transfer oxygen. The main values include:
| Test | What It Measures | Typical Finding in Pulmonary Fibrosis |
| Forced Vital Capacity (FVC) | Amount of air exhaled after deep breath | Decreased |
| Total Lung Capacity (TLC) | Total air the lungs can hold | Reduced |
| Diffusing Capacity (DLCO) | Gas exchange efficiency | Lowered |
These findings suggest restrictive lung disease. Your provider may repeat PFTs over time to track disease progression and treatment response.
Radiologists play a critical role in identifying fibrotic patterns on HRCT scans. They look for features such as honeycombing, reticulation, and traction bronchiectasis, which suggest irreversible scarring.
HRCT often provides enough information to avoid a surgical lung biopsy.
A multidisciplinary discussion (MDD) brings together pulmonologists, radiologists, and pathologists to review all data—clinical, imaging, and pathologic findings. This collaboration improves accuracy and consistency in diagnosis.
Diagnosis of idiopathic pulmonary fibrosis (IPF) follows international criteria established by the American Thoracic Society (ATS), European Respiratory Society (ERS), Japanese Respiratory Society (JRS), and Latin American Thoracic Society (ALAT).
These guidelines emphasize identifying a usual interstitial pneumonia (UIP) pattern on HRCT or, when needed, through lung biopsy. UIP shows patchy fibrosis, subpleural predominance, and honeycombing without features suggesting another cause.
If imaging and clinical data are inconclusive, your team may recommend a surgical or transbronchial lung biopsy.
You may see lung scarring on an X-ray that looks similar to other diseases. Certain infections, connective tissue disorders, and even lung cancer can appear like pulmonary fibrosis, so careful evaluation is important for accurate diagnosis.
Pulmonary infections can cause temporary or permanent scarring that mimics fibrosis. Bacterial pneumonia, viral infections, or tuberculosis may leave patchy opacities or reticular patterns on imaging.
These can appear as diffuse or localized areas of increased density, sometimes mistaken for chronic fibrotic change.
An acute exacerbation of pulmonary fibrosis often shows new ground-glass opacities or consolidation superimposed on existing scarring. This reflects sudden inflammation or injury to already damaged lung tissue.
You may also notice that infection-related changes tend to improve with treatment, while fibrotic patterns remain stable or progress slowly. Comparing prior imaging helps distinguish between reversible infection and chronic fibrosis.
Several connective tissue diseases (CTDs) can cause pulmonary fibrosis. Common examples include rheumatoid arthritis, systemic sclerosis, and polymyositis/dermatomyositis.
These conditions produce interstitial lung disease that can look similar to idiopathic pulmonary fibrosis (IPF) on X-ray. The fibrosis in CTD often shows bilateral, lower-lobe reticular markings and reduced lung volumes.
You may also see subtle ground-glass changes or honeycombing. Other causes include drug-induced lung injury, radiation exposure, and chronic hypersensitivity pneumonitis.
These conditions share overlapping imaging findings, but clinical history—such as medication use or occupational exposure—helps separate them from idiopathic forms.
| Common Cause | Typical Imaging Feature | Helpful Clue |
| Rheumatoid arthritis | Basal reticulation | Joint symptoms |
| Scleroderma | Subpleural fibrosis | Skin thickening |
| Drug toxicity | Diffuse opacities | Recent medication use |
Lung cancer can sometimes mimic fibrosis, especially when scarring surrounds a tumor. On X-ray, a localized fibrotic area may hide or resemble a mass.
Unlike diffuse fibrosis, cancer often appears as a focal opacity, spiculated mass, or asymmetric thickening. You may also see volume loss or pleural retraction near the lesion.
If findings are unclear, CT imaging helps identify irregular nodules or masses within fibrotic regions. PET scans and biopsy confirm malignancy when imaging alone cannot distinguish between fibrotic scarring and tumor growth.
Pulmonary fibrosis requires long-term management focused on slowing lung scarring, maintaining function, and reducing complications. Your treatment plan depends on the cause, disease stage, and how quickly your condition progresses.
Antifibrotic drugs such as nintedanib and pirfenidone can slow the rate of lung function loss in idiopathic pulmonary fibrosis (IPF) and other forms of progressive pulmonary fibrosis. These medications do not reverse existing scarring but help reduce further tissue damage.
You may experience side effects like nausea, diarrhea, or fatigue, which often improve with dose adjustments. Regular liver function tests are needed because these drugs can affect liver enzymes.
If your fibrosis worsens despite therapy, your doctor may discuss additional treatments such as oxygen therapy, pulmonary rehabilitation, or evaluation for lung transplantation.
You should have ongoing assessments to track how your lungs respond to treatment. Common tools include pulmonary function tests (PFTs), high-resolution CT scans, and oxygen saturation monitoring.
These tests measure changes in your forced vital capacity (FVC) and diffusing capacity for carbon monoxide (DLCO), which reflect how well your lungs exchange gases. Doctors also monitor for acute exacerbations, which are sudden worsening episodes linked to diffuse alveolar damage and rapid lung injury.
These events may require hospitalization, supplemental ventilation, or ICU care. Consistent follow-up visits allow early detection of complications such as pulmonary hypertension or infections.
Keeping track of your symptoms—especially increased cough or shortness of breath—helps guide adjustments in therapy.
Your prognosis depends on several factors, including the underlying cause and the rate of decline in lung function. Response to antifibrotic treatment also plays a role.
In untreated IPF, average survival is about three to five years. However, outcomes vary widely.
Indicators of poorer prognosis include rapid FVC decline and frequent exacerbations. Low oxygen levels at rest are also associated with a worse outlook.
Patients who require long-term oxygen or have high pulmonary arterial pressure often face more severe disease.
A summary of key predictors:
| Indicator | Associated Outcome |
| Rapid FVC decline | Faster disease progression |
| Frequent exacerbations | Increased hospitalization risk |
| Low DLCO | Reduced gas exchange efficiency |
| Pulmonary hypertension | Higher mortality risk |
Chest imaging can reveal the hidden story of how your lungs are functioning. Recognizing the signs of pulmonary fibrosis on an X-ray or CT scan is critical to early diagnosis and effective treatment. From identifying subtle reticular patterns to confirming advanced honeycombing, imaging helps pulmonologists monitor progression and tailor therapy for each patient. At Gwinnett Pulmonary & Sleep, these imaging insights guide personalized treatment plans designed to preserve lung function and quality of life. With the right expertise and technology, you can better understand your condition and take proactive steps toward improved breathing and health.
If you’ve been told you have scarring or changes on a lung X-ray, the specialists at Gwinnett Pulmonary & Sleep can help you understand your results and explore effective treatment options. Our board-certified pulmonologists use advanced imaging and diagnostics to provide accurate evaluations and personalized care.
Book your appointment today or call 770-995-0630 to schedule a consultation.
Plugin powered by Kapsule Corp
