COPD and airways disease on chest X‑ray

Written by the X-Ray Atlas editorial team from the sources listed below · Medical review pending · Updated 24 October 2026 · Level: Intermediate

Chronic obstructive pulmonary disease (COPD), bronchiectasis and asthma are among the most common chronic lung conditions in the UK. COPD is a clinical and spirometric diagnosis, not a radiological one, and the chest X-ray is insensitive to mild disease. So why does the film matter? Because in a patient with airways disease it is used to exclude other causes of symptoms, to find complications such as pneumothorax and pneumonia, and to spot the lung cancer that shares COPD's main risk factor, smoking. This page covers the signs of hyperinflation and emphysema, bullae and the dangerous bulla-versus-pneumothorax problem, bronchiectasis, and asthma.

1. What the film is for

NICE (NG115) recommends a chest X-ray at the time of diagnosis of COPD, mainly to exclude other conditions such as lung cancer, heart failure or ILD. In an acute exacerbation, the film looks for pneumonia, pneumothorax, pulmonary oedema and effusion. A normal film is common in COPD and does not argue against the diagnosis; spirometry makes it. CT shows emphysema much better but is not needed to diagnose COPD.

2. Hyperinflation and emphysema

Air trapping makes the lungs large and the diaphragm low and flat. Signs on the PA and lateral films include:

The distribution of emphysema can be a clue. Smoking-related (centrilobular) emphysema is typically upper-zone predominant. Lower-zone panacinar emphysema, especially in a younger patient or a non-smoker, should prompt consideration of alpha-1 antitrypsin deficiency.

3. Bullae and the pneumothorax trap

A large bulla and a pneumothorax both appear as an area of lucency with no lung markings, and patients with COPD are prone to both. Telling them apart matters because inserting a chest drain into a bulla can create a bronchopleural fistula and a life-threatening air leak.

Feature	Giant bulla	Pneumothorax
Inner margin	Concave towards the chest wall: the bulla pushes lung away around it	Convex lung edge running parallel to the chest wall
Internal lines	Thin septations may cross the lucency	No markings beyond the visceral pleural line
Comparison	Often present on old films	New

When in doubt, and the patient is stable, CT settles it before any drain is inserted. The double-wall sign (air on both sides of the bulla wall) on CT indicates a pneumothorax adjacent to a bulla. See pneumothorax and chest drain position.

4. The exacerbation film

When a patient with COPD presents acutely unwell, review the film for:

• Consolidation (pneumonia changes management and antibiotic choice).
• Pneumothorax, which may be small and loculated in emphysematous lungs, and is more dangerous in patients with little respiratory reserve. Secondary pneumothorax in COPD is managed more actively than primary pneumothorax in BTS guidance.
• Pulmonary oedema, which can look atypical in emphysema because destroyed lung does not fill with fluid in the usual pattern.
• Effusion, and a mass or collapse from an underlying cancer.
• Signs of pulmonary hypertension and cor pulmonale: enlarged central pulmonary arteries and an enlarged right heart.

5. Bronchiectasis

Bronchiectasis is permanent, abnormal dilatation of the bronchi, usually from previous infection, cystic fibrosis, immune deficiency, ABPA or primary ciliary dyskinesia. The chest X-ray may be normal in mild disease. Signs include:

• Tram-track lines: parallel lines from thickened bronchial walls that do not taper towards the periphery as normal bronchi should.
• Ring shadows: dilated bronchi seen end-on, sometimes containing air–fluid levels.
• Finger-in-glove opacities: branching tubular opacities from bronchi filled with mucus, classically in ABPA.
• Volume loss and crowding of the affected lobe.

Distribution is a clue: cystic fibrosis is upper-zone predominant; post-infective bronchiectasis is often lower-zone. Kartagener syndrome combines dextrocardia, bronchiectasis and sinusitis. HRCT is the definitive test (BTS bronchiectasis guideline). On CT, a bronchus wider than its accompanying artery (bronchoarterial ratio above 1, the "signet ring" sign) and lack of tapering confirm it.

6. Asthma

In asthma the chest film is usually normal, or shows hyperinflation during an attack. Routine chest X-rays are not needed for a typical exacerbation, but a film is indicated when a complication is suspected, the attack is severe or life-threatening, or the patient is not responding to treatment. Look for:

• pneumothorax;
• pneumomediastinum and surgical emphysema in the neck;
• consolidation;
• lobar or segmental collapse from mucus plugging.

In children with wheeze, also think of an inhaled foreign body, which can cause unilateral hyperinflation from air trapping. See swallowed and inhaled foreign bodies in children.

7. Pitfalls

• Mistaking a bulla for a pneumothorax, or the reverse. Use CT when unsure in a stable patient.
• Calling emphysema on an over-exposed film. Dark lungs alone are not emphysema.
• Unilateral hyperlucency has other causes: rotation, mastectomy, Poland syndrome, Swyer–James (MacLeod) syndrome, and an obstructed bronchus.
• Atypical oedema or consolidation in emphysematous lung: patchy, asymmetric patterns can be misread.
• Satisfaction of search: a hyperinflated chest is easy to label "COPD" and stop. Always complete the review areas for a nodule or hilar mass.

Red flags: act now

What to focus on, by role

Role	Priorities
Medical student	The signs of hyperinflation, bulla versus pneumothorax, tram-tracks and ring shadows, and the fact that COPD is diagnosed by spirometry.
Nurse	Recognise the COPD patient who deteriorates suddenly (possible pneumothorax), and controlled oxygen targets.
Junior doctor	On an exacerbation film, look for pneumonia, pneumothorax and cancer. Never insert a drain into a lucency you cannot confidently call a pneumothorax.
Radiographer	Correct exposure (over-exposure mimics emphysema) and full inspiration; a lateral helps assess the retrosternal space.
Advanced / FRCR	Emphysema subtypes, unilateral hyperlucency, ABPA, cystic fibrosis and pulmonary hypertension.

Practise on real chest X-rays →

References

1. Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy report. goldcopd.org
2. NICE. Chronic obstructive pulmonary disease in over 16s: diagnosis and management (NG115). nice.org.uk
3. Roberts ME, et al. British Thoracic Society Guideline for pleural disease. Thorax 2023;78(Suppl 3):s1–s42. thorax.bmj.com
4. British Thoracic Society. Guideline for bronchiectasis in adults. brit-thoracic.org.uk
5. Hansell DM, et al. Fleischner Society: glossary of terms for thoracic imaging. Radiology 2008. pubs.rsna.org

For education only. Not a substitute for a formal report, senior review or your local policy. Never use this page to make decisions about a real patient.