Chronic Obstructive Pulmonary Disease (COPD)

Table of Contents

Table of Contents

Brandon Fainstad, MD1

1 Assistant Professor, Department of Medicine, University of Coloardo


  1. Identify six characteristic radiographic features of chronic obstructive lung disease
  2. Determine appropriate escalation of inhaler therapy and comprehensive care for a patient with uncontrolled COPD

Teaching Instructions

Plan to spend 5-10 minutes familiarizing yourself with the animations of the power point and the key findings of this chest X-ray.

Instructions: Ask a leaner to provide an overall interpretation.  Advance using the arrows or scroll wheel on the mouse to reveal subsequent questions with answers and graphics.  You can go back to prior graphics and questions by using the back arrow or scrolling back on the mouse wheel.  Consider having learners break into brief pair-shares to discuss each question before advancing the slide. 

Official CXR Read: Hyperinflated lung fields with apical predominant lucency, flattened diaphragm, anterior mediastinal air, and multiple osteoporotic compress fractures of the spine.

Clinical Diagnosis: COPD

Teaching: This case highlights multiple characteristics of radiographic findings in COPD with apical emphysema.  Bring attention to the rectangular shape of the thorax, opposed to the triangular shape seen with normal lungs. 

The final questions asks for next steps in management.  They likely have severe, stage 3 or 4 COPD, but symptoms and hospitalizations guide most decisions around selection of therapy.  She is group C or D based on 2 or more exacerbations in the past year. Her comprehensive management should focus on limiting disease progression and enhancing function with tobacco cessation, pulmonary rehab, continuous O2, up to date vaccinations (influenza, streptococcal pneumonia and COVID).  Her escalation of inhaler therapy should include the addition of a LAMA, stopping her SAMA, and consideration of an ICS if her eosinophils are greater than 100.

Refer to this talk on outpatient management of COPD for additional teaching resources.

Presentation Board

Take Home Point

There are multiple key radiographic findings of obstructive lung disease and apical emphysema, including:

  1. Greater than 9 ribs over the lung fields
  2. Elongated cardiac silhouette
  3. Flattened diaphragms
  4. Enlarged and lucent apices with a rectangular-shaped thorax (opposed to triangle-shaped)
  5. Anterior mediastinal air
  6. Kyphosis from vertebral compression fractures often from steroid-induced osteoporosis.


McLoud, Boiselle, & Boiselle, Phillip M. (2010). Thoracic radiology : The requisites (2nd ed., Requisites in radiology). Philadelphia: Mosby/Elsevier.

Halpin, D. M., Criner, G. J., Papi, A., Singh, D., Anzueto, A., Martinez, F. J., … & Vogelmeier, C. F. (2021). Global initiative for the diagnosis, management, and prevention of chronic obstructive lung disease. The 2020 GOLD science committee report on COVID-19 and chronic obstructive pulmonary disease. American journal of respiratory and critical care medicine, 203(1), 24-36.
Brandon Fainstad


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