Chest X-ray - Pulmonary disease

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In normal subjects the diaphragm is intersected by the 5th to 7th anterior ribs in the mid-clavicular line
It is often difficult to see the ribs in patients with COPD as they are osteopenic due to long term steroid use - as in this patient
In this image, the 7th ribs, which are only just visible, intersect the diaphragm (red lines) level with the mid-clavicular line – so are the lungs hyperexpanded?
Patient positioning and use of accessory muscles of respiration can influence the anatomical positioning of the ribs on a chest X-ray
Flattening of the diaphragm (red lines) is often a more reliable feature of lung hyperexpansion
The green dotted lines indicate the predicted normal diaphragm shape and position

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The lungs may be so hyper-expanded that the inferior border of the heart becomes visible – the heart appears to float above the diaphragm
Note the flattened hemidiaphragms (white dotted lines)

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Bullous emphysema manifests on a chest X-ray with areas of low density (black) with thinning of the pulmonary vessels, predominantly affecting the upper zones
The lower part of the lungs may appear denser (whiter) in normal subjects because of overlying breast tissue, but in this individual the pulmonary vessels appear normal in this area