Chronic obstructive pulmonary disease (COPD) is a serious lung disease that includes two primary conditions. Emphysema is a disease that injures the small air sacs in the lungs. Chronic bronchitis is a disease that causes the airways to be constantly irritated and inflamed with increased mucus production. People with COPD often have trouble breathing, produce a lot of mucus, feel chest tightness, and have other symptoms depending on the severity of their condition.

If your doctor suspects you may have COPD, you will likely undergo a few different tests to help make a diagnosis. One of them is a chest X-ray.

A chest X-ray is quick, non-invasive, and painless. It uses electromagnetic waves to create pictures of the lungs, heart, diaphragm, and ribcage. It’s only one of several tests used in the diagnosis of COPD.

You don’t need to do much to prepare for your X-ray. You’ll wear a hospital gown instead of regular clothes. A lead apron may be provided to protect your reproductive organs from the radiation used to take the X-ray. You’ll also have to remove any jewelry that could interfere with the screening.

A chest X-ray may be done while you’re standing up or lying down. It depends on your symptoms. Typically a chest X-ray is performed while you are standing. If your doctor is concerned that you have fluid around your lungs, called a pleural effusion, they may want to see additional images of your lungs while lying on your side. Most often though, there are two images taken: one from the front and another from the side. The images are available immediately for the doctor to review.

One of the signs of COPD that may show up on an X-ray are hyperinflated lungs. This means the lungs appear larger than normal. Also, the diaphragm may look lower and flatter than usual, and the heart may appear more elongated.

An X-ray in COPD may not reveal as much if the condition is primarily chronic bronchitis. But with emphysema, more structural problems of the lungs can be seen on an X-ray. For instance, an X-ray may reveal bullae. In the lungs, a bullae is a pocket of air that forms near the surface of the lungs. Bullae are greater than 1 cm in size. Bullae can become quite large and take up significant space within the lung. Small bullae are called blebs. These are typically not seen on a chest X-ray because of their small size. If a bullae or bleb ruptures, air can escape out of the lung causing it to collapse. This is known as a spontaneous pneumothorax, and it requires urgent medical treatment. Symptoms are typically sharp chest pain and increased or new breathing difficulties.

On your chest X-ray, your lungs may appear to be normal shape and size and be clear of bullae or other signs of COPD.

Symptoms such a chest pain, difficulty breathing, and decreased ability to exercise can be a lung problem, but it can also be a heart problem. A chest X-ray can provide valuable information about your heart and blood vessels such as heart size, blood vessel size, signs of fluid around the heart, and calcifications or hardening of valves and blood vessels. A chest X-ray can also reveal broken ribs or other problems with the bones in and around the chest, all of which can cause chest pain.

A chest X-ray is one method of providing your doctor with images of your heart and lungs. A computed tomography (CT) scan of the chest is another tool that is commonly ordered in people with breathing problems.

Unlike a standard X-ray, which provides a flat, one-dimensional picture, CT scans provide a series of X-ray images taken from different angles. It gives doctors a cross-section look at the organs and other soft tissue. A CT scan gives a more detailed view than a regular X-ray. It can be used to check for blood clots in the lungs, which a chest X-ray can’t do. A CT scan can also pick up much smaller detail, identifying problems, like cancer, much earlier. It is often used to follow up any abnormalities seen within in the lungs on a chest X-ray.

It’s not uncommon for your doctor to recommend both a chest X-ray and a CT scan depending on your symptoms. A chest X-ray is often done first because it is fast and accessible and provides useful information in order to make decisions quickly about your care.

COPD is commonly separated into four stages: mild, moderate, severe and very severe. The stages are determined based on a combination of lung function and symptoms. A number grade is assigned based on your lung function, the higher the number the worse your lung function. Lung function is based on your forced expiratory volume in one second (FEV1); it measures how much air you can exhale from your lungs in one second.

A letter grade is assigned based on how your symptoms affect your daily life and how many flare-ups of COPD you have had in the last year. Group A individuals have the least symptoms and the fewest flare-ups. Group D individuals have the most symptoms and flares. A questionnaire such as the COPD Assessment Tool (CAT) is typically used to evaluate how your COPD symptoms impact your life.

An easy way to think about the stages are as follows. There are also variations within the grading system:

  • Patient group 1 A: Mild COPD with a FEV1 of about 80 percent of normal. Few symptoms in daily life and few flare-ups.
  • Patient group 2 B: Moderate COPD with a FEV1 of between 50 and 80 percent of normal.
  • Patient group 3 C: Severe COPD with a FEV1 of between 30 and 50 percent of normal.
  • Patient group 4 D: Very severe COPD with a FEV1 less than Stage 3 or with the same FEV1 as Stage 3, but with low blood oxygen levels, too. Symptoms and complications of COPD significantly affect quality of life.

Recently, this grading system has been modified several times. The hope is that the system guides doctors on how to best treat patients based on both their lung function and their symptoms and not just one or the other.

A chest X-ray alone can’t confirm a diagnosis of COPD, but it can provide useful information about your lungs and heart. A lung function study is also necessary to make a reliable diagnosis, along with a careful evaluation of your symptoms and the impact your symptoms have on your life.

Both a chest X-ray and a CT scan involve some radiation, so be sure to tell your doctor if you have had other X-rays or CT scans recently. If you have any questions about getting an X-ray or a CT scan, or about any test or treatment related to COPD, don’t hesitate to talk to your doctor. The best way to make smart decisions about your health is to have as much information as possible.