Emphysema. This smoker has hyperinflated lungs due to emphysema. Note the increased number of ribs that you can count anteriorly above the diaphragms – normally you should only be able to count 6 or 7 ribs. You’ll also note that both lungs look abnormally dark, i.e. lucent. The diaphragms are flattened, having been pushed down by the hyperinflated lungs. This patient also has pulmonary hypertension, a potential complication of severe emphysema. We can tell this from the appearance of the pulmonary vasculature – the hila are enlarged due to due the dilated pulmonary arteries, however immediately beyond the hila the vessels rapidly become very small in calibre (so-called ‘pruning’).