Pulmonary emphysema is the typical manifestation of advanced disease. Chest radiographs show that the apical section is not affected in 62% of cases. When emphysematous changes predominate in the basal regions of the lungs, the central and peripheral sections are also affected. Bullous changes are not unusual in alpha1 antitrypsin deficiency. Thickening of the bronchial walls and peripheral dilation are rare pulmonary changes.
Computed tomography (CT) allows more detailed visibility than conventional chest radiography. The base of the lungs tends to be more affected by the destruction of the lobular alveoli than in other forms of emphysema. Additionally, pronounced vascular loss can be detected in the peripheral lungs. In chronic bronchitis associated with AATD bronchial wall thickening is more pronounced than in chronic bronchitis caused by smoking.