OBJECTIVES: To compare the diagnostic performance of tomosynthesis with that of chest radiography for the detection of pulmonary emphysema, using multidetector computed tomography (MDCT) as reference. METHODS: Forty-eight patients with and 63 without pulmonary emphysema underwent chest MDCT, tomosynthesis and radiography on the same day. Two blinded radiologists independently evaluated the tomosynthesis images and radiographs for the presence of pulmonary emphysema. Axial and coronal MDCT images served as the reference standard and the percentage lung volume with attenuation values of -950 HU or lower (LAA-950) was evaluated to determine the extent of emphysema. Receiver-operating characteristic (ROC) analysis and generalised estimating equations model were used. RESULTS: ROC analysis revealed significantly better performance (P < 0.0001) of tomosynthesis than radiography for the detection of pulmonary emphysema. The average sensitivity, specificity, positive predictive value and negative predictive value of tomosynthesis were 0.875, 0.968, 0.955 and 0.910, respectively, whereas the values for radiography were 0.479, 0.913, 0.815 and 0.697, respectively. For both tomosynthesis and radiography, the sensitivity increased with increasing LAA-950. CONCLUSIONS: The diagnostic performance of tomosynthesis was significantly superior to that of radiography for the detection of pulmonary emphysema. In both tomosynthesis and radiography, the sensitivity was affected by the LAA-950. KEY POINTS : • Tomosynthesis showed significantly better diagnostic performance for pulmonary emphysema than radiography. • Interobserver agreement for tomosynthesis was significantly higher than that for radiography. • Sensitivity increased with increasing LAA -950 in both tomosynthesis and radiography. • Tomosynthesis imparts a similar radiation dose to two projection chest radiography. • Radiation dose and cost of tomosynthesis are lower than those of MDCT.