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Objectives: To determine the accuracy of scoutless, fixed-dose ultra-low-dose (ULD) CT compared to standard-dose (SD) CT for pulmonary nodule detection and semi-automated nodule measurement, across different patient sizes., Methods: Sixty-three patients underwent ULD and SD CT. Two readers examined all studies visually and with computer-aided detection (CAD). Nodules detected on SD CT were included in the reference standard by consensus and stratified into 4 categories (nodule category, NODCAT) from the Dutch-Belgian Lung Cancer Screening trial (NELSON). Effects of NODCAT and patient size on nodule detection were determined. For each nodule, volume and diameter were compared between both scans., Results: The reference standard comprised 173 nodules. For both readers, detection rates on ULD versus SD CT were not significantly different for NODCAT 3 and 4 nodules > 50 mm 3 (reader 1: 93% versus 89% (p = 0.257); reader 2: 96% versus 98% (p = 0.317)). For NODCAT 1 and 2 nodules < 50 mm 3 , detection rates on ULD versus SD CT dropped significantly (reader 1: 66% versus 80% (p = 0.023); reader 2: 77% versus 87% (p = 0.039)). Body mass index and chest circumference did not influence nodule detectability (p = 0.229 and p = 0.362, respectively). Calculated volumes and diameters were smaller on ULD CT (p < 0.0001), without altering NODCAT (84% agreement)., Conclusions: Scoutless ULD CT reliably detects solid lung nodules with a clinically relevant volume (> 50 mm 3 ) in lung cancer screening, irrespective of patient size. Since detection rates were lower compared to SD CT for nodules < 50 mm 3 , its use for lung metastasis detection should be considered on a case-by-case basis., Key Points: • Detection rates of pulmonary nodules > 50 mm 3 are not significantly different between scoutless ULD and SD CT (i.e. volumes clinically relevant in lung cancer screening based on the NELSON trial), but were different for the detection of nodules < 50 mm 3 (i.e. volumes still potentially relevant in lung metastasis screening). • Calculated nodule volumes were on average 0.03 mL or 9% smaller on ULD CT, which is below the 20-25% interscan variability previously reported with software-based volumetry. • Even though a scoutless, fixed-dose ULD CT protocol was used (CTDI vol 0.15 mGy), pulmonary nodule detection was not influenced by patient size., (© 2022. The Author(s), under exclusive licence to European Society of Radiology.)