Background Ultra-low-dose (ULD) CT could facilitate the clinical implementation of large-scale lung cancer screening while minimizing the radiation dose. However, traditional image reconstruction methods are associated with image noise in low-dose acquisitions. Purpose To compare the image quality and lung nodule detectability of deep learning image reconstruction (DLIR) and adaptive statistical iterative reconstruction-V (ASIR-V) in ULD CT. Materials and Methods Patients who underwent noncontrast ULD CT (performed at 0.07 or 0.14 mSv, similar to a single chest radiograph) and contrast-enhanced chest CT (CECT) from April to June 2020 were included in this prospective study. ULD CT images were reconstructed with filtered back projection (FBP), ASIR-V, and DLIR. Three-dimensional segmentation of lung tissue was performed to evaluate image noise. Radiologists detected and measured nodules with use of a deep learning-based nodule assessment system and recognized malignancy-related imaging features. Bland-Altman analysis and repeated-measures analysis of variance were used to evaluate the differences between ULD CT images and CECT images. Results A total of 203 participants (mean age ± standard deviation, 61 years ± 12; 129 men) with 1066 nodules were included, with 100 scans at 0.07 mSv and 103 scans at 0.14 mSv. The mean lung tissue noise ± standard deviation was 46 HU ± 4 for CECT and 59 HU ± 4, 56 HU ± 4, 53 HU ± 4, 54 HU ± 4, and 51 HU ± 4 in FBP, ASIR-V level 40%, ASIR-V level 80% (ASIR-V-80%), medium-strength DLIR, and high-strength DLIR (DLIR-H), respectively, of ULD CT scans (P < .001). The nodule detection rates of FBP reconstruction, ASIR-V-80%, and DLIR-H were 62.5% (666 of 1066 nodules), 73.3% (781 of 1066 nodules), and 75.8% (808 of 1066 nodules), respectively (P < .001). Bland-Altman analysis showed the percentage difference in long diameter from that of CECT was 9.3% (95% CI of the mean: 8.0, 10.6), 9.2% (95% CI of the mean: 8.0, 10.4), and 6.2% (95% CI of the mean: 5.0, 7.4) in FBP reconstruction, ASIR-V-80%, and DLIR-H, respectively (P < .001). Conclusion Compared with adaptive statistical iterative reconstruction-V, deep learning image reconstruction reduced image noise, increased nodule detection rate, and improved measurement accuracy on ultra-low-dose chest CT images. © RSNA, 2022 Online supplemental material is available for this article. See also the editorial by Lee in this issue.