Typical cylinder bore size for medium-speed engines ranges from 20 cm to 50 cm, and engine configurations typically are offered ranging from in-line 4-cylinder units to V-configuration 20-cylinder units. Most larger medium-speed engines are started with compressed air direct on pistons, using an air distributor, as opposed to a pneumatic starting motor acting on the flywheel, which tends to be used for smaller engines. There is no definitive engine size cut-off point for this.

It should also be noted that most major manufacturers of medium-speed engines make natural gas-fueled versions of their diesel engines, which in fact operate on the Otto cycle, and require spark ignition, typically provided with a spark plug.[79] There are also dual (diesel/natural gas/coal gas) fuel versions of medium and low speed diesel engines using a lean fuel air mixture and a small injection of diesel fuel (so-called "pilot fuel") for ignition. In case of a gas supply failure or maximum power demand these engines will instantly switch back to full diesel fuel operation.