Bronchiectasis Management
All adults with bronchiectasis should receive airway clearance techniques as foundational therapy, with long-term macrolide antibiotics strongly recommended for patients experiencing ≥2 exacerbations per year, and long-term inhaled antibiotics specifically for those with chronic Pseudomonas aeruginosa infection at high exacerbation risk. 1
Core Management Framework
Non-Pharmacological Interventions (Foundational for All Patients)
Airway clearance techniques receive a strong recommendation for most patients with bronchiectasis and should be implemented as first-line therapy 1. These techniques directly address impaired mucociliary clearance, which is central to disease pathophysiology 2.
Pulmonary rehabilitation is strongly recommended for patients with impaired exercise capacity, targeting dyspnea, fatigue, and quality of life 1, 3.
Risk Stratification for Pharmacotherapy
The 2025 ERS guidelines emphasize identifying high-risk patients who warrant long-term antibiotic therapy. High-risk is defined as:
- ≥2 exacerbations per year, OR
- 1 exacerbation per year plus severe baseline symptoms, OR
- ≥1 severe exacerbation requiring hospitalization per year 1
This risk-based approach represents a significant evolution from treating all patients uniformly and allows targeted intervention for those most likely to benefit 3.
Pharmacological Management Algorithm
For High-Risk Patients WITHOUT Chronic P. aeruginosa
Long-term macrolide therapy is the clear first-line option (strong recommendation) 1. This represents the most robust evidence base for reducing exacerbations and improving quality of life in bronchiectasis 2.
Critical caveat: Non-tuberculous mycobacteria (NTM) must be excluded before initiating macrolides, as monotherapy can promote macrolide resistance in NTM 1, 4.
For High-Risk Patients WITH Chronic P. aeruginosa
Patients may receive either long-term macrolides or long-term inhaled antibiotics as first-line treatment (both strong recommendations) 1. The choice should be individualized based on:
- Patient preference
- Tolerance and adverse effect profile
- Treatment burden considerations
Figure 3 algorithm from ERS guidelines: After 12 months of treatment, reassess response. If inadequate, consider switching between macrolide and inhaled antibiotic, or adding the alternative therapy 1.
Treatments to AVOID Routinely
The guidelines issue conditional recommendations against:
This is a critical distinction from COPD and asthma management. ICS lack evidence for benefit in bronchiectasis and may increase infection risk 4.
Acute Exacerbation Management
Defining an Exacerbation
Acute deterioration over several days with:
- Worsening local symptoms (increased cough, sputum volume/purulence, hemoptysis)
- Increased breathlessness or wheeze
- Systemic upset 5
Antibiotic Selection
Obtain sputum culture before starting antibiotics when possible 5. Previous culture results guide empirical therapy:
Common pathogens and first-line oral antibiotics (14-day course):
- Streptococcus pneumoniae: Amoxicillin 500mg-1g TID 5
- Haemophilus influenzae (β-lactamase negative): Amoxicillin 500mg TID 5
- H. influenzae (β-lactamase positive): Amoxicillin-clavulanate 625mg TID 5
- Moraxella catarrhalis: Amoxicillin-clavulanate 625mg TID 5
Important: Despite widespread use, there are no placebo-controlled RCTs proving antibiotic efficacy in bronchiectasis exacerbations—the evidence base is surprisingly weak 5. However, clinical practice universally supports their use, and cohort studies show good responses 5.
Pseudomonas aeruginosa Eradication
Conditional recommendation: Offer eradication treatment for new P. aeruginosa isolation 1.
First-line eradication regimen:
- Ciprofloxacin 500-750mg BD for 2 weeks 5
Second-line (if first-line fails):
- IV anti-pseudomonal β-lactam ± aminoglycoside for 2 weeks
- Followed by 3 months of nebulized colistin, gentamicin, or tobramycin 5
Evidence limitation: Only ~40% achieve sustained eradication at 12 months, and all evidence comes from observational studies 1. However, preventing chronic P. aeruginosa infection is clinically important as it associates with worse outcomes.
Mucoactive Drugs
Conditional recommendation for use in specific circumstances 1. These agents (hypertonic saline, mannitol) may benefit patients with difficulty expectorating sputum, but evidence is limited and should be used adjunctively with airway clearance techniques 2.
Key Pitfalls to Avoid
Do not treat bronchiectasis like COPD or asthma: ICS are not routinely indicated and differ fundamentally in evidence base 4
Do not start macrolides without NTM testing: This creates resistant NTM infections that are extremely difficult to treat 1, 4
Do not use antibiotics for every sputum culture positive: Treat clinical exacerbations, not colonization 5
Do not forget vaccination: Pneumococcal and influenza vaccines are crucial preventive measures 6
Reassess treatment response: The ERS algorithm recommends 12-month evaluation of long-term antibiotics, with earlier reassessment if adverse events or deterioration occur 1
Multidisciplinary Approach
Optimal management requires coordination between:
- Primary care (most patient interactions, exacerbation management) 4
- Respiratory specialists (diagnosis, complex management)
- Physiotherapists (airway clearance techniques)
- Consideration of surgery only for severe, localized, refractory disease 6, 7
The 2025 ERS guidelines 1 represent the most current, comprehensive, evidence-based framework and should guide contemporary practice, superseding older approaches that lacked risk stratification and targeted therapy.