Management of Adult Bronchiectasis: Diagnostic and Therapeutic Strategies
All adults newly diagnosed with bronchiectasis must undergo standardized testing to identify underlying causes, assess disease severity using the Bronchiectasis Severity Index (BSI), and identify treatable traits and comorbidities 1.
Diagnostic Workup
Imaging Confirmation
- Obtain thin-section CT chest to confirm diagnosis when clinically suspected, ideally during stable disease 2
- Diagnostic CT criteria include: bronchoarterial ratio >1, lack of bronchial tapering, or airway visibility within 1 cm of pleural surface 2
- Baseline chest X-ray should precede CT imaging 2
Mandatory Laboratory Screening (All Patients)
The 2025 ERS guideline provides the most comprehensive and current framework 1:
Blood tests:
- Serum immunoglobulins (IgG, IgM, IgA) to screen for immunodeficiency
- Total IgE, Aspergillus-specific IgG and IgE, plus blood eosinophils for ABPA screening
- Consider alpha-1 antitrypsin only if basal emphysema or severe airflow obstruction present
Sputum analysis:
- Mycobacterial microscopy and culture for all patients
- Obtain minimum three sputum samples or bronchoalveolar lavage in high-risk patients based on clinical/radiological features 1
Additional testing based on clinical features:
- Screen for cystic fibrosis and primary ciliary dyskinesia if childhood symptom onset or suggestive radiological patterns 1
Severity Assessment and Risk Stratification
Calculate BSI score at diagnosis to identify patients requiring intensive management 1. High-risk patients warranting closer follow-up and lower treatment thresholds include those with:
- COPD, primary ciliary dyskinesia, or rheumatoid arthritis-associated bronchiectasis
- Pseudomonas aeruginosa or other enteric Gram-negative infections
- ≥2 exacerbations annually or ≥1 severe exacerbation (hospitalization/IV antibiotics) in previous year
- High daily sputum volumes with purulence
- NTM infection or ABPA
Comorbidity Screening
Systematically assess for 1:
- Cardiovascular disease in at-risk patients
- Osteoporosis in at-risk patients
- Anxiety and depression symptoms
- Rhinosinusitis and gastroesophageal reflux disease
Therapeutic Strategies
Core Non-Pharmacological Management
Airway clearance techniques are strongly recommended for most patients 1, 3. This represents a foundational intervention that should be implemented early.
Pulmonary rehabilitation is strongly recommended for patients with dyspnea or impaired exercise capacity 1, 3. Regular exercise participation should be encouraged for all patients 4.
Pharmacological Management
Long-term Antibiotic Therapy
For patients at high risk of exacerbations (≥3 exacerbations annually), long-term macrolide therapy is strongly recommended 1, 3. This typically involves azithromycin and represents one of the strongest evidence-based interventions 4.
For patients with chronic Pseudomonas aeruginosa infection and frequent exacerbations, long-term inhaled antibiotics (colistin or gentamicin) are strongly recommended 1, 4, 3. This targets the specific pathogen driving disease progression.
Eradication therapy for newly identified P. aeruginosa is conditionally recommended 1, 3.
Anti-inflammatory and Mucoactive Agents
Routine long-term use of inhaled corticosteroids is NOT recommended unless concurrent asthma or COPD is present 1, 5, 4. This is a critical distinction from asthma/COPD management.
Mucoactive agents (nebulized saline) are conditionally recommended and may help loosen tenacious secretions 1, 4.
Inhaled bronchodilators are indicated only when concurrent asthma or COPD exists 4.
Novel Targeted Therapy
Brensocatib, a dipeptidyl peptidase 1 inhibitor, received FDA approval in August 2025 for non-cystic fibrosis bronchiectasis, representing the first mechanism-oriented targeted therapy for specific inflammatory endotypes 6.
Acute Exacerbation Management
Treat exacerbations promptly with oral or intravenous antibiotics based on severity and prior sputum culture results 7, 4. Exacerbations drive progressive lung function decline and mortality risk, making aggressive treatment essential.
Advanced Interventions
Consider lung transplantation for patients with severely impaired pulmonary function, frequent exacerbations despite optimal medical therapy, or both 4.
Surgical resection may be appropriate in highly selected patients with localized disease 7.
Implementation Considerations
The 2025 ERS guideline emphasizes that assessment of underlying cause, comorbidities, disease activity, and treatable traits should occur at every patient visit, not just at diagnosis 1. This ongoing reassessment allows for treatment optimization as disease evolves.
Treatment burden, cost, and quality of life impact must factor into therapeutic decisions 1, 7. Shared decision-making using a multidisciplinary approach is paramount 7.
The shift toward biomarker-driven endotyping (such as sputum neutrophil elastase activity and blood eosinophil counts) enables precision medicine approaches that are replacing one-size-fits-all strategies 6.