What are the differences between the previous and current guidelines for the management of adult bronchiectasis?

Comparison of 2017 vs 2025 ERS Bronchiectasis Guidelines

The 2025 ERS guidelines represent a major evolution from 2017, upgrading multiple conditional recommendations to strong recommendations based on substantially improved evidence quality, particularly for airway clearance techniques, pulmonary rehabilitation, long-term macrolides, and inhaled antibiotics in high-risk patients. 1

Key Strength-of-Recommendation Upgrades

Airway Clearance Techniques

• 2017: Weak/conditional recommendation (low quality evidence) 2
• 2025: Strong recommendation for most patients with bronchiectasis (improved evidence base) 1
• This reflects the accumulation of high-quality data over 8 years demonstrating clear benefits on morbidity and quality of life

Pulmonary Rehabilitation

• 2017: Strong recommendation only for patients with impaired exercise capacity (high quality evidence) 2
• 2025: Strong recommendation maintained and emphasized for those with impaired exercise capacity 1
• The strength remains consistent, but implementation guidance has been enhanced

Long-Term Macrolide Therapy

• 2017: Conditional recommendation for patients with ≥3 exacerbations/year (moderate quality evidence) 2
• 2025: Strong recommendation for patients at high risk of exacerbations (upgraded evidence quality) 1
• Critical shift: The 2025 guideline moves beyond simple exacerbation counting to comprehensive risk assessment including baseline symptom severity, underlying etiology, and pathogen colonization

Major Conceptual Changes

Risk Stratification Approach

The 2025 guidelines introduce a paradigm shift from the 2017 threshold-based approach:

• 2017 approach: Binary cutoff of "≥3 exacerbations per year" to trigger long-term antibiotic consideration 2
• 2025 approach: Multidimensional risk assessment incorporating:
  • Prior exacerbation history
  • Baseline symptom severity
  • Underlying cause of bronchiectasis
  • Chronic Pseudomonas aeruginosa infection status
  • Additional risk factors 1, 3

This represents a more nuanced, individualized approach to identifying patients who will benefit from preventive therapies.

Inhaled Antibiotics for Pseudomonas aeruginosa

• 2017: Conditional recommendation for chronic P. aeruginosa infection (moderate quality evidence) 2
• 2025: Strong recommendation for patients with chronic P. aeruginosa infection at high risk of exacerbation 1
• The upgrade reflects multiple large RCTs demonstrating mortality and morbidity benefits in appropriately selected patients

Recommendations That Remained Stable

Inhaled Corticosteroids

• Both guidelines suggest NOT routinely using inhaled corticosteroids in bronchiectasis without comorbid asthma/COPD 2, 1
• This negative recommendation has been consistently maintained with no change in strength

Recombinant Human DNase

• Both guidelines maintain a strong recommendation AGAINST using rhDNase in bronchiectasis (can cause harm) 2, 1

Eradication Therapy for Pseudomonas aeruginosa

• Both 2017 and 2025 maintain conditional recommendations for eradication treatment with new P. aeruginosa isolation 2, 1
• Evidence quality remains low/very low for this intervention

New Guidance in 2025

The 2025 guidelines provide expanded content not present in 2017:

• Enhanced algorithms for managing the deteriorating patient 1, 3
• More detailed guidance on exacerbation management beyond just antibiotic duration 1
• Clearer implementation pathways for translating recommendations into practice 4, 3
• Specific guidance on non-macrolide oral antibiotics: 2025 explicitly recommends against routine use (2017 had conditional support in limited circumstances) 1

Evidence Base Evolution

The 2017 guidelines explicitly noted that "the majority of recommendations were conditional and based on low or very low certainty of evidence, largely due to a lack of high-quality randomised controlled trials" 1. The 2025 update reflects:

• 8 years of additional RCT data from patient registries and clinical trials 1
• Improved understanding of disease heterogeneity and phenotyping 5
• Better quality evidence allowing upgrade of multiple recommendations from conditional to strong

Clinical Implications

For High-Risk Patients (2025 Definition)

The treatment algorithm is now more aggressive and evidence-based:

1. Airway clearance techniques (strong recommendation) 1
2. Pulmonary rehabilitation if exercise capacity impaired (strong recommendation) 1
3. Long-term macrolides for high exacerbation risk (strong recommendation) 1
4. Inhaled antibiotics if chronic P. aeruginosa and high risk (strong recommendation) 1

Common Pitfall to Avoid

Do not apply the old 2017 "≥3 exacerbations/year" threshold mechanistically. The 2025 guidelines require comprehensive risk assessment that may identify high-risk patients with fewer than 3 exacerbations if they have severe baseline symptoms, specific etiologies, or chronic P. aeruginosa infection 1, 3.