What are the key recommendations of the 2025 European Respiratory Society (ERS) guidelines for managing bronchiectasis?

Key Recommendations of the 2025 European Respiratory Society (ERS) Guidelines for Bronchiectasis Management

The 2025 European Respiratory Society (ERS) guidelines for bronchiectasis management strongly recommend airway clearance techniques, pulmonary rehabilitation, long-term macrolide treatment for high-risk patients, and inhaled antibiotics for those with chronic Pseudomonas aeruginosa infection. 1

Definition and Diagnostic Criteria

• Bronchiectasis is defined as a chronic respiratory disease characterized by permanent dilation of the bronchi (visible on CT scan) with clinical symptoms of cough, sputum production, and recurrent respiratory infections 2
• Diagnosis requires both clinical symptoms and radiological confirmation (permanent bronchial dilation on high-resolution CT scan) 2, 1
• The condition involves destruction of elastic and muscular components of bronchial walls, leading to permanent and abnormal dilation of the airways 2

Core Treatment Recommendations

Airway Clearance and Pulmonary Rehabilitation

• Strong recommendation for airway clearance techniques for most patients with bronchiectasis 1
• Strong recommendation for pulmonary rehabilitation for patients with impaired exercise capacity 1
• Regular airway clearance techniques are essential components of bronchiectasis management, tailored to individual needs and age-appropriate techniques 2, 3

Antibiotic Management

• Strong recommendation for long-term macrolide treatment for patients at high risk of exacerbations 1
• Strong recommendation for long-term inhaled antibiotics in patients with chronic Pseudomonas aeruginosa infection who are at high risk of exacerbation 1
• Conditional recommendation for eradication treatment of pathogens in specific circumstances 1
• Antibiotics play key roles in preventing exacerbations, eradicating pathogens, and managing acute exacerbations, guided by culture sensitivities and symptoms 3

Other Pharmacological Interventions

• Conditional recommendation for mucoactive drugs in specific circumstances 1
• Recommendation against routine use of long-term oral, non-macrolide antibiotic treatment 1
• Recommendation against routine use of inhaled corticosteroids 1
• Bronchodilators are used to address airflow obstruction in appropriate patients 2

Diagnostic Approach

• Minimum panel of tests recommended for children/adolescents with suspected or confirmed bronchiectasis includes: 4

  1. Chest CT scan (to diagnose bronchiectasis)
  2. Sweat test
  3. Lung function tests (in patients who can perform spirometry)
  4. Full blood count
  5. Immunological tests (total IgG, IgA, IgM, IgE and specific antibodies to vaccine antigens)
  6. Lower airway bacteriology

• Additional tests should be considered based on clinical presentation, including: 4

  1. In-depth immunological assessments
  2. Diagnostic bronchoscopy with bronchoalveolar lavage
  3. Tests for airway aspiration
  4. Tests for primary ciliary dyskinesia
  5. Tests for gastro-esophageal disease

Management of Exacerbations

• Exacerbations are associated with increased inflammation, accelerated lung function decline, and higher mortality 2, 5
• Exacerbations should be treated with appropriate antibiotics (oral or intravenous) based on culture results 5
• Patients with ≥3 exacerbations annually may benefit from long-term inhaled antibiotics or daily oral macrolides 5

Preventive Measures

• Vaccinations, including pneumococcal and influenza vaccines, are crucial for preventing infections and complications 3
• Early diagnosis and intervention are important to potentially reverse bronchial wall dilatation in early disease 4
• Strategies to prevent bronchiectasis include addressing household crowding, prematurity, and preventing frequent, early-onset and severe acute lower respiratory tract infections 4

Special Considerations

• Surgery and lung transplantation are reserved for severe, refractory cases after failure of medical therapies 3, 5
• The guidelines provide a framework for optimal management while acknowledging that bronchiectasis is heterogeneous and requires individualized approaches based on underlying causes and clinical presentation 1

Implementation Considerations

• The guidelines aim to serve as a benchmark for evaluating quality of care 1
• Access and strategies to improve early diagnosis and interventions to prevent and/or reverse bronchiectasis are required 4
• Management requires a multidisciplinary approach, including physiotherapy, pharmacotherapy, and vaccinations 3

The 2025 ERS bronchiectasis guidelines emphasize the importance of early diagnosis, targeted treatment based on underlying causes, and comprehensive management strategies to optimize lung function, enhance quality of life, minimize exacerbations, and prevent complications.