What are the latest guidelines for managing bronchiectasis?

Latest Bronchiectasis Guidelines

The most recent comprehensive guidelines for managing adult bronchiectasis are the 2019 British Thoracic Society (BTS) guidelines and the 2017 European Respiratory Society (ERS) guidelines, with a 2025 ERS update providing the most current evidence-based recommendations. 1, 2

Core Management Principles

The primary treatment objectives are preventing exacerbations, reducing symptom burden, improving quality of life, and preventing disease progression including lung function decline and mortality. 3, 4, 5

Key Context

Bronchiectasis causes quality of life impairment equivalent to severe COPD and idiopathic pulmonary fibrosis, with approximately 50% of European patients experiencing ≥2 exacerbations annually and one-third requiring hospitalization. 3, 4 Pseudomonas aeruginosa infection confers a 3-fold increased mortality risk, 7-fold increased hospitalization risk, and one additional exacerbation per year. 3, 4

Diagnostic Confirmation

• High-resolution CT (HRCT) without contrast is the gold standard for confirming permanent bronchial dilatation and establishing the diagnosis. 4, 5
• All patients require comprehensive etiological workup including differential blood count, serum immunoglobulins (IgG, IgA, IgE, IgM), testing for allergic bronchopulmonary aspergillosis, and sputum culture for bacteria, mycobacteria, and fungi. 4

Non-Pharmacological Management (Strong Recommendations)

Airway Clearance Techniques

• All patients with chronic productive cough or difficulty expectorating must be taught airway clearance techniques by a trained respiratory physiotherapist. 4, 5, 2
• Techniques include active cycle of breathing, postural drainage, and manual or mechanical devices performed for 10-30 minutes once or twice daily. 4
• This is a strong recommendation with high-quality evidence from the 2025 ERS guidelines. 2

Pulmonary Rehabilitation

• Strongly recommended for all patients with impaired exercise capacity. 1, 4, 2
• Benefits include improved exercise capacity, reduced cough symptoms, enhanced quality of life, and decreased exacerbation frequency. 4
• This represents a strong recommendation with high-quality evidence. 2

Pharmacological Management

Acute Exacerbations

• Treat all exacerbations with 14 days of antibiotics to reduce treatment failure risk and improve outcomes. 4, 5
• Select antibiotics based on previous sputum culture results whenever possible. 4
• Obtain sputum cultures before starting antibiotics. 4

Long-Term Antibiotic Therapy

Critical decision point: Consider long-term antibiotics ONLY for patients with ≥3 exacerbations per year, and ONLY after optimizing airway clearance and treating modifiable underlying causes. 4, 5

For Chronic Pseudomonas aeruginosa Infection:

• First-line: Long-term inhaled antibiotics (colistin or gentamicin) - this is a strong recommendation. 4, 5, 2
• This addresses the dramatic impact of P. aeruginosa on outcomes. 3, 5

For Patients WITHOUT Pseudomonas aeruginosa:

• First-line: Macrolides (azithromycin or erythromycin) for patients with ≥3 exacerbations per year. 1, 4, 5, 2
• This is a strong recommendation for high-risk patients. 2

Pseudomonas aeruginosa Eradication:

• Offer eradication treatment for new growth of P. aeruginosa (first isolation or regrowth). 1
• First-line: Ciprofloxacin 500-750 mg twice daily for 2 weeks. 1
• Second-line: IV antipseudomonal beta-lactam ± IV aminoglycoside for 2 weeks, followed by 3 months of nebulized colistin, gentamicin, or tobramycin. 1

What NOT to Routinely Use

• Do NOT routinely offer long-acting bronchodilators for all patients with bronchiectasis. 4, 2
• Do NOT routinely offer inhaled corticosteroids unless comorbid asthma or COPD is present. 4, 5, 2
• Do NOT use recombinant human DNase (dornase alfa) in non-CF bronchiectasis, as it may worsen outcomes. 5
• Do NOT routinely use long-term oral, non-macrolide antibiotics. 2

Immunizations (Strong Recommendations)

• Offer annual influenza immunization to all patients. 1, 4, 5
• Offer polysaccharide pneumococcal vaccination (23-valent) to all patients. 1, 4
• Consider 13-valent protein conjugate pneumococcal vaccine in patients without appropriate serological response to standard vaccine. 1
• Consider influenza vaccination in household contacts of immunodeficient patients to reduce secondary transmission. 1

Advanced Therapies

Oxygen and Ventilation

• Consider long-term oxygen therapy for patients with respiratory failure, using the same eligibility criteria as COPD. 1
• Consider domiciliary non-invasive ventilation with humidification for patients with respiratory failure associated with hypercapnia, especially with symptoms or recurrent hospitalization. 1

Surgical Management

• Do NOT offer surgery except for patients with localized disease and high exacerbation frequency despite optimization of all medical management. 4, 5
• Requires multidisciplinary assessment including bronchiectasis physician, thoracic surgeon, and experienced anesthetist. 1
• Video-assisted thoracoscopic surgery (VATS) is preferred over open surgery. 4

Lung Transplantation

• Consider transplant referral for patients aged ≤65 years if FEV₁ <30% with significant clinical instability or rapid progressive respiratory deterioration despite optimal medical management. 1, 4, 5
• Consider earlier referral with additional factors: massive hemoptysis, severe secondary pulmonary hypertension, ICU admissions, or respiratory failure requiring NIV. 1

Monitoring and Follow-Up

• Record patient's weight and BMI at each clinic appointment. 1
• Regular monitoring of sputum pathogens is essential, especially when using long-term antibiotics. 4
• Monitor for drug toxicity, particularly with macrolides and inhaled aminoglycosides. 4
• Annual assessment by respiratory physiotherapist to optimize airway clearance regimen. 4

Critical Clinical Pitfalls to Avoid

• Underutilization of airway clearance techniques and pulmonary rehabilitation despite strong evidence for benefit. 3, 5
• Failure to identify and aggressively treat P. aeruginosa infection given its dramatic impact (3-fold mortality increase, 7-fold hospitalization increase). 3, 5
• Inadequate etiological workup missing treatable causes like immunodeficiency or ABPA. 3, 5
• Extrapolating treatments from cystic fibrosis bronchiectasis, as treatment responses differ significantly. 5
• Routinely prescribing inhaled corticosteroids without comorbid asthma or COPD. 5

Guideline Hierarchy

The 2025 ERS guidelines 2 represent the most recent update, building upon the 2019 BTS guidelines 1 and 2017 ERS guidelines 1. All use GRADE methodology to define quality of evidence and strength of recommendations. 1, 2 The strong recommendations for airway clearance, pulmonary rehabilitation, macrolides for frequent exacerbators, and inhaled antibiotics for chronic P. aeruginosa infection represent the highest quality evidence available. 2