What is the optimal treatment approach for a patient with bronchiectasis, recurrent respiratory infections, and chronic symptoms?

Treatment for Bronchiectasis

The optimal treatment for bronchiectasis requires a comprehensive, multi-component approach targeting chronic infection, inflammation, impaired mucociliary clearance, and structural lung damage, with airway clearance techniques and pulmonary rehabilitation forming the foundation of therapy for all patients. 1, 2, 3

Core Treatment Algorithm

Step 1: Establish Foundational Non-Pharmacological Therapy

All patients with chronic productive cough or difficulty expectorating sputum must receive instruction from a trained respiratory physiotherapist in airway clearance techniques, performed 10-30 minutes once or twice daily. 1, 2, 3 This is a strong recommendation based on the most recent European Respiratory Society guidelines and represents the cornerstone of management. 1, 4

• Patients with impaired exercise capacity should participate in 6-8 weeks of supervised pulmonary rehabilitation, which improves exercise capacity, reduces cough symptoms, enhances quality of life, and decreases exacerbation frequency. 2, 3, 5 This is another strong recommendation from the 2025 ERS guidelines. 4

Step 2: Treat Acute Exacerbations Aggressively

All exacerbations must be treated with 14 days of antibiotics (not the typical 7-10 days used for other respiratory infections) to reduce treatment failure risk and improve outcomes. 1, 2, 3, 5 Antibiotic selection should be based on previous sputum culture results, and sputum cultures should be obtained before starting antibiotics whenever possible. 2

Common pathogens and recommended first-line antibiotics include:

• Haemophilus influenzae (beta-lactamase negative): Amoxicillin 500mg three times daily for 14 days 2
• Streptococcus pneumoniae: Amoxicillin 500mg three times daily for 14 days 2
• Pseudomonas aeruginosa: Ciprofloxacin 500-750mg twice daily for 14 days, or consider intravenous antibiotics for patients who are particularly unwell, have resistant organisms, or have failed to respond to oral therapy 2, 3, 5

Step 3: Consider Long-Term Antibiotic Prophylaxis (Only for High-Risk Patients)

Long-term antibiotics should only be considered for patients with ≥3 exacerbations per year, and only after optimizing airway clearance and treating modifiable underlying causes. 2, 3, 5 This is critical—do not jump to prophylactic antibiotics without first maximizing non-pharmacological therapy.

For patients with chronic Pseudomonas aeruginosa infection:

• First-line treatment is long-term inhaled antibiotics (colistin or gentamicin), as this is a strong recommendation from the 2025 ERS guidelines. 2, 3, 5, 4 This represents a significant evolution from the 2006 ACCP guidelines that recommended against aerosolized antibiotics in non-CF bronchiectasis. 1 The newer evidence clearly demonstrates benefit in patients with chronic P. aeruginosa infection and frequent exacerbations. 2

For patients without Pseudomonas aeruginosa infection:

• First-line treatment is long-term macrolides (azithromycin or erythromycin), which is also a strong recommendation from the 2025 ERS guidelines. 2, 3, 4 However, the 2006 ACCP guidelines noted that prolonged systemic antibiotics may produce small benefits but can be associated with intolerable side effects. 1 The key is patient selection—reserve this for those with ≥3 exacerbations per year despite optimal airway clearance.

Critical caveat: P. aeruginosa infection is associated with a three-fold increase in mortality risk, almost seven-fold increase in risk of hospital admission, and an average of one additional exacerbation per patient per year. 1, 3 Failure to identify and treat this pathogen aggressively is a critical error. 3, 5

Step 4: Bronchodilators (Only for Symptomatic Patients)

Offer a trial of long-acting bronchodilators (LABA, LAMA, or combination) only in patients with significant breathlessness, particularly those with chronic obstructive airflow limitation. 2, 5 If treatment does not result in a reduction in symptoms, it should be discontinued. 1, 2

• The 2006 ACCP guidelines noted there were no randomized studies validating bronchodilator usefulness in bronchiectasis, but recommended their use in patients with airflow obstruction and/or bronchial hyperreactivity based on expert opinion. 1 The more recent guidelines maintain this conditional approach. 2

Step 5: Mucoactive Treatments (Selective Use)

Consider long-term mucoactive treatment (such as nebulized hypertonic saline or humidification with sterile water/normal saline) for patients with difficulty expectorating sputum, poor quality of life, or failure of standard airway clearance techniques. 2, 5

Critical pitfall to avoid: Never use recombinant human DNase (dornase alfa) in non-CF bronchiectasis. 1, 2, 3, 5 This is a strong recommendation against its use, as it may worsen outcomes in non-CF bronchiectasis despite helping CF patients. 3, 5 This is the most dangerous example of extrapolating treatments from cystic fibrosis bronchiectasis, as treatment responses are different. 1, 3, 5

Step 6: Inhaled Corticosteroids (Rarely Indicated)

Do not routinely offer inhaled corticosteroids unless comorbid asthma or COPD is present. 2, 3, 5 Similarly, do not offer long-term oral corticosteroids without other indications such as ABPA, chronic asthma, COPD, or inflammatory bowel disease. 2 The 2006 ACCP guidelines noted that in CF patients, prolonged treatment with systemic corticosteroids should not be offered to most patients because of significant side effects. 1

Step 7: Immunizations (Universal Recommendation)

All patients with bronchiectasis must receive annual influenza immunization and pneumococcal vaccination to prevent infections and complications. 2, 3 Consider influenza vaccination in household contacts of patients with immune deficiency and bronchiectasis. 2

Step 8: Identify and Treat Underlying Causes

All patients must undergo a comprehensive etiological workup to identify treatable underlying causes such as immunodeficiency, ABPA, or non-tuberculous mycobacterial infection. 1, 3, 5 Missing these represents a missed opportunity to address the root cause. 3, 5

• For MAC (Mycobacterium avium complex) infection: Treatment with a macrolide (clarithromycin or azithromycin) with ethambutol and a rifamycin (rifabutin or rifampin) constitutes first-line therapy for patients with severe or progressive symptoms. 1, 2
• For ABPA: Immunosuppression with corticosteroids, with or without antifungal agents, is the mainstay of treatment. 1

Surgical Considerations

Surgery should not be performed except in cases of localized disease with high exacerbation frequency despite optimization of all other aspects of bronchiectasis management. 1, 2, 3, 5 This is a strong recommendation against routine surgery. 4

• Surgery to resect bronchiectatic lung should be limited to patients with local disease who have not responded to maximal medical therapy. 1
• Video-assisted thoracoscopic surgery (VATS) is often preferred to better preserve lung function and reduce scarring compared to open surgery. 2
• Emergency surgery in unstable patients with massive hemoptysis is associated with higher morbidity and mortality reaching 37%. 2

For multilobar disease, surgery is contraindicated because removing multiple lobes would cause unacceptable loss of lung function and respiratory reserve. 5

Lung Transplantation Referral Criteria

Consider transplant referral in bronchiectasis patients aged ≤65 years if FEV1 is <30% with significant clinical instability, or if there is rapid progressive respiratory deterioration despite optimal medical management. 2, 3, 5 Consider earlier transplant referral with additional factors such as massive hemoptysis, severe secondary pulmonary hypertension, ICU admissions, or respiratory failure. 2

Key Clinical Pitfalls and How to Avoid Them

Pitfall #1: Underutilizing airway clearance techniques and pulmonary rehabilitation despite strong evidence for their benefit. 3, 5 These are the foundation of therapy and must be implemented before escalating to pharmacological interventions.

Pitfall #2: Treating exacerbations with inadequate antibiotic duration (less than 14 days), which increases treatment failure risk. 1, 2, 3, 5 This is longer than typical respiratory infection courses and must be emphasized to patients.

Pitfall #3: Failing to identify and aggressively treat P. aeruginosa infection given its dramatic impact on outcomes. 1, 3, 5 Regular sputum surveillance is essential.

Pitfall #4: Using recombinant human DNase (dornase alfa) in non-CF bronchiectasis, which may harm patients. 1, 2, 3, 5

Pitfall #5: Routinely prescribing inhaled corticosteroids without comorbid asthma or COPD. 2, 3, 5

Pitfall #6: Inadequate etiological workup missing treatable causes like immunodeficiency or ABPA. 3, 5

Monitoring Strategy

• Regular monitoring of sputum pathogens is essential, especially when using long-term antibiotics. 5
• Monitor for drug toxicity, particularly with macrolides and inhaled aminoglycosides. 5
• Annual assessment by respiratory physiotherapist to optimize airway clearance regimen. 5
• Breathlessness is one of the strongest predictors of mortality and should trigger intensification of therapy. 3, 5