What does the latest American Thoracic Society guideline recommend for the treatment and management of adult bronchiectasis?

American Thoracic Society Bronchiectasis Treatment Guidelines

Note: The evidence provided consists primarily of British Thoracic Society (BTS) and European Respiratory Society (ERS) guidelines from 2019-2025, not ATS guidelines. The most recent and comprehensive recommendations come from the 2025 ERS Clinical Practice Guideline, which represents the current international standard of care. 1

Core Treatment Pillars

1. Airway Clearance Techniques (Foundation of All Management)

Every adult with bronchiectasis must receive instruction from a trained respiratory physiotherapist in airway clearance techniques—this is the cornerstone of therapy regardless of disease severity. 2

• Technique selection: Offer active cycle of breathing techniques OR oscillating positive expiratory pressure (PEP) devices as first-line options 3
• Duration and frequency: Perform 10-30 minutes once or twice daily until achieving two clear huffs or coughs 2, 4
• Forced expiration technique (huff): Incorporate with every airway clearance method to enhance mucus mobilization 3
• Gravity-assisted positioning: Use modified postural drainage (without head-down tilt) unless contraindicated by gastroesophageal reflux 3
• Alternative techniques: Consider autogenic drainage, high-frequency chest wall oscillation, or intrapulmonary percussive ventilation when standard methods fail or are not tolerated 3
• Follow-up schedule: Review technique within 3 months of initiation and conduct annual reassessments 2
• During exacerbations: Hospitalized patients require daily physiotherapy visits until airway clearance is optimized 3

2. Mucoactive Therapy

Consider adding mucoactive agents only for patients who continue struggling with sputum expectoration despite optimal airway clearance techniques. 2

• Humidification: Nebulized isotonic (0.9%) or hypertonic saline (≥3%) facilitates sputum clearance in patients with viscous secretions 2, 5, 4
• Pre-treatment requirements: Perform airway-reactivity challenge test before initiating hyperosmolar agents; pre-treat with bronchodilator if FEV₁ < 1L or documented bronchial hyper-reactivity 5
• Carbocysteine trial: Consider 6-month trial; continue only if clinical benefit observed 2
• Recombinant human DNase (dornase alfa): Absolutely contraindicated in non-CF bronchiectasis—it worsens clinical outcomes 2, 4, 1

3. Management of Acute Exacerbations

Treat every exacerbation with a 14-day antibiotic course—this duration reduces treatment failure compared to shorter regimens. 2, 4, 1

Antibiotic Selection Algorithm:

• Always obtain sputum culture before starting antibiotics whenever possible 2, 4
• Base antibiotic choice on most recent sputum culture and sensitivity results 2, 4

Empiric therapy when cultures unavailable:

• Streptococcus pneumoniae or Haemophilus influenzae: Amoxicillin 500mg three times daily for 14 days 2

• Pseudomonas aeruginosa: Ciprofloxacin 500-750mg twice daily for 14 days 2

• Escalation to IV antibiotics: Consider for severely unwell patients, resistant organisms, or failure to respond to oral therapy 4

• Self-management: Patients should maintain home antibiotic supply with written action plan for prompt self-initiation 2

4. Long-Term Antibiotic Prophylaxis (≥3 Exacerbations/Year)

Initiate long-term antibiotics only after optimizing airway clearance techniques and only for patients experiencing ≥3 exacerbations annually. 2, 5

For Chronic Pseudomonas aeruginosa Infection:

Clinical significance: P. aeruginosa infection increases mortality risk three-fold, hospitalization risk seven-fold, and adds one additional exacerbation per patient per year 2

Treatment hierarchy:

1. First-line: Inhaled colistin 1 million units twice daily via I-neb 2, 4
2. Second-line: Inhaled gentamicin (if colistin unsuitable) 2
3. Alternative: Long-term macrolide (azithromycin or erythromycin) if inhaled antibiotics contraindicated 2

Safety requirements for inhaled aminoglycosides:

• Avoid if creatinine clearance < 30 mL/min 5
• Use caution with significant hearing loss or vestibular dysfunction 5
• Do not combine with other nephrotoxic medications 5
• Administer short-acting bronchodilator before inhaled antibiotics to prevent bronchospasm (occurs in 10-32% of patients) 2
• Perform supervised test dose with pre- and post-spirometry 2

For Patients Without Pseudomonas aeruginosa:

First-line: Long-term macrolide therapy (e.g., azithromycin 250mg three times weekly) 2, 4

Critical prerequisite: Must confirm absence of nontuberculous mycobacterial (NTM) infection before starting macrolides—monotherapy promotes macrolide-resistant NTM 2

5. Eradication of New Pseudomonas aeruginosa Isolation

Offer eradication therapy when P. aeruginosa is first isolated or re-emerges with clinical deterioration. 2

Eradication protocol:

• First-line: Oral ciprofloxacin 500-750mg twice daily for 2 weeks 2
• Second-line: 2 weeks IV antipseudomonal β-lactam ± aminoglycoside, followed by 3 months nebulized colistin, gentamicin, or tobramycin 2
• Do not attempt eradication for pathogens other than P. aeruginosa 2

6. Pulmonary Rehabilitation

All patients with impaired exercise capacity must enroll in a supervised 6-8 week pulmonary rehabilitation program—this is a strong recommendation based on high-quality evidence. 2, 4, 1

Benefits demonstrated:

• Improves exercise capacity 2, 4, 1

• Reduces cough symptoms 2, 4

• Enhances quality of life 2, 4, 1

• Decreases exacerbation frequency 2, 4

• Maintenance: Encourage regular physical exercise combined with forced expiration technique after formal rehabilitation 2, 4

7. Bronchodilator Therapy

Bronchodilators are NOT routinely recommended for bronchiectasis alone. 5

Indications for bronchodilator trial:

• Significant breathlessness with chronic obstructive airflow limitation (FEV₁/FVC < 0.7) 2, 1
• Co-existing asthma or COPD 2, 5

Trial protocol:

• Offer long-acting bronchodilators (LABA, LAMA, or combination) 2
• Discontinue if no symptomatic improvement after adequate trial 2, 1

Adjunctive use:

• Administer short-acting bronchodilator before physiotherapy sessions 5
• Administer before inhaled antibiotics to improve pulmonary deposition 5

8. Inhaled Corticosteroids

Do not routinely prescribe inhaled corticosteroids for bronchiectasis—they do not improve exacerbation frequency or lung function beyond 6 months and increase adverse events. 5, 4, 1

Only continue ICS when patient has:

• Asthma 5, 4
• COPD meeting treatment criteria 5, 4
• Allergic bronchopulmonary aspergillosis (ABPA) 5
• Inflammatory bowel disease 5

Risks of ICS in bronchiectasis: Adrenal suppression, pneumonia, pharyngeal irritation, dysphonia 5

9. Anti-Inflammatory Treatments

• Long-term oral corticosteroids: Do not offer without specific indications (ABPA, chronic asthma, COPD, inflammatory bowel disease) 2
• Statins: Not recommended for bronchiectasis treatment (strong recommendation) 2

10. Immunizations

Vaccinate all patients with bronchiectasis against influenza and pneumococcus. 2

• Influenza: Annual vaccination for all patients 2
• Pneumococcal: 23-valent polysaccharide vaccine for all patients 2
• Inadequate response: Consider 13-valent conjugate vaccine if serologic response to polysaccharide vaccine is inadequate 2
• Household contacts: Consider influenza vaccination for household contacts of immunodeficient patients 2

11. Sequencing of Inhaled Therapies

When multiple inhaled treatments are prescribed, administer in this order: 5

1. Bronchodilator (if indicated)
2. Mucoactive nebulized saline
3. Airway-clearance technique (10-30 minutes)
4. Nebulized antibiotic (if prescribed)
5. Inhaled corticosteroid (only when asthma or COPD present)

Diagnostic Workup

Minimum test bundle after CT confirmation: 2

• Differential blood count
• Serum immunoglobulin levels (IgG, IgA, IgM)
• Testing for allergic bronchopulmonary aspergillosis
• Sputum culture for bacteria and mycobacteria at every clinical visit
• Serum protein electrophoresis if immunoglobulins elevated 3

Additional investigations:

• Bronchoscopy: Consider for localized disease to exclude endobronchial lesion or foreign body 3, 2
• Bronchial aspiration/wash: For patients who cannot expectorate, particularly helpful for NTM diagnosis 3, 2
• HIV serology: Consider based on prevalence and clinical features 3

Severity Assessment and Monitoring

• Use Bronchiectasis Severity Index to guide management decisions 3, 2
• Obtain sputum culture at every clinical visit to guide antibiotic selection 2
• Comprehensive annual review to assess disease severity and optimize all treatment components 2
• Monitor for drug toxicity with long-term antibiotics, especially macrolides and inhaled aminoglycosides 2, 4
• Secondary-care follow-up required for patients with chronic P. aeruginosa infection, ≥3 exacerbations/year, or on long-term antibiotics 2

Surgical Management

Surgery is reserved for highly selected cases only. 2, 1

Indications:

• Localized disease with high exacerbation frequency despite optimal medical management 2, 1
• Massive hemoptysis refractory to bronchial artery embolization 2

Surgical approach:

• Video-assisted thoracoscopic surgery (VATS) preferred over open surgery to preserve lung function and reduce scarring 2
• Emergency surgery carries mortality up to 37% 2

Lung Transplantation Referral

Refer patients ≤65 years for transplant evaluation when: 2

• FEV₁ < 30% with significant clinical instability OR
• Rapid progressive respiratory deterioration despite optimal medical management

Consider earlier referral with:

• Massive hemoptysis
• Severe secondary pulmonary hypertension
• ICU admissions
• Respiratory failure

Critical Pitfalls to Avoid

1. Never use dornase alfa in non-CF bronchiectasis—it worsens outcomes 2, 4, 1
2. Never start macrolides without excluding NTM infection—promotes resistance 2
3. Never extrapolate CF treatment data to non-CF bronchiectasis—treatment responses differ 2
4. Never prescribe ICS routinely—no benefit and increased adverse events 5, 4, 1
5. Never use antibiotic courses shorter than 14 days for exacerbations—increases treatment failure 2, 4, 1
6. Never initiate long-term antibiotics without first optimizing airway clearance 5
7. Never start hyperosmolar agents without airway-reactivity testing 5