What does the European Respiratory Society clinical practice guideline recommend for the management of adult bronchiectasis?

European Respiratory Society Guidelines for Adult Bronchiectasis Management

The 2025 European Respiratory Society guidelines establish airway clearance techniques as the universal foundation of bronchiectasis management, with escalation to long-term antibiotics (macrolides or inhaled agents) reserved exclusively for patients experiencing ≥3 exacerbations per year after optimizing non-pharmacological therapy. 1

Diagnostic Workup

Minimum testing bundle required for all newly diagnosed patients: 2

• Differential blood count to detect immunodeficiency patterns 2
• Serum immunoglobulins (total IgG, IgA, IgM) to identify antibody deficiencies 2
• Testing for allergic bronchopulmonary aspergillosis (ABPA) 2
• Sputum culture for bacterial pathogens and mycobacteria at every clinical visit 2

Additional testing should be pursued when clinical features suggest specific etiologies (e.g., CFTR testing for upper-lobe disease with chronic sinusitis, or mycobacterial cultures for cavitary disease). 2

First-Line Management: Airway Clearance

All adults with bronchiectasis must receive instruction in airway clearance techniques from a trained respiratory physiotherapist, performing 10-30 minute sessions once or twice daily. 2, 1 This is a strong recommendation based on high-quality evidence showing improvements in sputum clearance, quality of life, and exacerbation reduction. 1, 3

Preferred techniques: 4

• Active cycle of breathing techniques (first-line) 4
• Oscillating positive expiratory pressure (PEP) devices (first-line) 4
• Incorporate forced expiration (huff) maneuver with every session 4
• Use gravity-assisted positioning unless contraindicated by gastroesophageal reflux 4

Review airway clearance technique within 3 months of initiation and conduct annual reassessments to optimize the regimen. 4 During acute exacerbations requiring hospitalization, provide daily physiotherapy visits. 4

Pulmonary Rehabilitation

Patients with impaired exercise capacity should enroll in a supervised 6-8 week pulmonary rehabilitation program. 2, 1 This is a strong recommendation supported by high-quality evidence demonstrating improvements in exercise capacity, cough symptoms, quality of life, and reduced exacerbation frequency. 2, 1

Management of Acute Exacerbations

Treat every exacerbation with a 14-day course of antibiotics; this duration is superior to shorter courses in reducing treatment failure. 2, 5, 6 Select antibiotics based on the most recent sputum culture and sensitivity results obtained before therapy whenever possible. 2, 5

Empiric antibiotic selection when cultures unavailable: 5, 6

• Amoxicillin 500mg three times daily for Streptococcus pneumoniae or Haemophilus influenzae (14 days) 5, 6
• Ciprofloxacin 500-750mg twice daily for Pseudomonas aeruginosa (14 days) 5, 6

Intravenous antibiotics should be considered for severe exacerbations, treatment failures, or resistant organisms, maintaining the 14-day duration. 6

Eradication of New Pseudomonas aeruginosa Isolation

Offer eradication therapy when P. aeruginosa is first isolated or re-emerges with clinical deterioration. 2, 4 The clinical impact of chronic P. aeruginosa infection includes a three-fold increase in mortality, seven-fold increase in hospitalization risk, and one additional exacerbation per year. 4

Do not attempt eradication for pathogens other than P. aeruginosa. 2

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

Long-term antibiotics should only be initiated after patients experience ≥3 exacerbations per year, following optimization of airway clearance techniques and treatment of underlying causes. 2, 5, 6 This is a conditional recommendation based on moderate-quality evidence. 2

For Chronic Pseudomonas aeruginosa Infection:

First-line: Long-term inhaled antibiotics (strong recommendation). 2, 1

• Inhaled colistin 1 million units twice daily via I-neb 5
• Administer a short-acting bronchodilator before inhaled antibiotics to prevent bronchospasm (occurs in 10-32% of patients) 4
• Perform supervised test dose with pre- and post-spirometry to assess tolerance 4, 6

Second-line: Macrolides (azithromycin or erythromycin) if inhaled antibiotics are contraindicated, not tolerated, or ineffective. 2

For Patients Without Pseudomonas aeruginosa:

First-line: Long-term macrolides (azithromycin or erythromycin) (strong recommendation). 2, 1

• Before initiating macrolides, exclude active nontuberculous mycobacterial (NTM) infection, as macrolide monotherapy increases macrolide resistance in NTM. 4, 6
• The EMBRACE study demonstrated azithromycin for 6 months reduced exacerbations (RR 0.38,95% CI 0.26-0.54) 6

Second-line: Oral non-macrolide antibiotics based on antibiotic susceptibility if macrolides are contraindicated, not tolerated, or ineffective. 2

Minimum treatment duration: 6 months with regular reassessment to determine ongoing clinical benefit. 6 During long-term antibiotic therapy, perform regular sputum culture and sensitivity monitoring to track resistance patterns and identify treatment-emergent organisms. 4, 6

Mucoactive Therapy

Offer long-term mucoactive treatment (≥3 months) to patients with difficulty expectorating sputum and poor quality of life where standard airway clearance techniques have failed. 2, 6 Consider humidification with sterile water or normal saline to facilitate airway clearance. 4

Recombinant human DNase (dornase alfa) is contraindicated in non-cystic fibrosis bronchiectasis because it worsens clinical outcomes. 2, 4, 1 This is a strong recommendation based on moderate-quality evidence. 2

Bronchodilator Therapy

Do not routinely offer long-acting bronchodilators for adult patients with bronchiectasis. 2 However, offer a trial of long-acting bronchodilators (LABA, LAMA, or combination) for patients with significant breathlessness, particularly those with chronic obstructive airflow limitation. 2, 4, 1

Administer bronchodilators before physiotherapy sessions and before inhaled antibiotics to improve pulmonary drug deposition and tolerability. 2, 4 If no symptomatic improvement is observed after an adequate trial, discontinue bronchodilator therapy. 4, 1

Anti-Inflammatory Treatments

Do not routinely offer inhaled corticosteroids to adults with bronchiectasis. 2, 5, 1 This is a conditional recommendation based on low-quality evidence. 2

The diagnosis of bronchiectasis should not affect the use of inhaled corticosteroids in patients with comorbid asthma or COPD; follow asthma or COPD guideline recommendations for these patients. 2

Do not offer statins for the treatment of bronchiectasis. 2 This is a strong recommendation. 2

Immunizations

Offer annual influenza vaccination to all patients with bronchiectasis. 4, 5

Offer pneumococcal vaccination to all patients with bronchiectasis. 4, 5 Use the 23-valent pneumococcal polysaccharide vaccine; in patients who do not achieve adequate serologic response, consider the 13-valent pneumococcal conjugate vaccine. 4

Surgical Management

Surgery is not recommended except in cases of localized disease with high exacerbation frequency despite optimization of all other management aspects. 2, 5, 1 Video-assisted thoracoscopic surgery (VATS) is preferred over open surgery to preserve lung function and reduce scarring. 4

Emergency surgery for massive hemoptysis in unstable patients carries mortality rates reaching 37%. 4, 1

Lung Transplantation Referral

Consider transplant referral for patients ≤65 years old with FEV₁ <30% predicted accompanied by significant clinical instability or rapid progressive respiratory deterioration despite optimal medical therapy. 4, 5, 1 Additional factors warranting earlier referral include massive hemoptysis, severe secondary pulmonary hypertension, ICU admissions, or respiratory failure. 4

Critical Pitfalls to Avoid

Do not extrapolate treatments from cystic fibrosis bronchiectasis to non-CF bronchiectasis, as treatment responses differ significantly. 4, 5 The 2025 ERS guidelines emphasize that bronchiectasis is a heterogeneous disease requiring individualized approaches based on exacerbation frequency, microbiology, and disease severity. 1, 7

Ensure comprehensive sputum analysis (bacteria, mycobacteria, fungi) before and after initiating chronic antibiotics to guide drug choice, monitor resistance patterns, and detect emergent pathogens. 4 Drug toxicity monitoring is required, especially for macrolides and inhaled aminoglycosides, to detect adverse effects such as ototoxicity or hepatic injury. 4, 6