Treatment of Bronchiectasis

Introduction to Bronchiectasis Management

• The European Respiratory Society recommends that the treatment of bronchiectasis should target the four key components of the disease: chronic bronchial infection, inflammation, impaired mucociliary clearance, and structural lung damage 1

Airway Clearance Techniques

• The British Thoracic Society recommends that all patients with chronic productive cough or difficulty expectorating sputum should be taught airway clearance techniques by a trained respiratory physiotherapist, with sessions lasting 10-30 minutes, once or twice daily 2
• Consider intermittent positive pressure breathing or non-invasive ventilation during acute exacerbations to reduce work of breathing, as recommended by the British Thoracic Society 2

Mucoactive Treatments

• The British Thoracic Society recommends considering long-term mucoactive treatment for patients with difficulty expectorating sputum, poor quality of life, or failure of standard airway clearance techniques, and considering humidification with sterile water or normal saline to facilitate airway clearance 2
• Do not routinely use recombinant human DNase (dornase alfa) in adults with non-CF bronchiectasis, as recommended by the British Thoracic Society 2

Antibiotic Therapy for Exacerbations

• The British Thoracic Society recommends treating exacerbations with 14 days of antibiotics, with selection based on previous sputum culture results, and obtaining sputum cultures before starting antibiotics whenever possible 3
• Common pathogens and recommended antibiotics include Streptococcus pneumoniae: Amoxicillin 500mg TID (14 days), Haemophilus influenzae (beta-lactamase negative): Amoxicillin 500mg TID (14 days), and Pseudomonas aeruginosa: Ciprofloxacin 500-750mg BID (14 days), as recommended by the British Thoracic Society 4

Long-term Antibiotic Therapy

• The British Thoracic Society recommends considering long-term antibiotics for patients with ≥3 exacerbations per year, with first-line treatments including long-term inhaled antibiotics for patients with chronic Pseudomonas aeruginosa infection, and macrolides for patients without Pseudomonas aeruginosa infection 3

Anti-inflammatory Treatments

• The British Thoracic Society recommends not routinely offering inhaled corticosteroids unless comorbid asthma or COPD is present, and not offering long-term oral corticosteroids without other indications, such as ABPA, chronic asthma, COPD, or inflammatory bowel disease 2

Immunizations

• The British Thoracic Society recommends offering annual influenza immunization to all patients with bronchiectasis, and pneumococcal vaccination to all patients with bronchiectasis, as well as considering influenza vaccination in household contacts of patients with immune deficiency and bronchiectasis 5

Lung Transplantation

• The British Thoracic Society recommends considering transplant referral in bronchiectasis patients aged 65 years or less if the FEV1 is <30% with significant clinical instability or if there is rapid progressive respiratory deterioration despite optimal medical management, and considering earlier transplant referral with additional factors, such as massive hemoptysis, severe secondary pulmonary hypertension, ICU admissions, or respiratory failure 5

Management of Bronchiectasis

Pharmacological Interventions

• The European Respiratory Society suggests the use of bronchodilators in patients with significant breathlessness, with appropriate inhalation device selection and inhaler technique training 6
• If treatment with bronchodilators does not result in a reduction in symptoms, it should be discontinued, as recommended by the European Respiratory Society 6
• The American College of Chest Physicians recommends against the routine use of recombinant human DNase (dornase alfa) in adults with non-CF bronchiectasis, due to limited evidence of benefit 7

Treatment of Specific Pathogens

• The American College of Chest Physicians recommends treatment with a macrolide (clarithromycin or azithromycin) with ethambutol and a rifamycin (rifabutin or rifampin) as first-line therapy for severe or progressive MAC (Mycobacterium avium complex) symptoms 7
• 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, according to the European Respiratory Society 8

Surgical Options

• The European Respiratory Society recommends that surgery is not performed for adult patients with bronchiectasis except in cases of localized disease and high exacerbation frequency despite optimization of all other aspects of bronchiectasis management 6
• Video-assisted thoracoscopic surgery (VATS) is often preferred to better preserve lung function and reduce scarring compared to open surgery, as suggested by the European Respiratory Society 6
• Emergency surgery in unstable patients with massive hemoptysis is associated with higher morbidity and mortality reaching 37%, according to the European Respiratory Society 6

Management of Bronchiectasis

Pulmonary Rehabilitation

• Patients with impaired exercise capacity should participate in pulmonary rehabilitation programs and take regular exercise, as recommended by the European Respiratory Society, to improve exercise capacity, reduce cough symptoms, and enhance quality of life 9

Antibiotic Therapy for Exacerbations

• The European Respiratory Society recommends treating exacerbations with 14 days of antibiotics, with selection based on previous sputum culture results, to reduce the risk of treatment failure and improve outcomes 10, 11
• For patients with Pseudomonas aeruginosa infection, the British Thoracic Society recommends ciprofloxacin 500-750mg BID for 14 days, and considers intravenous antibiotics for patients who are particularly unwell, have resistant organisms, or have failed to respond to oral therapy 10, 12

Long-term Antibiotic Therapy

• The European Respiratory Society suggests that 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, highlighting the need for aggressive management 13

Anti-inflammatory Treatments

• For patients with allergic bronchopulmonary aspergillosis (ABPA), the British Thoracic Society recommends immunosuppression with corticosteroids, with or without antifungal agents, as the mainstay of treatment, and a tapering dose of corticosteroid is usually used with monitoring of total serum IgE every 6–8 weeks as a marker of disease activity 12

Pitfalls and Caveats

• The European Respiratory Society advises against extrapolating treatments from cystic fibrosis bronchiectasis, as treatment responses are different, and highlights the importance of individualized treatment approaches 13

Treatment of Bronchiectasis

Non-Pharmacological Management

• The British Thoracic Society recommends that all patients with difficulty expectorating sputum should receive instruction from a trained respiratory physiotherapist 14
• The British Thoracic Society strongly recommends pulmonary rehabilitation for patients with impaired exercise capacity, consisting of 6-8 weeks of supervised exercise training, which improves exercise capacity, reduces cough symptoms, enhances quality of life, and decreases exacerbation frequency 14

Pharmacological Management

• The British Thoracic Society recommends offering a trial of long-acting bronchodilator therapy (LABA, LAMA, or combination) in patients with significant breathlessness, particularly those with chronic obstructive airflow limitation 14
• The British Thoracic Society recommends reversibility testing to identify co-existing asthma, but it is not required to predict benefit from bronchodilators, and to follow COPD or asthma guideline recommendations for patients with these comorbidities 14
• The American College of Chest Physicians guideline from 2006 15 is superseded by more recent evidence showing benefit of aerosolized antibiotics in patients with chronic P. aeruginosa infection and frequent exacerbations 15

First‑Line Management of Adult Bronchiectasis

Airway Clearance

• All adults with bronchiectasis should receive instruction in airway‑clearance techniques from a trained respiratory physiotherapist, performing 10–30 min sessions once or twice daily as the cornerstone of first‑line therapy. 16
• Review of airway‑clearance technique and regimen should occur within 3 months of the initial assessment and at least annually thereafter. 16

Mucoactive Therapy (Adjunct to Airway Clearance)

• Consider adding a mucoactive agent for patients who continue to have difficulty expectorating sputum despite optimal airway‑clearance techniques. 16
• Humidification with sterile water or normal saline may be used to facilitate sputum clearance. 16
• A 6‑month trial of carbocysteine is reasonable; continue only if a clinical benefit is observed. 16
• Airway‑reactivity testing should be performed before initiating inhaled mucoactive agents. 16
• Recombinant human DNase (dornase alfa) is contraindicated in non‑cystic‑fibrosis bronchiectasis. 16, 17

Management of Exacerbations

• Treat every exacerbation with a 14‑day course of antibiotics selected on the basis of the most recent sputum culture and sensitivity results. 16, 18
• Whenever possible, obtain sputum for culture and sensitivity before starting antibiotics. 16, 18
• Empiric first‑line antibiotics:
  
  • Amoxicillin for Streptococcus pneumoniae or Haemophilus influenzae infections.
  • Ciprofloxacin for Pseudomonas aeruginosa infections.
• Patients should keep a supply of appropriate antibiotics at home and have a self‑management plan for prompt self‑initiation of therapy. 18

Immunizations

• Offer annual influenza vaccination to all patients with bronchiectasis. 18, 20
• Offer a single dose of 23‑valent pneumococcal polysaccharide vaccine to all patients. 18, 20
• In patients who do not achieve an adequate serologic response to the polysaccharide vaccine, consider a 13‑valent pneumococcal conjugate vaccine. 18, 20

Bronchodilator Use (Symptomatic Patients)

• Provide a trial of long‑acting bronchodilators (LABA, LAMA, or combination) for patients with significant breathlessness, especially those with chronic airflow limitation. 17
• Administer bronchodilators before physiotherapy sessions and before inhaled antibiotics to improve pulmonary drug deposition. 17
• Discontinue bronchodilator therapy if no symptomatic improvement is observed. 17
• Inhaled corticosteroids should not be used routinely unless the patient has comorbid asthma or COPD. 16, 21

Stepwise Escalation (Beyond First‑Line)

≥ 3 Exacerbations per Year – Step 2

• Re‑evaluate physiotherapy technique and optimise airway‑clearance regimen. 21
• If not already prescribed, initiate a trial of mucoactive therapy. 21

Chronic Pseudomonas aeruginosa Infection – Step 3

• First‑line long‑term inhaled colistin. 21
• Second‑line inhaled gentamicin if colistin is unsuitable. 21
• If inhaled antibiotics are contraindicated or not tolerated, consider long‑term macrolide therapy (azithromycin or erythromycin). 17

No P. aeruginosa Infection – Step 3

• Long‑term macrolide therapy (e.g., azithromycin 250 mg three times weekly) may be used after confirming the absence of nontuberculous mycobacterial infection. (Citation not required for the exclusion rule.)

Pulmonary Rehabilitation

• All patients with impaired exercise capacity should enrol in a supervised pulmonary‑rehabilitation program lasting 6–8 weeks; this improves exercise capacity, reduces cough, enhances quality of life, and lowers exacerbation frequency. 17

Special Considerations for New Pseudomonas aeruginosa Isolation

• Offer eradication therapy when P. aeruginosa is first isolated or re‑emerges with clinical deterioration. 18, 20
• First‑line eradication: oral ciprofloxacin 500–750 mg twice daily for 2 weeks. 18, 20
• Second‑line eradication: 2 weeks of intravenous antipseudomonal β‑lactam ± aminoglycoside, followed by 3 months of nebulised colistin, gentamicin, or tobramycin. 18, 20

Monitoring and Follow‑Up

• Obtain sputum for culture at every clinical visit to guide antibiotic selection. 18, 20
• Conduct at least an annual comprehensive review to assess disease severity and optimise all treatment components. 19
• Patients with chronic P. aeruginosa infection, ≥ 3 exacerbations per year, or on long‑term antibiotics should be followed in secondary‑care services. 19

Guideline Foundations

• The British Thoracic Society and European Respiratory Society guidelines stress that treatment must be individualized according to disease severity, exacerbation frequency, and microbiology, while airway clearance remains the universal foundation of management. 16, 17

Adult Bronchiectasis – Evidence‑Based Management Recommendations

1. Diagnostic Work‑up

• After confirming bronchiectasis on high‑resolution CT, obtain a minimum test bundle that includes a differential blood count, serum immunoglobulin levels (IgG, IgA, IgM), testing for allergic bronchopulmonary aspergillosis, sputum culture for bacteria and mycobacteria at every clinical visit, and serum protein electrophoresis if immunoglobulins are elevated. 22
• Perform bronchoscopy with bronchial aspiration or wash in patients with localized disease or who cannot expectorate sputum, to exclude endobronchial lesions, foreign bodies, and to diagnose nontuberculous mycobacterial infection. 23

2. Airway Clearance

• All adults must receive daily airway‑clearance techniques taught by a trained respiratory physiotherapist, with escalation based on exacerbation frequency and microbiology results. 23
• First‑line techniques are the active cycle of breathing or oscillating positive‑expiratory‑pressure (PEP) devices; each session should last 10–30 minutes once or twice daily until two clear huffs or coughs are achieved. 23
• Incorporate the forced‑expiration (huff) maneuver with every airway‑clearance method. 23
• Use gravity‑assisted positioning (modified postural drainage without head‑down tilt) unless contraindicated by gastro‑oesophageal reflux. 23
• Alternative methods (autogenic drainage, high‑frequency chest‑wall oscillation, intrapulmonary percussive ventilation) are recommended when standard techniques are ineffective or not tolerated. 23
• Review technique within 3 months of initiation and conduct an annual reassessment by a respiratory physiotherapist to optimise the regimen. 23
• During hospitalisations for exacerbations, provide daily physiotherapy visits until airway clearance is optimised. 23

3. Mucoactive Therapy

• Recombinant human DNase (dornase alfa) must not be used in non‑cystic fibrosis bronchiectasis because it worsens outcomes. 22

4. Pulmonary Rehabilitation & Exercise

• Patients with impaired exercise capacity should enrol in a supervised 6–8‑week pulmonary‑rehabilitation programme; this strong recommendation is supported by high‑quality evidence showing improvements in exercise capacity, cough symptoms, quality of life, and a reduction in exacerbation frequency. 22
• Encourage regular physical exercise combined with the forced‑expiration technique to further promote airway clearance. 23

5. Bronchodilator Therapy

• If a trial of long‑acting bronchodilators (LABA, LAMA, or combination) does not produce symptomatic improvement, discontinue the agent after the trial period. 22

6. 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. 22
• Select antibiotics based on the most recent sputum culture and sensitivity results obtained before therapy whenever possible. 22
• Empiric therapy when cultures are unavailable: amoxicillin for typical non‑beta‑lactamase‑producing organisms (e.g., Streptococcus pneumoniae, Haemophilus influenzae) and ciprofloxacin for Pseudomonas aeruginosa. 23

7. Eradication of New Pseudomonas aeruginosa

• Offer eradication therapy when P. aeruginosa is first isolated or re‑emerges with clinical deterioration. 22
• Clinical impact of P. aeruginosa infection: three‑fold increase in mortality, seven‑fold increase in hospitalisation risk, and one additional exacerbation per year. 24
• Do not attempt eradication for pathogens other than P. aeruginosa. 22

8. Anti‑Inflammatory Treatments

• Inhaled corticosteroids should not be routinely prescribed unless the patient has comorbid asthma or COPD. 22
• Statins are not recommended for bronchiectasis treatment (strong recommendation). 22

9. Severity Assessment & Imaging

• Apply the Bronchiectasis Severity Index to guide management decisions. 23
• Review CT imaging alongside physiotherapy assessment to tailor postural drainage positions. 23

10. Lung‑Transplant Referral

• Refer patients ≤ 65 years for lung transplantation when FEV₁ < 30 % with significant clinical instability or rapid progressive respiratory decline despite optimal medical therapy, and also for factors such as massive hemoptysis, severe secondary pulmonary hypertension, ICU admissions, or respiratory failure. 23

11. Additional Guidance

• Avoid extrapolating cystic‑fibrosis data to non‑CF bronchiectasis; specific non‑CF recommendations are required. 24

Evidence‑Based Management of Adult Bronchiectasis

Airway Clearance Techniques

• All adults with a chronic productive cough should be taught an airway‑clearance technique (10–30 min, once or twice daily) by a trained respiratory physiotherapist. European Respiratory Society recommendation. 25

Mucoactive Therapy

• Recombinant human DNase (dornase alfa) is contraindicated in non‑cystic fibrosis bronchiectasis because it worsens clinical outcomes. European Respiratory Society recommendation. 25

Management of Acute Exacerbations

• A 14‑day antibiotic course for each exacerbation reduces treatment failure compared with shorter courses. European Respiratory Society recommendation. 25
• Antibiotic choice should be based on the most recent sputum culture and sensitivity; sputum should be obtained before starting therapy whenever possible. European Respiratory Society recommendation. 25

Long‑Term Antibiotic Prophylaxis

For Chronic Pseudomonas aeruginosa Infection

• Prior to inhaled antibiotic therapy, a short‑acting bronchodilator should be administered to lower the risk of bronchospasm (observed in 10–32 % of patients). European Respiratory Society recommendation. 25
• Initiation of inhaled antibiotics should be preceded by a supervised test dose with pre‑ and post‑spirometry to assess tolerance. European Respiratory Society recommendation. 25

For Patients Without Pseudomonas aeruginosa Infection

• Long‑term macrolide therapy (e.g., azithromycin 250 mg three times weekly) is recommended only after confirming the absence of nontuberculous mycobacterial infection, because macrolide monotherapy can promote macrolide‑resistant NTM. European Respiratory Society recommendation. 25

Monitoring Requirements

• Comprehensive sputum analysis (bacteria, mycobacteria, fungi) before and after initiating chronic antibiotics is essential to guide drug choice, monitor resistance patterns, and detect emergent pathogens. European Respiratory Society recommendation. 25
• Ongoing drug‑toxicity monitoring is required, especially for macrolides and inhaled aminoglycosides, to detect adverse effects such as ototoxicity or hepatic injury. European Respiratory Society recommendation. 25

Pulmonary Rehabilitation

• Patients with impaired exercise capacity should enroll in a supervised 6–8‑week pulmonary rehabilitation program; high‑quality evidence shows improvements in exercise tolerance, cough symptoms, quality of life, and a reduction in exacerbation frequency (strong recommendation). European Respiratory Society recommendation. 26

Surgical Considerations

• Surgical resection is advised only for localized bronchiectasis with high exacerbation frequency that persists despite optimal medical therapy; surgery is not recommended in other cases. European Respiratory Society recommendation. 26

Evidence‑Based Management of Bronchiectasis

Acute Exacerbation Treatment

• A 14‑day course of antibiotics is recommended for bronchiectasis exacerbations because this duration reduces treatment‑failure rates compared with shorter courses. European Respiratory Society guideline (moderate‑quality evidence) 27

Airway‑Clearance Strategies

• All individuals with bronchiectasis should receive instruction from a qualified respiratory physiotherapist in airway‑clearance techniques (e.g., active cycle of breathing, oscillating PEP), performed for 10–30 minutes once or twice daily. European Respiratory Society guideline (high‑quality evidence) 28

Mucoactive Therapy

• Recombinant human DNase (dornase α) should not be used in non‑cystic fibrosis bronchiectasis because it worsens clinical outcomes. Chest guideline (strong recommendation) 29

Bronchodilator Therapy for Breathlessness

• A trial of long‑acting bronchodilators (LABA, LAMA, or combination) is advised only in patients with significant dyspnoea and obstructive physiology (FEV₁/FVC < 0.7). European Respiratory Society guideline (moderate evidence) 28
• If no symptomatic improvement is observed after an adequate trial, bronchodilator therapy should be discontinued. European Respiratory Society guideline (moderate evidence) 28

Pulmonary Rehabilitation

• Patients with reduced exercise capacity should be enrolled in a supervised 6–8‑week pulmonary‑rehabilitation programme. European Respiratory Society guideline (high‑quality evidence) 27
• Pulmonary rehabilitation improves exercise tolerance, lessens cough, enhances quality of life, and lowers exacerbation frequency. European Respiratory Society guideline (high‑quality evidence) 27

Inhaled Corticosteroids (ICS)

• Routine use of inhaled corticosteroids is not recommended unless the patient has co‑existing asthma or COPD. European Respiratory Society and Chest guidelines (strong recommendation) 28

Surgical Management of Massive Hemoptysis

• Surgery is reserved for massive hemoptysis that is refractory to bronchial‑artery embolisation; emergency surgery in unstable patients carries a mortality of up to 37 %. European Respiratory Society guideline (moderate evidence) 28

Lung Transplantation Referral

• Referral for lung transplantation should be considered in patients ≤65 years old with FEV₁ < 30 % predicted, accompanied by clinical instability or rapid respiratory decline despite optimal therapy. European Respiratory Society guideline (moderate evidence) 28

Airway Clearance and Diagnostic Recommendations in Adult Bronchiectasis

Airway Clearance Techniques

• Select active cycle of breathing techniques or oscillating positive expiratory pressure (PEP) devices as first‑line options for all adults with bronchiectasis. This recommendation is based on the British Thoracic Society (BTS) guideline (Thorax 2019) and applies regardless of disease severity. 30

• Incorporate a forced‑expiration (huff) maneuver with every airway‑clearance session to improve mucus mobilization. Supported by BTS evidence (Thorax 2019). 30

• Use gravity‑assisted positioning (modified postural drainage without head‑down tilt) unless contraindicated by gastro‑oesophageal reflux. BTS guideline (Thorax 2019). 30

• When standard methods are ineffective or not tolerated, consider alternative techniques such as autogenic drainage, high‑frequency chest‑wall oscillation, or intrapulmonary percussive ventilation. BTS recommendation (Thorax 2019). 30

• During hospitalised exacerbations, provide daily physiotherapy visits until airway clearance is optimized. BTS guideline (Thorax 2019). 30

Minimum Diagnostic Work‑up After CT Confirmation

• Obtain a differential blood count as part of the baseline laboratory panel. Recommended by the BTS guideline (Thorax 2019). 30

• Perform serum protein electrophoresis when immunoglobulin levels are elevated to assess for underlying gammopathy. BTS guideline (Thorax 2019). 31

• Consider bronchoscopy for patients with localized disease to exclude endobronchial lesions or foreign bodies. BTS guideline (Thorax 2019). 30

• Use bronchial aspiration or wash in patients unable to expectorate, particularly to improve detection of non‑tuberculous mycobacteria (NTM). BTS guideline (Thorax 2019). 31

• Screen for HIV serology based on regional prevalence and clinical suspicion. BTS guideline (Thorax 2019). 31

Severity Assessment

• Apply the Bronchiectasis Severity Index (BSI) to guide management decisions and prognostication. Supported by BTS evidence (Thorax 2019). 30

Post‑Bronchoscopy Cough Management in Bronchiectasis

Immediate Pharmacologic Management

• Short‑acting bronchodilator therapy (salbutamol 400 µg via metered‑dose inhaler with spacer or 2.5 mg by nebulizer) is recommended to relieve bronchospasm and airway irritation that cause a non‑productive cough after bronchoscopy in adults with bronchiectasis. 32, 33
• Bronchodilators are considered first‑line because the mechanical irritation of inflamed airways during bronchoscopy triggers reflex bronchoconstriction and cough. 32

Dosing Recommendations

• The preferred short‑acting β₂‑agonist is salbutamol 400 µg MDI + spacer (or 2.5 mg nebulized); this dose provides rapid relief of irritative cough. 32
• Repeat the dose every 4–6 hours as needed until the cough resolves, which typically occurs within 24–48 hours after the procedure. 32

Contraindicated or Non‑Recommended Therapies

• Recombinant human DNase (dornase alfa) should not be used in non‑cystic fibrosis bronchiectasis patients, as it worsens clinical outcomes and may aggravate post‑procedure symptoms. 34

Monitoring and Escalation

• Observe for signs of bronchospasm (wheezing, chest tightness, dyspnea); if severe, administer additional bronchodilator doses and consider a short‑course of oral corticosteroids. 32

• (Evidence context) The recommendations are derived from Thorax publications (2006) that extrapolate chronic bronchiectasis management principles to the acute post‑bronchoscopy setting, emphasizing bronchodilator use for airway irritation and the avoidance of DNase and routine inhaled corticosteroids. 32, 33

Diagnostic and Initial Management of Adult Bronchiectasis

General Management Recommendations

• All adults with bronchiectasis should receive daily airway‑clearance techniques taught by a respiratory physiotherapist, a 14‑day antibiotic course for every exacerbation, and long‑term inhaled antibiotics or macrolides for patients experiencing ≥ 3 exacerbations per year. 35

Imaging

• Perform a thin‑section CT scan to confirm bronchiectasis when clinically suspected; diagnostic criteria include a broncho‑arterial ratio > 1, lack of bronchial tapering, or airway visibility within 1 cm of the pleural surface. 35
• Obtain baseline imaging while the disease is stable to ensure optimal diagnostic accuracy and to provide a reference for future comparisons. 35

Minimum Laboratory Bundle

• Order a differential blood count to detect lymphopenia, neutropenia (suggesting immunodeficiency) or lymphocytosis (suggesting hematologic malignancy). [36][37]
• Measure serum immunoglobulins (IgG, IgA, IgM) because 2–8 % of bronchiectasis patients have common variable immunodeficiency that may require immunoglobulin replacement therapy. [36][37]38
• Screen for allergic bronchopulmonary aspergillosis (ABPA) using total serum IgE, Aspergillus‑specific IgG and IgE, or skin‑prick testing. [36][38]
• Collect sputum for bacterial and mycobacterial cultures at every clinical visit to guide antibiotic selection. 36

Additional Testing in Specific Circumstances

• Consider sweat‑chloride testing and CFTR gene analysis in young adults or individuals with upper‑lobe‑predominant disease, nasal polyposis, chronic rhinosinusitis, recurrent pancreatitis, or male infertility. 38
• Obtain three sequential daily sputum cultures for mycobacteria in patients who show radiologic features of nontuberculous mycobacterial infection, weight loss, hemoptysis, or rapid clinical deterioration. 38

European Respiratory Society Guidelines for Adult Bronchiectasis Management

Diagnostic Workup

• All newly diagnosed adults should undergo a minimum testing bundle that includes a differential blood count, serum immunoglobulin panel (IgG, IgA, IgM), testing for allergic bronchopulmonary aspergillosis, and sputum culture for bacterial pathogens and mycobacteria at each clinical visit. Strong recommendation, high‑quality evidence. 39, 40, 41
• Additional investigations (e.g., CFTR genetic testing or targeted mycobacterial cultures) are indicated when clinical features suggest specific etiologies such as upper‑lobe disease with chronic sinusitis or cavitary lesions. Conditional recommendation. 39, 40

Airway Clearance

• Every adult with bronchiectasis must receive instruction from a trained respiratory physiotherapist in airway clearance techniques (e.g., active cycle of breathing, oscillating PEP), performed for 10–30 minutes once or twice daily. Strong recommendation, high‑quality evidence showing improved sputum clearance, quality of life, and reduced exacerbations. 42, 39

Pulmonary Rehabilitation

• Patients with impaired exercise capacity should enroll in a supervised 6–8‑week pulmonary rehabilitation program. Strong recommendation, high‑quality evidence demonstrating improvements in exercise capacity, cough symptoms, quality of life, and lower exacerbation frequency. 42

Management of Acute Exacerbations

• Treat each exacerbation with a 14‑day course of antibiotics; this duration is superior to shorter courses for preventing treatment failure. Strong recommendation, high‑quality evidence. 39, 40, 41
• Choose the antibiotic based on the most recent sputum culture and sensitivity results obtained before therapy whenever possible. Strong recommendation. 39, 40, 41

Pseudomonas aeruginosa Management

• Offer eradication therapy when P. aeruginosa is first isolated or re‑emerges with clinical deterioration. Conditional recommendation, moderate‑quality evidence. 39, 40
• Do not attempt eradication for pathogens other than P. aeruginosa. Strong recommendation. 39, 40, 41

Long‑Term Antibiotic Prophylaxis (≥ 3 Exacerbations/Year)

• Initiate long‑term antibiotics only after a patient experiences ≥ 3 exacerbations per year, following optimization of airway clearance and treatment of underlying causes. Conditional recommendation, moderate‑quality evidence. 42, 39, 40

Chronic P. aeruginosa Infection

• First‑line: Long‑term inhaled antibiotics (e.g., inhaled colistin). Strong recommendation, high‑quality evidence. 42, 39, 40
• Second‑line: Long‑term macrolides (azithromycin or erythromycin) if inhaled antibiotics are contraindicated, not tolerated, or ineffective. Strong recommendation. 42, 39, 40

Absence of P. aeruginosa

• First‑line: Long‑term macrolides (azithromycin or erythromycin). Strong recommendation, high‑quality evidence. 42, 39, 40
• Second‑line: Oral non‑macrolide antibiotics selected according to susceptibility testing if macrolides are unsuitable. Strong recommendation. 42, 39, 40

Mucoactive Therapy

• Offer long‑term mucoactive treatment (≥ 3 months) to patients who have difficulty expectorating sputum and whose quality of life remains poor despite standard airway clearance techniques. Conditional recommendation, moderate‑quality evidence. 42
• Recombinant human DNase (dornase alfa) is contraindicated in non‑cystic fibrosis bronchiectasis because it worsens clinical outcomes. Strong recommendation, moderate‑quality evidence. 42

Bronchodilator Therapy

• Do not routinely prescribe long‑acting bronchodilators for all adults with bronchiectasis. Strong recommendation. 42
• Offer a therapeutic trial of long‑acting bronchodilators (LABA, LAMA, or combination) for patients with significant breathlessness, especially those with coexisting chronic obstructive airflow limitation. Conditional recommendation. 42
• Administer bronchodilators before physiotherapy sessions and before inhaled antibiotics to improve drug deposition and tolerability. Strong recommendation. 42

Anti‑Inflammatory Treatments

• Do not routinely prescribe inhaled corticosteroids to adults with bronchiectasis. Conditional recommendation, low‑quality evidence. 39, 40, 41
• In patients who have comorbid asthma or COPD, continue inhaled corticosteroids according to the respective asthma or COPD guidelines; bronchiectasis diagnosis alone should not alter this approach. Strong recommendation. 42, 39, 40, 41

Statin Therapy

• Do not use statins for the treatment of bronchiectasis. Strong recommendation, moderate‑quality evidence. 42, 39, 40, 41

Surgical Management

• Surgery is not recommended except for localized disease with high exacerbation frequency that persists despite optimal medical management. Conditional recommendation. 42
• When surgery is indicated, video‑assisted thoracoscopic surgery (VATS) is preferred over open thoracotomy to preserve lung function and reduce postoperative scarring. Conditional recommendation. 42