Management of Adult Bronchiectasis: An American College of Chest Physicians Clinical Practice Guideline

Persistent Notes

  • no evidence for shorter vs longer antibiotics duration
  • no recommendation for eradication of first culture positive for pseudomonas
  • use inhaled antibiotic for frequent ≥ 2 exacerbation
    • tobramycin, ciprofloxacin, colistin, gentamicin
  • use azithromycin: decreases exacerbation by 1, improves symptom but not statistically significant
  • use brensocatib: decreases exacerbation by 1, improves FEV1/FVC, QoL. Can use with azithromycin
  • consider surgery for local bronchiectasis

Highlights

  • non-cystic fibrosis (CF) bronchiectasis is most commonly attributed to idiopathic or post-infective causes.6-10 128 Other frequently reported associations include 129 post-tuberculous disease, connective tissue diseases, chronic airway diseases such as asthma 130 and chronic obstructive pulmonary disease (COPD), immunodeficiency, and allergic 131 bronchopulmonary aspergillosis, with less common causes including primary ciliary dyskinesia, 132 α1-antitrypsin deficiency, and inflammatory bowel disease. Importantly, the proportion of cases 133 classified as idiopathic varies widely and is strongly influenced by the depth and rigor of the 134 diagnostic evaluation, with incomplete workups likely obscuring underlying, potentially treatable 135 causes 136 Comprehensive management of patients with bronchiectasis includes a detailed diagnostic 137 workup to elucidate and appropriately manage co-morbidities, such as asthma/COPD, allergic 138 bronchopulmonary aspergillosis, nontuberculous mycobacterial lung disease (NTM-LD), 139 gastroesophageal reflux, and immunodeficiency. As newer therapies emerge targeting specific 140 underlying disease processes (such as CF-related disorders and primary ciliary dyskinesia), 141 accurate phenotyping and endotyping will be crucial to optimize patient outcomes. 142 143 Key management principles include an assessment of baseline disease severity, disease activity 144 and health impact. Individualized management plans should take a multidisciplinary approach and 145 coordinated care between primary healthcare providers, pulmonary and infectious diseases 146 physicians, physical/respiratory therapists, nutritionists/dieticians, psychologists, and other 147 healthcare providers as appropriate. 148 149 Bronchiectasis exacerbations are defined as acute deteriorations in respiratory symptoms, most 150 commonly increased cough, sputum volume or purulence, and/or dyspnea, that prompt a change 151 in therapy, typically antibiotic treatment. Exacerbations accelerate lung-function decline, diminish 152 health-related quality of life (QoL), and drive direct costs through emergency-department visits, 153 intravenous antibiotics, and prolonged hospitalizations. Patients experiencing three or more 154 exacerbations per year carry the highest risks of future hospitalizations and five-year mortality, underscoring the clinical urgency of standardized preventive strategies.11-15 155 156 157 These guidelines aim to harmonize care for patients with bronchiectasis, reduce practice variation, and optimize outcomes for this increasingly prevalent, high-burden disease.16 158 Bronchiectasis Journal Pre-pro attributed to idiopathic or post-infective causes.6-10 128 Other frequently reported associations include 129 post-tuberculous disease, connective tissue p.6
  • Current evidence is insufficient to determine optimal antibiotic duration for acute bronchiectasis 274 exacerbations. The available studies evaluated durations ranging from 8 to 21 days and do not 275 demonstrate clear superiority of longer courses (>10 days) over shorter courses (< 10 days) with 276 respect to future exacerbation rates. Shorter durations may therefore be considered based on 277 clinical response. This recommendation applies to both oral and intravenous antibiotic therapy as 278 current evidence in bronchiectasis does not demonstrate inherent superiority of one route over the 279 other. Selection of route of administration should therefore be guided by clinical factors such as 280 exacerbation severity, ability to tolerate oral therapy, prior treatment response, microbiologic data 281 and need for hospitalization, rather than by treatment duration alone. Moreover, clinical response 282 should be evaluated based on improvement in key symptoms (such as cough, sputum volume and 283 purulence and/or dyspnea). However, there is insufficient evidence to define standardized timing 284 or specific criteria for determining adequate clinical response, and assessment remains based on 285 clinical judgment. 286 287 Research priorities 288 RCTs assessing antibiotic duration in acute exacerbations requiring oral and IV antibiotic treatment 289 that account for baseline disease severity as well as exacerbation severity are needed. Easily 290 accessible, objective markers of clinical response to treatment should be utilized in such studies. 291 292 293 Question 3: In patients with bronchiectasis and a first isolate of Pseudomonas aeruginosa, 294 should eradication therapy be attempted? 295 296 Insufficient Evidence: For patients with bronchiectasis and a first isolate of P. aeruginosa, we 297 make no specific recommendation for or against eradication therapy compared to no eradication 298 therapy (Insufficient Evidence) 299 Journal Pre 274 exacerbations. The available studies evaluated durations ranging from 8 to 21 days and do not 275 demonstrate clear superiority of longer courses (>10 days) over shorter courses (< 10 days) with 276 respect to future exacerbation rates. Shorter durations may therefore be considered based on 277 clinical response. This recommendation applies to both oral and intravenous antibiotic therapy as 278 current evidence in bronchiectasis does not demonstrate inherent superiority of one route over the 279 other. Selection of route of administration should therefore be guided by clinical factors such as 280 exacerbation severity, ability to tolerate oral therapy, prior treatment response, microbiologic data 281 and need for hospitalization, rather than by treatment duration alone. Moreover, clinical response 282 should be evaluated based on improvement in key symptoms (such as cough, sputum volume and 283 purulence and/or dyspnea). However, there is insufficient evidence to define standardized timing 284 or specific criteria for determining adequate clinical response, and assessment remains based on 285 clinical judgment. 286 287 Research priorities 288 RCTs assessing antibiotic duration in acute exacerbations requiring oral and IV antibiotic treatment 289 that account for baseline disease severity as well as exacerbation severity are needed. Easily 290 accessible, objective markers of clinical response to treatment should be utilized in such studies. 291 292 293 Question 3: In patients with bronchiectasis and a first isolate of Pseudomonas aeruginosa, 294 should eradication therapy be attempted? 295 296 Insufficient Evidence: For patients with bronchiectasis and a first isolate of P. aeruginosa, we 297 make no specific recommendation for or against eradication therapy compared to no eradication 298 therapy (Insufficient Evidence) 299 Journal Pre 275 demonstrate clear superiority of longer courses (>10 days) over shorter courses (< 10 days) with 276 respect to future exacerbation rates. Shorter durations may therefore be considered based on 277 clinical response. This recommendation applies to both oral and intravenous antibiotic therapy as 278 current evidence in bronchiectasis does not demonstrate inherent superiority of one route over the 279 other. Selection of route of administration should therefore be guided by clinical factors such as 280 exacerbation severity, ability to tolerate oral therapy, prior treatment response, microbiologic data 281 and need for hospitalization, rather than by treatment duration alone. Moreover, clinical response 282 should be evaluated based on improvement in key symptoms (such as cough, sputum volume and 283 purulence and/or dyspnea). However, there is insufficient evidence to define standardized timing 284 or specific criteria for determining adequate clinical response, and assessment remains based on 285 clinical judgment. 286 287 Research priorities 288 RCTs assessing antibiotic duration in acute exacerbations requiring oral and IV antibiotic treatment 289 that account for baseline disease severity as well as exacerbation severity are needed. Easily 290 accessible, objective markers of clinical response to treatment should be utilized in such studies. 291 292 293 Question 3: In patients with bronchiectasis and a first isolate of Pseudomonas aeruginosa, 294 should eradication therapy be attempted? 295 296 Insufficient Evidence: For patients with bronchiectasis and a first isolate of P. aeruginosa, we 297 make no specific recommendation for or against eradication therapy compared to no eradication 298 therapy (Insufficient Evidence) 299 Journal P 276 respect to future exacerbation rates. Shorter durations may therefore be considered based on 277 clinical response. This p.9
  • Whilst eradication therapy for the first acquisition of 305 Pseudomonas is commonly performed in children with CF-related bronchiectasis, there is 305 Pseudomonas is commonly performed in children with CF-related bronchiectasis, there is little evidence to support eradication in adults with bronchiectasis not related to CF. 37,38 306 This evidence to support eradication in adults with bronchiectasis not related to CF. 37,38 306 This 307 fundamental difference in clinical practice represents a major barrier to p.10
  • For patients with bronchiectasis experiencing frequent exacerbations (i.e.,  2 350 per year), we suggest long-term (3 months) inhaled antibiotic therapy over no long-term inhaled 351 antibiotic therapy (Conditional recommendation, Low certainty 351 antibiotic therapy p.11
  • tobramycin 367 (nebulized and dry powdered inhaler), inhaled ciprofloxacin (nebulized and dry powdered 367 (nebulized and dry powdered inhaler), inhaled ciprofloxacin (nebulized and dry powdered inhaler), 368 nebulized colistin, and nebulized gentamicin. All studies evaluated exacerbation frequency (follow369 up range 16-52 weeks). Inhaled antibiotics were associated with a reduced number of patients with 370 exacerbations (risk ratio [RR], 0.83; 95% CI, 0.74-0.94) (e-Table 6). The evidence suggests little to 371 no difference in adverse effects between groups (RR 0.96; 95% CI 0.90 to 1.02) and few serious 372 adverse events. Adverse effects are an important consideration with long-term inhaled antibiotic 373 therapy. Bronchospasm is the most frequently reported respiratory adverse event, occurring in 374 approximately 10% of patients receiving tobramycin compared to 2.3% in controls, though most cases are mild.43 375 Other common adverse effects include cough, dysgeusia, dyspnea, and 376 wheezing. Importantly, systemic toxicity including ototoxicity and nephrotoxicity has not been 377 routinely reported in bronchiectasis studies, likely due to low systemic absorption with inhaled administration. However, the long-term safety profile remains poorly characterized.43,55 378 379 Eight studies reported on QoL using three assessment tools.44-47,49,51-53 380 One small study showed 381 improvement, with all other studies suggested little to no difference in QoL. Antibiotic resistance is 382 noted with the use of inhaled antibiotics but is difficult to interpret in the setting of heterogeneous 383 studies and this requires further evaluation. 384 385 Specific populations 386 It is important to recognize the underlying heterogeneity of patients with bronchiectasis. There is 387 currently insufficient evidence to inform which groups may benefit from this approach. 388 389 Research priorities 390 Given the limited and heterogeneous evidence base, key research priorities include adequately 391 powered RCTs evaluating the efficacy and safety of long-term inhaled antibiotics in well-defined 392 patient subgroups, including those with and without P. aeruginosa infection. Studies should assess 393 optimal antibiotic selection, dosing regimens (continuous versus intermittent), and treatment 394 duration, while monitoring for adverse effects, antimicrobial resistance development, and impact Journal Pre-p 368 nebulized colistin, and nebulized gentamicin. All studies evaluated exacerbation frequency (follow369 up range 16-52 weeks). Inhaled antibiotics were associated with a reduced number of patients with 370 exacerbations (risk ratio [RR], 0.83; 95% CI, 0.74-0.94) (e-Table 6). The evidence suggests little to 371 no difference in adverse effects between groups (RR 0.96; 95% CI 0.90 to 1.02) and few serious 372 adverse events. Adverse effects are an important consideration with long-term inhaled antibiotic 373 therapy. Bronchospasm is the most frequently reported respiratory adverse event, occurring in 374 approximately 10% of patients receiving tobramycin compared to 2.3% in controls, though most cases are mild.43 375 Other common adverse effects include cough, dysgeusia, dyspnea, and 376 wheezing. Importantly, systemic toxicity including ototoxicity and nephrotoxicity has not been 377 routinely reported in bronchiectasis studies, likely due to low systemic absorption with inhaled administration. However, the long-term safety profile remains poorly characterized.43,55 378 379 Eight studies reported on QoL using three assessment tools.44-47,49,51-53 380 One small study showed 381 improvement, with all other studies suggested little to no difference in QoL. Antibiotic resistance is 382 noted with the use of inhaled antibiotics but is difficult to interpret in the setting of heterogeneous 383 studies and this requires further evaluation. 384 385 Specific populations 386 It is important to recognize the underlying heterogeneity of patients with bronchiectasis. There is 387 currently insufficient evidence to inform which groups may benefit from this approach. 388 389 Research priorities 390 Given the limited and heterogeneous evidence base, key research priorities include adequately 391 powered RCTs evaluating the efficacy and safety of long-term inhaled antibiotics in well-defined 392 patient subgroups, including those with and without P. aeruginosa infection. Studies should assess 393 optimal antibiotic selection, dosing regimens (continuous versus intermittent), and treatment 394 duration, while monitoring for adverse effects, antimicrobial resistance development, and impact Journal P p.11
  • macrolides reduce exacerbations across obstructive lung diseases, including COPD.56-58 412 Targeting underlying inflammatory mechanisms offers additional therapeutic 413 opportunities: excessive neutrophil serine protease (NSP) activation contributes to inflammation 414 and lung destruction in bronchiectasis. Similarly, given the role of neutrophilic mediator release in 415 disease pathogenesis, statins represent another potential anti-inflammatory therapeutic target, 416 though not currently recommended based on existing evidence. 417 418 The systematic review identified four RCTs comparing macrolides, azithromycin, or erythromycin to 419 no macrolides in bronchiectasis patients with two or more exacerbations in the previous year, two 420 RCTs of oral brensocatib at 10 mg and 25 mg daily, and two small, proof-of-concept RCTs comparing atorvastatin to placebo.59-66 421 422 In three long-term macrolide trials (24–52 weeks follow-up) in patients with an average 423 exacerbation rate in the prior year of ≥2, exacerbation rates decreased by a mean of 1.01 events per year. 63,65,66 424 Quality of life, assessed using the St. George’s Respiratory Questionnaire (SGRQ), 425 showed a pooled mean improvement of 6.23 points; however, this difference did not reach 426 statistical significance, as the confidence interval crossed zero (95% CI −12.81 to 0.36; P=0.06). 427 Although the point estimate exceeded the established minimal clinically important difference, the 428 absence of statistical significance indicates that a definitive improvement in quality of life cannot 429 be concluded from the meta-analysis (e-Table 7a). Adherence to macrolides was 96%. Non-serious 430 side effects were slightly greater in the macrolide subjects, but serious adverse events were 431 comparable. There was a trend toward macrolide bacterial resistance against gram-positive cocci in the subjects receiving a macrolide.63,65,66 432 433 A phase 3 trial (n=1721) in bronchiectasis patients with ≥2 exacerbations in the prior year showed 434 reduced annualized rates of exacerbation with brensocatib versus placebo: 1.02 (10 mg), 1.04 (25 mg), and 1.29 (placebo) events per year (Rate Ratio 0.8, 95% CI 0.7-0.9) (e-Table 7b).62 435 Subgroup analyses demonstrated heterogeneity in treatment effect by geographic region and ethnicity62 436 The 437 25 mg brensocatib group showed borderline improvements in FEV1, FVC, and QoL (QoL-B 438 respiratory domain), though QoL differences were non-significant. In the ASPEN phase 3 trial, 439 19.8% of participants in the 25mg brensocatib arm were receiving stable background macrolide 440 therapy at baseline. In an exploratory subgroup analysis, the point estimates for brensocatib’s 441 effect on exacerbation rate were similar regardless of background macrolide use: rate ratio 0.79 Journal Pre-pro including COPD.56-58 412 Targeting underlying inflammatory mechanisms offers additional therapeutic 413 opportunities: p.12
  • exacerbation rates decreased by a mean of 1.01 events per year. 63,65,66 424 Quality of life, assessed using the St. George’s Respiratory Questionnaire (SGRQ), year. p.12
  • reduced annualized rates of exacerbation with brensocatib versus placebo: 1.02 (10 mg), 1.04 (25 mg), and 1.29 (placebo) events per year (Rate Ratio 0.8, 95% CI p.12
  • brensocatib arm were receiving stable background macrolide 440 therapy at baseline. In an exploratory subgroup analysis, the point estimates for brensocatib’s 440 therapy at baseline. In an exploratory subgroup analysis, the point estimates for brensocatib’s 441 effect on p.12
  • we suggest surgical resection be considered in 637 appropriate surgical candidates (Conditional recommendation, Very low certainty 637 appropriate surgical candidates p.17
  • most applicable to patients with disease limited to one or two 642 contiguous lobes, preserving lung function and acceptable peri-operative risk; it is unlikely to 642 contiguous lobes, preserving lung function and acceptable peri-operative risk; it is unlikely to 643 benefit those p.17

Reference

Thomson R, Thornton C, Aksamit T, et al. Management of Adult Bronchiectasis: An American College of Chest Physicians Clinical Practice Guideline. CHEST. Published online July 2026:S0012369226061805. doi:10.1016/j.chest.2026.06.057