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Headline

New North American Guideline Provides 13 Evidence-Based Recommendations for Managing Bronchiectasis in Adults

1-minute summary

A multidisciplinary panel of 17 experts has developed a new clinical practice guideline for the management of bronchiectasis in adults in North America, addressing an area in which clinicians previously lacked a dedicated North American guideline. The panel formulated 8 questions using the population, intervention, comparator, and outcome (PICO) framework and systematically reviewed 47 studies before developing 13 recommendations.

All 13 recommendations were classified as conditional, with the certainty of supporting evidence ranging from very low to moderate. The panel emphasized that the limited evidence base, including the relatively small number of studies with control groups, means that treatment decisions should be individualized rather than applied as rigid rules.

The guideline addresses several practical aspects of care, including:

• antibiotic duration during exacerbations;
• microbiologic testing;
• airway-clearance techniques;
• long-term prevention of exacerbations;
• anti-inflammatory treatment;
• management of hemoptysis; and
• individualized action plans for recurrent exacerbations.

A major theme is that bronchiectasis should be managed as a chronic disease characterized by interactions among infection, inflammation, airway damage and recurrent exacerbations, rather than simply as repeated episodes of infection.

Why this matters

Bronchiectasis has historically received less clinical attention than several other chronic respiratory diseases. According to lead author Rachel Thomson, MBBS, PhD, bronchiectasis was once thought by some clinicians to have largely disappeared, particularly as tuberculosis and childhood infections became better controlled.

However, increasing use of computed tomography has resulted in more patients being identified with bronchiectasis, while clinicians may still be uncertain about optimal management. Thomson described a continuing need for more uniform management and greater recognition of the disease burden.

The guideline is particularly relevant because the European Respiratory Society published a bronchiectasis guideline in 2017 and an update in 2025, whereas North American clinicians had not previously had a comparable dedicated guideline.

Study at a glance

The source describes the evidence base as limited, with relatively few studies incorporating control conditions. Consequently, every recommendation was categorized as conditional.

Feature details

What is bronchiectasis?

Bronchiectasis is a chronic respiratory disorder characterized by abnormal and persistent dilation of the bronchi, accompanied by impaired airway clearance and recurrent respiratory infections or exacerbations.

The disease can involve a self-perpetuating cycle in which infection contributes to inflammation, inflammation contributes to airway damage, and damaged airways become increasingly susceptible to further infection.

The source describes this historical concept as a “vicious cycle” involving:

infection → inflammation → airway damage → increased susceptibility to infection.

More recent research has suggested that inflammation may become dysregulated and continue even when infection is controlled. This has shifted attention toward therapies that target inflammatory pathways in addition to antimicrobial treatment.

What prompted the guideline?

The authors identified several reasons for developing North American guidance.

First, bronchiectasis appears to be increasingly recognized, partly because clinicians are performing more CT imaging. Second, management has not been consistent across clinicians, and some patients may not receive structured long-term management.

Thomson explained:

“There’s a clinical need.”

She described a shift from the historical perception that bronchiectasis was largely a disease of the past to recognition that it remains an important chronic respiratory condition.

The authors also noted that although European guidance existed, a dedicated North American guideline had not previously been available.

How the guideline was developed

The expert group formulated 8 PICO questions and conducted a systematic review of 47 studies.

The process can be summarized as:

Because the evidence base was relatively limited, all 13 recommendations were designated conditional.

What the researchers found

1. Management of acute exacerbations

One of the most important practical recommendations concerns the management of bronchiectasis exacerbations.

The guideline emphasizes:

• identifying the causative microbiology when possible;
• obtaining sputum testing;
• treating exacerbations with antibiotics when indicated; and
• tailoring treatment duration according to the patient’s clinical response.

Thomson specifically cautioned against automatically applying the short antibiotic courses commonly used for some other respiratory infections.

She explained:

“There’s a lot of push from the infectious diseases community to treat pneumonia and bronchitis with short courses (5 days), but for bronchiectasis, that often doesn’t work.”

The guideline allows for antibiotic courses of less than 10 days or more than 10 days, depending on the patient’s response rather than imposing one universally appropriate duration.

Antibiotic-duration principle

The key message is individualization rather than a fixed antibiotic duration.

2. Sputum testing and microbiology

The guideline emphasizes microbiologic evaluation during exacerbations.

Instead of reflexively prescribing a commonly used antibiotic for a productive cough and infectious symptoms, clinicians should consider obtaining a sputum sample first.

Thomson described a common clinical pattern in which clinicians might immediately prescribe:

• amoxicillin;
• azithromycin; or
• doxycycline.

The guideline instead emphasizes obtaining a sputum test, because microbiology may help identify the organism and guide antibiotic selection.

This becomes particularly important in patients with known colonization by organisms such as:

• Pseudomonas;
• Staphylococcus; or
• Haemophilus.

3. Long-term prevention of exacerbations

The guideline emphasizes that treatment should not focus solely on the management of individual exacerbations.

Repeated exacerbations contribute to:

• inflammation;
• disease progression;
• symptom burden;
• fatigue;
• chronic sputum production; and
• loss of work or daily functioning.

Thomson emphasized:

“The goal of bronchiectasis management is to reduce exacerbations and improve quality of life.”

This means that long-term strategies designed to reduce exacerbation frequency and control symptoms are an important component of care.

4. Airway-clearance therapy

The guideline recommends that all patients receive physiotherapy and instruction in airway-clearance techniques.

Airway clearance is considered an important component of:

• symptom control;
• mucus management; and
• reduction of exacerbations.

The specific technique should be individualized because different patients may respond differently.

Thomson described airway clearance as:

“a really important component of management that’s often missed.”

Airway-clearance principle

5. Hemoptysis

Hemoptysis is another important aspect of bronchiectasis management addressed by the North American guideline.

The authors specifically considered whether patients with relatively minor hemoptysis need immediate hospitalization or whether earlier outpatient management may be appropriate.

For minor hemoptysis, the guideline recommends considering tranexamic acid, either orally or by inhalation.

The source notes that supporting studies have included patients with bronchiectasis as well as individuals with lung cancer and COPD.

Hemoptysis management

However, the evidence remains limited. The guideline authors noted that there have not been large randomized controlled trials comparing tranexamic acid with placebo specifically in bronchiectasis.

6. The changing role of inflammation

The management philosophy of bronchiectasis has evolved.

Historically, clinicians often viewed infection as the central driver:

infection → inflammation → airway injury → further infection.

More recent research indicates that inflammatory pathways may become dysregulated and continue to contribute to airway injury even after infection is controlled.

This has increased interest in anti-inflammatory therapies.

7. Azithromycin

Azithromycin has been an important development in bronchiectasis management because of both its antimicrobial and anti-inflammatory effects.

According to Thomson, its anti-inflammatory properties may contribute substantially to its effectiveness.

She noted that azithromycin can:

• reduce inflammation;
• decrease mucus; and
• reduce exacerbations.

The source also notes that erythromycin has been studied, but its more frequent dosing schedule and tolerability have limited its practical appeal compared with azithromycin.

8. Brensocatib

Brensocatib (Brinsupri) is highlighted as an important newer development.

According to the source, it is the only medication with a specific FDA indication for bronchiectasis in the United States at the time of the report. Other available medications may be used off-label.

Brensocatib targets the dipeptidyl peptidase 1 (DPP1) pathway.

The source discusses 2 major trials:

• WILLOW
• ASPEN

In those trials, different doses of brensocatib were compared with placebo and were reported to reduce exacerbations, slow lung-function decline and improve quality of life, supporting its US approval.

Brensocatib evidence described in the source

The source specifically cautions that although ASPEN provided 1-year safety information, longer-term safety remains uncertain.

9. Individualized patient action plans

An important practical component of the guideline is converting recommendations into an action plan that patients can use when symptoms worsen.

Thomson described an approach in which patients with established bronchiectasis may have:

• respiratory PCR testing arrangements;
• sputum culture requests;
• a sputum collection container;
• predefined instructions for exacerbations;
• antibiotic plans based on known microbiology; and
• specific instructions for hemoptysis when applicable.

For patients with known colonization, such as Pseudomonas, the clinician may already know which antibiotic is appropriate.

The source emphasizes that early testing and treatment can help patients begin appropriate management sooner.

10. The guideline is not a one-size-fits-all protocol

One of the most important messages from the lead author is that clinicians should not treat the guideline as an automatic decision tree.

Thomson stated:

“There’s no one-size-fits-all answer for patient management.”

She also emphasized:

“You’ve still got to think, use your clinical judgment and know your patients.”

The guideline is therefore intended to support clinical judgment rather than replace it.

Clinical significance

The guideline represents an effort to standardize care in a disease where practice has historically varied.

Its most clinically relevant themes include:

Microbiology-directed treatment

Sputum testing can help clinicians avoid empiric treatment that does not adequately account for the patient’s established airway microbiology.

Individualized antibiotic duration

The guideline does not impose a universal 5-day treatment duration for bronchiectasis exacerbations.

Long-term prevention

Preventing recurrent exacerbations is a major objective because repeated exacerbations can contribute to ongoing inflammation and disease progression.

Airway clearance

Physiotherapy and airway-clearance education should form part of routine management.

Recognition of hemoptysis

The guideline provides an option for clinicians managing less severe hemoptysis and highlights tranexamic acid as a possible treatment.

Anti-inflammatory treatment

The evolving understanding of bronchiectasis as a disease involving dysregulated inflammation supports increasing interest in therapies beyond conventional antibiotics.

Limitations

Evidence certainty is limited

All 13 recommendations were conditional because the supporting evidence ranged from very low to moderate certainty.

Limited controlled studies

The guideline panel noted that relatively few studies incorporated control conditions.

Hemoptysis evidence remains incomplete

There are insufficient large randomized trials specifically evaluating tranexamic acid against placebo in bronchiectasis.

Mucolytic evidence is uncertain

The panel could not reach a firm conclusion regarding N-acetylcysteine, because only one relevant trial was identified and considered insufficient for a strong recommendation.

Long-term anti-inflammatory safety requires further study

Brensocatib has 1-year safety information from ASPEN, but longer-term adverse effects remain uncertain.

Pseudomonas eradication remains controversial

European recommendations have supported eradication when Pseudomonas first appears, but this North American guideline did not adopt that approach because the panel considered the evidence insufficient.

Long-term outcomes remain uncertain

The authors emphasized the need for longer follow-up to determine whether apparent eradication of organisms such as Pseudomonas is sustained and how long-term antibiotic exposure affects patients.

What doctors should know

1. Obtain sputum testing during exacerbations when feasible

Microbiologic information can help guide antibiotic selection, particularly in patients with known airway colonization.

2. Do not automatically apply 5-day antibiotic courses

Some patients with bronchiectasis may require longer treatment, with duration guided by clinical response.

3. Establish an individualized action plan

Patients can benefit from knowing what to do when they develop:

• increased respiratory symptoms;
• infective symptoms;
• viral symptoms; or
• hemoptysis.

4. Include airway clearance in routine care

Physiotherapy and airway-clearance education are important components of management.

5. Address recurrent exacerbations

Repeated exacerbations are not merely isolated infections; they contribute to cumulative disease burden and may drive further inflammation and progression.

6. Consider anti-inflammatory strategies where appropriate

The treatment landscape is evolving, with azithromycin and newer targeted approaches such as brensocatib receiving increasing attention.

7. Individualize treatment

The guideline should support—not replace—clinical judgment.

8. Be cautious about prolonged antimicrobial exposure

The authors highlight unanswered questions about antimicrobial resistance and potential effects of long-term antibiotics on the gut microbiome.

Important unanswered research questions

The guideline identifies several areas requiring further investigation.

The authors also highlight the need to understand how the gut microbiome may influence susceptibility to infection and immune responses.

Bottom line

A new North American clinical practice guideline provides 13 conditional recommendations for the management of bronchiectasis in adults, based on 8 PICO questions and a systematic review of 47 studies. The evidence supporting the recommendations ranges from very low to moderate certainty, emphasizing the importance of individualized clinical judgment.

The guideline emphasizes microbiology-guided antibiotic selection, individualized antibiotic duration, airway-clearance therapy, prevention of recurrent exacerbations and management of hemoptysis. It also reflects the evolving understanding that bronchiectasis involves persistent dysregulated inflammation in addition to infection.

For clinicians, one of the most practical messages is that a bronchiectasis exacerbation should not necessarily be managed with the same short antibiotic course used for other respiratory infections. Sputum testing and clinical response should help determine treatment, while long-term management should incorporate airway clearance and strategies aimed at reducing recurrent exacerbations.

The guideline also highlights substantial gaps in evidence, particularly concerning hemoptysis treatment, mucolytics, long-term anti-inflammatory therapy, Pseudomonas eradication, antimicrobial resistance and the effects of prolonged antibiotic exposure on the microbiome.

Original research / DOI

Article type: Clinical practice guideline / expert guideline based on systematic evidence review.

Evidence base: 47 studies.

PICO questions: 8.

Recommendations: 13.

Recommendation certainty: Conditional; very low to moderate certainty.

Primary randomized trial: Not applicable—the source describes a guideline rather than an individual clinical trial.

DOI: Not provided.

Source: Interview with lead author Rachel Thomson, MBBS, PhD. The source identifies the article as based on the newly developed North American bronchiectasis guideline.

Author disclosure: Thomson reported previous advisory-board relationships and institutional research funding involving Merck Sharp & Dohme, Johnson & Johnson, and Boehringer Ingelheim, as described in the source.