Decision support only — not a substitute for the ERS 2025 / BTS guidelines, TSANZ position statement, eTG, or your respiratory team. Diagnosis is by HRCT. Management breaks the vicious cycle of impaired clearance → infection → inflammation → airway damage: clear the airways, treat infection, find and treat the cause. Verify all doses and check microbiology before antibiotics.
1 Chronic management — step up by exacerbations & Pseudomonas
Everyone — foundationstrong recommendation
All patients with bronchiectasis.
Daily airway clearance (physio techniques ± device) + treat the cause + vaccinate, pulmonary rehab if exercise-limited, smoking cessation.
Difficult clearance / mucussymptomatic
Tenacious sputum, hard to clear despite technique.
Add nebulised hypertonic saline or mannitol as part of the clearance regimen. Not DNase.
Frequent exacerbator≥2–3 /year or ≥1 severe
High exacerbation risk despite the foundation.
Long-term azithromycin 250 mg daily or 3×/wk BAT · BLESS · EMBRACE. Exclude NTM, baseline ECG/QTc, hearing first.
Chronic Pseudomonas+ frequent exacerbations
Persistent P. aeruginosa + high exacerbation risk despite standard care.
Long-term inhaled antibiotic (nebulised colistin / tobramycin / gentamicin) PROMIS. Supervised test dose (bronchospasm risk).
Refractory / severedespite optimisation
Ongoing frequent exacerbations on optimal therapy.
Brensocatib (oral DPP-1 inhibitor) new 2025 ASPEN. Consider surgery for localised disease; transplant referral if end-stage.
High exacerbation risk = ≥2 exacerbations in the prior year, OR ≥1 severe (hospitalised), OR 1 plus severe daily symptoms. Treat the cause sits under every rung. P. aeruginosa is the key prognostic organism — its presence drives both inhaled-antibiotic decisions and overall risk. Reassess long-term therapies (macrolide, inhaled antibiotic) for ongoing benefit and adverse effects at 6–12 months.
2 Diagnose, find the cause, stratify
Confirm & assess
- HRCTBronchial dilatation, signet-ring sign, lack of tapering, airways at the periphery.
- SeverityBronchiectasis Severity Index (BSI) or FACED; track exacerbation frequency.
- MicroSputum culture incl P. aeruginosa & NTM screen — baseline and at exacerbations.
Hunt the treatable cause
- ImmuneImmunoglobulins (± vaccine responses) — immunodeficiency is treatable with replacement.
- ABPATotal IgE, Aspergillus-specific IgE/IgG — steroids ± antifungal.
- OtherCF (selected), PCD, connective tissue disease, alpha-1, aspiration, IBD.
Pseudomonas eradication
- New isolateAttempt eradication on first isolation (inhaled ± oral/IV) — don't just observe.
- WhyChronic Pseudomonas worsens lung function, exacerbations, and survival.
3 Acute exacerbation
Recognise & treat
- DefineDeterioration in ≥3 of: cough, sputum volume, purulence, breathlessness, fatigue, haemoptysis — for ≥48h, needing antibiotics.
- CultureSputum before antibiotics. Be guided by the patient's known microbiology.
- Antibiotics14 days (longer than typical chest infections). Ciprofloxacin if Pseudomonas-colonised; amoxicillin-clavulanate or doxycycline otherwise.
- ClearanceIntensify airway clearance during the exacerbation.
When it's serious
- IV / admitSystemically unwell, failing oral therapy, or resistant organism → hospitalise for IV antibiotics.
- HaemoptysisCan be life-threatening. Massive haemoptysis → bronchial artery embolisation; resuscitate, protect the airway (bleeding side down).
- ReassessRecurrent exacerbations → revisit the cause, microbiology, and adherence; step up chronic therapy.
4 What not to do — bronchiectasis isn't CF or COPD
Don't extrapolate from other diseases
- DNaseRecombinant DNase (dornase alfa) is harmful in non-CF bronchiectasis — worse outcomes rhDNase trial. Works in CF; don't transfer it.
- ICSNot routine — only for coexisting asthma/COPD. Carries pneumonia and NTM risk without benefit in bronchiectasis alone.
- Oral abxLong-term non-macrolide oral antibiotics not first-line — unfavourable risk/benefit.
Before you start long-term antibiotics
- NTMExclude NTM before macrolide monotherapy — azithromycin alone risks macrolide-resistant NTM.
- MacrolideBaseline ECG (QTc), hearing; warn re GI/ototoxicity; review for resistance.
- InhaledSupervised first dose — risk of bronchospasm.
5 The whole patient
Look wider
- ComorbidChronic rhinosinusitis, GORD, asthma/COPD overlap, anxiety/depression — treat them; they drive symptoms and exacerbations.
- SupportSelf-management + written action plan; rescue antibiotic supply for appropriate patients.
- ReferSpecialist/MDT bronchiectasis service for frequent exacerbators, Pseudomonas, NTM, or unclear cause.
Keep reviewing
- MonitorSymptoms, exacerbation frequency, sputum micro, spirometry; reassess long-term therapy at 6–12 months.
- VaccinateInfluenza, pneumococcal, COVID.
- NutritionAddress weight loss / low BMI — associated with worse outcomes.
Sources.
ERS — Clinical Practice Guideline for the Management of Adult Bronchiectasis 2025 (Eur Respir J; airway clearance, long-term macrolide & inhaled antibiotics, eradication, against DNase/ICS). BTS Guideline for bronchiectasis in adults 2019. TSANZ / Lung Foundation Australia position statement (chronic suppurative lung disease & bronchiectasis). eTG.
Key trials: BAT, BLESS, EMBRACE (long-term azithromycin); PROMIS (inhaled colistin); WILLOW & ASPEN (brensocatib, DPP-1 inhibitor); rhDNase trial (recombinant DNase harm in non-CF).
Caveats: brensocatib is newly FDA-approved (Aug 2025) — local availability/PBS will lag. Inhaled-antibiotic trial data (RESPIRE/ORBIT for ciprofloxacin) are mixed; agent choice depends on organism and tolerance. Exclude NTM before any long-term macrolide. Antibiotic selection is microbiology- and resistance-dependent — confirm against local/eTG. Verify all doses.