23/12/2025
* ERS recommendations - Bronchiectasis 2025 *
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The 2025 European Respiratory Society (ERS) clinical practice guidelines for adult bronchiectasis provide an evidence-based framework for managing this chronic inflammatory lung disease. The guidelines focus on improving quality of life, preventing exacerbations, and managing disease progression by addressing the "vicious vortex" of airway infection, inflammation, structural damage, and impaired mucociliary clearance.
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Core Management Recommendations
The guidelines categorize recommendations as Strong (indicated by "we recommend") or Conditional (indicated by "we suggest").
Airway Clearance & Rehabilitation:
Airway Clearance Techniques (ACT): Strong recommendation for all patients, ideally taught by a respiratory physiotherapist.
Pulmonary Rehabilitation: Strong recommendation for patients with breathlessness or impaired exercise capacity.
Antibiotic Therapy:
Long-term Macrolides: Strong recommendation for patients at high risk of exacerbations despite standard care.
Inhaled Antibiotics: Strong recommendation for patients with chronic Pseudomonas aeruginosa infection at high risk of exacerbations. Conditional recommendation for those with other chronic pathogens.
Eradication Treatment: Conditional recommendation to attempt eradication for a new isolation of P. aeruginosa.
Non-macrolide Oral Antibiotics: Suggested against as first-line long-term therapy.
Other Pharmacological Treatments:
Mucoactive Drugs: Suggested if airway clearance alone fails to control symptoms. Recombinant DNase is suggested against.
Inhaled Corticosteroids (ICS): Suggested against for patients without coexisting asthma or COPD.
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Diagnosis and Evaluation
Standardized testing is strongly recommended at diagnosis and during follow-up to identify underlying causes and "treatable traits".
Initial Screening: Includes serum immunoglobulins (IgG, IgM, IgA), testing for Allergic Bronchopulmonary Aspergillosis (ABPA), blood eosinophils, and sputum cultures for bacteria and non-tuberculous mycobacteria (NTM).
Severity Assessment: Use the Bronchiectasis Severity Index (BSI) to assess future risk.
Comorbidities: Routine screening for cardiovascular disease, osteoporosis, anxiety, depression, and rhinosinusitis is advised.
Managing the Deteriorating Patient
For patients experiencing rapid worsening of symptoms or frequent exacerbations (the "RAPID" approach), the guidelines suggest a comprehensive re-evaluation.
Assess: Review treatment adherence, airway clearance technique, and potential new infections (e.g., NTM or ABPA).
Intervene: Optimize therapy, refer to specialists, and consider lung transplantation referral if FEV_1 falls below 30%.
