The European Respiratory Society guideline for management of adult bronchiectasis: clinical summary

European Respiratory Society guidelines for the management of adult bronchiectasis.

Bronchiectasis in adults is a chronic disorder associated with poor quality of life and frequent exacerbations in many patients. There have been no previous international guidelines. The European Respiratory Society...

Bronchiectasis is a chronic lung disorder that affects the lives of many South Africans. Post-tuberculosis (TB) bronchiectasis is an important complication of previous pulmonary TB and a common cause of bronchiectasis in South Africa (SA). No previous statements on the management of bronchiectasis in SA have been published. To provide a position statement that will act as a template for the management of adult patients with bronchiectasis in SA. The South African Thoracic Society appointed an editorial committee to compile a position statement on the management of adult non-cystic fibrosis (CF) bronchiectasis in SA. A position statement addressing the management of non-CF bronchiectasis in adults in SA was compiled. This position statement covers the epidemiology, aetiology, diagnosis, investigations and various aspects of management of adult patients with non-CF bronchiectasis in SA. Bronchiectasis has largely been a neglected lung condition, but new research has improved the outlook for patients. Collaboration between interprofessional team members in patient management is important. In SA, more research into the epidemiology of bronchiectasis, especially post-TB bronchiectasis and HIV-associated bronchiectasis, is required. The South African Thoracic Society mandated a multidisciplinary team of healthcare providers to compile a position statement on the management of non-cystic fibrosis bronchiectasis in South Africa (SA). International guidelines on the management of bronchiectasis were reviewed and used as a basis from which the current position statement was compiled. This is the first position statement on the management of adult non-cystic fibrosis bronchiectasis in SA. A description of the epidemiology and aetiology of bronchiectasis is provided, as well as guidance on its diagnosis and management. The position statement provides guidance on the management of bronchiectasis to healthcare providers, policymakers and regulatory authorities.

Background/AimsThe sit-to-stand test is a quick and cost-effective measure of exercise tolerance and lower body strength. The literature focuses on its use in stable patients with chronic obstructive pulmonary disease. This study in patients hospitalised for chronic obstructive pulmonary disease exacerbation aimed to investigate possible associations of the sit-to-stand test with pulmonary function and risk of future acute exacerbations.MethodsThis study was conducted on a sample of 22 patients with chronic obstructive pulmonary disease. Participants' clinical details were recorded before they undertook spirometry, 30-second and five-repetition sit-to-stand tests. Participants were assessed via a structured telephone interview for the occurrence of acute exacerbation events in the 12 months following discharge.ResultsPatients were classified based on the presence or absence of acute exacerbations of chronic obstructive pulmonary disease over 12 months. A negative correlation was observed between five-repetition sit-to-stand test performance time and number of repetitions during the 30-second sit-to-stand test; longer sit-to-stand times and fewer repetitions were observed in patients who experienced exacerbations during follow up. The 30-second sit-to-stand test repetitions correlated positively with forced expiratory volume in 1 second (FEV1). Five-repetition sit-to-stand test performance correlated negatively with FEV1, FEV1% predicted, forced vital capacity and FEV1/forced vital capacity ratio. From the various exercise parameters, five-repetition sit-to-stand test performance time demonstrated a moderate ability to predict exacerbations.ConclusionsThis study is the first to focus on the use of the sit-to-stand tests in inpatients with acute exacerbation of chronic obstructive pulmonary disease. There was a significant correlation between the 30-second sit-to-stand test and five-repetition sit-to-stand test results. Both tests were associated with pulmonary function indices and risk of future chronic obstructive pulmonary disease exacerbations.

BackgroundWhether risk of exacerbations of chronic obstructive pulmonary disease (COPD) is influenced by severity of symptoms and maintenance treatment is unclear. ObjectiveWe hypothesized that in addition to history of exacerbations of COPD, the severity of dyspnoea and use of maintenance medications are associated with risk of future exacerbations. MethodsWe included 96,462 adults from the Copenhagen General Population Study and assessed risk of moderate and severe exacerbations from 2003 to 2013 according to exacerbation history, dyspnoea score (mMRC), and presence/absence of maintenance treatment with inhaled long-acting bronchodilators and/or inhaled corticosteroids. FindingsAmong 13,380 individuals with COPD, we observed 1543 moderate and 348 severe exacerbations. In treatment naïve individuals and in those on maintenance treatment, history of previous exacerbations and to a smaller degree also dyspnoea were associated with a higher risk of future exacerbations; 32% of the treatment naïve individuals with mMRC≥2 and a single moderate exacerbation in the previous year experienced a moderate exacerbation during the following year compared with only 3% in the individuals with similar severity of dyspnoea but no exacerbations in the previous year yielding an adjusted hazard ratio of 6.26 (95% confidence interval, 3.70–10.58). InterpretationThis observational study of the general population suggests that in addition to exacerbation history also the severity of dyspnoea predicts the risk of future COPD exacerbations. In subjects with severe dyspnoea, a history of a single moderate exacerbation is associated with a high risk of future exacerbations, suggesting that this subgroup needs special attention in order to prevent these events.

Management of Adult Bronchiectasis - Consensus-based Guidelines of the German Respiratory Society.

Exacerbations are significant events in the course of bronchiectasis. Exacerbations are associated with accelerated lung function decline and deterioration in quality of life (QoL). Prevention of exacerbations is therefore one of the key objectives of management of bronchiectasis. A few treatments have been proven to reduce the risk of exacerbations, but these include the treatment of underlying causes of bronchiectasis and the use of prophylactic antibiotic therapies (macrolides and inhaled antibiotics). Nonantibiotic therapies, such as airway clearance and pulmonary rehabilitation, also play an important role in the prevention of exacerbations. Acute exacerbations are treated with antibiotics directed against the known bronchiectasis pathogens and guided by previous sputum culture results. This emphasizes the importance of screening sputum cultures in stable patients. Assessment of severity is used to determine whether patients should be treated at home or in hospital. Supportive therapy for exacerbations should include airway clearance alongside oxygen, hydration, and treatment of bronchospasm as required. Bronchiectasis is a rapidly developing field and new therapies, both for the prevention of exacerbations and the treatment of acute exacerbations, are currently being developed.

Acute exacerbations are major events in the natural history of chronic obstructive pulmonary disease (COPD) and are associated with increased morbidity and mortality. Although pulmonary rehabilitation increases exercise capacity, reduces dyspnea and improves health-related quality of life, the effects on risk of future exacerbations (and by extension, healthcare utilization) are less well documented. Furthermore, there has been a growing evidence base to support provision of pulmonary rehabilitation in the acute phase of COPD, for example, shortly after hospitalization for an acute exacerbation. This article reviews the role of pulmonary rehabilitation in the prevention and treatment of acute exacerbations of COPD.

Once neglected in research and underappreciated in practice, there is renewed interest in bronchiectasis unrelated to cystic fibrosis. Bronchiectasis is a chronic lung disease characterised by chronic cough, sputum production and recurrent pulmonary exacerbations. It is diagnosed radiologically on high resolution computed tomography chest scan by bronchial dilatation (wider than the accompanying artery). The causes of bronchiectasis are diverse and include previous respiratory tract infections, chronic obstructive pulmonary disease, asthma, immunodeficiency and connective tissue diseases. A large proportion of cases are idiopathic, reflecting our incomplete understanding of disease pathogenesis. Progress in the evidence base is reflected in the 2017 European management guidelines and the 2015 update to the Australian guidelines. Effective airway clearance remains the cornerstone of bronchiectasis management. This should be personalised and reviewed regularly by a respiratory physiotherapist. There is now robust evidence for the long term use of oral macrolide antibiotics in selected patients to reduce exacerbation frequency. The routine use of long term inhaled corticosteroids and/or long-acting bronchodilators should be avoided, unless concomitant chronic obstructive pulmonary disease or asthma exists. The evidence for nebulised agents including hypertonic saline, mannitol and antibiotics is evolving; however, access is challenging outside tertiary clinics, and nebulising equipment is required. Smokers should be supported to quit. All patients should receive influenza and pneumococcal vaccination. Patients with impaired exercise capacity should attend pulmonary rehabilitation. There is an important minority of patients for whom aetiology-specific treatment exists. The prevalence of bronchiectasis is increasing worldwide; however, the burden of disease within Australia is not well defined. To this end, the Australian Bronchiectasis Registry began recruitment in 2016 and is interoperable with the European and United States bronchiectasis registries to enable collaborative research. The recent addition of a bronchiectasis diagnosis-related group to the Australian Refined Diagnostic Related Group classification system will allow definition of the disease burden within the Australian hospital system.

Chronic neutrophilic inflammation, both in the presence and absence of infection, is a feature of bronchiectasis in adults and children. The anti-inflammatory properties of non-steroid anti-inflammatory drugs (NSAIDs) may be beneficial in reducing airway inflammation and thus potentially improve lung function and quality of life in patients with bronchiectasis. To evaluate the efficacy of inhaled NSAIDs in the management of non-cystic fibrosis bronchiectasis in children and adults. We searched the Cochrane Airways Group Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2009, issue 3), MEDLINE, OLDMEDLINE and EMBASE databases. The latest searches were carried out in October 2009 All randomised controlled trials comparing inhaled NSAIDs to a control group (placebo or usual treatment) in children or adults with bronchiectasis not related to cystic fibrosis. We reviewed the results of the searches against pre-determined criteria for inclusion. One small, short-term trial was eligible for inclusion. We included this study of 25 adults with chronic lung disease (including bronchiectasis) as the other conditions were linked to development of bronchiectasis and all had chronic sputum production.The single trial in adults reported a significant reduction in sputum production over 14 days in the treatment group (inhaled indomethacin) compared to placebo (difference -75.00 g/day; 95% CI -134.61 to -15.39) and a significant improvement in a dyspnoea score (difference -1.90; 95% CI -3.15 to -0.65). There was no significant difference between groups in lung function or blood indices. No adverse events were reported. There is currently insufficient evidence to support or refute the use of inhaled NSAIDs in the management of bronchiectasis in adults or children. One small trial reported a reduction in sputum production and improved dyspnoea in adults with chronic lung disease who were treated with inhaled indomethacin, indicating that further studies on the efficacy of NSAIDs in treating patients with bronchiectasis are warranted.

Acute Exacerbation According to GOLD 2017 Categories in Patients with Chronic Obstructive Pulmonary Disease

Acute Exacerbation According to GOLD 2017 Categories in Patients with Chronic Obstructive Pulmonary Disease

Adult patients with bronchiectasis typically have poor quality of life and mostly frequent exacerbations. This is the first international guideline on this topic. This guideline is based on systematic search of published literature including clinical trials, systematic reviews, and observational studies. A multidisciplinary group of specialists including respiratory physicians, microbiologists, physiotherapeutists, thoracic surgeons, primary care physicians, methodologists and patients developed the guidelines on nine most important clinical questions relevant to bronchiectasis. The GRADE system was used to define the quality of the evidence and the level of recommendations. The guideline covers causes of bronchiectasis, management of exacerbations, pathogen eradication, long term antibiotic treatment, anti-inflammatory treatment, mucoactive drugs, bronchodilators, surgical treatment and physiotherapy.

European Respiratory Society guidelines for the management of children and adolescents with bronchiectasis

Since the first European Respiratory Society (ERS) bronchiectasis guideline published in 2017, the clinical and research scenarios have substantially changed, with a growth in RCTs, international registries and new pathophysiological insights. The 2025 ERS guidelines have provided an updated, evidence-based framework for management of adults with clinically significant bronchiectasis, through PICO (Patients, Intervention, Comparator, Outcomes) question-based recommendations, with narrative guidance on aetiological assessment, exacerbation management and the rapidly deteriorating patient. Compared with 2017, key changes include: upgrading recommendations for airway clearance, aetiological testing, macrolides and inhaled antibiotics from conditional to strong recommendations; a shift from a simple “≥3 exacerbations per year” threshold to the concept of individualised risk assessment to identify patients “at high risk for exacerbations”; and greater emphasis on treatable traits and comorbidities. This chapter summarises the main recommendations of the 2025 ERS guidelines and translates them into practical, educational messages for clinicians, especially targeting interventions such as airway clearance, mucoactive drugs, pulmonary rehabilitation, long-term macrolides and inhaled antibiotic therapy, and long-term inhaled corticosteroids, together with a structured assessment of aetiology, disease activity and severity and the management of deteriorating patients. <bold>Cite as:</bold> Aliberti S, Chalmers JD. Principles of management: an overview of the 2025 European Respiratory Society bronchiectasis guidelines. <italic>In:</italic> Chalmers JD, Shoemark A, Aliberti S, eds. Bronchiectasis (ERS Monograph). Sheffield, European Respiratory Society, 2026; pp. 231–243 [<ext-link>https://doi.org/10.1183/2312508X.10002325</ext-link>].