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Bronchiectasis

NICE guideline [NG117] Bronchiectasis (non-cystic fibrosis), acute exacerbation: antimicrobial prescribing. Published: Dec 2018. NICE CKS Bronchiectasis. Last revised: Mar 2025. BTS Guideline for Bronchiectasis in Adults. Published: Jan 2019.

Background Information

Bronchiectasis: chronic, progressive lung disease characterised by irreversible bronchial dilation (focal or diffuse).

Exacerbation of bronchiectasis: persistent ≥48h worsening with ≥3 of: increased cough, sputum (volume/consistency), sputum purulence, breathlessness, fatigue/malaise, or haemoptysis, requiring a clinician-directed treatment change.[Ref]

The following mechanisms contribute to the pathogenesis of bronchiectasis: [Ref]
  • Respiratory infections or inflammation 
  • Airway obstruction 

Specific causes
  • Idiopathic (~40% of cases)
  • Chronic or recurrent respiratory infections
  • Airway obstruction 
    • Disorders of secretion / mucociliary clearance
      • Cystic fibrosis
      •  Primary ciliary dyskinesia (e.g., Kartagener syndrome)
    • Other
      • COPD
      • Aspiration 
      • Tumors 
  • Immunodeficiency (e.g., HIV, congenital immunodeficiencies) 
  • Allergic bronchopulmonary aspergillosis (ABPA)
  • Systemic inflammatory diseases (e.g. rheumatoid arthritis, IBDInflammatory bowel disease) 
  • Rare syndromes / congenital defects

Pathogens 
  • Several pathogens colonise the airways and are implicated in the development / progression of bronchiectasis 
  • Most common:
    • Haemophilus influenzae (20-40%) 
    • Pseudomonas aureginosa (10-30%)

Main cause → pathogen airway colonisation or acute infection [Ref]
  • Bacteria 
    • Haemophilus influenzae
    • Pseudomonas
    • Staphylococcus aureus
  • Fungi (esp. Aspergillus spp.)
  • Viruses (e.g., influenza, rhinovirus, coronaviruses)

Symptoms
  • Common 
    • Chronic productive cough with expectoration of large volumes of purulent sputum 
    • Dyspnoea 
    • Rhinosinusitis 
  • Additional 
    • Haemoptysis (minor → massive)
    • Nonspecific symptoms → Fatigue, Weight loss, Fever 
    • Non-pleuritic chest pain 
O/E
  • Signs
    • Nail clubbing (uncommon)
  • Auscultation
    • Coarse crackles (esp lower zones)
    • Wheezing 

Suspect if:
  • There is a worsening of common symptoms from baseline AND/OR
  • Development of new symptoms such as fever, pleuritic chest pain or haemoptysis

Exacerbations 

  • Very common & accelerates disease progression 
Pulmonary 
  • Haemoptysis → blood in sputum is common; may be massive (>250ml) and life-threatening
  • Respiratory failure → from progressive lung damage 
  • Cor pulmonale 

  • Mild disease → Normal life expectancy possible.
  • Worse prognosis with:
    • Extensive disease
    • Frequent/severe exacerbations 
    • Breathlessness (strong mortality predictor) 
    • Chronic Pseudomonas colonisation
    • Comorbidities, smoking 

Guidelines

  • 1st line: chest X-ray 
  • Confirmatory test: HRCTHigh-resolution computed tomography
 
Imaging modality Interpretation
Chest X-ray Note that chest X-ray can often be normal or non-diagnostic

Possible findings:
  • Tram-track opacities (parallel lines indicative of dilated bronchi)
  • Ring shadows (indicative of dilated terminal bronchi)
  • Coarsened lung markings
  • Increased bronchovascular markings
HRCT
  • Signet ring sign - diameter of bronchus > adjacent pulmonary artery
  • Bronchial dilatation
  • Lack of bronchial tapering
  • Visualisation of bronchi within 1cm of pleural surface (normally airways are not seen so peripherally)

  • Test for cystic fibrosis
  • Test for primary ciliary dyskinesia (if there is a history of neonatal distress / symptoms from childhood / recurrent otitis media / rhinosinusitis / infertility)
  • Sputum culture
  • Antibody testing
    • Screen for antibody deficiency
    • Test serum total IgE and specific IgE or skin prick test to Aspergillus (to exclude allergic bronchopulmonary aspergillosis)
    • Test specific antibody levels against capsular polysaccharides of Streptococcus pneumoniae

Consider other testing:
  • Rheumatology serology screening (RF, Anti-CCP, ANA, ANCA)
  • Test for alpha 1 antitrypsin deficiency
  • HIV-1 serology
  • Serum protein electrophoresis (in those with raised immunoglobulins)
  • Bronchoscopy (to rule out endobronchial lesion or foreign body aspiration)

All patients:
  • Airway clearance technique (taught by physiotherapist)
  • Smoking cessation
  • Immunisation against Streptococcus pneumoniae, annual influenzae, COVID-19

Consider:
  • Humidification with normal saline / sterile water to facilitate airway clearance
  • Long-acting bronchodilator in those with significant breathlessness
 

Do not routinely offer antibiotic prophylaxis.

Antibiotic prophylaxis may be offered if there are ≥3 exacerbations per year (only offered by specialist)

  • 1st line for most patient: azithromycin / erythromycin
  • If there is concurrent Pseudomonas aeruginosa infection: inhaled colistin
  • Offer antibiotic prophylaxis for at least 6 months

 

Monitoring prophylactic oral macrolides:

  • Baseline ECG to assess QTc and LFTs
  • After starting treatment: check ECG (one-off) and LFTs

Consider lung resection in localised disease and not controlled by medical therapy.

Consider referral for lung transplantation if:
  • ≤65 y/o, and
  • FEV1 <30%, and
  • Significant clinical instability or rapid progressive respiratory deterioration despite optimal medical therapy

Obtain a sputum sample (for culture and susceptibility testing), then offer an antibiotic
  • If previous microbiology cultures are available, use them to guide antibiotic choice
 

Standard empirical antibiotic choice (for 7-14 days):
  • 1st line: amoxicillin
  • 2nd line: clarithromycin / doxycycline 

If there is high risk of treatment failure:
  • 1st line: co-amoxiclav
  • 2nd line: levofloxacin 

Choice for IV antibiotic therapy (if unable to take oral antibiotic or severely unwell):
  • 1st line: co-amoxiclav / tazocin (piperacillin with tazobactam)
  • 2nd line: levofloxacin

1st line antibiotics for common organisms from NICE CKS:
 
Organism 1st line antibiotic
Streptococcus pneumoniae
  • Amoxicillin 
Haemophilus influenzae 
  • Amoxicillin (if beta-lactamase -ve)
  • Co-amoxiclav (if beta-lactamase +ve)
Moraxella catarrhalis
  • Co-amoxiclav 625 mg three times daily
Staphylococcus aureus 
  • Flucloxacillin 500 mg four times daily
MRSA
  • Rifampicin + doxycycline (if <50 kg)
  • Rifampicin + trimethoprim (if >50 kg)
Coliforms (e.g. Klebsiella or Enterobacter)
  • Ciprofloxacin
Pseudomonas aeruginosa
  • Ciprofloxacin

References

Author: Adams Lau
Reviewer:
Last edited: 29/07/25