Screening and impact of comorbidities in bronchiectasis: a forward-looking perspective

Bronchiectasis is a chronic, complex, and heterogeneous respiratory disease characterized by irreversible bronchial dilation, persistent airway inflammation, and recurrent infections. Traditionally viewed from a lung-centered perspective, its pathophysiology has been explained by the "vicious cycle" hypothesis, later refined into the more dynamic concept of the "vicious vortex." However, emerging evidence highlights the pivotal role of comorbidities in influencing disease progression, symptom burden, and prognosis. This review explores the evolving understanding of bronchiectasis by integrating comorbidities into current pathophysiological frameworks. We illustrate how coexisting conditions interact with components of the vicious vortex, amplifying airway inflammation, impairing host defenses, and disrupting clearance mechanisms. We summarize evidence on the prevalence, clinical impact, and prognostic significance of key comorbidities and discuss their implications for patient management. Finally, we emphasize the importance of an integrated, multidisciplinary approach and the emerging role of the treatable traits framework, which focuses on identifying clinically relevant, biologically measurable, and modifiable traits-regardless of whether they are etiological or nonetiological. In this sense, we propose a conceptual "Copernican Revolution" in bronchiectasis care: recognizing comorbidities not as secondary features, but as potential drivers of disease trajectory. By adopting this pragmatic strategy, clinicians can optimize quality of life, achieve patient-centered care, and improve outcomes in this condition.