Management of Adult Bronchiectasis: An American College of Chest Physicians Clinical Practice Guideline

Bronchiectasis is a chronic respiratory condition involving a cycle of impaired mucociliary clearance, chronic infections, inflammation, and progressive airway destruction, leading to persistent cough with sputum production, dyspnea, and fatigue. Without appropriate management, patients can experience increased exacerbations, reduced quality of life, declining lung function, and increased mortality risk. Variability exists in clinical practice regarding treatment selection, highlighting the need for evidence-based guidance to optimize patient outcomes and standardize care delivery across health care settings.

An expert panel developed 8 population, intervention, comparator, and outcome (PICO)-based questions addressing treatment of bronchiectasis in adults and conducted a systematic review. The panel applied the Grading of Recommendations, Assessment, Development, and Evaluations approach to assess the certainty of evidence and to formulate and grade recommendations. A modified Delphi technique was used to reach consensus on the recommendations.

Based on 47 studies, the panel developed 13 evidence-based recommendations addressing key management domains, including antibiotic treatment for acute exacerbations, duration and route of antibiotic therapy, long-term suppressive antibiotic and anti-inflammatory therapies, airway clearance strategies, management of hemoptysis and consideration of surgical resection in selected patients.

All recommendations are conditional, primarily based on low-certainty evidence. Bronchiectasis research should aim to address many of the uncertainties in management, and priorities are identified within each PICO question. Accurate phenotyping and endotyping may help guide therapeutic decision-making and risk stratification. Treatment interventions must consider potential treatment burdens, including cost, and impact on quality of life. Finally, shared decision-making with patients utilizing a multidisciplinary approach is paramount.