Reflux in bronchiectasis: current evidence and clinical implications

To describe the relationship between reflux and bronchiectasis and to appraise recent literature on reflux characterization, clinical outcomes, and management strategies in patients with bronchiectasis.

Reflux is common in bronchiectasis and has been linked to worse respiratory symptoms and quality of life, more exacerbations and healthcare use, lower lung function, and higher mortality. These associations are seen across several cohorts, but nearly all data are observational, use variable reflux definitions, and cannot determine whether reflux contributes to bronchiectasis progression or simply identifies patients with more severe disease. Proposed pathways include microaspiration-related airway injury, reflex-mediated cough amplification, and microbial dysbiosis. No randomized bronchiectasis-specific trial has shown improved respiratory outcomes with reflux-directed therapy, and acid suppression alone is unlikely to address nonacid reflux, microaspiration, cough-reflex pathways, or airway dysbiosis.

In bronchiectasis, reflux should be separated into clinically relevant phenotypes, including typical gastroesophageal reflux disease, proximal or nonacid reflux, laryngopharyngeal symptoms, dysphagia, and aspiration. Management should be guided by the suspected reflux or aspiration pattern because acid suppression alone may not address airway-relevant reflux. Future studies should pair objective reflux and swallowing measures with bronchiectasis-specific outcomes.