Bronchiectasis is a chronic lung disease in which the bronchi become permanently and abnormally widened, with thickened walls and pooled mucus. Clients have a daily productive cough and repeated chest infections.

The "vicious cycle" (vortex). Four processes drive one another:

1. Impaired mucociliary clearance — mucus is not cleared
2. Chronic bacterial infection — pooled mucus is colonized (commonly Haemophilus influenzae, Pseudomonas aeruginosa)
3. Neutrophilic inflammation — neutrophil enzymes (elastase and other proteases) damage the airway wall
4. Structural damage — the airways dilate further and clear mucus even less

Breaking any part of the cycle — especially clearing secretions and preventing infection — is the aim of treatment.

Causes

• Post-infectious: severe pneumonia, tuberculosis, pertussis, measles (particularly in childhood)
• Cystic fibrosis (CF-related bronchiectasis is managed as part of CF — see Topic 15)
• Primary ciliary dyskinesia, immunodeficiency (e.g., low immunoglobulins)
• Allergic bronchopulmonary aspergillosis (ABPA), nontuberculous mycobacteria (NTM)
• COPD, asthma, rheumatoid arthritis and other connective tissue diseases, inflammatory bowel disease
• Airway obstruction (foreign body, tumor), aspiration
• Idiopathic in a large proportion

Bronchiectasis vs. COPD: COPD is defined by persistent airflow limitation, usually from smoking; bronchiectasis is defined by structural airway dilation on CT with chronic sputum production. They can coexist, and the combination has worse outcomes.

Subjective

• Chronic cough with large amounts of purulent sputum, often daily and worse in the morning
• Recurrent chest infections, fatigue, dyspnea, pleuritic chest pain
• Hemoptysis (from streaks to large volumes)
• Chronic rhinosinusitis, weight loss

Objective

• Sputum: copious, purulent, sometimes foul-smelling; may separate into layers when standing
• Coarse crackles (often at the bases), rhonchi, wheezes
• Clubbing in advanced disease
• Signs of exacerbation: fever, increased sputum volume and purulence, worsening dyspnea, fatigue
• Late: hypoxemia, cyanosis, cor pulmonale (edema, JVD)

Airway clearance — the cornerstone

• Daily airway clearance techniques: active cycle of breathing technique, huff coughing, oscillating positive expiratory pressure devices, postural drainage with or without percussion, high-frequency chest wall oscillation vests
• Nebulized hypertonic saline (e.g., 7%) to loosen mucus in selected clients — give a bronchodilator first because it can cause bronchospasm
• Pulmonary rehabilitation for clients with reduced exercise capacity
• Vaccination: influenza, pneumococcal, and others per schedule

Treating infection

• Exacerbations: antibiotics guided by previous sputum cultures, commonly for 14 days (7–10 days may be enough for sensitive organisms or a rapid response); IV antibiotics for severe exacerbations or resistant organisms (e.g., Pseudomonas when oral options fail)
• New Pseudomonas isolation: eradication treatment is usually offered because chronic Pseudomonas infection worsens outcomes
• High exacerbation risk — 2 or more exacerbations a year, 1 a year with severe symptoms, or 1 or more requiring hospitalization (ERS 2025; the older threshold was 3 or more): long-term therapy may be added
  • Long-term macrolide (azithromycin or erythromycin) — screen for NTM first (monotherapy can cause macrolide-resistant NTM)
  • Inhaled antibiotics (e.g., colistin, tobramycin, gentamicin) for chronic Pseudomonas
  • Brensocatib (below) is another option to reduce exacerbations

Anti-inflammatory therapy

• Brensocatib, an oral dipeptidyl peptidase-1 (DPP-1) inhibitor, was approved by the FDA in 2025 as the first drug specifically for non-CF bronchiectasis (ages 12 years and older). It reduces activation of neutrophil proteases and lowers exacerbation rates
• Inhaled corticosteroids are not routine; they are used when the client also has asthma (or COPD with high eosinophils)

Mucolytics

• Recombinant human DNase (dornase alfa) is not used in non-CF bronchiectasis — it was found to worsen outcomes (it is used in CF)
• Acetylcysteine may be ordered to thin sputum; inhaled acetylcysteine can trigger bronchospasm

Surgery / procedures

• Bronchial artery embolization for massive or recurrent hemoptysis
• Lobectomy for localized disease with uncontrolled symptoms or bleeding; lung transplant in end-stage disease

Drug safety

Listed in priority order.

1. Airway — massive hemoptysis is an emergency
   • Position the client lying on the bleeding side (affected lung down) to protect the healthy lung from aspirated blood; keep suction ready
   • Give oxygen, keep NPO, establish IV access, monitor vital signs and SpO₂; do not give sedatives that blunt the cough
   • Prepare for bronchoscopy, bronchial artery embolization, or intubation as ordered
2. Airway clearance and breathing
   • Perform or coach airway clearance before meals (or 1–2 hours after) and before bedtime
   • Postural drainage: position the affected segment uppermost so gravity drains it toward the central airways. Example: right lower lobe → lie on the left side with head and chest lowered
   • Percuss with a cupped hand over the ribs of the affected segment — avoid the spine, sternum, breasts, and kidneys; then have the client huff cough and expectorate
   • Stop and reposition if the client develops dyspnea, hypoxemia, chest pain, or hemoptysis. Head-down positions are avoided with increased intracranial pressure, recent eye or brain surgery, uncontrolled hypertension, significant hemoptysis, or severe reflux
   • Teach diaphragmatic and pursed-lip breathing to reduce dyspnea and airway collapse
3. Infection management
   • Collect sputum for culture before starting antibiotics when possible
   • Administer antibiotics on time; monitor drug levels and kidney function for aminoglycosides
   • Standard precautions; follow facility policy for multidrug-resistant organisms
4. Hydration — adequate fluids (unless restricted) to thin secretions
5. Nutrition — high-calorie, high-protein diet; oral care after sputum clearance improves appetite
6. Monitor sputum volume, color, and odor; temperature; oxygen saturation; weight

• Airway clearance every day, even when well — it is the most important self-care routine
• Stop smoking and avoid secondhand smoke, dust, and fumes; smoking accelerates airway damage
• Prevent infections: hand hygiene, avoid sick contacts during outbreaks, stay up to date on influenza and pneumococcal vaccination (and others recommended)
• Know the signs of an exacerbation — increased sputum amount or purulence, fever, worsening breathlessness, fatigue, or new blood in sputum — and start the action plan or call the provider early
• Collect a sputum sample before starting rescue antibiotics if instructed
• Drink plenty of fluids; exercise regularly and attend pulmonary rehabilitation
• Clean nebulizers and airway-clearance devices after each use and let them dry
• Seek emergency care for coughing up more than a few spoonfuls of blood, severe breathlessness, or chest pain
• On long-term azithromycin: report palpitations, fainting, hearing changes, or ringing in the ears
• On brensocatib: keep regular dental checkups and report gum problems or skin changes

• Bronchiectasis = permanent bronchial dilation with a vicious cycle of poor clearance, infection, inflammation, and damage
• Hallmark: chronic cough with copious purulent sputum, coarse crackles, clubbing
• HRCT is the diagnostic standard; chest X-ray is insensitive
• Daily airway clearance is the cornerstone of care
• Postural drainage: affected area uppermost; right lower lobe → left side-lying, head down
• Most common complication: recurrent infection; most dangerous: massive hemoptysis
• Massive hemoptysis: bleeding side down, suction, oxygen, prepare for embolization
• Pseudomonas worsens prognosis; exacerbation antibiotics commonly 14 days (7–10 days in selected cases)
• Long-term macrolides: check QT and hearing, rule out NTM first
• Brensocatib (2025) is the first approved drug for non-CF bronchiectasis
• Dornase alfa is not used in non-CF bronchiectasis
• Give a bronchodilator before hypertonic saline or inhaled antibiotics
• Core self-care: smoking cessation, vaccination, early treatment of exacerbations