CHEST Issues Adult Bronchiectasis Guideline

A clinical practice guideline from the American College of Chest Physicians published in CHEST, offers 13 evidence-based recommendations for adults with non-cystic fibrosis bronchiectasis. Developed from 47 studies, the recommendations address antibiotic treatment, anti-inflammatory therapy, airway clearance, hemoptysis, and surgical resection. All recommendations are conditional and rely primarily on low-certainty evidence.

A multidisciplinary expert panel developed eight population, intervention, comparator, and outcome (PICO) questions and conducted a systematic review. The panel assessed evidence using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach and used a modified Delphi process to reach consensus.

For acute exacerbations, the guideline conditionally suggests targeted antibiotic therapy based on microbiological culture results. It permits either courses longer than 10 days or those shorter than 10 days, depending on clinical response. The panel found insufficient evidence to recommend for or against eradication therapy after a first isolate of Pseudomonas aeruginosa.

For patients with at least two exacerbations annually, the panel conditionally suggests at least 3 months of inhaled antibiotic therapy. Long-term macrolide therapy and long-term brensocatib also received conditional recommendations supported by moderate-certainty evidence. The guideline conditionally recommends against long-term atorvastatin for frequent exacerbations.

Airway-clearance recommendations support nebulized hypertonic saline, breathing techniques, positive expiratory pressure, and high-frequency chest wall oscillation while recommending against recombinant human deoxyribonuclease. The panel also conditionally suggests tranexamic acid for hemoptysis and consideration of surgical resection for localized disease with refractory symptoms despite optimized medical management. The authors emphasized accounting for treatment burden, cost, and quality-of-life effects through multidisciplinary shared decision-making.

Sources: Thomson R, Thornton C, Aksamit T, et al. Management of adult bronchiectasis: an American College of Chest Physicians clinical practice guideline. Chest. 2026. doi:10.1016/j.chest.2026.06.057