A 2025 update to European Respiratory Society (ERS) guidelines for the management of adult bronchiectasis reflects increased global recognition and research focus on the disease—a chronic respiratory condition associated with substantial morbidity, frequent exacerbations, impaired quality of life, high health care utilization, and mortality.1
“As the burden of disease became clearer across multiple health care systems, the need for evidence-based interventions became increasingly compelling,” said Stefano Aliberti, MD, Co-Chair of an ERS task force charged with updating prior recommendations from 2017.
“We now know that bronchiectasis has not a single pathophysiology but is characterized by diverse inflammatory profiles, microbiological patterns, and trajectories,” said Dr. Aliberti, Professor of Respiratory Medicine at Humanitas University and Chief of the Respiratory Department at IRCCS Humanitas Research Hospital in Milan, Italy. “During the past decade, greater standardization of definitions—including exacerbation, chronic infection, severity indices, and patient-reported outcomes—has made trial design more robust and reproducible.
The new ERS clinical practice guidelines, which were co-chaired by James D. Chalmers, MBChB, PhD, Rhodes Professor of Experimental Therapeutics and Clinical Pharmacology at the University of Oxford in England, focus on addressing the disease’s “vicious vortex”—airway inflammation, impaired mucociliary clearance, airway infection, and structural lung damage.1
“The updated recommendations reflect a meaningful shift toward individualized care, grounded in a more refined assessment of patient risk and disease trajectory,” Dr. Aliberti said. “Perhaps the most important conceptual advance is the move beyond rigid exacerbation threshold toward a multidimensional evaluation of disease activity and the likelihood of deterioration.”
The guidelines encourage clinicians to identify high-risk patients earlier, including those with unfavorable microbiology, worsening symptoms, functional decline, radiological progression, or significant comorbidity. The guideline introduces an integrated concept of exacerbations plus severe symptoms to explicitly recognize the prognostic importance of daily symptom burden.
The goal is to intervene as early as possible to prevent progression to irreversible damage. Emerging evidence suggests that severe symptoms predict future exacerbations. That association allows clinicians to identify and target patients for earlier intervention who may have had only a single exacerbation but endure significant symptom burden. Anticipating adverse outcomes may help to mitigate disease progression and support earlier initiation of long-term preventive therapies when appropriate.
Another key message from the guidelines is the importance of respiratory physiotherapy and airway clearance. All patients should be taught bronchial clearance techniques, preferably by respiratory physiotherapists or trained health care professionals. This strong recommendation emphasizes the central role of nonpharmacologic interventions, as airway clearance is a cornerstone of disease management, not an option.
“The intention is for these guidelines to function as an adaptable clinical framework rather than a region-specific protocol,” Dr. Aliberti said. “Simple quality indicators such as the proportion of patients undergoing etiological testing, receiving airway clearance training, [or] having regular sputum cultures can transform recommendations into actionable quality improvements.”
International registries and collaborative research networks have fundamentally changed the feasibility of bronchiectasis treatment, Dr. Aliberti noted.
“Registries do far more than describe epidemiology; they allow accurate estimation of event rates, facilitate patient enrichment strategies, identify experienced recruiting centers, and provide real-world benchmarks for background care,” he said. “This infrastructure reduces operational risk and makes bronchiectasis a more attractive area for investment.”
References
1. Chalmers JD, Haworth CS, Flume P, et al. European Respiratory Society clinical practice guideline for the management of adult bronchiectasis. Eur Respir J. 2025;66(6):2501126. doi:10.1183/13993003.01126-2025
