Bronchiectasis care is entering a new era. Evidence supporting airway clearance techniques (ACTs), pulmonary rehabilitation, microbiologic surveillance, and multidisciplinary management continues to expand. With it, contemporary European Respiratory Society (ERS) and American College of Chest Physicians (CHEST) guidelines increasingly define high-quality care. Yet for many, a gap remains between what guidelines recommend and what patients receive.
This gap matters. Bronchiectasis is a chronic disease with substantial effects on quality of life, health care utilization, morbidity, and mortality. Improving outcomes requires more than identifying effective therapies; it requires ensuring they can be accessed and sustained. Barriers arise at multiple levels: treatment burden, fragmented referral pathways, insurance restrictions, work force limitations, and social determinants of health.1,2
The patient challenge
ACTs remain a cornerstone of management, yet self-reported adherence remains at approximately 41%.3,4 Lack of perceived benefit, limited motivation, time demands, inadequate access to equipment, and insufficient physiotherapy follow-up all influence sustained use.4 Treatment burden compounds this: A patient may need to perform airway clearance multiple times daily while also using inhaled or nebulized medications, cleaning equipment, exercising, and monitoring symptoms and comorbidities. What is straightforward in a guideline can become a burdensome daily commitment in reality.
The solution is not simply to prescribe more—it is to make treatment achievable. Individualized regimens, shared decision-making, patient education, and reinforcement by respiratory therapists or physiotherapists can help transform ACT from a prescribed intervention into a sustainable routine.3,4
Access to equipment is another critical barrier. Positive expiratory pressure devices, nebulizers, and other equipment require appropriate selection, correct technique, and maintenance. Although many qualify as durable medical equipment under Medicaid, prior authorization, copayments, and quantity limits can delay or prevent access.5
The health system challenge
Implementation barriers begin before treatment. Bronchiectasis may be mistaken for asthma, COPD, or recurrent respiratory infection, delaying diagnosis. The 2025 ERS implementation guide emphasizes reducing diagnostic delay and standardizing investigations, including spirometry and sputum microbiology.1 Even after diagnosis, care remains variable. Clinicians differ in how frequently sputum cultures are obtained for a patient who is stable despite recommendations supporting routine surveillance.1,6 Missed surveillance can mean missed opportunities to identify new pathogens and disease progression.
Pulmonary rehabilitation remains strikingly underutilized despite recommendations and evidence of improved exercise capacity and quality of life.2,7 Limited program availability, work force shortages, geographic distance, and inconsistent pathways can make this evidence-based intervention inaccessible, particularly in rural and underserved communities.
Standardized tools may help close these gaps. The British Thoracic Society algorithm identifies features warranting referral, while resources such as the European Lung Foundation Bronchiectasis Patient Checklist and Lung Foundation Australia’s Lung Health Checklist can support structured assessment across primary care, pulmonology, physiotherapy, and rehabilitation teams.8,9 Embedding similar tools into electronic health records could turn recommendations into actionable prompts at the point of care.
The equity challenge
Guideline implementation does not occur in a social vacuum. Socioeconomic deprivation, geographic disparities, and limited health care access are associated with higher prevalence, hospitalization, and mortality. Additionally, disparities are pronounced among Indigenous populations in Australia, New Zealand, and Canada.10 In the United States, similar disparities were described among patients treated for exacerbations in the New York City public hospital system.11
Transportation, medication affordability, insurance coverage, access to specialists, and ability to attend appointments may determine whether an optimal treatment plan is realistic. Bronchiectasis-specific evidence quantifying social determinants remains limited, which is an area for future research.
Making the right care the easy care
The next frontier in bronchiectasis is not producing more evidence—it is building systems capable of delivering existing evidence reliably and equitably. Implementation strategies should operate simultaneously at the patient, provider, health system, and policy levels. Personalized education and ACT support can reduce treatment burdens. Standardized referral and surveillance pathways can decrease unwarranted variations. Electronic clinical decision support can identify missed sputum surveillance, rehabilitation eligibility, or specialist referral opportunities. Telehealth and respiratory therapist-led or physiotherapist-led programs may extend expertise beyond traditional specialty centers. Policies that reduce insurance-related barriers to respiratory devices and medications can further improve access.
Ultimately, the measure of a guideline is not how comprehensively it describes ideal care but how consistently its recommendations reach the patients who need them. As bronchiectasis therapeutics advance, implementation science, multidisciplinary care, and health equity must advance alongside them.
The goal should be clear: Move bronchiectasis care from knowing what works to making what works possible for every patient.
References
1. Mosgrove F, Kocks JW, Kompatsiari E, et al. The European Respiratory Society guideline for adult bronchiectasis 2025: summary and implementation guide for primary care. NPJ Prim Care Respir Med. Published online June 8, 2026. doi:10.1038/s41533-026-00528-z
2. Thomson R, Thornton C, Aksamit T, et al. Management of adult bronchiectasis: an American College of Chest Physicians clinical practice guideline. Chest. Published online July 21, 2026. doi:10.1016/j.chest.2026.06.057
3. Herrero-Cortina B, Lee AL, Oliveira A, et al. European Respiratory Society statement on airway clearance techniques in adults with bronchiectasis. Eur Respir J. 2023;62(1):2202053. doi:10.1183/13993003.02053-2022
4. Low AYH, Tan JS, Ganesan R, Tan J, Lim AYH. Systematic review on adherence, barriers to treatment and impact of airway clearance in bronchiectasis. Arch Clin Biomed Res. 2020;4(5):481-497. doi:10.26502/acbr.50170120
5. Respiratory Therapy Access Working Group. Improving access to respiratory care. Institute for Patient Access. Published online April 2016.
6. 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
7. Metersky ML, ZuWallack RL. Pulmonary rehabilitation for bronchiectasis: if not now, when? Eur Respir J. 2019;53(1):1802474. doi:10.1183/13993003.02474-2018
8. European Lung Foundation. The bronchiectasis patient checklist.
9. Lung Foundation Australia. Lung health checklist.
10. Nigro M, Laska IF, Traversi L, Simonetta E, Polverino E. Epidemiology of bronchiectasis. Eur Respir Rev. 2024;33(174):240091. doi:10.1183/16000617.0091-2024
11. Flowers RC, Imperato AE, Mangalick K, et al. Socioeconomic and racial disparities in patients with acute exacerbations of bronchiectasis: insights from the New York City public hospital system. Am J Respir Crit Care Med. 2025;211:A1441. doi:10.1164/ajrccm.2025.211.Abstracts.A1441
