PassFinals
Respiratory

Bronchiectasis

Bronchiectasis is permanent bronchial dilatation with impaired mucus clearance, recurrent infection and inflammation; high-quality care combines CT confirmation, aetiology work-up, physiotherapist-led airway clearance, culture-directed antibiotics and specialist prevention of exacerbations.

In a nutshell

Bronchiectasis is permanent bronchial dilatation with impaired mucus clearance, chronic infection and recurrent exacerbations. Confirm it on CT, send stable and exacerbation sputum cultures, investigate treatable causes, and make physiotherapist-led airway clearance the foundation. Antibiotics are culture- and severity-guided; Pseudomonas and repeated exacerbations need specialist pathways, and major haemoptysis is an emergency.

Classic presentation

Chronic productive cough with daily purulent sputum, recurrent chest infections, coarse crackles and occasional haemoptysis.

Key points

  • Bronchial dilatation is permanent structural damage; treatment controls symptoms and exacerbations rather than reversing anatomy.
  • Thin-section CT confirms bronchiectasis; chest X-ray alone is insufficient.
  • Send sputum for routine culture and consider mycobacterial culture; use prior microbiology to guide antibiotics.
  • Airway-clearance physiotherapy is core treatment and should be reviewed when the patient deteriorates.
  • NICE recommends sputum culture and antibiotics for acute exacerbations, with reassessment for sepsis, pneumonia or cardiorespiratory failure.
  • New Pseudomonas requires specialist eradication planning; long-term antibiotics are not routine and need specialist review.
  • Exclude NTM and check macrolide safety before long-term macrolide monotherapy.
  • Significant haemoptysis requires urgent hospital assessment; bronchial-artery embolisation is the usual definitive first-line intervention.

First-line investigation

Thin-section CT chest with routine sputum culture, susceptibility testing and cause-directed blood tests.

Management

Assess deterioration and bleeding

  • Escalate severe breathlessness, hypoxaemia, sepsis, cardiorespiratory failure or significant haemoptysis to emergency hospital care.3,2

Confirm and phenotype

  • Use thin-section CT, stable/exacerbation sputum microbiology, spirometry and cause-directed testing including immunoglobulins and ABPA assessment.1,2

Clear secretions and prevent triggers

  • Teach regular physiotherapist-led airway clearance, optimise exercise/pulmonary rehabilitation and associated airway disease, stop smoking and keep vaccinations current.1,2

Treat infection intelligently

  • Culture and treat exacerbations; arrange specialist Pseudomonas eradication and consider long-term inhaled/oral antibiotics only after recurrent exacerbations despite optimised care.3,1,5

Review progression and complications

  • Review exacerbation frequency, cultures, lung function, airway-clearance technique and treatment toxicity; escalate recurrent haemoptysis or decline for specialist imaging and embolisation pathways.1,4,2

Exam traps

  • Do not label a chronic purulent cough as COPD or asthma without considering CT-confirmed bronchiectasis.
  • Do not use prophylactic antibiotics routinely; optimise airway clearance and seek specialist advice first.
  • A new Pseudomonas isolate changes the pathway and should not be treated as an ordinary empiric exacerbation.
  • Macrolide monotherapy without considering NTM can promote resistance and compromise future treatment.
  • Large-volume haemoptysis is not managed in primary care; assess for respiratory compromise and arrange emergency hospital care.
  • Inhaled corticosteroids and bronchodilators are for coexisting indications, not automatic bronchiectasis treatment.

Illustrations

Normal versus bronchiectatic airwayDiagram contrasting a normal tapering bronchus with a permanently dilated, thick-walled bronchiectatic airway pooling mucus.PassFinals · original
The vicious cycle of infection and damageCircular diagram showing impaired clearance leading to mucus pooling, bacterial colonisation, inflammation and further wall damage, perpetuating the cycle.PassFinals · original
High-resolution CT showing bronchiectasisAxial high-resolution CT showing dilated thick-walled bronchi larger than adjacent pulmonary arteries, producing signet-ring and tram-track appearances highlighted by the arrows.Mcgfowler, Wikimedia Commons · CC-BY-SA-3.0

Key sources

  1. British Thoracic Society: Guideline for Bronchiectasis in Adults (UK BTS guideline for diagnosis, aetiology assessment, airway clearance, microbiology, exacerbations, Pseudomonas, long-term antibiotics, haemoptysis and follow-up; published 2018/2019.)Updated 1 Jan 2019
  2. NHS: Bronchiectasis (NHS information on symptoms, CT diagnosis, airway clearance, antibiotics, vaccination, haemoptysis and emergency escalation; page last reviewed 11 June 2025.)Updated 11 Jun 2025
  3. NICE NG117: Bronchiectasis (non-cystic fibrosis), acute exacerbation: antimicrobial prescribing (NICE antimicrobial guidance on sputum culture, antibiotic choice, reassessment, referral and prophylaxis; last reviewed 18 April 2019.)Updated 18 Apr 2019
  4. British Thoracic Society: Guideline for Long Term Macrolide Use (UK guidance on specialist long-term macrolide use, safety checks and monitoring in respiratory disease; published April 2020.)Updated 1 Apr 2020
  5. BNF online (Current UK prescribing information for antibiotics, inhaled therapies, macrolides, corticosteroids, bronchodilators and monitoring requirements.)

This page is exam revision material, not medical advice, and must not be used for patient care. Always check drug doses against the BNF and current guidance. Full disclaimer.