Bronchiectasis: Permanently Widened and Damaged Airways

Bronchiectasis is a long term condition in which one or more airways become permanently widened and damaged. Mucus then clears less effectively, increasing the risk of repeated infection and inflammation. Diagnosis requires thin section CT, while treatment combines airway clearance, cause specific care and carefully selected antibiotics.

What bronchiectasis is Bronchiectasis is permanent abnormal widening of one or more bronchi, which are the larger airways within the lungs. The airway walls become damaged and mucus clearance becomes less effective. Mucus can then remain within the airways, supporting infection and further inflammation. Bronchiectasis describes a structural abnormality alongside a clinical pattern, not one single cause. Healthy airways normally clear mucus Airway glands produce mucus that traps particles and microorganisms. Microscopic hairs called cilia move this mucus towards the throat. Coughing provides an additional clearance mechanism when secretions increase. Effective clearance helps prevent microorganisms remaining within the lower airways. What permanent widening means The damaged airway does not return completely to its previous shape after an infection settles. Its wall can become thickened, scarred or less able to maintain normal structure. Widened airways can collect secretions in areas that are difficult to clear. Treatment can improve symptoms and prevent deterioration, but it does not usually reverse established structural widening. The infection, inflammation and damage cycle Retained mucus can allow bacteria or other microorganisms to persist. The immune system responds with inflammation intended to control infection. Ongoing inflammation can injure airway walls and impair ciliary function further. Worsening clearance then encourages more mucus retention and infection. This reinforcing process is often described as a cycle of infection, inflammation and airway damage. The cycle is not identical in everyone Some people have frequent bacterial exacerbations. Others have daily mucus and inflammation with fewer obvious infections. An underlying immune, genetic, inflammatory or swallowing disorder can sustain the process. Treatment is therefore individualised rather than based on one assumed mechanism. Localised and widespread bronchiectasis Bronchiectasis can affect one segment, one lobe or several areas in both lungs. Localised disease may follow a severe infection or obstruction affecting one airway region. Widespread disease raises greater concern for systemic, immune or inherited causes. The CT distribution provides clues but rarely identifies the cause by itself. Causes vary widely Bronchiectasis is a final structural outcome of several different diseases and injuries. A cause may be identified through the history, blood tests, microbiology and targeted investigations. In some people, no definite cause is found despite appropriate assessment. This is called idiopathic bronchiectasis. Post infective bronchiectasis A severe previous lung infection can damage airway walls. Recognised triggers include severe pneumonia, tuberculosis, whooping cough and some childhood infections. The infection may have occurred many years before symptoms become fully recognised. A past infection should not be assumed to be the cause until other treatable conditions are considered. Immune deficiency Antibodies help recognise and control respiratory microorganisms. Some immune deficiencies reduce antibody quantity or function, causing repeated infections and progressive airway damage. Bronchiectasis can be the first clue to an antibody deficiency diagnosed in adulthood. Identifying the problem matters because immunoglobulin replacement may help selected people. Primary ciliary dyskinesia Primary ciliary dyskinesia is an inherited disorder affecting ciliary movement. Mucus clearance can be impaired from early life. Supporting features include neonatal breathing problems, chronic sinus disease, recurrent ear infections and symptoms beginning in childhood. Fertility problems or organs positioned differently from usual can also provide clues. Specialist testing is required because ordinary spirometry cannot diagnose the disorder. Aspiration Aspiration means saliva, food, drink or stomach contents entering the lower airways. Repeated aspiration can cause inflammation, infection and bronchiectasis. Possible contributors include swallowing difficulty, neurological disease and significant reflux. BTS advises investigating aspiration when symptoms or other clinical features make it plausible, rather than testing everyone routinely. Autoimmune and inflammatory disease Bronchiectasis occurs more often with some systemic inflammatory conditions. Associations include rheumatoid arthritis, Sjögren syndrome and inflammatory bowel disease. The relationship can involve immune dysregulation, infection susceptibility or treatment related immune suppression. Joint or bowel disease does not prove that it caused the airway damage. Allergic bronchopulmonary aspergillosis Allergic bronchopulmonary aspergillosis is usually shortened to ABPA. It is an exaggerated immune response to Aspergillus within the airways, most often in people with asthma or cystic fibrosis. It can cause mucus plugging and central bronchiectasis. Blood allergy testing and the clinical pattern guide diagnosis. ABPA needs specific treatment and should not be mistaken for ordinary bacterial infection. Airway obstruction A foreign body, scar or tumour can block one bronchus. Secretions then collect beyond the obstruction and repeated infection can damage that region. Localised bronchiectasis can therefore lead to bronchoscopy when obstruction remains possible. The CT pattern alone cannot reliably exclude an endobronchial lesion. Nontuberculous mycobacteria Nontuberculous mycobacteria are environmental organisms that can infect structurally abnormal lungs. They can cause bronchiectasis, complicate existing disease or be present without active progressive infection. Diagnosis requires the clinical pattern, imaging and repeated microbiological evidence. A single positive sample does not always establish active disease. Idiopathic bronchiectasis Idiopathic means that no definite cause has been identified after appropriate investigation. It does not mean that the condition appeared without any biological process. A younger person, progressive disease or an unusual pattern can justify renewed investigation. New diagnostic methods may reveal a cause that earlier testing could not identify. Cystic fibrosis related bronchiectasis Cystic fibrosis is an inherited disorder affecting the CFTR protein. It causes unusually thick secretions in several organs and commonly leads to bronchiectasis. Cystic fibrosis related bronchiectasis follows a distinct specialist pathway with different microbiology, treatments and infection control arrangements. The BTS adult bronchiectasis guideline discussed here excludes bronchiectasis managed as part of confirmed cystic fibrosis. When cystic fibrosis testing is considered Adults with bronchiectasis are assessed for cystic fibrosis when supporting features are present. Clues include early onset disease, malabsorption, pancreatitis, male infertility or a suggestive health problems in the family. A gene test, sweat test and specialist assessment may be required. A CT showing bronchiectasis does not diagnose cystic fibrosis. Bronchiectasis itself is not contagious The structural condition cannot pass from one person to another. Respiratory viruses and some bacteria causing exacerbations can still spread. Good hand hygiene, vaccination and appropriate infection control advice remain important. People with cystic fibrosis follow additional cross infection precautions through specialist services. Chronic productive cough A persistent cough producing sputum is the most characteristic symptom. Some people bring up sputum every day. The amount ranges from small quantities to several cupfuls during severe disease. A chronic productive cough has several other causes and does not confirm bronchiectasis. Sputum appearance Sputum may be clear, white, yellow, green or blood streaked. Colour can reflect inflammatory cells and does not identify one microorganism. Green sputum does not prove that a new bacterial infection is present. A change from the person's stable sputum pattern is often more useful than colour alone. Recurrent chest infections People can experience repeated episodes of increased cough, sputum and systemic illness. These episodes are commonly called exacerbations or flare ups. Frequent antibiotic treated infections should prompt review of diagnosis, airway clearance, microbiology and underlying causes. Not every brief cough or colour change is an exacerbation. Breathlessness Breathlessness can result from airflow obstruction, mucus plugging, reduced fitness or extensive lung damage. It may worsen during an exacerbation. Asthma, COPD, heart disease, anaemia and anxiety can produce similar symptoms. The symptom needs interpretation with examination, lung function and imaging. Haemoptysis Haemoptysis means coughing blood originating from the respiratory tract. Inflamed airways can develop enlarged fragile bronchial blood vessels that bleed. Small streaks can occur during an exacerbation, but all new haemoptysis needs clinical assessment. More than a few spots or streaks can represent serious pulmonary bleeding and requires emergency action. Wheeze and chest sounds Bronchiectasis can cause wheeze, crackles and coarse airway noises. These sounds reflect airflow, secretions and airway opening rather than one diagnosis. A normal chest examination does not exclude bronchiectasis between exacerbations. Chest discomfort Repeated coughing can cause chest wall pain. Inflammation around the lung can cause sharper pain during breathing or coughing. Chest pain can also indicate pneumonia, pulmonary embolism or a cardiac condition. New severe or unexplained pain requires assessment rather than being attributed automatically to bronchiectasis. Fatigue and reduced wellbeing Chronic inflammation, disturbed sleep and repeated infection can cause marked fatigue. Breathlessness and fear of coughing can reduce physical activity. Anxiety, low mood and social embarrassment about sputum are common but can be overlooked. Fatigue remains non specific and should not be assumed to come from the lungs alone. Some people produce little sputum A minority have dry or minimally productive bronchiectasis. This can occur with localised upper lobe disease or difficulty expectorating secretions. Lack of daily sputum therefore does not completely exclude the condition. The overall history and CT findings remain important. When bronchiectasis should be considered Persistent mucopurulent or purulent sputum is a key reason to investigate. Recurrent chest infections, chronic cough and unexplained haemoptysis can also raise suspicion. Bronchiectasis should be considered when asthma or COPD appears unusually difficult to control with frequent infections. Clinical suspicion leads to imaging rather than confirming the diagnosis directly. Clinical assessment The clinician asks about cough duration, sputum quantity, infections and previous pneumonia or tuberculosis. They review childhood symptoms, sinus disease, ear infections, swallowing, reflux and fertility history. The assessment includes autoimmune disease, immune suppression, smoking and health problems in the family. This history guides the later investigation for cause. Chest X ray A chest X ray provides a baseline view and can identify alternative lung disease. It may show thickened airway markings, collapse or infection. However, many people with bronchiectasis have a normal or non specific X ray. A chest X ray cannot reliably confirm or exclude bronchiectasis. Thin section CT is the key structural test BTS recommends thin section CT when bronchiectasis is clinically suspected. This is often called high resolution CT or HRCT in clinical communication. It provides detailed cross sectional images of the airways and surrounding lung. The scan confirms permanent abnormal airway dilatation when interpreted with the clinical pattern. What CT can show A bronchus may appear wider than the nearby pulmonary artery branch. The airway may fail to narrow normally as it travels towards the edge of the lung. Bronchi can remain visible unusually close to the pleura. CT also shows mucus plugging, airway wall thickening and the distribution of disease. CT does not identify the whole diagnosis alone Mild airway widening can be found incidentally, particularly with age or another lung disease. The radiological finding must be linked with symptoms and clinical significance. CT cannot determine whether bacteria are causing a current exacerbation. It also cannot establish most immune, genetic or swallowing causes without further tests. Imaging is ideally performed while stable Active infection can temporarily increase mucus plugging and inflammatory change. Baseline CT is therefore ideally obtained during clinically stable disease when possible. Emergency imaging still takes priority when haemoptysis, pulmonary embolism or another acute complication is suspected. Spirometry Spirometry measures airflow during forced breathing manoeuvres. Bronchiectasis may produce obstructive airflow limitation, but results can also be normal or restrictive. Spirometry helps assess physiological impact and coexisting asthma or COPD. It cannot confirm the structural airway widening. Oxygen assessment Pulse oximetry estimates blood oxygen saturation. It can be normal in mild bronchiectasis and fall during severe exacerbations or advanced disease. Pulse oximetry does not measure carbon dioxide or identify the cause of breathlessness. People with chronically low readings need formal respiratory assessment. Sputum culture Sputum culture identifies microorganisms growing from a respiratory sample and tests antibiotic susceptibility. BTS recommends routine bacterial and mycobacterial cultures for people with bronchiectasis. Samples are also useful during clinical deterioration. A culture result must be interpreted with symptoms because chronic airway infection can persist when the person is stable. Collecting sputum during an exacerbation A sputum sample should be obtained before antibiotics when this is practical. Treatment should not be delayed when someone is severely unwell or cannot produce a sample. Previous culture results help guide initial antibiotic choice. The prescription can be adjusted when current susceptibility results return. Pseudomonas aeruginosa Pseudomonas aeruginosa is a bacterium that can establish chronic airway infection. Its presence is associated with more frequent exacerbations and more severe disease at population level. A first new isolation can prompt specialist discussion about eradication treatment. A positive culture does not describe the person's whole prognosis or prove that every symptom is caused by Pseudomonas. Other common microorganisms Haemophilus influenzae, Streptococcus pneumoniae and Moraxella catarrhalis are commonly identified. Staphylococcus aureus and several Gram negative organisms can also occur. Fungal growth may represent sensitisation, colonisation or disease depending on the context. Microbiology guides treatment but does not replace clinical assessment. Investigating an underlying cause BTS recommends a standard panel of investigations after bronchiectasis is diagnosed. The past health problems is reviewed for asthma, COPD, autoimmune disease, inflammatory bowel disease and reflux or aspiration. Testing aims to find treatable causes and conditions affecting prognosis or family counselling. Blood and immune tests A full blood count can identify anaemia, eosinophilia or other clues. Serum IgG, IgA and IgM assess major antibody classes. Total IgE and Aspergillus sensitisation testing support assessment for ABPA. Some people need vaccine response testing or specialist immunology assessment. Targeted genetic and functional testing Cystic fibrosis testing is offered when the clinical pattern supports it. Primary ciliary dyskinesia testing is considered with childhood symptoms, chronic sinus or ear disease, neonatal distress or infertility. These are specialist diagnostic pathways rather than routine labels from CT appearance. Aspiration and reflux assessment Swallowing or reflux investigations are selected when symptoms or risk factors suggest recurrent aspiration. A speech and language therapist may assess swallowing safety. Treating reflux symptoms alone does not prove that aspiration caused the bronchiectasis. Autoimmune testing Autoantibody testing is guided by joint, skin, kidney, nerve or systemic features. Tests without a relevant clinical pattern can produce incidental positive results. Rheumatology and respiratory teams may coordinate care when inflammatory disease and bronchiectasis coexist. Bronchoscopy Bronchoscopy passes a flexible camera into the airways. It can investigate localised disease, suspected obstruction, unusual bleeding or a foreign body. Bronchial wash samples may help when someone cannot produce sputum. Bronchoscopy is not required to confirm every uncomplicated case. Bronchiectasis and asthma are different Asthma is characterised by variable respiratory symptoms and variable expiratory airflow limitation. Airway narrowing often changes over time and commonly responds to anti inflammatory treatment. Bronchiectasis is a permanent structural widening confirmed on CT. A person can have both conditions, and each requires its own evidence based treatment. Bronchiectasis and COPD are different COPD is persistent airflow obstruction usually linked to smoking or other harmful exposures. It can involve small airway disease and emphysema without bronchiectasis. Bronchiectasis can occur in people who have never smoked and may have normal spirometry. CT and symptoms and background help distinguish the structural conditions. The conditions can coexist Asthma, COPD and bronchiectasis are not mutually exclusive. Bronchiectasis may explain frequent purulent sputum or repeated infections in someone with obstructive airway disease. Coexistence can increase treatment complexity and exacerbation risk. One label should not be used to ignore evidence for another condition. Inhaled corticosteroids are not routine bronchiectasis treatment Inhaled corticosteroids are central treatments for asthma and selected COPD patterns. BTS advises against routine use for bronchiectasis without another indication. They may be appropriate with asthma, ABPA or selected COPD. Unnecessary steroid exposure can increase infection and other adverse effect risks. Bronchodilators Bronchodilators widen airways by relaxing airway muscle. They are used according to asthma or COPD guidance when those conditions coexist. BTS also supports a trial of a long acting bronchodilator for significant breathlessness in selected people. Improvement should be reviewed rather than assuming every person needs an inhaler. Management goals Treatment aims to improve mucus clearance and daily symptoms. It also aims to reduce exacerbations, preserve lung function and treat the underlying cause. The plan depends on symptoms, CT distribution, microbiology and previous exacerbations. Airway clearance is a core treatment BTS recommends teaching airway clearance to people with clinically significant bronchiectasis. A specialist respiratory physiotherapist or appropriately trained professional selects the technique. The method should be effective, acceptable and sustainable for the individual. It is not simply forceful coughing throughout the day. Airway clearance techniques Options include the active cycle of breathing technique and autogenic drainage. Oscillating positive expiratory pressure devices can help loosen and move secretions. Gravity assisted positions are used when appropriate and tolerated. Technique choice depends on symptoms, reflux, haemoptysis, mobility and preference. How often clearance is performed Many people perform airway clearance daily when stable. The duration and frequency are personalised according to sputum volume and response. Exacerbations often require more frequent sessions or a modified technique. A physiotherapist should review the plan when symptoms deteriorate or clearance becomes ineffective. Clearance during haemoptysis Small blood streaks can accompany infection, but airway clearance may need modification. The person should contact the respiratory team for advice rather than stopping every technique indefinitely. Significant bleeding requires emergency assessment before routine clearance continues. Mucoactive treatment Mucoactive treatments aim to make sputum easier to expectorate. Nebulised saline can hydrate airway secretions before physiotherapy in selected people. A supervised test may be needed because inhaled solutions can provoke bronchospasm. Recombinant human DNase used in cystic fibrosis is not recommended routinely for non CF bronchiectasis and can worsen outcomes. What an exacerbation is An exacerbation is an acute deterioration, usually developing over several days. There may be increased cough, sputum volume, thickness or purulence. Breathlessness, wheeze, haemoptysis or systemic illness can also worsen. The pattern is judged against the person's usual stable state. Treating exacerbations Antibiotics are used when the clinical pattern supports a bacterial bronchiectasis exacerbation. Choice is guided by previous sputum cultures, allergy, illness severity and resistance risk. The person may also need increased airway clearance, hydration review and treatment of bronchospasm. Hospital care is needed when oral treatment is unsafe or the person is severely unwell. Antibiotic duration NICE recommends a total antibiotic course of 7 to 14 days for an acute non CF bronchiectasis exacerbation. The exact duration reflects disease severity, exacerbation history, microbiology and clinical response. Intravenous antibiotics are reviewed by 48 hours and changed to oral treatment when appropriate. Shorter courses used for uncomplicated acute cough should not be transferred automatically to bronchiectasis. Antibiotic stewardship Antibiotics can cause adverse effects and select resistant microorganisms. They should be used for a defined clinical indication and reviewed when results return. Fluoroquinolone antibiotics have important restrictions and should only be used when other recommended options are inappropriate. People should follow the prescribed course rather than saving tablets for unrelated future symptoms. Written self management plans BTS quality standards recommend an individualised written plan. It explains the person's stable symptoms, airway clearance and signs of an exacerbation. It can include when to provide sputum, start a prescribed rescue antibiotic and seek urgent help. A rescue pack should only be used according to the agreed plan. Long term antibiotics Long term antibiotics can reduce exacerbations in selected people. BTS recommends considering them when three or more exacerbations occur each year. The threshold can be lower when episodes cause substantial harm or the person is highly vulnerable. Treatment is started and monitored by a respiratory specialist after other management is optimised. Macrolide treatment Azithromycin or erythromycin can reduce exacerbations in selected non Pseudomonas and some Pseudomonas pathways. Before long term macrolides, at least one respiratory culture should exclude active nontuberculous mycobacterial infection. Hearing, balance, heart rhythm and medicine interaction risks require review. Long term treatment is reassessed regularly for benefit, toxicity and continuing need. Inhaled antibiotics Inhaled antibiotics deliver high concentrations to the airways with less systemic exposure than intravenous treatment. They are used mainly in selected people with chronic Pseudomonas infection and frequent exacerbations. Bronchospasm, cough, kidney or hearing considerations depend on the specific medicine. A supervised challenge and ongoing specialist monitoring may be required. Vaccination BTS recommends annual influenza vaccination for people with bronchiectasis. Pneumococcal vaccination is also recommended according to the appropriate national schedule. COVID 19 and other vaccines follow current eligibility guidance. Vaccination reduces some infection risks but cannot prevent every exacerbation. Pulmonary rehabilitation Pulmonary rehabilitation combines exercise training, education and self management support. BTS recommends it for people functionally limited by breathlessness. It can improve exercise capacity, confidence and quality of life. The programme should include bronchiectasis specific education such as airway clearance and infection planning. Exercise Regular physical activity supports fitness and can help move airway secretions. The amount and intensity should reflect symptoms and other health conditions. Exercise does not replace dedicated airway clearance when that treatment is required. Severe breathlessness, chest pain or haemoptysis during activity needs assessment. Smoking and inhaled irritants Smoking is not the cause of every case, but it damages airway defence and increases respiratory risk. Stopping smoking can reduce further harm and improve wider cardiovascular health. Occupational dusts, fumes and indoor smoke may also worsen symptoms. Nutrition and hydration Severe bronchiectasis can increase energy needs and contribute to unintended weight loss. Obesity can also worsen breathlessness and sleep apnoea. Dietetic support is useful when weight, appetite or muscle loss becomes concerning. Adequate hydration may help secretions, but forced excessive fluid intake is not a treatment for everyone. Oxygen and ventilatory support Long term oxygen is prescribed only after formal assessment of chronic hypoxaemia. Some people with advanced disease need non invasive ventilation for respiratory failure. Oxygen treats low oxygen levels rather than the underlying bronchiectasis. Smoking around oxygen creates a serious fire risk. Surgery Surgical removal of a lung segment is considered rarely. It may help selected people with localised disease and severe symptoms despite optimised specialist treatment. The team assesses how much healthy lung would remain and whether bleeding or infection is truly localised. Surgery is not appropriate for most widespread disease. Lung transplantation Transplant assessment is reserved for advanced disease with severe respiratory failure or poor quality of life despite optimal treatment. Age, other organ function, infection and overall fitness affect eligibility. Referral is considered before the person becomes too unwell to benefit. Annual review BTS quality standards recommend at least annual review while clinically stable. Review includes symptoms, exacerbation number, sputum microbiology, lung function and treatment technique. Vaccination, nutrition, oxygen levels and the underlying cause are reconsidered. More frequent specialist review is needed with severe or deteriorating disease. Prognosis varies Some people have mild stable symptoms for many years. Others experience progressive lung damage, frequent admission or respiratory failure. Exacerbation frequency, chronic Pseudomonas infection, breathlessness and lung function contribute to population risk. No single CT image or sputum result predicts one person's future with certainty. What this lesson should not be used for This lesson cannot diagnose bronchiectasis from sputum colour, cough or crackles. It cannot identify the underlying cause without a structured clinical investigation. Do not start rescue or long term antibiotics outside an agreed treatment plan. Do not assume that asthma or COPD inhalers treat bronchiectasis itself. Call 999 for major haemoptysis, severe breathing difficulty, collapse or rapidly reduced consciousness.

Bronchiectasis is permanent abnormal airway widening sustained by impaired mucus clearance, infection, inflammation and further damage. Thin section CT confirms the structural abnormality, while sputum culture and cause directed investigations guide treatment. Airway clearance is central, and antibiotics are selected according to exacerbations, microbiology and specialist review.