Bronchiectasis recommendations: American vs European | CHEST 2026

Bronchiectasis is a complicated condition to take care of, partly because the cause is often uncertain and the pathophysiology is complex. Now clinicians taking care of patients with bronchiectasis have two new set of guidelines to help them make decisions on what is best for their patients. The European Respiratory Society published guidelines in 2025, and the American College of Chest Physicians came out with its set in July 2026. The guidelines were a topic of conversation at the 2026 CHEST meeting earlier this week, especially at a session on Sunday titled "Bronchiectasis 2026: Guidance for the General Pulmonologist.”

The two sets of guidelines are in agreement on many topics. Both, for example, recommend long-term macrolide therapy for patients with frequent exacerbations or, in the case of the European guidelines, at elevated risk for having them. The American guidelines offer more detail on airway clearance, but the European guidelines also endorse it. Both sets of guidelines recommend against recombinant DNase.

One area of disagreement is antibiotic treatment to eradicate an infection with Pseudomonas aeruginosa, one of the most common bacterial infections in bronchiectasis. The European favor eradication of the infection while the American guidelines make no specific recommendation, pointing to insufficient evidence.

Here is an AI-assisted comparison of the American and European guidelines. These are summaries of the recommendations. You can find the full recommendations of the American guidelines here and the European recommendations here.

American vs. European bronchiectasis guidelines

American College of Chest Physicians = black; European Respiratory Society = red

Acute exacerbations

• For the management of acute exacerbations of bronchiectasis, we suggest targeted antibiotic therapy based on microbiological culture results. (Conditional recommendation, very low certainty of evidence.)
• For the treatment of acute exacerbations of bronchiectasis, we suggest either longer-duration antibiotic therapy (i.e., ≥ 10 days) or shorter-duration antibiotic therapy (i.e., < 10 days) depending on clinical response. (Conditional recommendation, very low certainty of evidence.)

Eradication of Pseudomonas aeruginosa

• For patients with bronchiectasis and a first isolate of P aeruginosa, we make no specific recommendation for or against eradication therapy compared to no eradication therapy. (Insufficient evidence, very low certainty of evidence.)
• We suggest to offer eradication treatment to patients with a new isolation of P. aeruginosa. (Conditional recommendation for the intervention, very low certainty of evidence.)

Long-term inhaled antibiotics

• For patients with bronchiectasis experiencing frequent exacerbations (i.e., ≥ 2 per year), we suggest long-term (≥ 3 months) inhaled antibiotic therapy over no long-term inhaled antibiotic therapy. (Conditional recommendation, low certainty of evidence.)
• We recommend to offer long-term inhaled antibiotics to patients at high risk of exacerbations and chronic infection with P. aeruginosa despite standard care. (Strong recommendation for the intervention, moderate certainty of evidence.)
• We suggest to offer long-term inhaled antibiotics for patients at high risk of exacerbations and chronic infection with pathogens other than P. aeruginosa despite standard care (Conditional recommendation for the intervention, moderate certainty of evidence.)

Long-term macrolides

• For adults with frequent exacerbations of bronchiectasis, we suggest long-term macrolide antibiotic therapy. (Conditional recommendation, moderate certainty of evidence.)
• We recommend to offer long-term macrolides to patients at high risk of exacerbations despite standard care. (Strong recommendation for the intervention, moderate certainty of evidence.)

Other long-term therapies

• For adults with frequent exacerbations of bronchiectasis, we suggest long-term brensocatib therapy. (Conditional recommendation, moderate certainty of evidence.)
• For adults with frequent exacerbation of bronchiectasis, we suggest against long-term atorvastatin therapy. (Conditional recommendation, low certainty of evidence.)
• The panel suggests NOT to offer long-term non-macrolide oral antibiotics as a first-line treatment to adult patients with bronchiectasis and a high risk of exacerbations. (Conditional recommendation against the intervention, very low certainty of evidence.)
• We suggest not to offer long-term inhaled corticosteroids to patients with bronchiectasis who do not have coexisting COPD or asthma. (Conditional recommendation against the intervention, low certainty of evidence.)

Airway clearance and mucoactive therapy

• For patients with bronchiectasis, we suggest the use of breathing techniques (ELTGOL or active cycle of breathing) for airway clearance. (Conditional recommendation, low certainty of evidence.)
• For patients with bronchiectasis, we suggest the use of positive expiratory pressure for airway clearance. (Conditional recommendation, very low certainty of evidence.)
• For patients with bronchiectasis, we suggest the use of high-frequency chest wall oscillation for airway clearance. (Conditional recommendation, very low certainty of evidence.)
• For patients with bronchiectasis, we suggest the use of nebulized hypertonic saline for airway clearance. (Conditional recommendation, very low certainty of evidence.)
• For patients with bronchiectasis, we suggest against the use of rhDNase for airway clearance. (Conditional recommendation, low certainty of evidence.)
• We recommend that patients with bronchiectasis should be taught airway clearance techniques. (Strong recommendation for the intervention, very low certainty of evidence.)
• We suggest to offer mucoactive treatments to patients with bronchiectasis where airway clearance has failed to control symptoms. (Conditional recommendation for the intervention, very low certainty of evidence.)
• We suggest not to offer recombinant DNase to patients with bronchiectasis. (Conditional recommendation against the intervention, very low certainty of evidence.)

Hemoptysis

• For patients with bronchiectasis and hemoptysis, we suggest tranexamic acid. (Conditional recommendation, very low certainty of evidence.)

Surgical resection

• For patients with bronchiectasis and localized disease with refractory symptoms despite optimized medical management, we suggest surgical resection be considered in appropriate surgical candidates. (Conditional recommendation, very low certainty of evidence.)

Pulmonary rehabilitation

• We recommend that patients with breathlessness and/or impaired exercise capacity should be offered pulmonary rehabilitation. (Strong recommendation for the intervention, very low certainty of evidence.)

ELTGOL = expiration with an open glottis in the lateral position; rhDNase = recombinant human deoxyribonuclease.