For bronchiectasis, a new era of guideline-guided care | CHEST 2026

Bronchiectasis, a chronic inflammatory lung disease characterized by clinical cough, sputum production and recurrent respiratory infections, is entering the spotlight, with clinicians, guideline writers and drug developers all giving it more attention. The European Respiratory Society updated its bronchiectasis treatment guidelines in 2025, and the American College of Chest Physicians issued its recommendations in July 2026. The FDA approved Brinsupri (brensocatib) as a treatment in August 2025, and other drugs in the dipeptidyl peptidase 1 (DPP-1) inhibitor class, such as verducatib, are in the later stages of development.

(Scroll down to see summaries of the two sets of recommendations.)

The introduction to the European guidelines says that 40% of cases of bronchiectasis have no identified cause, and it describes the disease pathology colorfully as a “vicious vortex” in which interrelated airway inflammation, impaired mucociliary clearance, airway infection and structural lung damage drive the worsening of the disease.

The background section of the American guidelines describes the pathology similarly, if more dryly, as an “interdependent cycle in which impaired mucociliary clearance, infection, inflammation, airway remodeling, and further structural damage occur, creating a heterogeneous disease spectrum.” The American guidelines also mention that clinicians will need to target underlying disease processes as newer therapies become available.

At the 2026 CHEST meeting in Phoenix earlier this week, four experts on bronchiectasis spoke about the new guidelines and their approach to treating patients with bronchiectasis at a session titled “Bronchiectasis 2026: Guidance for the General Pulmonologist.” Sunjay Devarajan, M.D., a pulmonologist with Baylor Medicine, described the new guidelines as less rigid in focusing on the number of a patient’s exacerbations and moving toward “more granularity and nuance.”

Devarajan and his colleagues wove their insights and observations about guidelines into the discussion of a particular case of bronchiectasis, a 49-year-old woman with a history of nonproductive cough, a history of exacerbations that were treated with antibiotics and evidence of bronchiectasis on a CT scan.

Identifying the etiology

Macrolide antibiotics, such as azithromycin, are a mainstay of treatment for bronchiectasis. But Ashwin Basavaraj, M.D., director of the bronchiectasis and non-tuberculous mycobacteria (NTM) education program at NYU Langone Health, cautioned against using macrolides for the patient in this case because of her history of a positive test for mycobacterium avium complex (MAC).

“We wouldn’t consider macrolides for this particular patient because she did have one MAC-positive culture, so we won’t want to expose her to the potential for resistance.”

Basavaraj also spoke about seeking to identify the underlying cause of bronchiectasis. “It’s really important to undergo a thorough evaluation for potential etiologies because if we find an etiology that’s causing the bronchiectasis, we want to try to treat that appropriately and try to prevent further bronchiectasis from developing,” he said, although in this case, none of her symptoms or tests or her history was terribly revealing about the etiology of her bronchiectasis. Chronic sinusitis could be a clue that the patient has cystic fibrosis or another genetic condition such as primary ciliary dyskinesia.

Malvika Kaul, M.D., of the Division of Pulmonary, Critical Care, Sleep, and Allergy at University of Illinois Hospital & Clinics, spoke about the thickening of mucus and how neutrophilic inflammation worsens the problem. She mentioned the stagnation of mucus and impaired clearance intertwining into “this vicious vortex,” an apparent reference to the European guidelines. Kaul noted the importance of coughing to clear the airways and how patients with bronchiectasis have difficulty with

“You might recall some of your patients saying, ‘Hey, my doc, I keep coughing, but nothing comes up,’” Kaul said. That is important because there is airway dysfunction in bronchiectasis, she continued, “and normally for a normal cough, you need a good expiratory flow. And what happens is that if you don’t have a good expiratory flow with that open glottis, even if you are having the normal cough reflex, your airways become floppy, and because of that floppiness in the airway, that expiratory flow is reduced. So, in general, even if they have a normal cough reflux, their cough may be impaired just for that particular reason.”

Kaul explained the value of some of the nonpharmacological interventions that the American guidelines mentioned. She compared active cycle breathing to the Heimlich maneuver. Kaul recommended the Bronchiectasis Toolbox website as having videos that demonstrated some of the nonpharmacological breathing techniques.

DPP-1 inhibitors are ‘new kids on the block’

Devarajan spoke about a wide range of topics, including the overuse of inhaled steroids. He said macrolide antibiotics are very ineffective, irrespective of the organism causing the bronchiectasis exacerbations, while sounding a note of caution about NTM and courting the possibility of macrolide resistance. Devarajan described the DPP-1 inhibitor brensocatib (he used the generic name) as the “new kid on the block” that made it into both the European and American guidance. The phase 3 ASPEN trial of brensocatib showed a 20% decrease in exacerbations among high-risk patients, he noted, adding that the safety results showed that it was a “fairly safe drug.” Devarajan said that ASPEN trial data show that patients assigned to brensocatib who were not taking a macrolide did as well as those who did.

“This may indicate that DPP-1 inhibition on its own actually can do a pretty good job at reducing exacerbations even without a macrolide on board,” Devarajan said.

Summaries of recent guidelines for bronchiectasis

American College of Chest Physicians Clinical Practice Guidelines, 2026

• For the management of acute exacerbations of bronchiectasis, we suggest targeted antibiotic therapy based on microbiological culture results.
• 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.
• For patients with bronchiectasis and a first isolate of P aeruginosa, we make no specific recommendation for or against eradication therapy compared with no eradication therapy.
• 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.
• For adults with frequent exacerbations of bronchiectasis, we suggest long-term macrolide antibiotic therapy.
• For adults with frequent exacerbations of bronchiectasis, we suggest long-term brensocatib therapy.
• For adults with frequent exacerbations of bronchiectasis, we suggest against long-term atorvastatin therapy.
• For patients with bronchiectasis and hemoptysis, we suggest tranexamic acid.
• For patients with bronchiectasis, we suggest against the use of rhDNase for airway clearance.
• For patients with bronchiectasis, we suggest the use of nebulized hypertonic saline for airway clearance.
• For patients with bronchiectasis, we suggest the use of breathing techniques (ELTGOL or active cycle of breathing) for airway clearance.
• For patients with bronchiectasis, we suggest the use of positive expiratory pressure for airway clearance.
• For patients with bronchiectasis, we suggest the use of high-frequency chest wall oscillation for airway clearance.
• For patients with bronchiectasis and localized disease with refractory symptoms despite optimized medical management, we suggest surgical resection be considered in appropriate surgical candidates.

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

European Respiratory Society guidelines, 2025

• For the management of acute exacerbations of bronchiectasis, we suggest targeted antibiotic therapy based on microbiological culture results.
• 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.
• 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.
• 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.
• For adults with frequent exacerbations of bronchiectasis, we suggest long-term macrolide antibiotic therapy.
• For adults with frequent exacerbations of bronchiectasis, we suggest long-term brensocatib therapy.
• For adults with frequent exacerbations of bronchiectasis, we suggest against long-term atorvastatin therapy.
• For patients with bronchiectasis and hemoptysis, we suggest tranexamic acid.
• For patients with bronchiectasis, we suggest against the use of rhDNase for airway clearance.
• For patients with bronchiectasis, we suggest the use of nebulized hypertonic saline for airway clearance.
• For patients with bronchiectasis, we suggest the use of breathing techniques (ELTGOL or active cycle of breathing) for airway clearance.
• For patients with bronchiectasis, we suggest the use of positive expiratory pressure for airway clearance.
• For patients with bronchiectasis, we suggest the use of high-frequency chest wall oscillation for airway clearance.
• For patients with bronchiectasis and localized disease with refractory symptoms despite optimized medical management, we suggest surgical resection be considered in appropriate surgical candidates.