Where current bronchiectasis treatment falls short — and why exacerbations are so costly

Current treatment for non-cystic fibrosis bronchiectasis falls into four categories, Sala said: airway clearance modalities, mucolytics, anti-inflammatory drugs, and antibiotics. A substantial share of clinical time also goes toward patient education — longitudinal, visit-to-visit conversations helping patients understand the disease, its effect on quality of life, and what to expect, given that treatment regimens can take more than an hour a day to complete. Because nothing reverses bronchiectasis once it develops, Sala said the focus of care is improving quality of life and, where possible, preventing further progression.

On exacerbation prevention specifically, Sala said the evidence base is thin. Airway clearance has some data supporting improved quality of life and exacerbation mitigation, but antibiotics are generally used to treat exacerbations rather than prevent them. Azithromycin remains the only available option used for prevention, despite fundamentally being an antibiotic rather than a purpose-built anti-inflammatory drug. He characterized the field's ability to influence disease progression as similarly limited, underscoring a significant need for innovation.

Sala said this gap is well recognized — not just by clinicians, but by payers and patients, thanks in part to advocacy from bronchiectasis-focused professional societies. He pointed to the real cost of exacerbations as evidence: an outpatient flare might be managed with a course of antibiotics and airway clearance, but an inpatient admission can mean a hospital stay of up to two weeks, a PICC line for durable IV access, nursing care, and in-house respiratory therapy — even before home health care is factored in. For patients with frequent flares, hospitalization three to four times a year is not uncommon, and that pattern tends to compound on itself.