The American College of Chest Physicians (CHEST) has published its first clinical practice guideline on managing adult bronchiectasis, a condition characterized by chronic inflammation and damage to the airways. This guideline comes after the approval of brensocatib, a treatment for non-cystic fibrosis bronchiectasis, and the revision of the European Respiratory Society’s guideline.
A session at the CHEST 2026 annual meeting, “Bronchiectasis 2026: Guidance for the General Pulmonologist,” walked clinicians through the new guideline and how to apply it to patient care. The session used a single patient case to illustrate the diagnosis and treatment of bronchiectasis, from initial workup to refractory disease.
Diagnosing Bronchiectasis
Ashwin Basavaraj, MD, presented the case of a 49-year-old teacher with a nonproductive cough, asthma, gastroesophageal reflux disease, and a history of pneumonia. Her spirometry results showed mild obstruction, and CT imaging revealed bronchiectasis mainly in the lower lobes. Basavaraj emphasized the importance of a thorough evaluation to identify potential causes of bronchiectasis, as treating the underlying cause can help prevent further damage.
Basavaraj stated that the baseline workup should include a full blood count, evaluation for allergic bronchopulmonary aspergillosis, immunoglobulins, and sputum cultures that test for nontuberculous mycobacteria (NTM). Further testing depends on the clinical picture, and clinicians should consider chronic sinusitis, localized disease, and systemic symptoms when evaluating patients.
Basavaraj’s team tests aggressively for cystic fibrosis (CF) and CFTR-related disease using genetic sequencing, a sweat chloride test, or both. In this patient’s case, the workup did not identify a cause, but her sputum cultures grew Pseudomonas aeruginosa and Mycobacterium avium complex (MAC), which would shape her treatment.
Inside the 13 Recommendations
The CHEST guideline panel, which included international and multidisciplinary members, drafted 8 questions in the population, intervention, comparator, and outcome (PICO) format and ran a systematic review of 47 studies. The panel required 80% agreement for each recommendation, resulting in 13 key recommendations for managing adult bronchiectasis.
Basavaraj summarized the main recommendations, including choosing antibiotics based on prior sputum culture results for acute exacerbations, and considering long-term inhaled antibiotics, macrolides, and brensocatib for prevention. The guideline also recommends specific airway clearance techniques, such as oscillatory positive expiratory pressure (PEP) and high-frequency chest wall oscillation (HFCWO), and suggests against recombinant human DNase.
Basavaraj urged caution when using macrolides in the United States, as more than half of patients with bronchiectasis are colonized with NTM, which can lead to resistance. The guideline states that chronic macrolide use is contraindicated when NTM is cultured from sputum and recommends NTM screening before starting therapy.
Clinicians should also manage reflux, aspiration, and sinus disease to limit further airway inflammation, encourage exercise, and refer patients with anxiety or depression to mental health services. For the female patient, the acute-exacerbation and eradication recommendations did not apply, but her exacerbation history made her a candidate for nebulized antibiotics or brensocatib.
The patient’s MAC culture argued against starting with a macrolide, and Basavaraj emphasized the importance of considering the patient’s individual needs and clinical picture when making treatment decisions. The guideline’s recommendations are conditional, and patient-centered outcomes should guide choices.
Airway Clearance Techniques
Airway clearance is a critical component of bronchiectasis management. Healthy mucus is mostly water, but in bronchiectasis, chronic neutrophilic inflammation makes mucus thicker, driving the “vicious vortex” of infection, inflammation, and airway damage.
Pharmacologic options, such as hypertonic saline, and nonpharmacologic techniques are available. The guideline’s recommendations are conditional due to the disease’s heterogeneity.
Practical barriers, such as access to respiratory therapists and insurance coverage, can affect treatment choices. The guideline notes that HFCWO equipment can cost more than $10,000, highlighting the need for clinicians to consider cost and access when making treatment decisions.
Preventive Therapy Options
Sunjay Devarajan, MD, addressed the question of which preventive therapy to use first, noting that macrolides are strongly associated with large reductions in exacerbations but may be limited by NTM colonization.
Devarajan cited a network meta-analysis that found macrolides had the largest effect size. He emphasized the importance of considering cost, access, and NTM status when sequencing preventive therapies, and noted that azithromycin comes first for most patients due to its effect size, cost-effectiveness, and tolerability.
Brensocatib comes first for patients colonized with NTM, although it is more expensive and harder to get. Inhaled antibiotics remain an option for patients who can manage the treatment burden, and inhaled corticosteroids should be avoided where possible.
Ashley Losier, MD, closed the session by discussing refractory disease, noting that the goals are fewer exacerbations and better patient-reported quality of life. She highlighted the pipeline of new treatments, including more DPP1 inhibitors, such as verducatib and florensocatib, which are in phase 3 trials.
Losier also mentioned biologics, including an anti–IL-5 receptor α antibody, and novel agents, such as ARINA-1. She ended with a note of caution, stating that “promising biology does not always lead to clinical benefit,” emphasizing the need for further research and careful consideration of treatment options.