Why co-morbidities matter in bronchiectasis

Bronchiectasis is a chronic condition in which parts of the airways become permanently widened. Abnormal airways retain mucus, increasing the risk of infection, inflammation and repeated exacerbations.

Many patients also live with another respiratory or systemic condition. These co-morbidities may have contributed to the development of bronchiectasis, may worsen its severity, or may create similar symptoms that are difficult to distinguish.

For example, wheeze can reflect asthma, COPD, mucus plugging or an acute infection. Cough may arise from bronchiectasis, reflux, rhinosinusitis, ABPA or several of these at the same time.

Good care therefore requires a whole-patient approach rather than treating every symptom as though it comes from bronchiectasis alone.

Understanding bronchiectasis and its common co-morbidities

Asthma causes variable airway narrowing, inflammation and bronchial hyperresponsiveness. It may coexist with bronchiectasis, particularly in patients with eosinophilic inflammation or ABPA.

Typical clues include variable wheeze, night symptoms, reversible airflow obstruction and raised type-2 inflammatory markers.

COPD produces persistent airflow obstruction and commonly causes cough, sputum and breathlessness. Bronchiectasis may identify a COPD subgroup with more infection and exacerbations.

Smoking history, emphysema, spirometry and exacerbation pattern help clarify the overlap.

Reflux may provoke cough and throat symptoms. In selected patients, refluxate or swallowed material may enter the airways and contribute to aspiration-related injury or infection.

Heartburn may be absent, so clinical assessment may also consider regurgitation, swallowing difficulty, night cough and recurrent lower-lobe infection.

Nasal and sinus inflammation can coexist with lower-airway disease as part of a united-airways pattern.

Nasal blockage, discharge, facial pressure, reduced smell and throat clearing can add significantly to cough and sleep disturbance.

Bronchiectasis may occur before or after rheumatoid arthritis. Disease activity, immune-modifying treatment and infection risk must all be considered together.

Other rheumatoid lung manifestations, including interstitial lung disease and pleural disease, may also cause breathlessness.

ABPA is an immune reaction to Aspergillus, usually in people with asthma or cystic fibrosis but also recognised in bronchiectasis.

It can cause mucus plugging, fluctuating infiltrates, eosinophilia, markedly raised IgE and progressive airway damage.

NTM are environmental organisms that can infect structurally abnormal lungs. A positive culture does not always mean active disease.

Diagnosis requires clinical symptoms, compatible imaging and microbiological criteria, interpreted by an experienced respiratory and microbiology team.

A co-morbidity may be causal, aggravating or incidental

The presence of another diagnosis does not prove that it is responsible for every symptom. Treatment should be based on objective evidence and response rather than labels alone.

The overlap: why diagnosis can be difficult

Bronchiectasis and its co-morbidities share many symptoms. This can delay recognition of a new problem or lead to unnecessary escalation of the wrong treatment.

Persistent or changing cough

Increased sputum volume

Wheeze or chest tightness

Breathlessness

Fatigue and poor exercise tolerance

Recurrent chest infections

A careful review may include sputum colour and volume, trigger pattern, spirometry, bronchodilator response, eosinophils, FeNO, reflux or swallowing symptoms, sinus symptoms, CT findings and microbiology.

A change from the patient’s usual pattern is often informative

Purulent sputum and systemic illness may suggest infection. Variable wheeze or night symptoms may suggest asthma. Progressive weight loss, haemoptysis or changing CT nodules may require investigation for NTM or another diagnosis.

Building an accurate, personalised assessment

Confirm the bronchiectasis diagnosis and distribution Review thin-section CT findings, symptom history and previous imaging.
Identify the underlying cause Investigate immune deficiency, ABPA, NTM, aspiration and other relevant causes.
Record co-morbidities objectively Use spirometry, inflammatory markers, microbiology, reflux or swallowing assessment and rheumatological information where appropriate.
Define current treatable traits These may include retained mucus, airflow obstruction, eosinophilic inflammation, bacterial infection or aspiration.
Review treatment interactions Consider whether one condition’s medication increases infection, cardiac, liver, hearing or gastrointestinal risk.
Agree patient-centred goals Prioritise outcomes such as fewer exacerbations, improved sleep, reduced cough, better exercise tolerance or lower treatment burden.

Airway-clearance treatment

Airway-clearance techniques are a central component of bronchiectasis care when mucus clearance is impaired. The method should be taught and reviewed by a respiratory physiotherapist or another appropriately trained professional.

Breathing techniques

Active-cycle breathing, autogenic drainage, huffing and positioning can help move mucus while reducing exhausting uncontrolled coughing.

Devices

Oscillating positive expiratory pressure devices such as Acapella or Flutter may help selected patients when taught and maintained correctly.

Nebulised treatment

Isotonic or hypertonic saline may improve mucus clearance in selected patients. A supervised challenge may be needed because bronchospasm can occur.

Airway clearance may need adjustment when asthma is unstable, reflux is provoked by positioning, arthritis limits hand function, or fatigue makes a long routine difficult.

Managing asthma or COPD alongside bronchiectasis

When it may help

Short-acting or long-acting bronchodilators may improve breathlessness, wheeze and airflow obstruction in asthma, COPD or selected symptomatic bronchiectasis.

What should be checked

Review inhaler technique, adherence, spirometry, symptom response and adverse effects rather than adding multiple inhalers automatically.

Airway clearance

A bronchodilator may sometimes be used before nebulised saline or airway clearance when bronchospasm is a concern.

Appropriate use

ICS remain important for asthma and selected patients with COPD, particularly when eosinophilic inflammation or exacerbation criteria support their use.

Bronchiectasis alone

ICS should not be prescribed routinely solely because a patient has bronchiectasis, cough or sputum.

Risk review

Use the lowest effective dose and review oral thrush, dysphonia, pneumonia risk and possible mycobacterial or fungal infection.

Do not stop prescribed asthma corticosteroids abruptly

Removing effective anti-inflammatory treatment can cause a severe asthma deterioration. Dose reduction should follow review of the asthma diagnosis, control, inflammatory phenotype and infection risk.

Antibiotic management in complex bronchiectasis

Antibiotic decisions should use previous and current sputum microbiology wherever possible. The presence of asthma, COPD, rheumatoid arthritis, ABPA or NTM may change the balance of benefit, risk and drug interaction.

Assessment

Increasing cough, sputum volume or purulence, breathlessness, wheeze or systemic symptoms may indicate an exacerbation.

Antibiotic choice

Select oral or intravenous treatment using prior culture, allergy, disease severity and clinical response.

Failure to improve

Reassess microbiology, adherence, airway clearance, ABPA, NTM, resistant organisms, aspiration or a non-infective cause.

Macrolides

Long-term azithromycin or erythromycin can reduce exacerbations in selected high-risk patients after standard care has been optimised.

Inhaled antibiotics

Long-term inhaled antibiotics are particularly relevant in chronic Pseudomonas aeruginosa infection with continued exacerbation risk.

Safety checks

Exclude active NTM before macrolide monotherapy and consider ECG, hearing, liver, kidney and interaction risks.

Treating allergic bronchopulmonary aspergillosis

ABPA should be diagnosed using a combination of clinical features, Aspergillus sensitisation, total IgE, eosinophils, Aspergillus IgG and compatible imaging. A positive fungal culture alone does not establish ABPA.

Treatment	Possible role	Important monitoring
Oral prednisolone	One first-line option for acute newly diagnosed ABPA or an acute ABPA exacerbation	Infection, glucose, blood pressure, bone health and adrenal suppression
Oral itraconazole	Alternative first-line monotherapy in acute ABPA or an option when steroid exposure is undesirable	Liver function, drug level where appropriate, cardiac risk and drug interactions
Prednisolone plus itraconazole	More commonly considered for recurrent ABPA exacerbations rather than routine initial treatment	Combined steroid and azole adverse effects and interactions
Other azoles	Selected refractory or intolerant cases under specialist care	Drug levels, liver function, photosensitivity, QT effects and interactions
Biologic therapy	Selected treatment-dependent or refractory ABPA, particularly with coexisting severe asthma	Phenotype, response, infection risk and commissioning criteria

High-dose inhaled corticosteroids do not replace systemic ABPA treatment

Inhaled corticosteroids may remain necessary for associated asthma, but they are not considered adequate first-line treatment for an acute ABPA episode.

Response monitoring may include symptoms, imaging and total IgE trends. IgE should be interpreted as a change from the patient’s own baseline rather than expected to return to normal.

Managing nontuberculous mycobacterial lung disease

NTM lung disease is not diagnosed from one isolated sputum culture alone. The organism, number of positive cultures, symptoms and CT pattern must be considered together.

MAC disease

Macrolide-susceptible MAC treatment commonly includes a macrolide, ethambutol and rifamycin, with frequency and additional agents determined by disease pattern and severity.

Other NTM species

M. kansasii, M. xenopi and M. abscessus require different regimens and susceptibility interpretation.

Duration

Treatment is prolonged and often continues for at least 12 months after culture conversion, depending on species and guideline recommendations.

Intravenous amikacin

May be included initially in cavitary, advanced, severe-bronchiectatic or macrolide-resistant MAC disease and in selected other NTM infections.

Inhaled liposomal amikacin

Generally considered for refractory MAC disease that remains culture-positive after at least six months of guideline-based therapy.

Monitoring

Hearing, balance, kidney function, vision, liver function, ECG and drug interactions may require monitoring depending on the regimen.

Avoid macrolide monotherapy when active NTM disease is possible

A macrolide given alone for bronchiectasis prevention can select macrolide-resistant NTM. Appropriate mycobacterial cultures should therefore be reviewed before long-term macrolide treatment.

Bronchiectasis and rheumatoid arthritis

The goals are to control joint inflammation, protect mobility and minimise infection risk. Poorly controlled arthritis can make airway clearance, exercise, sleep and self-management more difficult.

Coordinate respiratory and rheumatology care Treatment decisions should consider infection history, sputum microbiology and rheumatoid disease activity.

Review immunosuppression individually The risk of infection must be balanced against the harm of uncontrolled inflammatory disease.

Adapt airway-clearance equipment Hand pain, deformity or weakness may make some devices difficult to clean or use.

Assess other rheumatoid lung disease Breathlessness may also reflect interstitial lung disease, pleural disease, nodules or medication toxicity.

Do not stop disease-modifying treatment without specialist advice

Abruptly withholding effective rheumatoid treatment can cause severe disease activity. Changes should be coordinated between the treating teams, particularly during infection.

Addressing reflux, aspiration and chronic rhinosinusitis

Avoid lying flat soon after meals.
Use smaller meals when large meals worsen symptoms.
Raise the head of the bed for troublesome night reflux.
Address obesity, alcohol or trigger foods individually.
Use acid-suppression treatment for an appropriate indication.
Investigate swallowing difficulty or aspiration symptoms.

Use saline nasal irrigation with safe preparation.
Consider intranasal corticosteroids when indicated.
Review allergy, nasal polyps and smell disturbance.
Seek ENT input for persistent or severe disease.
Consider surgery only after appropriate specialist assessment.

Post-nasal symptoms do not necessarily mean infected secretions are entering the lungs

Upper-airway inflammation can trigger cough and throat clearing, but aspiration is a separate mechanism that may require swallowing or reflux assessment.

Practical tips for managing several conditions

Keep a symptom diary Record sputum colour, volume, wheeze, reflux, nasal symptoms, fatigue, temperature and treatment changes.

Follow a structured airway-clearance routine Make the plan practical enough to continue and ask for review if it is ineffective or too burdensome.

Know the purpose of every inhaler Distinguish preventers, relievers and bronchodilators, and check technique regularly.

Keep vaccinations under review Influenza, pneumococcal, COVID-19, RSV and other vaccines may be relevant according to age and risk.

Maintain nutrition and hydration Adequate intake supports muscle, recovery and general health, while fluid advice should respect cardiac or kidney restrictions.

Reduce avoidable triggers Smoking, vaping, fumes, allergens and individual reflux triggers may worsen symptoms.

Use support networks Patient organisations, rehabilitation groups and psychological support can reduce isolation and improve confidence.

Attend regular reviews Bring a current medication list, sputum results and questions so that different treatment plans remain coordinated.

Exercise, pulmonary rehabilitation and fatigue management

Pulmonary rehabilitation is strongly recommended for patients with impaired exercise capacity. It can improve fitness, breathlessness, confidence and health status.

Arthritis, COPD, asthma, deconditioning and fatigue may all limit exercise differently. A personalised programme can combine aerobic exercise, strength work, pacing and education.

Activity should support rather than replace airway clearance

Exercise can help mobilise secretions and improve fitness, but patients with substantial sputum retention usually still require a specific airway-clearance plan.

Creating one coordinated care plan

Area	What should be recorded	Why it matters
Airway clearance	Technique, frequency, device, nebulised treatment and exacerbation adjustments	Prevents conflicting or duplicated instructions
Inhalers	Indication, dose, device, technique and planned review	Reduces unnecessary corticosteroid or bronchodilator burden
Microbiology	Routine sputum organisms, Pseudomonas status and NTM results	Guides acute and preventive antibiotic choices
Immune-modifying treatment	Steroids, biologics, rheumatology medicines and infection plan	Balances control of inflammation against infection risk
ABPA or NTM monitoring	IgE, imaging, cultures, drug levels and toxicity tests	Detects response, relapse and adverse effects
Patient goals	Sleep, work, exercise, exacerbations, cough and treatment burden	Keeps treatment focused on outcomes that matter

When urgent medical assessment is needed

Seek urgent help for significant deterioration

Severe or rapidly worsening breathlessness
Blue or grey lips, collapse or confusion
Significant coughing of fresh blood
Chest pain with breathlessness or fainting
Low oxygen levels or a marked fall from usual readings
Persistent fever, rigors or severe weakness
New symptoms during intensive immunosuppression
Severe wheeze not responding to the prescribed rescue plan

Call 999 for severe breathing difficulty, collapse, heavy bleeding or another immediately life-threatening symptom.

Living well despite the complexity

Bronchiectasis commonly coexists with asthma, COPD, reflux, rhinosinusitis, rheumatoid arthritis, ABPA and NTM lung disease. These conditions can overlap in symptoms while requiring very different treatment.

Effective care begins by identifying the active treatable traits: retained mucus, infection, eosinophilic inflammation, airflow obstruction, fungal hypersensitivity, aspiration or systemic inflammatory disease.

Airway clearance remains central when mucus clearance is impaired. Bronchodilators and inhaled corticosteroids should be used for a clear asthma, COPD or airflow-obstruction indication rather than automatically for bronchiectasis.

Long-term macrolides and inhaled antibiotics can reduce exacerbations in appropriately selected patients, but microbiology, NTM status and adverse effects must be reviewed.

Acute ABPA is generally treated with oral prednisolone or oral itraconazole, while NTM disease requires species-specific, prolonged multidrug therapy under specialist supervision.

A coordinated plan, regular review, pulmonary rehabilitation and practical self-management can reduce treatment burden and help many patients maintain an active and fulfilling life.

Frequently asked questions

Can asthma and bronchiectasis occur together?

Yes. The diagnoses can coexist. Asthma treatment should be guided by variable airflow obstruction, symptoms and inflammatory markers, while bronchiectasis care should also address mucus clearance and infection.

Should everyone with bronchiectasis use an inhaled steroid?

No. Inhaled corticosteroids are not routine treatment for bronchiectasis alone. They remain appropriate for asthma and selected COPD or eosinophilic indications.

Can reflux worsen bronchiectasis?

Reflux can aggravate cough and, in selected patients, aspiration may contribute to airway injury or infection. Symptoms should be assessed rather than assuming every cough is reflux-related.

Is post-nasal drip the same as aspiration?

No. Nasal or sinus secretions can cause throat symptoms and cough, while aspiration refers to material entering the lower respiratory tract. Swallowing or reflux assessment may be needed when aspiration is suspected.

Are inhaled corticosteroids the first treatment for ABPA?

No. Acute ABPA is generally treated with oral prednisolone or oral itraconazole. Inhaled corticosteroids may still be used for associated asthma.

Does one positive NTM sputum sample mean I need treatment?

Not necessarily. Diagnosis requires compatible symptoms and imaging together with microbiological criteria. Some patients are monitored rather than treated immediately.

Can I take long-term azithromycin if NTM has been found?

Macrolide monotherapy can select resistant NTM and should not be started without specialist review of mycobacterial cultures and the clinical context.

Can rheumatoid arthritis medicines be continued?

Often they can, but the balance depends on arthritis activity, infection frequency, the medicine used and other lung disease. Changes should be coordinated between rheumatology and respiratory teams.

Does pulmonary rehabilitation help when several conditions are present?

Yes. A personalised programme can improve exercise capacity, breathlessness and confidence while accounting for arthritis, asthma, COPD and deconditioning.

What is the most useful thing to bring to a clinic review?

Bring an up-to-date medication list, inhalers, recent sputum results, a record of exacerbations and a short list of the symptoms or goals that matter most to you.

References and further information

Chalmers JD, et al. European Respiratory Society clinical practice guideline for the management of adult bronchiectasis. European Respiratory Journal. 2025. View the 2025 ERS guideline
Hill AT, et al. British Thoracic Society guideline for bronchiectasis in adults. Thorax. 2019;74(Suppl 1):1–69. View the BTS guideline
Agarwal R, et al. Revised ISHAM-ABPA working group clinical practice guidelines for diagnosing, classifying and treating allergic bronchopulmonary aspergillosis/mycoses. European Respiratory Journal. 2024. View the ABPA guideline
Daley CL, et al. Treatment of nontuberculous mycobacterial pulmonary disease: an official ATS/ERS/ESCMID/IDSA clinical practice guideline. Clinical Infectious Diseases. 2020;71:905–913. View the NTM guideline
Herrero-Cortina B, et al. European Respiratory Society statement on airway-clearance techniques in adults with bronchiectasis. European Respiratory Journal. 2023. View the airway-clearance statement

Living with Bronchiectasis and Co-Morbidities

Treatable traits should be identified separately

Some treatments can conflict