What’s new in the 2025 ERS bronchiectasis guidelines (compared with the previous guideline)
The new guidelines put you at the centre. They focus on treatable traits—the things that most affect you.
- Personalised care first: Your team now builds a plan around your symptoms, your sputum (phlegm), your infection risk, and any other conditions you have. No more one-size-fits-all.
- Clearer do’s and don’ts: The guidance now labels advice as strong or conditional, so your team can act with confidence and explain choices to you.
- Airway clearance for everyone: Physiotherapist-taught airway clearance techniques (ACTs) now sit at the heart of care for all patients, as should always have been.
- Sharper use of long-term antibiotics: Doctors offer macrolides when you have frequent flare-ups. They use inhaled antibiotics if you have long-term Pseudomonas aeruginosa infection and keep getting chest infections.
- First Pseudomonas plan: If Pseudomonas shows up for the first time, your team may try to clear it early with an eradication course.
- Less routine steroid inhalers: Inhaled corticosteroids (ICS) are not a standard bronchiectasis treatment unless you also have asthma or COPD.
- Exacerbation (flare-up) pathway tightened: Teams act fast, send sputum for testing when possible, choose antibiotics that fit your bacteria, and review prevention after each flare.
- Rehab and activity highlighted: Pulmonary rehabilitation and daily movement now have a stronger role.
- Earlier escalation when things worsen: If you decline despite treatment, your team rechecks the diagnosis, looks for hidden causes, and considers surgical options or transplant assessment sooner.
Understanding bronchiectasis in simple terms
In bronchiectasis, some airways become wider and inflamed. Mucus pools and germs can thrive. You cough more, bring up sputum, and face more chest infections. You can still live well with bronchiectasis. The new guidelines give you and your team a clearer roadmap.
Getting the right tests at diagnosis
Your care works best when your team knows why you have bronchiectasis and how severe it is. At or soon after diagnosis, your team should:
- Confirm the condition with a high-resolution CT scan.
- Check blood tests, including your immune system (immunoglobulins).
- Send sputum samples for bacteria and, when needed, nontuberculous mycobacteria (NTM).
- Look for causes such as primary ciliary dyskinesia (PCD), allergic bronchopulmonary aspergillosis (ABPA), reflux and aspiration, or immune problems—when your history suggests them.
- Score severity with a simple tool (for example BSI). This helps plan follow-up.
- Screen common comorbidities (other health issues), like sinus problems, reflux (GORD), heart disease, bone health, anxiety, and depression.
- Record your symptoms and your goals. Your voice matters.
Airway clearance: your daily cornerstone
You clear mucus more effectively when a respiratory physiotherapist teaches you airway clearance techniques (ACTs). Everyone with bronchiectasis should learn ACTs.
- Techniques you may learn: active cycle of breathing (ACBT), autogenic drainage, and devices that vibrate your airways (oscillatory PEP).
- How often: your physio will set a routine that fits your life. Many people clear twice daily, and more often during a flare.
- Why it helps: ACTs reduce congestion, make coughs more productive, and may cut your risk of infections.
- When to add a salt solution: if mucus stays thick, your team may prescribe hypertonic saline to inhale before ACTs. It draws water into the mucus and makes it easier to shift.
- What to avoid: dornase alfa (rhDNase), used in cystic fibrosis, does not help in bronchiectasis and may harm. The guidelines advise against it.
Long-term antibiotics: who needs them and why
Not everyone needs long-term antibiotics. Your team looks at your exacerbation risk (how often you flare) and your microbiology (which germs grow in your sputum).
Macrolides (such as azithromycin)
If you get two or more chest infections a year, or you had a severe infection needing hospital care, your team may offer a macrolide.
- Benefits: fewer flare-ups and better quality of life for many people.
- Safety checks: before starting, your team checks for NTM infection (macrolides can make NTM harder to treat). They also check heart rhythm (QT interval) and ask about hearing and tummy side effects.
- Review: you and your team review at 6–12 months to see if it still helps.
Inhaled antibiotics
If you have chronic Pseudomonas aeruginosa, you face a higher risk of flare-ups. In this case, the team often prescribes inhaled antibiotics.
- How they help: they deliver the drug straight to your lungs, reduce bacterial load, and may reduce flare-ups.
- What to expect: you use a nebuliser or inhaler on a regular schedule. Some people get cough or wheeze; your team can help manage this.
What about other long-term oral antibiotics?
The guidelines do not recommend routine long-term non-macrolide tablets for prevention. They bring fewer benefits and more risks in most people.
First isolation of Pseudomonas: act early
If Pseudomonas appears for the first time, your team may try eradication. This means a planned course to clear the bug before it settles in long term. You then repeat a sputum test to check the result.
Inhaled corticosteroids (ICS): use only with a clear reason
ICS are not a standard bronchiectasis treatment on their own. They can raise infection risk in some people.
- When ICS make sense: you also have asthma or COPD, and your symptoms improve with ICS.
- When to avoid: you have bronchiectasis without those conditions. Your team will look for better options first.
- Grey areas: some people have high eosinophils (a type of white blood cell). Your team may discuss ICS in selected cases, but this is not routine.
Pulmonary rehabilitation and everyday activity
Pulmonary rehabilitation is a short, structured programme that combines exercise and education. If you feel breathless or less active, ask for a referral.
- What you gain: stronger muscles, better stamina, less breathlessness, and more confidence.
- Daily activity tips: aim to move most days. Walk, cycle, or do chair-based exercises. Use a step counter to track progress. On flare days, break activity into short chunks and rest between sets.
Recognising and treating a flare-up (exacerbation)
You will know your own pattern. Everyone is different. Common signs include:
- More cough than usual
- More sputum, or a change to greener or thicker sputum or coughing blood
- More breathlessness or fatigue
- Fever, chest tightness, or streaks of blood in sputum
What to do if flaring-up
- Act early: contact your GP or Consultant. Use your rescue plan if you have one.
- Send a sputum sample if you can, before starting antibiotics. This helps target treatment.
- Start antibiotics as advised. A typical course runs 10–14 days.
- Step up ACTs: clear your chest more often during the flare.
- Know when to seek urgent help: high fever, severe breathlessness, confusion, chest pain, or coughing up more than a few streaks of blood.
After you recover, book a review. Your consultant will check what triggered the flare and how to prevent the next one.
Vaccinations, lifestyle, and other conditions
Small steps add up.
- Vaccinations: keep your flu and pneumococcal vaccines up to date. Ask about others that may help you such as RSV vaccine for the right age group.
- Stop smoking: if you smoke, you can quit. Ask for stop-smoking support and medication.
- Sinuses and reflux: treat sinus problems and GORD. Post nasal drip and reflux can worsen your cough.
- Nutrition and bones: eat well, keep to a healthy weight, and protect your bones with vitamin D and weight-bearing exercise.
- Mental health: anxiety and low mood are common and treatable. Tell your team how you feel and let them help with the treatment burden.
- Inhaler technique: if you use inhalers for asthma or COPD, ask for a quick technique check at each visit with your GP or pharmacist.
When treatment needs to change
Sometimes bronchiectasis worsens despite good care. Do not blame yourself. The team will:
- Recheck the diagnosis and search for hidden causes (for example NTM, ABPA, aspiration, immune problems).
- Optimise the basics: ACTs, mucoactive therapy, vaccines, and the right long-term antibiotics.
- Consider surgery for disease stuck in one area that causes repeated infections.
- Discuss transplant assessment earlier if your breathing declines or you need oxygen. Early referral gives you time to prepare and decide.
Your clinic checklist
Ensure you have this information to your next appointment. You need this information to take control of your management.
- I understand my airway clearance plan and I’m happy with the technique.
- I know when and how to send a sputum sample.
- I have a rescue plan for flare-ups and enough standby medication if agreed.
- I know whether I qualify for macrolides or inhaled antibiotics and what the checks involve.
- My vaccinations are up to date.
- I have a pulmonary rehab referral or a clear activity plan.
- We have discussed smoking support (if I smoke), nutrition, bone health, and mental wellbeing.
- I know the red flags that mean I should get urgent help.
- I have a date for my next review and know what outcomes we’re tracking (flare count, hospital visits, lung tests, quality of life).
Bottom line for people living with bronchiectasis
The 2025 ERS bronchiectasis guidelines ask your team to personalise your care. You learn airway clearance and use it daily. You stay active. You get the right antibiotics if you keep flaring, especially if Pseudomonas is present. You avoid steroid inhalers unless there is a clear reason. You act early in a flare and review your plan after each one. This approach helps you breathe easier, cut infections, and live the life you want.
FAQ
What is the main message of the 2025 ERS bronchiectasis guidelines?
Your care should be personalised. Your plan depends on your germs, your flare risk, your symptoms, and your other health issues.
Do I need airway clearance even if I don’t cough much?
Yes. ACTs help you move hidden mucus and lower infection risk. A physio can adapt the routine to busy days.
When would I take long-term antibiotics?
If you have frequent flares or a high risk of infection, your team may offer macrolides. If you carry Pseudomonas, you may use inhaled antibiotics.
What is Pseudomonas and why does it matter?
Pseudomonas aeruginosa is a tough germ that can live in damaged airways. It can cause frequent, severe flares. Inhaled antibiotics and early eradication aim to keep it under control.
Should I use steroid inhalers for bronchiectasis?
Not usually. You avoid ICS unless you also have asthma or COPD. Ask your team why you need any inhaler and how it helps.
How do I spot a flare early?
Watch for more cough, thicker or greener phlegm, breathlessness, fever, chest pain, or fatigue. Start your rescue plan and contact your team quickly.
Will pulmonary rehabilitation help me?
Most people feel stronger and breathe easier after rehab. You learn safe exercise, breathing control, and flare-management skills.
What everyday steps make the biggest difference?
Do ACTs daily, stay active, keep vaccines up to date, treat reflux and sinus issues, eat well, and ask for support with mood or stopping smoking.
When should I worry about worsening symptoms?
If flares keep coming, your walking distance drops, or you need more oxygen, see your team. They can re-check causes, strengthen treatment, and discuss advanced options.
How can I prepare for appointments?
Bring a symptom diary, a list of medicines, and your goals. Ask about sputum tests, rehab, prevention options, and your personalised flare plan.
<figure class="testimonial" style="margin:1.5rem 0; padding:1rem 1.25rem; border-left:4px solid #ccc; background:#f9f9f9; font-family:system-ui,-apple-system,Segoe UI,Roboto,Helvetica,Arial,sans-serif;">
<blockquote style="margin:0; font-size:1.05rem; line-height:1.6;">
“For the past eight years, I have been managing patients with bronchiectasis in line with what the ERS 2025 guidelines now recommend—showing that my practice met this standard long before their publication.”
</blockquote>
<figcaption style="margin-top:.75rem; font-weight:600; color:#333;">
— Dr Ricardo Jose
</figcaption>
</figure>
GET IN TOUCH
Schedule a Visit with Dr Jose
For an assessment of your diagnosis and treatment.
Disclaimer: The information provided in this article is for informational purposes only and is not a substitute for professional medical advice, diagnosis, or treatment, and is not an advertisement for medical products. Always seek the advice of your healthcare provider with any questions you may have regarding a medical condition or treatment. Your healthcare professional can assess your individual circumstances. Consultation does not guarantee suitability for any specific treatment; all clinical decisions follow an individual assessment and shared decision-making