The American College of Chest Physicians (CHEST) has released a new bronchiectasis management guideline containing 13 conditional, evidence-based recommendations for adults with non-cystic fibrosis bronchiectasis, published in the journal CHEST.1
The guideline stems from a systematic review of 47 studies addressing 8 PICO-based clinical questions, graded using the GRADE approach and finalized through a modified Delphi consensus process among a multidisciplinary expert panel. All 13 recommendations are conditional, and certainty of evidence ranges from moderate to very low.1 CHEST said the guideline is intended to reduce variability in treatment selection and standardize care across settings.2
“The new aspects that are covered by the CHEST guidelines: 1 is brensocatib, obviously because it wasn't available when the other guidelines were being produced… the other the other issue that we address is what to do with patients with hemoptysis. So our guidelines do tackle that and recommend pharmacologic treatment for hemoptysis, which is something that… may not be on the radar screen for many pulmonologists,” investigator Mark Metersky, MD, Professor of Medicine, Associate Chief of Service, Department of Medicine Chief, Division of Pulmonary, Critical Care and Sleep Medicine Director, University of Connecticut, told HCPLive.
How to Navigate Antibiotic Therapy and Pseudomonas Management?
Recommendation #1: For acute exacerbations, the panel suggests targeted antibiotic therapy guided by sputum culture results when available, a conditional recommendation based on very low certainty evidence. Sputum should be collected before starting therapy when possible, with initial treatment drawing on prior culture data, particularly for patients known to carry Haemophilus influenzae, Staphylococcus aureus, or Pseudomonas aeruginosa.1 If no prior culture exists, broad-spectrum empiric therapy is appropriate, with symptom improvement expected by day 7.1
Recommendation #2: On duration, the panel found no clear superiority of longer (10 days or more) versus shorter (fewer than 10 days) antibiotic courses across the 2 identified studies and suggests either approach guided by clinical response rather than a fixed timeline.1 Route of administration should be guided by exacerbation severity, oral tolerance, and prior treatment response.1
For a first isolate of P aeruginosa, the panel issued no recommendation for or against eradication therapy, citing a single small randomized trial (n = 35) and observational data showing a 40% eradication rate at 12 months, with combined systemic and inhaled antibiotics outperforming systemic therapy alone (48% vs 27%).1
"In the clinical setting, this guideline is not a blanket recommendation for everyone," said Rachel Thomson, MBBS, FCCP, lead author and co-chair of the guideline panel, in a statement.2 "We work with a heterogeneous population, and each clinician needs to make decisions that are right for their patients." Thomson added the panel's central objective is breaking the cycle of exacerbations that drives inflammation and disease progression.
Which Long-Term Therapies to Prevent Exacerbations?
Recommendation #4: For adults with 2 or more exacerbations per year, the panel suggests long-term macrolide antibiotic therapy, a conditional recommendation with moderate certainty evidence.1 Pooled data from 3 trials (BAT, BLESS, EMBRACE) showed exacerbation rates decreased by a mean of 1.01 events per year with 24 to 52 weeks of macrolide therapy.1 Quality-of-life improvement on the St. George's Respiratory Questionnaire did not reach statistical significance.1
Recommendation #5: The panel also suggests long-term brensocatib therapy, also conditional with moderate certainty evidence, based on the phase 3 ASPEN trial (n = 1721), which showed annualized exacerbation rates of 1.02 events per year with 10 mg brensocatib and 1.04 events per year with 25 mg versus 1.29 with placebo (rate ratio, 0.8; 95% CI, 0.7-0.9).1 Brensocatib is currently the only licensed DPP-1 inhibitor with randomized trial evidence supporting a recommendation.1
Recommendation #3: For patients with frequent exacerbations, the panel also suggests long-term (3 months or more) inhaled antibiotic therapy, with pooled data across 11 studies showing a reduced exacerbation rate (risk ratio, 0.83; 95% CI, 0.74-0.94).1
Recommendation #6: Long-term atorvastatin is not recommended, given conflicting trial results on cough and quality-of-life outcomes.1
What is Recommended for Airway Clearance and Surgery?
Recommendations #10-12: The panel suggests airway clearance for all patients with bronchiectasis, including breathing techniques such as ELTGOL or active cycle of breathing, oscillatory positive expiratory pressure, and high frequency chest wall oscillation, each a conditional recommendation with low to very low certainty evidence.1 Prescriptions should be individualized in conjunction with a respiratory physiotherapist or respiratory therapist.1
Key Facts
What are the key recommendations in the new CHEST bronchiectasis guideline?
The guideline offers 13 conditional recommendations covering culture-guided antibiotics for exacerbations, long-term macrolide and brensocatib therapy for frequent exacerbators, airway clearance techniques, tranexamic acid for hemoptysis, and surgical resection for localized refractory disease.
How strong is the evidence behind the recommendations?
All 13 recommendations are conditional, with certainty of evidence ranging from moderate (macrolides, brensocatib) down to very low (antibiotic duration, Pseudomonas management, airway clearance devices, hemoptysis, and surgery).
Does the guideline apply to cystic fibrosis-associated bronchiectasis?
No. The guideline is limited to non-cystic fibrosis bronchiectasis in adults, as CF-related bronchiectasis is covered by separate disease-specific management guidelines.
Recommendation #9: Nebulized hypertonic saline is also suggested for airway clearance, though evidence did not definitively favor it over isotonic saline.1 The panel suggests against recombinant human deoxyribonuclease, after a multicenter trial (n = 349) showed a higher exacerbation rate with the agent compared with placebo.1
Recommendation #7: For hemoptysis, the panel suggests tranexamic acid, which reduced escalation of care in pooled analysis of 3 small trials (risk ratio, 0.17; 95% CI, 0.05-0.51).1
Recommendation #13: For patients with localized disease and refractory symptoms despite optimized medical therapy, the panel suggests surgical resection be considered in appropriate surgical candidates at high-volume thoracic centers.1
CF-associated bronchiectasis was excluded from the guideline's scope, given existing disease-specific management guidelines. The panel noted emerging trial data on carbocysteine and N-acetylcysteine may inform future updates, though the current panel did not reach consensus to recommend either agent.1
References
Thomson R, Thornton C, Aksamit T, et al. Management of Adult Bronchiectasis: An American College of Chest Physicians Clinical Practice Guideline. Chest. 2026. doi:10.1016/j.chest.2026.06.057
American College of Chest Physicians. CHEST releases guideline on managing adult bronchiectasis. Published July 30, 2026. Accessed August 3, 2026. https://www.chestnet.org/newsroom/press-releases/2026/07/chest-releases-guideline-on-managing-adult-bronchiectasis
