Introduction to Bronchiectasis
Bronchiectasis is a chronic and progressive inflammatory lung disease characterised by permanent and abnormal dilatation of the bronchi, cough, sputum production, recurrent bronchial infection, and exacerbations.1-3
Interview Summary
Joseph Khabbaza
Pulmonary and Critical Care Physician; Director of the non-CF bronchiectasis program, Cleveland Clinic, Ohio, USA
Structural abnormalities
Pathophysiology
Hallmarks
Aetiology
Prevalence
Normal Lung
Bronchiectasis
The Challenges of Managing Bronchiectasis
Joseph Khabbaza, Pulmonary and Critical Care Physician and Director of the non-CF bronchiectasis program, Cleveland Clinic, Cleveland, Ohio, USA; and Christopher Richards, Pulmonary and Critical Care Physician at the Massachusetts General Hospital, Boston, USA, started by exploring the avenues taken by patients who come into their practice to seek care for bronchiectasis.
Ways patients are seeking care for bronchiectasis
Lack of comprehensive interventions
Bronchiectasis diagnosis
The vicious
vortex
Underdiagnosis
Overlapping symptoms and misdiagnosis
Chest CT scan
Sputum cultures
Patient empowerment
Patient symptoMs
The lightbulb moment
For many patients, receiving a diagnosis of bronchiectasis can be a true lightbulb moment.
As Richards describes, the ability to sit down with a patient, show them their CT scan, explain the lab results, and discuss intervention options can be genuinely life-changing.
These interventions are sometimes remarkably simple yet profoundly effective, offering clarity and hope where there was once confusion.
For clinicians like Khabazza and Richards, it’s these moments of insight and transformation that make working with patients who have bronchiectasis especially fulfilling.
References
Connecting pieces of the puzzle for Bronchiectasis diagnosis
Throughout their discussion, Richardsand Khabazza explored the challenges of reaching a diagnosis for bronchiectasis.
Often, patients can spend years in the vicious vortex of disease progression following misdiagnosis and subsequent mismanagement.
Click through the “roadblocks” to reveal their insights.
This content has been organised and funded by Insmed Incorporated
Bridging the Diagnostic Gap: A Patient-Centred Perspective on Delayed and Missed Bronchiectasis Diagnoses
Respiratory
Support statement: This content was created with financial support from Insmed Incorporated, who were also involved in its conceptual development and review.
Disclosure: Khabbaza is on the advisory board for Insmed and Baxter; has received speaking fees from Sanofi/Regeneron; and consulting fees from Tactile and Baxter. Richards has conducted educational work with the France foundation.
Acknowledgements: Interactive article summary was written by Jessica Jinks, EMJ, London, UK.
Keywords: Bronchiectasis, diagnosis, hallmarks, high resolution computed tomography (HRCT), imaging, management, patient empowerment, vicious vortex.
Interview Summary
Join leading pulmonary experts Joseph Khabazza (Pulmonary and Critical Care Physician and Director of the non-CF bronchiectasis program, Cleveland Clinic, Ohio, USA) and Christopher Richards (Pulmonary and Critical Care Physician, Massachusetts General Hospital, Boston, USA) for an in-depth discussion on bronchiectasis. Explore the challenges of delayed or missed diagnosis, and discover strategies to optimise patient care. Learn how to empower patients through open dialogue; structured discussions, including radiology input; and a comprehensive, collaborative approach to disease management.
Aetiology
Bronchiectasis is a heterogeneous disease associated with multiple aetiologies or co-morbidities including asthma, COPD, or NTM and often emerging post-infection.4,5
Up to 40% of cases of bronchiectasis are idiopathic.6
Prevalence
An estimated 500,000 people in the USA have bronchiectasis.7
67% of patients with bronchiectasis are women.7
76% of patients with bronchiectasis are aged ≥65 years; 24% are aged 18–64 years.7
About half of patients with bronchiectasis experience ≥2 annual exacerbations.8
Normal bronchus
Bronchiectasis1,3
Abnormal dilation of bronchi (dilation throughout)
Smooth muscle
Basement membrane
Epithelial cell
Christopher Richards Pulmonary and Critical Care Physician, Massachusetts General Hospital, Boston, USA
Cilia
Goblet Cell
Mucus (thin layer)
Blood vessel
Loss of cilia
(on epithelial cells)
Increased mucus (filling airway)
Destruction of wall
Thickened airway wall
Airway
Airway
Chest CT scan of Bronchiectasis patient1-3
Chronic inflammation leads to structural changes that can be visualised on a chest CT.1,3,9
Hallmarks of Bronchiectasis
Diagnosis of clinically significant bronchiectasis is based on CT scan and clinical symptoms.2,10
Chronic cough
Fatigue and/or malaise
Breathlessness
History of exacerbations
Most patients with bronchiectasis experience daily cough and sputum production. Many also have episodes of unexpected worsening of symptoms that is greater than normal day-to-day variation, commonly referred to as pulmonary exacerbations.12
Exacerbations are typically triggered by bacterial infections, but can be associated with viral infections.12
Despite current management strategies, most patients still experience two or more exacerbations per year.12
Haemoptysis
Greater sputum purulence (darker sputum colour) is associated with greater disease severity, frequency of exacerbations and mortality in bronchiectasis.11
MUCOID
MUCOPURULENT
PURULENT
PURULENT
Severe
Mild
Sputum colour chart, adapted from Murray et al with copyright permission.10
Click to see clinical sputum samples:
Sputum production
Bronchiectasis Pathophysiology: The Vicious Vortex
The pathophysiology of bronchiectasis has been characterised as a vicious vortex or cycle consisting of four primary drivers:3,14
Chronic airway infection14
Bacteria
Viruses
Fungi
Lung damage15
Permanent dilation of the bronchi
Lung function decline
Impaired mucociliary clearance14
Epithelial dysfunction
Mucus hypersecretion
Ciliary dysfunction
Chronic airway inflammation1,3,14
Predominantly neutrophil mediated
Exacerbations primarily driven by excessive NSPs
The vicious vortex of chronic infection, inflammation, impaired mucociliary clearance, and structural lung damage creates an environment susceptible to exacerbations. The interplay between these various triggers can destabilise the respiratory system's homeostasis, leading to the clinical manifestation of an exacerbation.13
Richards explained that most of his patients arrive with a diagnosis already made, either through referrals from other providers or increasingly through self-referral.
Khabbaza noted that, while many of his patients come in with general pulmonary symptoms, a significant number are ultimately found to have bronchiectasis.
Consensus-based strategies for managing and preventing bronchiectasis exacerbations have the goal of improving health related quality of life, reducing symptoms, and stopping disease progression.16-20
The Challenges of Managing Bronchiectasis:
Lack of Comprehensive Interventions
However, Richards explains that there is not a truly comprehensive set of interventions and treatments.
“So, unless you really recognise all the layers and the different ways you can intervene on the disease, you may just wind up not giving it the attention it deserves.”
The speakers emphasised the importance of maintaining a high index of suspicion for bronchiectasis, noting that the disease is often misunderstood or underestimated.
Khabazza discussed how, contrary to common belief, bronchiectasis is not as rare as previously thought, underscoring the need for greater awareness among clinicians.2,21
The Challenges of Managing Bronchiectasis:
Underdiagnosis
“Anyone producing sputum with lung disease should have respiratory and acid-fast bacillus (AFB) cultures done regularly, and we should be thinking about bronchiectasis,” noted Khabazza.
The speakers agreed that recurrent infections with pathogens such as Pseudomonas, Staphylococcus aureus, or non-tuberculous mycobacteria13 should prompt sputum culture and chest CT to evaluate for bronchiectasis, yet this step is often missed, delaying diagnosis until after repeated admissions.
The Challenges of Managing Bronchiectasis: Overlapping Symptoms and Misdiagnosis
Richards and Khabazza discussed common themes in patients who have bronchiectasis but are misdiagnosed, explaining that there are a group of diagnoses that are mimicking bronchiectasis.2,22
Cough, productive cough, shortness of breath, wheezing. I mean, these are all things that are hallmarks of bronchiectasis, but also are big parts of asthma and COPD
- Khabazza
Healthcare providers should recognise that bronchiectasis is different to chronic bronchitis, viral bronchitis, asthma or pneumonia
- Richards
Khabazza explained that dry cough, productive cough, shortness of breath, wheezing, etc, are all symptoms that are hallmarks of bronchiectasis but are also key symptoms of asthma and COPD.2 Depending on spirometry, age of onset, and smoking status, patients who have symptoms of bronchiectasis can be labelled as either asthma or COPD:
Asthma23,24
Current age 30; diagnosed at age 10
Non-smoker
Chest tightness Shortnessof breath Wheezing
Clear chest X-RAY
The patient does not respond to treatment for asthma
The patient could have bronchiectasis
The patient could have bronchiectasis
COPD25,26
Age 65
Smoker
Productive cough
Shortness of breath
Recurrent pneumonia
Khabazza also noted that recurrent pneumonia raises a red flag for bronchiectasis. “People shouldn’t get pneumonia multiple times a year without a clear cause.”
Treatments for asthma and COPD include inhaled corticosteroids (ICS), which are not recommended to treat bronchiectasis (unless patients have concurrent asthma or COPD).2,21,27
Khabazza explains that these patients then get treated for asthma and COPD, oftentimes
for years, going down the disease vortex13 with step-up therapy for these diseases.
Khabazza and Richards
discussed how the treatments for asthma and COPD can be insufficient and sometimes impair airway clearance, making it easier to acquire and harder to clear infections.2,20
Chronic airway inflammation1,3,14
Impaired mucociliary clearance14
Lung Damage15
Chronic airway infection14
Khabazza and Richards highlighted the frequent delays in diagnosing bronchiectasis, often months or even decades after a patient’s first symptoms.
"One of the big delays is the obtaining of a CT chest, that's where the diagnosis is made." – Richards
Richards described how patients often have persistent symptoms but normal chest X-rays, leading to misdiagnosis or missed opportunities.
He explained that in some cases, signs of bronchiectasis are visible in old abdominal CT scans, showing the disease had been present for years but was overlooked because no one connected the pieces of the puzzle.
A chest CT is required for bronchiectasis diagnosis:
Richards explained that on a chest CT, tree and bud nodules can be a sign of bronchial dilation with mucus impaction.
For diagnosis, detailed guidelines state:
≥1 of the following on high resolution computed
tomography (HRCT):10
Inner airway-artery diameter ratio ≥1.0
Outer airway-artery ratio ≥1.0
Lack of tapering of the airways
Visibility of airways in the periphery
I think one thing we're all taught pretty well in pulmonary is to always look at your own (patient CT) images.
- Khabazza
Khabazza and Richards noted that misdiagnosed patients, especially those with recurrent infections, are often maximised for years on ICS or frequent antibiotics without getting sputum cultures.
Khabazza advocated that anyone with lung disease who is producing sputum with chronic cough should have respiratory and acid-fast bacillus cultures done regularly.10
“… and we should be thinking about bronchiectasis.” - Khabazza
Richards agreed, adding that if he sees an abnormal sputum culture in these cases, he immediately requests a CT scan.
For diagnosis, detailed guidelines state:
≥2 of the following:10
Cough most days of the week
Sputum production most days of the week
History of exacerbations
In practice, patients may present first with symptoms that raise clinical suspicion of bronchiectasis, or evidence may be seen incidentally on a chest CT, leading to bronchiectasis diagnosis.10,27 Click to find out more:
Diagnosis of Clinically Significant Bronchiectasis Requires Both Clinical and Radiological Criteria.10,28
Incidental evidence of bronchiectasis on a chest CT scan10
Clinical suspicion of bronchiectasis10
≥1 of the following on HRCT:
Inner airway-artery diameter ratio ≥1.0
Outer airway-artery ratio ≥1.0
Lack of tapering of the airways
Visibility of airways in the periphery
≥2 of the following:
Cough most days of the week
Sputum production most days of the week
History of exacerbations
Yes
Yes
≥2 of the following:
Cough most days of the week
Sputum production most days of the week
History of exacerbations
≥1 of the following on HRCT:
Inner airway-artery diameter ratio ≥1.0
Outer airway-artery ratio ≥1.0
Lack of tapering of the airways
Visibility of airways in the periphery
No
Yes
No
Yes
Radiological evidence of bronchiectasis in absence of significant disease
Radiological evidence of clinically significant bronchiectasis;
consider as a chronic lung disease
Does not have bronchiectasis;
other causes for symptoms
should be considered
Khabazza and Richards highlighted the power of reviewing imaging with patients.
Richards shared that reviewing imaging together during first visits helps explain the disease and its progression.
Both agreed that when patients can see what’s happening in their lungs, it impraoves understanding, encourages engagement, and supports better adherence to treatment.
“I think above anything else, trust your patients.” - Richards
Khabazza adds that this moment of realisation is often deeply rewarding: patients begin to connect the dots, understanding why their symptoms persisted despite previous disease management and why past approaches fell short.
References
1. Chalmers JD et al. Bronchiectasis. Nat Rev Dis Primers. 2018;4(1):45.
2. O'Donnell AE. Bronchiectasis - a clinical review. N Engl J Med. 2022;387(6):533-45.
3. Keir HR et al. Pathophysiology of bronchiectasis. Semin Respir Crit Care Med. 2021;42(4):499-512.
4. Aksamit TR et al. Association between bronchiectasis exacerbations and longitudinal changes in FEV1 in patients from the US bronchiectasis and NTM research registry. Respir Med. 2025;228:107660.
5. Chalmers JD et al. Bronchiectasis in Europe: data on disease characteristics from the European Bronchiectasis registry (EMBARC). Lancet Respir Med. 2023;11(7):637-49.
6. Gómez-Olivas JD et al. Etiology of bronchiectasis in the world: data from the published national and international registries. J Clin Med. 2023;12(18):5782.
7. Weycker D et al. Prevalence and incidence of noncystic fibrosis bronchiectasis among US adults in 2013. Chron Respir Dis. 2017;14(4):377-84.
8. Flume PA et al. Pulmonary exacerbations in insured patients with bronchiectasis over 2 years. ERJ Open Res. 2023;9(4):00021-2023.
9. Dettmer S et al. Computed Tomography in Adults with Bronchiectasis and Nontuberculous Mycobacterial Pulmonary Disease: Typical Imaging Findings. J Clin Med. 2021;10(12):2736.
10. Aliberti S et al. Criteria and definitions for the radiological and clinical diagnosis of bronchiectasis in adults for use in clinical trials: international consensus recommendations. Lancet Respir Med. 2022;10(3):298-306.
11. Aliberti S et al. Objective sputum colour assessment and clinical outcomes in bronchiectasis: data from the European Bronchiectasis Registry (EMBARC). Eur Respir J. 2024;63(4):2301554.
12. Chalmers JD et al. Characterization of the "frequent exacerbator phenotype" in bronchiectasis. Am J Respir Crit Care Med. 2018;197(11):1410-20.
13. De Angelis A et al. Exacerbations of bronchiectasis. Eur Respir Rev. 2024;33(172):240085.
14. Flume PA et al. Advances in bronchiectasis: endotyping, genetics, microbiome, and disease heterogeneity. Lancet. 2018;392(10150):880-90.
15. Murray MP et al. Sputum colour: a useful clinical tool in non-cystic fibrosis bronchiectasis. Eur Respir J. 2009;34(2):361-4.
References
16. National Institute for Health and Care Excellence (NICE). Bronchiectasis (non-cystic fibrosis), acute exacerbation: antimicrobial prescribing. Available at: https://www.nice.org.uk/guidance/ng117. Last accessed: 24 June 2025.
17. Chang AB et al. Thoracic Society of Australia and New Zealand (TSANZ) position statement on chronic suppurative lung disease and bronchiectasis in children, adolescents and adults in Australia and New Zealand. Respirology. 2023;28(4):339-49. 18. AWMF online. S2k guideline management of adult patients with bronchiectasis disease. 2024. Available at: https://register.awmf.org/de/leitlinien/detail/020-030. Last accessed: 24 June 2025.
19. Al-Jahdali H et al. The Saudi Thoracic Society evidence-based guidelines for the diagnosis and management of chronic obstructive pulmonary disease. Ann Thorac Med. 2025;20(1):1-35.
20. Polverino E et al. European Respiratory Society guidelines for the management of adult bronchiectasis. Eur Respir J. 2017;50(3):1700629.
21. Choi H, Chalmers JD. Bronchiectasis exacerbation: a narrative review of causes, risk factors, management and prevention. Ann Transl Med. 2023;11(1):25.
22. Martínez-García MÁ et al. Spanish guidelines on the evaluation and diagnosis of bronchiectasis in adults. Arch Bronconeumol (Engl Ed). 2018;54(2):79-87.
23. Global Initiative for Asthma. Global strategy for asthma management and prevention: 2024 update. 2024. Available at: https://ginasthma.org/2024-report/. Last accessed: 19 March 2025.
24. Porsbjerg C et al. Asthma. Lancet. 2023;401(10379):858-73. Global Initiative for Chronic Obstructive Lung Disease.
25. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: 2025 report. 2025. Available at: https://goldcopd.org/wp-content/uploads/2024/11/GOLD-2025-Report-v1.0-15Nov2024_WMV.pdf. Last accessed: 16 April 2025.
26. Agustí A et al. Global Initiative for Chronic Obstructive Lung Disease 2023 Report: GOLD Executive Summary. Eur Respir J. 2023;61(4):2300239.
27. Pasteur M et al.; British Thoracic Society Non-CF Bronchiectasis Guideline Group. British Thoracic Society guideline for non-CF bronchiectasis. Thorax. 2010;65(7):577.
28. Hill AT et al. British Thoracic Society guideline for bronchiectasis in adults. Thorax. 2019;74(Suppl 1):1-69.
This newfound understanding not only helps to simplify their disease management but also fosters long-term trust and stronger doctor-patient relationships.
Chest CT scan of a Bronchiectasis patient
The patient does not respond to treatment for asthma
The patient could have bronchiectasis
“We need to find out why this culture is the way it is.” - Richards
VIdeo Summary