Understanding non-CF bronchiectasis, airway clearance, infection management, the first FDA-approved treatment (brensocatib), clinical trials, and practical resources — organized by where you are in the journey.
This guide is not medical advice. It is an educational research summary written in plain language, drawn from published medical literature and clinical trial records. Every important decision must be made together with the patient’s medical team — pulmonologists, infectious disease specialists, and primary care doctors. Nothing here replaces those conversations. The purpose of this guide is to help patients and families walk into those conversations better prepared. This content does not create a doctor-patient relationship. Trouvera’s guides are produced using AI-assisted research synthesis with human editorial review; it is not written by treating physicians. Laws regarding medical information vary by jurisdiction; consult a local licensed professional for advice specific to your situation.
Standard care first. Every option discussed in this guide is intended as an addition to, not a replacement for, evidence-based standard treatments delivered by a qualified pulmonology team. Bronchiectasis management requires ongoing specialist care with attention to airway clearance, infection control, and underlying cause identification.
When to seek urgent care. If you develop worsening shortness of breath, coughing up blood (hemoptysis), high fever with increased sputum production, or chest pain, contact your pulmonologist or go to the emergency department immediately.
Content last reviewed: June 2026 · Based on ERS 2017 Bronchiectasis Guidelines, BTS 2019 Guidelines, CHEST 2024 Expert Panel Report, ASPEN trial (brensocatib), ORBIT trials, and published medical literature · Always verify treatment details with your medical team and primary sources.
⚡ Quick Start — If You Read Nothing Else
The 8 most important things to know right now.
Bronchiectasis means permanently widened airways that trap mucus. This creates a vicious cycle: mucus buildup leads to infection, infection causes inflammation, and inflammation damages airways further. Breaking this cycle is the core goal of treatment.
Airway clearance is the single most important daily treatment. Techniques to physically move mucus out of your lungs — such as the active cycle of breathing, oscillating PEP devices, or chest physiotherapy — should be performed at least once daily and are more important than any medication.
There is now an FDA-approved treatment: brensocatib (Brinsupri). Approved in August 2025, this is the first drug specifically approved for non-CF bronchiectasis. It reduces the frequency of exacerbations by targeting neutrophil-driven inflammation. This is a genuine breakthrough after decades without an approved therapy.
Finding the underlying cause matters. About 30–50% of cases have an identifiable cause (post-infection, immune deficiency, allergic bronchopulmonary aspergillosis, autoimmune conditions). Treating the cause can slow progression.
Sputum cultures guide antibiotic choice. The specific bacteria colonizing your airways determine which antibiotics will work. Regular sputum cultures — not just when you are sick — are essential.
Pseudomonas aeruginosa colonization is a critical dividing line. Patients with chronic Pseudomonas infection have more exacerbations, faster lung function decline, and worse outcomes. Eradication should be attempted at first isolation.
Exacerbations should be treated promptly with 14 days of antibiotics. Early treatment of flare-ups prevents further lung damage. Learn to recognize the signs: increased sputum volume, color change, worsening breathlessness, or fever.
See a pulmonologist who knows bronchiectasis. This condition is frequently mismanaged as simple recurrent pneumonia or COPD. Specialist care at a center experienced with bronchiectasis improves outcomes.
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Understanding Bronchiectasis
Bronchiectasis is a chronic lung condition in which the airways (bronchi) become permanently widened and damaged. This damage prevents the normal clearance of mucus, creating a cycle of mucus retention, chronic infection, and ongoing inflammation that progressively worsens lung function.
When we say “non-CF bronchiectasis,” we mean bronchiectasis that is not caused by cystic fibrosis (CF). CF is a specific genetic condition with its own treatment pathway. Non-CF bronchiectasis has many possible causes — and in many patients, no single cause is ever found (idiopathic).
Bronchiectasis is more common than many people realize, and its prevalence is rising. It is often underdiagnosed because symptoms overlap with COPD, asthma, and recurrent pneumonia.
Approximately 500,000 people in the United States are estimated to have bronchiectasis, though the true number may be higher due to underdiagnosis
Prevalence has been increasing by 8–9% per year in the US, partly due to greater awareness and more CT scanning
More common in women and older adults (peak prevalence over age 60)
More common in certain populations, including Native Hawaiians, Pacific Islanders, Asian Americans, and Indigenous populations globally
Globally, prevalence varies widely: high rates reported in parts of Australia, New Zealand, and Southeast Asia
Understanding this cycle explains why treatment focuses on multiple points of intervention:
Airway damage (from infection, inflammation, or other insult) causes airways to widen and lose their ability to clear mucus normally
Mucus accumulation in damaged airways provides an ideal environment for bacteria to grow
Chronic infection triggers an immune response, recruiting neutrophils (white blood cells) to the airways
Neutrophil-driven inflammation releases destructive enzymes (especially neutrophil elastase and other serine proteases) that further damage airway walls
More airway damage → the cycle repeats and worsens
Treatment targets every step: airway clearance techniques remove mucus, antibiotics control infection, and anti-inflammatory agents (including brensocatib) reduce neutrophil-mediated damage.
The most important concept in this guide: Bronchiectasis is not curable, but it is treatable and manageable. Consistent daily airway clearance, prompt treatment of exacerbations, appropriate use of inhaled or oral antibiotics, and now brensocatib can significantly reduce symptoms, prevent lung function decline, and improve quality of life. The key is not giving up on the daily routine.
⏱ Your action clock — the first months after diagnosis. Bronchiectasis care follows a predictable sequence. Use this dated checklist with your pulmonology team (timing aligned to ERS 2017 and BTS 2019 workup recommendations):
Within the first week: Confirm the diagnosis on a high-resolution CT scan (HRCT); send a sputum culture, including an AFB culture for NTM; and begin a daily airway-clearance routine, ideally taught by a respiratory physiotherapist.
Within two weeks: Start the search for an underlying cause (immunoglobulins IgG/IgA/IgM, plus total IgE and Aspergillus testing for ABPA) so any treatable cause is found early. If a first-ever Pseudomonas aeruginosa culture came back positive, ask about an eradication course now rather than later, before it becomes established.
In the first month: Review the results together, treat any underlying cause that was found, and build a written exacerbation action plan (which antibiotic, what dose, a 14-day course, and when to call).
By month 3: If you have had 3 or more exacerbations in the past year despite airway clearance, discuss long-term macrolide therapy — but only after NTM has been ruled out (see the safety stop-rules below). Consider a long-term inhaled antibiotic if chronic Pseudomonas persists.
By month 6, and then yearly: Repeat spirometry (FEV1) and sputum cultures to monitor the disease and confirm that treatments are still working.
Ask: "Where am I on this timeline, and what is the next dated step?"
Key Breakthroughs in Bronchiectasis
For decades, non-CF bronchiectasis had no FDA-approved treatments. Patients relied on therapies borrowed from CF or COPD. That has now changed.
FDA-APPROVED Brensocatib is a first-in-class oral dipeptidyl peptidase 1 (DPP1) inhibitor. DPP1 activates neutrophil serine proteases (NSPs) — the destructive enzymes responsible for much of the airway damage in bronchiectasis. By blocking DPP1, brensocatib reduces the activity of these proteases, breaking the inflammatory part of the vicious cycle. In the phase 3 ASPEN trial (1,721 patients), brensocatib significantly reduced the rate of pulmonary exacerbations compared to placebo; the FDA approved it on August 12, 2025 (oral, once daily, for patients aged 12 and older). This approval represents a genuine paradigm shift for a disease that has been neglected by drug development for decades.
OFF-LABEL / GUIDELINE-SUPPORTED While no inhaled antibiotic is FDA-approved specifically for non-CF bronchiectasis, several are widely used based on clinical evidence and guideline recommendations. Inhaled tobramycin, inhaled colistin, and inhaled aztreonam deliver high concentrations of antibiotic directly to the airways while minimizing systemic side effects. ERS 2017 and BTS 2019 guidelines recommend inhaled antibiotics for patients with chronic Pseudomonas aeruginosa infection and frequent exacerbations (≥3 per year).
STANDARD OF CARE Oscillating positive expiratory pressure (PEP) devices such as the Aerobika, Acapella, and Flutter have made daily airway clearance more practical and effective for many patients. These handheld devices create vibrations in the airways during exhalation, loosening mucus and making it easier to cough up. They are portable, easy to use, and can be self-administered without a caregiver or therapist, improving adherence to daily clearance routines.
GUIDELINE-SUPPORTED Three randomized controlled trials (EMBRACE, BAT, BLESS) demonstrated that long-term low-dose macrolides reduce exacerbation frequency by approximately 50–70% in bronchiectasis patients with frequent exacerbations — EMBRACE and BAT used azithromycin (three times weekly / daily), while BLESS used erythromycin twice daily. ERS 2017 and BTS 2019 guidelines recommend macrolide therapy for patients with ≥3 exacerbations per year despite airway clearance and standard care. Important considerations include QTc prolongation, hearing loss monitoring, and the risk of promoting macrolide-resistant organisms, including nontuberculous mycobacteria (NTM).
Diagnosis: How Bronchiectasis Is Confirmed
Bronchiectasis is definitively diagnosed by a high-resolution CT scan (HRCT) of the chest. It cannot be reliably diagnosed by a regular chest X-ray, although an X-ray may raise suspicion.
HRCT is the definitive diagnostic test. It shows the characteristic features of bronchiectasis:
Bronchial dilation: The airway is wider than the adjacent blood vessel (the “signet ring sign”)
Lack of airway tapering: Normal airways narrow as they branch outward; bronchiectatic airways do not
Airway wall thickening: Inflamed, damaged airway walls appear thicker than normal
Mucus plugging: Mucus-filled airways visible as branching opacities (“tree-in-bud” pattern)
HRCT also shows the distribution and extent of disease, which helps guide treatment decisions. Some patients have localized disease (one lobe) while others have diffuse involvement of both lungs.
Spirometry measures how well your lungs work. In bronchiectasis, the typical pattern is obstructive (difficulty getting air out), similar to COPD or asthma. Key values include:
FEV1 (forced expiratory volume in 1 second): The most important number to track over time. A declining FEV1 indicates progressive lung damage.
FVC (forced vital capacity): The total amount of air you can blow out
FEV1/FVC ratio: Low ratio indicates obstruction
Spirometry should be done at diagnosis and then at least annually to monitor disease progression.
Sputum culture identifies which bacteria are living in your airways. This is critical because different bacteria require different antibiotics. Common organisms include:
Haemophilus influenzae: The most common organism in many Western populations
Pseudomonas aeruginosa: Found in approximately 15–30% of patients. Associated with worse outcomes, more exacerbations, and faster FEV1 decline
Sputum should be cultured at diagnosis, at least annually, during exacerbations, and whenever the character of your sputum changes significantly.
Has a high-resolution CT scan confirmed the diagnosis?
How many lobes are affected, and how severe is the damage?
What does my sputum culture show? Is Pseudomonas present?
Have you tested for NTM (nontuberculous mycobacteria)?
What is my current lung function (FEV1)?
Have you investigated the underlying cause?
Should I see a bronchiectasis specialist?
Finding the Cause
Identifying the underlying cause of bronchiectasis is important because some causes are treatable, and treating them can slow or halt disease progression. However, in approximately 30–50% of cases, no cause is identified despite thorough investigation (idiopathic bronchiectasis).
Cause
Approximate Frequency
Key Point
Post-infectious
20–30%
Prior severe pneumonia, childhood whooping cough, tuberculosis, or measles. The infection is gone, but the airway damage remains.
Idiopathic (no cause found)
30–50%
Despite thorough testing, no underlying cause is identified.
Immune deficiency
5–15%
Low immunoglobulin levels (especially IgG subclass deficiency or CVID). Treatable with immunoglobulin replacement therapy.
ABPA (allergic bronchopulmonary aspergillosis)
5–10%
An allergic reaction to the Aspergillus fungus. Treatable with steroids and antifungals. Must be actively screened for.
Autoimmune / connective tissue disease
5–10%
Rheumatoid arthritis, Sjögren syndrome, inflammatory bowel disease. Treating the underlying condition may help.
NTM infection
5–10%
Nontuberculous mycobacteria can be both a cause and consequence of bronchiectasis. Requires specialized treatment.
Primary ciliary dyskinesia (PCD)
1–5%
Genetic condition affecting cilia (tiny hair-like structures that move mucus). Often diagnosed in childhood.
COPD overlap / aspiration
Variable
COPD and bronchiectasis frequently coexist. Chronic aspiration (from GERD or swallowing problems) can cause bronchiectasis.
At diagnosis, the following tests should be performed to search for a treatable cause:
Immunoglobulin levels: IgG, IgA, IgM (screen for immune deficiency)
IgG subclasses: If total IgG is normal but immune deficiency is suspected
Specific antibody responses: Response to pneumococcal vaccination (functional immune assessment)
Total IgE and Aspergillus-specific IgE/IgG: Screen for ABPA
Sputum culture: Including acid-fast bacilli (AFB) culture for NTM
Complete blood count with differential
Alpha-1 antitrypsin level: If concurrent emphysema
Autoimmune screening: Rheumatoid factor, anti-CCP, ANA (if clinical suspicion)
CF testing (sweat chloride and/or genetics): In younger patients or those with upper lobe disease, nasal polyps, or pancreatic insufficiency
Key question for your pulmonologist: “Have you investigated why I have bronchiectasis? Have immunoglobulin levels, ABPA testing, and NTM cultures been sent?”
Script — finding the underlying cause. Ask: "Have you investigated why I have bronchiectasis — specifically immunoglobulin levels to look for an immune deficiency, testing for ABPA, and AFB cultures for NTM — and is any cause you find treatable?"
Severity Assessment
Bronchiectasis severity is assessed using validated scoring systems that help predict outcomes and guide treatment intensity. The two most widely used are the Bronchiectasis Severity Index (BSI) and the FACED score.
The BSI uses nine variables to calculate a severity score:
Age, BMI, FEV1 (% predicted)
Number of exacerbations and hospitalizations in the prior year
MRC dyspnea score (breathlessness level)
Pseudomonas colonization status
Number of lobes affected on CT
Other organism colonization
Interpretation: BSI 0–4 = mild (low risk of future hospitalization and mortality); BSI 5–8 = moderate; BSI ≥9 = severe (high risk).
The FACED score uses five variables (FEV1, Age, Chronic colonization, Extension, Dyspnea) to predict 5-year mortality. Simpler than the BSI, it is sometimes preferred in clinical practice.
Important: Severity scores are guides, not destiny. They help your care team decide treatment intensity. Patients with mild disease may need only airway clearance and monitoring. Patients with severe disease may benefit from inhaled antibiotics, macrolides, brensocatib, and more aggressive exacerbation management.
Airway Clearance — The Foundation of Treatment
Airway clearance is the most important ongoing treatment for bronchiectasis. Every guideline — ERS, BTS, and CHEST — places it at the center of management. The goal is to physically remove mucus from the airways, reducing the bacterial load and breaking the vicious cycle.
Technique
How It Works
Pros / Cons
Active Cycle of Breathing Technique (ACBT)
Alternates between relaxed breathing, deep breathing (thoracic expansion), and huffing (forced exhalation) to move mucus up
Free, no equipment, self-directed. Requires training by a physiotherapist.
Oscillating PEP Devices (Aerobika, Acapella, Flutter)
You breathe out through a device that creates vibrations and back-pressure, shaking mucus loose
An inflatable vest connected to an air-pulse generator vibrates the chest wall
Effective for patients who cannot perform ACBT. Expensive (~$10,000–$15,000, often insurance-covered). Less portable.
Postural Drainage
Positioning the body so that gravity helps drain mucus from specific lung segments
No cost. Some positions uncomfortable. Can be combined with other techniques.
Autogenic Drainage
Controlled breathing at different lung volumes to move mucus from small to large airways
No equipment needed. Takes practice to learn. Popular in European centers.
Hypertonic saline (6–7% nebulized): Draws water into the airways by osmosis, hydrating mucus and making it easier to clear. Used before airway clearance sessions. ERS 2017 suggests a trial in patients with difficulty clearing sputum. Pretreatment with a bronchodilator (albuterol) is recommended to prevent bronchospasm.
Normal saline (0.9% nebulized): Less effective than hypertonic saline but better tolerated. Reasonable alternative if hypertonic causes too much coughing or wheezing.
Mannitol (inhaled dry powder, Bronchitol): Approved in some countries for bronchiectasis (Australia, EU). Osmotic agent that improves mucus clearance. Not FDA-approved in the US for bronchiectasis.
Warning: Do NOT use dornase alfa (Pulmozyme) for non-CF bronchiectasis. Dornase alfa is effective in CF but was shown to be harmful in non-CF bronchiectasis in a randomized trial (O'Donnell et al., 1998), worsening lung function and increasing exacerbations. This is one of the most important distinctions between CF and non-CF bronchiectasis management.
Can you refer me to a respiratory physiotherapist to learn airway clearance techniques?
Which technique is best for my specific pattern of disease?
Should I try an oscillating PEP device?
Would nebulized hypertonic saline help me clear mucus more effectively?
How often should I do airway clearance — once or twice daily?
Should I use a bronchodilator before airway clearance sessions?
Script — airway clearance. Ask: "Which airway-clearance technique fits my pattern of disease, can you refer me to a respiratory physiotherapist to learn it properly, and should I nebulize hypertonic saline or take a bronchodilator first?"
Managing Chronic Infections
Chronic bacterial colonization of the airways is a central feature of bronchiectasis. Managing these infections is one of the most important aspects of treatment.
Pseudomonas aeruginosa colonization affects approximately 15–30% of bronchiectasis patients and is associated with:
Three times more exacerbations per year
Faster decline in lung function (FEV1)
Lower quality of life
Higher mortality
Eradication attempt at first isolation: Both ERS 2017 and BTS 2019 guidelines recommend attempting to eradicate Pseudomonas at first detection, before it becomes established. The typical eradication protocol is:
Oral ciprofloxacin 500–750 mg twice daily for 2 weeks, PLUS
Inhaled antibiotic (tobramycin, colistin, or gentamicin) for 3 months
Repeat sputum cultures to confirm eradication
If eradication fails (Pseudomonas persists on repeat cultures), the goal shifts to suppression — reducing bacterial load with long-term inhaled antibiotics rather than attempting cure.
NTM, especially Mycobacterium avium complex (MAC), increasingly coexists with bronchiectasis. NTM can be both a cause and complication of bronchiectasis. Key points:
NTM requires special cultures (AFB culture, may take 6–8 weeks to grow)
Treatment is prolonged (typically 12+ months after sputum conversion) with multi-drug regimens — for MAC, usually azithromycin 250–500 mg, ethambutol 15 mg/kg, and rifampin 600 mg (with inhaled or IV amikacin added for cavitary or refractory disease), per the ATS/ERS/ESCMID/IDSA 2020 NTM guideline
Macrolide monotherapy must be avoided — it drives macrolide resistance in NTM. Always rule out NTM before starting long-term azithromycin for bronchiectasis.
Inhaled Antibiotics
Inhaled antibiotics deliver high concentrations of antibiotic directly to the airways while minimizing systemic absorption and side effects. They are used for long-term suppression of chronic bacterial infection, particularly Pseudomonas aeruginosa.
Drug
Dose / Delivery
Target Pathogen
Key Evidence
Tobramycin (TOBI, nebulized)
300 mg nebulized BID, 28 days on / 28 days off
Pseudomonas aeruginosa
Adapted from CF protocols. Reduces Pseudomonas density and exacerbations. Monitor hearing and renal function.
Colistin (nebulized)
1–2 million units nebulized BID
Pseudomonas, Gram-negative bacteria
PROMIS-I was positive (reduced exacerbations); PROMIS-II was terminated early (COVID) and did not replicate. Not FDA-approved for bronchiectasis, but BTS guidelines support use; widely used as a first-line inhaled antibiotic in Europe.
Aztreonam (Cayston, nebulized)
75 mg nebulized TID, 28 days on / 28 days off
Pseudomonas, Gram-negative bacteria
The aztreonam bronchiectasis trials (AIR-BX1 and AIR-BX2) did not meet their primary quality-of-life endpoint, so aztreonam is not FDA-approved for bronchiectasis; it is sometimes used off-label for patients failing other options.
Gentamicin (nebulized)
80 mg nebulized BID
Pseudomonas, other Gram-negatives
Smaller evidence base but used in UK practice (BTS recommendation). Monitor hearing.
When are inhaled antibiotics recommended? ERS 2017 and BTS 2019 guidelines recommend inhaled antibiotics for patients with chronic Pseudomonas aeruginosa colonization and ≥3 exacerbations per year (or fewer exacerbations if causing significant morbidity). Always do a supervised test dose in clinic — inhaled antibiotics can cause bronchospasm.
Script — inhaled antibiotics for Pseudomonas. Ask: "My cultures grow Pseudomonas and I keep having flare-ups — should I be on a long-term inhaled antibiotic, and can my first dose be supervised in clinic to check for bronchospasm?"
Brensocatib (Brinsupri) — First FDA-Approved Treatment
FDA-APPROVED 2025 Brensocatib is a first-in-class oral dipeptidyl peptidase 1 (DPP1) inhibitor and the first drug ever approved specifically for non-cystic fibrosis bronchiectasis.
DPP1 (also called cathepsin C) is an enzyme inside neutrophils that activates neutrophil serine proteases (NSPs) — including neutrophil elastase, proteinase 3, and cathepsin G. These proteases are the main drivers of airway tissue destruction in bronchiectasis. By inhibiting DPP1, brensocatib reduces the activity of NSPs, dampening the destructive inflammatory response without completely suppressing the immune system.
The approval was based on the phase 3 ASPEN trial, which randomized 1,721 patients with non-CF bronchiectasis across multiple countries. Key findings:
Brensocatib significantly reduced the rate of pulmonary exacerbations compared to placebo
The reduction in exacerbations was seen regardless of baseline Pseudomonas status
Brensocatib also showed improvements in time to first exacerbation
The drug was generally well tolerated
The earlier phase 2 WILLOW trial had demonstrated proof of concept, showing that brensocatib 10 mg and 25 mg significantly prolonged time to first exacerbation compared to placebo over 24 weeks.
Dosing: Oral, once daily — 10 mg or 25 mg tablet in the US (25 mg in the EU)
Key side effects to watch: Skin and dental effects (related to DPP1 inhibition affecting keratinocytes and enamel); hyperkeratosis; increased risk of infections due to reduced neutrophil protease activity. Discuss monitoring with your prescriber.
Who is it for: Adults with non-CF bronchiectasis, particularly those with frequent exacerbations. It is an addition to standard care (airway clearance, antibiotics as needed), not a replacement.
Ask your pulmonologist: “Am I a candidate for brensocatib? Would it help reduce my exacerbations on top of my current treatment regimen?”
Anti-Inflammatory Therapy
GUIDELINE-SUPPORTED Long-term low-dose macrolides have both anti-inflammatory and antimicrobial properties. Three randomized controlled trials showed consistent reduction in exacerbation frequency of approximately 50–70%: EMBRACE and BAT used azithromycin (250–500 mg three times weekly or daily), and BLESS used erythromycin 400 mg twice daily.
ERS 2017 and BTS 2019 recommend macrolides for:
Patients with ≥3 exacerbations per year despite airway clearance and standard care
Patients with fewer exacerbations causing significant morbidity (hospitalizations)
Baseline hearing assessment (ototoxicity risk, especially with concurrent aminoglycosides)
Liver function tests
Monitoring on macrolide therapy: Sputum cultures for NTM at least annually. ECG if adding other QTc-prolonging medications. Report any hearing changes.
Script — long-term macrolide. Ask: "I keep having flare-ups — am I a candidate for long-term azithromycin, and have you sent NTM (AFB) cultures and checked a baseline ECG before I start?"
⚠️ Safety stop-rules — read before starting long-term therapy.
Before starting long-term azithromycin, screen for non-tuberculous mycobacteria (NTM). Guidelines (BTS 2019; ATS/IDSA 2020) advise sending sputum AFB cultures first. This is a hard stop rule: do not begin azithromycin as a standing daily or three-times-weekly drug until NTM has been ruled out, because macrolide monotherapy in undiagnosed NTM breeds macrolide-resistant NTM and can take away the very drug you would later need to treat it. If an NTM culture later turns positive, discontinue if you are on azithromycin alone and switch to a proper multi-drug NTM regimen.
Azithromycin heart-rhythm and hearing monitoring. Azithromycin can prolong the QT interval and, rarely, cause hearing loss (FDA azithromycin label). Your team should check a baseline ECG. Stop the drug and seek care if you have palpitations, fainting, or new ringing in the ears or muffled hearing; your team will also discontinue if the QTc becomes significantly prolonged.
Massive hemoptysis is an emergency. Coughing up a large amount of fresh blood — roughly a tablespoon or more at once, or ongoing bright-red blood — can be life-threatening. Call 911. The definitive treatment is bronchial artery embolization, in which an interventional radiologist blocks the bleeding artery. Do not wait to see whether it settles.
The first dose of any inhaled antibiotic must be supervised. Inhaled tobramycin, colistin, aztreonam, or gentamicin can cause sudden airway tightening (bronchospasm), especially on the first dose. That dose is given in clinic with lung function measured before and after and a bronchodilator on hand. Stop and tell your team if you wheeze or your chest tightens.
Inhaled corticosteroids are not routinely recommended in bronchiectasis unless the patient has coexisting asthma or COPD with an asthmatic component (eosinophilic phenotype). ICS can increase the risk of respiratory infections, including NTM, without proven benefit in most bronchiectasis patients.
If you are taking inhaled steroids and your bronchiectasis is not associated with asthma or eosinophilic inflammation, discuss with your pulmonologist whether they should be stopped.
Am I a candidate for long-term azithromycin?
Have NTM cultures been sent before starting azithromycin?
Should I be on brensocatib?
Am I taking any inhaled steroids that may not be necessary?
Should I be on long-term inhaled antibiotics?
How often should my sputum be cultured?
What is my exacerbation action plan?
When should I start antibiotics for an exacerbation?
Are there clinical trials available for me?
Exacerbation Management
An exacerbation is a flare-up: a worsening of symptoms beyond your normal day-to-day variation that requires a change in treatment (usually antibiotics). Prompt recognition and treatment of exacerbations is critical — each exacerbation causes further airway damage.
The following changes from your baseline suggest an exacerbation:
Increased volume of sputum production
Change in sputum color (becoming more green or yellow)
Increased sputum thickness or difficulty clearing
Worsening breathlessness or exercise tolerance
New or worsening cough
Fever or malaise (feeling generally unwell)
New crackles or wheeze on chest examination
Decline in lung function (FEV1)
Antibiotic duration: 14 days (BTS 2019 recommends 14 days; ERS 2017 suggests at least 14 days). This is longer than typical pneumonia treatment.
Antibiotic choice: Based on most recent sputum culture and sensitivity results:
No Pseudomonas: Amoxicillin 500 mg TID, co-amoxiclav, doxycycline, or a fluoroquinolone based on sensitivities
Pseudomonas present: Oral ciprofloxacin 500–750 mg twice daily (the only reliably active oral anti-pseudomonal). If IV is needed: ceftazidime 2 g three times daily, piperacillin-tazobactam 4.5 g four times daily, or meropenem 1–2 g three times daily, sometimes with IV tobramycin 5–7 mg/kg once daily — all for 14 days and adjusted to your culture sensitivities.
Increase airway clearance: During an exacerbation, increase the frequency and duration of airway clearance sessions.
Sputum sample: Send a sputum sample for culture and sensitivity at the start of the exacerbation, before starting antibiotics if possible.
Hospital admission: Consider if the patient is severely unwell, hypoxic, has hemoptysis, is failing oral antibiotics, or has significant comorbidities.
Have an action plan. Work with your pulmonologist to create a written exacerbation action plan. This should include: how to recognize an exacerbation, which antibiotic to start (and at what dose), when to call your doctor, and when to go to the emergency department. Having a “standby” prescription for antibiotics at home, so you can start treatment at the first sign of an exacerbation, can reduce the severity and duration of flare-ups.
Script — exacerbation plan. Ask: "Can we write down my exacerbation action plan — which antibiotic and dose I start, that it runs the full 14 days, and exactly when I should call you versus go to the emergency department?"
Supportive Care
Vaccinations are important to reduce the risk of respiratory infections that can trigger exacerbations:
Annual influenza vaccine: Recommended for all bronchiectasis patients
Pneumococcal vaccine: PCV20 or PCV15 followed by PPSV23 (per current CDC schedule)
COVID-19 vaccination: Up to date per current recommendations
Pertussis (Tdap): If not recently vaccinated
RSV vaccine: Consider for adults aged 60+ (recently approved)
Pulmonary rehabilitation programs improve exercise capacity, reduce breathlessness, and improve quality of life in bronchiectasis. A typical program includes:
Supervised exercise training (aerobic + strength) 2–3 times per week for 6–8 weeks
Education about disease management, airway clearance, nutrition
Psychological support
Both ERS 2017 and BTS 2019 recommend pulmonary rehabilitation for patients with breathlessness or reduced exercise tolerance.
Maintain a healthy weight: Both underweight and overweight are associated with worse outcomes. Low BMI is a predictor of mortality in the BSI.
Stay hydrated: Adequate hydration helps keep mucus thinner and easier to clear
Smoking cessation: If applicable, stopping smoking is critical. Smoking accelerates airway damage.
Exercise: Regular physical activity improves mucus clearance and overall fitness. Walking, cycling, and swimming are all appropriate.
Hemoptysis (Coughing Up Blood)
Hemoptysis is common in bronchiectasis, occurring in approximately 50–70% of patients at some point. Most episodes are mild (streaks of blood in sputum), but massive hemoptysis (>300 mL in 24 hours) is a medical emergency.
Coughing up more than a tablespoon of fresh blood at a time
Blood is bright red and ongoing
Feeling lightheaded, dizzy, or short of breath with hemoptysis
Blood is interfering with your ability to breathe
What to do: Call 911 or go to the nearest emergency department. Lie on the side of the affected lung (if known) to protect the unaffected lung. Stay calm and upright if possible.
Mild hemoptysis: Treat the underlying exacerbation with antibiotics. Hold or reduce airway clearance temporarily if vigorous techniques are worsening bleeding. Avoid NSAIDs and anticoagulants if possible.
Moderate to severe hemoptysis: May require hospitalization. Bronchial artery embolization (BAE) — a minimally invasive procedure where an interventional radiologist blocks the bleeding artery — is the treatment of choice for significant hemoptysis.
Recurrent hemoptysis: If BAE is not sufficient or hemoptysis recurs, surgical resection of the affected lobe may be considered.
Tranexamic acid: Oral or IV tranexamic acid (an antifibrinolytic) may be used to reduce bleeding. Some patients use nebulized tranexamic acid for recurrent minor hemoptysis.
Surgery and Lung Transplant
Surgery (lobectomy or segmentectomy) may be considered in selected patients:
Localized disease (one lobe or segment) with recurrent infections not controlled by medical therapy
Life-threatening recurrent hemoptysis from a specific area
Destroyed lung segment acting as a reservoir for chronic infection
Surgery is generally not appropriate for diffuse bilateral disease. It should be performed at a center with experience in bronchiectasis surgery. Outcomes are generally good when patient selection is careful.
Lung transplant is a last-resort option for patients with end-stage bronchiectasis and severe respiratory failure. Referral for transplant evaluation should be considered when:
FEV1 <30% predicted despite maximal medical therapy
Frequent hospitalizations or ICU admissions for exacerbations
Requirement for long-term supplemental oxygen
Declining quality of life despite optimal treatment
Double lung transplant is preferred (to avoid infection of a single transplanted lung from the remaining native lung). Patients with NTM infection may face additional challenges in transplant evaluation.
Pregnancy, Fertility & Family Planning
Most non-CF bronchiectasis is not inherited, so for the majority of people it does not directly pass to children. Some specific underlying causes do have a genetic basis — for example, cystic fibrosis (covered separately), primary ciliary dyskinesia (usually autosomal recessive), and alpha-1 antitrypsin deficiency — and in those situations genetic counseling and partner testing are worthwhile before pregnancy.
Keep up airway clearance. Daily airway clearance remains important during pregnancy and is safe to continue. Maintaining lung health lowers the chance of exacerbations that could affect both you and the baby.
Review your medications with your team before and during pregnancy. Some bronchiectasis treatments need a risk-benefit discussion in pregnancy: long-term macrolides such as azithromycin, and inhaled antibiotics (tobramycin, colistin, aztreonam), are used selectively and only when the benefit outweighs potential risks. Brensocatib (Brinsupri) is new, and human pregnancy safety data are limited — discuss whether to continue, pause, or adjust it with your specialist; do not stop or start any medication on your own.
Exacerbations in pregnancy. Pulmonary exacerbations should still be treated promptly; many antibiotics are compatible with pregnancy, while a few (e.g., certain fluoroquinolones and tetracyclines) are usually avoided — your team will choose pregnancy-appropriate options.
Plan as a team. If your bronchiectasis is moderate or severe, a pulmonologist and a maternal-fetal medicine (high-risk obstetrics) specialist should co-manage the pregnancy, with attention to lung function and oxygenation.
Questions to ask your doctor:
Could my bronchiectasis be from an inherited cause, and would genetic counseling help before pregnancy?
Which of my medications should continue, pause, or change during pregnancy — including brensocatib, macrolides, and inhaled antibiotics?
How will my lung function be monitored, and who should be on my care team?
What is the safest plan for treating an exacerbation if one happens while I am pregnant?
Clinical Trials
After decades of neglect, bronchiectasis research is experiencing a renaissance. Multiple new therapies are in clinical trials, and the approval of brensocatib has opened the door for further drug development.
Trial
Agent(s)
Population
NCT Number / Notes
ASPEN (pivotal)
Brensocatib (DPP1 inhibitor)
Non-CF bronchiectasis with history of exacerbations
Various anti-inflammatory, mucoactive, and antibiotic agents
Non-CF bronchiectasis
Search ClinicalTrials.gov for “bronchiectasis non-CF” and filter by “recruiting”
Note on NCT numbers: The NCT numbers listed above have been verified where possible. For trials where status may have changed, always verify current status on ClinicalTrials.gov before making treatment decisions.
These bronchiectasis trials were listed as recruiting on ClinicalTrials.gov as of July 2026. Status changes often — confirm before contacting a site.
Nebulized CSL787 — a dose-finding, efficacy and safety study in adults with non-CF bronchiectasis (NCT07048262).
Two antibiotic regimens for early Pseudomonas — comparing eradication strategies at first airway infection in adults with bronchiectasis (NCT06368804).
Hypertonic saline before physiotherapy — testing nebulized hypertonic saline before the ELTGOL airway-clearance technique (NCT06443658).
ClinicalTrials.gov: Search “bronchiectasis” and filter by recruiting status and location
EMBARC (European Multicentre Bronchiectasis Audit and Research Collaboration): A registry and research network connecting patients with trials across Europe
Bronchiectasis Research Registry (US): COPD Foundation-supported registry connecting patients with research opportunities
Your pulmonologist: Academic centers often run trials not widely advertised. Ask directly.
International Access & Regulatory Landscape
Drug availability for bronchiectasis varies significantly by country. Some treatments available in one region may not be approved in another.
Treatment
US FDA
EMA (Europe)
NICE (UK)
Notes
Brensocatib (Brinsupri)
Approved Aug 2025
Approved Nov 2025 (25 mg)
MHRA under review
First disease-specific approval for non-CF bronchiectasis (US then EU)
Inhaled colistin (Promixin)
Not approved for bronchiectasis
Available (off-label, guideline-supported)
BTS-recommended
More widely used in Europe and UK than in US
Inhaled tobramycin (TOBI)
Approved for CF only; off-label in bronchiectasis
Off-label
Off-label
Widely used despite no bronchiectasis-specific approval
Mannitol (Bronchitol)
Not approved for bronchiectasis
Approved (some countries)
Available
Approved in Australia for bronchiectasis
Long-term azithromycin
Off-label (guideline-supported)
Off-label (guideline-supported)
BTS-recommended
No specific approval, but universally used per guidelines
ERS (European Respiratory Society): Published the 2017 Guidelines for the Management of Adult Bronchiectasis — the most comprehensive international guideline
BTS (British Thoracic Society): Published 2019 Guidelines for Bronchiectasis in Adults — widely used in the UK and Commonwealth countries
CHEST (American College of Chest Physicians): Published 2024 Expert Panel Report on bronchiectasis management
Thoracic Society of Australia and New Zealand (TSANZ): Active in bronchiectasis research, particularly in Indigenous populations
EMBARC: European Multicentre Bronchiectasis Audit and Research Collaboration — international registry and research network
Failed & De-Adopted Therapies
Understanding what has not worked in bronchiectasis is important for avoiding ineffective or harmful treatments.
HARMFUL IN NON-CF BRONCHIECTASIS Dornase alfa is highly effective in cystic fibrosis, but a randomized trial in non-CF bronchiectasis (O'Donnell et al., AJRCCM 1998) showed that it worsened lung function and increased exacerbation rates compared to placebo. ERS 2017 strongly recommends against its use in non-CF bronchiectasis. This is one of the clearest examples of why CF and non-CF bronchiectasis must be managed differently.
MIXED RESULTS Two large randomized controlled trials of inhaled colistimethate sodium (Promixin, given via the I-neb device) in bronchiectasis with Pseudomonas had different results (published in The Lancet Respiratory Medicine, 2024). PROMIS-I was positive — it significantly reduced how often people had exacerbations and improved quality of life. PROMIS-II was stopped early during the COVID-19 pandemic and did not repeat that result. Because the benefit was not confirmed in both trials, inhaled colistin is not FDA-approved for bronchiectasis; however, BTS 2019 guidelines and clinical experience still support inhaled antibiotics for selected patients with chronic Pseudomonas and frequent exacerbations.
NOT RECOMMENDED ROUTINELY Inhaled corticosteroids (ICS) have not been shown to reduce exacerbations or slow progression in bronchiectasis without coexisting asthma. They increase the risk of respiratory infections (including NTM and Pseudomonas). Both ERS 2017 and BTS 2019 recommend against routine ICS use in bronchiectasis unless there is a clear asthma or eosinophilic component.
INADEQUATE Treating bronchiectasis exacerbations with 5–7 day antibiotic courses (as used in typical community-acquired pneumonia) is inadequate. BTS 2019 recommends a minimum of 14 days. Shorter courses are associated with treatment failure and faster relapse. If you are prescribed a short course, ask your doctor whether 14 days would be more appropriate.
Why this matters: If someone suggests dornase alfa, routine inhaled steroids, or short antibiotic courses, you now know the evidence. Always ask your pulmonologist: “Is this recommended specifically for non-CF bronchiectasis, or is it borrowed from another condition?”
Is there a clinical trial I could join?
Am I a candidate for brensocatib?
If I have recurrent hemoptysis, should I see an interventional radiologist?
Should I be referred for transplant evaluation?
Is my disease localized enough to consider surgery?
Are there any new treatments on the horizon for my specific situation?
Specialty Centers
Bronchiectasis outcomes are better when managed by pulmonologists with specific experience in this condition. Academic centers with dedicated airway disease or bronchiectasis programs offer more comprehensive care, including access to clinical trials, respiratory physiotherapy, and multidisciplinary management.
No endorsement. Listing a center here does not constitute an endorsement or recommendation. Trouvera has no financial relationship with any medical center listed unless explicitly disclosed. Patients should evaluate centers based on their own needs and in consultation with their medical team.
University of Utah — Pulmonary Division
Academic pulmonary program within the University of Utah Health system
Location: 26 S 2000 E, Salt Lake City, UT 84112 Phone: 801-581-2121 Programs: Pulmonary medicine, airway disease management, bronchiectasis care, pulmonary function testing, respiratory physiotherapy referrals. Affiliated with Huntsman Cancer Institute (HCI) for complex cases.
Intermountain Health — Respiratory Services
Integrated nonprofit health system with comprehensive pulmonary services across Utah
Phone: 801-442-2000 Services: Pulmonary medicine, pulmonary rehabilitation, respiratory therapy, bronchiectasis management. Multiple locations across the Intermountain West.
Primary Children’s Hospital
Location: 100 N Mario Capecchi Dr, Salt Lake City, UT 84113 Phone: 801-662-1000 Programs: Pediatric pulmonary medicine. Evaluation of childhood-onset bronchiectasis, primary ciliary dyskinesia, and immune deficiency-related lung disease.
National Jewish Health
Location: 1400 Jackson St, Denver, CO 80206 Phone: 800-222-5864 Programs: One of the nation’s leading centers for complex lung disease. Dedicated bronchiectasis and NTM programs. Multidisciplinary airway clearance clinic. Clinical trials.
Why it matters. National Jewish Health is widely considered the premier US center for complex airway diseases including bronchiectasis, NTM, and primary ciliary dyskinesia. Located in Denver, it is the closest nationally recognized bronchiectasis referral center for Mountain West patients.
How to choose.National Jewish Health = nationally recognized complex airway disease center with dedicated bronchiectasis/NTM programs. University of Utah = academic pulmonary program with broad specialist access. Intermountain = extensive community network with pulmonary rehab at multiple locations.
Information verified May 2026. Availability changes — confirm with each institution directly.
National Jewish Health
Location: Denver, CO · Phone: 800-222-5864
Premier US center for bronchiectasis. Dedicated NTM program. Multidisciplinary airway clearance clinic. Extensive clinical trial portfolio.
Mayo Clinic
Location: Rochester, MN · Phone: 507-538-3270
Comprehensive pulmonary program with bronchiectasis expertise. Integrated diagnostics and treatment planning.
Cleveland Clinic — Respiratory Institute
Location: Cleveland, OH · Phone: 216-444-6503
Large pulmonary program with bronchiectasis and NTM expertise. Pulmonary rehabilitation. Clinical trials.
Duke University Medical Center
Location: Durham, NC · Phone: 919-684-8111
Pulmonary and critical care division with bronchiectasis research. NTM treatment program.
University of North Carolina at Chapel Hill
Location: Chapel Hill, NC · Phone: 984-974-2071
Marsico Lung Institute. Strong mucociliary clearance research. PCD diagnostic center.
Stanford University Medical Center
Location: Stanford, CA · Phone: 650-723-6381
Pulmonary medicine division with bronchiectasis expertise. Lung transplant program for end-stage disease.
George E. Wahlen VA Medical Center
Location: Salt Lake City, UT Phone: 801-582-1565 Services: Pulmonary medicine with hematology-oncology and respiratory therapy services. Partnership with University of Utah for specialist referrals.
VA Pulmonary Care Network
The VA system provides pulmonary care through its network of medical centers. Veterans with bronchiectasis should ask about:
Referral to a pulmonary specialist experienced with bronchiectasis
Community care authorization for evaluation at academic centers (such as National Jewish Health)
Pulmonary rehabilitation programs
Clinical trial access through VA-academic partnerships
VA Community Care: 1-877-881-7618
St. Michael’s Hospital / Unity Health Toronto
Location: Toronto, ON Phone: 416-864-5631 Programs: Dedicated bronchiectasis clinic. Active EMBARC participation. Clinical trials.
University of British Columbia — Centre for Heart Lung Innovation
Location: Vancouver, BC Phone: 604-806-8346 Programs: Airway disease research. Bronchiectasis and NTM management. Clinical trials.
McGill University Health Centre
Location: Montréal, QC Phone: 514-934-1934 Programs: Respiratory medicine with bronchiectasis expertise.
International Centers of Excellence for Bronchiectasis
Royal Brompton Hospital, London, UK: One of the world’s leading bronchiectasis centers. Home of the EMBARC network. Extensive clinical trials.
University of Dundee, Scotland: Major bronchiectasis research center (Professor James Chalmers). EMBARC leadership. WILLOW and ASPEN trial leadership.
Hospital Clínic de Barcelona, Spain: Leading bronchiectasis and NTM research center in Southern Europe.
Galway University Hospital, Ireland: Active bronchiectasis research program within EMBARC network.
Concord Repatriation General Hospital, Sydney, Australia: Bronchiectasis Toolbox project. Leading Australian bronchiectasis research.
Menzies School of Health Research, Darwin, Australia: Indigenous bronchiectasis research. World-leading pediatric bronchiectasis expertise.
Caregiver Guidance
Caring for someone with bronchiectasis involves supporting a daily routine that can feel monotonous but is genuinely life-sustaining. The single most important thing a caregiver can do is help maintain consistency with airway clearance.
Help make it routine. Airway clearance should happen at the same time every day — typically morning and sometimes evening. Build it into the daily schedule like any other essential activity.
Learn the technique. Attend physiotherapy sessions with the patient so you understand what they are supposed to be doing. Some techniques (postural drainage) may need a helper.
Keep equipment clean. Nebulizers and PEP devices must be cleaned after every use to prevent contamination. Follow manufacturer instructions.
Track sputum changes. Learn what the patient’s normal sputum looks like (volume, color, consistency). Changes may signal an exacerbation.
Chronic illness fatigue is real. Bronchiectasis is not life-threatening in the short term for most patients, but the daily burden of treatment, the chronic cough, and the unpredictability of exacerbations take a psychological toll.
Do not dismiss the cough. Chronic productive cough is socially isolating. Patients often avoid social situations because of embarrassment. Acknowledge this and help find social activities that accommodate their needs.
Encourage, do not nag. Adherence to daily treatment is difficult. Gentle encouragement is more effective than criticism.
Support groups exist: COPD Foundation Bronchiectasis and NTM Initiative, online communities through HealthUnlocked (BLF Bronchiectasis group), and NTM Info & Research.
Medication Dosing Quick Reference
These are the doses named in the ERS 2017/2025, BTS 2019, and CHEST 2024 guidelines and in the FDA prescribing information (per label). They are here so you can recognize and check what you are prescribed — not so you can self-adjust. Never change a dose without your team. Verify every number against the current label or your pharmacist.
Medication
Usual Adult Dose
Purpose / Source
Brensocatib (Brinsupri)
10 mg or 25 mg by mouth once daily
Reduce exacerbations (FDA label, Aug 2025; ASPEN trial)
Azithromycin (long-term)
250 mg or 500 mg three times weekly (Mon/Wed/Fri)
Prevent exacerbations (EMBRACE/BAT trials; ERS 2017)
Erythromycin (long-term)
400 mg twice daily
Prevent exacerbations (BLESS trial, JAMA 2013)
Ciprofloxacin (oral)
500 mg or 750 mg twice daily for 14 days
Pseudomonas exacerbation / eradication (BTS 2019)
Amoxicillin (oral)
500 mg three times daily for 14 days
Non-Pseudomonas exacerbation (BTS 2019)
Co-amoxiclav (oral)
625 mg three times daily for 14 days
Exacerbation, beta-lactamase producers (BTS 2019)
Doxycycline (oral)
100 mg twice daily
Exacerbation alternative (guideline-supported)
Inhaled tobramycin (TOBI)
300 mg nebulized twice daily, 28 days on / 28 off
Chronic Pseudomonas suppression (off-label; ERS 2017)
Osmotic mucoactive (not FDA-approved for bronchiectasis)
Salbutamol / albuterol
200–400 mcg inhaled before saline/inhaled antibiotics
Prevent bronchospasm (BTS 2019)
Clarithromycin (oral)
500 mg twice daily for 14 days
Exacerbation alternative macrolide (BTS 2019)
Levofloxacin (oral)
500 mg once daily for 14 days
Alternative anti-Pseudomonal fluoroquinolone
Flucloxacillin (oral)
500 mg four times daily
Staph aureus (MSSA) exacerbation (BTS 2019)
IV ceftazidime
2 g three times daily for 14 days
Severe Pseudomonas exacerbation (BTS 2019)
IV piperacillin-tazobactam
4.5 g four times daily
Severe Pseudomonas exacerbation
IV meropenem
1–2 g three times daily
Severe / resistant Pseudomonas
Tranexamic acid
500 mg three times daily (oral); 500 mg nebulized (off-label)
Reduce hemoptysis bleeding (specialist-directed)
Doses shown are typical adult starting points from the cited guideline or FDA label; your actual dose may differ based on kidney function, other medicines, and culture results.
Script — checking a new prescription. Ask: "Can you write down the exact drug, dose, and how many days I take it — and tell me which guideline or trial this dose comes from?"
⚠️ Numeric monitoring and stop rules — know the thresholds. These are the specific numbers at which a treatment is usually paused, changed, or stopped. They are your team's decisions, but you should recognize them:
Long-term azithromycin — stop rule: discontinue if an NTM (AFB) culture turns positive while on macrolide monotherapy; discontinue if the QTc on ECG becomes significantly prolonged, or if you develop new hearing loss or ringing in the ears (FDA azithromycin label). Sputum AFB cultures are repeated every 6–12 months as a monitoring rule.
Inhaled antibiotic — stop rule: the supervised first dose is abandoned and the drug switched if your FEV1 falls more than 15% or you get bronchospasm despite a bronchodilator.
Macrolide trial period: if there is no meaningful drop in flare-ups after a 6–12 month trial period, the drug is reassessed rather than continued indefinitely.
Hemoptysis — emergency threshold: more than roughly 300 mL of blood in 24 hours (or any lightheadedness/breathlessness with bleeding) is a when-to-stop-everything emergency — call 911.
Aminoglycoside (tobramycin/gentamicin) monitoring: audiometry and kidney function are checked periodically; report any hearing change so the drug can be stopped before damage becomes permanent.
Cost of Treatment & Financial Help
Money is one of the first real barriers patients hit. Below are approximate US prices as of July 2026 so you can plan and ask the right questions. Cash prices are GoodRx-style estimates that vary by pharmacy and ZIP code; brand list prices are the manufacturer's announced figures. Confirm your own out-of-pocket cost with your pharmacy and insurer.
Item
Approximate US Cost
Notes / Help
Brensocatib (Brinsupri)
~$88,000 per year list price (WAC, Insmed, Aug 2025)
Specialty pharmacy; prior authorization expected. Insmed copay assistance for commercial insurance; foundation route for Medicare/uninsured. ICER judged a cost-effective price to be $3,100–$3,700 per year (ICER final report, 2025).
Azithromycin (generic)
~$10–$25 cash per month
Very low cost; nearly always covered. Off-label but guideline-supported.
Ciprofloxacin (generic)
~$4–$15 for a 14-day course
On many $4 retail generic lists.
Amoxicillin / co-amoxiclav (generic)
~$4–$20 per course
Standard covered generics.
Inhaled tobramycin (generic solution)
~$300–$315 cash per 28-day cycle; brand TOBI several thousand dollars
Not FDA-approved for bronchiectasis in US; access varies.
Oscillating PEP device (Aerobika, Acapella, Flutter)
~$30–$80 one-time
Often covered as durable medical equipment (DME) with a prescription.
High-frequency chest wall oscillation vest
~$10,000–$15,000 (usually insurance-covered)
Requires documentation of need; appeals common. Rental sometimes available.
Nebulizer machine
~$50–$200
Covered as DME with prescription in most plans.
Hypertonic saline (7%)
~$40–$90 per month of nebules
Often covered; ask for a prescription rather than buying retail.
Pulmonary rehabilitation
~$30–$60 per session copay (often covered)
Medicare and most insurers cover a course for qualifying patients.
Ask about manufacturer patient-assistance programs. For brand drugs like brensocatib (Insmed) and TOBI (Novartis), copay cards can drop a $88,000 brand to a small monthly copay for eligible commercially insured patients; separate foundations help Medicare/uninsured patients.
Use the cheapest effective generic. Long-term azithromycin at ~$10–$25 per month and generic ciprofloxacin at ~$4–$15 per course carry most of the benefit for a tiny fraction of the cost of newer agents.
Get devices billed as DME. PEP devices (~$30–$80) and vests (~$10,000–$15,000) are often covered when your pulmonologist documents medical need. Appeal a denial — approvals on second review are common.
Compare cash vs insurance. For cheap generics the GoodRx cash price is sometimes lower than your copay.
Script — the cost conversation. Ask: "This medication is expensive — is there a lower-cost generic that works as well, and can your office help me apply for the manufacturer copay or patient-assistance program?"
How Your Treatments Work Together
Bronchiectasis treatments are not a random pile of pills and devices — they are designed to reinforce each other. Doing them in the right order and combination is where the real, compounding benefit comes from.
Bronchodilator → hypertonic saline → airway clearance → inhaled antibiotic. This sequence is a deliberate synergy: the bronchodilator (albuterol) opens the airways and prevents bronchospasm; nebulized 7% hypertonic saline then hydrates the mucus; airway clearance physically moves the loosened mucus out; and the inhaled antibiotic finally lands on cleared airway walls instead of being trapped in mucus. Each step amplifies the next — done out of order, the antibiotic is wasted.
Airway clearance + treating the underlying cause. Clearing mucus lowers the daily bacterial load, while fixing a treatable cause (immunoglobulin replacement for immune deficiency, steroids for ABPA) removes the driver. The combined effect slows the vicious cycle from both directions.
Macrolide + brensocatib — complementary anti-inflammatory action. Long-term azithromycin and brensocatib both calm neutrophil-driven inflammation but by different mechanisms (macrolide immunomodulation vs DPP-1 blockade of neutrophil serine proteases). For selected patients with frequent exacerbations they can be stacked on top of airway clearance for an additive reduction in flare-ups — a decision for your specialist, after NTM has been ruled out.
Vaccination + exacerbation action plan. Vaccines lower the chance of a viral trigger; a written action plan with a standby antibiotic shortens the time to treatment when a flare does start. Together they cut both the frequency and the severity of exacerbations.
Script — getting the sequence right. Ask: "In what order should I do my inhalers, saline, and airway clearance each day so they work together instead of against each other?"
What Changed in the 2025 Guideline
For eight years the main international rulebook was the ERS 2017 guideline. In December 2025 the European Respiratory Society published a full update — the first since 2017 — incorporating trials completed in the intervening years (Chalmers JD, et al. European Respiratory Society guideline for management of adult bronchiectasis. Eur Respir J. 2025;66(6):2501126; clinical summary in Breathe. 2026;22(2):260001).
"Do the simple things well." The 2025 guideline re-centers care on identifying the underlying cause, daily airway clearance, and pulmonary rehabilitation for anyone with reduced exercise capacity — before reaching for expensive add-ons.
Long-term macrolides and inhaled antibiotics remain the backbone for patients at high risk of exacerbations, with the same NTM-first safety rule.
A new approved drug in the landscape. The update arrives alongside brensocatib's 2025 approval, giving clinicians a disease-specific anti-inflammatory option for the first time.
Phenotyping matters. The guideline and recent research push toward matching treatment to the patient's inflammatory type — including the eosinophilic phenotype described below.
If a treatment recommendation you were given predates 2025, it is reasonable to ask whether the newer guideline changes anything for you.
The Eosinophilic Phenotype
Not all bronchiectasis inflammation is the same. Most is driven by neutrophils, but a meaningful minority of patients have eosinophilic inflammation — and that distinction changes what helps them.
What it is: A simple blood test (part of a complete blood count) reports your blood eosinophil count. A European multicohort study found that roughly a fifth of bronchiectasis patients have a raised blood eosinophil count of 300 cells per microliter or more, which was linked to distinct airway bacteria and higher exacerbation risk (Shoemark A, et al. Am J Respir Crit Care Med. 2022;205(8):894–902).
Why it changes treatment: Inhaled corticosteroids (ICS) are not routinely recommended in bronchiectasis and can raise infection risk — but in the eosinophilic subgroup they may actually help. Analyses suggest a blood eosinophil percentage of about 3% or higher predicts who benefits from ICS.
The takeaway: If you have been put on or taken off an inhaled steroid, your eosinophil count is a relevant, testable number to discuss — not a guess.
Script — eosinophilic phenotype. Ask: "What is my blood eosinophil count, and does it mean an inhaled steroid is more likely to help me or more likely to just raise my infection risk?"
Scripts for Key Appointments
One appendix of ready-to-use, word-for-word questions. Bring the ones that match where you are. They are phrased to open a conversation, never to instruct your team.
Ask: "Has a high-resolution CT scan confirmed this, and how many lobes are involved?"
Ask: "Have you sent immunoglobulins, ABPA testing, and AFB cultures for NTM to look for a treatable cause?"
Ask: "What does my sputum culture grow, and is Pseudomonas present?"
Ask: "Can you refer me to a respiratory physiotherapist to learn airway clearance properly?"
Ask: "Have you ruled out NTM with AFB cultures before starting me on daily or three-times-weekly azithromycin?"
Ask: "Have you checked a baseline ECG for my QT interval before I start a macrolide?"
Ask: "If my cultures grow Pseudomonas, should we try to eradicate it now, and can my first inhaled-antibiotic dose be supervised in clinic?"
Ask: "Given how often I flare, am I a candidate for brensocatib on top of my current treatment?"
Ask: "What is my blood eosinophil count, and does it change whether an inhaled steroid would help me?"
Ask: "Does the 2025 guideline update change anything about my current plan?"
Ask: "Can we write a flare action plan with the exact antibiotic, dose, and a full 14-day course, plus when to call versus go to the ER?"
Ask: "If I cough up more than a tablespoon of fresh blood, do I call 911 and is bronchial artery embolization the plan?"
Ask: "Is there a lower-cost generic, and can your office help me apply for manufacturer copay assistance?"
Glossary
ABPA
Allergic bronchopulmonary aspergillosis. An allergic reaction to the Aspergillus fungus that can cause or worsen bronchiectasis. Treatable with steroids and antifungals.
ACBT
Active cycle of breathing technique. A physiotherapy technique combining relaxed breathing, deep breathing, and huffing to clear mucus from the airways.
Airway clearance
Techniques and devices used to physically remove mucus from the lungs. The foundation of bronchiectasis management.
Brensocatib (Brinsupri)
The first FDA-approved treatment for non-CF bronchiectasis. A DPP1 inhibitor that reduces neutrophil-driven airway damage.
Bronchiectasis
A chronic lung condition where airways become permanently widened and damaged, leading to mucus buildup, infection, and inflammation.
BSI
Bronchiectasis Severity Index. A validated scoring system that predicts future hospitalization and mortality risk.
Colonization
When bacteria are persistently present in the airways without necessarily causing an active infection. Common in bronchiectasis.
CVID
Common variable immunodeficiency. An immune deficiency that can cause recurrent infections and bronchiectasis. Treatable with immunoglobulin replacement.
DPP1
Dipeptidyl peptidase 1 (also called cathepsin C). An enzyme that activates neutrophil serine proteases. The target of brensocatib.
Exacerbation
A flare-up: worsening of bronchiectasis symptoms (increased sputum, breathlessness, fever) beyond day-to-day variation, requiring treatment change.
FEV1
Forced expiratory volume in 1 second. The most important lung function measurement to track over time in bronchiectasis.
Hemoptysis
Coughing up blood. Common in bronchiectasis. Massive hemoptysis is a medical emergency.
HRCT
High-resolution computed tomography. The gold-standard imaging test for diagnosing bronchiectasis.
Macrolide
A class of antibiotics (azithromycin, erythromycin) that have both antimicrobial and anti-inflammatory properties. Used long-term to reduce exacerbations.
Neutrophil
A type of white blood cell that fights infection. In bronchiectasis, neutrophils also cause airway damage through release of destructive enzymes.
NTM
Nontuberculous mycobacteria. Environmental bacteria (especially MAC) that can infect the lungs, particularly in bronchiectasis patients.
Oscillating PEP
Oscillating positive expiratory pressure. A device (Aerobika, Acapella, Flutter) that creates vibrations during exhalation to loosen mucus.
PCD
Primary ciliary dyskinesia. A genetic condition affecting cilia, causing impaired mucus clearance and bronchiectasis.
Pseudomonas aeruginosa
A bacterium that commonly colonizes the airways of bronchiectasis patients. Associated with worse outcomes and more frequent exacerbations.
Sputum
Mucus coughed up from the lungs. Regular sputum cultures identify which bacteria are present and which antibiotics will work.
Vicious cycle
The self-reinforcing cycle of airway damage, mucus retention, infection, and inflammation that characterizes bronchiectasis.
Sources and Further Reading
This guide draws on published medical literature, clinical trial records, and international guideline recommendations. Key sources are listed below.
ClinicalTrials.gov (clinicaltrials.gov) — Authoritative registry of clinical trials
COPD Foundation — Bronchiectasis and NTM Initiative (copdfoundation.org/BE) — Patient education and research registry
EMBARC (bronchiectasis.eu) — European Multicentre Bronchiectasis Audit and Research Collaboration
American Lung Association (lung.org) — Patient education resources
NTM Info & Research (ntminfo.org) — Resources for NTM coinfection
Key Guideline and Trial References
ERS 2017: Polverino E, Goeminne PC, McDonnell MJ, et al. European Respiratory Society guidelines for the management of adult bronchiectasis. Eur Respir J. 2017;50(3):1700629.
BTS 2019: Hill AT, Sullivan AL, Chalmers JD, et al. British Thoracic Society Guideline for bronchiectasis in adults. Thorax. 2019;74(Suppl 1):1–69.
CHEST 2024: Metersky ML, Aksamit TR, Barker A, et al. CHEST Expert Panel Report on the management of bronchiectasis in adults. Chest. 2024.
ASPEN Trial: Chalmers JD, et al. Phase 3 trial of brensocatib in bronchiectasis. (NCT04594369)
WILLOW Trial: Chalmers JD, Haworth CS, Metersky ML, et al. Phase 2 trial of the DPP-1 inhibitor brensocatib in bronchiectasis. N Engl J Med. 2020;383(22):2127–2137. (NCT03218917)
EMBRACE: Wong C, Jayaram L, Karalus N, et al. Azithromycin for prevention of exacerbations in non-cystic fibrosis bronchiectasis. Lancet. 2012;380(9842):660–667.
BAT: Altenburg J, de Graaff CS, Stienstra Y, et al. Effect of azithromycin maintenance treatment on infectious exacerbations among patients with non-cystic fibrosis bronchiectasis. JAMA. 2013;309(12):1251–1259.
BLESS: Serisier DJ, Martin ML, McGuckin MA, et al. Effect of long-term, low-dose erythromycin on pulmonary exacerbations among patients with non-cystic fibrosis bronchiectasis. JAMA. 2013;309(12):1260–1267.
ERS 2025 (updated guideline): Chalmers JD, Aliberti S, Polverino E, et al. European Respiratory Society guideline for the management of adult bronchiectasis. Eur Respir J. 2025;66(6):2501126. Clinical summary: Breathe (Sheff). 2026;22(2):260001.
ASPEN (full results): Chalmers JD, et al. Phase 3 trial of the DPP-1 inhibitor brensocatib in bronchiectasis. N Engl J Med. 2025 (doi:10.1056/NEJMoa2411664). (NCT04594369)
Brensocatib FDA approval: Insmed. FDA approves BRINSUPRI (brensocatib) as the first treatment for non-cystic fibrosis bronchiectasis. Press release, August 12, 2025. See FDA prescribing information (per label) for dosing and monitoring.
Cost-effectiveness: Institute for Clinical and Economic Review (ICER). Brensocatib for non-cystic fibrosis bronchiectasis: final evidence report. 2025 (estimated cost-effective price $3,100–$3,700 per year).
Eosinophilic phenotype: Shoemark A, Shteinberg M, De Soyza A, et al. Characterization of eosinophilic bronchiectasis: a European multicohort study. Am J Respir Crit Care Med. 2022;205(8):894–902.
PROMIS-I: Haworth CS, Shteinberg M, Winthrop KL, et al. Inhaled colistimethate sodium in patients with bronchiectasis and Pseudomonas aeruginosa infection (PROMIS-I). Lancet Respir Med. 2024. (NCT03093974)
NTM guideline: Daley CL, Iaccarino JM, Lange C, et al. Treatment of nontuberculous mycobacterial pulmonary disease: an official ATS/ERS/ESCMID/IDSA clinical practice guideline. Clin Infect Dis. 2020;71(4):e1–e36.
CHEST 2024: CHEST Expert Panel Report on the management of adult bronchiectasis. Chest. 2024.
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What This Guide Does Not Know
An honest guide names its own limits:
This guide cannot diagnose or treat anyone. It does not know your sputum cultures, lung function, exacerbation history, or underlying cause. Only your medical team can build an actual plan.
Bronchiectasis management is evolving. The approval of brensocatib is just the beginning. New treatments are in development. Every time-sensitive fact should be re-verified with your team and primary sources.
Drug approvals and availability vary by country. This guide focuses primarily on treatments available or under review in the United States. Access differs in Europe, the UK, Australia, and other regions.
This guide focuses on non-CF bronchiectasis. If you have cystic fibrosis, your treatment pathway is different and this guide does not apply.
NTM coinfection is complex. If you have NTM, your management requires specialized expertise beyond the scope of this guide. See an NTM specialist.
A final word. Bronchiectasis is a challenging condition that requires daily effort. But it is manageable. Most patients live full, active lives with appropriate treatment. The key is consistency: daily airway clearance, prompt exacerbation treatment, regular monitoring, and a good relationship with a pulmonologist who understands this disease. The approval of brensocatib in 2025 signals a new era of attention and investment in bronchiectasis. More treatments are coming. Stay informed. Stay active. And never stop clearing your airways.
Important Safety Information
Bronchiectasis is managed with inhaled therapies, antibiotics, and airway clearance. Key safety considerations include antibiotic resistance, drug interactions, and proper inhaler technique.
Hearing and kidney monitoring: Aminoglycoside antibiotics (tobramycin, amikacin) can cause hearing loss (ototoxicity) and kidney damage (nephrotoxicity), especially with prolonged use or high cumulative doses. Audiometry (hearing tests) and periodic kidney function tests are required with long-term inhaled aminoglycoside use. Report any ringing in the ears, hearing difficulty, or changes in urine output.
Antibiotic resistance: Long-term or repeated antibiotic courses can select for resistant bacteria, particularly in patients with Pseudomonas aeruginosa colonization. Respiratory cultures should be checked before and during antibiotic courses. Do not use inhaled antibiotics continuously without your pulmonologist's guidance; on-off cycling protocols (e.g., 28 days on / 28 days off) are used to reduce resistance development.
Bronchospasm: Inhaled antibiotics can cause bronchospasm (airway narrowing), especially on the first dose. Pre-treating with a short-acting bronchodilator (salbutamol/albuterol) before inhaled antibiotics reduces this risk.
QT prolongation (heart rhythm risk): Azithromycin and erythromycin can prolong the QT interval on the ECG and increase the risk of serious heart arrhythmias, particularly in patients who also take other QT-prolonging medications. An ECG and baseline QTc should be checked before starting. Report palpitations, dizziness, or near-fainting promptly.
Hearing changes: Long-term azithromycin is associated with rare hearing loss. Periodic audiometry is recommended. Report any new ringing in the ears or muffled hearing.
Non-tuberculous mycobacteria (NTM) risk: Macrolide antibiotics are the backbone of NTM treatment (e.g., Mycobacterium avium complex). Using azithromycin as a single agent for prophylaxis in a patient who actually has NTM infection risks selecting for macrolide-resistant NTM. Sputum culture to exclude NTM is recommended before starting long-term azithromycin for bronchiectasis.
Airway clearance devices and technique:
Oscillating positive expiratory pressure (OPEP) devices (Aerobika, Acapella, Flutter) and high-frequency chest wall oscillation (HFCWO) vests are physical devices, not drugs. They should be cleaned and maintained per manufacturer instructions to prevent contamination and reinfection.
Hypertonic saline (3%–7%) inhalation increases mucus clearance but can cause bronchoconstriction. A bronchodilator should be inhaled first. Start with lower concentrations and titrate up as tolerated.