Bronchiectasis AND Suppurative Lung Disease

The answer first

Non-cystic fibrosis bronchiectasis is a chronic suppurative airway disease defined radiologically by irreversible bronchial dilatation and clinically by a vicious cycle of impaired mucociliary clearance, microbial colonisation, neutrophilic airway inflammation, recurrent exacerbations, and progressive structural damage. [1] [2] The answer-first physician approach is to (1) confirm the diagnosis with high-resolution computed tomography (HRCT), (2) systematically search for an underlying and treatable cause, (3) quantify severity with the Bronchiectasis Severity Index (BSI) and FACED score, (4) deliver a sequenced plan combining airway clearance, anti-inflammatory macrolide therapy, microbiologically-guided antibiotics, and (5) prevent exacerbations and complications with vaccination and structured multidisciplinary follow-up. [1] [7]

For the FRACP candidate, bronchiectasis is a high-yield long case because it demands integration of upper airway disease (allergic bronchopulmonary aspergillosis, primary ciliary dyskinesia, immunodeficiency), lower airway infection (Pseudomonas aeruginosa, non-tuberculous mycobacteria, Haemophilus influenzae), and the physiology of chronic inflammation. The opening sentence must name the dominant phenotype ("a 58-year-old never-smoker with post-infectious bronchiectasis colonised with Pseudomonas and three exacerbations in the last year on long-term azithromycin") and the problem list must order threats first: recurrent septic exacerbations, progressive airflow obstruction, haemoptysis, and the reversible driver that, if untreated, will continue to drive airway destruction. [1] [13]

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1. [1]Hill AT, Sullivan AL, Chalmers JD, et al. British Thoracic Society Guideline for bronchiectasis in adults Thorax, 2019.PMID 30545985
2. [2]Polverino F, Goeminne PC, McDonnell MJ, et al. European Respiratory Society guidelines for the management of adult bronchiectasis Eur Respir J, 2017.PMID 28889110
3. [3]Chalmers JD, Haworth CS, Flume P, et al. European Respiratory Society clinical practice guideline for the management of adult bronchiectasis Eur Respir J, 2025.PMID 41016738
4. [4]Wong C, Jayaram L, Karalus N, et al. Azithromycin for prevention of exacerbations in non-cystic fibrosis bronchiectasis (EMBRACE): a randomised, double-blind, placebo-controlled trial Lancet, 2012.PMID 22901887
5. [5]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: the BLESS randomized controlled trial JAMA, 2013.PMID 23532242
6. [6]Altenburg J, de Graaff CS, Stienstra Y, et al. Effect of azithromycin maintenance treatment on infectious exacerbations among patients with non-cystic fibrosis bronchiectasis: the BAT randomized controlled trial JAMA, 2013.PMID 23532241
7. [7]Chalmers JD, Goeminne P, Aliberti S, et al. The bronchiectasis severity index. An international derivation and validation study Am J Respir Crit Care Med, 2014.PMID 24328736
8. [8]Chalmers JD, Aliberti S, Polverino E, et al. Pulmonary exacerbation in adults with bronchiectasis: a consensus definition for clinical research Eur Respir J, 2017.PMID 28596426
9. [9]Lee AL, Burge AT, Holland AE Airway clearance techniques for bronchiectasis Cochrane Database Syst Rev, 2015.PMID 26591003
10. [10]Haworth CS, Shteinberg M, Winthrop K, et al. Inhaled colistimethate sodium in patients with bronchiectasis and Pseudomonas aeruginosa infection: results of PROMIS-I and PROMIS-II, two randomised, double-blind, placebo-controlled phase 3 trials assessing safety and efficacy over 12 months Lancet Respir Med, 2024.PMID 39270696
11. [11]Agarwal R, Sehgal IS, Dhooria S, et al. Revised ISHAM-ABPA working group clinical practice guidelines for diagnosing, classifying and treating allergic bronchopulmonary aspergillosis/mycoses Eur Respir J, 2024.PMID 38423624
12. [12]McShane PJ Common Variable Immunodeficiency and Other Immunodeficiency Syndromes in Bronchiectasis Semin Respir Crit Care Med, 2021.PMID 34261177
13. [13]Chalmers JD, Polverino E, Crichton ML, et al. Bronchiectasis in Europe: data on disease characteristics from the European Bronchiectasis registry (EMBARC) Lancet Respir Med, 2023.PMID 37105206
14. [14]Chalmers JD, Burgel PR, Daley CL, et al. Phase 3 Trial of the DPP-1 Inhibitor Brensocatib in Bronchiectasis N Engl J Med, 2025.PMID 40267423