Common symptoms

Chronic productive cough — often daily, with large amounts of mucus (sputum)
Recurrent respiratory infections or pneumonias
Hemoptysis (coughing up blood) — ranging from blood-streaked sputum to significant bleeding
Shortness of breath, especially with exertion
Fatigue and reduced exercise tolerance
Wheezing or chest pain in some patients

Common causes

Post-infectious: Prior severe pneumonia, childhood infections, or tuberculosis
Cystic fibrosis: The most common genetic cause, though non-CF bronchiectasis is far more prevalent overall
Immune deficiency: Immunoglobulin deficiencies (e.g., common variable immunodeficiency) that predispose to recurrent infection
NTM infection: Nontuberculous mycobacteria can cause and worsen bronchiectasis
Allergic bronchopulmonary aspergillosis (ABPA): An allergic reaction to Aspergillus fungus
Autoimmune and connective tissue diseases: Rheumatoid arthritis, Sjögren syndrome
Ciliary dyskinesia: Primary ciliary dyskinesia (PCD) impairs mucociliary clearance
Idiopathic: In many patients no specific cause is identified despite thorough workup^[1]

Evaluation

How is bronchiectasis diagnosed?

A high-resolution CT scan of the chest is the gold standard for diagnosing bronchiectasis. It shows permanently dilated airways that fail to taper normally.^[1]

Imaging and pulmonary function

CT chest (HRCT): Shows bronchial dilation, airway wall thickening, and mucus plugging. The "signet ring sign" (dilated bronchus larger than its adjacent artery) is characteristic.
Spirometry: Often shows an obstructive pattern, though can be normal in early disease. Used to track disease progression.
Chest X-ray: May show "tram tracks" or ring shadows, but CT is far more sensitive.

Workup for underlying cause

Immunoglobulin levels (IgG, IgA, IgM, IgG subclasses)
Sputum cultures including mycobacterial (AFB) cultures to evaluate for NTM
Aspergillus IgE and IgG, total IgE (to screen for ABPA)
CF testing (sweat chloride, CFTR genetics) in younger patients or if clinically suspicious
Autoimmune markers if connective tissue disease is suspected
Alpha-1 antitrypsin level
Nasal nitric oxide or ciliary biopsy if primary ciliary dyskinesia is suspected^[1]

Treatment

Managing bronchiectasis

The goals of treatment are to reduce infections, clear mucus, slow disease progression, and improve quality of life. There is no cure, but consistent daily management makes a significant difference.^[1,2]

Airway clearance

Daily airway clearance is the cornerstone of bronchiectasis management. Techniques include oscillating positive expiratory pressure (PEP) devices (Aerobika, Acapella, Flutter), high-frequency chest wall oscillation vests, active cycle of breathing, and postural drainage.
Hypertonic saline nebulization (3–7%) helps thin secretions and improve clearance. Often used before airway clearance therapy.
Mucolytics: Dornase alfa (Pulmozyme) is used in cystic fibrosis bronchiectasis but is generally not recommended in non-CF bronchiectasis.

Airway Clearance Techniques →

Medications

Antibiotics for exacerbations: Oral or IV antibiotics guided by sputum culture results. Common pathogens include Pseudomonas aeruginosa, Haemophilus influenzae, and Staphylococcus aureus.
Chronic suppressive antibiotics: Inhaled antibiotics (tobramycin, aztreonam) or chronic macrolide therapy (azithromycin 3 times weekly) may be used in patients with frequent exacerbations, especially if colonized with Pseudomonas.^[2]
Bronchodilators: Short- or long-acting inhaled bronchodilators for patients with airflow obstruction or reversibility.
Treating the underlying cause: Immunoglobulin replacement for immune deficiency, antifungal therapy for ABPA, NTM-specific antibiotic regimens.

Lifestyle and monitoring

Vaccines: Annual influenza, pneumococcal, COVID-19, and RSV vaccines are important given increased infection susceptibility.
Pulmonary rehabilitation: Improves exercise tolerance, reduces dyspnea, and helps with airway clearance. Learn more →
Sputum surveillance: Periodic sputum cultures (including AFB) help track colonizing organisms and guide antibiotic choices.
Monitoring: Regular spirometry, symptom tracking, and CT imaging at intervals to assess progression.
Hemoptysis management: Minor hemoptysis is common; massive hemoptysis may require bronchial artery embolization or, rarely, surgery.

Surgery

Surgical resection (lobectomy) is considered only in highly selected cases: localized bronchiectasis causing recurrent infections or significant hemoptysis that is not controlled by medical therapy.
Lung transplantation may be an option for end-stage bronchiectasis with progressive respiratory failure.

NTM Lung Disease

Nontuberculous mycobacteria (NTM) & MAI

NTM are environmental bacteria found in water and soil. Mycobacterium avium-intracellulare complex (MAC/MAI) is the most common NTM species causing pulmonary disease, especially in patients with underlying bronchiectasis or structural lung disease.^[3]

Who is at risk?

Patients with pre-existing bronchiectasis, COPD, or prior tuberculosis
Older adults, particularly thin women ("Lady Windermere syndrome" — nodular bronchiectatic NTM in the right middle lobe and lingula)
Immunocompromised patients (HIV/AIDS, organ transplant recipients, patients on immunosuppressive medications)
Cystic fibrosis patients
NTM is not contagious — it is acquired from the environment, not person-to-person^[3]

Diagnosis

Diagnosis requires meeting ATS/IDSA criteria: clinical symptoms, radiographic findings (nodular/bronchiectatic or cavitary disease on CT), and microbiologic confirmation^[3]
Microbiologic criteria: At least two positive sputum cultures on separate occasions, or one positive bronchoscopic wash/lavage, or a lung biopsy showing mycobacterial features with a positive culture
Cultures take 2–8 weeks to grow — patience is needed
Species identification and drug susceptibility testing guide treatment choices
Not all patients who culture NTM need treatment — the decision depends on symptoms, imaging progression, and the specific NTM species

Treatment of MAC/MAI

Multi-drug regimen: Standard treatment for MAC pulmonary disease is a three-drug combination: a macrolide (azithromycin or clarithromycin) + ethambutol + a rifamycin (rifampin or rifabutin)^[3]
Duration: Treatment continues for at least 12 months after sputum cultures convert to negative — total treatment duration is typically 15–20 months or longer
Dosing schedule: Three-times-weekly therapy may be used for nodular/bronchiectatic disease; daily therapy is used for cavitary or more severe disease
Inhaled amikacin (Arikayce): FDA-approved add-on for refractory MAC lung disease that does not respond to guideline-based therapy
Monitoring: Monthly sputum cultures during treatment, regular vision checks (ethambutol can cause optic neuritis), hepatic function, CBC

Challenges and what to expect

Side effects are common: GI upset, fatigue, drug interactions, hearing changes (macrolides), vision changes (ethambutol), liver toxicity (rifamycins), rash
Relapse and reinfection: Even after successful treatment, NTM can recur — either from the same strain (relapse) or a new environmental exposure (reinfection). Recurrence rates are approximately 25–50%^[3]
Treatment is not always necessary: For patients with stable, mild disease and minimal symptoms, watchful waiting with serial imaging and cultures may be appropriate
"Watch and wait": Some patients are monitored for years without treatment if the disease is not progressing
Multidisciplinary care: NTM treatment benefits from infectious disease and pulmonary specialist collaboration

Trusted resources

References

Hill AT, Sullivan AL, Chalmers JD, et al. British Thoracic Society guideline for bronchiectasis in adults. Thorax. 2019;74(Suppl 1):1-69. doi:10.1136/thoraxjnl-2018-212463
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. doi:10.1183/13993003.00629-2017
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. doi:10.1093/cid/ciaa241

Bronchiectasis & NTM Lung Disease