European Respiratory Society Clinical Practice Guideline for the Management of Adult Bronchiectasis.

BACKGROUND Bronchiectasis is a common lung condition associated with wide range of infectious, immunological, autoimmune, allergic and genetic conditions. Exacerbations and daily symptoms have the largest impact on patients and healthcare systems, and they are the key focus of treatments. Current practice is heterogeneous globally, and bronchiectasis has historically been a neglected disease. Here, we present evidence-based international guidelines for the management of adults with bronchiectasis. METHODS A European Respiratory Society (ERS) Task Force, comprising global experts, a methodologist, and patient representatives, developed clinical practice guidelines in accordance with ERS methodology and the GRADE (Grading of Recommendations, Assessment, Development and Evaluations) approach. Systematic literature searches, data extraction, and meta-analysis were performed to generate evidence tables, and recommendations were formulated using the evidence-to-decision framework. A total of 8 PICO (Patient, Intervention, Comparator, Outcomes) questions and 3 narrative questions were developed. RECOMMENDATIONS The Task Force recommendations include strong recommendations in favour of airway clearance techniques for most patients with bronchiectasis and pulmonary rehabilitation for those with impaired exercise capacity. We issue a strong recommendation for the use of long-term macrolide treatment for patients at high risk of exacerbations and a strong recommendation in favour of long-term inhaled antibiotics in patients with chronic Pseudomonas aeruginosa infection at high risk of exacerbation. Conditional recommendations support the use of eradication treatment or mucoactive drugs in specific circumstances. We suggest not to routinely use long term oral, non-macrolide antibiotic treatment or inhaled corticosteroids. Additional guidance is also provided on testing for underlying causes, managing exacerbations, and managing the deteriorating patient. CONCLUSION The ERS bronchiectasis guidelines provide an evidence-based framework for optimal management of adults with bronchiectasis and serve as a benchmark for evaluating the quality of care. SCOPE AND OBJECTIVES The European Respiratory Society (ERS) guidelines for the management of bronchiectasis in adults provide evidence-based recommendations for the care of people with clinically significant bronchiectasis, defined by the presence of permanent dilatation of the bronchi evident on chest CT scan, along with characteristic clinical symptoms. [1] These guidelines are intended for all healthcare professionals involved in the care of adults with bronchiectasis, as well as for policymakers, regulatory authorities, and pharmaceutical companies. Bronchiectasis is a complex and heterogeneous disease; therefore, no guideline can be entirely comprehensive or replace clinical judgement. All guideline recommendations must be interpreted within the specific clinical context in which they are applied. Separate ERS guidelines for the management of bronchiectasis in children exist [2]. Bronchiectasis due to cystic fibrosis (CF) has a distinct evidence base; therefore, guidance for the management of CF is provided elsewhere. [3] Some bronchiectasis-associated conditions also have distinct guidelines for investigation and management, such as primary ciliary dyskinesia (PCD) [4], allergic bronchopulmonary aspergillosis (ABPA) [5] and non-tuberculous mycobacterial (NTM) pulmonary disease [6]. While the present guidelines apply for these conditions, they should be interpreted in conjunction with the relevant syndrome-specific recommendations.