Bronchiectasis: Symptoms, Types, Causes and Treatment

Bronchiectasis is a chronic respiratory condition that can dramatically impact a person's quality of life. Once considered rare, it is now increasingly recognized worldwide as a common cause of persistent cough and recurrent chest infections. Whether you are a patient, caregiver, or simply curious, understanding bronchiectasis—from its telltale symptoms to its underlying causes and treatment options—can empower better health decisions. This comprehensive guide brings together the latest research to help you navigate the complexities of this condition.

Symptoms of Bronchiectasis

Bronchiectasis presents with a constellation of symptoms that often develop gradually, making early diagnosis challenging. Recognizing these symptoms is crucial for timely intervention and management.

Symptom	Frequency/Prevalence	Notable Features	Sources
Chronic cough	Nearly all patients	Persistent, often productive of sputum	1 2 3 5 14
Sputum production	80–98%	Purulent, daily, can be large in volume	1 2 5 14
Fatigue	62–74%	Can be severe, affecting daily life	2 4
Dyspnea (breathlessness)	60–62%	Worsens with exertion or infection	2 5 14
Crackles (on chest exam)	70%+	Often bi-basal, detected with stethoscope	1 2
Hemoptysis (coughing blood)	15–37%	Can range from mild to severe	1 14
Exacerbations	Most patients	Worsening symptoms, often needing antibiotics	5 14
Anxiety/Depression	20–38%	Linked with poorer quality of life	4

Table 1: Key Symptoms

Chronic Cough and Sputum Production

The most consistent and defining symptom of bronchiectasis is a chronic cough, almost always accompanied by daily sputum production. Patients often report coughing up thick, purulent mucus—sometimes for decades before diagnosis. The sputum can be copious and sometimes foul-smelling, indicating ongoing infection or inflammation in the airways. This symptom tends to persist, even when infections are not active, and typically worsens during exacerbations 1 2 3 5 14.

Fatigue and Breathlessness

Many patients experience significant fatigue, which may be overlooked but can severely impact daily functioning. Dyspnea, or shortness of breath, is also common, especially during physical activity or respiratory infections. These symptoms are related to impaired lung function and the chronic inflammation characteristic of bronchiectasis 2 4 14.

Physical Examination Findings

On physical examination, healthcare providers often detect crackles—particularly over the lower lobes—when listening to the lungs with a stethoscope. Wheezing can also be present, though less frequently 1 2.

Hemoptysis

Coughing up blood, or hemoptysis, occurs in a significant minority of patients. While it is usually mild, severe bleeding can occasionally occur, representing a medical emergency 1 14.

Exacerbations and Psychological Symptoms

Patients often suffer from recurrent "exacerbations"—acute worsening of symptoms such as increased cough, sputum volume or purulence, and sometimes fever. These episodes often require antibiotics and, in severe cases, hospitalization 5 14. Additionally, anxiety and depression are common and independently contribute to a lower quality of life 4.

Types of Bronchiectasis

Bronchiectasis is a heterogeneous disease, meaning it can appear in several different forms or "types," each with unique features, causes, and potential complications.

Type/Phenotype	Defining Features	Risk/Severity Profile	Sources
Cylindrical	Uniform, tube-like airway dilation	Most common, milder	9 7
Varicose	Irregular, beaded airway walls	Intermediate severity	9 7
Cystic (Saccular)	Ballooned, cyst-like dilations	Most severe, higher morbidity	9 7
Clinical Phenotypes	Daily sputum, chronic infection, "dry" (no sputum)	Vary in symptoms and prognosis	6 10 16
Etiological Subtypes	Post-infectious, immunodeficiency, ABPA, CF, idiopathic	Guide specific treatments	11 10

Table 2: Types and Phenotypes of Bronchiectasis

Radiological Types: Cylindrical, Varicose, and Cystic

Radiologists classify bronchiectasis based on the appearance of the airways on CT scans:

• Cylindrical: Airways appear uniformly widened, resembling tubes.
• Varicose: Airways show irregular narrowing and bulging, like varicose veins.
• Cystic (Saccular): Airways are ballooned into sacs or cysts, often representing advanced disease 9 7.

These types can coexist within the same patient, and severity often increases from cylindrical to cystic forms.

Clinical Phenotypes

Recent research has identified "clinical phenotypes"—groups of patients sharing similar clinical features or disease behavior:

• Daily Sputum Producers: Patients with persistent, daily sputum, often due to chronic infection.
• Chronic Infection Types: Especially with Pseudomonas aeruginosa or other pathogens, linked to more severe disease and frequent exacerbations.
• Dry Bronchiectasis: Patients with little or no sputum, sometimes with milder symptoms 6 10 16.

These phenotypes can predict the risk of exacerbations, hospitalizations, and overall prognosis.

Etiological Subtypes

Bronchiectasis may be categorized by cause, which can include:

• Post-infectious: Following severe pneumonia, tuberculosis, or childhood infections.
• Immunodeficiency-associated: Due to primary or secondary immune system disorders.
• Allergic Bronchopulmonary Aspergillosis (ABPA): Hypersensitivity to the fungus Aspergillus.
• Cystic Fibrosis-related: Genetic, most common in children and young adults.
• Idiopathic: No identifiable cause, common in adults 11 10.

Understanding the type and phenotype is critical for guiding treatment and predicting outcomes.

Causes of Bronchiectasis

Bronchiectasis is not a single disease, but rather a final common outcome of many different underlying processes that damage and permanently widen the airways.

Cause/Category	Common Examples/Details	Prevalence/Importance	Sources
Post-infectious	Pneumonia, tuberculosis, pertussis	Most common globally	1 12 14
Genetic	Cystic fibrosis, primary ciliary dyskinesia	Children/young adults	11 12
Immunodeficiency	CVID, IgG subclass deficiencies	Children/adults	3 11 14
Allergic/Inflammatory	ABPA, autoimmune diseases (RA, IBD)	Variable	3 11 13 14
Aspiration	Recurrent inhalation of food/fluid	Elderly, neurologic patients	9 11
Idiopathic	No cause found	Up to 50% of cases	2 11 14

Table 3: Causes of Bronchiectasis

Post-Infectious

The most common cause of bronchiectasis worldwide is damage from severe lung infections, such as pneumonia, tuberculosis, or whooping cough, especially when these occur in childhood. In regions with high rates of lung infections, post-infectious bronchiectasis predominates. This form remains common in developing countries and among older adults who had severe infections before the antibiotic era 1 12 14.

Genetic and Congenital Causes

• Cystic Fibrosis (CF): The most well-known genetic cause, particularly in children and young adults. CF-related bronchiectasis is characterized by thick, sticky mucus and recurrent infections.
• Primary Ciliary Dyskinesia (PCD): Rare, inherited disorders affecting ciliary function, leading to poor mucus clearance and recurrent infections 11 12.

Immunodeficiency

Both inherited (primary) and acquired (secondary) immune deficiencies can predispose to recurrent lung infections and bronchiectasis. Examples include common variable immunodeficiency (CVID), IgG subclass deficiencies, and HIV infection 3 11 14.

Allergic and Inflammatory Causes

• Allergic Bronchopulmonary Aspergillosis (ABPA): An exaggerated immune response to the fungus Aspergillus causes airway inflammation and damage.
• Autoimmune Disorders: Conditions like rheumatoid arthritis and inflammatory bowel disease can be associated with bronchiectasis due to chronic inflammation 11 13 14.

Aspiration and Miscellaneous Causes

Repeated inhalation (aspiration) of food, stomach acid, or fluids can injure the airways, especially in people with swallowing problems or neurologic disorders. Other less common causes include airway obstruction from tumors or foreign bodies, congenital structural abnormalities, and rare syndromes 9 11.

Idiopathic Bronchiectasis

Despite thorough testing, no cause is found in up to half of adult cases. This "idiopathic" bronchiectasis remains an area of active research, with some evidence suggesting subtle genetic, immune, or environmental factors may play a role 2 11 14.

Treatment of Bronchiectasis

Effective management of bronchiectasis focuses on relieving symptoms, reducing exacerbations, treating infections, and improving quality of life. Treatment strategies are individualized, often involving multiple approaches.

Treatment Approach	Purpose/Effect	Indications	Sources
Airway Clearance	Remove mucus, reduce infection risk	All patients	3 8 15 18 19
Antibiotics (oral/IV)	Treat/Prevent infections	Acute exacerbations, chronic infection	3 5 15 17 18
Long-term Macrolides	Reduce exacerbations	Frequent exacerbations	17 18
Inhaled Therapies	Mucolytics, bronchodilators	Select patients	15 18 19 16
Anti-inflammatory	Reduce airway inflammation	Selected cases	15 16 18
Vaccination	Prevent respiratory infections	All patients	18 19
Surgery	Remove localized disease	Severe, localized cases	3 15 18
Address Underlying Cause	Targeted therapy	As identified	10 11 15
Pulmonary Rehabilitation	Improve fitness/QOL	Severe or advanced disease	18

Table 4: Treatment Strategies

Airway Clearance

Clearing mucus from the lungs is the cornerstone of bronchiectasis care. This may involve:

• Daily chest physiotherapy (percussion, postural drainage)
• Devices that help mobilize mucus (oscillating PEP devices)
• Breathing exercises taught by respiratory physiotherapists

These techniques help reduce the frequency of infections and improve breathing 3 8 15 18 19.

Antibiotic Therapy

Antibiotics are used both acutely during exacerbations and, in some cases, long-term to suppress chronic infection.

• Acute Exacerbations: Prompt antibiotic therapy tailored to likely bacteria (e.g., Pseudomonas, Haemophilus) is essential. Sputum cultures help guide choice.
• Long-term Suppression: For patients with frequent exacerbations, long-term oral macrolides (e.g., azithromycin) have been shown to reduce the number and severity of flare-ups and improve quality of life, even in subgroups with Pseudomonas infection 17 18.

However, long-term antibiotic use carries risks, including antibiotic resistance and side effects, and must be carefully monitored 17.

Inhaled Therapies and Anti-Inflammatory Agents

Some patients benefit from inhaled therapies, such as:

• Bronchodilators: For those with coexisting asthma or COPD features.
• Mucoactive agents: To thin mucus and ease expectoration.
• Inhaled corticosteroids: Not routinely recommended but may be considered in specific inflammatory subtypes 15 18 19 16.

Vaccination and Pulmonary Rehabilitation

Vaccination against influenza and pneumococcus is recommended to help prevent infections that could worsen bronchiectasis. Pulmonary rehabilitation programs, including exercise and education, improve physical capacity and quality of life in patients with significant disease 18 19.

Surgical Approaches

In rare cases where bronchiectasis is localized and medical therapy fails, surgical removal of the affected lung segment may be considered 3 15 18.

Treating Underlying Causes

Whenever possible, therapies are tailored to the specific underlying cause:

• Immunoglobulin replacement for immunodeficiency
• Antifungal therapy for ABPA
• CFTR modulator therapy for cystic fibrosis
• Avoidance of aspiration in at-risk populations 10 11 15

A Patient-Centered, Multidisciplinary Approach

Management is most effective when coordinated by a multidisciplinary team—respiratory physicians, physiotherapists, microbiologists, and, when needed, surgeons—to address the diverse and evolving needs of each patient 15 18 19.

Conclusion

Bronchiectasis is a complex, chronic respiratory disease with substantial personal and societal impacts. Early recognition and individualized, multidisciplinary management are key to improving outcomes and quality of life.

Key Takeaways:

• Symptoms: Chronic productive cough, daily sputum, fatigue, dyspnea, frequent exacerbations, and sometimes hemoptysis are hallmark symptoms 1 2 3 5 14.
• Types: Radiological types (cylindrical, varicose, cystic) and clinical phenotypes (sputum producers, chronic infection, "dry" types) help guide prognosis and treatment 6 7 9 10 16.
• Causes: Range from post-infectious and genetic to immune, allergic, and idiopathic origins. Identifying the cause can influence treatment decisions 1 11 12 14.
• Treatment: Centers on airway clearance, targeted antibiotics, long-term macrolide therapy for some, addressing underlying causes, and supportive strategies like vaccination and rehabilitation. Surgery is reserved for select cases 3 15 17 18 19.

Living with bronchiectasis is challenging, but with an informed and proactive approach, many patients can achieve improved health and quality of life.