Bronchiectasis
- Fysiobasen
- Sep 8
- 6 min read
Bronchiectasis is a chronic lung disease characterized by permanent and irreversible dilation of the bronchi (the airways in the lungs). This leads to accumulation of mucus, recurrent infections, and gradual loss of lung function¹. The condition causes significant morbidity and affects the quality of life in both children and adults. Most patients are diagnosed in adulthood, but the disease can begin as early as childhood.
Causes and Pathophysiology
The causes of bronchiectasis may be both known and unknown. Common triggers include recurrent or severe infections (e.g., pneumonia, whooping cough, tuberculosis, measles), chronic lung diseases such as asthma, COPD, or cystic fibrosis, and congenital ciliary dysfunctions. Immunodeficiency, allergic bronchopulmonary aspergillosis (ABPA), and airway obstruction (e.g., tumor or foreign body) are also important causes¹².
Pathophysiologically, the disease begins with damage to the bronchial wall, often following infection. Inflammation leads to loss of elasticity and ciliary function, impairing normal mucus clearance. This results in mucus retention, increased risk of bacterial growth, and a vicious cycle of new inflammation, fibrosis, and further bronchial progression¹. Over time, permanent dilation and thickening of the bronchial walls occur, with gradual loss of normal lung function.
Risk Factors
Frequent respiratory infections in childhood or adulthood
Underlying conditions such as asthma, COPD, or cystic fibrosis
Primary ciliary dysfunction
Immunodeficiency disorders
Airway obstruction (foreign body, tumor)
Smoking
Socioeconomic factors, malnutrition
Family history of similar disease
Epidemiology
Bronchiectasis can affect all age groups, but its prevalence has particularly increased among older adults and women in recent decades¹. In Western countries, most cases are diagnosed in adults. Previously, the disease was more common in childhood due to poor infection control, but this has changed with improved antibiotic treatment. Exact prevalence remains uncertain, but it is believed to be rising.
Symptoms and Clinical Presentation
The main symptom is chronic cough with large amounts of sputum, often purulent and daily. Recurrent respiratory infections and exacerbations are common. Other symptoms include shortness of breath, wheezing, hemoptysis (bloody sputum), fatigue, and weight loss. In long-standing disease, clubbing of the fingers (“drumstick fingers”) may develop as a sign of chronic hypoxia².
Diagnostics
The diagnosis is established through a combination of medical history, clinical examination, and imaging:
High-resolution CT of the chest (HRCT) is the gold standard, showing dilated, thickened bronchi and lack of tapering³.
Chest X-ray is used as a supplement but is less sensitive for early changes.
Microbiological examination of sputum provides information about bacteria during exacerbations.
Pulmonary function testing (spirometry) often shows an obstructive pattern.
Immunodiagnostics and evaluation of underlying diseases are performed when indicated.
Pathophysiology
Three main mechanisms contribute to disease progression:
Repeated infections and inflammation damage the bronchial walls.
Mucus stasis occurs because normal clearance is impaired.
Increased inflammation and fibrosis cause further dilation, loss of ciliary function, and worsening disease.
The result is persistent inflammation, thickened and dilated bronchi, and gradual loss of normal lung function¹.
Treatment and Medical Management
Treatment aims to control symptoms, reduce infections, and slow progression:
Antibiotics are prescribed during exacerbations, guided by sputum culture.
Expectorants and mucolytics may be used to facilitate mucus clearance.
Bronchodilators are indicated when coexisting obstructive disease is present.
Vaccination against influenza and pneumococcus is recommended.
Surgery is considered only in localized disease or serious complications such as major bleeding.
Self-care including smoking cessation and infection prevention is essential.
Objective Examination
A thorough objective examination is essential to assess severity, progression, and treatment effect in bronchiectasis. The assessment includes evaluation of typical signs of chronic lung disease, lung function, cough, sputum, and potential complications¹.
During clinical examination, the following are assessed:
Fingers: Clubbing may occur in long-standing disease.
Cough quality: Strength, character, and quantity of sputum are noted.
Auscultation: Focal or generalized crackles (crepitations), wheezing, and sometimes reduced breath sounds are frequently heard over affected lung regions².
Dyspnea on exertion: Most patients experience significant breathlessness, especially during activity.
Stress incontinence: May occur as a result of chronic cough and increased intra-abdominal pressure.
Exacerbations: Typically occur multiple times per year and are characterized by four or more of the following: change in sputum, increased dyspnea, worsening cough, fever (>38 °C), increased wheezing, reduced activity level, fatigue, malaise, or radiological evidence of new infection².
Treatment and Medical Management
The aim of treatment is to promote mucus clearance, reduce infections, and improve quality of life.
Mucus clearance: Optimal positioning, breathing exercises, and coughing techniques.
Early and aggressive treatment of infection: Antibiotics are often used during exacerbations.
Prophylactic antibiotics: Considered in patients with frequent infections.
Surgical treatment: Resection of affected lung lobe may be considered in severe localized disease with adequate lung reserve.
Lung transplantation: Considered in widespread disease with bilateral lung failure, especially in cystic fibrosis.
Physiotherapy
Physiotherapy is crucial in ensuring effective mucus clearance and reducing complications in bronchiectasis³. Patients have severely reduced ciliary function and must be trained in techniques to manage increased sputum, coughing, and fatigue.
Key interventions include:
Active Cycle of Breathing Technique (ACBT): A sequence of deep breaths, controlled breathing, and huffing/coughing to mobilize and move mucus from small to large airways.
Forced Expiration Technique (huffing): Strong exhalation with an open mouth to loosen and move secretions, often combined with ACBT.
Manual techniques: Percussion, vibration, shaking, and rib springing may be used to mobilize secretions. Contraindicated in patients on anticoagulants and those with osteoporosis.
Postural drainage: Using gravity by placing the patient in specific positions to drain secretions from different lung regions.
Autogenic drainage: Controlled breathing technique to move mucus from small to large airways, requiring training.
PEP (Positive Expiratory Pressure): Breathing against resistance via specialized devices or pursed lips to open airways and mobilize mucus.
High-frequency chest wall oscillation: Vest therapy delivering mechanical vibrations to loosen mucus, especially useful in frequent exacerbations or limited mobility.
Intrapulmonary Percussive Ventilation (IPV): Device delivering small bursts of air to vibrate airways and mobilize mucus; used in short-term or refractory cases.
Intermittent Positive Pressure Breathing (IPPB): Short-term mechanical ventilation to increase lung expansion and facilitate secretion clearance, often combined with inhaled medication.
Physical activity: Tailored programs including endurance training, resistance training, and daily activity are vital for lung health, stamina, and reduced fatigue. Physical activity lowers the risk of exacerbations and improves quality of life⁴.
Measuring Treatment Outcomes
Assessment of effectiveness includes:
Dyspnea scales (e.g., Borg’s RPE, Dyspnea Management Questionnaire)
Incentive spirometry for lung expansion
Walking distance measurement (2-minute walk test)
Cough questionnaires (Leicester Cough Questionnaire)
Frequency of exacerbations and need for hospitalization
Follow-up
Long-term, structured follow-up with a physiotherapist and multidisciplinary team is necessary to tailor interventions, ensure optimal self-management, and prevent disease progression.
Prognosis and Course
Bronchiectasis is a lifelong condition. With appropriate follow-up and treatment, most patients can maintain good quality of life and lung function. If untreated, the disease may cause recurrent infections, progressive lung damage, and serious complications such as hemoptysis and respiratory failure¹. Up to half of patients experience recurrent exacerbations during their lifetime.et.
References
Bird K, Memon J. (2017). Bronchiectasis. Available from: https://www.ncbi.nlm.nih.gov/books/NBK430810/ [last accessed: 05.07.2025]
Australian Institute of Health and Welfare (AIHW). Bronchiectasis. Available from: https://www.aihw.gov.au/reports/chronic-respiratory-conditions/bronchiectasis/contents/bronchiectasis [last accessed: 05.07.2025]
salamhossein. Bronchiectasis Animation – What is Bronchiectasis? Available from: https://www.youtube.com/watch?v=uNeprw1rsgE [last accessed: 05.07.2025]
Hough A. (2014). Physiotherapy in Respiratory and Cardiac Care: An evidence-based approach. 4th ed. Hampshire: Cengage Learning EMEA.
Bronchiectasis.com. How is it diagnosed? Available from: https://bronchiectasis.com.au/bronchiectasis/diagnosis-2/how-is-it-diagnosed [last accessed: 05.07.2025]
Radiopaedia. Bronchiectasis. Available from: https://radiopaedia.org/articles/bronchiectasis [last accessed: 05.07.2025]
Van der Schans CP. (1997). Forced expiratory manoeuvres to increase transport of bronchial mucus: a mechanistic approach. Monaldi Archives for Chest Disease, 52(4), 367.
Syed N, Maiya AG, Siva Kumar T. (2009). Active Cycles of Breathing Technique (ACBT) versus conventional chest physical therapy on airway clearance in bronchiectasis – a crossover trial. Advances in Physiotherapy, 11(4), 193–198.
Diehl N, Johnson MM. (2016). Prevalence of osteopenia and osteoporosis in patients with noncystic fibrosis bronchiectasis. Southern Medical Journal, 109(12), 779–783.
Paneroni M, Clini E, Simonelli C, et al. (2011). Safety and efficacy of short-term intrapulmonary percussive ventilation in patients with bronchiectasis. Respiratory Care, 56, 984–988.
Lee AL, Hill CJ, Cecins N, et al. (2014). The short and long term effects of exercise training in non-cystic fibrosis bronchiectasis – a randomised controlled trial. Respiratory Research, 15, 44.
Birring SS, Prudon B, Carr AJ, et al. (2003). Development of a symptom-specific health status measure for patients with chronic cough: Leicester Cough Questionnaire (LCQ). Thorax, 58(4), 339–343.
