The importance of symptoms in bronchiectasis

Authors: Alessandro De Angelis, Pau Marrades, Lidia Perea, Rosa Faner, Alessandra Iorfida, Stefano Aliberti, James D. Chalmers, Oriol Sibila

Abstract

Bronchiectasis is a chronic respiratory disease characterised by irreversible bronchial dilatation, persistent airway inflammation and recurrent infections. Symptoms, particularly cough, sputum production and dyspnoea, are the most immediate and patient-relevant expression of the disease, linking clinical presentation, airway biology and outcomes. While asthma and COPD management algorithms already integrate symptom burden into therapeutic decision-making, bronchiectasis care has historically relied on exacerbation history to guide preventive interventions. Over the past decade, an expanding body of evidence has demonstrated that daily symptoms mirror current infection and inflammation, profoundly impact quality of life, and predict future exacerbations. Comparative analyses across chronic lung diseases further highlight the central role of symptom monitoring in defining disease activity and risk. The updated European Respiratory Society guidelines translate this evidence into clinical practice, marking a paradigm shift from an exacerbation-driven to a symptom-centred and treatable-traits model. This review synthesises clinical, biological and therapeutic insights linking symptoms to bronchiectasis pathophysiology, disease activity and treatment response. We discuss how airway clearance, mucoactive therapy, antibiotics, pulmonary rehabilitation and targeted anti-inflammatory strategies, including dipeptidyl peptidase-1 inhibition, can address specific symptom profiles. We also mention the role of comorbidities and psychosocial management, establishing symptoms as the cornerstone of a holistic, multidimensional care approach. Recognising symptoms as both biomarkers of activity and therapeutic targets represents a major step toward precision medicine in bronchiectasis, aligning clinical management with patient experience and the biological drivers of disease.

Introduction

Bronchiectasis is a chronic respiratory condition characterised by irreversible bronchial dilatation, persistent airway inflammation and recurrent respiratory infections, ultimately leading to progressive structural lung damage [1]. Beyond this unifying definition, bronchiectasis is highly heterogeneous in its causes, clinical phenotype, imaging features, microbiology and therapeutic response, with variability evident across individuals and longitudinally within individuals [2–5].

Respiratory symptoms, together with radiological criteria, define the disease and are central to its clinical expression [1]. Patients typically report a substantial symptom burden, most commonly chronic cough, sputum production, dyspnoea, wheeze and, in a subset, haemoptysis, which strongly affects daily life and care priorities [6]. From the patient perspective, dealing with daily symptoms is among the greatest concerns, with sputum, dyspnoea and cough ranking among the most difficult aspects to manage [7, 8].

Symptom intensity and patterns may vary widely across patients. Differences in underlying etiologies, airway biology, sudden shifts in lung microbiome homeostasis and the presence or activity of comorbidities contribute to distinct constellations of signs and symptoms across aetiological groups [9, 10].

Despite the centrality of symptoms, bronchiectasis treatment pathways have so far relied primarily on exacerbation history to trigger preventive strategies (e.g. long-term macrolides or inhaled antibiotics). In contrast, asthma and chronic obstructive pulmonary disease (COPD) algorithms explicitly integrate symptom burden into treatment selection and escalation [11, 12]. Since the publication of the first international bronchiectasis guidelines in 2017, a growing body of literature has systematically characterised symptom burden, its variability during exacerbations and its impact on health status and clinical outcomes; thereby reinforcing the rationale for symptom-centred assessment and management [13–15].

With the recent release of the new international guidelines, symptoms have now been formally placed at the centre of both disease assessment and treatment decision-making [16]. This shift reflects the evidence generated over the past years and underscores the need for a narrative synthesis of how symptoms shape bronchiectasis expression, outcomes and management. In this light, we aimed to provide an overview of the impact of symptoms in bronchiectasis, linking clinical manifestations to biological underpinnings and outcomes, compare bronchiectasis with other chronic lung diseases, and outline how symptom-centred assessment can inform both current practice and future research priorities.

Methods

We performed a narrative review of the literature using the PubMed database to identify English-language studies published up to December 2025. A predefined set of keywords related to bronchiectasis and symptoms was used, including “bronchiectasis”, “symptoms”, “disease activity”, “quality of life” and “treatable traits”. We considered randomised controlled trials (RCTs), cohort and cross-sectional studies, registry analyses, as well as relevant reviews and international guidelines.

Given the narrative scope of the review, evidence was synthesised qualitatively, with priority given to larger and methodologically robust studies to provide a balanced overview of the topic. The preparation and reporting of this narrative review were guided by the SANRA (Scale for the Assessment of Narrative Review Articles) recommendations to ensure transparency and methodological rigor [17].

The importance of symptoms in bronchiectasis and in other chronic lung diseases

Bronchiectasis is clinically defined as much by symptoms as by imaging findings. Current diagnostic criteria require both radiological evidence of bronchial dilatation and the presence of typical respiratory manifestations [1, 18, 19]. Relying on imaging alone risks overdiagnosis, as radiological bronchial dilatation can occur without clinical disease, particularly in older adults or after infections [20]. Thus, symptoms remain essential for defining clinically significant bronchiectasis and distinguishing it from incidental radiological findings.

Core respiratory symptoms

The cardinal manifestations of bronchiectasis are chronic cough and sputum production. While chronic cough is reported in a broad range of patients, reaching up to 98.5%, the prevalence of sputum production varies widely, reaching up to 92.7% of patients [6]. Furthermore, data from the European Bronchiectasis Registry (EMBARC) indicates that daily sputum expectoration was specifically reported by 69.8% of the enrolled population [21, 22]. Sputum could be mucoid, mucopurulent or purulent and its appearance often reflects the degree of airway inflammation and bacterial load [23, 24]. Dyspnoea is another key symptom, typically affecting about one-quarter to one-third of patients in large multicentre cohorts, and its severity, captured by the modified Medical Research Council (mMRC) scale, correlates strongly with lower forced expiratory volume in 1 s, greater sputum purulence and worse quality of life [6]. Wheezing is reported in a substantial minority of cases, around 15–20% in major registries, while haemoptysis, though less common, remains a characteristic feature of advanced or post-infectious disease and is observed in roughly 15–40% of patients, with the highest prevalence in post-tuberculosis bronchiectasis, where nearly one-third may be affected [25–29]. Its severity varies from mild blood-streaked sputum to life-threatening bleeding, especially during exacerbations.

Symptom profiles may vary according to the underlying aetiology. Single-aetiology studies have reported more intense cough and wheeze in PCD patients, increased sputum production and purulence in COPD-associated disease, and haemoptysis as a prominent feature in post-tuberculosis or post-infectious bronchiectasis [25–27].

Exacerbations represent acute worsening of one or more key symptoms lasting ≥48 h and requiring treatment escalation [30]. They reflect a surge in airway inflammation and infection and remain major determinants of long-term outcomes [31]. During these episodes, patients typically experience a marked intensification of cough, increased sputum volume and purulence, with more than 70–85% reporting deterioration in these core symptoms [6]. Chest tightness, systemic features, or haemoptysis, particularly in post-infectious disease, may also occur [6]. However, not all patients exhibit the “classic” productive phenotype, some experience predominantly dry cough, breathlessness, or fatigue-driven patterns [32]. This heterogeneity underscores the need to identify distinct symptom clusters and their biological underpinnings, an approach aligned with current precision medicine framework [33].

In addition, bronchiectasis may also present with more severe and acute clinical manifestations. Exacerbations can occasionally represent the first presentation of previously undiagnosed disease, particularly in patients presenting with pneumonia, new purulent sputum or haemoptysis. Among these, haemoptysis is a clinically relevant feature, ranging from mild to life-threatening bleeding and requiring tailored management depending on severity [28, 34]. Severe exacerbations requiring hospitalisation are associated with a substantial clinical burden, including non-negligible in-hospital mortality and high readmission rates, particularly in older patients and those with advanced disease or chronic infection [35, 36].

Comparison with other chronic airway diseases

In COPD, symptom burden is the principal driver of treatment selection. Dyspnoea is typically the dominant and most disabling symptom and its severity, captured using the mMRC scale or the COPD Assessment Test (CAT), guides both initial and follow-up therapy [37, 38]. Higher scores prompt escalation from monotherapy to dual or triple inhaled bronchodilation and to nonpharmacologic interventions such as pulmonary rehabilitation [11]. Biomarkers such as blood eosinophils increasingly inform inhaled corticosteroid use and the selection of newer therapies adding a biological dimension to symptom-guided decision-making [11, 39].

In asthma, symptoms also inform treatment decisions; however, as in COPD, escalation is guided not only by symptom persistence but also by biomarkers and exacerbation risk [12]. Before stepping up therapy, guidelines emphasise reassessing modifiable factors, such as adherence, inhaler technique and comorbidities, to avoid overtreatment. Escalation is generally considered when symptoms persist despite optimisation or when patients exhibit frequent exacerbations. Furthermore, elevated biomarkers such as total IgE or blood eosinophils play a central role in determining treatment step-up [40].

Patients with multiple chronic airway diseases present an additional challenge. Symptom overlap between bronchiectasis, COPD and asthma often complicates diagnosis and clinical interpretation. While COPD is characterised predominantly by exertional dyspnoea, asthma presents with wheeze and variable airflow limitation driven by eosinophilic inflammation and airway hyperresponsiveness [41, 42]. Bronchiectasis may share features of both, making the clinical picture difficult to disentangle. Clinically, coexisting disease is highly relevant; asthma–bronchiectasis overlap is associated with greater symptom burden and more frequent exacerbations, whereas COPD–bronchiectasis overlap is linked to worse lung function and increased mortality risk [43–45].

Historically, such overlap syndromes were poorly defined, but current precision medicine approaches instead prioritise the identification of “treatable traits” and comorbidities rather than categorising patients into overlapping diagnostic labels [46–48]. This shift enables more personalised management, guided by the dominant biological and clinical features, be they infection, type of inflammation, mucus stasis or airway obstruction.

Psychological impact

The consequences of respiratory symptoms in bronchiectasis extend far beyond the physical domain, profoundly affecting psychological well-being, social participation and daily functioning (figure 1) [6, 49]. Patients frequently report fatigue, chest tightness, anxiety and depressive symptoms, which often intensify during exacerbations. Data from the European and Chinese registries indicate a prevalence of affective disorders of approximately 14%, although studies using dedicated and validated scales report substantially higher rates of up to 30–35% for both [22, 50–53]. A recent meta-analysis confirmed that symptoms of depression and anxiety are highly prevalent in bronchiectasis, with pooled estimates of 31% and 34%, respectively [49]. Importantly, most available data are derived from patient-reported screening tools rather than formal psychiatric diagnoses, which may partly explain variability across studies. These comorbidities are also linked to worse treatment adherence, increased healthcare utilisation and higher economic burden [53, 54]. Risk factors for psychological distress include female sex, longer disease duration and adverse social or economic circumstances [55]. In particular, symptoms of depression have been associated with more frequent exacerbations and poorer health-related quality of life (HRQoL), whereas the relationship with anxiety symptoms is less consistent [49]. These findings highlight the importance of incorporating psychological assessment and support into routine care for bronchiectasis.

Quality of life and patient-reported outcomes

Impairment in HRQoL among bronchiectasis patients arises primarily from the persistence and variability of symptoms. Surveys consistently show that patients rank sputum, cough, dyspnoea and fatigue among the most burdensome aspects of their disease, followed by sleep disturbance and fear of exacerbations or hospitalisation [8, 56]. Conceptually, HRQoL represents “the perception of the impact of health on an individual's satisfaction with life in areas they consider important” [57]. In bronchiectasis, symptoms, through their intensity and day-to-day fluctuation, are the main determinants of this impact [8].

To capture this multidimensional burden, validated patient-reported outcome measures (PROMs) are increasingly employed in both research and clinical practice. PROMs quantify symptom frequency, severity and variability directly from the patient's perspective, complementing physiological and imaging data. The most widely used HRQoL instruments include the St George's Respiratory Questionnaire (SGRQ), COPD Assessment Test (CAT) and the disease-specific Bronchiectasis Health Questionnaire (BHQ) and Quality of Life–Bronchiectasis Respiratory Symptoms Scale (QoL-B-RSS) [58–60] (table 1). Although originally developed for COPD, the CAT has been formally validated in bronchiectasis and has demonstrated good psychometric performance [61, 62]. Given its widespread use across chronic airway diseases, the CAT has recently been conceptually renamed as the Chronic Airways Assessment Test (CAAT) [63]. Importantly, this modification involved only minimal changes to the title and introductory wording, replacing COPD-specific terminology with “chronic airways” or “pulmonary disease”, without altering the questionnaire items, scoring system or interpretation. Consistently, EMBARC has adopted the CAAT as an outcome measure to further evaluate its applicability in bronchiectasis alongside disease-specific instruments. Notably, CAT/CAAT and QoL-B have established minimal clinically important differences (MCIDs) [60]. PROMs are valuable for quantifying treatment effects in clinical trials and for providing a structured, patient-centred framework in clinical care. However, their systematic use outside research settings remains limited, partly due to practical constraints such as questionnaire length and time requirements in routine practice. In addition, their integration into dynamic clinical decision-making, such as guiding treatment adjustments based on longitudinal changes, remains limited and represents an important area for future research.

Complementary to these static tools, daily symptom diaries offer insight into the dynamic variability of symptoms and the early detection of exacerbations. In a prospective study using the BEST diary, Artaraz et al. [64] demonstrated strong correlations with established HRQoL instruments (SGRQ, CAT, LCQ) and functional measures. Nearly half of diary-detected exacerbations were not clinically reported, yet were associated with measurable declines in daily well-being. These findings highlight the value of integrating digital symptom monitoring into routine workflows, enabling earlier recognition of deterioration and more responsive management.

Symptoms and disease activity

Disease activity refers to the current expression of pathological processes driving tissue injury, whereas disease severity reflects the cumulative extent of organ dysfunction and physiological decline that defines prognosis [65]. In bronchiectasis, assessment of disease activity begins with clinical history, physical examination and review of imaging or laboratory findings for signs of ongoing inflammation. In addition, PROMs add depth, capturing multidimensional quality of life burden directly from the patient's perspective [60].

Why does this matter? Because disease activity dictates urgency. High activity warrants prompt intervention, as reducing inflammation early may prevent further lung damage and progression to more severe disease [65]. In contrast, severity assessment is based on a broader evaluation that includes also microbiology, radiological extent, lung function, underlying aetiology and comorbidities [66–68] (table 2). No single biomarker fully captures activity; rather, it emerges from integrating multiple clinical signals.

Among these, daily symptom burden may be the principal marker of disease activity. Recent evidence supports that highly symptomatic patients are more likely to experience exacerbations and progression, with even small fluctuations precipitating deterioration. In a large cohort study, symptoms measured by the QoL-B-RSS independently predicted future exacerbations and identified patients who may benefit from preventive strategies such as long-term macrolides [15]. Earlier work similarly showed that worse SGRQ and QoL-B-RSS scores were consistently associated with higher risks of exacerbations and hospitalisations; for example, an SGRQ >70 conferred nearly a seven-fold increase in hospitalisation risk, while each 10-point drop in QoL-B-RSS corresponded to a 25% higher exacerbation rate over 12 months [14, 69]. These associations were independent of prior exacerbation history, challenging the long-held paradigm that intervention thresholds should be based solely on exacerbation frequency.

Among individual symptoms, purulent sputum is a particularly strong predictor of adverse outcomes. Its green colour, caused by myeloperoxidase released from neutrophils, reflects airway inflammation [70]. When assessed with the validated Murray sputum colour chart, purulence correlates with lower lung function, higher bacterial load (especially Pseudomonas aeruginosa), greater disease severity scores, poorer quality of life and more frequent exacerbations [21, 70]. More importantly, each one-step increase on the chart has even been linked to a 12% rise in mortality risk [21].

Other markers of disease activity

Bronchiectasis research has also shown that exacerbations are tightly linked to airway inflammation and represent major expressions of disease activity [9, 71]. At the same time, exacerbations are associated with worse lung function, impaired performance status and increased mortality, thereby serving as markers of severity [66, 67]. In a large European cohort, frequent past exacerbations were the strongest predictor of future episodes [31].

Radiological evidence of active disease, such as mucus plugging or tree-in-bud opacities, has been associated with worse severity scores, greater radiological extent and higher sputum myeloperoxidase levels in bronchiectasis [72–74]. In other chronic muco-obstructive lung diseases, mucus plugging also predicts adverse outcomes, including airflow obstruction, higher exacerbation rates and increased mortality, underscoring its role as an imaging biomarker of disease activity and prognosis [75–77]. However, these findings remain impractical for routine monitoring due to cost and radiation exposure [18, 19]. Systemic inflammatory markers (e.g., C-reactive protein and procalcitonin) have also shown associations with exacerbations and severity indices such as lung function and radiological extent [78–80]. However, they lack specificity, validated thresholds and proven utility in guiding treatment.

Linking symptoms to airway biology

Symptoms in bronchiectasis are not merely clinical descriptors but reflect the underlying airway biology. Neutrophilic inflammation is a hallmark of the disease and contributes to mucus hypersecretion and purulence, tissue injury and clinical instability [81]. This inflammatory response is characterised by the release of serine proteases, such as neutrophil elastase (NE) and the formation of neutrophil extracellular traps (NETs) [82]. Using sputum proteomics, Keir et al. [83] demonstrated that increasing NET concentrations and NET-associated proteins are linked to greater disease severity, more severe exacerbations and worse quality of life as measured by the QoL-B-RSS. Notably, treatment with azithromycin significantly reduced sputum NET levels. Similarly, patients with a high daily symptom burden measured by the Leicester Cough Questionnaire show increased sputum purulence and higher sputum neutrophil counts [84].

Sputum neutrophils and protease activity also correlate with chronic infection and airway bacterial load [23, 24, 85]. Although the data regarding correlation between bacterial load and symptom scores are relatively inconsistent, bacterial burden nevertheless plays a central role in bronchiectasis pathophysiology. Higher loads are associated with more intense airway and systemic inflammation, reflected by increased sputum neutrophils and elevated myeloperoxidase activity, as well as with worse quality of life and higher exacerbation risk [14, 86]. Notably, in some inhaled antibiotic trials, reductions in bacterial load were paralleled by improvements in quality of life, suggesting that microbiological control can directly translate into symptomatic benefit [87–89].

Emerging evidence indicates that eosinophilic inflammation contributes to the symptom burden and disease activity of bronchiectasis. In one study, the T2-high endotype, defined by a blood eosinophil count (BEC) >300 cells·µL^−1^ and exhaled nitric oxide fraction (FENO) >25 ppb, was associated with more severe dyspnoea, with a significantly higher proportion of patients in mMRC categories 3–4 compared with non-T2-high cases [90]. Similarly, another study reported that patients with eosinophilic bronchiectasis (BEC >300 cells·µL^−1^) had worse dyspnoea always measured with mMRC [91]. A U-shaped association between BEC and dyspnoea has also been described, with greater severity observed in both eosinopenic (<50 cells·µL^−1^) and eosinophilic (>300 cells·µL^−1^) groups compared with the intermediate range [92].

The impact of eosinophilic inflammation also extends to quality of life. T2-high patients reported significantly lower scores in the QoL-B respiratory symptom domain, reflecting a greater symptomatic impact [90]. Moreover, post hoc analyses have shown that patients with BEC ≥150 cells·µL^−1^ or ≥3% experienced greater improvements in quality of life when treated with inhaled corticosteroids [91].

Taken together, symptoms represent the outward expression of bacterial infection and neutrophil- or eosinophil-driven inflammation, serving as clinical indicators of complex underlying biological processes. They remain the most patient-centred marker of disease activity in bronchiectasis, bridging airway biology with clinically meaningful outcomes. The variability of symptoms across individuals and over time mirrors the heterogeneity of the underlying mechanisms. Recognising, quantifying and addressing these manifestations through both clinical assessment and patient-reported measures is central to modern bronchiectasis care and fully aligns with the treatable-traits framework that underpins the new European Respiratory Society (ERS) 2025 guidelines [16].

Symptoms and treatment

Mapping symptoms to treatable traits and interventions

Symptoms in bronchiectasis represent not only the most visible expression of disease activity but also actionable treatable traits [46, 47]. Mapping specific symptoms to targeted interventions enables a pragmatic, patient-centred approach aimed at reducing burden, improving quality of life and preventing long-term deterioration (figure 2) [15, 93]. For example, daily sputum production and purulence can be addressed through airway clearance techniques, mucoactive therapy and antibiotics (oral or inhaled). Frequent exacerbators may respond to macrolides, inhaled antibiotics, or emerging anti-inflammatory therapies such as dipeptidyl peptidase-1 (DPP-1) inhibitors. Dyspnoea and exercise limitation can be managed with pulmonary rehabilitation, inspiratory muscle training and, when appropriate, bronchodilators or inhaled corticosteroids.

Beyond respiratory symptoms, comorbidities and psychosocial dysfunction are major gateways to address to achieve disease control lowering symptom perception and overall burden [48, 49]. Thus, symptoms serve as for identifying treatable traits, facilitating a multidimensional, patient-centred management strategy.

A change of paradigm with the new ERS guidelines

The updated 2025 ERS guidelines mark a major paradigm shift in bronchiectasis management. While the 2017 guidelines based the initiation of long-term preventive therapies mainly on exacerbation history, three or more per year, the updated recommendations now recognise daily symptom severity as an equally important determinant of disease progression risk and treatment decisions [13, 16] (table 3). Patients with one prior exacerbation plus severe daily symptoms, defined as symptoms with a marked impact on daily functioning and quality of life, are now considered high risk [13, 16]. Although this construct relies largely on clinical judgement using clinical features such as daily sputum volume and purulence, it can also be supported by PROMs such as SGRQ and QoL-B RSS. Recent studies have also proposed pragmatic thresholds using PROMs, including SGRQ scores >40 and/or QoL-B respiratory symptom scores <60, which may help operationalise this definition and identify patients at increased risk of adverse outcomes [14, 15].

Airway clearance and mucoactive therapy

Daily cough and sputum production reflect impaired mucociliary clearance and inflammation-driven mucus stasis [94]. Airway clearance techniques remain a cornerstone of management and, in the new guidelines, their recommendation has been expanded beyond patients with productive cough to include selected individuals with dry cough and radiological evidence of mucus plugging [16, 95].

Similarly, mucoactive agents (e.g. hypertonic saline, mannitol, N-acetylcysteine) can be considered for patients whose airway clearance remains inadequate or whose quality of life is significantly impaired by cough and sputum retention. These agents improve mucus hydration and expectoration and may modestly enhance cough control and sputum-related quality of life. However, the recent CLEAR trial, a multicentre, randomised factorial study, found that neither 6% hypertonic saline nor carbocisteine significantly reduced pulmonary exacerbations compared with standard care [96]. Secondary outcomes, including quality-of-life scores (QoL-B, SGRQ), lung function and time to next exacerbation, were also unchanged and no major safety concerns emerged. Recent observational data from a large registry in Spain (RIBRON) have suggested a potential beneficial effect of N-acetylcysteine, with reductions in exacerbations, hospitalisations and sputum burden. However, these findings should be interpreted with caution given the observational design and the lack of standardised quality-of-life assessment [97].

Overall, these data suggest that, while mucoactive therapy remains physiologically plausible and may benefit selected patients, particularly those with high symptom burden, robust evidence supporting its routine long-term use is still limited.

Pulmonary rehabilitation

Pulmonary rehabilitation (PR) remains strongly recommended but with a broader scope. Whereas the 2017 ERS guidelines restricted PR to patients with impaired exercise capacity, the 2025 update extends this indication to those with breathlessness, fatigue or reduced functional status, regardless of spirometric values [13, 16]. PR has a direct impact on symptom burden, significantly reducing breathlessness and improving exercise tolerance, while also enhancing HRQoL. These benefits are supported by improvements in standardised measures such as the 6-min walk test and SGRQ scores, although their long-term sustainability remains uncertain [98]. Importantly, regular physical activity is now considered a core component of disease management and an integral part of airway clearance strategies, contributing to overall symptom control [13, 16].

Long-term antibiotics

The paradigm for long-term antibiotic therapy has also evolved. Previous guidelines emphasised exacerbation frequency as the main criterion for treatment initiation; while new guidelines now recommend considering both exacerbation frequency and symptom severity when identifying high-risk patients [13, 16]. Inhaled antibiotics (e.g., tobramycin, colistin, ciprofloxacin formulations) and macrolides have consistently been shown to reduce exacerbation frequency and, in several trials, improve respiratory symptoms and quality of life [99–101].

Bronchodilators and inhaled corticosteroids

Bronchodilators may relieve dyspnoea and wheeze in patients with coexisting airflow obstruction, although their use should be guided primarily by symptom response rather than spirometry thresholds. Inhaled corticosteroids are not routinely indicated for all patients with bronchiectasis, but some studies suggested their potential benefit in the T2-high endotype or eosinophilic bronchiectasis (defined by BEC >300 cells·µL^−1^ or FENO >25 ppb) [102]. In these subgroups, inhaled corticosteroids may improve quality of life and decrease exacerbations, supporting a precision-medicine, treatable-traits approach, although evidence is still scarce and further studies are needed [92, 103].

DPP-1 inhibitors

Although not yet incorporated into the 2025 ERS recommendations, new therapies such as DPP-1 inhibitors and others are expected to feature in future updates [104]. By inhibiting neutrophil serine protease activation, DPP-1 inhibitors target upstream drivers of purulent sputum, cough and airway damage. Phase 2 and 3 trials demonstrated significant reductions in exacerbation frequency and preservation of lung function, suggesting a potential to modulate both inflammation and symptom burden [105–108].

Comorbidities and psychosocial management

For the first time, the 2025 ERS guidelines place strong emphasis on the assessment and management of respiratory and extra-respiratory comorbidities, recognising their contribution to symptom amplification and overall disease complexity [13, 16]. Conditions such as asthma, COPD, gastro-oesophageal reflux disease, chronic rhinosinusitis and affective disorders can exacerbate cough, breathlessness and fatigue [48, 109, 110]. Targeted treatment of these comorbidities, combined with psychological and social support, is now considered an integral component of bronchiectasis care [16].

Deteriorating patient

For the first time, the 2025 ERS guidelines explicitly address the issue of the deteriorating patient, while previous guidelines offered only indirect guidance for patients with progressive or severe disease. This update formalises the concept of deterioration, defined by worsening symptoms, increasing exacerbation frequency or rapid lung function decline, and establish its management with a structured approach that includes re-assessment of aetiology, imaging, airway clearance and long-term therapies [16].

Conclusions

Symptoms represent the most immediate and patient-relevant expression of bronchiectasis, linking clinical presentation with underlying airway biology and long-term outcomes. Accumulating evidence over the past decade demonstrates that daily symptom burden reflects ongoing infection and inflammation, predicts future exacerbations and critically shapes quality of life. The updated ERS guidelines translate this evidence into clinical practice, marking a shift from an exacerbation-driven, event-based approach toward a symptom-centred, activity-guided model aligned with the treatable traits framework.

Looking ahead, future research should prioritise treat-to-activity strategies that stratify patients based also on symptom burden, to understand the associated biological mechanisms and to determine a targeted treatment. In parallel, the integration of clinical data with genomics, radiomics and artificial intelligence may further refine early disease detection, more precise phenotyping and personalised management. Recognising and understanding symptoms as a central pilar of disease activity in bronchiectasis may improve quality of life and long-term prognosis of patients with bronchiectasis.