Bronchiectasis is a long-term lung disease where the bronchi and bronchioles, the airways or breathing tubes of the lungs, become abnormally and permanently widened, scarred, and thickened.

To understand this, it is essential to first picture a healthy airway. Healthy airways are like smooth, muscular tubes lined with a thin layer of mucus and covered in tiny, hair-like structures called cilia. The mucus traps inhaled dust, pollen, and germs. The cilia then act like a coordinated “escalator,” constantly sweeping this mucus upward and out of the lungs, where it can be coughed out or swallowed. This self-cleaning mechanism is called mucociliary clearance.

In bronchiectasis, the airway walls are damaged. They lose their elasticity and become flabby, widened, and scarred. Cilia in these damaged areas are also destroyed. This leads to a vicious cycle of disease:

1. Airway Damage: An initial severe infection or other insult damages the muscular and elastic components of the airway walls.
2. Mucus Pooling: Because the airways are wide and sagging, and the cilia escalator is broken, mucus can no longer be cleared effectively. It pools in these damaged pockets.
3. Chronic Infection: This stagnant, warm, and nutrient-rich pool of mucus becomes a perfect breeding ground for bacteria, leading to a state of chronic infection.
4. Chronic Inflammation: The body’s immune system mounts a constant inflammatory response to this chronic infection. This inflammation releases chemicals that cause further damage to the airway walls, worsening the bronchiectasis and creating even more space for mucus to pool.

This self-perpetuating cycle of mucus buildup, infection, and inflammation is the core problem in bronchiectasis.

I’ve seen patients go years with chronic coughs misdiagnosed as asthma or postnasal drip. A CT scan often reveals the real problem, permanent airway damage that needs long-term management.

Bronchiectasis is not a single disease but is the end result of a wide variety of conditions that can cause severe, damaging inflammation in the airways. In about half of all cases of non-cystic fibrosis bronchiectasis, a specific underlying cause cannot be identified; this is known as idiopathic bronchiectasis. In the other half, a clear preceding cause can be found.

The most common known causes include:

Post-Infectious Causes

This is a major category. A severe, damaging lung infection, particularly in childhood when the lungs are still developing, can lead to permanent airway damage.

• Tuberculosis (TB): Globally, TB is one of the leading causes of bronchiectasis. The intense inflammatory and scarring response to the tuberculosis bacteria can cause severe, localized lung damage.
• Severe Childhood Infections: A history of severe pneumonia, measles, or whooping cough in early life can also lead to the development of bronchiectasis years later.
• Other Respiratory Infections: Less commonly, other viral or bacterial pneumonias in adulthood can be the initiating event.

Genetic Conditions

• Cystic Fibrosis (CF): In populations of European descent, CF is the most common genetic cause of bronchiectasis. CF causes the body to produce abnormally thick and sticky mucus that is very difficult to clear from the lungs, leading to the classic vicious cycle of obstruction, infection, and inflammation.
• Primary Ciliary Dyskinesia (PCD): This is a rare genetic disorder where the cilia themselves are defective and cannot beat properly to clear mucus.

Airway Obstruction

If a single bronchus is blocked, the area of the lung it supplies can develop bronchiectasis behind the blockage. This can be caused by:

• An inhaled foreign object.
• An enlarged lymph node or a tumor pressing on the airway from the outside.

Immune System Problems

• Immunodeficiency: Conditions that weaken the immune system (such as Common Variable Immunodeficiency or CVID) leave a person susceptible to recurrent and severe lung infections, which can eventually lead to airway damage.
• Allergic Bronchopulmonary Aspergillosis (ABPA): This is an allergic reaction in the lungs to a common fungus called Aspergillus. Intense allergic and inflammatory reactions can damage the airway walls.

Other Conditions

• Conditions associated with widespread inflammation, such as rheumatoid arthritis or inflammatory bowel disease (Crohn’s disease and ulcerative colitis), can also have bronchiectasis as a complication.

Any condition that interrupts normal mucus flow in the lungs can lead to bronchiectasis. I always investigate past infections or genetic issues when a patient presents with unexplained, persistent lung symptoms.

Bronchiectasis can develop gradually after repeated lung infections or as a complication of an underlying medical condition that damages the bronchial walls. It is not contagious, but it may be inherited (e.g., in cystic fibrosis or primary ciliary dyskinesia).

Therefore, you are at a higher risk of developing bronchiectasis if you:

• Have a history of a severe lung infection like tuberculosis or whooping cough.
• Have cystic fibrosis or primary ciliary dyskinesia.
• Have a diagnosed immunodeficiency disorder.
• Have an inflammatory autoimmune disease like rheumatoid arthritis.
• Have aspirated a foreign object into your lungs.

I often see bronchiectasis in adults who had repeated chest infections as children but were never diagnosed. In others, it develops silently due to conditions like reflux or immune deficiencies.

Bronchiectasis symptoms can vary in severity, but most patients experience chronic respiratory symptoms that gradually worsen over time.

The hallmark signs and symptoms of bronchiectasis include:

• A Chronic, Daily Cough: This is the most common and persistent symptom.
• Copious Sputum (Mucus) Production: The cough is typically very productive, with the person coughing up a large amount of phlegm every day. The sputum can be clear, white, yellow, or green, especially during an infection.
• Recurrent Chest Infections (Exacerbations): Frequent episodes of worsening cough, increased sputum, and shortness of breath that require antibiotics.
• Shortness of Breath (Dyspnea).
• Hemoptysis: Coughing up small amounts of blood is common due to the chronic inflammation and damage to the blood vessels in the airway walls.
• Other common symptoms can include wheezing, chest pain (often pleuritic, meaning it’s sharp and worse with a deep breath), and fatigue.
• In advanced cases, clubbing (a widening and rounding of the tips of the fingers and toes) may occur.

When someone tells me they’ve had a “wet cough” for years and frequent antibiotics, bronchiectasis is always on my radar. The color and consistency of the mucus can often reveal if something more than asthma is going on.

Diagnosis typically involves imaging tests and lab work to identify the cause and extent of airway damage.

• High-Resolution Computed Tomography (HRCT) Scan: This is the gold standard and the definitive test for diagnosing bronchiectasis. A standard chest X-ray is not sensitive enough and can miss the condition. An HRCT scan provides a highly detailed, cross-sectional view of the lungs and can directly visualize the signs of bronchiectasis, which include thickened and permanently widened, dilated airways.
• Sputum Culture: A sample of phlegm is sent to the laboratory to be cultured. This helps to identify any specific bacteria that may be chronically colonizing the airways, which is crucial for guiding antibiotic choices during an exacerbation.
• Pulmonary Function Tests (PFTs): These breathing tests are done to measure lung capacity and airflow. They help assess the overall extent of lung damage.
• Investigating the Underlying Cause: Once bronchiectasis is confirmed, a doctor will often perform a series of blood tests to look for an underlying cause. This may include testing for immunodeficiencies, specific antibodies related to autoimmune diseases, or allergy testing for Aspergillus. A sweat test may be ordered to rule out cystic fibrosis.

A HRCT scan is the game-changer. I’ve had many patients misdiagnosed for years until we saw the “tram-track” or “signet ring” appearance on imaging, hallmarks of bronchiectasis.

There is no cure, but treatment focuses on managing symptoms, preventing infections, and preserving lung function.

Management is often described as having three main pillars:

1. Airway Clearance Techniques (ACTs)

This is the absolute cornerstone of daily management. The goal is to physically clear the pooled mucus from the damaged airways every day to reduce the bacterial load and prevent infections. There are several different techniques, and a respiratory therapist can help you find the best one for you.

• Breathing Techniques: Specific methods like the Active Cycle of Breathing Technique (ACBT) use a combination of deep breathing, huffing, and coughing to move mucus up and out of the lungs.
• Postural Drainage and Percussion (Chest Physical Therapy): This involves positioning the body in different ways to use gravity to help drain mucus from different lung segments, often combined with a caregiver clapping firmly on the chest and back to help loosen the mucus.
• Airway Clearance Devices: A variety of handheld devices, such as a flutter valve or an Acapella device, use positive pressure and vibration to help dislodge mucus from the airway walls.

2. Treating Infections and Inflammation

• Antibiotics for Exacerbations: Prompt treatment with a course of antibiotics is essential whenever a chest infection develops (indicated by a change in cough and sputum color/volume).
• Long-term or Inhaled Antibiotics: For patients with frequent infections or chronic colonization with certain bacteria like Pseudomonas aeruginosa, a doctor may prescribe a long-term, low-dose oral antibiotic or a nebulized (inhaled) antibiotic to suppress the bacteria.
• Anti-inflammatory Medications: Inhaled corticosteroids or macrolide antibiotics may be used to help reduce the inflammation in the airways.

3. General Health and Supportive Care

• Vaccinations: It is critical for individuals with bronchiectasis to get an annual flu vaccine and the pneumococcal vaccine to prevent these common and dangerous respiratory infections.
• Bronchodilators: Inhaled medications that help to open up the airways may be prescribed to make coughing and clearing mucus easier.
• Pulmonary Rehabilitation: These supervised programs can help improve exercise tolerance and quality of life through exercise, education, and breathing strategies.
• Surgery: In very rare cases, if the bronchiectasis is severely damaged but confined to a small, single area of the lung, surgery to remove that lobe or segment may be considered.

Airway clearance is the backbone of managing bronchiectasis. Teaching patients how to use flutter devices or do postural drainage often leads to fewer flare-ups and better quality of life.

Bronchiectasis is a serious, chronic lung disease that results from permanent airway damage. While its causes are diverse, with past severe infections like tuberculosis being a major driver, the outcome is the same: a debilitating, self-perpetuating cycle of mucus retention and chronic infection. While the structural damage cannot be cured, the disease can be managed. The key to living well with bronchiectasis is a steadfast, daily commitment to airway clearance techniques. This, combined with prompt antibiotic treatment for exacerbations and overall health maintenance, can effectively control symptoms, reduce the frequency of infections, and allow individuals to maintain the best possible lung function and quality of life for years to come.

American Lung Association. (2023). Bronchiectasis. Retrieved from https://www.lung.org/lung-health-diseases/lung-disease-lookup/bronchiectasis

National Heart, Lung, and Blood Institute (NHLBI). (2022). Bronchiectasis. Retrieved from https://www.nhlbi.nih.gov/health/bronchiectasis

American Thoracic Society (ATS). (2022). What is Bronchiectasis? Retrieved from https://www.thoracic.org/patients/patient-resources/resources/what-is-bronchiectasis.pdf