What causes bronchiectasis?

The most common cause worldwide is post-infective damage — severe or recurrent childhood pneumonia, whooping cough (pertussis), measles, or tuberculosis leaving permanent bronchial scarring. Other important causes include cystic fibrosis (managed at specialist CF centres), primary ciliary dyskinesia, immune system deficiency (including common variable immunodeficiency), allergic bronchopulmonary aspergillosis (ABPA), autoimmune conditions such as rheumatoid arthritis or lupus, and chronic aspiration from severe reflux or swallowing problems. Despite investigation, roughly 30–50% of cases remain idiopathic. Identifying the underlying cause matters because it may change treatment.

What does bronchiectasis feel like day to day?

Most people with bronchiectasis experience a chronic daily cough that produces significant volumes of mucus or phlegm — often described as mucopurulent (coloured, thick). Breathlessness on exertion, fatigue, and recurrent chest infections are common. Blood in the sputum (haemoptysis) occurs in a proportion of people, usually in small amounts; rarely it can be heavy. Chronic sinusitis and wheeze often coexist. Many people have periods of stability interrupted by exacerbations — flares where symptoms worsen, sputum becomes more purulent, and energy drops — often requiring a course of antibiotics.

What is the signet ring sign on CT?

When radiologists report a 'signet ring sign' on a CT scan, they are describing an airway whose internal diameter is larger than the diameter of the adjacent blood vessel — the pulmonary artery branch that normally matches it in size. This is one of the hallmarks of bronchiectasis on high-resolution CT. Additional CT features include airways that fail to taper as they travel toward the lung periphery, and airways visible within one centimetre of the lung pleura (normally they are not visible so close to the edge). The pattern and distribution across the lung lobes may give clues to the underlying cause.

What is airway clearance and do I need to do it every day?

Airway clearance is a set of breathing and positioning techniques designed to help you move mucus out of the damaged airways — techniques that the airways' own impaired clearance mechanisms can no longer do effectively. The active cycle of breathing technique (ACBT) involves breathing control, deep thoracic expansion exercises, and forced expiration (huffing). Oscillating positive expiratory pressure (PEP) devices such as the Acapella or Aerobika add vibration. Daily airway clearance — typically 15–30 minutes once or twice per day — is the single most important self-management strategy in bronchiectasis. A respiratory physiotherapist teaches the technique and tailors it to your situation.

Why does the GP need to take sputum samples regularly?

The bacteria colonising and infecting bronchiectatic airways evolve over time, and the organisms vary between individuals. Common culprits include Haemophilus influenzae, Pseudomonas aeruginosa, Staphylococcus aureus, Moraxella, and non-tuberculous mycobacteria (NTM). Regular sputum cultures — and cultures at the start of every exacerbation before starting antibiotics — allow antibiotic treatment to be targeted to the actual organism and resistance pattern rather than guessed. Identifying Pseudomonas aeruginosa is particularly important because it signals more aggressive disease and triggers a specific eradication protocol, followed by suppressive inhaled antibiotics if eradication fails.

What vaccinations are important if I have bronchiectasis?

Annual influenza vaccination is strongly recommended for everyone with chronic lung disease including bronchiectasis — influenza exacerbations in bronchiectasis can be severe. Pneumococcal vaccination (Prevenar 20) is recommended for all people aged 70 and over, and for at-risk groups including chronic respiratory disease at any age — discuss eligibility with your GP. COVID-19 boosters follow current ATAGI recommendations. RSV vaccination is emerging as relevant for those aged 75 and over and for those with significant chronic lung disease. Pertussis (dTpa) boosters are worthwhile if not recently received. Your GP can check your vaccination history and advise.

Bronchiectasis

Bronchiectasis: the AU general practice approach to chronic lung damage

By Dr HB Lo, FACRRM Reviewed 12 July 2026 10 min read

Bronchiectasis is chronic, irreversible widening of the bronchial airways caused by repeated infection and inflammation. Mucus retention, recurrent infection, and progressive airway damage create a self-perpetuating cycle.

HRCT confirms the diagnosis. Aboriginal and Torres Strait Islander Australians carry a disproportionate burden — up to 5–10 times the general rate — often traceable to childhood chronic suppurative lung disease.

Daily airway clearance by a physiotherapist is foundational. Nebulised hypertonic saline, antibiotics for flares, long-term azithromycin for frequent exacerbators, and annual vaccination complete the core approach.

Bronchiectasis — chronic, irreversible widening and distortion of the bronchial airways — is more common in Australian general practice than many clinicians appreciate. Lung Foundation Australia estimates that around 200,000 Australians live with bronchiectasis, though significant underdiagnosis means the true burden is higher. The condition is not rare: in Aboriginal and Torres Strait Islander communities it is endemic, with prevalence rates five to ten times the non-Indigenous general population.

The condition develops when repeated infection and inflammation destroy the elastic and muscular components of the bronchial wall, leaving behind dilated, non-tapering airways that cannot clear secretions effectively. This creates a self-perpetuating cycle: mucus stasis breeds bacterial colonisation, colonisation drives infection, and infection drives further airway damage. The diagnosis is confirmed by high-resolution CT (HRCT); management centres on daily airway clearance, infection control, and immunisation rather than any single pharmaceutical treatment.

A. Core clinical — the AU general-practice framework

Symptoms and who to suspect

Think bronchiectasis when: a patient has a chronic productive cough lasting more than eight weeks, recurrent chest infections (three or more per year), or haemoptysis — blood in the sputum — without another explanation. Daily large-volume mucopurulent sputum (coloured, thick phlegm) is the hallmark. Breathlessness on exertion, fatigue, wheeze, and recurrent sinusitis frequently coexist.

Key populations to have a lower threshold for investigation:

Aboriginal and Torres Strait Islander patients — particularly those from rural or remote areas with a history of childhood respiratory illness. Lung Foundation Australia highlights chronic suppurative lung disease (CSLD) — defined by a chronic wet cough for more than four weeks — as the preventable paediatric precursor to bronchiectasis. Intervening at the CSLD stage with early antibiotic treatment and airway clearance can prevent irreversible damage.
People with known immunodeficiency (including common variable immunodeficiency, IgA deficiency, HIV, or post-transplant immunosuppression).
People with established autoimmune disease (rheumatoid arthritis, SLE, Sjögren’s syndrome), particularly with chronic respiratory symptoms.
Adults with a childhood history of severe pneumonia, pertussis, measles, or tuberculosis.

Physical examination

Coarse inspiratory and expiratory crackles — particularly basal — are characteristic. Wheeze is common, reflecting coexistent airway hyperreactivity. Clubbing of the fingers indicates established, usually long-standing, disease. Tachypnoea and central cyanosis appear in severe cases. The chest may be hyperinflated if significant obstructive physiology has developed.

Investigations

HRCT chest — the diagnostic gold standard per TSANZ and ERS 2017 guidelines. Key features:

Signet ring sign — internal airway diameter exceeds the diameter of the adjacent pulmonary artery.
Lack of bronchial tapering — airways maintain or increase in diameter toward the periphery.
Peripheral airways visible within 1 cm of the pleura — normally not visible.
Additional features: bronchial wall thickening, mucus plugging, tree-in-bud opacities, mosaic attenuation.

Sputum microbiology — MC&S, AFB (acid-fast bacilli), and fungal cultures at baseline and at every exacerbation before antibiotics. Common organisms: Haemophilus influenzae, Pseudomonas aeruginosa, Staphylococcus aureus, Moraxella catarrhalis, non-tuberculous mycobacteria (NTM; MAC, M. abscessus), Aspergillus.

Spirometry — typically shows an obstructive pattern; may be normal in early or mild disease.

Bloods for underlying cause — immunoglobulins (IgG, IgA, IgM, IgE) and IgG subclasses (immunodeficiency); Aspergillus precipitins, total IgE, specific IgE Aspergillus (allergic bronchopulmonary aspergillosis, ABPA); ANA, RF, anti-CCP (connective tissue disease); HIV; alpha-1-antitrypsin (selected). Sweat chloride testing for cystic fibrosis is appropriate at any age in newly diagnosed bronchiectasis. Ciliary studies (nasal nitric oxide test, electron microscopy of brushings) when primary ciliary dyskinesia is suspected.

A systematic aetiological workup is worthwhile in all newly diagnosed patients — BTS 2019 estimates 30–50% of causes are identifiable, and some (immunodeficiency, ABPA, allergic aetiology) have specific treatments that alter the disease course.

B. Daily airway clearance — the therapeutic foundation

Daily airway clearance is the single most important non-antibiotic treatment in bronchiectasis. Lung Foundation Australia’s Bronchiectasis Toolbox and TSANZ both identify it as foundational. The impaired mucociliary escalator of diseased airways cannot clear secretions unaided; without daily assisted clearance, mucus stasis perpetuates the infection-inflammation cycle.

Active cycle of breathing technique (ACBT) — the first-line technique, taught by a respiratory physiotherapist:

Breathing control — gentle tidal breathing at the patient’s own pace, relaxing the shoulders.
Thoracic expansion exercises — deep slow breaths to mobilise secretions from peripheral airways.
Forced expiration (huffing) — controlled expiration through an open mouth, generating airflow to propel secretions centrally; followed by breathing control before repeating.

ACBT is performed 15–30 minutes once or twice daily, and intensified to two or three times daily during exacerbations.

Oscillating positive expiratory pressure (PEP) devices — the Acapella and Aerobika are hand-held devices that deliver oscillating positive pressure during exhalation, vibrating the airways and reducing mucus viscosity. These are as effective as ACBT for many patients and some find them more convenient. Cost (approximately $70–120) is met privately; some private health funds provide coverage.

Postural drainage with percussion or vibration — gravity-assisted positioning combined with chest physiotherapy. Less commonly used now but still appropriate in selected patients, particularly those with significant lower-lobe disease.

High-frequency chest wall oscillation vests — compress and release the chest at high frequency, simulating ACBT. Primarily used in children or adults unable to perform active techniques; expensive and not routinely funded.

Referral to a physiotherapist with respiratory expertise is appropriate at diagnosis and whenever technique requires review. Access is supported under GPCCMP allied health referrals and, for Aboriginal and Torres Strait Islander patients, under item 715 health assessment.

C. Mucoactive agents, inhaled antibiotics, and long-term macrolides

Mucoactive agents

Nebulised hypertonic saline (7%) — the Cochrane-supported first-line mucoactive agent in non-CF bronchiectasis. Multiple trials demonstrate improvement in sputum clearance, quality of life, and exacerbation frequency. It is nebulised before airway clearance sessions to reduce sputum viscosity and is administered using an ultrasonic or mesh nebuliser. Bronchospasm can occur; a bronchodilator pre-treatment is used for those with coexistent airway hyperreactivity. Available as pharmacy-compounded preparation.

Mannitol dry powder (Bronchitol) — TGA-approved for cystic fibrosis; used off-label in non-CF bronchiectasis in selected patients under specialist guidance.

Avoid dornase alfa (Pulmozyme/DNase) in non-CF bronchiectasis — a randomised controlled trial demonstrated harm rather than benefit in this population. Dornase alfa is reserved for cystic fibrosis only.

Inhaled antibiotics for chronic Pseudomonas colonisation

Identification of Pseudomonas aeruginosa in sputum is a key clinical event. At first isolation, an eradication attempt is recommended — typically oral ciprofloxacin combined with inhaled tobramycin or colistin for the defined eradication protocol per eTG Respiratory. If Pseudomonas becomes chronically established, long-term inhaled antibiotic suppression is used to reduce bacterial burden, exacerbation frequency, and decline in lung function:

Inhaled tobramycin (TOBI/Bramitob) — alternating months on/off; PBS Section 100 authority for cystic fibrosis, specialist-initiated off-label for non-CF bronchiectasis.
Inhaled colistin (Promixin) — PBS authority; specialist-initiated.

Regular sputum surveillance for emerging resistance is essential. Specialist respiratory input is required for chronic inhaled antibiotic initiation and monitoring.

Long-term azithromycin for frequent exacerbators

Three landmark trials — BAT (JAMA 2013), EMBRACE (Lancet 2012), and BLESS (JAMA 2013) — established that long-term azithromycin 250 mg three times weekly reduces exacerbation frequency by 30–50% in patients with three or more exacerbations per year.

ERS 2017 and BTS 2019 guidelines recommend offering long-term macrolide therapy to this group, with important caveats:

Pre-screen for NTM with sputum AFB cultures — macrolide monotherapy drives macrolide resistance in NTM, particularly M. avium complex, rendering future NTM treatment far more difficult. Do not commence azithromycin if NTM is present without specialist ID/respiratory guidance.
Baseline ECG — azithromycin prolongs the QT interval; check baseline QTc and avoid in patients with long QT syndrome or QTc >450 ms.
Baseline audiology — risk of macrolide ototoxicity with prolonged use; ongoing hearing monitoring.
Antimicrobial stewardship — this is a significant commitment to long-term antibiotic use; document the indication clearly and review regularly.

Acute exacerbation management

An acute exacerbation is defined by worsening cough with increased sputum purulence or volume, increased breathlessness, fatigue, or fever. eTG Antibiotic recommends:

Obtain sputum MC&S before starting antibiotics.
Oral antibiotic for 14 days — longer than uncomplicated community-acquired pneumonia, reflecting the need to adequately treat colonised airways.
Choice guided by prior sputum culture and sensitivity:
- H. influenzae — amoxicillin 500 mg three times daily, or amoxicillin-clavulanate 875/125 mg twice daily if beta-lactamase-producing.
- Pseudomonas aeruginosa — ciprofloxacin 750 mg twice daily (note boxed warning for tendon and neuropathy risk).
- MRSA or resistant organisms — culture-directed; specialist input.
Intensify airway clearance to two to three times daily.
Severe exacerbations or those with low oxygen saturation warrant hospital admission and IV antibiotics.

D. Australian operations

PBS-subsidised medications (PBS). Amoxicillin, amoxicillin-clavulanate, and ciprofloxacin for exacerbations are PBS general benefit. Long-term azithromycin is PBS general benefit (written off-label for bronchiectasis; document indication). AMH provides prescribing guidance including dose adjustments. Inhaled tobramycin and colistin require specialist initiation and PBS Section 100/Authority. Bronchodilators (salbutamol, formoterol, tiotropium) are PBS general benefit for symptomatic relief where reversibility is demonstrated. Inhaled corticosteroids are PBS general benefit but are not routinely recommended in bronchiectasis without coexistent asthma — randomised data suggest they may increase pneumonia risk.

MBS items (MBS Online). Standard GP consultation items (23/36/44) cover assessment and management. GPCCMP items (965/967, replacing 721/723/732 from 1 July 2025) support chronic disease management plans and allied health referrals for physiotherapy, exercise physiology, and dietitian input. The Aboriginal and Torres Strait Islander Health Assessment (item 715) enables comprehensive respiratory review in eligible patients. The 75+ Health Assessment (item 707) is appropriate for older patients. Pulmonary rehabilitation is supported under MBS items 81100 series and allied health under GPCCMP. HRCT is Medicare-rebatable with specialist referral. Spirometry and sputum MC&S are rebatable in general practice.

Specialist services. Refer to a respiratory physician for all confirmed diagnoses. Major tertiary centres run specialist multidisciplinary bronchiectasis clinics. Lung Foundation Australia maintains specialist directories. Physiotherapists with respiratory expertise are essential for airway clearance training; NACCHO-affiliated Aboriginal Community Controlled Health Services offer culturally safe respiratory care in communities.

Devices. Oscillating PEP devices (Acapella, Aerobika) cost approximately $70–120 and are purchased privately; some private health funds provide rebates. Nebulisers for hypertonic saline are also private purchases.

E. Special populations

Aboriginal and Torres Strait Islander Australians. Bronchiectasis is a significant health equity issue in these communities. Lung Foundation Australia’s national Indigenous bronchiectasis program provides targeted screening, community education, and clinical support, particularly in remote NT, Queensland, and WA. The emphasis on early identification and treatment of CSLD in children is crucial — preventing bronchiectasis by treating CSLD before permanent damage occurs. Culturally safe care through ACCHOs and liaison with remote area nurses and Aboriginal Health Workers forms the backbone of ongoing management in these settings.

Cystic fibrosis. CF-related bronchiectasis is managed through specialist CF centres. The CFTR modulator era (elexacaftor/tezacaftor/ivacaftor — Trikafta) has transformed CF lung disease for eligible genotypes. CF patients are managed on a distinct pathway and are not included in the general bronchiectasis management framework above.

Primary ciliary dyskinesia. Requires specialist respiratory assessment; ciliary studies (nasal nitric oxide, electron microscopy of brushings, genetic testing) confirm the diagnosis. Management mirrors non-CF bronchiectasis with specific consideration of male and female infertility (immotile sperm/abnormal ciliary beat), situs inversus (Kartagener’s syndrome), and recurrent sinusitis and otitis media.

Older adults. Age-related immune decline, swallowing dysfunction, GORD, and chronic aspiration become more important causes of exacerbations in older patients. Functional capacity and respiratory reserve guide intensity of intervention. Falling exacerbation frequency with reduced activity of daily living may mask clinical deterioration; formal physiotherapy assessment is worthwhile.

Massive haemoptysis. Large-volume haemoptysis (classically defined as more than 300 mL in 24 hours, though any clinically significant bleed warrants emergency care) is an uncommon but life-threatening bronchiectasis complication. Call 000. Hospital management includes stabilisation, bronchoscopy, and bronchial artery embolisation.

When to escalate

Arrange urgent hospital assessment for:

Haemoptysis that is more than minimal or where the patient is distressed or haemodynamically compromised — call 000.
Severe exacerbation with low oxygen saturation, high fever, respiratory distress, or failure to improve within 48 hours of outpatient antibiotic.
First isolation of Pseudomonas aeruginosa — specialist input for eradication protocol.
Suspected NTM, fungal infection, or complications (pneumothorax, empyema).

Refer to a respiratory physician (non-urgent) for:

All confirmed diagnoses of bronchiectasis.
Three or more exacerbations per year — consider long-term azithromycin.
Suspected underlying CF, PCD, or immunodeficiency.
Consideration of long-term inhaled antibiotics.
Suitability for pulmonary rehabilitation, or assessment for lung resection (localised disease) or transplant (end-stage).

What this article is and is not

This is general health information based on current Australian respiratory guidelines — Therapeutic Guidelines (eTG), AMH, Lung Foundation Australia, TSANZ — and major bronchiectasis trials (BAT, EMBRACE, BLESS, ERS 2017, BTS 2019). It is not personal medical advice and does not create a doctor–patient relationship. Decisions about your specific situation, including investigations and treatment, are made with your GP and treating clinicians.

For Australian consumer resources: HealthDirect — Bronchiectasis, Lung Foundation Australia — Bronchiectasis Toolbox, TSANZ.

For acute respiratory distress or heavy haemoptysis: call 000.

Sources cited

Frequently asked questions

What causes bronchiectasis?

The most common cause worldwide is post-infective damage — severe or recurrent childhood pneumonia, whooping cough (pertussis), measles, or tuberculosis leaving permanent bronchial scarring. Other important causes include cystic fibrosis (managed at specialist CF centres), primary ciliary dyskinesia, immune system deficiency (including common variable immunodeficiency), allergic bronchopulmonary aspergillosis (ABPA), autoimmune conditions such as rheumatoid arthritis or lupus, and chronic aspiration from severe reflux or swallowing problems. Despite investigation, roughly 30–50% of cases remain idiopathic. Identifying the underlying cause matters because it may change treatment.
What does bronchiectasis feel like day to day?

Most people with bronchiectasis experience a chronic daily cough that produces significant volumes of mucus or phlegm — often described as mucopurulent (coloured, thick). Breathlessness on exertion, fatigue, and recurrent chest infections are common. Blood in the sputum (haemoptysis) occurs in a proportion of people, usually in small amounts; rarely it can be heavy. Chronic sinusitis and wheeze often coexist. Many people have periods of stability interrupted by exacerbations — flares where symptoms worsen, sputum becomes more purulent, and energy drops — often requiring a course of antibiotics.
What is the signet ring sign on CT?

When radiologists report a 'signet ring sign' on a CT scan, they are describing an airway whose internal diameter is larger than the diameter of the adjacent blood vessel — the pulmonary artery branch that normally matches it in size. This is one of the hallmarks of bronchiectasis on high-resolution CT. Additional CT features include airways that fail to taper as they travel toward the lung periphery, and airways visible within one centimetre of the lung pleura (normally they are not visible so close to the edge). The pattern and distribution across the lung lobes may give clues to the underlying cause.
What is airway clearance and do I need to do it every day?

Airway clearance is a set of breathing and positioning techniques designed to help you move mucus out of the damaged airways — techniques that the airways' own impaired clearance mechanisms can no longer do effectively. The active cycle of breathing technique (ACBT) involves breathing control, deep thoracic expansion exercises, and forced expiration (huffing). Oscillating positive expiratory pressure (PEP) devices such as the Acapella or Aerobika add vibration. Daily airway clearance — typically 15–30 minutes once or twice per day — is the single most important self-management strategy in bronchiectasis. A respiratory physiotherapist teaches the technique and tailors it to your situation.
Why does the GP need to take sputum samples regularly?

The bacteria colonising and infecting bronchiectatic airways evolve over time, and the organisms vary between individuals. Common culprits include Haemophilus influenzae, Pseudomonas aeruginosa, Staphylococcus aureus, Moraxella, and non-tuberculous mycobacteria (NTM). Regular sputum cultures — and cultures at the start of every exacerbation before starting antibiotics — allow antibiotic treatment to be targeted to the actual organism and resistance pattern rather than guessed. Identifying Pseudomonas aeruginosa is particularly important because it signals more aggressive disease and triggers a specific eradication protocol, followed by suppressive inhaled antibiotics if eradication fails.
What vaccinations are important if I have bronchiectasis?

Annual influenza vaccination is strongly recommended for everyone with chronic lung disease including bronchiectasis — influenza exacerbations in bronchiectasis can be severe. Pneumococcal vaccination (Prevenar 20) is recommended for all people aged 70 and over, and for at-risk groups including chronic respiratory disease at any age — discuss eligibility with your GP. COVID-19 boosters follow current ATAGI recommendations. RSV vaccination is emerging as relevant for those aged 75 and over and for those with significant chronic lung disease. Pertussis (dTpa) boosters are worthwhile if not recently received. Your GP can check your vaccination history and advise.

Source quality

Sources grouped by evidence tier. AU primary tier first; international where AU is silent or lagging; named-author reconstruction where guidelines have not yet caught up. How tiers work.