Bronchiectasis: The Forgotten Lung Disease That Deserves Your Attention
Millions of people live with bronchiectasis without ever receiving a correct diagnosis — their daily cough, repeated chest infections, and breathlessness dismissed as something else for years. A pulmonologist explains what bronchiectasis truly is, why it is so often missed, and how it can be managed effectively.
If you asked most people — including many healthcare professionals outside of respiratory medicine — what bronchiectasis is, you would likely be met with a blank look. It is not a condition that features prominently in public health campaigns. It does not have an awareness ribbon. It lacks the cultural familiarity of asthma or the feared reputation of lung cancer. And yet it affects tens of millions of people globally, causes profound daily suffering, and is almost certainly underdiagnosed on a massive scale.
In my pulmonology clinic, I see bronchiectasis patients who have spent five, ten, sometimes fifteen years being treated for "recurrent chest infections" or "chronic bronchitis" — never having been told that their airways were permanently damaged, and never having received the specific, targeted management that might have slowed that damage and improved their quality of life considerably.
This article is for those patients — and for the family members who watch them struggle every day with a condition that has never properly been explained to them. Bronchiectasis may be forgotten by the wider medical conversation. But it should not be forgotten by the people who live with it.
What Is Bronchiectasis?
Bronchiectasis is a chronic lung condition characterised by permanent, abnormal widening and scarring of the bronchi — the large and medium airways that carry air from the windpipe into the deeper lung tissue. In a healthy airway, the bronchi are elastic tubes lined with tiny hair-like structures called cilia that sweep mucus, debris, and inhaled particles upward and out of the lungs. The airways narrow progressively as they branch deeper into the lung, maintaining efficient airflow and effective mucus clearance.
In bronchiectasis, this architecture is irreversibly disrupted. The airway walls are thickened, scarred, and permanently dilated — often described as having a "dilated" or "floppy" appearance on imaging. The damaged airways lose their ability to clear mucus effectively. Mucus pools in the widened, abnormal segments, creating an environment in which bacteria colonise and multiply. This leads to chronic infection, further inflammation, more damage — and a self-perpetuating cycle that, without proper management, drives progressive deterioration of lung function over years.
It is important to understand that bronchiectasis is not a single disease. It is a final common pathway — an end result — that can be reached through many different disease processes. Identifying the underlying cause is not merely academic. It directly shapes the management approach and, in some cases, can identify treatable conditions that, if addressed, prevent further progression.
What Causes Bronchiectasis?
The causes of bronchiectasis are numerous, and in a significant proportion of patients — particularly in the developing world — no specific cause is ever identified despite thorough investigation. This is termed idiopathic bronchiectasis. However, the following causes account for the majority of identifiable cases.
Post-Infectious Bronchiectasis
This is the most common identifiable cause globally and is particularly prevalent in Pakistan and other parts of South Asia. Severe or poorly treated respiratory infections — particularly in childhood — can cause permanent airway damage that becomes apparent as bronchiectasis years or decades later. The most important infectious causes include:
- Tuberculosis — one of the most significant causes of bronchiectasis in Pakistan. TB-related bronchiectasis results from direct airway destruction during the active infection and from post-TB scarring and airway distortion. Many patients with TB-related bronchiectasis are not aware that their ongoing respiratory symptoms are a legacy of their previous infection.
- Severe childhood pneumonia — particularly whooping cough (pertussis) and measles pneumonia, which can cause extensive airway damage in young children whose lungs are still developing. This is a particularly important cause in settings with incomplete childhood vaccination coverage.
- Non-tuberculous mycobacterial (NTM) infection — increasingly recognised as both a cause and a complication of bronchiectasis. NTM bacteria can infect the already-damaged airways of bronchiectasis patients, causing further deterioration.
Immune Deficiency
The immune system plays a critical role in protecting the airways from infection. When immune defences are impaired — whether from a congenital immune deficiency, HIV infection, or immunosuppressive medication — recurrent, severe respiratory infections occur that progressively damage the airways. Common variable immunodeficiency (CVID) is the most frequent primary immune deficiency associated with bronchiectasis and should always be considered in patients with recurrent sino-pulmonary infections.
Primary Ciliary Dyskinesia (PCD)
PCD is a rare genetic condition in which the cilia lining the airways are structurally abnormal and unable to beat effectively. Without functional cilia, mucus cannot be cleared from the airways, leading to recurrent infections and progressive bronchiectasis from early childhood. PCD is significantly underdiagnosed — many patients are not identified until adulthood despite having had symptoms since infancy.
Cystic Fibrosis
Cystic fibrosis is a genetic condition causing abnormally thick, sticky mucus that cannot be cleared from the airways, leading to chronic infection and progressive bronchiectasis. While more commonly diagnosed in childhood in high-income countries, mild or atypical forms of cystic fibrosis are increasingly identified in South Asian adults who were not diagnosed in childhood.
Allergic Bronchopulmonary Aspergillosis (ABPA)
ABPA is an inflammatory condition caused by an immune reaction to the fungus Aspergillus fumigatus in the airways of people with asthma or cystic fibrosis. Recurrent episodes of inflammation cause progressive central airway damage and a characteristic pattern of bronchiectasis. It is more common in South Asia than in Western populations and should always be considered in asthmatic patients with difficult-to-control symptoms and recurrent mucus plugging.
Connective Tissue Diseases
Rheumatoid arthritis, Sjögren's syndrome, and other connective tissue diseases are associated with bronchiectasis — sometimes presenting before the articular manifestations of the underlying disease are apparent. The mechanism involves immune-mediated airway inflammation that progressively damages the bronchial walls.
Chronic Aspiration
Recurrent aspiration of food, liquid, or gastric acid into the airways — due to swallowing disorders, neurological conditions, or severe gastro-oesophageal reflux — can cause progressive lower lobe bronchiectasis. This is an underappreciated cause that should be considered particularly in elderly patients and those with neurological conditions affecting swallowing.
Recognising the Symptoms
The symptoms of bronchiectasis are not dramatic or sudden — they are grinding, daily, and easily normalised by patients who have lived with them for years. This normalisation is the primary reason diagnosis is so often delayed.
The most consistent and defining symptom. Patients cough up significant quantities of mucus — often described as thick, coloured (yellow, green, or brown), and foul-smelling — particularly in the morning. The daily mucus volume can range from a few teaspoons to more than a cupful in severe disease.
Frequent episodes of worsening — called exacerbations — in which cough increases, mucus becomes more purulent, breathlessness worsens, and systemic symptoms such as fever and fatigue develop. Many patients require multiple courses of antibiotics per year. Each exacerbation causes further airway damage.
Progressive breathlessness on exertion that worsens over years as lung function declines. In early disease it may be minimal; in advanced bronchiectasis it can be severely limiting, preventing patients from performing basic daily activities.
Blood in the sputum — ranging from blood-streaked mucus to significant bleeding — occurs in up to 50 percent of bronchiectasis patients at some point. It results from rupture of the fragile, inflamed blood vessels lining the damaged airways. Significant haemoptysis requires urgent medical attention.
Narrowing of the damaged airways and the presence of excess mucus produce wheeze and a sensation of chest tightness. This can lead to bronchiectasis being misdiagnosed as asthma, particularly when other symptoms are not fully explored.
The combination of chronic infection, poor sleep from nocturnal coughing, the physical effort of clearing secretions daily, and the psychological burden of a chronic illness produces profound fatigue that significantly undermines quality of life and daily functioning.
The patients who move me most in my clinic are the ones who have spent years apologising for their cough — in meetings, in restaurants, in their children's school plays — never knowing it had a name, a cause, and a treatment. Bronchiectasis is not something you simply have to endure. It is something we can manage together, meaningfully and specifically.
— Dr. Nabila Zaheer, Pulmonologist
Who Is at Greatest Risk?
Key Risk Factors for Bronchiectasis
- History of tuberculosis — one of the strongest risk factors in Pakistan. Anyone with a previous TB diagnosis should be assessed for post-TB bronchiectasis if they continue to experience respiratory symptoms after completing treatment.
- Severe or recurrent childhood chest infections — particularly whooping cough, measles pneumonia, or severe bacterial pneumonia in early childhood before the lungs are fully developed.
- Childhood in a setting with limited healthcare access — infections that were inadequately treated or left to resolve without antibiotics carry a higher risk of permanent airway damage.
- Recurrent sino-pulmonary infections in adulthood — frequent infections of both the sinuses and the lower respiratory tract suggest an underlying immune deficiency or ciliary disorder that predisposes to bronchiectasis.
- Diagnosed asthma with poor control — particularly in patients with ABPA, where recurrent episodes of fungal inflammation cause progressive central bronchiectasis that is often mistaken for difficult-to-control asthma.
- Connective tissue disease — particularly rheumatoid arthritis and Sjögren's syndrome, where airway involvement may precede or accompany joint disease.
- Immunosuppressive therapy — patients on long-term immunosuppressants for any reason are at risk of recurrent pulmonary infections that may lead to bronchiectasis.
- Female sex — bronchiectasis is significantly more common in women than men for reasons that are not fully understood but may relate to airway anatomy and immune differences.
How Is Bronchiectasis Diagnosed?
Bronchiectasis is a radiological diagnosis — it is confirmed by imaging rather than by symptoms or breathing tests alone. However, the clinical story is what triggers the appropriate investigation, which is why it is so important for both patients and clinicians to recognise the characteristic symptom pattern.
High-Resolution CT Scan (HRCT) of the Chest
HRCT is the gold standard for diagnosing bronchiectasis. It reveals the characteristic features with high sensitivity and specificity: dilated, thickened bronchial walls, often described as having a "signet ring" appearance when the dilated airway sits beside its accompanying blood vessel; "tramline" shadows indicating parallel thickened airway walls; and in severe disease, cystic or saccular airway dilations. HRCT also identifies the distribution and extent of disease, guides the search for an underlying cause, and provides a baseline against which future progression can be measured. A standard chest X-ray may suggest bronchiectasis in advanced disease but frequently appears normal or non-specifically abnormal in milder cases, which is why HRCT is essential.
Pulmonary Function Tests (Spirometry)
Spirometry assesses the degree of airflow obstruction caused by the damaged and mucus-filled airways. Results are typically obstructive — similar to the pattern seen in COPD and asthma — though a mixed or restrictive pattern may occur in severe, extensive disease. Serial spirometry over time tracks disease progression and the response to treatment.
Sputum Microbiology
Sending a sputum sample for culture and sensitivity testing is essential in bronchiectasis management. It identifies the bacteria chronically colonising the airways — most commonly Haemophilus influenzae, Pseudomonas aeruginosa, Streptococcus pneumoniae, or Staphylococcus aureus — and their antibiotic sensitivity patterns. This information directly guides the choice of antibiotics for treating exacerbations and informs decisions about long-term suppressive antibiotic therapy. Pseudomonas aeruginosa colonisation is particularly significant, as it is associated with more frequent exacerbations and faster lung function decline.
Investigation for Underlying Cause
A thorough search for the underlying cause of bronchiectasis should be undertaken in all patients. This includes blood tests for immunoglobulin levels (to detect immune deficiency), serum IgE and Aspergillus-specific IgE (to assess for ABPA), rheumatological antibodies (to screen for connective tissue disease), and sweat chloride testing or genetic testing for cystic fibrosis where appropriate. Nasal nitric oxide measurement and ciliary biopsy may be performed in specialist centres where PCD is suspected.
Treatment: Managing Bronchiectasis Effectively
There is currently no treatment that reverses established bronchiectasis or regenerates damaged airway tissue. However — and this is critically important — effective management can break the cycle of infection and inflammation, reduce exacerbation frequency significantly, slow the rate of progression, and produce meaningful improvements in daily symptoms and quality of life. The earlier management begins, the greater the benefit.
Clearing mucus from the damaged airways every day is the single most important self-management behaviour in bronchiectasis. Without daily airway clearance, mucus pools in the abnormal airways, bacteria multiply, and the cycle of infection and inflammation accelerates. Techniques include active cycle of breathing technique (ACBT), postural drainage, oscillating positive expiratory pressure (OPEP) devices such as the Acapella or Flutter, and high-frequency chest wall oscillation vests. The right technique for each patient depends on disease distribution, severity, and patient preference — a respiratory physiotherapist with expertise in bronchiectasis is the ideal person to teach and optimise this. Most patients should be performing airway clearance at least once — and ideally twice — daily.
When an exacerbation occurs — recognised by increased sputum volume or purulence, worsening breathlessness, fever, or general deterioration — antibiotic treatment should begin promptly based on the patient's known sputum microbiology where possible. Delaying treatment allows the infecting bacteria to establish more deeply and causes further airway damage. Most patients with established bronchiectasis benefit from having a supply of an appropriate antibiotic at home — an "rescue pack" — with clear written instructions on when and how to use it, rather than waiting to see a doctor before starting treatment.
For patients with frequent exacerbations — typically three or more per year — long-term low-dose antibiotic therapy reduces the bacterial burden in the airways and significantly reduces exacerbation frequency. Azithromycin taken three times weekly is the most widely used and studied option. Inhaled antibiotics — such as inhaled tobramycin or colistin — deliver high antibiotic concentrations directly to the airway surface and are particularly used in patients chronically colonised with Pseudomonas aeruginosa. Long-term antibiotic therapy requires careful monitoring and should be managed by a pulmonologist experienced in bronchiectasis.
Many bronchiectasis patients have coexisting airflow obstruction that responds to bronchodilator inhalers — the same medications used in asthma and COPD. These improve symptom control and may facilitate airway clearance by opening the airways. Mucolytic agents — medications that thin and loosen mucus — can make airway clearance easier and more effective. Nebulised hypertonic saline (a concentrated salt solution) is one of the most effective mucolytics in bronchiectasis, hydrating the airway surface and making mucus less viscous and easier to expectorate.
Pulmonary rehabilitation — a structured programme of supervised exercise, breathing education, and self-management support — significantly improves exercise capacity, reduces breathlessness, and improves quality of life in bronchiectasis patients. It also teaches and reinforces airway clearance techniques. Despite strong evidence for its benefits, it remains underutilised in bronchiectasis compared to COPD. I recommend it to all patients whose breathlessness or exercise intolerance is affecting daily life.
Where a specific underlying cause is identified, treating it is a fundamental part of management. Patients with immune deficiency benefit from immunoglobulin replacement therapy, which dramatically reduces infection frequency. Patients with ABPA require antifungal treatment and corticosteroids to control the immune-mediated inflammation. Patients with connective tissue disease may benefit from disease-modifying antirheumatic therapy. Addressing reflux and aspiration in those with chronic aspiration bronchiectasis can slow further progression significantly.
Surgery plays a limited but important role in selected patients. Surgical resection — removal of the most severely affected lobe or segment — can be considered in patients with localised bronchiectasis causing frequent, severe exacerbations that are not responding to medical management, or in patients with significant recurrent haemoptysis from a localised area. In patients with diffuse, bilateral disease and very advanced lung function impairment, lung transplantation is occasionally considered in carefully selected younger patients.
Managing Bronchiectasis Day to Day
Living well with bronchiectasis requires active, consistent self-management — not passive acceptance of symptoms. The patients who do best are those who take ownership of their daily airway clearance, recognise exacerbations early, and maintain close contact with their specialist team.
- Perform airway clearance every single day — not just when you feel congested or unwell. Daily clearance prevents mucus from accumulating and bacteria from establishing. Think of it the same way as brushing your teeth — a non-negotiable daily habit.
- Stay well hydrated — adequate fluid intake keeps mucus thinner and easier to clear. Dehydration — even mild — thickens secretions and makes airway clearance significantly harder. Aim for at least 1.5 to 2 litres of fluid daily.
- Know your exacerbation warning signs — increased sputum volume, change in colour to yellow or green, worsening breathlessness, or fever. Act on these signs promptly — earlier treatment leads to faster recovery and less airway damage.
- Vaccinate every year — annual influenza vaccination and pneumococcal vaccination significantly reduce infection-triggered exacerbations. COVID-19 vaccination is equally important. Respiratory infections are the most common exacerbation trigger in bronchiectasis.
- Exercise regularly — physical activity assists mucus clearance through increased breathing rate and chest movement, improves cardiovascular fitness, and reduces breathlessness over time. Even walking daily produces measurable benefits.
- Do not smoke — smoking worsens bronchiectasis profoundly. It impairs the already-compromised mucociliary clearance, increases infection susceptibility, and accelerates lung function decline. If you smoke and have bronchiectasis, stopping is the most important thing you can do for your lung health.
- Attend regular specialist follow-up — bronchiectasis is a dynamic condition requiring regular review of sputum microbiology, lung function, and treatment response. Annual CT imaging may be needed to monitor structural progression. Do not wait until you are unwell to see your pulmonologist.
Bronchiectasis will not disappear — the structural damage is permanent. But the symptoms, the exacerbations, the progressive decline — these are things we can influence substantially. Patients who do their airway clearance, who treat infections early, who exercise and stay hydrated — these patients live remarkably well with this condition. The disease does not have to define the life.
— Dr. Nabila Zaheer, Pulmonologist
Frequently Asked Questions
Is bronchiectasis the same as COPD?
No — though they share some features and can coexist. COPD involves damage to the small airways and air sacs, causing air trapping and obstruction primarily driven by smoking. Bronchiectasis involves permanent widening and scarring of the larger airways, driven by recurrent infection and inflammation. The two conditions have different causes, different patterns on CT imaging, and some differences in their management — though both involve airflow obstruction on spirometry and both benefit from bronchodilators and pulmonary rehabilitation. A significant proportion of patients have both conditions simultaneously, particularly in Pakistan where smoking and TB exposure are both common.
Will bronchiectasis get worse over time?
Without appropriate management, bronchiectasis typically does progress over time — each exacerbation causing incremental further damage, and lung function declining gradually over years. However, with consistent airway clearance, prompt treatment of exacerbations, long-term suppressive antibiotics where indicated, and addressing underlying causes, the rate of progression can be slowed significantly. Many patients maintain stable lung function over many years with good management. This is why early diagnosis and early specialist involvement matters so much.
I had TB ten years ago and was fully treated. Could my current cough be related?
Yes — this is a very important question in Pakistan. Post-TB bronchiectasis is extremely common and frequently unrecognised. The airway damage caused by tuberculosis can result in bronchiectasis that becomes symptomatic years or even decades after the TB itself was cured. If you have a chronic productive cough, recurrent chest infections, or breathlessness following a previous TB diagnosis, you should be assessed specifically for post-TB bronchiectasis with an HRCT scan. This is a different condition from active TB and requires a completely different management approach.
How often should I see a pulmonologist if I have bronchiectasis?
Most stable bronchiectasis patients should be reviewed by a pulmonologist at least every six to twelve months. Reviews should include assessment of exacerbation frequency, sputum microbiology, lung function testing, review of airway clearance technique, and medication optimisation. More frequent review is appropriate during periods of instability, after hospitalisation, when starting long-term antibiotic therapy, or when a new underlying cause has been identified and treatment initiated. Patients who have not seen a specialist in more than a year should arrange a review regardless of how stable they feel.
Is bronchiectasis contagious?
No — bronchiectasis itself is not contagious. It is a structural condition of the airways, not an infection. The bacteria that colonise bronchiectatic airways are common environmental organisms that most people encounter regularly without developing infection. However, if bronchiectasis has been caused by tuberculosis in the past, the TB itself was infectious during its active phase — though a patient who completed TB treatment is not infectious from the TB. The current chronic cough of bronchiectasis, while distressing and socially challenging, poses no infectious risk to people around the patient.
A Daily Cough Is Not Something to Simply Live With
If you have been coughing up mucus every day, suffering repeated chest infections, or managing breathlessness that limits your life — and have never been properly investigated — it is time to find out what is really happening in your lungs. Book a consultation with Dr. Nabila Zaheer at PulmoCare today.
Book an Appointment