From evidence to practice: What the 2025 European Respiratory Society Bronchiectasis Guideline means for India

INTRODUCTION

Bronchiectasis, long neglected in many regions, is finally receiving the clarity of a comprehensive, international guideline. The European Respiratory Society (ERS) has recently published its Clinical Practice Guideline for the Management of Adult Bronchiectasis (2025), providing evidence-based recommendations to standardize care and reduce unwarranted variation in clinical practice.[1]

However, guidelines written for multiple settings and healthcare systems need to be interpreted and applied within local contexts. The strength of the guidelines this time was that there was representation from four continents and it took geographical variations into account. This is particularly relevant for India and other low- and middle-income countries (LMICs), where disease aetiology, microbiology, and health-system capacity differ substantially from Western cohorts. In this editorial, we discuss the implications of the ERS guideline for India using available national and regional evidence to contextualise its recommendations.[2,3,4]

KEY MESSAGES FROM THE ERS GUIDELINE

Holistic assessment

The ERS guideline emphasises comprehensive aetiological testing, including immunology, microbiology, and high-resolution computed tomography, alongside systematic assessment of disease activity, severity, and comorbidities. This approach underpins the identification of treatable traits and personalised management, enabling clinicians to target therapies more effectively and to stratify future risk.[1]

Airway clearance techniques and pulmonary rehabilitation

Airway clearance techniques are strongly recommended for all patients, ideally taught and reviewed by trained respiratory physiotherapists. Pulmonary rehabilitation is also strongly recommended for patients with breathlessness or impaired exercise capacity. Despite strong evidence supporting both interventions, access and uptake remain suboptimal in many settings, particularly in LMICs.[1,2,3]

Pharmacologic strategies

Long-term macrolide therapy is strongly recommended for patients at high risk of exacerbations, while inhaled antibiotics are recommended for those with chronic Pseudomonas aeruginosa infection and frequent exacerbations, with conditional recommendations for suppression of other Gram-negative pathogens. Muco-active drugs may be considered in selected patients, whereas routine use of oral non-macrolide antibiotics and inhaled corticosteroids (ICSs) is discouraged in the absence of clear co-existing indications such as asthma or COPD.[1]

Exacerbations, deterioration, and treatable traits

The guideline introduces structured approaches to the management of exacerbations and deterioration, emphasising early sputum sampling, timely escalation of care, specialist review, and a treatable-traits framework that incorporates comorbidities such as cardiovascular disease, gastro-oesophageal reflux, rhino-sinusitis, and mental health disorders.[1]

RELEVANCE TO THE INDIAN AND LMIC CONTEXT

In India, bronchiectasis is predominantly post-infectious, frequently following tuberculosis or severe pneumonia, and is associated with a high burden of allergic bronchopulmonary aspergillosis (ABPA). This contrasts with Western cohorts, where idiopathic and immune-mediated causes are more common. These differences underscore the importance of systematic aetiological evaluation and tailored management strategies in the Indian context.[2,4]

Resource constraints pose challenges to implementing physiotherapist-led airway clearance, inhaled antibiotic therapy, and pulmonary rehabilitation at scale. Nevertheless, the ERS guideline provides an aspirational benchmark and highlights priority areas for capacity-building within health systems.[1]

Indian registry data demonstrate a high frequency of exacerbations and hospitalisations, emphasising the importance of preventive strategies. Low-cost, effective interventions such as airway clearance techniques and long-term macrolides remain underutilised. Knowledge of airway microbiology is critical, particularly in a setting characterised by frequent Gram-negative infections and antimicrobial resistance.[2,3]

One of the most immediate implications of the ERS guideline for India relates to inhaled corticosteroid use. EMBARC India data show that more than half of bronchiectasis patients receive ICS, reflecting an asthma- or COPD-centric treatment paradigm. This practice is not supported by evidence and is explicitly discouraged by current guidelines and international registry analyses.[1,2,5]

PULLING TOGETHER KEY CONCEPTS

Individualised risk assessment

Indian data have identified specific predictors of poor outcomes, including COPD–bronchiectasis overlap, cardiovascular comorbidities, smoking history, prior exacerbations, infection with Pseudomonas or Klebsiella, and higher dyspnoea scores. These findings support a pragmatic approach to initial assessment incorporating spirometry, symptom burden, exacerbation history, sputum culture, and validated severity indices.[3,6]

The deteriorating patient

The ERS guideline provides a structured framework for recognising and managing deterioration, defined by increasing exacerbation frequency, worsening symptoms, or lung-function decline. Early specialist review, repeat imaging, reassessment of aetiology, and proactive treatable-traits-based intervention are emphasised to prevent disease progression.[1]

Proactive management

Earlier treatment paradigms often restricted macrolide therapy to patients with three or more exacerbations per year. Emerging evidence suggests that exacerbation history alone does not fully predict future risk and that earlier intervention may benefit a broader group of patients. In India, macrolide use remains low despite substantial exacerbation-related morbidity, indicating a major opportunity for improving outcomes through guideline-aligned care.[1,2,3]

CHALLENGES AND FUTURE DIRECTIONS

The implementation of guideline-recommended care will require sustained investment in training, infrastructure, and service delivery models adaptable to different levels of the healthcare system. EMBARC India has already transformed understanding of bronchiectasis nationally, and the proposed INBARC initiative offers an important platform for phenotyping, identifying Indian-specific aetiotypes, and conducting prospective studies.[2,3]

Policy engagement is essential to recognise bronchiectasis as a priority respiratory disease. Development of Indian bronchiectasis guidelines, aligned with ERS principles but adapted to local epidemiology, microbiology, and access barriers, represents a logical next step.[7]

Finally, generating local evidence is critical. Indian patients exhibit distinct disease characteristics and remain under-represented in clinical trials. Building national clinical-trial networks and translational research capacity will be key to delivering truly context-appropriate, evidence-based care.[4,7]

CONCLUSION

The ERS Clinical Practice Guideline for Adult Bronchiectasis represents a landmark, providing a robust and patient-centred framework for care. For India and other LMICs, its greatest value lies in guiding rational adaptation, prioritising effective interventions, and stimulating the generation of local evidence. The convergence of structured clinical frameworks with expanding translational research capacity may define the next phase of bronchiectasis care in India.