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Non Cystic Fibrosis Bronchiectasis Care
Improving Non–Cystic Fibrosis Bronchiectasis Care From Diagnosis to Treatment

Released: June 11, 2025

Expiration: June 10, 2026

David E. Griffith
David E. Griffith, MD, ATSF, FACCP, FRSM
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Key Takeaways
  • A timely diagnosis is critical for patients with NCFBE, and when evaluating possible therapies, the most important thing is educating patients on their diagnosis.
  • Routine airway clearance regimens should include an OPEP device plus 7% hypertonic saline.
  • Brensocatib is currently under FDA evaluation for treatment of NCFBE.
  • If approved by the FDA, HCPs should prescribe it for as many people as possible who meet the FDA-approved criteria. 

In this commentary, David E. Griffith, MD, ATSF, FACCP, FRSM, addresses questions posed by healthcare professionals (HCPs) during a live symposium titled “The Road to Victory Over the Vortex: Innovations in Non–Cystic Fibrosis Bronchiectasis,” held at the American Thoracic Society 2025 International Conference. These questions highlight the need to diagnosis patients with non–cystic fibrosis bronchiectasis (NCFBE) early and tailor treatment to meet patients’ specific needs. 

What are your key takeaways from the symposium?
A main point was the lack of timely diagnosis of NCFBE. It appears that many patients go several years before they have appropriate imaging and a confirmed diagnosis. Of note, the American Lung Association defines chronic cough as any cough lasting ≥8 weeks. That may seem relatively short, but when looking at patients diagnosed with NCFBE, sometimes several years pass before they have an appropriate radiographic diagnosis. I urge HCPs to think about NCFBE early, particularly in patients who are women and 60-70 years of age when there are no other likely explanations for cough. There also is no “normal” cough. Cough is always abnormal no matter how long it has been present or how used to it patients are. After these considerations, other aspects of the NCFBE evaluation can be started, such as evaluating the etiology.

When evaluating possible therapies for NCFBE, the most important thing is educating patients on their diagnosis. Many patients may have never heard of NCFBE, and most do not already know someone with NCFBE. I am frequently struck by the patients whose biggest concern is that they do not know what NCFBE is. Of more importance, they do not know what their disease prognosis is. I have patients who think that they have a fatal diagnosis. Certainly that can occur, but it is unusual. Therefore, I would urge HCPs to spend time with patients to define NCFBE, show a few representative cuts on a scan, and illustrate what it looks like. It can be a bit frightening for patients, which can be easily fixed with conversation and a little bit of time. 

I recognize that time is the biggest problem here for many HCPs. But there is no substitution for explaining what the disease is, how patients developed it, and its management or prognosis. Education does not have to occur in every visit, but it should happen at least at the time of initial diagnosis.

Given the increasing suggestion that patients should have more frequent CT imaging to monitor disease progression, do you see a role for chest MRI, especially to reduce lifetime cumulative radiation exposure in younger patients?
Of course patients are concerned about radiation exposure with serial chest CTs. To be frank, CT imaging does not have to be done frequently because in most circumstances NCFBE is a slowly progressive process. Chest CTs are more important for evaluating comorbidities like mycobacterial disease or other infections. Most CT scanners these days are low-dose scanners, so the cumulative radiation exposure is not astronomically high. Again, NCFBE occurs in patients aged 60 and older. If performing a chest CT scan every 6 months for example, it is unlikely that the total accumulative radiation exposure would put a patient at risk for hematologic malignancy. However, CT imaging should only be done when there is a specific question being asked.

I try to reassure patients that once a diagnosis is made, and particularly if there are comorbidities, a chest CT is an essential element of monitoring their treatment. For evaluating the emergence of newer issues or comorbidities, unfortunately chest MRI currently is not an adequate substitute for chest CT. There are advances being made with MRI, which might make it more of a useful tool in the future.

Do you use hypertonic saline as part of an airway clearance treatment? Is there any good evidence for its use?
My routine airway clearance regimen includes an oscillating positive expiratory pressure (OPEP) device plus 7% hypertonic saline. I generally do not use acetylcysteine simply because there is no evidence that it is more effective or as effective as a hypertonic saline. It is of interest that although some patients can have a transformative, positive response to airway clearance, there are no perspective studies to confirm the efficacy of airway clearance with hypertonic saline vs acetylcysteine. Whereas some patients see improvements both immediately and dramatically, not everyone has such a dramatic response. So there are other ways to do airway clearance, such as with a vibratory vest, an OPEP device, and hypertonic saline.

Can N-acetylcysteine be used long term? If so, what regimen do you recommend?
I very rarely use N-acetylcysteine. As far as I can tell, it can be used long term for certain respiratory illnesses, but it is not something that I routinely recommend to patients with NCFBE.

With sputum collection, do you recommend measuring sputum eosinophils/neutrophils to further define NCFBE endotypes to guide treatment?
There is a growing trend now in defining endotypes of NCFBE to guide treatment. Currently it is not recommended to do routine sputum cell analysis via the evaluation of eosinophils and neutrophils, but it is possible that that will become common practice. Experts, particularly in the United Kingdom, have proposed these endotypes and how they are associated with bronchospasm and steroid response. There are experts in the field who feel that treatment can be guided based on the nature of the inflammation in the bronchial tubes, especially eosinophilic and neutrophilic inflammation. As of right now though, that is not routinely recommended.

What is your inhaled antibiotic strategy?
Many patients with NCFBE have potentially pathogenic bacteria in their tracheobronchial tree, which can be cultured via their sputum. The most common and most important one is Pseudomonas aeruginosa. For most patients, P aeruginosa can be managed with periodic oral or intravenous antibiotics. But some patients with recurrent exacerbations caused by P aeruginosa are candidates for inhaled antibiotics. The clinical use of inhaled antibiotics is a bit controversial, as international guidelines conditionally recommend them. Some experts recommend inhaled antibiotics if patients have 2 or 3 exacerbations within 12 months. I consider an inhaled antibiotic for patients with 2 exacerbations or pneumonia within 12 months.

Now there are other diseases like refractory chronic cough where patients might benefit from inhaled antibiotics. My sense is that the inhaled antibiotics are underused in patients with NCFBE, but not all patients can tolerate them. This treatment option underscores the importance of routine sputum respiratory cultures. HCPs must know what is growing in the tracheobronchial tree other than mycobacteria. And the other part of the inhaled antibiotic story is that inhaled tobramycin, which was introduced a couple of decades ago, was approved by the FDA to administer for 28 days on and 28 days off. That strategy was based on a concern that patients might develop resistance if they use continuous inhaled antibiotics. It is of interest that some experts in the field recommend the routine use of inhaled antibiotics without interruption. So there are several choices that patients can be given. Of note, the regimen should be tailored to the specific needs of each patient.

How often do you check ECG and audiometry in patients on macrolide therapy?
Patients receiving macrolide therapy are at risk for hearing loss and prolonged QT intervals on ECG. I generally do a baseline ECG and another a few weeks after patients start macrolide therapy to see its effect on QT intervals. Now absent the introduction of other medicines that might affect QT intervals, I generally do not check an ECG again unless it is indicated per patients’ symptoms. Similarly, a baseline audiogram is necessary at macrolide therapy initiation, and there is some disagreement about how often an audiogram should be done. After patients begin macrolide therapy, I often repeat audiometry at symptom onset. I do not have a routine interval with which I obtain follow-up audiometries.

Have you seen allergic bronchopulmonary aspergillosis (ABPA) or other different fungi in your practice?
I have seen some patients with ABPA, but it is not common. In the right setting and with the right diagnostic criteria, you can see patients with ABPA. As the name implies, it is most often associated with Aspergillus fumigatus. It can also be associated with an ABPA clinical picture.

If the FDA approves brensocatib, will you use it in every patient? Why or why not?
This question rests with the FDA-approved indication. I think every patient who has heard about brensocatib would like to try it. But it is important to remember that the study that established efficacy with brensocatib enrolled patients with frequent exacerbations. The primary endpoint was the annualized rate of exacerbations during the treatment period, and a key secondary endpoint was the time between treatment start to patients’ first exacerbation. If the FDA takes a literal interpretation of the data, it might require evidence of frequent exacerbations to meet prescribing criteria. Now that can be quite difficult, but frankly I am unsure how the FDA will label the drug. My personal feeling is that I will prescribe it for as many people as I can who meet those criteria. I doubt that it will receive a blanket approval for all patients diagnosed with NCFBE, and certainly every patient who has NCFBE would like to use it. I think there will be limitations to its use.

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