Mark Metersky, MD, FCCP

In "The Future of Bronchiectasis Care: Precision Medicine Ahead," the panel closes the series with its outlook on where bronchiectasis care is headed next.

The Future of Bronchiectasis Care: Precision Medicine Ahead

In a closing round, Dr. Basavaraj asks each panelist what excites them most about the future of bronchiectasis care. Dr. Metersky points to two converging trends: increasing incidental diagnosis through imaging obtained for unrelated reasons, and growing general awareness of the disease, both of which should allow earlier intervention before patients become severely symptomatic. He also highlights a robust and diverse therapeutic pipeline, spanning anti-inflammatory agents, novel biofilm-targeting compounds, and monoclonal antibodies directed at bacteria, alongside growing understanding of disease endotypes.

Dr. ElMaraachli emphasizes that the success of DPP1 inhibition validates an entirely new therapeutic strategy: targeting the underlying pathophysiology of bronchiectasis rather than only managing its consequences. He believes this validation has opened the door for the additional anti-inflammatory therapies currently in earlier-phase development. He also highlights a broader shift in clinical thinking, from simply confirming a bronchiectasis diagnosis toward characterizing which endotype a given patient has, moving the field closer to genuinely personalized, precision-based treatment selection.

Dr. Khabbaza says he is encouraged simply by how much more bronchiectasis is discussed across medicine now, crediting recent educational campaigns around brensocatib's launch with raising awareness among providers. He compares the trajectory to asthma and COPD, fields where multiple biologic options eventually allowed clinicians to target specific inflammatory pathways, and expresses hope that treating inflammation earlier, whether eosinophilic or neutrophilic, may ultimately modify long-term disease course.

Dr. ElMaraachli adds that the growing bronchiectasis and NTM care center network represents an important parallel effort to standardize care delivery worldwide. Dr. Metersky closes by noting that brensocatib's approval matters beyond its individual efficacy, since it demonstrates a viable regulatory pathway for bronchiectasis drugs after years of high-profile late-phase failures had discouraged pharmaceutical investment in the space.

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A more precise, endotype-driven understanding of bronchiectasis, paired with an expanding treatment pipeline, is reshaping expectations for what long-term disease control can look like.

"Bringing Bronchiectasis Guidelines Into Everyday Practice" takes up the practical hurdles of translating new bronchiectasis guidelines into day-to-day patient care.

Bringing Bronchiectasis Guidelines Into Everyday Practice

Dr. Basavaraj asks Dr. Khabbaza what challenges he anticipates in translating the new CHEST guidelines into everyday clinical practice. Dr. Khabbaza notes that a gap between guideline publication and routine bedside adoption is typical of any new guidance, and he expects the underlying knowledge gap to remain a central obstacle. He observes that even patients correctly labeled with bronchiectasis are sometimes still managed as though they have asthma or COPD, reflecting treatment inertia that persists even once terminology improves. He credits growing patient and provider awareness, including direct-to-consumer education, with moving the field in the right direction, but cautions that many clinicians lack hands-on experience with newer modalities such as inhaled antibiotics or tranexamic acid, which involve more operational complexity than writing a standard prescription. He recommends that community physicians partner with bronchiectasis care centers for initial guidance while directly managing components themselves to build practical experience over time.

Dr. Metersky adds that reducing the burden on physicians is equally important to successful implementation. He points to time-intensive tasks such as patient education for airway clearance and prior authorization paperwork, both of which can be delegated to a nurse practitioner or respiratory therapist and dedicated nursing staff, freeing physicians to focus where their expertise is most needed. Dr. Khabbaza adds that portal-delivered educational videos are a valuable adjunct, allowing patients and families to review material together outside the office visit.

Dr. Basavaraj notes that published guidelines are inherently limited to what available evidence supports, and highlights the Bronchiectasis and NTM Association's planned clinical consensus statements as a complementary resource. Dr. ElMaraachli frames these statements as practical, experience-based guidance from high-volume centers addressing questions where formal evidence remains too thin to support a guideline recommendation.

Up next, in the final episode, "The Future of Bronchiectasis Care: Precision Medicine Ahead," the panel shares its outlook on the future of bronchiectasis care.

Turning new bronchiectasis guidelines into everyday practice demands more than awareness, requiring hands-on familiarity with unfamiliar therapies and dedicated staff to share the treatment burden.

In "Emerging DPP1 Inhibitors and Closing the Education Gap in Bronchiectasis," the panel looks ahead to additional DPP1 inhibitors in development and the gaps still limiting bronchiectasis care.

Emerging DPP1 Inhibitors and Closing the Education Gap in Bronchiectasis

Dr. Basavaraj asks Dr. Metersky about other DPP1 inhibitors currently in development beyond brensocatib. Dr. Metersky describes two additional agents that have completed phase 2 trials, both showing overall results similar to brensocatib, with strong signals for improved exacerbation rates and quality of life. One agent showed a notably more robust reduction in exacerbation rate, he notes, but that trial was conducted exclusively in China, raising the question of whether the stronger effect reflects genuine drug superiority or an Asian-specific treatment response. He points out that even within the ASPEN trial, patients enrolled in Japan showed a more robust response than patients elsewhere, leaving open whether genetics, baseline treatment differences, or underlying disease etiology explain the pattern. Global phase 3 trials will be needed to resolve the question, he says, though both additional DPP1 inhibitors appear promising overall.

Dr. Basavaraj then asks Dr. Khabbaza to identify remaining gaps in bronchiectasis care. Dr. Khabbaza names education as the most significant gap, recalling that his own pulmonary fellowship training included minimal coverage of bronchiectasis, echoed by the sparse sections devoted to the disease in standard board review materials. He acknowledges that his own early management of patients suffered as a direct result of that training gap. He argues for greater emphasis on bronchiectasis within pulmonary fellowship curricula and continuing education, noting that fellows and advanced practice providers seem particularly eager to learn and adjust their practice. Beyond education, Dr. Khabbaza cites the lack of validated biomarkers as a persistent limitation, since clinicians currently have few objective tools to guide treatment duration or assess whether a given therapy is truly working for an individual patient.

In "Bringing Bronchiectasis Guidelines Into Everyday Practice," the panel will discuss what it will take to bring the new CHEST guidelines into routine clinical practice.

Additional DPP1 inhibitors in development show early promise, even as persistent gaps in physician education and validated biomarkers continue to limit optimal bronchiectasis care.

This episode, "Sequencing Therapies for Bronchiectasis: A Practical Approach," features the panel weighing how to choose among macrolides, DPP1 inhibitors, and emerging antibody therapies.

Sequencing Therapies for Bronchiectasis: A Practical Approach

Dr. Basavaraj asks Dr. Metersky how he sequences macrolides, brensocatib, and monoclonal antibodies for individual patients. Dr. Metersky explains that safety, tolerability, efficacy, and cost all factor into the decision. Chronic low-dose azithromycin is often his first choice for eligible patients, since it robustly reduces exacerbations and costs considerably less than newer options, though many patients are excluded due to prior MAC growth, QT prolongation risk, or intolerance such as nausea. For patients unable to take macrolides, or those with persistent symptoms despite them, Dr. Metersky adds or starts with brensocatib, almost always choosing the 25-milligram dose because only that dose demonstrated benefit across all three measured outcomes: exacerbation reduction, symptom improvement, and slowed FEV1 decline.

Turning to monoclonal antibodies, Dr. Metersky notes that currently approved options target Th2 or eosinophilic inflammation and were originally developed for asthma. These agents may help bronchiectasis patients with overlapping eosinophilic or asthmatic features, supported by case series though not yet randomized trials. Antibodies targeting IL-17, IL-13, and IL-33 remain in phase 2 development and are not yet available.

Dr. ElMaraachli describes his approach as built around identifying underlying etiology and comorbidities alongside a consistently tailored airway clearance plan. When an immunoglobulin deficiency is found, replacement therapy is started; chronic aspiration prompts a speech pathology referral; and alpha-1 antitrypsin deficiency or CFTR defects may warrant targeted replacement or modulator therapy. Frequent exacerbators and patients colonized with drug-resistant organisms need closer respiratory therapist follow-up and more vigilant microbiology surveillance. Dr. ElMaraachli highlights routine surveillance sputum cultures as a practical way to have recent microbiologic data available before a patient becomes acutely ill.

Our next episode, "Emerging DPP1 Inhibitors and Closing the Education Gap in Bronchiectasis," turns to the next generation of DPP1 inhibitors and the education gaps still facing the field.

With multiple therapeutic classes now available, sequencing macrolides, DPP1 inhibitors, and emerging antibody therapies requires weighing safety, cost, and each patient's underlying disease drivers.

Mark Metersky, MD, FCCP

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